In part two, AMA President Jack Resneck Jr. MD, and guest Rob Jordan, director of AMA political and legislative grassroots, talk about the Physicians Grassroots Network and best practices for grassroots change. They're also joined by Jason Marino, director of AMA Congressional Affairs and Sandra Adamson Fryhofer, MD, chair, AMA Board of Trustees.
In part two, AMA President Jack Resneck Jr., MD, and guest Rob Jordan, director of AMA political and legislative grassroots, talk about the Physicians Grassroots Network and best practices for grassroots change. They're also joined by Jason Marino, director of AMA Congressional Affairs and Sandra Adamson Fryhofer, MD, chair of the AMA Board of Trustees.
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Unger: In today’s episode of Moving Medicine, a podcast by the American Medical Association, we pick up our conversation with AMA President Dr. Jack Resneck and our second guest, Rob Jordan, director of AMA political and legislative grassroots, to talk about the Physicians Grassroots Network and best practices for grassroots change. And joining us again is Jason Marino, director of AMA Congressional Affairs.
Leading the conversation is Dr. Sandra Fryhofer, chair of the AMA Board of Trustees. Here’s Dr. Fryhofer.
Dr. Fryhofer: Our first panelist is our AMA President Dr. Jack Resneck, the public face and the voice of our AMA on these issues and so many more. Our second guest is Rob Jordan, AMA's director of political and legislative grassroots. Rob oversees AMA's Physicians Grassroots Network and will share some of his insights into that work, and how these efforts are activating physicians to engage on these issues. So welcome, Rob.
Jordan: Thank you. It's great to be here.
Dr. Fryhofer: And back with us again is Jason Marino, AMA's director of Congressional Affairs. Rob, please, tell us about AMA and Physician Grassroots and what's the best way to get involved year-round.
Jordan: Sure. Thank you, Dr. Fryhofer. When advocating on health care issues with your elected officials, whether it's here in D.C. or back at home, you all have such a built-in advantage, being physicians. You're really looked to as the experts because lawmakers know that you're the ones that are implementing the policy on the front lines.
What you can impart from your own experiences and that of your colleagues and providing patient care, it's much more powerful than any one chart or graph or simple statistic. So being involved and you guys staying involved at the grassroots level, I think is absolutely critical for us to be successful. The best way to do that really throughout the year, from the AMA's perspective, is to ensure that you're signed up as a member of the Physicians Grassroots Network. This includes physicians, residents, the students all across the country, all committed to strengthening medicine's voice in Washington, D.C.
Our online platforms—the website is physiciansgrassrootsnetwork.org―as well as Twitter, Facebook and Instagram channels that we have through the Physicians Grassroots Network. We'll keep you updated on the key issues. We'll give you the access to the online tools that puts you in touch with your elected officials and ensure that your message is being seen and being felt by these Capitol Hill offices.
We talked about a few issues, and Jason went through, but Medicare, first and foremost, it's going to be soon that we're talking about that with the Grassroots, with specific to-do items. So I really encourage, if you're not already a member, sign up there so that you're staying up-to-date on what you can do, the latest on the issues and activities that we're going to have to really start to raise the volume on this, as well as other issues, but Medicare first and foremost.
The other thing I would say, in addition to just again, ensuring that you're a member with our PGN, is take part in AMA events. Now that we're back to doing more in person, thankfully, the AMA's Annual/Interim meetings, as well as advocacy events like the NAC, State Advocacy Summit that's held in January and others, where possible, we incorporate grassroots training programming in these events. We have grassroots resources, like our advocacy handbook, congressional calendars, directories, things like that on hand. But moreover, members of my team and I attend these meetings typically, and it's a great opportunity to ask us questions, get to know us a little better. We get to know you better and we find out what else we can be providing and how we can better help you with your individual legislator on a particular issue and help you craft messaging or do whatever we can.
Dr. Fryhofer: So PGN—Physicians Grassroots Network—it sounds like a great way to get involved and it sounds like you're doing some very effective work through this. Rob, I have one more question for you. For those in-person Hill visits, what are some of the best tips you'd offer up?
Jordan: The first thing I'd say is don't be disheartened if you're not meeting with the member. The nature of the Congressional calendar just, it is what it is. With Congress not in session, I imagine a lot of you will be meeting with staff, but that's not necessarily a bad thing. A congressional office is not what you would think of as a large operation. I mean, even Senate offices, the staff that you're going to be talking to, chief of staff often, legislative director, but even a health LA—health legislative assistant—they have the ear of the member on the issues that you're there to discuss, and they're going to help shape his or her opinion. Jason talked a little bit about the demographic of congressional staff, and you can have a huge impact on how they view the issue, and that, in turn, will affect their boss's view on the issue.
For the meeting itself, I would say a few things. Be aware of how much time you have. Stay on task in terms of the issues that you're there to talk about. Make sure you're able to communicate all your points in the time that you have―just a simple little agenda or an outline you can sketch for yourself to talk through with your fellow attendees. Many of you are going as groups, which is great. You can just tick things off right in the meeting as you're going through.
With policy materials and we have a lot of intellectual ammo on this stuff and we're going to have great information there, talking points on the issue and other resources. You may have some things that you put together from other organizations or other sources, but for materials that you want to leave behind with the staff that you meet with or with the office—and that's a good idea to do that—but keep it simple. Keep it concise. Dense policy studies and 50-page whitepapers, those are just going to get tossed. So I would just try to keep it as concise as you can and to the point.
Ask what you can do to help them is another thing. Is there more information in a particular area that they need? Do they have specific questions? You can bring that back to us and we can help there.
Are they in need of specific examples, real-life stories that demonstrate the problem? I think you guys, you have those in droves. But whatever it may be, I think, just being willing to help and expressing that. I don't think many people do that, but it is appreciated, particularly from the perspective of a staffer. And it also reinforces your level of commitment.
And then the last thing I would say is provide us with feedback. I mean, that's an easy thing to forget. And especially, ironically, when the meeting went well, a lot of times we don't hear that, but we'll have feedback forms for you, and you can follow back up with the office as well. Just a short note to thank them, recap the discussion and periodically stay in touch with them throughout the year because this will be, as Jason said, a tortoise and hare thing. It's going to be throughout the year for us. So make sure to keep in touch, but those are just a few things as it relates to meetings.
Dr. Fryhofer: Well, those are some great tips. And I love that term "intellectual ammo," and as Jason outlines so many specific things that we know really need to get done, and you mentioned the role of the LAs—the legislative assistants—these younger people that might have a little more time to dive into some of these important issues and dot the I's and cross the T's. And there's so much to be done this year, so thank you so much for those tips.
Okay. How different are in-person Hill visits than ones that are done virtually and which one is more effective?
Jordan: Well, in-person are more effective, I think that's the short answer, but you're always going to have greater focus and just an all-around better exchange, I think, in person. There's no technical filter that's going to get in the way. I think just about all of us probably can attest to at least some amount of Zoom virtual fatigue, but I would say also at the same time though not to discount virtual meetings altogether, especially when an in-person meeting isn't feasible.
Offices have really gotten much, much better about doing them. There was a survey done recently where I think it was like 77% of offices plan on doing these going forward, regardless of pandemic. They're working for them and providing constituent service so they've invested in video conferencing capabilities. They're learning how to conduct these virtual meetings better. They take them seriously. Sometimes when a member would not be able to do an in-person meeting, they can do a Zoom or a Teams call, and the member has greater comfort level now that they've been doing them for a while as well. So again, I'd say in-person are preferable, but if a virtual option is there, I wouldn't discount it entirely. I would definitely take advantage of that.
Dr. Fryhofer: And so it sounds like you're kind of evolving into some sort of a hybrid model, so you do the in-person, get that connection going and maybe use that virtual interaction to keep that relationship going so we can continue to make our points.
Jordan: That's a great point, yeah.
Dr. Fryhofer: Yeah. So Jack, this one's for you. As our AMA president and the public face of our AMA, we'd love to hear your take as well about this, and perhaps you can share your experiences doing Hill visits last year virtually as compared to previous years and recently when you were able to meet in person in D.C.
Dr. Resneck: Well, I think Rob captured this really well. What I would add is that every opportunity to interact with either a member or their staff is an important opportunity. And sometimes that gets to be in their fancier office in a building on the Hill, sometimes it's in a hallway outside their office, sometimes it's in a basement cafeteria, sometimes it's back in the district when they're back home when Congress isn't in session, and sometimes, yeah, it is on Zoom or on the phone. And we are moving into this hybrid world where we can use all those. It's all about relationship building. And so I think really it's like, as we talked about seamlessly integrating in-person health care and telemedicine, it's the same thing, really taking advantage of all those opportunities.
I agree with Rob. I'd be lying if I said I preferred virtual. I like in-person meetings. I like that connection, being able to read body language and read the room. I still get chills walking the halls of those office buildings on the Hill and feeling like, hey, I'm actually petitioning my government and speaking up for the profession, but there are some occasional advantages to building in virtual, as well. And if you have members still accepting those virtual meetings, you can actually cover a lot more meetings in the same period of time because you're not going through security and walking through tunnels and doing all that.
And then I think, we heard about this earlier from both Jason and Rob, but the last thing I would say is do not be dismissive of staff. And if you end up at the last minute getting a meeting with a member of the staff, they have such influence over the members. And really recognizing that and treating them as such is important because you can have just as much influence building those relationships, as well.
Dr. Fryhofer: And I think, a lot of times, they will have a particular staff focusing on an issue and they'll be reporting back to the senator or the representative so those relationships, as you say, are so, so important, and giving them the information that they need and connecting with them.
So Jason, back to you. How do you tailor your lobbying to lawmakers on opposite sides of the aisle? Are there some issues supported more by one party than the other?
Marino: There are. I think big picture, if you look at our advocacy agenda, it's very bipartisan. Fixing Medicare, it's not a Democratic or Republican issue. It's an issue that just needs to get fixed and work better for everyone. And telehealth and prior authorization issues, our issues that we deal with are mostly all bipartisan.
So the messaging in general, I'm not giving a whole different talk to different staff based on what party. I'm trying to be consistent because you don't want to be too all over the place. “You were just meeting with so and so ... ” Because people are friends, too, on both sides, and they go out. “The Jason Marino guy was in there and he was saying this ... ” You want to keep your credibility and our issues are our issues and we're very focused on having a non-partisan message.
And of course there’s times when you do your homework and certain members have things that can trigger them in a negative way or positive way, and you always be mindful of those and some of those are along ideological fault lines. And you don't go out of your way to rub something in someone's eye. If you know they're somewhere else and you're not going to move them, you play it smart.
And so you don't walk into some offices that you know what you're saying is not going to—you respect that people have different opinions in Congress and you focus on the champions and those on the issue that you can lie with or you can get or gettable. And most people are gettable, but some are not and you've got to be smart about that.
So it's more selective in what you say and don't trigger people, but on the whole, our message is consistent to everyone. And it's kind of boring, but that's how it is. It's Medicare payment and there's a lot of complexity to it and we're not trying to chase the latest, hot, controversial topic. That happens time to time, but I think a consistent message is important.
Dr. Fryhofer: Right, and our messages are not partisan. Our messages focus on physicians and helping patients and helping the physicians who care for these patients. So I think that's an important message, too.
Rob, I'd like you to help with this next one. For those of us who may not already have relationships with our lawmakers, what can we do to establish ongoing relationships with them, particularly when we don't have a specific ask?
Jordan: That's a great question. It's a good opportunity for me to promote the AMA's Very Influential Physicians—VIP—program. This helps physicians who already have relationships, but also those who, as you say, want to establish relationships with members of Congress and their staff to do so over the course of time, but also, to maintain them, to make them stronger and ultimately leverage them at key times as well. We have a host of content available through the program and things like exclusive newsletters, updates, advocacy webinars like this one, that are more specific to training tactics that you can use and effective ways to communicate with your legislators. Things that are tailored for this type of grasstops, as opposed to grassroots, activity.
And when there's not a specific ask, a specific bill, or a piece of legislation, we can help you tailor messages that will continue to give you touch points with the legislators, with the office to keep that relationship going so that you're building that all the time. So anyone who's interested in that, it's physiciansgrassrootsnetwork.org—just like the PGN website—and then it's /vip. You can learn more about the program and also sign up for it there.
Dr. Fryhofer: Oh, great to know. Jack, you're our AMA House of Medicine expert on this one and we'd love to hear your insight. How have you established relationships with your lawmakers and how have you kept those relationships going?
Dr. Resneck: I'm not sure that I’m the expert, but I've certainly learned a lot from our advocacy team and from fellow physicians who've been at this a long time. But I think at the end of the day it's about being a trusted voice to the lawmaker and to their staff. And right now, we have some pretty big important asks, and it's important if we show up to actually focus on those asks and not get derailed.
But I think in order to build those relationships, it's also important to show up sometimes when you don't have an ask. And sometimes it's easier when the member is back in the district and just scheduling a meeting and saying, actually, I'm not asking for anything from you today. I just want to know what's on your mind, what can we help you with, are there issues that you want to talk about with me. And that just gives you more credibility when you come back the next time and you really need to talk to them about why the Medicare physician payment system is broken, for example.
It means really being available to them when they happen to have questions and urgent questions or something they want to talk about. And it means being consistently credible. As physicians, we always want to come in and be the experts and have the data, but it means never exaggerating or if they ask us something that we don't know, I've learned to say, “I need to get back to you about that; I'll go research that for you,” when we don't know something. But that relationship building and making it durable over time, I think is the most important way to get there.
Dr. Fryhofer: And Dr. Jack Resneck, our AMA president, you have credibility with a capital C, but hold on. How do we coordinate efforts at the federal and state levels for prior authorization or insurance problems?
Dr. Resneck: This is a great question. And anybody who's heard me speak pretty much anywhere knows that in my list of top issues, the annoyance of the prior auth burden and how it's gotten completely out of control is very high on my list. It's an enormous burden for our physician offices and practices, where the average doctor is doing 41 of these a week. It's no longer focused on brand-new expensive things. And patients are showing up at the pharmacy and getting frustrated and not able to get their medications, and a bunch of them never even come back after we fight those battles to get their medications approved. So it's a huge problem.
As the person who asked this question, I think gets it that unfortunately, this is a patchwork of regulation. So, Medicare Advantage Plans, for example, are regulated by Congress and HHS, whereas some commercial insurance plans are regulated at the state. So we have to be in all those places in partnership with state medical associations and a number of states have passed some really cool laws to try to rein this in.
And in Congress, for example, we got a bill across the finish line in the House in shockingly bipartisan fashion to try to rein in prior auth and Medicare Advantage Plans. We still need to do some work to get that across the finish line in the Senate in the year ahead. We've seen some—actually, the CMS, the Center for Medicare and Medicaid Services—just released a few weeks ago a couple of proposed rules where it's the most heard I have felt as a profession on this prior auth issue in a long time. I don't have time to get into the details today, but some really great stuff in there to fix some problems in prior auth.
And we've seen states do similar things. Texas, for example, passed a gold card bill, which is sort of like TSA Pre-check for prior auth that says, hey, if you're a physician practicing evidence-based medicine, as the vast majority of us are, and you ultimately get your prior auths approved, you shouldn't even have to do these anymore. And the way that we're coordinating that all around is having very consistent asks. We have on our website, at fixpriorauth.org, we have a list of what our asks are. And so there are five very clear asks on prior auth and they're the same in all those places in Congress, at HHS and in the states.
Dr. Fryhofer: Well, I know, you have been working so hard on this issue for many years and so has our AMA advocacy staff. So let's hope that we'll have some real progress this year with this new Congress.
All right. I think this one we'll turn to Jason. A recent article noted more physicians in AMA are supporting reproductive choices, much to the consternation of one side of the aisle. Will this continue?
Marino: Well first I want to jump into the last question first because I want to tell more to the story on the prior auth because—
Dr. Fryhofer: Go for it.
Marino: If I had to give this talk two years ago and I had a four-point plan to get prior authorization addressed in Congress, it largely happened in that we got a bill dropped, bipartisan in the House and Senate. We had 300-plus co-sponsors on a prior authorization bill. We had almost 60 in the Senate and we got it through the committees in the House. We got it passed by voice vote in the House and then we got this horrible $16 billion score from the Congressional Budget Office they based on. We questioned their assumptions and you can't—$16 billion was too much and it was the fatal blow. And it killed it, the bill, but it didn't kill the issue and it didn't kill momentum.
This is a tortoise and hare play in that here we are in 2023, and we have two rules that came out that largely mirror the bill—the legislation that we were pushing—and it does it through regulation. And it does it even more so because it applies not just to Medicare Advantage but some other plans.
So it's a great win. We're on the cusp of a great win that no one's seeing because it's kind of complicated because of the rulemaking. And it may help—because now you have the key staff, members of Congress on both sides following this rule because it may change the scoring for CBO because CMS uses different assumptions. And if you get it finalized as a rule, then it also becomes the new law, so to speak, and it changes CBO scoring. So we may be on the cusp of a follow-on bill that this rule is making possible.
But even if the bill doesn't happen right away, the rule is still promising, and it will be really, real world and do largely what the bill was doing and it was all because of this foundation Rob's grassroots team, all the physicians calling in, Dr. Resneck telling all the stories about how this is real-world. And so have a lot of momentum on that issue.
And the second question—some of those issues have been around for a long time, some of these social issues. It's hard as a D.C. lobbyist, we're not going to move certain members on some issues that people have had strong opinions on their entire lives. You try and do the best you can to make your points and your cases.
And I'll just say that we're just very focused on the Medicare issue because it's such a big issue that it can consume—most groups don't have the issues that the physicians have, where we have to get things passed. Usually, you're on the defensive and trying to block bad bills and so it can take a lot of your oxygen and need to focus to get—because our bill could be $100 billion-plus. That's where most of my energy and what keeps me up at night is, how do we get a $100 billion bill passed through Congress at a time when they're trying to cut the budget deficit?
Dr. Resneck: Sandy, can I jump in and just say one additional thing on that? And Jason is right about where a lot of our congressional energy is right now on Medicare, but as I mentioned earlier, our policy is set by our House of Delegates, and it's spoken loudly and clearly about government interference in health care in our exam rooms. So as the spokesperson in my role, I'm going to speak up about that and give voice to that because that's what the profession really feels and believes.
But I also―I'm an optimist that lawmakers, when they happen to disagree with us on an issue like that, are ultimately going to do the right thing for Medicare beneficiaries and physicians and are ultimately going to do the right thing on prior auth. And we'll have areas of disagreement, and we'll talk about those, but I know that all of these issues are so important and that ultimately we're going to work with Congress to get these things done.
Dr. Fryhofer: Thank you, Jack. I'm going to send this one to Rob. Does PGN have information as to the cost of medications to pharmacy benefit managers to use as arguments against prior authorization recommendations?
Jordan: Well, I'm not going to punt exactly on that. I would say, stay tuned. I know we've been talking with policy folks and there will be more information coming. I can't speak as to the level of specificity as it goes to prices for PBMs, but more stuff directed at PBMs coming through the pipeline. We're going to be updating through TruthinRX.org—another campaign site for you to remember—but through the PGN, as well. So if you're signed up, you will get our updates on that issue as well, and that will be coming in the weeks and months to come certainly, new information on that front.
Dr. Fryhofer: So as a reminder, how do people sign up for PGN?
Jordan: It's physiciansgrassrootsnetwork.org.
Dr. Fryhofer: Thank you. Many thanks to our wonderful panel of experts, thank you for being here, and thank you for being engaged on issues that most directly impact America's physicians and our patients. And remember, AMA is your ally and your partner as we work to create a health care system that's better for patients and the physicians who care for them.
Unger: You can learn all about AMA’s advocacy efforts by visiting our website, ama-assn.org. Subscribe to the Moving Medicine podcast today.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.