Executive Director of the National Physicians Alliance in Washington, DC. E-mail: gro.ecnaillapn@naej.
Copyright © 2015 The Permanente JournalFounded in 2005 by General Surgeon Lydia J Vaias, MD, MPH, the National Physicians Alliance is a 501c3 public charity with a mission to create research and education programs that promote health and foster active engagement of physicians with their communities to achieve high-quality, affordable health care for all. The National Physicians Alliance offers a professional home to physicians across medical specialties who share a commitment to professional integrity and health justice. As the organization celebrates its tenth birthday, the history and scope of this mission-aligned group is described.
Founded in 2005 by General Surgeon Lydia J Vaias, MD, MPH, the National Physicians Alliance is a 501c3 public charity with a mission to create research and education programs that promote health and foster active engagement of physicians with their communities to achieve high-quality, affordable health care for all. The National Physicians Alliance offers a professional home to physicians across medical specialties who share a commitment to professional integrity and health justice. As the organization celebrates its tenth birthday, the history and scope of this mission-aligned group are described.
It is not a coincidence that the National Physicians Alliance (NPA)—a nonpartisan, multispecialty organization of physicians and others committed to social justice and health care reform—was founded by a surgeon from Kaiser Permanente (KP). To hear Lydia Vaias, MD, MPH talk about KP is to hear the linkages laid bare:
“What’s great about [KP] is its alignment. [KP] allows me to practice in a model where I can focus on the values of medicine instead of on money. I get paid to do the right thing for the patient. Years ago, the [KP] system was mocked. People were once embarrassed to say they worked there. It wasn’t until very recently that people have come to see [KP] as a leading light, delivering health care around a set of values.” (Lydia Vaias, MD, MPH, personal communication; 2015 Jan 29.) a
Ten years ago, Dr Vaias set out to organize physicians anew. “There are few physicians in this country who practice in settings that align the payors’, providers’, and hospitals’ incentives to keep patients at the center of care. I feel so lucky to be here at this time in history.” (Lydia Vaias, MD, MPH; personal communication; 2015 Jan 29.) a
National Physicians Alliance logo.
Dr Vaias wasn’t looking for me when she called my house back in 2005. She was looking for her old medical school buddy, my husband Ari Silver-Isenstadt, MD, MSEd, with whom she and a few others had organized 6 separate chapters of the American Medical Student Association (AMSA) about a decade earlier. In October 1993, student chapters from Hahnemann, Jefferson, the Medical College of Pennsylvania, the Philadelphia College of Osteopathic Medicine, the University of Pennsylvania, and Temple University joined forces as “Philadelphia AMSA” and delivered an unprecedented regional conference that laid the groundwork for generational change in medicine. They called the conference “Physician Activism: The Call Beyond Call.” Hugely ambitious, the program offered 5 to 6 concurrent tracks during 2 1/2 days and featured 75 speakers, including M Joycelyn Elders, MD, the US Surgeon General. Hoangmai Pham, then a 3rd-year student at Temple University and now Director of the Seamless Care Models Group at the Center for Medicare and Medicaid Innovation Center, served as Chair of the Programming Committee. The conference was a smash hit, drawing more than 600 registrants—and it did so without any pharmaceutical industry sponsorship or staff support. AMSA’s national president, David Evans, MD, set the event’s tone in the printed program’s welcome letter: “It is activism that rounds out our education … .”
Program from the October 1993 Philadelphia American Medical Student Association conference.
Philadelphia AMSA was the twinkle in the eye—the spark. Twelve years later, Dr Vaias was on the phone, bringing the band back together to launch the NPA.
I had helped with the conference too, although in 1993 I was not yet a medical student. At the University of Pennsylvania, I was a doctoral student, studying the history and sociology of medicine, specifically 19th century health reform movements. I explored social change efforts led by utopian radicals and feminists—progressive troublemakers who challenged the use of corsets and bloodletting, who touted exercise and bathing, who fought for women’s right to education and self-ownership.
Across campus, my husband and his medical school classmates got to know their cadavers, took countless exams, and learned their way around the wards. Their professors recycled the old adage: Fifty percent of what we will teach you is wrong; we just don’t know which 50%. The lecturers were playfully referring to the content of their slide sets—acknowledging dynamic scientific change—but they may as well have been referring to the curricular priorities themselves, the physical plant and workflow of the hospital, the food in the cafeteria, the nature of clinical communication, the financing of health care, the workforce … or even the 50% estimate.
Dr Vaias went on to become a general surgeon with a master’s degree in public health. She moved to Long Beach, CA, joined the KP system and, in 2005, was just beginning a three-year term on the Board of the Southern California Permanente Medical Group. My husband became a Baltimore-based general pediatrician and I went to medical school myself. It was organized medicine’s muted response to the Terri Schiavo case (a nationally debated legal struggle involving prolonged life support) 1 that led Dr Vaias to start rounding up past AMSA leaders. She was dismayed by the political grandstanding but even more so by the house of medicine, which seemed less engaged in repairing its own broken systems than in deepening ties with industry. Like many others, she saw the medical profession drifting from its core values. Patients were not at the heart of health care. I remember Ari and I were chopping stir-fry ingredients that spring evening ten years ago when Dr Vaias called with a characteristically modest proposal: “Let’s fix this.”
Meeting with lawmakers on Capital Hill, National Physicians Alliance members: (left to right)
Charu Sawhney, MD; Lydia Vaias, MD, MPH; Judy Zerzan, MD; Bethany Picker, MD; Marc Dalton, MD; Rupin Thakkar, MD; Stephen R Smith, MD, MPH; Jean Silver-Isenstadt, MD, PhD; Mara Merritt, MD; and Lenny Lesser, MD.
The NPA’s first official organizing effort took place at AMSA’s 55th convention in Washington, DC, where many past student leaders had gathered to honor Paul R Wright, the organization’s beloved Executive Director who was retiring after 30 years in the position. In a dedicated side room reserved for the discussion, approximately thirty former leaders of the organization agreed that the time had come to build a new professional home for physicians across specialties—an organization that would not function as a trade association, but rather as a community whose first concern was patients. It was something AMSA members had imagined building since their split from the American Medical Association (AMA) 38 years earlier. (AMSA had begun in 1950 as a student branch of the AMA but split off in 1967 after its parent organization had opposed the creation of Medicare and showed insufficient support for the civil rights and community health movements.) 2
The group pledged $20,000 in immediate support of NPA’s launch and scheduled a follow-up meeting at AMSA’s headquarters in Reston, VA. During the next year, an executive planning committee met for 2-hour phone calls every Friday afternoon. It was a monumental gift of volunteer energy from practicing physicians, all inspired by Dr Vaias’s mantra (with a hat-tip to Joan Baez): “The antidote to despair is action.”
It helped that the group included longtime friends with a shared organizational history. It also helped that they had taken different professional paths. Stephen S Cha, MD, MHS—currently the Chief Medical Officer for the Center on Medicaid and CHIP Services—had recently completed his internal medicine residency at Montefiore in New York and was a Robert Wood Johnson Foundation Clinical Scholar at Yale. David V Evans, MD—now an attending physician at the University of Washington—had for the previous decade practiced family medicine in the small rural town of Madras, OR. David Grande, MD, MPA—now an attending physician of internal medicine at the University of Pennsylvania—was a Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania; his policy research focused on the health of vulnerable populations. Kavita Patel, MD, MS—now Fellow and Managing Director at the Brookings Institution after two years at the White House and time on Capitol Hill—was working on health policy at the RAND Corporation. Alexa Oster, MD—now a Medical Epidemiologist in the Centers for Disease Control and Prevention’s Division of HIV/AIDS Prevention—was in the midst of her residency in primary care internal medicine at the University of California, San Francisco/San Francisco General Hospital. (I remember her often biking between clinical sites during our phone calls.) Stephen R Smith, MD, MPH—now retired from academia and practicing family medicine part-time at a community health center in New London, CT, was an Associate Dean at the Warren Alpert Medical School of Brown University when he joined the NPA’s founding executive committee.
After my own years in the medical archives studying the audacious work of 19th-century health reformers, I found myself unexpectedly surrounded by health reformers focused on the 21st century. But more than that, I found myself surrounded by something crystalline and rare: a group of brilliant people who were full of initiative but not full of ego—collaborative, funny, optimistic physicians who were singularly focused on making health care better for their patients. And they worked like demons.
Developing an organizational structure, finalizing a mission and bylaws, building a Web site, formally incorporating, and myriad other details involved lengthy discussion. But one decision was easy: the NPA would not accept funding from pharmaceutical or medical device companies. Out of the gate, this made NPA unique among medical organizations. Everywhere, financial conflict of interest was compromising medical research, education, and practice. 3 It was not only eroding patients’ trust in their physicians, but also eroding trust within the profession. Commitment to conflict-free leadership was an undisputed core value of the NPA; because it so clearly distinguished the organization from others, the “Unbranded Doctor Campaign” became our introductory calling card.
Through this advocacy campaign—an ally of the “No Free Lunch” movement and AMSA’s “PharmFree” efforts—NPA voiced loud concern over the scope and influence of pharmaceutical marketing tactics; supported full transparency regarding industry payments to physicians and medical institutions; challenged the AMA’s lucrative sale of personal Physician Masterfile records for industry data mining and the legitimacy of data mining itself; and called on physicians to take the reins and simply stop accepting industry largesse. These efforts all sought to ensure that medical education, research, and clinical decisions are guided by scientific evidence and not by marketing hype.
A different issue would have been an easier lift and surely a more enticing recruitment strategy—one that didn’t ask physicians to give up the comforts of free continuing medical education dinners at posh restaurants; coffee and donuts delivered right to the office by cheerful, healthy drug reps; generous speaking fees, etc—but the profession had grown complacent about these entanglements and therefore complicit in the marketing enterprise. This contamination of purpose had to be addressed. Just as the AMA was launching a $60 million new ad campaign depicting physicians as “everyday heroes,” the NPA’s Unbranded Doctor Campaign was pointing out the dirt under the rugs and the mold in the bathroom tiles. We were handing out buckets and mops by way of recruitment: join the NPA—help us clean our house. We knew the only way to restore trust in medicine would be to earn it.
Transparency about industry payments to physicians and hospitals is now mandated by the Sunshine Act section of the Affordable Care Act (ACA) 4 —a component of the law that the NPA fought hard to include and continues to defend. This year, NPA President William B Jordan, MD, MPH, was featured on CSPAN commenting on how far we’ve come but also on what still goes unreported, for example free medication samples that remain at the heart of marketing but are unmentioned in the ACA’s Sunshine Act provisions. These provisions require manufacturers of drugs, medical devices, and biologics that participate in US federal health care programs to report certain payments and items of value given to physicians and teaching hospitals for inclusion in a content management system database known as Open Payments. 5 The Open Payments Web site enables anyone to search physicians and institutions by name to learn the details of their financial relationships with industry. Thanks in many ways to the work of the NPA, it has become less comfortable for physicians to accept these payments, let alone make light of them. For the first time, researchers, journalists, policymakers, physicians, and patients are gaining access to alarming data about the magnitude and direction of industry cash flow in the system. It’s a necessary first step in opening up space for substantive reform.
This “pharma work” often set the NPA apart from other physician organizations, testifying on panels and working with consumer advocacy groups quite literally opposite our professional siblings who were defending the status quo. It was then that we could most clearly see the void we were filling: patients needed physician allies.
From the outset, NPA’s founders were determined to protect the organization from ever becoming a doctors’ lounge. The board of directors was structured to include nonphysicians to ensure that no discussions of patients’ best interests would take place without patients. Very naturally, the NPA found itself working in regular coalition with groups ranging from Community Catalyst and the National Center for Health Research to the National Committee to Preserve Social Security and Medicare and the Law Center to Prevent Gun Violence. The NPA board was proud to be the first physician organization to join the Health Care for America Now! coalition in support of the ACA’s passage—a coordinated effort of more than 1000 national and state-based groups dedicated to achieving federal health reform and defending Medicare and Medicaid. In 2014, the NPA was honored to have Consumer Reports host our 9th annual conference at their National Testing and Research Center in Yonkers, NY.
Logo for The Unbranded Doctor campaign.
Warm relationships with such allies encouraged NPA members—who valued not only the organization’s bridge-building instincts, but also the NPA’s willingness to step outside the profession’s usual comfort zones—to struggle publicly with medicine’s problems and to champion civic engagement.
I will never forget Gene Copello, MSW, MDiv, PhD, late co-chair of NPA’s Secure Health Care for All campaign, softly assuring other members of the NPA’s board back in 2008: “The NPA will succeed because it has to succeed. Patients need NPA to succeed.” The room fell silent with the weight of this charge. Dr Copello, whose doctorate had focused on medical ethics and public policy, was then serving as the Executive Director of the AIDS Institute. He died that year, unable to see the passage of the ACA 4 ; the NPA’s Copello Health Advocacy Fellowship was named in his memory.
It had become clear that if we wanted health reporters to interview physicians who voiced a different perspective from that of traditional guilds, we would have to provide advocacy, media, and communications training to physicians who viewed policy through the lens of its potential impact on patients. Becky Martin, NPA’s Director of Project Management and a seasoned community organizer, has for years connected NPA Fellows and other members to local opportunity and opened up relationships that fuel lasting change.
Advocacy, let alone “activism,” are terms rarely associated with white-coat professionalism. Yet our democratic society grants enormous social capital to the medical degree, and physicians are coming to understand advocacy skills as part of their responsibility to patients. The white coat itself may have more benefit for patients when worn at a public podium than when worn in the hospital.
The NPA’s immediate past president, James Scott, MD, discovered the organization at a 2009 health reform rally in Washington, DC, where NPA leaders David Evans, MD, and Valerie Arkoosh, MD, MPH, spoke boldly in support of federal health reform. Dr Scott had flown from Oregon to take part in the growing movement for quality, affordable health care for all. As he described it in a recent e-mail to me, “At a reception after the rally, I found real soul-mates—progressive doctors passionate about improving the system for everyone. I thought, after 40 years in medicine, I’ve found my people!” (James Scott, MD; personal communication; 2015 Jan 20) b
For many physicians, the opportunity to meet with elected officials and to speak to public audiences on behalf of a like-minded cohort became a reason to deepen involvement with the organization. For others, it was the opportunity to focus on individual practice reform.
Dr Smith was only half kidding when he first proposed the idea that NPA generate “Top 5” lists–à la David Letterman—to highlight “things doctors keep doing even though they know better.” The Board of Directors was having lunch and brainstorming.
A longtime leader of NPA’s work to reduce professional conflicts of interest, Dr Smith wanted to see physicians take more responsibility for their role as stewards of limited clinical resources. This would require acknowledging overtreatment and waste—calling out bad habits. What if NPA developed a “Top 5” list of evidence-based, quality-improving, resource-sparing activities that could be incorporated into the routine practice of primary care physicians in family medicine, internal medicine, and pediatrics? Under Dr Smith’s leadership, the idea quickly took shape as the NPA’s Good Stewardship Project, funded by the American Board of Internal Medicine Foundation. A mouse that roared, this modest initiative has since blossomed under the American Board of Internal Medicine Foundation’s direction into the celebrated Choosing Wisely campaign. Conceiving and piloting this culture-changing project has been one of the NPA’s most significant contributions. More than 60 specialty societies have since developed lists of “tests or procedures commonly used in their field, whose necessity should be questioned and discussed.” 6 Similar efforts are now happening abroad.
NPA’s Good Stewardship work challenged physicians to acknowledge and address prescribers’ responsibility for systemic waste and consequent patient harm. Organized medicine has begun to embrace stewardship as a core component of professionalism, and consumers have welcomed this awakening.
It was no trivial thing to shift the national conversation in this direction. The challenge now is to see these values broadly translated to practice. New and broad-ranging calls for price transparency and fairness are providing wind at the back of this push for high-value care. In short, as a nonprofit organization without a great deal of money, NPA has made a great deal of difference. With little more than stamina, purpose, and a value set that aligns the incentives of physicians with those of patients, the NPA has been able to make important contributions in a short period of time.
At ten years old, the NPA continues to attract physicians who understand that the future of US health care will be shaped by those who show up to shape it—and that working with patients, we now have a historic opportunity to put health at the heart of medicine. There are gains to be defended and new battles to engage.
Relatively recent areas of NPA focus also continue to build momentum, including the creation of NPA national taskforces on gun violence prevention and on the FDA’s drug and medical device approval processes—two areas brought to the fore during Cheryl Bettigole, MD, MPH’s, tenure as NPA President. Although these issues may at first seem to have little to do with one another or with past NPA efforts to expand access to high-quality health care, they are united by the influence of corporate lobbying.
The National Rifle Association’s lobbyists have choked off research funding for gun violence prevention 7 , 8 and have successfully backed state laws that forbid physicians from asking standard screening questions about gun ownership and storage. 9 Fracking companies have successfully backed the passage of state laws that require physicians to sign confidentiality agreements before learning what chemicals a sick patient may have been exposed to. 10 , 11 Drug companies continue to press the FDA to approve applications on the basis of surrogate endpoint data and mathematical modeling rather than requiring full clinical trials. 12 And far too many medical devices continue to reach the market without any clinical trials at all. 13 These are areas that cry out for more attention from organized medicine to ensure patient safety.
For our federal watchdog agencies, our clinical guidelines, our pharmacopeia, our educational resources, our state laws, and our individual clinical relationships to be grounded in trust and science, physicians and patients will have to claim more power in these debates.
It is fair to say that with my background in medicine and medical history, I never expected to become the Executive Director of a nonprofit organization. But I have always been drawn to visionaries. I had the good fortune to help unite this multispecialty band of serious idealists, this growing force for good. NPA’s presidents have included a surgeon, Dr Vaias; four family practice physicians—Drs Evans, Bettigole, Scott, and Jordan; and an obstetric anesthesiologist, Dr Arkoosh. Around the NPA conference table, consensus has always emerged quickly among family physicians, surgeons, pediatricians, internists, cardiologists, anesthesiologists, patient advocates, and more. We have found there is no fighting for turf when the fight is for patients. As Dr Vaias says, “The NPA reminds me why I got into medicine in the first place.”(Lydia Vaias, MD, MPH; personal communication; 2015 Apr 27) a
We have a vision for the next ten years: sparking a transformation of the medical profession that returns us to the core value of serving patients. We have seen this vision made real at places like KP, but we will continue to press on until it is the default setting for health care in our country. Join us in October in Washington, DC, as we launch our second decade at our annual meeting, themed Truth to Power: Alliance for the Public Good.
You may learn more about the NPA’s past and future work at www.npalliance.org.
a General Surgeon and Founder, the National Physicians Alliance; Washington, DC.
b Immediate Past President of the National Physicians Alliance; Washington, DC.
The true physician cannot remain outside the manifold of the events he observes.
— Alan Gregg, MD, 1890–1957, Associate Director of the Medical Education Division, Director of Medical Sciences Division and Vice President of the Rockefeller Foundation
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