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Governors discuss Medicare fees, expert panels, more

According to the meeting's keynote speaker, the push is on to help wire the nation's primary care physicians

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

Tucson, Ariz.—At its fall meeting, the Board of Governors approved a slate of resolutions on topics that ranged from ACP's legislative agenda to forming a panel of expert witnesses to advise College members in liability suits.

The Board also approved several recommendations related to residents, including the need for more flexibility in implementing new residency work hour rules. And the Governors spent time discussing how to move the nation's physicians to broader adoption of health care information technology.

Information technology 'payoff'

Leading that discussion was the meeting's keynote speaker, David J. Brailer, MD, PhD, the Health and Human Services' national coordinator for health information technology. Appointed earlier this year, Dr. Brailer is charged with getting the health care industry to accept and use electronic health records (EHRs).

He acknowledged both the pitfalls and promises of that mission and made it clear that information technology won't be able to drive significant improvements in patient safety and care quality unless the nation's primary care physicians are on board.

"The focus is on the primary care physician, because that is where the biggest value has payoff," Dr. Brailer told the Board. "It's the only way to incorporate prevention and the only place to get leverage."

In addition to reducing errors, he pointed out, information technology will make it possible to deliver more comprehensive care, via e-mail and telemedicine, to patients with chronic illnesses in rural areas. And technology will increasingly be a key factor in physician reimbursement, Dr. Brailer said.

(In support of that point, the Governors heard details of the Doctors Office Quality-Information Technology, or DOQ-IT, demonstration program. A pilot program being launched by the Centers for Medicare and Medicaid Services, DOQ-IT will track the use of information technology in reporting physician performance data.)

At the same time, Dr. Brailer detailed the many barriers to widespread information technology adoption, particularly in small practices.

Chief among those is money. Finding ways to level the playing field and mitigate the financial risk for small practices is his No. 1 goal for 2005, he said. Dr. Brailer is on record as saying that the government should consider offering funding mechanisms, including low-interest loans and higher Medicare reimbursement, to help physicians finance information systems. He told the Governors that the mean information technology investment for a clinic is about $30,000 per physician, a major reason why only 10% of the nation's physicians have EHRs.

Vendor problems, the lack of technical support and the challenges of incorporating information technology into practice workflow are other hurdles frustrating physicians.

"There is a 50% rate of failure," Dr. Brailer admitted. "Everyone knows someone who has tried and failed" to implement an EHR system.

For Janelle A. Rhyne, FACP, Governor for the North Carolina Chapter, the major obstacle is "interoperability," the ability of different systems to communicate seamlessly with one another when exchanging patient information. While her office has made the investment in technology, it does her and her colleagues little good when other providers aren't connected.

Dr. Brailer acknowledged that interoperability is a huge stumbling block and said he sees the government playing a key role in establishing those vital standards and connections. In a separate interview, he put the price tag for a national interoperable infrastructure at between $25 billion and $30 billion, a financial burden that "purchasers, buyers and government need to share."

Given these problems, the Governors asked, should doctors make the investment now? "The short answer is 'yes,' " Dr. Brailer replied, adding that physicians need to make an "incremental evolution" in moving to EHRs.

If physicians don't make that move, pointed out David N. Podell, FACP, Governor for the Connecticut Chapter, internal medicine may have more problems attracting young physicians.

"The majority of residents have a positive experience with computers, but they don't have them in their practices," Dr. Podell said. "There will be a backlash from the younger population if we don't get this going."

In other actions, the Governors approved 17 resolutions that now go to the Board of Regents for consideration. They included:

  • Care management fees. The Board approved a resolution asking the Regents to make passage of legislation like the Geriatric and Chronic Care Management Act of 2004 (S. 2593/H.R. 4689) the College's top legislative priority. If passed, the bill would authorize Medicare to pay for geriatric assessments and comprehensive care coordination under a physician's supervision. The bill would also provide better reimbursement for physician services in coordinating care for patients with complex or chronic illnesses.

  • Expert witness panel. The Governors approved a recommendation asking the Regents to establish a panel of medical experts to be available to College members facing liability suits.

    Kay M. Mitchell, FACP, Governor for the Florida Chapter, pointed out that organizations considering expert witness panels should proceed with caution. In her home state, she said, the Florida Medical Association's expert witness program ran into trouble when its panel challenged witnesses it deemed unqualified and was sued by some witnesses for defamation. "There needs to be quite a bit of study" before convening expert witness panels, she said.

  • Unbundling of preventive, problem-related office visits. The Board approved a resolution urging the Regents to work with the AMA and other medical societies to advocate for reimbursing physicians for preventive and problem-related office visit services without bundling payments.

    The resolution also calls on the Regents to work to modernize and simplify Current Procedural Terminology codes, and to press payers to not delay payment or require visit documentation for routine visits that feature both prevention and problem-related services.

  • Residency work hours. The Governors approved a resolution asking the Regents to promote greater flexibility for training programs in meeting new resident work hour rules.

    Governors pointed out that residents now feel they must stop working during a procedure to avoid violating the consecutive 24-hour-rule—a situation that could compromise patient care. The resolution asks the Regents to work with the Accreditation Council for Graduate Medical Education and the Residency Review Committee for Internal Medicine to refine work hour rules and develop practical strategies for meeting defined restrictions.

  • Insurance market monopolies. The Board approved a resolution asking the Regents to develop legislative policy to change antitrust laws to prevent market domination by one or only a few insurers. Such domination, the resolution claims, restricts patients' ability to choose insurers, increases health care costs and prevents physicians from negotiating fair payment for their services.

  • Associate and student representation. The Governors also passed a resolution asking the Regents to continue exploring ways to give chapters financial support so more Associate and student representatives can attend ACP's Leadership Day.

    In another resolution designed to help young physicians, the Governors asked the Regents to help develop and implement an electronic system for Associate and medical student members to submit abstracts to national competitions.

  • Maintenance of certification. The Governors approved a resolution backing discussions currently taking place between College leaders and the American Board of Internal Medicine on how recertification "can best evolve into a high value process." The resolution also calls on ACP leaders to give Governors and College members timely information about those discussions and to encourage member feedback.

    In another resolution related to member communication, the Board passed a resolution asking the Regents to post on the ACP Web site agendas for all Regents, Governors and ACP committee meetings. Members would be encouraged to send comments to their chapter Governor to be forwarded to committee vice chairs.

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