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What makes medicine stronger: diversity or consensus?

From the July-August ACP Observer, copyright 2005 by the American College of Physicians.

By Robert B. Doherty

A common refrain among physicians is, "Wouldn't it be better if we all worked together?"—the "we" being the national and state medical societies that comprise what we call "organized medicine." It stands to reason that if ACP, the AMA, and all the other national, state, and county societies would just speak with one voice, then the medical profession's clout would be that much greater.

The fact is, of course, that medicine rarely presents a united front. Just in sheer numbers, more physician organizations now advocate for increasingly narrow areas of interest and expertise than ever before. The current AMA House of Delegates includes 120 different specialty societies and special interest groups, ranging from ACP—the largest medical specialty society—to much more specialized organizations like the American Roentgen Ray Society and scores of state medical society delegations.

Even that figure doesn't tell the whole story: Dozens of other specialty-based organizations, such as the Society of Hospital Medicine, don't have seats in the AMA House. While the AMA is still the only member organization that represents physicians from every specialty, the days when the AMA could claim to speak for everyone are long gone.

Real diversity

It isn't just numbers that makes consensus difficult. Just about every medical society has its own ideas, and none is shy about sharing them with the government, the press and other opinion leaders. Physicians' clinical and practice experiences are now so diverse that each specialty approaches policy and business issues from a different vantage point. How does the experience of a general surgeon working in a large urban multispecialty group compare to that of a solo practice family physician in a rural state? Or a pathologist's who never sees patients to a general internist's who does nothing but?

The problems with adopting one unified voice are glaringly apparent in the current debate on pay for performance. I am writing this column three days before the AMA House of Delegates convenes its annual meeting in Chicago, where pay for performance is sure to be this year's hot topic. As organizations express conflicting positions prior to the meeting, it seems clear that achieving consensus in the House of Delegates may be out of reach.

Pay for performance

At one end of the spectrum, organizations like ACP and the American Academy of Family Physicians (AAFP) are convinced the issues surrounding pay for performance are so important that medicine needs to be at the table with the federal government and large employers, wrestling with the issue. These groups are willing to work with the regulatory and business communities to design a pay-for-performance program that meets the needs of physicians and their patients, rather than reject the concept out-of-hand or present an unrealistic set of conditions.

At the spectrum's other end, some surgical specialty societies don't want any type of pay-for-performance program that goes beyond demonstration projects. At one recent meeting, for example, a representative from a surgical specialty argued that medicine should "just say no" to a Medicare-sponsored pay-for-performance program—even if that meant Congress would allow pending Medicare cuts to take effect. (As discussed in last month's "Washington Perspective," many members of Congress are unwilling to support relief from physician payment cuts unless it's linked to a Medicare pay-for-quality program.)

In the middle are many state and specialty societies that are only now beginning to develop policy on pay for performance, and aren't sure how best to proceed. They are looking to the AMA for leadership and direction—but the AMA itself must take its cue from a House of Delegates that seems deeply divided.

Different views of change

The different views being expressed aren't just a matter of deciding which tactic—engagement or confrontation—is more likely to bring about desired change.

Our differences also reflect our organizations' very diverse opinions on what needs to be changed. The surgical subspecialties most vehemently opposed to pay for performance claim there aren't good evidence-based measures for their specialties, so they'd inherently be disadvantaged under a Medicare pay-for-performance program. Not coincidentally, these subspecialties also tend to be highly compensated under the current Medicare payment system, so they have no reason to seek change.

By comparison, ACP and AAFP have been participating in the Ambulatory Care Quality Alliance (AQA), a national consortium that has produced a "starter set" of 26 good measures for ambulatory care. ACP and AAFP represent specialties that have been disadvantaged under the current Medicare payment system. Both organizations have good reason to want to realign Medicare payments in such a way that would benefit their members who participate in quality improvement programs using the AQA measures.

Finding common ground

The AMA House of Delegates may be able to find common ground. Nearly everyone agrees that Medicare payment cuts need to be averted, that a Medicare pay-for-performance program should be voluntary and that any performance measures used should not impose heavy administrative burdens on practitioners.

If the House of Delegates develops policy that includes only those areas where there is strong general agreement, then the AMA may end up with a platform it can use to contribute to the debate in Congress. However, the House of Delegates may have to choose between conflicting camps and take a position that will leave many groups in organized medicine unhappy.

Speaking with one voice is a laudable goal that should be pursued whenever possible--but there are times when a wide range of viewpoints may be just what the doctor ordered. Pay for performance is a tough, complicated and controversial topic, and no one organization has it all figured out. Medicine may benefit from having different organizations speak to the issue from their unique perspective, rather than with a monolithic voice that implies a common understanding when none exists. This would be particularly true if the one voice that ends up being adopted is "just say no" to any form of pay for performance.

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

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