Ep. 19 AMA President Dr. Bobby Mukkamala: Fighting for Physicians and Patients from the Front Lines

Dr. Bobby Mukkamala, President of the American Medical Association and practicing ENT surgeon in Flint, Michigan, joins Value Health Voices to discuss the critical challenges facing American healthcare from both the physician and patient perspective.

As a solo practice physician treating cancer patients while leading the nation's largest physician organization, Dr. Mukkamala provides unique insights into the policy battles affecting healthcare delivery. The conversation covers prior authorization barriers that delay cancer care, the Medicare payment crisis with 25 years of declining physician reimbursement, and the collapse of independent medical practices due to site neutrality issues.

Dr. Mukkamala also addresses Medicare Advantage's aggressive denial tactics, the physician workforce shortage, and dangerous trends toward independent nurse practitioner practice without physician oversight. The discussion includes the AMA's role in CPT coding and RUC valuation, as well as Dr. Mukkamala's personal cancer journey and its impact on his advocacy for NIH research funding.

This episode reveals how physician advocacy organizations fight for both healthcare providers and patients as the system faces mounting pressures. Dr. Mukkamala's dual perspective as practicing physician and cancer patient offers invaluable insights into what's really happening in American healthcare.

About the Guest: Dr. Bobby Mukkamala is President of the American Medical Association, a practicing otolaryngologist in Flint, Michigan, and graduate of University of Michigan Medical School. He previously served on the AMA Council on Science and Public Health while maintaining his solo practice.

Value Health Voices makes healthcare policy and finance accessible through engaging discussions with industry leaders, policymakers, and practitioners working to transform care delivery.

A Sudden Health Scare

I was giving a speech at the American Medical Association as its President-elect. In the middle of the speech, all the words got goofy. I thought, my iPad has put me on the wrong page. And that's at least what I thought happened. The audience, who has heard me speak for a decade or more now, was like, "Dude, you just had a stroke."

I said, "Yeah, I don't think so." They called my wife, and we went to the emergency department. They said, "We don't see anything that looks like a stroke. Maybe it was a TIA. When you get home, go see somebody about that."

I ended up getting an MRI. It showed a deviated septum, and the tech was like, "Oh, your nose is a little crooked." And then, boom, we get back here, and there's an 8-centimeter tumor in the medial aspect of my left temporal lobe. I was like, "My nose is crooked, but that ain't my problem. I got a big tumor in there." So that's where it all began.

Welcome and Introduction

Amar, we are back with Value Health Voices. We are getting up there in episode count. I think this is going to be 19 for us. Little summer hiatus here after a busy earlier summer recording episodes. Great to be back with you.

Likewise, Anthony. And yeah, we did take a summer recess like everybody else, so hopefully everyone enjoyed that break. We have a great lineup of guests coming on, including Bobby Mukkamala, who is our AMA president, who is going to be with us today. We're excited to have him on. We'll introduce him right after the intro.

Introducing Dr. Bobby Mukkamala

On today's episode of Value Health Voices, we have Bobby Mukkamala, who we are very excited, thrilled, and honored, honestly, to have on our show. He is an otolaryngologist, which is, to the layperson, an ENT surgeon, and he was elected to the American Medical Association as their president. He graduated Michigan Medical School and continues to practice in a solo practice in Flint, Michigan.

He's been involved with the AMA since his residency as a past Michigan representative to the AMA Young Physicians Section, as a past recipient of the AMA Foundation's Excellence in Medicine Leadership Award, and for 13 years served as a member of the Michigan delegation to the AMA House of Delegates. In 2009, he was elected to the AMA Council on Science and Public Health and served as chair from 2016 to 2017. So we are very excited to have you on. Welcome, Bobby. Is it okay if I call you Bobby?

Absolutely. In fact, if you said Dr. Mukkamala, I'd be looking to see if my dad was in this room or something.

Absolutely. Thanks. Really great to have you. Maybe, Bobby, you could tell us a little bit more about your background and what brought you into physician advocacy.

The Path to Physician Advocacy

This is my 25th year in practice as an otolaryngologist here in Flint, Michigan. But I guess it started as it always does, when I was in high school and I told my parents when I saw Peter Jennings on ABC News in the evening when we turned on the TV, that I was going to be a journalist. My parents both being retired physicians, when they immigrated here to the US from India at the age of 25, they saw being a doctor as the guarantee of happiness, success, and stability. When I told them I wanted to be like Peter Jennings, they basically grounded me and locked me in my room until I changed my mind.

So I ended up applying to medical school and I got into one of those seven-year programs, the Inteflex program at the University of Michigan. Then I thought, "You know what? I'm guaranteed this med school admission, which, as anyone can tell you, is pretty competitive. I can take that guaranteed position and keep my parents happy, or I can give that up and make my parents angry and become a journalist." That was kind of a no-brainer. I decided, fine, I'll do all that other stuff and I'll go to med school.

You know how that is at that age. I had skipped kindergarten, I was in a seven-year program. So by the time I finished medical school, I was two years younger than everybody else. Now we're in a generation where people take a gap year, which is fantastic to mature as a human being, to see parts of the world, to see parts of healthcare, and then get your MD or DO. That's awesome. I did it the opposite way.

What that means is all I cared about was keeping my parents happy and getting the highest grades I could and then matching into otolaryngology, which is also competitive. Then, when I lecture medical students as president of the AMA, I basically tell them that I was apathetic at that age. They're not apathetic because they're sitting in a room with me learning about healthcare at a phase where I wasn't even into it when I was their age or at their stage in career.

I guess what I would say is practicing medicine and seeing all the hassle factors changed things. Like when I set up my solo practice and I was doing everything I learned in medical school—taking care of people's sinus issues, their crooked nose, their tumors, their larynx cancers—and getting denial after denial after denial. When I started my practice, I was like, "What the heck is going on?" I got great grades all the way through, got into a competitive residency program, and passed my boards. And you're telling me that I'm not doing something right, so you're not going to pay for it?

I was like, "This is new." I thought I was going to get my law degree. This was my idea. Then sue the heck out of insurance companies for being cheaters. So I went down to the orientation at Michigan State University, where they had a night school for a law degree. This was when my kids were like six months old and my wife was like, "What are you doing? We need you at home." I'm like, "This is going to kill our practices." She and I share the same office. She's an OB-GYN, so it's not exactly like we cover each other. I stick to things that are north of here, and she does stuff that's down south of here. This is the way we live.

So I went to orientation for law school. I was planning on doing that, and then somebody told me about organized medicine. They said, "You know what? You don't need to do that. Just do what you love and we'll take care of it." This was the Michigan State Medical Society. As you would say, the rest is history. I got involved with them.

It was a funny story there, too. I showed up in March for the meeting of the Young Physician Section of the Michigan State Medical Society. In March, in Michigan where I live, sometimes it's sunny and sometimes it's snowy. This was a really snowy day. I show up for this meeting, and there were three people in the room, and we had to elect a chair, a chair-elect, and a secretary. So at my first meeting, within minutes, I was secretary of the Young Physician Section of the Michigan State Medical Society. And now I'm president of the American Medical Association. You can figure out where it went.

Half of it is showing up, right? If I have that right. That's so interesting. So that was the start. It was a kind of trial by fire. If you like being in the trenches, facing these problems. Someone put the bug in your ear, you showed up, and then one position and level of experience after another, all the way up to the AMA president.

Yep, that's pretty much how it happened. I love being in practice here in Flint, my hometown, where my parents came when they were 25 years of age, and seeing things at the absolute ground level. I was in my office today, I was in the operating room today, dealing with things like somebody that we schedule surgery for because they got a lump in their throat or they got something that we need to kind of urgently deal with. And yet the procedure that I need to do doesn't get prior authorization because of some hiccup, some problem at the insurance company.

Seeing that at a ground level, watching one of my patients suffer, and then having the microphone, having the platform, having an opportunity like this with you guys to talk about at a national level is fantastic. I really appreciate the fact that I have a foot in both worlds.

Absolutely. You really got to one of the main objectives of Value Health Voices. We want to make sure people understand the vital role of organizations like the AMA that you play on the entire healthcare landscape, organized medicine, as you call it, and how the positions that the AMA takes really affect so many aspects of health policy. And really, ultimately, what the government does.

That's the hope. When we know the right thing—just like the example I gave about prior authorization—when we know the consequences to our patients, to our office staff. When they deal with prior authorization, that's the only time I've ever seen my office staff in tears. This is my 25th year in practice. When they've got a patient that they know, and I know, that there's something urgent going on and they have to navigate through the system.

There's an icon for every different insurance company where we practice that says, "Click here if you want this insurance with prior authorization, click there." They send everything in and it gets denied. Then they're trying to get somebody on the phone and they need to set up an appointment to talk to me about why we need prior authorization for a PET scan for somebody with some head and neck cancer, and that's what brings them to tears. We don't want a patient to go from a stage one cancer to a stage two cancer just because we're waiting for a PET scan.

That's exactly what happened to me. I literally had a patient with tonsil CA and no lymph node, and while waiting for a PET scan, developed a lymph node.

As you and I all know, these are standard of care, staging workups, imaging studies. To couch it in the way that insurance companies sometimes do, saying that they're trying to promote more value-based care when it's really more of cost savings and a cost management type of a system.

And you know, you can say something based on the theoretical principle or the advertised principle of something, but the reality is when they're going to put in some sort of AI machine on their end of the prior authorization process. Which is something that they're talking about a lot now, and automatically sort of look at something and say, "Yep, no, this is something that requires prior authorization."

And not even that. Now we're hearing about down coding. So I see a patient with some neck mass and I say, "That's a 99204." Because I spent 30 minutes with them going over everything, talking about what we need to do, what it could be, what it likely is, what that holds in the future. And then they've got some AI thing that looks at the note that I document all this in and it says, "No, this is a 99203." It's not like there's a physician on the other end of it saying, "No, this is not really what a 99204 is." No, this is some automated AI type thing that says that I didn't do what I said I did. And that's just inexcusable.

For those listening and watching, you can already get a sense that whether it's Bobby, somebody who is 25 years experienced practicing and president of AMA, or guys like Amar and myself, is that we can't wait for the opportunity to talk about these headaches. It's a kind of commiseration. It's more than that, of course, but I'm not surprised that we got right into it.

Bobby, if I could ask you, and of course we'll have plenty of time to talk about that in detail and many other issues. It might be useful for those listening in who aren't neck deep in health policy like Amar and I are, to get a sense of really the scope of what the AMA does. Why they, as whatever they are and stakeholders in healthcare, should care about the AMA's activities. Can you help ground us in that?

The Mission of the AMA

Let me start by saying that when we work with our patients, we use everything we learn in medical school. But then when we deal with insurance companies, deal with other policies, that's not what we learn in medical school. It's not something that I need to go to law school to do. So what do we need there? We need organized medicine. Sometimes that's at the county level, definitely at the state level, and sometimes it's a national level.

What the American Medical Association does is, our mission statement is to promote the art and science of medicine and the betterment of public health. That's our goal. And we know that there are barriers to doing that. So the role of the American Medical Association for those that are like, "What does the American Medical Association do for me? I know what my American Academy of Otolaryngology–Head and Neck Surgery does for me. But what does the AMA add to that because I'm an ENT doc?" That's a logical thought process.

But the things that we do with, like Medicare payment. It goes up a couple percent one year and it drops by another couple percent next year. When we look at the past 25 years of my career, it's something that there's been a 6% increase in payment in the past 25 years while we've had a 30% increase in costs in that amount of time. It doesn't even keep up with inflation. It's way behind when it comes to that.

Is that something that the American Academy of Otolaryngology–Head and Neck Surgery is going to be effective on their own at dealing with? Absolutely not. Is it going to be the RadOnc Group that does that? No. The ability of an individual specialty to be able to deal with something that huge is pretty minimal.

When all of us get together to talk about those things that affect all of us, whether that's Medicare payment system or prior authorization like we talked about, we need a louder voice. It gets louder when the million physicians in our country come together to speak that. As opposed to 10,000. That's what the American Medical Association does. We represent every specialty in every state. Even though a big chunk of that million physicians decide they don't want to be members of the AMA, we still work for them. They get it for free, which I don't think is right. But yes, that's the role of the American Medical Association is to be the loudest voice of medicine when we need to yell at somebody about what they're doing.

Addressing Membership Concerns

I agree with you that having a unified voice is critical. We're both very active in our radiation oncology society, and having a unified voice that helps amplify it, like you said, especially with the microphone that the AMA has. One of the questions that people ask, particularly people like us who are radiation oncologists, yourself who are ENT physicians, other specialty physicians, is why should I pay dues to the AMA if I'm already paying it to my own individual society? If I believe that the AMA only represents primary care? That's a criticism you sometimes hear. How would you address that?

I wouldn't start by saying, "Well, it's only 400 bucks," and sometimes it's as little as a hundred bucks if it's a big group. I wouldn't start by saying, "Well, the specialty that I'm in cost $1,000, and you're going to get a bargain for this for 400." That's not the logic I would use when somebody says that, because if it's a philosophical concern—like you guys only represent primary care physicians or you only represent specialists—that's what needs to be discussed, not the dollar value for something that isn't valued, period.

What I would say to somebody like that is, I hear from specialists talking about the American Medical Association only representing primary care physicians, and I hear from primary care physicians that the American Medical Association only represents specialists. Fair point. So when you hear it from both sides, it means you're pretty much in the middle, which is exactly where we need to be.

I think it's more of an awareness. When a primary care physician sees the RUC, the Relative Value Unit, the committee that looks at that and decides, "This is how much effort it takes to take out a brain tumor, and this is how much effort it takes to prevent somebody's prediabetes from turning into diabetes." It comes up with something that's based on a calculation of how much risk is there, how much time does it take, how much training did it take, those sorts of things. Then we give that information to the government, to the feds, and they basically decide based on that and many other things whether or not something should pay a hundred bucks or 150 bucks.

There's a formula, there's a process that looks at all of these factors, and then we promote other things. When I see the billboards in my hometown of Flint, Michigan, and every single one of them is about a hernia or a knee or a hip, and none of them are about preventing prediabetes from turning into diabetes, I know we got a problem. Our job as the American Medical Association is to share that with the people that have the ability to reward and compensate for prevention of disease. That's a problem that I think is in our country, we are great at treating problems when the blank hits the fan, but we are not very good at all about prevention of disease.

These are the kind of things that the American Medical Association strongly advocates for. But it's also what I would say to a specialist that thinks this is totally going in the direction of primary care physicians and primary care physicians that totally think it's going in the direction of specialists. And then when they start nodding their heads just like you did, that's when I would say, you can join for 400 bucks a year, which is a whole lot cheaper than your specialty society, and this is what you get for it.

This is true. That's a great point. And I want to make sure we highlight this very clearly and concisely and remind our listeners. Amar beautifully explained the process that really the AMA oversees—I think is the right way to say it—of how a medical procedure code, a CPT code, is created and how the AMA runs that part of the process. And then after that, how it runs the process for valuation, or let's call it a proposed valuation, that is all under the auspices of the AMA recommendations made to Medicare. If you look at the history, Medicare generally accepts the recommendations that come out of the AMA process. I want to make sure our listeners really understand that.

CPT Codes and Valuation

Just to clarify a little bit, Anthony, so CPT—the codes that we use to describe all of these procedures that we do and the codes that we use for that—that's something that the AMA has created, and that's something that we monitor. That's the kind of thing that we have entire conversations with anybody and everybody that thinks that something specific, a new code, is necessary.

Now, the RUC, which is the formula that we use, that's something that we send that information to the folks that decide what they're going to compensate. Then they look at other things, and it's about 80%, not 100% of what we recommend that gets done. And I think that's totally fine because there are other things besides the malpractice cost of something that should determine how much it compensates. How about the value to our country being part of that? That's not something we measure. That's something that Congress measures. That's something that the federal government measures. 80% of the stuff we submit gets approved, 20% doesn't because there's a different philosophy, a different input, and I think that's how it should be.

The Medicare Efficiency Factor Adjustment

I think this conversation around the RUC is a good way to pivot us to the next topic. So for our listeners, again, the RUC is the Relative Value Scale Update Committee that sits within the AMA. As our listeners may remember from our prior episode, I'm an advisor for Radiation Oncology to that committee.

One of the things that is happening in the new fee schedule, the proposed rule for the Medicare physician fee schedule this year, is there's this concept of an efficiency factor. The efficiency factor is the idea behind it, as there was criticism that the RUC doesn't value what you learn in terms of if you're doing a procedure, over time, you become more efficient doing it. So there's not an efficiency adjustment that acknowledges that it will take you less time as you become more efficient and skilled at doing it. CMS this year in their proposed rule has recommended a blanket cut over of 2.5% as an efficiency adjustment to account for this uptake in the skill that you do with a new technology over time. So I was curious, Bobby, what do you think about this efficiency adjustment as they propose it?

I think it's totally disconnected from what it's like to actually take care of patients. If I'm doing a procedure in the operating room and I did it today—somebody had a totally opacified maxillary sinus. It could have been a tumor, could have been fungus. Turns out it was a yeast infection. It was fungal debris that was there. But to say that because I'm in my 25th year of practice, it's going to be faster than it was when I was 15 years into practice? No way.

There are things that are required. We put in local, we wait 10 minutes, we come back, we start dissecting, we open up the maxillary sinus. Too much detail for you guys, I know, but the point is that doesn't change. To say that all of a sudden they're going to cut this X percentage off because I've gotten so much better at it? No.

And then to say that that applies to all doctors. What if I was 10 years into my practice and it took me an extra 10 minutes and all of a sudden that's something that's not something that they're going to be able to get compensated for? This is just the wrong way to calculate what something is worth. And I think it's just totally misguided.

I think CMS is going to receive quite a lot of feedback on that from the entire house of medicine. I've spoken to many cardiologists, especially like EP cardiologists, high intensity to their procedures, critical misstep, and that's a big problem. I was talking to some of our colleagues. In fact, a previous guest we had on here, President of ACRO, Dr. Lally mentioned, and I agree with him as a practicing radiation oncologist, over time, the cases we're treating are actually more complex, sicker patients as well. So I don't see it. But maybe they have data that I don't have.

To that point, it kind of brings up another comment that I have about if somebody loses their health insurance because of Medicaid now and the new rules about Medicaid. They're not going to come in to see me with a small lesion on their palate because they're going to come in to see me when things get much worse. And it's going to be much harder to take out. It's still removing a palate lesion, but it ain't going to be a 2 millimeter one. It's going to be a 2 centimeter one. And if it's the same code and it's going to be cut and yet somebody is sicker, just like you said, Anthony, that's a major failure.

Physician Payment vs. Inflation

One of the other criticisms about this type of a policy is unlike hospitals—hospitals get an update kind of tied to inflation. In essence, they get an update for pricing tied to what's the cost of their supplies is, we call it a market basket adjustment. But physicians over the last several decades have not had any updates based on inflation. So to just all of a sudden have an arbitrary cut of 2.5% for quote unquote efficiency without accounting for updates for the cost of inflation, of all the cost of paying salaries and maintaining your overhead and all that over time, it just doesn't seem to be very realistic.

Absolutely. That's the graph that I use all the time in my presentations as I hit the road for the American Medical Association as president. We spend about 200 days a year on the road. It's a lot of conversations. One of the slides that's in almost all of my conversations with fellow physicians is that graph that shows hospital compensation over the course of the past 20 years is like this. If I'm running a hospital and my cost goes up by 1.5%, automatic Medicare goes up by 1.5% in their compensation. But if you look at that physician line, it's flat. Our costs can go up 30% like they did and our payment goes up 6%. You know, 20 some percent short. It's actually more than that. It's about a 30% difference.

We would love to be treated like hospitals when it comes to compensation for the work that we do. We were pretty close at the end of last year. There was a bill, it was going to tie this to the Medicare economic index that basically looked at what it cost and then tries to keep up the compensation with that. Of course, it wasn't a perfect formula. I think it was like 10% of what the cost does will compensate you for. But at least it was a step in the right direction. And then that disappears.

Legislative Impacts: Medicaid and Student Loans

And our consolation prize is a one time 2.5% increase in the conversion factor as a result of a stipulation in the federal legislation from this summer, the one big beautiful bill. I'm bringing that up now, first of all because it's directly related to that topic you were saying. But also I was thinking about this already, Bobby, as you were talking about Medicaid, and of course that's a fundamental aspect of that legislation. I was curious, and I probably should have researched this in preparing to talk to you tonight, but where is the AMA's official stance on that legislation and the various consequences of it? Is there one?

Absolutely. There's so many details in it that it's not the kind of thing we would say, "This whole thing is terrible." But there are certainly components of it, and that's what we talk about. Medicaid is one of the critical ones. The fact that, you know, my personal opinion is that for what we spend on healthcare in this country—almost $5 trillion a year, more than anybody else on this planet—to not be able to take care of somebody that comes into my office with a stage one cancer because they lose their insurance, because they don't have a job, can't find a job, even if they're just not looking for a job, and now they're going to die of their cancer? Despite the fact that we spend $5 trillion a year, to me, that's just wrong.

When up to almost 12 million people, based on the prediction of what's going to happen in the aftermath of this Medicaid restructuring... that's going to be bad. I don't want to see that in my country. The American Medical Association doesn't want to see that.

Then there's other things in that "big, beautiful bill" piece that talks about student loans. The fact that now student loans will be capped, the ones that they usually get from the federal government, at $200,000. You find me a med school where your debt after four years of medical school is going to be 200,000 or less. That's like finding... what do they say about that? Finding a diamond in a haystack or something like that? I don't know. There's some saying I remember.

I always also get all the American expressions wrong. Needle in a haystack, diamond in the rough. You guys have that in common. Among many other things.

We're going to get to the topic of why that's happening to me, and it has something to do with what was missing from in here. But yeah, everything from Medicaid to student loans being capped off at a fraction of what it actually costs. If you go to a private medical school, you're graduating with $350,000 in debt. And what is that going to do for the brilliant young person from Flint, Michigan, where I live right now, that wants to go to medical school? They get into medical school, but they don't come from a lot of money, and therefore they only get loans that cover a half at best of their tuition. They're going to be like, "I can't do that," and they're not going to go into it. Flint suffers. They suffer. And that's just wrong.

I'm glad you called that out, Bobby, because that piece of it really gets lost in the shuffle. It's a huge bill obviously, like many of them are, lots of far-reaching effects, even effects on things that were not even directly mentioned in the bill like the Medicare program, which if Congress doesn't intervene will also be cut as a result of the increasing deficit that comes from the core part of that bill. Medicare is cut as a consequence of that, which we've covered in some detail in a two-part episode series by the way, from earlier this summer with Eric Bricker. We spoke to him twice right before the law was passed but it was already clear what was going to be in it. So I would direct listeners back to that for more detail on that bill.

Site Neutrality and Payment Parity

Where would you like to go next, gentlemen? Maybe a little thoughts from the AMA about site neutrality? That there are different payments for private practices or physician offices versus hospitals. What's the AMA's stance on that?

Yeah, that's not right. So I'm in private practice. If I patch somebody's eardrum in my office, let's say that compensates 200 bucks. If I sell my practice to a hospital system, to the university, and the name and the sign on top of the building changes to "Bobby Mukkamala Otolaryngologist to University Otolaryngologist," now what I would have collected 200 bucks for, for that procedure I did in my office, I'll get 300 bucks. The site of service differential.

And what does that do? Private practice is difficult as it is. When I mentioned my parents, they were in private practice when they got here at the age of 25. They finished their residency, they set up their private practices in radiology and pediatrics. They loved it. It was fantastic. My mom would work so hard. She'd see 40 patients a day and come back when it's dark already, finish dinner for us and then sit and do her charting. And it never fazed her. She loved it because she was in control of everything and the system supported her.

Now, total opposite. We see somebody in that situation and they're on the verge of burning out. At the age of 55, 60, they're like, "I can't do this anymore. This is just terrible." And so what do they do? They either quit early or they're like, "Who wants to take over my practice? Who wants to put their sign over my name?" And then they sell to an entity like that. Those groups love it because they're going to generate income, they're going to make money by doing that. And the physician community suffers.

So that's why I think the site of service differential is a real punch in the gut. But the solution for that, I don't like the idea of robbing from Peter to pay Paul. Paul should live the same life as Peter, not stealing from one to give to the other. And so that's what I would say is that, look, there is a cost to taking care of patients and it's high in a hospital system, it's high at a university system, it's high in my practice. Compensate us all equally. Bring us to where they are. That's a step in the right direction. Not bringing these folks down to get these folks to meet somewhere in between. But both of them are not getting what they should. So, yeah, site of service differential is a big problem. Getting to the right solution is a big focus of the American Medical Association.

And for our listeners, what Bobby's referring to with robbing Peter to pay Paul is in the new proposed rule. They're looking to cut the indirect expenses that a physician who practices in a hospital setting gets, saying they're double-dipping because the indirect expenses are going both to the hospital and the physician. So they're trying to cut that, saying that they're going to use that to promote just physician practice. But that is the essence of robbing Peter to pay Paul.

I'd say one of the other things you brought up that was very interesting about this site neutrality is not only does it affect physicians, it affects patients tremendously. Because if there's two different payments or charges if you get care in a hospital versus in a freestanding setting or physician office, oftentimes the insurance companies won't want to allow patients to go to the one that is more expensive. And so that decreases access for the patients to go to someplace that's near their house to get a PET scan or any other radiology exam or radiation treatment or surgery. So having a single unified payment, I think would make more sense and allow patients to not suffer like that.

Absolutely. And, you know, it takes me to the overall observation of the complicated nature of healthcare in this country. So I go to the World Medical Association. I represent our country at the World Medical Association. And when I look at some of the simplicity that exists, I get jealous. The fact that I got 15 icons on my computer and those guys have one, I'm like, "Oh, my gosh, that's freaking awesome." And yet that's exactly what you describe is the complicated, unnecessarily complicated nature of how we do the math and what our care that we give our patients deserves. How does it get calculated? It's just unnecessarily complicated.

Bobby, what do you think about the counterpoint from hospitals? And perhaps there isn't actually necessarily that much space between what you're saying and what they're saying, that the facilities, the hospitals and hospital outpatient departments in particular, handle sicker patients, perhaps a higher portion of underserved patients, and that they're being able to achieve a higher level of reimbursement is ultimately supporting the local economy, reinvested to some extent. And that we all know what the ideal would be, but we also know what the practical reality is going to be. That quote, unquote, "neutralizing payments" is probably going to result in less and less cost for the government, which their cost is, of course, revenue for the facility. So what do you think about that counterargument?

I don't think it's a very good counterargument at all. I think that rewinding this tape to the 90s, when I was in medical school and the University of Michigan had the one hospital in Ann Arbor, and it was the place where people went when they had tough cases. And it was a challenging thing. In just the office visit, the procedures, I mean, it was going to just take a long time and they're taking care of it. It's a tertiary care center then. I understand that logic.

But when systems like that are acquiring hospitals in my suburb of Flint, Michigan, and the name on the thing changes, but nothing else does... that's not tertiary care. That's taking out tonsils in the kids in Flint, Michigan, just like I do. And all of a sudden that's just totally unjustifiable. And that's not unique to Michigan. That's all over the country that happens. I've got colleagues who are in a wonderful multi-partner private practice whose partners are slowly getting brought into the university hospital that happens to be down the road.

And this is, again, it kind of goes back to some of the math when a hospital can tell you when you're employed by them: "If you order this blood test, if you order this scan, if you do this procedure, it's gotta be at one of our buildings." And so that's why they can compensate better because they're making a lot more by keeping it in their system. That has nothing to do with tertiary care. Absolutely nothing. This is just a calculation that says we will have a better bottom line if we do it this way. And that's just wrong. And so that's why I think that getting compensated more for taking care of the sickest among us doesn't apply anymore.

Sure. Amar, if I could just make a connection between something Bobby was just saying and what you were talking about previously. It's interesting to me, over the time of doing this podcast, more and more laypeople are listening. I know because they're contacting me, asking me questions, perhaps same thing for you, Amar. So I want to call this out. What the hospital outpatient departments can do and regularly do is charge something completely on top of the regular fees for the medical care. That is what is called in the business, a "facility fee."

This is an extra charge that in many cases will come out of the patient's pocket. To tie it back to what you were talking about, what CMS is saying is that CMS believes it is in a way double paying. That in one component of reimbursement for the professional services related to practice expense they're paying there, and they're paying on top for a facility fee. And what they want to do is stop paying both. So I just wanted to make that connection. That's a fundamental piece of the proposed rule, as Amar said. If you guys have any further comment about that, I'll give you the floor.

Again, I think there's a way to look at that from their perspective. And they say, "We're paying for this, and we're paying for that." Assuming that they're both the same thing again, and it's not. When you look at the hospital, they're the ones that cover the cleaning and the cleansing and the overnight sort of prep of this facility. And then there's the doctor that uses that facility. And they're not the ones that are responsible for making sure that everything's sterile. It's a different responsibility that it comes to.

I think that the government's perspective, when they look at this, is one perspective: "What can we cut?" And that is north on their compass. And it has nothing to do with why it is the way that it is. Come and talk to us. Let us show you. Don't just assume you know what it is in Washington, D.C.

Prior Authorization Reform

Thanks, Bobby. And I wanted to bring us back to what you brought up in the beginning of this episode around prior authorization. As you said, it's a burden. It affects patients, it affects physicians. We were commiserating about it in the beginning. But it ultimately affects outcomes and survival for some of these cancer patients. There's a lot of statistics showing that. I'm wondering, what is the AMA specifically doing around prior authorization, whether it's through legislative efforts or other such efforts? I'd be curious to know what is the actual advocacy happening around that.

It's a great question. And I guess I'll say we do a lot. Where I am, we have two big insurance companies and maybe a dozen other ones that have a little bit less market share. What they do is unique to my state. Blue Cross Blue Shield in Michigan, it's going to be different than what your Blue Cross Blue Shield does. So the AMA helps the states deal with this at the state level.

Here in Michigan, we had something that was called Health Can't Wait. This was a proposal to change the laws around prior authorization that basically says: look, if I request something about the larynx cancer that I'd like to treat, if you're going to deny the scan that I order, you better be an otolaryngologist also. Not a nurse practitioner that works in a psychologist's or psychiatrist's office. That's just wrong. But yet there was no law that prevented that. And that's exactly what would happen.

So now if it gets denied, it needs to be somebody with my training. That's the kind of thing that the American Medical Association supports, what we call kind of "right-sizing" prior authorization. And then we want that to be something that is open for us to look at year after year. Meaning, what percentage of things require prior authorization? What percentage of them got approved? And if that number is 99 out of 100, then why do you have it?

Right now, if that data is not available, how can we make that argument? So that's what the American Medical Association does, is it tries to right-size prior authorization, make it transparent.

Then also, there's things that are federal. The same thing applies there. And now with Medicare Advantage. Don't even get me started on that.

Medicare Advantage Concerns

You read my mind, Bobby. Every time I turn on my TV there's a Medicare Advantage advertisement. I take a lunch break every day, I come home because I live seven minutes from my office. I turn on the news, boom, every 15 minutes, "Sign up for our Medicare Advantage plan." And that's going to be a big-time prior authorization problem.

It's a big-time prior authorization problem. And I wanted to really take a broader view of the whole thing because, as I've come to understand from talking to people locally here but also around the country, Medicare Advantage, more than perhaps other payer types, has been the most aggressive at what people call "slow pay and no pay" for authorized care. So care that they have prior authorized, they are then not paying various hospital systems and others. We calculate payer yield, right? So you look at payer X, all the care that they've approved, what are they actually paying and when? And I think that's a segment that really leads the way in both these areas. Is the AMA thinking about that, taking a position on that?

Absolutely. This is exactly what we want to shine a bright light on, right? Because this is just not good for the healthcare of our country. To require prior authorization is one thing. It's a bigger sin to say "yeah, you can do this" and then not get compensated for it. That's ridiculous.

So this is exactly what we point out when we talk about what CMS needs to do about what they kind of created, and have more scrutiny of those programs that are getting paid 130% of what Medicare used to pay. Use that 30% to manage this program to improve the quality of care, but meanwhile, not even pay for the things that were authorized? That's not ethical. That's just wrong.

This is exactly what the AMA points out: to shine a bright light on that kind of behavior, to correct that. Because the idea that... I was just shocked when I heard that these advertisements that I see, that when somebody signs up, the company that does the advertising gets paid 700 bucks. When somebody sees that commercial, calls that number and says, "Yep, I'm going to sign up for your plan," that's all a sales pitch. That's not about improving the quality of care. That's like getting them to sign up with my company instead of that company. That's just wrong.

Bobby, you got me thinking also about a previous episode we did with Tricia Neuman, who is an executive with KFF, formerly known as Kaiser Family Foundation. And what we talked about in that episode is that if all the seniors who are currently covered by MA plans were instead in traditional Medicare, that the total cost to the healthcare system would be about 85 billion less. I just wanted to call that out. It's pretty incredible what we're spending for what we're getting.

And the theory is that they're going to save 85 billion more than that by putting them in this kind of program. And that's just wrong. The way they save is by cheating, by saying that, "Sure, you did this neck dissection and we did give it prior authorization, but we changed our mind."

That's right. And unfortunately, the people who go on those programs, because the premiums—they entice them with these lower premiums—oftentimes are struggling with socioeconomic status or they're in rural areas or they're single mothers. These are the people who are going on these MA programs, which is creating almost a two-tiered healthcare system, which is horrible.

Yeah, that and the commercial is what gets them in. "Oh man, I can get free hearing aids when I sign up for this. I can't get that with regular Medicare." Boom. They call and they join. And then God forbid they need a PET scan and they're waiting an extra three weeks to get the scan because they got this lump in their neck and they're freaking out. They would gladly get rid of their hearing aid to get this lump taken care of faster. But how can they do that at that point?

Bobby, do you have your own personal library of all the appeal letters you've written to commercial insurance, especially including Medicare Advantage? Because I do. It's about 60 letters at this point over my post-residency career.

Absolutely, I figured you probably would.

Workforce Shortages and Team-Based Care

I was thinking maybe we can tie this to the next segment which is that a lot of this prior authorization creates a lot of administrative burden. Especially for primary care physicians who are struggling. They're seeing all these patients back to back and then to deal with this is tough, and some of them are leaving the workforce. And so we're also seeing a little bit of a physician shortage out there. I was wondering if maybe you could talk a little bit about workforce issues, physician shortage, and what do you feel about those who say maybe we'll just recruit more PAs and NPs, other physician extenders, to fill that gap.

There's a big problem in our country, the fact that we are going to be 80-some thousand physicians short within the next decade and more than that as time goes on. We live with chronic disease that we never used to live with. It used to be that people with metastatic breast cancer had months, and we're going to say goodbye. Not anymore. They survive indefinitely, which is a wonderful thing. But what does that mean? It's going to be tougher to care for patients like that. There's a lot that needs to be done.

When we have a physician shortage and our solution in some states is to basically say, "You know what, we're short on doctors, the nurse practitioners look like they have enough training, let's go ahead and have them be able to practice independently," that's not good for the direction we're going.

I tend to do this a lot and I'll share a story with you, and that is that I don't like saying that we should do something without having tried and explored it myself. So when I became the chair of the Task Force on Substance Use Disorder and Pain Care, I decided I'm going to get my X waiver to see what it's like to be able to prescribe buprenorphine for somebody that has a substance use disorder. When the AMA realized that here's an ENT guy that got his X waiver, that sounds like a perfect way to chair this work group by having somebody that is broadening their education.

So I did the same thing when it comes to scope of practice. I signed up to be a nurse practitioner on my computer, and literally within 24 hours, my email is blowing up from schools that are asking me to come and sign up to go to nurse practitioner school in their program. Like I got 10 of them within 24 hours.

I printed them, I put them in my slideshow. And what they all say is that you can do all of this online. I could be sitting in this chair for 18 months doing all of it on this computer. And then I figure out a way to get 600 hours out there with some doctor that will train me for 600 hours, and then I'll become a nurse practitioner and I can go to 20-some states and be a doctor.

That is not a solution for the shortage that we have. The solution is twofold. I think one is to do better on the burnout. When people retire when they're 55 or 60 instead of 75 or 80 like my parents' generation, that's making this problem worse. So prevent us from burning out. Help us. What do they say in that movie with Tom Cruise? Jerry Maguire. "Help me to help you." I'd be Jerry Maguire if I was in Washington D.C. right now. Help me to help you. And that's by preventing me from burning out.

Then we have the narrow part of that funnel where medical students have to find a residency program, which has pretty much been frozen since the 90s. So we have not as many people getting in as we need, and we have too many people getting out for these burnout factors. And that's just a recipe for failure when they're being replaced by people that have 600 hours of training instead of 10,000 hours of training. These are the things that the American Medical Association is super vocal about and working hard to sort of convince people of the right way to go and the right direction to go because it's important for the health of our country.

Those are all great points. And I just wanted to also mention that I think APPs, as we call them—nurse practitioners, physician assistants—have an important role to play in providing care. Absolutely. But I agree completely with the AMA's position that independent practice with no physician oversight is exactly what you're highlighting there, Bobby. We need team-based care.

Exactly. We need team-based care. I can take care of more patients where there's an ENT shortage in Flint, Michigan, if I have nurse practitioners working with me to see the routine things. And if there's any question, I'm right there to be able to say, "You know what, let me come in there and take a look and decide whether or not this lump is normal post-op, or is there some residual tumor?" That's the kind of thing that I need to be involved in.

International Medical Graduates

Where do foreign trained physicians fit in in terms of making it easier or not for them to fill the gap?

It's a huge thing. I mean, that's exactly how my parents, at the age of 25, ended up in this town for their residency. We had a huge physician shortage and this country welcomed them at that time. And now it ain't so easy. There's a lot of challenges to that, but it's still a critical component of it.

Right now there's a pending bill, I think there's 14,000 unused visas for physicians that are trained internationally that can come to this country. Our bill that we're supporting seeks to allow that to happen so that international medical graduates can come and help us with our physician shortage. So that's something that we're excited about, but that's exactly one of the components of the solution to this problem of a physician shortage.

And for our listeners, I think there's a great book by Abraham Verghese—actually he is the one that got me interested in medical school, my own country—that kind of highlights the foreign medical graduates first coming here during that timeframe and treating during the AIDS epidemic. So, yeah, great book.

Yep, absolutely. He spoke to us at the American Medical Association meeting and gave just a wonderful perspective to healthcare in this country and where it was and where it should go.

Preventive Care and Lifestyle Medicine

Bobby, as we cover a lot of topics that we wanted to hit on, perhaps we're getting close to ticking them all off. I know that preventive care and health equity are big priorities for you personally and also for the AMA. Any comments you'd like to add about what you have currently in the hopper on that?

Yeah, for sure. When I go across the world for the World Medical Association meetings and I think about where we are and where I would like us to be... I want to see us live longer, not with disease, but without disease. It's great that people with metastatic cancer can live longer. That is awesome. That is wonderful. But how about the prevention of something like that?

How about not just seeing billboards around every town in this country that say, "If you have a stroke, come to our place, we got a gold star in managing a stroke"? We will never see a billboard that says, "Do you have stage one hypertension? Come in to see us so we can help you make sure that it doesn't turn into a stroke, that it doesn't turn into a heart attack." This is a failure of our country and I would love to see us change that direction.

I have this funny story to tell. I took my lifestyle medicine boards. It was something that I was planning for. This was just last year in 2024. And you know how we are when we're busy, we kick the can down the road: "Okay, I got this, I got this program. I'll study, I'll study, I'll study." Well, this test comes up in the second of the last week in November. The problem was, literally a week before I was going to the testing center to go take this, I got diagnosed with brain cancer.

I was like, "Oh, man." There's so much going on in my mind. But one of them was, I got this test on Saturday. Am I going to take this exam after I get diagnosed with this thing? And I thought, "You know what? If I fail this exam, I've got the best excuse on the planet for failing an exam. And if I pass it, it's a freaking miracle." So I was like, I got nothing to lose.

So I go and take this exam. It's a lifestyle medicine boards, and I passed. I was just excited to be able to focus on the prevention of disease. And it's just basic things. When you look at it, it's not trying to figure out what do I do with this patient that had a stroke, where do I need to put this catheter, what sort of blood thinner do I use. That's complicated. It's critical. But when you look at the simplicity of preventing that stroke, relative to the complicated nature of what do you do after somebody has a stroke, this is amazing.

It's the simple things like a plant-based diet. There's a lot of data to show that a plant-based diet is better for you. Getting seven hours of sleep. Minimizing alcohol and not smoking. Social interaction. These are all things that are the principles of lifestyle medicine. And I was amazed at how new this was for me. But I think it's a wonderful direction to at least explore and train ourselves so we can keep people out of the hospital so they don't need as many billboards that say, "If you had a stroke or a heart attack, call us," because we're preventing that.

I don't think that's going to be an immediate thing. This is an investment in prevention so that over time, we don't have as many sick people and we're not spending as much on healthcare—which is more than anybody on the planet, again—because we're preventing disease. And honestly, that's what I think might be interesting to somebody like our HHS secretary, who I think is also very interested in disease prevention. How we do that, we might have some differences of opinion, but the overall principle of keeping people healthy... whether that's avoiding food colorings and stuff that's bad in food to getting good exercise.

I would love to talk to him about the fact that here I am in Flint, Michigan. If I wanted to go to a park right now to just burn some calories from my dinner, I'd worry about being shot. That's the reality. And so how do we help a community like this make America healthy again? That's the kind of thing I'd love to work on.

Navigating a Brain Tumor Diagnosis

And, Bobby, you talked a little bit about this test that you undertook. I don't know if you want to tell our listeners about how that took you on a personal journey through the healthcare system yourself.

Yeah. I was giving a speech at the American Medical Association as its president-elect last year in November. And in the middle of the speech, all the words got goofy. I thought my iPad had sort of put me on the wrong page. As I was looking, that was at least what I thought happened. And the audience who's heard me speak for a decade or more now was like, "Dude, you just had a stroke." And I'm like, "I don't think so. I think my iPad was not working." I was like, "No, you weren't making any sense."

And of course, then immediately, we were in Orlando. They call my wife, we go to the emergency department, and they're like, "You know, we don't see anything that looks like a stroke. Maybe it was a TIA. When you get home, go see somebody about that." So I finished there, and I didn't have any other issues. But I got home Tuesday night. I ended up getting an MRI scan at a colleague of mine who's a neurosurgeon at his office. He's got a scanner.

It was funny because the tech that was getting the scan, it was like 9 PM and it was just me and this tech. Then as we were going through the images, as you guys do, all of a sudden it showed a deviated septum. And she was like, "Oh, your nose is a little crooked." And then boom, we get back here and there's an 8-centimeter tumor in the medial aspect of my left temporal lobe. I was like, "Nose is crooked, but that ain't my problem. I got a big tumor in there."

So that's where it all began. And then of course, the next weekend, I take my lifestyle medicine boards. My parents flew home from India, kids came home immediately. Long story short, three weeks later, I go to the Mayo Clinic in Rochester and I get a 13-hour awake craniotomy and tumor removal. They got 90% of it out. Ended up being a grade two astrocytoma, which if you Google it, says about a 10-year survival rate, but I predict it'll be longer because there's new stuff available.

There's so many stories to tell about this, but one quick one I'll mention, if you don't mind. So I get diagnosed with this grade two astrocytoma. Usually I would get radiation and chemo. You'd be talking to a bald guy right now. But this is real. This ain't a wig. And the reason for that is that I got this pill that was just approved in August of this past year, when I got my diagnosis in November, after more than a decade of research. This is a pill that can prevent the growth and maybe even shrink this grade two astrocytoma. And it was only possible because of NIH funding to the labs and the researchers that did this.

All of a sudden, after taking this pill, starting in December, in January we find out that NIH funding is going to be dramatically cut based on the new administration's opinion on having to supplement the private industry's research and not having the government do that anymore.

I think that somebody up there had a plan that basically said: "Look, you're going to be president of the AMA. You've got all the education to have that position. But I'm going to push you a little bit harder. I'm going to give you a brain cancer. I'm not going to kill you. I'm going to keep you alive. But it's going to help inform the things that you talk about to improve healthcare." And I think it's been wonderful preparation. I'm glad to be alive.

And we're so happy that you're doing well. And what a great story and such an inspiration to use your personal story to fight for the NIH funding, which, as you personally know, is so critical to all our patients. So thank you for that.

No, thanks. You know, NIH funding is just one component of it. But physician shortage, my ability to find a neurosurgeon... I can go to Mayo Clinic. My neighbors on either side of me in Flint, they can't do that. We would love to have more neurosurgeons around the country to be able to deal with this. The prior authorization... I got my MRI scan because I could. What if I was waiting another three weeks to get a prior authorization? I mean, everything that we've talked about, I had to experience as a patient. And I think, again, that's wonderful preparation to be able to talk about it from a personal perspective.

Conclusion

Bobby, I'm struck by you giving these other examples, if I be so bold as to call them more mundane examples, of you deciding to experience yourself the things that you were getting into. You learned a lot of things from that. You mentioned getting the approval to prescribe buprenorphine, the X waiver. And signing up for NP school. And then all the way to, of course, you didn't sign up for it, but the experience of requiring cancer care... you really are a voice of somebody who can speak to really the realities of the American healthcare system like really few other people can. And so we, of course, knew about this in getting to know you before coming on. And we just really can't thank you enough for sharing these experiences with us.

No, thank you. Because, you know, when it's going on in here and you're thinking something that's useful, but when we can have the conversation so other people can hear it and perhaps even be convinced about the merits of trying to do what we are trying to do, that's where my experience and what I went through is so much more useful. So thanks for this opportunity.

Thank you.

You're welcome.

And one thing, Amar, before closing, I want to call out is for those who are listening who are going to be at the ASTRO annual meeting, you're going to have a chance to listen to Bobby again.

Yeah, that's right. Yep, I'm going to be speaking there. So if I start telling a story that those of you that hear it here are hearing again, don't hesitate to take a nap.

We'll pretend like we're hearing it for the first time, Bobby. As we wrap up, thinking, Bobby, maybe you could just leave us with some parting words about either physician advocacy, the future of the AMA, or anything else you want to leave our viewers and listeners with.

Thanks, Amar. I think that's a wonderful point. You know, I have a slide I present to medical students. I just did it the other day because Michigan State University has M3 and M4 students here right down the street. And I'm going out to dinner with them again tomorrow because they enjoyed it so much. But one of those slides was the goal of leaving things better than I found it.

I have a picture of my kids, and it was the anniversary of 9/11, the first year anniversary, and it was the big American flag. And then my two little kids, the twins, were under it. And the title of the slide said, "Leave things better than we found it." That's the goal of the American Medical Association, to improve healthcare so that the next generation and the generation after that enjoys the wonderful consequences of the hard work that we do in organized medicine and at the American Medical Association, where I'm currently serving as president, to leave things better than we found it.

It's wonderful to have this conversation, to be able to just let others know what it is we think about how things should be left. So thank you, guys.

Thanks again.

Thank you, Bobby. We'll see you in San Francisco, Bobby.

Sounds good. Looking forward to it.