American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP's long, continuing fight for better reimbursement

From the January/February ACP Observer, copyright © 2004 by the American College of Physicians.

Last September, I wrote about the crisis facing internal medicine, particularly the circumstances that threaten general internal medicine. In a letter in the November 2003 ACP Observer, one concerned College member responded that what I had to say failed to convey the great urgency of internists' financial plight.

That reader also felt I didn't sufficiently explain the College's advocacy work to improve internists' reimbursements. When one physician takes the time to voice his alarm in print, I realize that many more ACP members may have similar concerns. As a result, I want to discuss the reimbursement issues that affect internists and the College's sustained efforts on their behalf.

Tough calls

The College has consistently and actively advocated for more equitable reimbursement for internists. Our goal has been to better align payment rates with physicians' actual time commitments and practice costs. We have pushed especially hard to improve reimbursements for office visits and evaluation and management (E/M) codes based on the resource-based relative value scale (RBRVS).

We've had significant success. Medicare payment rates for some frequently used codes have risen more than 20% above inflation since the RBRVS was first implemented in 1992.

But these efforts have not been simple or straightforward. Indeed, several years ago, when our advocacy efforts helped improve rates for general internists, procedure-based internal medicine subspecialists actually suffered a loss in reimbursement.

The College found itself in the tough position of having to represent different—and adversarial—constituencies within our own membership. Until total payment for all physician services grows, we will continue to be forced to redivide a fixed financial pie. When any one physician faction wins, another loses, keeping members of the medical community at odds with one another.

Short-term victories

As I write this column, we've just learned that after a fierce political fight over Medicare reform, we were able to avert another deep cut in Medicare reimbursements. To avoid the 4.5% reduction scheduled to take effect this month, the College backed Medicare reform legislation. (See "What will new Medicare legislation mean for reimbursement, practice hassles, patient care?")

If the Medicare bill had not passed, the cut in physician payments scheduled for 2004 would have been the fifth such decrease since 1991. In fact, between 1991 and 2003, payment rates for physicians fell a full 14% behind cost inflation, as measured by Medicare.

Robert B. Doherty, ACP's Senior Vice President for Governmental Affairs and Public Policy, urged ACP members to ask their senators and representatives for their support. Your huge response—College members sent more than 5,700 messages to Congress on the legislation—contributed to the bill's passage and a substantial victory. Not only did we halt the backward slide in income, but internists will be guaranteed a minimum increase of 1.5% a year for the next two years. Internists working in rural areas will see even bigger gains.

Even with this good news, however, it is discouraging to recall that only a year ago, the College, along with the AMA and other organizations, had to mount a formidable lobbying effort to prevent a similar cut. Those efforts met with success, but not because legislators fully appreciated our concerns.

Rather, we persuaded Congress of the short-term consequences (and political fallout) of physician pay cuts: disastrously curtailed access to care for elderly constituents. From 1999 to 2002, the percentage of physicians accepting new Medicare fee-for-service patients declined by more than 7%. Further cuts in physician payments, we argued, would further shrink that dwindling pool.

Looming implications

While concerns about access remain a real problem, most lawmakers still aren't looking at the long-term consequences of our reimbursement predicament, nor do they understand its national implications.

We desperately need a reimbursement system that recognizes and pays physicians equitably for the time it takes to manage the elderly, particularly those with multiple, complex illnesses. These are the patients we as a specialty care for, yet the supply of internists to provide care in coming decades is being threatened. This was a prominent theme when ACP held a summit meeting on the "revitalization of internal medicine" in November 2003.

Medical students are voting with their feet to train and practice in "greener" fields. From 1999 to 2002, the number of graduating medical students who chose general internal medicine dropped from 12.2% to 5.9%, a stunning 51% decrease. (The number of new graduates choosing family medicine in those years dropped even more.) At the same time, internal medicine subspecialties—especially those with highly-reimbursed procedures—saw a 39% increase in new "recruits."

While factors such as lifestyle and practice environment contribute to those decisions, it's no coincidence that generalist physicians occupy the bottom rung of the reimbursement ladder. Why are graduates turning away from internal medicine? They consistently cite the fact that the health care system doesn't recognize or adequately reimburse internists' time-intensive practice.

We as internists should not be the only ones alarmed by these trends. The projected shortage of internists is a profession-wide issue and a national health policy concern. This is especially true when we consider the aging of our population—all those silver-haired baby boomers—and the growing numbers of adults of all ages with chronic and complex illnesses. A national medical crisis is looming because of the serious mismatch between the mounting needs of an aging population and the declining numbers of new internists entering practice.

That crisis may be increasingly felt in the short term as well. A study jointly funded by the ACP Foundation and the Commonwealth Fund was published in the November/December 2003 Health Affairs. It found that almost 70% of general internists provide charity care to the uninsured, typically to existing patients who have lost coverage. (Click here for a study abstract.)

Approximately two-thirds of general internists reduce their fees or provide free care in millions of office visits every year to uninsured patients. But current forces—reimbursement cuts and market pressures from managed care plans, for example—are almost certain to restrict internists' ability to continue to provide gratis services.

To do so, physicians need financially viable practices—exactly what is being threatened by a profoundly flawed approach to physician reimbursement. With growing numbers of long-term unemployed, the access crisis we foresee for baby boomers may be upon us even sooner.

A broader advocacy agenda

While the College will continue its efforts to improve all revenue streams, achieving positive results within the present system is extremely difficult. Consider the challenge that Mr. Doherty recently issued as part of ACP's efforts to revitalize internal medicine:

"If we limit our thinking to how best to tweak the existing payment methodologies used by Medicare and other payers," he said, "internists are going to be faced with continued cuts in reimbursements, or at best stagnant reimbursement, for the foreseeable future. We need to develop policy recommendations that align the interests of policy-makers and payers with policies that benefit the specialty of internal medicine."

Last November's revitalization summit called for definite action plans and for broadening our agenda to improve reimbursement. To my mind, ACP's policy paper on resolving payment and practice hassle issues is a good start. In it, we call for reimbursement for health-related, Web-based communications, as well as pay for geriatric assessments and preventive care and screening services.

Nevertheless, the College and the other organizations participating in the summit must develop new proposals to improve the reimbursement system. It is propitious—and a challenging opportunity for us—that the new Medicare legislation authorizes demonstration projects for developing and testing new reimbursement models that reward physicians for effective management of patients with chronic illnesses.

Above all, if we are to have a hand in improving our situation, we must focus our advocacy efforts on helping the public and lawmakers understand the bottom line: that equitable reimbursements for internists of every stripe will mean there will be more internists available to care for the nation's burgeoning population of elderly and other, chronically ill adults. It's not simply that we internists want to be reimbursed fairly. It's that fair physician reimbursement will ensure that aging and chronically ill Americans have the good doctors they need and the good care those doctors provide.

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