Creative solutions to physicians' time and pay dilemmas
By Robert B. Doherty
Ask internists about their greatest frustrations with medical practice, and you likely will hear a refrain that goes something like this:
"I am working harder than ever for less pay. Patients expect more of my time—time that I don't have and payers won't reimburse me for anyway."
The College is committed to developing creative solutions to fairly compensate internists for the time they spend with patients. Before we can propose solutions, however, we need to understand how changes in medical practice are straining internists' capacity to meet patients' needs.
Not enough time
A May 2003 report from the Center for Studying Health System Change, "So Much to Do, So Little Time: Physician Capacity Constraints, 1997-2001," lent support to ACP Members' anecdotal complaints.
The report, based on annual surveys of physicians conducted from 1997 through 2001, found that patients waited longer for appointments. It also found that physicians felt they did not spend enough time with patients.
While physicians said they spent more time overall in direct patient care—from 44.7 hours a week in 1997 to 46.6 hours a week in 2001—a growing number said that they didn't spend enough time with individual patients. In 1997, 28% of physicians disagreed with the statement, "I have adequate time to spend with my patients during office hours." In 2001, by comparison, 34% disagreed.
If doctors followed all government recommendations aimed at preventing disease and injury, they would spend more than seven hours a day meeting just those standards.
The report offered several explanations for the apparent contradiction. People are living longer with chronic illnesses that require more complex coordination with other caregivers. And with more diagnostic and treatment options available, physicians may be spending more time on patient care activities, but not on face-to-face visits.
The report also suggested that a growing list of recommended preventive services may be consuming much of the time primary care physicians spend with patients. The author cited one study that claimed following all the government recommendations aimed at preventing disease and injury would consume more than seven hours of a physician's day. "Physicians may be frustrated by having too much to discuss with their patients in too little time," the report concluded.
While the report did not categorize responses by specialty, internists are likely feeling frustrated about longer hours and inadequate time with patients as much as or more than other specialties.
Internists treat more patients with chronic diseases, and they rely on diagnostic and treatment alternatives that require coordination with other caregivers. As primary care physicians, internists are also expected to provide or arrange for the growing number of preventive services the government recommends.
The amount of time doctors spend with patients, however, is only half of the equation. Equally important is how much—or how little—they are being compensated for that time.
While accurate information on physician incomes is hard to come by, another study, also by the Center for Studying Health System Change, found that physicians' average net incomes fell by 5% between 1995 and 1999. Primary care physicians saw their incomes drop by 6.4%, while specialists took a 4% hit.
Part of the problem is that Medicare payments—a major component of the typical internist's practice revenue—continue to lag behind inflation. Because of Medicare's flawed formula for determining physician reimbursement, Medicare payments were lower in 2002 than in 1992.
Congress enacted legislation in March to avert another 4.4% cut for this year, but the outlook remains grim. The Centers for Medicare and Medicaid Services is projecting that Medicare payments are likely to be cut another 4.2% on Jan. 1, 2004, unless Congress acts before then to correct the flawed formula.
Developing solutions to the time and economic pressures that practicing internists face won't be easy. With record budget deficits and private health insurance premiums rising, it will be hard to persuade payers to pay more for the time internists spend with their patients.
The task may be difficult, but it is certainly not impossible. The solution lies in first understanding how medical practice is changing, then designing reimbursement and delivery systems to accommodate those changes.
None of the widely used payment methodologies work well for patients with chronic conditions. Traditional fee-for-service pays a set amount for each billable procedure or visit, rather than paying for the coordination and management of chronic diseases. Direct capitation pays the same amount per patient per month regardless of health status, placing physicians at financial risk if patients with chronic diseases require more services and time from their doctors.
One partial solution is to continue to improve the resource-based relative value scale (RBRVS). Medicare's RBRVS system is largely the result of the American Society of Internal Medicine's efforts in the late 1980s to persuade Congress to enact legislation to improve reimbursement for internists' cognitive services.
The RBRVS helped reduce payment disparities between nonprocedural and procedural cognitive services, but it remains grounded in an episodic, procedure-code, acute-care model of medical delivery. It is also subject to government budget-neutrality constraints and spending caps that have eroded many of the gains analysts expected the RBRVS system to produce.
We can develop new payment policies to reimburse for services that fall outside traditional office visits. A new College position paper on payment for e-mail consultations demonstrates how we can advocate for a reimbursement structure to pay for services that fall outside the traditional office visit.
Finally, we can develop entirely new ways to reimburse internists for their services. For instance, the College could develop reimbursement proposals to pay internists a set fee to manage certain chronic conditions. We could also explore linking payments to how well physicians meet accepted clinical performance measures, a concept that has considerable support in the payer community but is highly controversial among physicians.
ACP's Medical Services Committee is taking on the responsibility of exploring solutions to the time and reimbursement dilemmas facing internists. Just as we led the charge to enact the RBRVS in late 1980s and early 1990s, we now need to advocate for innovative reimbursement methodologies that meet consumers' demands for more accountability and greater management of chronic diseases. By doing so, internists can chart the path for a better economic future for internal medicine.
Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.
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