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Focusing the College's policy agenda on revitalization

From the September ACP Observer, copyright 2004 by the American College of Physicians.

By Robert B. Doherty

One of ACP's top priorities is revitalizing the practice of internal medicine. By revitalization, we mean addressing the reasons why practicing physicians are unhappy with the current state of internal medicine practice.

The move to revitalize internal medicine also intends to change those factors that discourage medical students from choosing internal medicine as a career. And the revitalization movement plans to keep internal medicine relevant and thriving in the fast-changing U.S. health care system.

There are no easy answers or simple solutions, but one thing is clear: To reinvigorate the specialty, the College must advocate for changes in public policies that affect internal medicine.

ACP's vision is that public policy and advocacy efforts can help revive the environment and attractiveness of internal medicine through reforms in two key areas: payment policy and the use of technology to improve internal medicine practice. Although I have written extensively about these issues in recent ACP Observer columns, it may be helpful to review how College efforts in both areas support ACP's larger revitalization agenda.

Fixing the payment system

Many internists today are working harder than ever but earning less. Physician payments are not keeping pace with costs, and the reimbursement system remains heavily weighted toward surgical and other procedural services.

That puts internists' average annual earnings far below many other specialties, with the low-paid office visit—not highly-compensated procedures—as their core unit of payment and service. At the same time, internists are doing more and more work outside the office visit itself, with telephone calls to nurses, home health agencies, and patients and their families, all to help manage patient care. Yet Medicare and other payers still refuse to reimburse physicians for many of those services.

As practice expenses continue to grow, driven to a large extent by the rules and paperwork requirements of third party payers and the government, is it any wonder that many practicing internists question how they can survive in the current financial environment? Or that medical students view the economic climate of internal medicine with a wary eye?

To address the adverse economics of internal medicine practice, the College is advocating for changes in the dysfunctional payment system. First, we worked to halt continued Medicare reimbursement cuts caused by the flawed sustainable growth rate (SGR) formula. Because of efforts made by ACP, the AMA and other organizations, we convinced Congress to block scheduled reimbursement cuts in 2003, 2004 and 2005.

These measures are only temporary, however, and unless Congress passes a permanent legislative solution to the physician payment formula, we can expect more cuts beginning in 2006. But even if the SGR is fixed, we will probably see small updates that at best will barely keep pace with costs. Without additional reforms that go beyond fixing the flawed SGR, most internal medicine practices will be left treading water, when they need a lifeboat to survive.

That's why ACP is leading a second reform effort: to increase Medicare payments for office visits and other evaluation and management (non-procedural) services. This June, the College convened a meeting of representatives from different specialty societies. Our goal was to devise a strategy for taking advantage of a provision in the Medicare law that requires the Center for Medicare and Medicaid Services (CMS) to review and update relative values every five years.

The next review cycle begins this fall, and revised relative values will be implemented in 2007. If the five-year review leads to increased relative values for office visits, internists will do better—but if relative values decrease, internists will lose ground. Under ACP's leadership, the participating specialties are now collecting evidence to persuade the CMS that a substantial increase is justified.

Third, ACP is committed to developing a bold and comprehensive plan of fundamental financial reforms. We have already started, for instance, to push for payment mechanisms that would reimburse physicians for leading chronic care teams of health care professionals.

And we want to make sure that physicians get paid for services that fall outside the traditional office visit. These reform initiatives are still being developed, but they are essential if we are going to revive internists' sense of control over their own practice and students' interest in internal medicine.

Promoting technology

It seems like everyone these days is touting the benefits of electronic medical records (EMRs). In the past year, government officials, lawmakers, private payers and large employers have all trumpeted the need for an interconnected information technology network that can improve patient care, cut costs and reduce medical errors.

But while everyone is apparently determined to make that vision a reality, most stakeholders unfortunately still ignore the practical reasons why many physicians have been slow to jump on the bandwagon.

As with any new tool, practical considerations will determine how fast information technology systems—including EMRs, electronic prescribing software and patient registries—will be adopted. How much will they cost, and what will their return on investment be? Will they work as intended, and how well will they fit into the regular workflow of a busy internal medicine practice? And will they add to or reduce the time spent on unproductive (and unreimbursed) tasks?

ACP believes that health information technology will have one of two major effects on internal medicine. It can help revitalize the specialty—as long as the technology improves quality and patient satisfaction, increases office productivity and efficiency, boosts office workflow, and cuts the time spent on office administration.

But if information technology becomes another unfunded regulatory mandate that piles more costs and hassles onto already overburdened practices, it will only increase internists' dissatisfaction and become another major barrier to revitalization efforts.

The College has taken a leadership role within medicine in advocating for public policies to overcome practical obstacles to technology adoption. We recently released a legislative proposal to provide direct financial incentives—in the form of loans, grants, tax credits and reimbursement increases—to internists who acquire essential health information technology The proposal is online.

We are also calling for the development and pilot-testing of industry standards. Along with the American Academy of Family Physicians, we co-chair the new Physician Electronic Health Record Coalition, a group of 14 medical societies working together to develop a strategy that will help make affordable electronic health records available to physicians. And we are supporting the development of a manufacturers' certification program to ensure that certified products meet essential quality standards.

Repairing the dysfunctional payment system and harnessing the benefits of health information technology represent important steps toward the College's overarching goal of revitalizing internal medicine. Success won't come overnight, and some of our gains will be incremental. But the College has a good grasp of the public policy changes that are required—as well as the knowledge, experience and commitment we need to get results.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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