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


Building on 'big idea' momentum in a breakthrough year

Will 2006 be a breakthrough year in fixing what is wrong with America's health care system?

From the March ACP Observer, copyright 2006 by the American College of Physicians.

By Robert B. Doherty

On the surface, we have little reason to be optimistic that very much will be accomplished. Health care costs and the number of uninsured continue to rise. A tight federal budget leaves little room for new programs to improve access and quality, while many existing ones are being downsized or eliminated.

And history suggests that big changes do not take place without presidential leadership. President Bush begins the last two years of his administration with diminished political clout and declining poll numbers. Congress' Republican majority is worried about potential losses in the upcoming midterm elections, while Democrats sense an opportunity for big gains. That leaves little room for the bipartisan cooperation needed to tackle health care.

There is, however, another way to view the situation. Because the problems are so great, there is a hunger for new ideas. Breakthroughs do not happen when things are going well and the public is content. Instead, they occur when things are going badly and the public demands change.

2006 could be just such a breakthrough year. The College believes we have a genuine opportunity to introduce "big ideas" to fundamentally improve quality and access to care. One big idea is that the value of the physician-patient relationship needs to be supported and strengthened before we can improve health care quality and control spiraling costs.

Enhanced relationship

On Jan. 30, ACP released its annual "State of the Nation's Health Care" report. (See "College warns of looming collapse of nation's primary care.") The report argued that primary care medicine in the U.S. is on the verge of collapse, due to a sharp decline in the number of medical students and young physicians going into general internal medicine and family medicine. At the same time, many established physicians are leaving primary care.

This decline will create a shortage just as demand for primary care is about to balloon, due to an aging population with more chronic diseases. Primary care medicine is the backbone of the health care system, the College points out, and its collapse will lead to higher costs and lower quality. The report specifically discusses the critical role that internal medicine specialists in office-based practice play in providing comprehensive, continuous care of adult patients, particularly those with multiple chronic conditions.

New proposals

The report presented several possible solutions to help avert that growing crisis and strengthen the physician-patient relationship.

One proposal is to design and pilot test a new model for financing and organizing primary care delivery. Called the "advanced medical home," the model would provide ongoing, sustained financing for practices that organize their care processes to center on the needs of patients.

Practices would voluntarily apply for advanced-medical home recognition. To qualify, they would demonstrate that they have internal processes in place to improve their coordination of care. Such processes could include scheduling systems that minimize delays in getting appointments; access to nonurgent medical advice through telephone calls and e-mail; arrangements with other health care professionals to provide the full spectrum of services patients need; and the use of information technology to track, measure and report performance.

Advanced medical home practices would be eligible for care management fees to cover the physician work that falls outside the face-to-face office visit. In addition, practices would receive risk-adjusted payments to ensure adequate reimbursement for treating patients with multiple chronic diseases.

In its "State of the Nation" report, the College recognized that not all internal medicine practices would be interested in or able to qualify as an advanced medical home. ACP is also advocating for immediate changes in Medicare reimbursement policies to boost payments for office visits and other evaluation and management services, provide for separate payment for nonurgent e-mail and telephone consultations, and recognize the value of physician-directed care coordination. These improvements would apply to any physician who bills for and can provide the documentation needed to support reimbursement for each service.

Signs of a breakthrough?

The ACP report generated a phenomenal response from the news media, health plans and physicians.

It was covered by influential newspapers nationwide—including the Wall Street Journal and the Washington Post—and worldwide (including news reports in Australia, Qatar and India!), and in the national broadcast media.

Key members of Congress, as well as administration and health plan officials, approached the College to gain a better understanding of the factors behind the collapse of primary care and to specifically explore the idea of testing the advanced medical home model. ACP's goal is to build upon the report's momentum and get agreement on concrete steps we can take now to restore the value of the physician-patient relationship.

One such step is already well underway. In early February, a private-sector committee to Medicare—the RVS Update Committee (RUC)—met to consider recommendations to substantially increase the physician work relative values for office and hospital visits. The RUC was created by the AMA and medical specialty societies to provide ongoing physician input to Medicare on the work involved in physician services.

Those relative values make up approximately 55% of the Medicare-approved payment rate for each service, so any increase can translate into big reimbursement increases. Specialties, such as internal medicine, whichprovide a proportionately greater share of visits could expect to gain the most from such changes.

ACP led a coalition of medical organizations formed almost two years ago to develop the evidence needed to show the RUC and the Centers for Medicare and Medicaid Services (CMS) that the typical complexity of such services has increased substantially since they were last reviewed ten years ago.

The final results of ACP's efforts won't be known until the RUC submits its confidential recommendations to the CMS later this spring--and the CMS decides whether to incorporate any recommended increases into the Medicare fee schedule, beginning in 2007. There are strong indications, however, that the CMS is inclined to look favorably on the data to support major increases in the work relative values for evaluation and management services.

Another sign of progress is that the Medicare Payment Advisory Commission, which advises Congress on Medicare payment policies, plans to issue a report this month, calling on the CMS to implement policies to reduce payment disparities between primary care and other specialties. The commission has told ACP that it shares our concern that inadequate reimbursement is driving physicians away from primary care.

These developments suggest that ACP's key message on the importance of primary care and the patient-physician relationship is beginning to be heard. We still have much to do to translate our initial momentum into tangible improvements for internists and their patients. But we have reason to hope that 2006 may be the year when the College's ideas on the importance of the patient-physician relationship begin to break through to policy-makers and the public.

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


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