Thursday, February 16, 2012

A surgeon, an internist and a family physician walk into . . .

. . . a congressional office (sorry, not a bar!), and actually speak with one voice on an important health care issue. No joke! Despite the reputation that doctors (deservedly so) have for not being able to agree on much of anything when it comes to health care policy, the American College of Surgeons, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association recently joined forces to lobby Congress on repeal of the Medicare Sustainable Growth Rate (SGR) formula.

And, when it became clear last night that Congress would not go along with repeal, the groups today collectively told Congress that the announced deal to extend the current Medicare rates for 10 months “neither solves, nor moves us closer to solving, the Medicare physician payment crisis.” The doctors noted that after the extension expires, the next cut will be steeper—an estimated 32 percent cut on January 1, 2013—and that “as a result, the threat to access will be greater, the budget price tag to eliminate the cut will be even higher, and the barriers to comprehensive payment reform will be even steeper.”

The four organizations represent a combined membership of nearly 400,000 physician and medical student members, which if they were one organization, would make them by far the largest single physician membership organization in the United States, representing almost 65% of all active U.S physicians! The AMA remains the largest single physician membership organization, with about 215,000 members in 2010, the most recent information I can find. ACP is second, with 132,000 members. (This is not to say that the loose coalition formed by the four specialty membership groups can or should replace the AMA—there remains a need for a national membership organization whose membership includes all physicians, without regard to their specialty, and includes strong representation from geographic (state) societies. The AMA is the only organization that fits the bill.)

But if ACP, ACS, AOA, and AAFP can continue to find common ground, just think about how much influence they could carry—and how much good it could do for the public! Even the idea that surgeons and primary care physicians can agree defies the usual expectation that their economic interests inevitably will collide with each other.

Now, I am not being Pollyannaish about the possibilities of cross-specialty collaboration. The potential for conflict remains, especially if the issue is one of redistributing dollars from one group of specialties to another. But as I look at the big issues facing medicine, I sense that there are wonderful opportunities for surgeons, internists, and family physicians, both MDs and DOs, to find common ground on such things as:

· Promoting high-value, cost-conscious care
· Ensuring that there are enough physicians in all fields to meet the demand for health care services
· Improving coordination and transitions of care
· Reducing red tape and regulatory hassles
· Reducing the costs of defensive medicine
· Influencing new models of health care payment and delivery, from ACOs to patient-centered medical homes
· Ensuring that health information technology works to the benefit of both physicians and patients
· Establishing team-based models of care that recognize each specialty’s contributions, and the contributions of non-physicians (including nurse practitioners and physician assistants)

Collaboration on such issues for the purposes of health care advocacy would parallel the movement at the practice level away from “siloed” physician practices to team-based and collaborative models.

It may take some time for the four biggest specialty organizations, and the specialties they represent, to put aside decades of suspicion and distrust, resulting mainly from battles over redistribution of money under the RBRVS, but the potential is there. This initial collaboration of ACP, ACS, AAFP and AOA may not have won the day (yet) on the SGR, but it was an important step forward to bringing the largest and most influential specialty organizations together. And that may have been the best thing to come out so far from what otherwise is another huge disappointment from Congress’ ongoing failure to fix the SGR.

Today’s question: Do you think surgeons, family physicians, and internists, DOs and MDs, can speak with one voice on critical health care policy issues? On which issues? And what should the next step be in the emerging relationship between ACP, ACS, AOA, and AAFP?


Steve Lucas said...


You are being generous towards the AMA. My understanding is the AMA represents only about 10% of practicing physicians after you subtract academics, students, and others who are having their dues paid for by someone else.

The groups mentioned are those who are practicing medicine in this country today and dealing with patients on a day to day basis.

My suggestion is a committee be selected with two representatives from each group with a separate chair whose function is to organize and only vote to break a tie. The problem with large groups is you dilute the ideas and the end product has little or no clout. Additionally, if I argue my point in front of a small group, no matter what the outcome, I have been heard. Speak to a room and someone will say the decision does not represent their point, and they will continue on regardless of the group decision.

If this committee is expanded you cut the number of representatives down to one per society so as to always keep the total number under ten.

Back in the day we said a Nobel was never awarded to a committee. Al Gore changed that, and we can all see how that is working out.

Steve Lucas

Jeffrey Jaeger said...


I absolutely think it is possible for these groups to speak with one voice on critical policy issues. I think that payment reform (including but not limited to SGR repeal and RUC reform) is the issue that can gain the most acceptance from these groups, which, as Steve says, represent the docs who are doing most of the day to day patient care in this country.

The failure of the Supercommittee, and now the failure of this group to manage their three-part charge, stands as a monument to the ineffectiveness of the current batch of leaders in Congress. It will be very important for organized medicine to make it known that we were willing to make changes and sacrifices for the economic and physical health of the nation. We supported solutions that reflected compromise and collaboration, with patient well-being at the center. These solutions were turned aside in favor of short-term fixes which benefit no one except those running for election.

Please tout this collaboration in Oped's and interviews, and please do what you can to continue the collaboration, even if it means standing in opposition to the AMA.

Jeffrey Jaeger, MD, FACP

Arvind said...

We are already doing it through Docs4PatientCare. The AMA is irrelevant. The four societies that you mention do not have the ear of Congress. There is nothing you can do via all legacy organizations because of the bad baggage they all carry. The main reason for this is that none of these organization, especially the AMA is not a true member-representative organization. it is in fact consider by many to be THE PROBLEM.

if we simply insisted that price-fixing be eliminated in favor of true free market value-based purchase of medical services, we could care less about SGR. And if we got rid of CPT as the sole (monopoly) of transacting medical care, all the fighting about RUC, RBRVS, etc. would be history. We put the sword on our neck, and then we wonder why it hurts?

Harrison said...

What happens to the SGR as ACO's are phased in?
ACO's are likely going to transform Medicare into a capitation based payment system instead of fee for service.
If Congress continues to ignore the SGR, and instead allows CMS to continue expanding the ACO concepts that have already started, will our focus on the SGR become moot?