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Medicare, P4P and hospital medicine sparks debate at Governors' meeting

From the June ACP Observer, copyright © 2007 by the American College of Physicians.

By Jessica Berthold

SAN DIEGO—Medicare coverage, performance measurement and hospital medicine were just some of the issues on tap at the Board of Governors' April business meeting held during Internal Medicine 2007.

The Governors asked the Regents to develop methods to monitor the fairness of pay-for-performance activities and ensure that quality measures, not economic considerations, are the primary factor in evaluating doctors. Insurance plans should also periodically report to doctors on their performance measures, and allow enough time for appeals and corrections before penalties are instituted, they said.

"The College should be proactive in trying to monitor for problems with pay-for-performance systems," said District of Columbia Governor Lawrence E. Klein.

Medicare and reimbursement issues topped the agenda at the Board of Governors meetings Tuesday and Wednesday


Medicare and reimbursement issues topped the agenda at the Board of Governors meetings Tuesday and Wednesday. Rhode Island internist Yul D. Ejnes, FACP, immediate past chair, presided during the two days of discussions.



The Governors also asked the Regents to help assure that pay-for-performance programs take into account patient non-adherence and case mix models that include sample size when assessing a doctor's performance. Additionally, they asked the Regents to advocate to private and governmental insurers for satisfactory reimbursement of oral anticoagulant monitoring in person and by phone.

Several Governors expressed support for a measure recommending Regents find ways to recruit and retain physicians who practice hospital medicine. Kimberly C. Bates, ACP Associate Member, Chair of the Council of Young Physicians, noted the large number of young doctors who are specializing in hospital medicine, while James Foody, FACP, Governor-Elect for Illinois, opined that internal medicine "will fracture" if it doesn't align itself with hospitalists.

Also generating much discussion was a request that Regents examine how ACP Chapters might receive more financial support, perhaps by instituting mandatory chapter dues or designating 25% of future national dues increases to Chapters. Keeping Chapters healthy is vital, said South Carolina Governor Dawn E. Clancy, FACP, noting that "all politics is local." Part of the problem, she added, was lack of membership renewals, and urged the College "to market itself to itself better."

Additional recommendations for the Board of Regents to consider included:

  • Providing Medicare coverage for preventive health visits on an annual basis, for which physicians would be reimbursed for their time and effort advising patients on preventive benefits and Medicare coverage.
  • Mandating that third-party payers recognize and reimburse doctors for periodic visits that promote age-appropriate screening, prevention and counseling, and that the visits not be subjected to deductibles.
  • Extending the "Welcome to Medicare Exam" eligibility period from six to 12 months and modify coverage to include preventive medical service.
  • Advocating that the accreditation of pharmacy benefit plans be made contingent upon ensuring doctors can efficiently interact with the plans, and that benefit plans either include independent representatives from major subspecialties on their formulary committees, or have protocols for consulting with specialists about medication.

An item to support rigorous research into the possible therapeutic effects of marijuana squeaked by on a 35-31 vote. Other measures recommended that Regents examine the impact of resident duty hours on clinical faculty; study flexible work options; amend eligibility requirements for ACP Fellowship; support a tax deduction for individuals who purchase health insurance; and support CDC recommendations on HIV testing.

Heavily discussed, and ultimately tabled for further study, was a measure to advocate for a streamlined process to obtain J-1 and H1B visas for non-U.S. citizen international medical graduates (IMGs). New Hampshire Governor Dana Merrithew, FACP, said he feared that importing doctors diverted the College's energy from improving internal medicine in the U.S. and drained other countries of doctors they may desperately need.

Others, however, noted that international medical graduates help fill positions that don't easily attract U.S. residents. "If we limit the number of (IMGs) who come in, it will negatively impact under-served areas in communities," Dr. Bates said.

Also generating much discussion was a proposal to develop and support universal health care access through a single payer system. While many spoke up in strong support of the College's advocating access to care for everyone, they felt it was too soon to put forward a precise mechanism for doing so, and stripped "single payer" from the resolution. "If we run ahead of our members to support or not support (single payer), we will end up fracturing the membership," said Oklahoma Governor Dean Drooby, FACP.

Universal coverage is "a top priority" for the College, Robert Doherty, Senior Vice President of Governmental Affairs and Public Policy, told the Governors. "The College has endorsed a number of bills that were introduced on a bipartisan basis, which essentially let the states set up universal coverage with the help of federal funding."

Following the business meeting, a combined gathering of Regents and Governors heard talks from ACP and ABIM speakers on focused recognition, which aims to use the maintenance of certification process to acknowledge where a doctor practices. It's a concept the College is studying but about which many Members are concerned may fracture the field of internal medicine.

Indeed, the comments of governors and regents were nearly unanimous in their opposition to the concept of tailoring certification for those who practice hospital or ambulatory medicine. "Just to be clear, I didn't hear anyone speak in favor of this concept," said Virginia Collier, Governor for Delaware, after more than a dozen audience members had offered remarks.

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