Speaker 1 00:00:00 I feel like David versus Goliath. But what do you do in that situation? Right. You do what David did. You put up a fight. Right. And that fight is on behalf of patients and on behalf of physicians ability to take care of those patients.

Speaker 2 00:00:22 Welcome to Off the Chart, a Business of Medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Littrell. I'm the assistant editor at Medical Economics, and I'd like to thank you for joining us today. This week we have part one of a two part conversation between Medical Economics editorial director Chris Mazzolini and president of the American Medical Association, Dr. Bobby Mukkamala. They're diving into his goals as president, including what the AMA is doing for primary care, health policy and reimbursement. Dr. Mukkamala also talks about his personal experience as a patient during his own health battle with a brain tumor just earlier this year. Be sure to come back next Monday, July 28th for part two of their conversation about hot topics like Prior Auths, AI and Scope of Practice available right here and wherever you get your podcasts.

Speaker 2 00:01:09 Thank you, Dr. Mukkamala, again for joining us. And with that, let's get into the episode.

Speaker 3 00:01:22 Dr. Bobby Mukkamala, thanks so much for joining me today.

Speaker 1 00:01:25 Oh thanks, Chris. Good to be here.

Speaker 3 00:01:27 Can you start off by telling our physician audience just a bit about yourself and your background?

Speaker 1 00:01:31 Sure. Yeah. I'm, in ear, nose and throat doc and otolaryngologist and I practice here in Flint, Michigan. I've been in practice for the past 25 years. and I share the office, with an ob gyn, which sounds kind of weird, but the reason I do is that she's my wife. We met, back in college. We went to med school together. and then moved back to Flint. Flint is my hometown. My parents immigrated here from India back in 1970, and I kind of dragged my wife here to see what practice would be like in Flint, promising her that if she didn't like it, we moved back to Chicago. But we had twins born and we started our new practice and we shared the office, and we still do 25 years later.

Speaker 1 00:02:07 So it's a wonderful town to practice in because it's the one that welcomed my parents, you know, 50 years ago.

Speaker 3 00:02:14 Yeah. Thanks for sharing that. you're obviously taking on a big role as president of the AMA. what do you see as the mission of the AMA, you know, this year and into the future? And what do you see as your primary goals, in the role of president?

Speaker 1 00:02:29 Yeah. You know, when I think about what my parents practice was like, when they started their practices in the early 70s and how happy they were taking care of their patients. And my mom's a pediatrician. She worked until it was dark outside here in Michigan, in Flint to see all those patients. And yet she would come home with all her charts. You know, before electronic health records and just do that work at home and loved it and only retired. They only retired when they just couldn't work anymore. And now I look at all of the hassles that are involved in taking care of patients.

Speaker 1 00:03:01 Right. The, you know, not looking at my patient, but instead looking at a computer screen, working on things like prior authorization and, and the cost of health care and access to care for people that that can't afford it. And now, you know, with a new uninsured population, if they lose their Medicaid, those sorts of challenges are just extremely frustrating. And so the mission of the American Medical Association is to put us back facing our patients and improving their care and the public health. and so it's an honor to serve as the president, because we've done a lot of work over the past several decades in the history of the AMA, and there's still a whole lot of work to do based on what we see about our country's health.

Speaker 3 00:03:42 You mentioned patients a lot, and I know you've spoken about some of the health challenges that you've dealt with. Can you talk a little bit about what that experience of, you know, seeing medicine from the patient's perspective, how that sort of changed your, your, your feeling about medicine practicing and the health system in general.

Speaker 1 00:04:04 Yeah, it was an amazing experience. As I look back on it. So it wasn't even a year ago. It was back in November. I got diagnosed with a brain tumor that ended up being a grade two astrocytoma, which is a cancer, but one that has, you know, not the grade for lifespan of about ten months, but, you know, at least ten years, maybe more. In the first day or two. I was like, oh, crap, you know, how did this happen? My whole family is in tears, like wondering what's going to be the future of our dad, our husband, our son. but within a day or two of just being exposed to the healthcare system as a patient for the first time, it was an amazing experience. and so it was wonderful to have that kind of access. But what I realized immediately, and it was almost with the feeling of guilt that when I look at any of my neighbors here in Flint, Michigan, in this neighborhood, and the trouble they would have finding a neurosurgeon, right.

Speaker 1 00:04:57 having their insurance sort of allow them to get an MRI scan, let alone schedule a surgery. The shortage of physicians in general in the community that they have just trying to get in to be seen. Whereas I got taken care of within a month of my diagnosis and other people. A month later, are still waiting for the MRI scan or another follow up scan or access. And that's immediately when I felt like this was something that happened to me for a reason. as I'm, you know, six months before being inaugurated as the president of the American Medical Association, after 25 years of career in medicine, taking care of patients to become a patient on death's door, was an amazing preparation. And so after that, after a couple of days of misery, I was like, you know what? This is amazing, right? And not just that, but the affection from friends and the whole community. Flint's a small town. I love it here. and every day, even today, I was in my office, and at least half a dozen patients are seeing me for the first time since then, and they're just happy to see me alive and that's been an amazing experience.

Speaker 3 00:06:01 Yeah, thanks for sharing that. I think, you know, we talked to a lot of physicians. And when physicians have to deal with, you know, you know, we all become patients at some point. but they they've always expressed, you know, this the same sort of sort of joy of practicing that, that you did. So thanks for sharing, I appreciate it. Thanks. I wanted to kind of take a tour through some of the pressing issues that are facing physicians. You know, we could probably talk for hours about these, but I want to start with primary care. many of our physicians in primary care, you know, they feel under threat for from a bunch of different areas. I'm wondering, like, what is your your feeling in terms of the AMA and what that organization is doing to to try to center the needs and address the challenges that are facing primary care?

Speaker 1 00:06:48 Yeah. I mean, it's such a good observation because it is so frustrating. I mean, the AMA is very aware of the demands that are on primary care physicians right now.

Speaker 1 00:06:58 I mean, they're the ones that, you know, they they're the cumulative impact that physicians feel because of burdensome regulations. You know, the financial strains, things like prior authorization. And they are the captains of the ship. That's what I tell my patients, right? That your primary care sent you to me as a specialist because of X, Y, z. And this is the reason that they did that, and this is what they had to do to allow this, right? And my patients call all the time and they say, hey, you know, can we get an appointment with you? And I say, well, with your insurance, you have to go through your primary care physician, and the primary care physician has to do a prior authorization. So all of these things that we all deal with. Right. Me as a specialist, my patients as somebody that need care, have to go through something that the primary care physician has to handle. Right. And so that impact is miserable.

Speaker 1 00:07:46 And so that's why the American Medical Association is fighting all of these things that make it difficult to take care of patients. Everything from prior authorization to, you know, something that primary care physicians, there's a shortage, right? We're going to be 87,000 positions short very soon, and looks like it's going to be getting worse than that in the decades to come. And so now there's fewer people, primary care physicians, to be the captains of the ship, to take care of a population that is getting older, right, but older with chronic disease, it's not like they're super healthy and aren't going to need a primary care physician. The older we get, the more we need them and the less supply there is. And so what does that do for the people that are the primary care physicians in these communities? They burn out, right? They're like, you know what? I just can't take this anymore. It's frustrating to them. They love taking care of patients, just like my mom and dad.

Speaker 1 00:08:35 But now all these hassles are making them burn out. And instead of working until their 70s, like my parents did, like the previous generation of doctors did, when they get to be in their 60s, they're just looking for that exit door because of this frustration, and nobody feels it more for them, more than them, because they're the ones that see it as soon as the patient walks in the door. And then we, as specialists, see it later, we all see it, but they're on the front lines Big time.

Speaker 4 00:09:02 Say, Keith, this is all well and good, but what if someone is looking for more clinical information? Oh.

Speaker 5 00:09:09 Then they want to check out our sister site, Patient Care Online, the leading clinical resource for primary care physicians. Again, that's patient care online. Com.

Speaker 3 00:09:21 Just a quick follow. you know, one of the things we hear from primary care doctors all the time is that health care is becoming too transactional. It's not focused on the relationship, especially, you know, there's certain specialties obviously, that are transactional.

Speaker 3 00:09:34 But there are other specialties where, you know, you're forming that long term relationship. And, you know, what can we do to bring the relationship between the physician and the patient back to the forefront?

Speaker 1 00:09:47 You know, it's it's a wonderful goal. and it's an important question to ask. And that's exactly why the AMA exists, right, to to bring that back, to bring that relationship to be north on the compass for everything that we do in healthcare. Right. But instead, I mean, we have to deal with things like the like the, multi plan. Right? So the multi plan is something that the compensation to physicians to these primary care physicians and every other physician is now being tinkered with where all the insurance companies, whether you participate with them or not, sort of have a plan that can figure out how to pay the minimum, right, how to put them all together so that they all can pay the minimum. But it doesn't even keep up with the cost of doing practice, right.

Speaker 1 00:10:32 When I look at what my practice costs now relative to what it did 25 years ago, I mean, it's gone up like this. And yet payment, you know, for Medicare, which is a government program. And, you know, Congress is the one that kind of decides that is pretty much stagnant. It's it's well short of when you look at inflation, it's like 30% short. and then private insurance companies that come up with something like multi plan to sort of figure out what's the how do we get to the minimum that we can pay doctors to take care of patients. That's bad for the future of our country. When that sort of frustration adds to the frustration of things like being short and having, you know, so many people that need me to help. But yet the math around supporting me to to deliver that help is way short because of things that the insurance companies are doing.

Speaker 3 00:11:19 Yeah. And, you know, one of the words you mentioned, Congress, you know, we got to talk about policy and politics a bit.

Speaker 3 00:11:25 You know, 2025 has been a year of massive change so far. You know, you could start with sort of all of the big restructuring of federal health agencies, everything from HHS, you know, obviously HHS down through the FDA, NIH, CDC, we've there's been a lot of discussion about what's going on with the ACIp committee and, you know, what's going on with vaccination and the policy around vaccination. We've got the tax law changes with, you know, Medicaid cuts. And just, you know, there's changes to student funding that I think, you know, based on some of what I've read is going to obviously impact, you know, future medical students when it comes to student loans. you know, it's it's a ton of stuff. So like, I'm wondering, you know, how does the AMA sort of, you know, approach, you know, the politics of the country and like when to weigh in, when to step back. Like, how do you sort of approach like a big change year like 2025 has been.

Speaker 1 00:12:25 Yeah. It's you know, it's, as you mentioned, that list. I'm sinking in my chair. I'm like, you know, when you put it all together on that list as opposed to, okay, this is what we're working on today and this is what I'm I'm meeting so-and-so today to work on this issue as the president of the AMA. When you hear all of that put together, you're like, Holy crap, I feel like, David, I went to Catholic school my whole life. I feel like David versus Goliath. but what do you do in that situation? Right. You do what? David, did you put up a fight? Right. And that fight is on behalf of patients and on behalf of physicians ability to take care of those patients and the public health of this country. Right. That's the that's the mission of the American Medical Association. And so when you see things, you know, like, you know, totally taking apart a government task force that deals with things like immunizations.

Speaker 1 00:13:13 Right. Something that deals with the Preventive Services Task Force. Right. That basically says, you know what? The science supports this sort of test for this age patient because of this reason. Right. Totally based on science. Something that I need to be made aware of so I know what to do. I mean, the science I learned was from 1995 when I graduated from the University of Michigan Medical School. Right. And so there's always updates. And of course, we have our CME and we stay up to date as we can. But these are people whose core purpose at Uspstf is to figure out, okay, this is why we should test somebody for X or Y. and that's something that now is taken apart or at least delayed. and then I think about, you know, my own health care history. Right. This pill that I'm taking for the last 10% of the cancer that they couldn't get out. is, was created, discovered by, scientists and by a pathologist at Duke University.

Speaker 1 00:14:14 And his whole lab was big time funded by the NIH, the National Institute of Health. And it got approved just literally four months before I needed it, after more than a decade of research. Right. And again, I think that somebody up there that said, you know what? We're going to put you through this, too, after your surgery, this pill that you take just got approved. And when NIH funding gets cut, that's going to take much longer. And you wouldn't have it. Right. And so again, it's it's making it personal. but what does that do to motivate the American Medical Association? You know, you get punched in the gut, you stand up and you know, you know, it's another. Another metaphor is, not David and Goliath, but but Rocky Balboa and that's, you know, I grew up in the 70s and 80s, and I saw, like, all the way through Rocky six or whatever many they made. But that's what it makes me feel like.

Speaker 1 00:15:00 Right. You take a punch in the gut and you keep on going. On behalf of the health of this country. And that's how I feel. Difficult. But I'm proud that the American Medical Association exists with the capacity to deal with everything you mentioned. Right. It's not like we're got to work on this one and it's like that. What's that game where you whack a mole? Right. Pops up over here, you whack it down, pops up over here. We whack it. All of them.

Speaker 6 00:15:30 Hey there, Keith Reynolds here. And welcome to the P2 Management Minute. In just 60s, we deliver proven real world tactics you can plug into your practice today. Whether that means speeding up check in, lifting staff morale, or nudging patient satisfaction. North. No theory, no fluff. Just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow hack and an employee engagement win, or a lesson learned the hard way.

Speaker 6 00:15:58 I want to feature it. Shoot me an email at KReynolds@MJHLifeSciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching and I'll see you in the next P2 management minute.

Speaker 3 00:16:21 So I want to talk to you about health equity and outcomes. But while we're talking about policy, let's go to another question that is about reimbursement Medicare. You know, I always see this chart. I believe it's from the AMA. that just shows how Medicare reimbursement, you know, against inflation has fallen for, you know, for years, decades. Now, at this point, you know, what what specific reforms like what what can we do? Obviously, Congress is in control here. But what what can physicians and the AMA and other physician groups do to try to stabilize, you know, the reimbursement system in this country and to make sure that physicians are, you know, paid, you know, for their expertise, for the awesome care that they give to patients.

Speaker 3 00:17:07 You know, what can we do about this reimbursement challenge?

Speaker 1 00:17:09 Yeah, I mean, as you mentioned, the authority to fix that graph that you just mentioned, right. That shows the cost of care going like this, even hospital reimbursement going like this over the decades and physician reimbursement stagnant down here doesn't even keep up with inflation. The authority to fix that is in Washington, D.C. as it relates to Medicare. There's a ripple effect of that, for sure. Right. In my hometown, when I look and see what private insurance companies pay, not not government insurance companies, it's always some percentage of Medicare. Sometimes it's 90% of what Medicare pays, sometimes it's 110%. But wherever Medicare goes, everybody follows. And the majority of the time that's a problem. And so the American Medical Association, we spent months in the past, you know, the past six months talking to as many people as we could talk to about the consequences of a bad decision about Medicare payment to physicians. Right. And we had a pretty darn good idea.

Speaker 1 00:18:07 Or the starts a good idea saying, look, look at what you do with hospitals when the cost of providing care to patients in the hospital setting goes up automatically. Medicare payment goes up to those hospitals. And yet, here we are as physicians, trying to do our best to keep people out of hospitals, to keep them healthy. To deal with stage one hypertension instead of, you know, stage three hypertension, you know, preventing prediabetes from turning into diabetes, that doesn't happen in a hospital setting at all. Right. That happens in our offices. And if the goal is to keep our country healthier and you keep up with the cost of acute care when when the blank hits the fan, but are not able to do that to prevent disease by by compensating a doctor that keeps up with just the cost of doing practice. That's a problem. And so we had a solution. We said, you know what, just tie this to the my right, the Medicare economic Index that basically says costs went up by 2%, increase it by 2%.

Speaker 1 00:19:08 The solution wasn't perfect. It was going to be a 10th of what the cost went up. So it goes up by 2%. You get point 2%, right. But at least it was going to be tied to a formula instead of going up and down from year to year based on what the budget looks like. Nothing that hospitals have to go through, but something that doctors have to go through. So they didn't do it right. We got a temporary increase, as we usually do in a random year, so 2.1% this year and then have to deal with it again next year. And who knows where it's going to go. That's exactly what's happened in the entire time of my practice. So what do we do about that? I think the best way to do that is to have patients knowledgeable about what the what the government role is in health care, where Medicare goes. All the other insurances follow, especially my senior population, where it doesn't follow anywhere. It's Medicare and let them know what the consequences are of a bad government decision to not keep up with the cost of care, right? It causes burnout in a physician's mind when the when the reimbursement for taking the best care we can of our patient population, particularly the elderly, is, is not realized and the compensation drags behind, and it causes me to feel like, you know what? I just can't keep up anymore.

Speaker 1 00:20:18 And then they close. What's going to happen to those people? And when we tell those people that, I think they will be right beside us when we talk to Congress and try to convince them, we gotta fix this better.

Speaker 3 00:20:31 So I want to talk about health equity and gaps and outcomes. you know, during your inaugural address, you described the health equity gaps that you witnessed in Flint, Michigan. and I think that that's something that it's seen across cities and states, you know, across our country where we have gaps between, you know, there's racial gaps, there's socioeconomic gaps, and there's just a big gap between the access and the outcomes. what what do you believe the AMA and individual physicians can do to start trying to narrow these gaps?

Speaker 1 00:21:05 Yeah, I think that, you know, there's a million physicians in this country. and awareness of this issue. Right. Health equity or the lack thereof, is something that varies among these million doctors. Right. Some are on the cutting edge of this.

Speaker 1 00:21:20 You know, they they live in a town like Flint, where you look and see the access that some people have and other people don't. When you look at where I live, I live in the city of Flint. Right. You're looking at me right here in the city of Flint. If I go ten miles south on I-75 to a suburb of Flint, the life expectancy goes up by 12 years, ten miles, 12 years, 68 years of age. Here is a life expectancy 80 years of age in a suburb of Flint, just a few exits away. Right. And so there's some people that just didn't realize that, right? They're just not something that they're aware of in these million physicians. So the AMA has a ton of work to lead to the raising the level of understanding about health equity, right. And embedding health equity, not just, you know, in the in the work that we do, but within the AMA. Right? This is something that we've really grown from as we look back at our own history, and then also the consequences of a lack of health equity in our country.

Speaker 1 00:22:19 And this isn't something that an individual organization could or should do alone. It comes from raising the level of understanding about this throughout the country and just ensuring that that everything from innovation, right, the new things that we create. I remember growing up learning about the pulse oximeter, right. The thing that you put on your finger to measure, measure your oxygen levels and how the numbers, if you have dark skin versus light skin are different. And I had no clue when I was in medical school that that was the case. But this is exactly the kind of thing that having a mission and a goal to improve health equity, to have a center for health equity like we do at the AMA, to help people understand at the very ground level about where what, where, where is the evidence of health inequity, right. What is it about? And it's not something that people do intentionally, right. This isn't a blame game at all. This is just about realizing that that thing that you put on people's fingers, just so you know, it's going to give you a wrong number if you if it's because it was all developed with people with white skin, if you put it on a brown person's skin, the number ain't going to be right.

Speaker 1 00:23:22 That's just basic education that we help people get to, to raise the level of understanding, to close some of these gaps so that people in Flint, Michigan, get to the point where they're living. As long as the people in the suburbs of Flint, Michigan, and multiply that by, you know, coast to coast. That would be a wonderful consequence of the AMA's efforts to improve health equity in this country.

Speaker 2 00:23:52 Once again, you just listen to part one of a two part conversation between American Medical Association President Dr. Bobby Mukkamala and Medical Economics editorial director Chris Mazzolini. Don't miss the rest of the conversation in part two, where they discuss pressing issues like prior auths, AI in medicine, and scope of practice available right here and wherever you get your podcasts. My name is Austin Littrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss any future episodes. Also, if you'd like the best stories that Medical Economics and Physicians practice publish delivered straight to your emails six days of the week.

Speaker 2 00:24:27 Subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart: A Business of Medicine podcast, is executive produced by Chris Mazzolini and Keith Reynolds and produced by Austin Littrell. Medical Economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Thank you.