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

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Change for the future and a look at the past

From the October ACP Internist, copyright © 2010 by the American College of Physicians

By J. Fred Ralston, FACP

Recently I was asked to describe my vision of what a typical day in the office will be like in 2015. My thoughts first turned to the past. In 1983, I was excited to return home to Fayetteville, Tenn., to begin my practice. At the time, there was little outside interference in medicine. Much of what I did for patients occurred in the exam room and was completed when I dictated my office note. Fees were set in a competitive environment. Patients asked about fees because they paid most of them, at least until deductibles were met. Overhead in our office was under 40%, and income in general internal medicine was sufficient to attract many of the most talented medical students. They didn’t go into internal medicine to make a fortune, but they were not financially daunted, either.

Toward the end of the 1980s I was somehow wrangled into gathering data for the Resource-Based Relative Value Scale System (RBRVS) project. I took a clipboard with a cheap electronic clock on top and noted time in and time out for the patient visit, dictation, and other details. We now all live with the results. Yet since that time major external factors have changed. In the early 1980s significant overhead was paid in internal medicine offices by lab profits that disappeared overnight. That lab revenue was not covered under RBRVS, nor was the loss of it accounted for during the change to RBRVS. Prior approvals were rare, and we did not have the task of writing and rewriting the same prescriptions first for 30 days, then for 90 days, and finally for 90 days again when the pharmacy benefit manager changed. This and many other tasks have crept into our work day and have never truly been reflected by the RBRVS.

Many internists are now employed in health systems that value the contributions we make to the care of patients. However, the direct evaluation and management revenue from comprehensive care for complex internal medicine patients does not usually generate the kind of cash flow needed to support that medical practice. Many of us try to practice longitudinal care for patients, but our payment comes from a fee-for-service system. The care that patients need either is subsidized by those in private practice earning below-market incomes or paid for from ancillary services or direct subsidy by the physician’s employers.

I would argue that payment for the services actually provided would allow the testing of a variety of practice options to see what meets the needs of our patients in a country with a very diverse population. A system based upon properly funded patient-centered medical homes would have the ability to test outcomes and efficiency in a variety of practice settings. I would argue that appropriate payment for internists would allow more creativity in practice design by not requiring cash subsidies.


Many of us try to practice longitudinal care for patients, but our payment comes from a fee-for-service system.


How do I envision practice in 2015? Some elements remain up in the air. I hope the patient-centered medical home and true payment reform will value what internal medicine specialists and subspecialists do and build continuous quality improvement into the practice. Data measurement should allow us to regularly refine the way we deliver care, much like we currently use data to refine the way we treat various illnesses. Likely many of us will be in large integrated groups, but others will be in groups of a variety of sizes, empowered by technology, improved payment and the ability to change easily as opportunity presents. ACP is reinforcing its commitment to develop and expand innovative practice-oriented programs, products and services that will be helpful in this practice transformation.

While predicting the future and the timing of events is notoriously difficult, there is hope and promise that the general internal medicine practice of the future will be based on the principles of the patient-centered medical home and operate smoothly for patient and physician alike. Such a practice will use a team approach where patients will benefit from the services of a variety of health professionals working together seamlessly. Hassle factors will be minimized, handled predominantly by ancillary staff, and viewed appropriately as a detriment to patient care. The primary care office will be seen as an anchor in the larger health system, and linked to other specialty and subspecialty offices in a fashion that freely benefits the patient. The latest information on best clinical practices will be easily available for both doctor and patient. After years of turbulence, I see my practice and others being desirable medical homes for physicians, medical students planning their career, and most important, patients.

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