In the News for the Week of 4-11-06
- ACP calls for major reforms in internal medicine training
Annual Session 2006 highlights
- P4P: the latest fix has potential and pitfalls
- Bolstering disaster response post-Katrina
- ACP’s diabetes initiative posts impressive gains
- Regents recommend ways to avert primary care ‘collapse’
- Governors tackle payment reform, more
In a new policy paper posted online last week, the College urged far-reaching changes in undergraduate and graduate medical education to strengthen internal medicine and help avert a looming crisis in primary care.
The paper proposed retaining three years of residency training, but dividing residency into two years of core internal medicine training with a third year of customized training that residents could tailor to their chosen career. The proposed model was part of a series of recommendations to give students and residents more exposure to internal medicine career opportunities, support outstanding faculty role models and improve ambulatory care education.
Strengthening training in office-based care is particularly urgent, the paper said, because the future supply of primary care physicians and general internists will not be sufficient to meet the needs of an aging U.S. population. The paper, entitled “Redesigning Training for Internal Medicine,” was published online in Annals of Internal Medicine.
Highlights of the paper included:
Redesigning residency programs. Two years of core internal medicine training plus a customized third year would give residents more flexibility to pursue hospital-based or ambulatory care experiences or training relevant to a chosen subspecialty.
Enhancing ambulatory training. Programs need to give residents much broader ambulatory care training that is independent of inpatient responsibilities. The paper recommended, for instance, instituting frequent block rotations in place of half-day clinics, to avoid the conflict between inpatient and outpatient responsibilities.
Integrating educational and service needs. Program redesign must be guided primarily by residents' educational needs, not facilities' service needs.
Providing more "translational education" in medical school. The paper called for redesigning medical students' fourth year to give seniors a much firmer foundation in how to translate medical knowledge into effective clinical practice and optimal patient care.
The training redesign paper is part of a series of new ACP position papers on reforming the health care system and revitalizing internal medicine. These include: "The Advanced Medical Home," "Linking Physician Payments to Quality Care" and "The Impending Collapse of Primary Care Medicine."
Annual Session 2006 highlights
At a Town Hall held during Annual Session, ACP members voiced their concerns about pay for performance, despite a broad consensus that the nation’s physician reimbursement system needs to be fixed. The session also featured a panel of government, business and ACP leaders offering different views on the controversial topic.
“There is too much spending for the quality of care that we’re getting,” said panelist and Regent Kevin B. Weiss, FACP, Chair of ACP’s Performance Measurement Subcommittee. While pay for performance may be a thoughtful solution to the business community’s worries about medical care expenses, Dr. Weiss said, “it’s a little fix for a big problem.”
But addressing the dysfunctional payment system—the root problem—is complex and expensive, said panelist Barry M. Straube, MD, acting chief medical officer and acting director of the CMS’ office of clinical standards and quality. The current focus of Medicare's consideration of pay for performance is “increasing value and efficiency.”
Attendee Emily R. Transue, FACP, a general internist in Seattle, complained that incentive programs lack consistency. “I received one report from a payer that said I was doing spectacularly, and another that said I was below average,” she told the panel.
Panelist John Tooker, FACP, the College’s Executive Vice President and Chief Executive Officer, suggested that physicians in small practices start moving toward pay for performance by participating in Medicare’s Physician Voluntary Reporting Program, which was launched this year. The program, he said, allows physicians to pilot the use of data to initiate quality improvement planning.
Other College resources he recommended for quality improvement efforts included PIER, the online decision support tool; the Practice Management Center, which can help with purchasing electronic health record systems; and the Washington-based Center for Practice Innovation, which focuses on practice reengineering.
What lessons can be learned from Hurricane Katrina—particularly in the face of the widening global spread of avian flu—was the subject of an Annual Session presentation on emergency preparedness. Expert panelists said that Hurricane Katrina had exposed the country’s extreme medical vulnerability in the face of natural disasters.
The fact that Gulf Coast citizens had to relocate nationwide, said a panelist, Capt. Ann Yoshihashi, MD, an endocrinologist with the Naval Operational Medicine Institute in Pensacola, Fla., makes a decisive case for widespread use of electronic health records.
In the wake of the devastation, she added, it also became clear that a much stronger health care infrastructure must be put in place locally to provide care beyond the first wave of volunteer relief. To that end, she said, federal and local government officials have expanded national networks of trained health care responders.
Regarding flu vaccine, audience members noted that physicians still have trouble getting timely delivery of vaccine during flu season—and urged federal agencies to take a much stronger role in supply issues.
And panelist Anna M. Likos, MD, a CDC epidemiologist, told attendees that the CDC is using several channels to track the possibility of a U.S. avian flu outbreak. One network of 1,300 providers across the country reports weekly to the CDC on any influenza-like symptoms.
As the College’s three-year, multimillion-dollar diabetes initiative heads into its second year, the program’s various components—multidisciplinary team training, patient education, physician self-assessment and the creation of multimedia educational tools—are coming together to bridge the gap between diabetes standards of care and current practice.
At an Annual Session press conference held to highlight the initiative’s progress, Vincenza Snow, FACP, Director for ACP's Department of Clinical Programs and Quality of Care and the initiative Director, was part of a panel that outlined the program’s progress. Among those accomplishments: the development of a new self-assessment diabetes program for multidisciplinary teams and new clinical skills modules.
A patient-focused brochure on self-management for diabetes patients will be released next year in both English and Spanish, she said. And 20 practice teams of physicians and staff are now participating in a key component of the College's diabetes initiative: the “Closing the Gap” project, ACP’s quality improvement program that trains teams of physicians and allied professionals to improve care for patients with diabetes.
“We know that to achieve success, no single caregiver—the doctor, diabetes educator, eye doctor, nurse, even the patient who acts as caregiver when he selects meals—can tackle this disease alone,” Dr. Snow told reporters.
More information about Closing the Gap is online.
At its meeting last week, the Board of Regents approved several position papers that focus on physician workforce, payment and care delivery issues. In approving those new positions, the Board noted that widespread reforms are needed to meet growing challenges to the nation’s primary care system and to avoid a growing exodus of primary care physicians.
The following were among the action items approved:
Payment reform. The Regents approved a paper calling for the overhaul of the current payment system and recommending that Congress increase relative value units for evaluation and management services. The paper also recommended that Medicare pay physicians for coordinating and managing complex care and for e-mail and telephone consults. The paper also stated that Medicare should provide add-on payments for care facilitated by information technology.
Internal medicine workforce. This paper, which advocated for creating a new national workforce for internal medicine, included several recommendations on how to redesign and strengthen internal medicine training. The paper was posted online.
The Board also approved recommendations for preparing for an influenza pandemic, enacting tighter direct-to-consumer advertising regulations and exploring the use of health courts to reform the medical professional liability insurance system.
At its spring meeting last week, ACP’s Board of Governors tackled critical issues facing internal medicine, including the need for payment reform and a pay-for-performance appeals system.
Several chapters co-sponsored a resolution urging the Board of Regents to advocate for reallocating Medicare payments from specialty procedures to case management and cognitive services. “We have to make sure this is a reallocation, not just a reduction,” said Yul D. Ejnes, FACP, Governor for the Rhode Island Chapter and incoming Board Chair.
Another approved resolution recommended that the College call for increased oversight of “minute clinics,” which are staffed by non-physicians and are appearing in large retail stores and chain pharmacies. Concerned about the clinics’ rapid growth, the Governors voted to ask the Regents to provide materials that would help chapters ensure that such clinics meet quality and safety standards.
Other resolutions approved and sent to the Board of Regents included:
Pay-for-performance appeals. The resolution urged the College to advocate for systems that would allow physicians to complain about the inappropriate application of pay-for-performance criteria.
Formulary requests. The approved resolution, if adopted by the Regents, would work to promote the use of a single, universal form by all insurers, including Medicare, for administrative processes.
Malpractice immunity. The resolution recommended that ACP promote legislation to hold physicians immune from malpractice litigation when they volunteer care.
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Copyright 2006 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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