Thursday, December 9, 2010

Looking out for internists . . . and their patients

A defining characteristic of the American College of Physicians is that it has a very broad public policy/advocacy agenda that emphasizes what it believes to be best for the public. In the past 15 months alone, ACP has published position papers on such topics as health care transparency, racial and ethnic disparities, EHR quality based measurement and reporting, tobacco control and prevention, accountable care organizations, FDA regulation of prescription drugs, and controlling the costs of health care.

The downside of having such a broad agenda is that some ACP members question if the organization also is looking out for their interests. They want to know if the ACP understands the daily frustrations faced by practicing internists – the drip, drip, drip of dissatisfaction created by unrelenting paperwork and unfair and inadequate pay.

The answer is yes. While ACP prides itself on addressing broad societal issues that affect access to care, much of ACP’s advocacy is directed at reversing, preventing, or altering policies that threaten to make members lives miserable, and getting policies adopted to make things better.

Yesterday, Congress cleared legislation for President Obama’s signature to exempt physicians from the FTC’s “red flags” rule. The FTC rule would have defined physicians as “creditors” and as creditors, physicians would have been required to implement burdensome procedures to prevent and detect identity theft. ACP joined in a lawsuit to challenge the rule and was part of a coalition of professional organizations to persuade Congress to get involved. Now that Congress has expressly exempted physicians from the Red Flags rule, judicial intervention should no longer be necessary to prevent the FTC from imposing more hassles on doctors.

Also, today the House of Representatives joined the Senate in passing bipartisan legislation to prevent a 23% Medicare pay cut that would have gone into effect on January 1 and extend current rates through 2011. President Obama has promised to sign it into law. For many years now, putting an end to the cuts caused by the Medicare SGR formula has been a top ACP priority. Most recently, ACP distributed to Capitol Hill a video of internists making a heartfelt plea for Congress to “just fix” the SGR. Although the bill passed by Congress doesn’t provide the permanent solution to the SGR sought by ACP, physicians can at least be ensured of stable updates through the end of next year. For most physicians, this means a continuation of their current Medicare rates for another year, but as a result of ACP advocacy, primary care internists stand to get a big Medicare raise on January 1.

The Affordable Care Act directs Medicare to provide a 10% bonus payment to primary care physicians for designated “primary care services” – office, nursing home, home and custodial care visits. To qualify, the ACA requires that a physician be in a recognized primary care specialty (internal medicine, pediatrics, family medicine, and geriatrics) and that 60% of their total Medicare billings must come from the designated primary care visits.

Originally, CMS interpreted the ACA as requiring that Medicare count hospital visits and ancillary procedures against the 60% billing requirement. ACP pointed out to CMS that this would exclude many office-based internists who see patients in the hospital or operate an in-office lab from the bonus. Now, in response to ACP’s comments, CMS has decided that hospital visits and ancillary procedures no longer will count against a primary care physician in determining eligibility for the bonus. With this change, the vast majority of general office-based internists will get the 10% increase in pay for their primary care services. For an office-based general internist with a typical number of Medicare patients and primary care services, the result will be a $12,000 increase in total Medicare payments, starting on January 1 and continuing each year through 2015, or an average total gain of $60,000 over next five years for each eligible internist. (Internists with an above average mix of Medicare patients and primary care visits will do even better.)

ACP is unapologetic about caring deeply about broad societal issues that affect the public, including ensuring that all Americans have access to affordable health insurance coverage, but advocacy on such issues does not come at the expense of looking out for the interests of members. The fact is that in recent weeks ACP has achieved several substantial victories for its members: preventing a federal agency from imposing another unnecessary administrative burden, ensuring stable Medicare payments for 12 more months, and ensuring that most primary care internists get a raise. More needs to be done to slow the drip, drip, drip of dissatisfaction created by unrelenting paperwork and unfair and inadequate pay, but these wins will certainly make things better for most ACP members.

Today’s question: What is your reaction to ACP’s successful advocacy on exempting doctors from the FTC’s red flags rule, stopping the SGR cuts, and ensuring that most general internists will qualify for increased Medicare payments?


ryanjo said...

Thank you ACP. Of course, many of us privately contacted our legislators as well, but the organized approach and video made an impact, I'm sure.

I hope that the ACP realizes that focusing on a target and enlisting broad member support made a difference.

A lesson for the future.

PCP said...

Out of the three "victories" you point out Bob. I would consider only one a "victory" that being the 10% bonus payment. That is the only one that gives any respite to the beleagured general internist.
I consider the other two defensive plays. Trying to stave off yet more burden.
That difference between defence and offence is vital to point out.
The reason is simple. The status quo is sufficient to ensure the demise of General IM. Further angst is bad to be sure but will not change the downward trajectory. True "victories" are to be measured as factors that will lead to more young doctors deciding to open up private practices. On that we have some far way to go.

Jay Larson MD said...

Not having the SGR ultra-short time fixes, not having increased governmental red tape and a 10% bonus is welcomed for 2011. Will this stop war weary general internists from leaving practice or infuse internal medicine training programs with residents planning to become outpatient internists, hardly.

One of the biggest strengths of the ACP has been its educational wares. Brain food to nourish intelligence that later is used to improve people’s lives and health. Over the years the financial allure of endoscopies, angiograms, and other procedures have drawn many medicine sub-specialists away from the exam room to the procedure room.

The ACP should focus on its strength and fight for the value of Knowledge. The value of Evaluation and Management codes have to increase compared to procedure codes or the thinking internist is doomed to extinction. Personally, I rather have the RBRVU become extinct rather than the general internist. Many people with complex chronic disease would also agree.

Arvind said...

Very interesting analysis, and celebrating, Bob. Just want to point out - not loosing is not the same as winning.

Also, you have very succinctly avoided mentioning the very cold calculation that the ACP did in hanging out all dues-paying sub-specialist members and Fellows of the ACP out to dry.

Its time to admit the disastrous decisions taken by the ACP.