In the News for the Week of 4-24-07
Internal Medicine 2007 Special Edition
- Regents hash out details of Medical Home
- Governors tackle payment issues
- New ACP President, Regents Chair take office
- ACP and Foundation launch tools to improve diabetes care
- Survey finds physicians struggle with language barriers
- Promoting professionalism in practice
- Call for fall 2007 Board of Governors resolutions
ACP Observer's complete daily coverage of Internal Medicine 2007 is online.
The Patient-Centered Medical Home (PCMH) took top billing at the Board of Regents meeting at Internal Medicine 2007 in San Diego last week.
The Regents voted to work with outside consultants to determine how much it will cost practices and purchasers to implement various elements of the model, which would reimburse primary care physicians for coordinating all aspects of a patient’s health care.
Several Regents expressed concern about the PCMH’s financial feasibility, especially for small practices, noting that it will involve a substantial investment in electronic health records (EHRs).
Robert Doherty, ACP Senior Vice President of Governmental Affairs and Public Policy, acknowledged this was a valid concern, but noted the plan called for a “laddered” approach that would allow small practices to make a gradual transition.
Mr. Doherty also spoke with Regents about the College’s efforts to work with large employers, consumer groups and other physician groups to agree on a unified set of principles for patient-centered care, which are expected to be unveiled in the next few weeks.
The Regents also approved the following:
- A statement of principles governing the process by which physicians can appeal performance measurement ratings;
- A resolution to promote legislation that provides medical malpractice liability protection for physicians who provide care on a voluntary basis;
- A resolution to negotiate College-member discounts on approved EHR systems, which will listed on the Practice Management Center's Web site;
- Clinical practice guidelines (pending publication) for pharmacological treatment of dementia;
- Recommendations to globalize ACP’s activities by, for example, increasing funding for the International Speakers Program, enhancing recruitment abroad and translating key educational materials.
- A resolution to collaborate with subspecialty societies to increase funding for graduate medical education for Internal Medicine and subspecialty training programs.
The Board of Governors passed resolutions on Medicare coverage and payment issues at last week's meeting during Internal Medicine 2007. Items dealing with member dues and medical marijuana research generated lively discussion before being approved.
The Governors asked the Regents to develop methods to monitor the fairness of pay-for-performance activities, ensuring that quality measures, not economic considerations, are the primary factors in evaluating doctors. Insurance plans also should periodically report to doctors on their performance measures, and allow enough time for appeals and corrections before penalties are instituted, they said.
Governors also asked that Regents develop specific mechanisms for P4P programs to better assess a doctor’s efforts, such as case mix models that include sample size and patient non-adherence issues. They also asked Regents to advocate for adequate reimbursement of oral anticoagulant monitoring in person and by phone.
Other resolutions passed by the Governors included:
- Extending the “Welcome to Medicare Exam” eligibility period from six to 12 months and modifying coverage to include preventive medical service.
- 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 subject to deductibles.
An item asking Regents to support rigorous research into the potential therapeutic role of marijuana narrowly passed on a 35-31 vote. The Governors also proposed possible ways to increase funding for ACP Chapters, such as 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.”
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 from Illinois, opined that internal medicine “will fracture” if it doesn’t align itself with hospitalists.
Other measures recommended that Regents advocate for universal health care access; 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.
David C. Dale, FACP, professor of medicine at the University of Washington in Seattle, took office as the 2007-08 ACP President last week. The following officers also took office during the College's annual meeting in San Diego:
- Chair, Board of Regents: Joel S. Levine, FACP, professor of medicine in the Division of Gastroenterology and Senior Associate Dean for Clinical Affairs at the University of Colorado School of Medicine in Denver.
- President-elect: Jeffrey P. Harris, FACP, an internist in private practice in Millwood, Va. He is also clinical associate professor of medicine at the University of Virginia School of Medicine.
- Chair-elect, Board of Regents: William B. Applegate, FACP, senior vice president, Wake Forest Health Sciences and dean, Wake Forest University School of Medicine in Winston-Salem, N.C.
- Chair, Board of Governors: David L. Bronson, FACP, executive director, Cleveland Clinic Health Centers in Cleveland.
- Chair-elect, Board of Governors: Donald W. Hatton, FACP, a practicing physician with the Reed Medical Group in Lawrence, Kansas.
The College and the ACP Foundation (ACPF) last week unveiled three comprehensive educational tools for ACP members, healthcare professionals and patients to improve diabetes treatment and care. The resources, introduced at Internal Medicine 2007 in San Diego, are the culmination of an ambitious three-year Diabetes Initiative funded by an educational grant from Novo Nordisk. The materials include Living with Diabetes: An Everyday Guide for You and Your Family, a self-management guide for patients; The ACP Diabetes Care Guide for physicians and practice teams; and the Diabetes Portal, a free Web-based resource for physicians and patients.
The Diabetes Initiative was launched to elevate current practice standards, based on high-quality, evidence-based care. The initiative is aimed at increasing participation by both physician and patient as well as raising overall awareness of the disease and developing educational interventions and practical tools. The following resources produced by the initiative were designed to meet these objectives with specific goals for physicians and patients:
- Living with Diabetes is an innovative model for patient education and empowerment and provides tips for dieting and exercise, as well as for monitoring blood sugar, insulin and other medications.
- The ACP Diabetes Care Guide was developed for physicians and practice teams, and contains tools for better practice management as well as a practice manual, answers and critiques.
- The Diabetes Portal provides resources for both patients and clinicians: clinicians can search for information under the headings of quality improvement, practice issues and clinical topics; patient resources include information about diabetes related complications.
A free CD-ROM of all diabetes-related presentations given at the three previous Internal Medicine meetings (2005-2007) will be distributed to members. The CD-ROM contains audio and synchronized PowerPoint slides from the presentations.
Living with Diabetes and the ACP Diabetes Care Guide are free to members and can be ordered online.
Nearly two-thirds of internists have patients with Limited English Proficiency (LEP), yet physicians are rarely reimbursed for the extra time and expense of treating these patients, a new survey of College members found.
“On average, patients with LEP comprise 12% of active patients in the practices of ACP member internists,” said College President Lynne M. Kirk, MACP, in a press briefing Friday announcing the survey results. “Physicians encounter such patients on a fairly frequent basis.”
The College’s Board of Regents voted this week to ask Medicare to reimburse doctors for the extra expense and time it takes to treat LEP patients, and to advocate for a national clearinghouse of translated documents and patient education materials.
Because patients with limited English have more difficulty understanding basic health information, they usually require more time during office visits, the survey found. Roughly half of survey respondents said they spend an extra five to 15 minutes with LEP patients versus those who are proficient in English; another quarter reported spending an extra 16 to 30 minutes; while 15% said they spent no additional time with LEP patients.
“The extra time comes with patients taking a longer time to explain symptoms, ask questions and understand health information and treatment,” said Board of Regents Chair William E. Golden, MACP. “Health literacy is a challenge as is, and it is made more challenging for patients who speak English as a second language.”
The College’s survey, conducted in late 2006, found that 54% of those doctors who treat LEP patients see such patients several times a week, and that 39% of the patients are older than age 65. All told, internists reported seeing patients who speak nearly 80 languages, with Spanish being the most common.
About two-thirds of practices with LEP patients provide language services, typically via a bilingual physician or staff member. Of these practices, 38% said the services didn’t cost them extra money, while 24% estimated the extra annual cost at between $5,000 and $25,000. The estimated average cost across all practices is about $19,000. Most of these costs are for language resources internal to the practice.
A paper summarizing the survey findings can be found online.
The ACP Ethics, Professionalism and Human Rights Committee released a new case study on how to deal with disruptive physicians at Internal Medicine 2007 last week. It is the 32nd in series of ethical studies available through the College's Center for Ethics and Professionalism.
The case study recommends actions that physicians and institutions might take to deal with disruptive physicians in light of ethics and professionalism responsibilities. The Center's case studies use hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed by published guidelines, drawing upon the most recent edition of the ACP Ethics Manual.
Over the past year, the Ethics Committee has also developed a new pamphlet on "Volunteering for a Research Study" and completed its "Ethics Manifesto: Pay-for-Performance Principles that Ensure the Promotion of Patient-Centered Care." The document has been submitted for publication in a medical journal.
The deadline for members to submit new resolutions to their Governors for hearing at the September 2007 Board of Governors Meeting is May 15, 2007. Initiating a resolution provides ACP members an opportunity to focus attention at the ACP national level on a particular issue or topic that concerns them. A resolution becomes a resolution of the chapter once the chapter council approves it.
In accordance with the ACP Board of Governors Resolutions Process, resolutions should clearly distinguish the action requested within its resolved clause(s) as either a policy resolve (“Resolved that ACP policy…”), or a directive, which requests action/study on an issue (“Resolved that the Board of Regents…”). If more than one action is proposed, each should have its own resolved clause. Please contact your Governor if you have any questions regarding the resolution format.
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Copyright 2007 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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