Internal medicine takes a hard look at itself during summit on revitalization
By Edward Doyle
PHILADELPHIA—A few years ago, David E. Bybee, FACP, and his colleagues noticed a disturbing trend: Their incomes were stagnant and falling behind inflation.
"We knew that we were going to be paid less for our time," recalled Dr. Bybee, an endocrinologist at a five-physician practice in Louisville, Ky., and Governor for ACP's Kentucky Chapter. "We reasoned that if we worked longer hours and saw more patients, we could preserve our income."
The practice was able to boost its patient volume by more than 4% a year, annually bringing in more than $1 million extra dollars. But the physicians saw little in the form of take-home pay for their efforts. Because they had to hire extra administrative staff to help handle the growing patient load, overhead jumped 10%, consuming nearly 60% of the practice's revenue.
While the strategy didn't bring in much in the way of extra dollars, it devastated the group's morale. "Everyone in the office is working harder and longer, and enjoying the practice of medicine less," Dr. Bybee said.
Dr. Bybee's experience was just one of many related at a two-day meeting held in early November to examine the future of internal medicine. At the ACP-sponsored "summit" to revitalize internal medicine, Dr. Bybee and about 70 other internal medicine leaders discussed how the specialty can reinvent parts of itself so that it remains vibrant and relevant in the fast-changing U.S. health care system.
Not everyone at the meeting focused on financial matters. During a series of presentations, in fact, internists from several groups, many of them large practices, said that income and reimbursement issues came in as a distant second to more pressing issues.
Many, for example, said they worried about the waning interest of residents and medical students in internal medicine and talked about the need to redesign medical school education and internal medicine training. Others talked about the need to redesign practice systems to streamline and coordinate care and reinvigorate the doctor-patient relationship, in part by incorporating technology and teamwork. And others discussed ways to reform physician reimbursement and slash practice overhead.
The meeting pulled together participants from a wide range of work settings and perspectives. Leaders in the field wanted to give all organizations representing internists a unique opportunity to develop an action plan for the specialty's future.
The meeting was planned by a broad group of organizations including ACP, the American Board of Internal Medicine, the Alliance of Academic Internal Medicine, the Society of General Internal Medicine, the Society of Hospital Medicine and subspecialty organizations that belong to the Council of Subspecialty Societies.
Attendees represented the many faces of internal medicine and included general internists, subspecialists and hospitalists, residents and medical students, as well as leaders from academic medicine.
"An exchange of detailed experiences and perspectives from everyone under the internal medicine 'tent' was critical to gain understanding and respect for each other's role in the system," explained Mary T. Herald, FACP, Chair of ACP's Board of Regents. "No one group has the answer, and we can achieve major change only if we work together."
The summit's goals were broad: to identify ways to revitalize the careers of practicing internists frustrated by certain aspects of American medicine, and to attract more medical students, whose interest in general internal medicine has waned over the last few years. The summit meeting is just one step in a larger dialogue taking place among internal medicine organizations.
To analyze such a wide range of topics, attendees divided up into different workgroups that focused on issues like finance, the practice of medicine, education, appropriate care and accountability. Each workgroup identified specific recommendations for action.
By the end of the summit's second day, the workgroups had identified a "treatment plan" consisting of 18 concrete proposals to help revitalize the specialty. While many of the suggestions reflected policies and positions the College is already advocating, others presented new solutions to take internal medicine through the 21st century.
Here is a look at some of the proposals that received the most discussion—and support—from internists attending the summit.
A positive theme that ran through the meeting was internists' satisfaction with the most basic elements of their specialty: caring for patients, and the intensely personal relationships that result. Early in the meeting, several internists shared moving stories about how their relationships with patients have shaped their lives—and made them glad that they chose internal medicine as a career.
"Overwhelmingly, participants said that their career satisfaction stemmed from the personal relationships with patients and the sense of making a difference," Dr. Herald said. "These relationships are not only the core of internal medicine, but the source of our strength as internists."
The challenge is to convey that sense of satisfaction and pride to the next generation of physicians, many of whom are not choosing to enter general internal medicine. Internal medicine's numbers have been faltering in the Match, and a number of internists at the summit presented anecdotal evidence that the specialty has lost some appeal among the current wave of medical students and residents.
Some said they've heard that medical students are avoiding the specialty out of worries about paying back student loans and working long hours for low pay. Still others—including one internal medicine fellow who told the group that she was going to enter hospital medicine instead of private practice—said that some students are avoiding the specialty because they don't feel their training has prepared them for community practice.
One recommendation at the summit that generated significant discussion called for revamping the system used to train medical students and residents. "We have an old system that can't be tweaked," said ACP Regent Barbara L. Schuster, MACP, who led the workgroup on education issues. "We have to rethink all of the pathways that we use to educate students and residents."
The workgroup called for a process to examine both current and evolving internal medicine practice models so educators have a better idea of what they should be teaching. The group also called for improving the caliber and scope of residency training in office-based internal medicine, and for redesigning training to better reflect new systems of care.
To encourage more students to enter general internal medicine, the workgroup said that medical student debt should be reduced through loan forgiveness programs, low interest loans and deferred payments through expanded support for programs like Title VII funding. At the same time, medical schools should be encouraged to limit tuition increases, and all payers—not just Medicare—should be required to help fund graduate medical education.
The workgroup also made recommendations about CME for practicing physicians. New CME models need to be developed, the workgroup urged, to give physicians new skills in informatics, systems management and procedures.
Throughout the meeting, a number of internists talked about the "dysfunctional" payment system that undervalues internists' services. The workgroup charged with examining financial issues made several recommendations, all of which focused on finding new funds and new payment models for internists.
The workgroup also said that internal medicine should find ways to be paid for the high quality of care and the preventive services they provide. Internists coordinate care for many of the country's elderly patients, the argument went, and they should be paid for that work.
The workgroup concluded that the internal medicine community needs to start to design demonstration projects to begin within the next two years to provide evidence of the benefits that result from that coordinated care.
The workgroup also suggested that internists advocate to be paid for care that is provided or enhanced by telephone and electronic communication like e-mail. In addition, the workgroup recommended that internists continue to push to change the way the government calculates physician pay. The College has argued repeatedly that the government's flawed formula punishes physicians when the volume of health care services goes up.
While much of the conversation at the meeting focused on reimbursements, internists made it clear that the issue was not just a matter of dollars and cents. One internist explained that as reimbursements go down, so does quality of care. In an effort to keep their incomes from being hurt, he said, physicians adjust by spending less time with individual patients.
In the end, he said, everyone loses: Physicians work harder for the same amount of money, and patients have less face time with their physician.
Reducing practice hassles
The flip side of internists' slipping reimbursements is practice overhead: If you can't increase reimbursement, you can reduce expenses. Many internists at the summit called on organized medicine to help internists control their costs. One solution is to eliminate practice hassles, which a number of internists said were driving up physicians' costs—and their blood pressure.
A workgroup on practice issues said that the College should work with other organizations—including the AMA and the Medical Group Management Association—to standardize forms. The workgroup also said that health plans should be required to post their formularies online and use standard forms. (One internist reported that her practice pays one staff person roughly $40,000 a year to handle referral and pre-authorization forms.)
The workgroup also identified what it said was another priority: identifying best practices to increase productivity and decrease overhead and expenses.
Throughout the meeting, another practice hassle that surfaced was administrative services—such as filling out forms—that eat up valuable time but produce no revenue. One recommended solution: Charge patients an "administrative fee" of as little as $50 a year to fill out paperwork.
While the workgroup released few specifics about which patients would pay this administrative fee and how it would work, the recommendation resonated among internists frustrated by forms that add 10 more minutes per patient to their already-packed schedules.
Another proposal urged organized medicine to work with a vendor to develop electronic medical record technology that internists could subscribe to on a monthly basis. Such a model would give internists access to technology without forcing them to come up with a large initial investment.
And several workgroups stressed the importance of continuing to pursue liability reform to reduce physicians' expenses.
Identity and accountability
In discussions about establishing internists' identity and accountability in the eye of the public, several proposals captured the imagination of summit attendees.
To accomplish both goals, one workgroup suggested forging alliances with patient and consumer groups to create a new care model where a single physician is responsible for patient care. Far from functioning as a gatekeeper—a barrier to care—the physician would coordinate the care of individual patients, overseeing the fragmented care that many patients now receive.
Lawrence G. Smith, FACP, past president of the Association of Program Directors in Internal Medicine, talked about a "physician of first resort," a concept that he said harkens back to the way internists have traditionally practiced. By bringing physicians and patients closer together, this type of model could help restore the identity of internists among the U.S. public and improve the doctor-patient relationship.
To rebuild the public's trust in medicine, several internists said, physicians need to put patients' needs and interests ahead of their own. One workgroup suggested that organized medicine establish a public forum in which patients could articulate issues to help guide health policy and redefine the physician-patient relationship to increase trust, access to care and patient satisfaction.
The discussion of identity morphed into a discussion of accountability. With several payers studying the idea of compensating physicians based at least in part on quality measures, the pay-for-performance model was on the minds of a number of summit leaders. (For more, see "As NCQA turns its attention to physicians, performance measures find some ready takers.")
The notion of a single physician taking responsibility for a patient, some said, would make it easier to measure that physician's quality of care. Perhaps more importantly, it would also help internists defend the idea that they produce value through their coordination of complex patient care. Several participants said that the roles of patients and other physicians in making this type of model a reality would need to be defined.
Some participants worried that endorsing—or failing to oppose—highly specific performance measures would create increased dissatisfaction among physicians in general and internists in particular. While many quality measure programs have used "nonthreatening" ways to identify outliers and encourage physicians to correct their behavior, overly specific performance measures may lead to a heightened sense among physicians of being micromanaged. That in turn could drive more physicians from the profession.
One workgroup suggested that organized medicine work with payers and regulatory agencies to influence the creation and use of performance measures. The workgroup also said that internists need support tools to help them become engaged in the quality measurement movement and embrace practice guidelines.
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