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CHICAGO -- The criminalization of medicine is taking its toll on physicians -- and not just those who perform abortions, members of the American Medical Association (AMA) House of Delegates said here Saturday during the AMA annual meeting.

"A doctor who can't get in trouble for malpractice because no patient has been harmed can end up in federal prison for 20-plus years, because they prescribed off-guidelines," said Stuart Gitlow, MD, MPH, MBA, of New York City, a delegate for the American Society of Addiction Medicine (ASAM). "This is unacceptable. It's been unacceptable for more than 2 decades now. And it's time for us to push back."

Gitlow was speaking at an AMA reference committee meeting in favor of a resolution introduced by ASAM that called for the AMA to "study the rapidly changing environment in which the practice of medicine has been criminalized" and how that is affecting medical practice. The resolution also sought a report back to the delegates by the AMA June 2024 annual meeting. ASAM's resolution was discussed in conjunction with a similar resolution from the New York delegation.

Gitlow noted that the Controlled Substances Act "requires that physicians who prescribe controlled substances do so by issuing the prescription for a legitimate medical purpose," but the Justice Department sees it differently from physicians. The department "has said on multiple indictments, that if somebody departs from guidelines, such as by prescribing a medication off-label, for instance, that they are then not acting in the usual course of professional practice, and therefore, they are subject to indictment," he said. "As a result, we have past presidents of three different state addiction societies, and multiple pain medicine societies, who are either under indictment, have been raided, or are in prison."

Monalisa Tailor, MD, of Louisville, Kentucky, speaking for the Kentucky delegation in support of the resolution, said that when gender-affirming care came up for discussion in the Kentucky legislature this year, "there were many terrible things said about the practice of medicine and physicians in my state. This is also applied to our abortion providers and our ob/gyns ... We're going to continue to see state legislatures propose these types of laws that suggest that the practice of medicine should be criminalized -- for us just taking care of our patients."

Criminalization also increases the likelihood of violence towards physicians "because it gives people the idea that we are doing something wrong," said Sean Figy, MD, of Omaha, Nebraska, who spoke on behalf of the Young Physicians Section and the Plastic Surgery Caucus. "And therefore, for some reason, it makes people think they can threaten us and threaten death for our families ... So I do think it's really important to help us figure out how we can make it better."

Delegates also discussed a report by the AMA Council on Ethical and Judicial Affairs (CEJA) on ethical principles for physicians involved in practices owned by private equity firms. The report recommended that physicians who contract with these companies make sure that the contract "minimizes conflict of interest" in the way doctors are paid and doesn't encourage undue restrictions on patient care, and that it also "does not compromise physicians' own financial well-being or ability to provide high-quality care."

In addition, the contract should "allow the physician to appropriately exercise professional judgment" and "enable physicians to participate in, if not outright control, decisions about practice staffing," the report said.

Several people spoke up in favor of the report. "As we know, there is a national trend to more and more practices being taken over by private equity, with the consequent pressure on the physicians to do things not in the best interest of the patients," said Tim Fagan, MD, alternative delegate from Arizona speaking on behalf of the PacWest delegation. "So the PacWest speaks strongly in support of this report."

But others complained the report didn't go far enough. "[The report] did discuss the requirement for physicians to maintain fiduciary responsibility, but does not discuss whether or not it is ethical for a corporation to take large profits out of healthcare," said former AMA president Barbara McAneny, MD, of Albuquerque, New Mexico, a delegate from the American Society of Clinical Oncology (ASCO) who was speaking for herself.

"Private equity companies are composed of wealthy people seeking to increase their wealth; they expect to exit their investment with returns of five to 10 times the investment. And that level of profit is not going to be generated by efficiencies of delivering care or by avoiding unnecessary care," said McAneny. "That money will come from somewhere -- and the only options are that that money comes from patients, physicians, and the taxpayers who support governmental programs." She urged the committee to "send this report back to CEJA and ask them to give us guidance on one of the more pressing issues of our time, which is whether or not private equity should be playing any role in profiteering in healthcare."

"This is a pretty toothless report," said Brett Coldiron, MD, an Ohio delegate from Cincinnati who spoke for the Great Lakes delegation in favor of sending the report back to CEJA. "Private equity has devastated dermatology and anesthesiology, and it's coming your way." When private equity-owned practices go broke, "they seize their accounts receivable and [the doctors] still have a non-compete," he added. "So it's a terrible situation and we need a better recommendation to work with."

The committee will consider the delegates' comments and then issue a report with its own recommendations, which the entire House of Delegates will vote on during its general session starting on Monday.

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