American College of Physicians: Internal Medicine — Doctors for Adults ®

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Are you ready for the new physician credentialing?

How new quality measures—not just the diplomas on your wall—will affect how you practice

From the March 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Edward Doyle

First it was board certification. Then, with the advent of managed care, it was economic credentialing. Most recently, it was mandatory recertification for new internists.

For physicians, the concepts of certification, credentialing and accreditation have been a growing part of professional life. Soon, however, the process of how physicians are measured, ranked and rated may be turned up a notch.

While education, training and board certification have been the traditional keys to success for American physicians, that may change in the not-so-distant future. How you perform on a growing number of quality measures—not the diplomas and degrees that hang on your wall—will soon have a real effect on your career.

Patients and health plans want to know that their physicians are competent today, not 20 years ago when they received their medical degree or last passed the boards. That's why several physician-led organizations are developing quality measures that take a close look at how clinicians put their knowledge into practice.

One of the newest—and most comprehensive—efforts is the AMA's American Medical Accreditation Program, better known as AMAP, which is still being pilot-tested. At its most basic level, AMAP will operate as a credentials verification organization (CVO) that will store all of a physician's credentials in one place. AMAP promises to relieve physicians of the burden of sending the same credentials to different health plans and hospitals. The idea is that whenever a hospital or health plan wants a particular physician's training and licensure credentials, it can ask AMAP. (Physicians will pay an annual fee of $75 to take part in the program, while health plans and other organizations will pay $250 per query.)

But AMAP adds another step: It requires physicians who want to become AMAP-accredited to take a self-assessment exam and open up their practice to outside auditors. As part of the site visit, on-site auditors will review other factors, from the disposal of infectious materials and after-hours coverage for patients to the staff's CPR training, explained Randolph Smoak Jr., MD, chair of the AMAP governing body and vice chair of AMA's board of trustees. Auditors will also review patient charts to make sure that records are complete and that appropriate referrals are made.

While AMAP portends to be the most comprehensive program to credential physicians, other organizations also are developing new ways to measure physicians. Last year, for example, the American Board of Internal Medicine (ABIM) created the Institute for Clinical Evaluation, known as ICE, to study proficiency testing for physicians. ICE is currently exploring the idea of working with the College to develop joint educational evaluation programs in areas like women's health and office dermatology; ICE would credential physicians who prove that they're competent in those areas.

And the American Society of Internal Medicine (ASIM) has created the Internal Medicine Center to Advance Research and Education (IMCARE) to help assess and improve the quality of care physicians offer. One IMCARE program, which is still being pilot-tested, will give physicians information about state-of-the-art treatment of patients with atrial fibrillation.

"Ultimately we would hope that internists could take this information and have a staff person collect some data," said ASIM's Executive Vice President Alan Nelson, FACP. "If physicians find that only 20% of their atrial fibrillation patients are on anticoagulants, then they know that they need to look at how they identify and bring patients into a treatment program."

Unlike AMAP, however, the ASIM program is not part of any formal credentialing process, so its results are forwarded only to the physicians themselves. In many ways, then, it is more like traditional educational offerings that physicians take for their own enrichment and not necessarily for credentialing purposes.

Increasingly, that model of physician education is changing. A good example is a three-year-old program from the American College of Cardiology (ACC) that administers a proficiency test for reading electrocardiograms. The exam is offered two or three times a year; takers go to a local exam center and are presented with about 50 ECG tracings and asked to list possible diagnoses. The ACC then sends test scores to anyone the physician chooses, or keeps them confidential if the physician requests.

Gaining an edge

How do physicians feel about the proliferation of so many new tests and measures? Certainly, clinicians already short of time are not anxious to take any new tests. On the other hand, many of these measures promise to give internists insight into the way they practice—and how they can do better.

There are also indications that if there is a competitive edge to be gained from a quality measure, some physicians will bite. Each one of ACC's ECG exams, for example, draws between 400 and 500 takers. Interestingly, the majority are not cardiologists, but general internists. ACC officials speculate that so many internists are showing up for their exams to get a leg up on the competition for reading ECGs, a procedure that pays well.

Leaders point out that there is a societal responsibility to get involved. "We have to be responsive and responsible with regard to what society needs from us," said ACP's Executive Vice President, Walter J. McDonald, FACP. "That's the whole key. If society says we need some indication that you are a good doctor, and they want it not 40 years ago or five years ago or two years ago, then our responsibility is to give that information to them."

Precisely because of that societal obligation, some leaders are concerned about the way physicians are being measured, particularly by AMAP. They wonder whether the AMA, which depends on its members to pay dues, will set standards that are rigorous enough to be taken seriously by health plans and the public. "If the standards don't have a certain amount of rigor, they're probably not worth much," Dr. McDonald said. "Physicians are already so busy. They shouldn't start jumping through a bunch of new hoops unless there is some meaning to it."

AMA's Dr. Smoak noted that the AMA is already involved in other areas of physician accreditation like its work in residency training, medical school curriculum and specialty board certification exams. Besides, he asked, who but physicians are better qualified to set the standards for other physicians?

Clearly, physicians need to be involved in setting standards, but some question to what degree. "It's important for the profession to be involved in helping set those standards," Dr. McDonald said, "but it has to be done in a fashion that minimizes conflicts of interest and keeps the standards meaningful." Ideally, he said, physicians should keep the whole measurement process "at arm's length."

Even as leaders worry about the legitimacy of some new measures, practicing physicians are likely to be even more concerned about what is done with information that is collected on them. As ASIM's Dr. Nelson said, most internists probably would like to know how they rate, but "they don't want to read about it in the newspaper."

This is likely to create tension between health plans, which want detailed information, and physicians. Dr. Nelson said that even with self-assessment tests like EMM-SAP, health plans pushed for details. "In negotiation with managed care plans, the first thing they said they wanted was the test scores," he said. "Our answer was 'No, this is an educational program.' "

The trick may be to nurture physicians' desire to improve their practices without penalizing those who are found to need help. But can medicine resist pressure from the public and health plans to provide detailed information?

For now, AMAP will only reveal whether physicians are accredited with AMAP and will not provide any details about scores on the in-office site visit. AMA's Dr. Smoak noted, however, that eventually more details might be provided.

The issue is far from settled, but, as Dr. Nelson said, "There's a balance between public accountability, which is a requirement of professionalism, and honest efforts to improve your performance. The one can become the enemy of the other if the accountability is not done with sensitivity to the legitimate desire for improvement."

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