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



From the May ACP Observer, copyright 2004 by the American College of Physicians.


Your article about overhead is especially timely considering information published in the February 2004 issue of Managed Care. ("Physicians try to rein in runaway overhead," March ACP Observer letters online.)

The articles in Managed Care found that while office overhead rose 12% last year, reimbursement increased only 6%. A novel approach might be to look at why overhead is going up, and whether patients are getting value for the increased costs.

Unfunded mandates like HIPAA-compliance officers and five-digit codes offer little benefit to patients but increase overall costs.

Physicians and hospitals spend an enormous amount of money making their medical charts look better to protect themselves in the event of a malpractice lawsuit. And while computers and software may help physicians and hospitals increase billing or improve documentation, those costs seem to provide only marginal benefit to patients when compared to the costs incurred.

At a time when the costs of health care and liability insurance are driving jobs overseas, we can ill afford the 37 cents per collected dollar our office spends on billing and collections, particularly when it provides no added value to patient care.

Unfortunately, we are likely to see more documentation and regulation not based on patient care benefits or to reduce fraud, but essentially for its own sake. Focusing new or existing costs on value for the patient would eliminate wasteful excesses, reduce costs and make the American economic system more competitive in a world market.

James C. Maher, FACP
Marshall, Mich.

Your suggestions on how to reduce overhead were paltry and another example of how we persist in inviting our own demise. The reason, harking back to Shakespeare, is in ourselves.

Why don't we ever say "no"? No to obscene malpractice rates; no to reimbursements incompatible with real life; no to the constant micromanagement that endangers our patients and engages us in daily, mind-numbing wars with insurers.

I am 61 and have been in solo practice in medicine and gastroenterology for 31 years. While I love being a doctor, I can no longer afford my office and I'm tired of asking permission-givers for permission. If every doctor from Bangor to San Diego said "no" instead of constantly accepting this wholesale destruction, things would improve.

I'm embarrassed, as a College member, to hear you tell me to dispense with my answering service and give out my home phone number to save money. When lemmings jump off the cliff, they all die.

Wendy S. Aronson, FACP
New York

Internal medicine crisis

The current "crisis" in general internal medicine is more than just a crisis. We are dying as a profession. (Letters, March ACP Observer online.)

When reimbursement for a hospital visit equals reimbursement for an office visit, it no longer makes sense for community based general internists to see and manage hospitalized patients. We didn't train to practice only office-based medicine, but financial realities are forcing us into that model.

Because vacations and CME come only after all overhead is paid, they cost more in lost income than the direct cost of any trip or conference. Most of my partners can no longer afford to see new Medicare patients, yet we are the physicians best trained to take care of this population.

In our town, the only new general internists in the past five years have been those hired by the VA or directly employed by hospitals. Starting salaries there are more than what I earn as a geriatrician with 25 years of experience. Residents and students understand these issues and are voting with their feet.

I applaud the College's efforts to increase reimbursement for "cognitive" services, but let's be honest with ourselves. Without a wholesale reorganization of American medicine that places a financial priority on our ability to manage complex older patients, we as a specialty are dead.

Thomas H. Roberts, ACP Member
Missoula, Mont.

Performance measures

I would like to thank Michael E. Miller, ACP Member, for his comments on the growing use of performance measures. (Letters, March ACP Observer online.)

The rationale for performance measures reminds me of how physicians were duped in the past, when insurance companies claimed managed care would not only benefit patient care but be profitable for doctors.

It is no coincidence that both the government and the insurers are pushing for "quality assurance" measures. The federal government is creating a universal billing number system that it will use to track billing for not only government-covered health care services, but all services. The insurance industry is supporting this system under the guise that it will help cut costs and simplify billing for physicians.

I worry that the government and insurers are going to use this system to exclude physicians who they say don't provide "good quality." After a computer-generated review of a few charts, for example, a computer-generated notice will conclude that Dr. X is a poor quality doctor because he or she didn't give all his or her congestive heart failure patients ACE inhibitors. Eventually, I suspect, we'll find ourselves jumping through more hoops to earn the same pay we made five years earlier—with higher overhead because of all the extra paperwork.

If we remain complacent, others will continue to tell us not only how much we can charge for our services, but eventually how to perform those services. Let's use the only clout we have: unanimity.

Randy D. Visser, ACP Member
Redmond, Ore.

As someone who works in an organization that regularly uses quality indicators to improve health care, I found the claim that all data reports are "truly useless" simplistic.

I work for the Delmarva Foundation of the District of Columbia, which serves Medicare beneficiaries on behalf of the Centers for Medicare and Medicaid Services (CMS). As the District's quality improvement organization, we regularly collect and analyze physician data for quality improvement projects.

Under our current contract with the CMS, we collect information from the office encounters of a group of private physicians. (Most are primary care physicians, but a few are specialists.) We are currently collecting information about diabetes care, breast cancer prevention and immunizations.

Physicians in the project, who represent about 7% of the primary care providers in Washington, have volunteered to participate. After establishing a baseline, we collect data on a quarterly basis for three years.

Delmarva's staff works with each physician's office staff, as well as the physicians, to review and recommend interventions, where needed, to improve both efficiency and compliance with quality indicators. We give feedback on a quarterly basis and compare those results to both national and local data. Thus far, both physicians and their staffs have accepted the project with enthusiasm.

Evidence that this type of system works can be found in an article in the Jan. 15, 2003, Journal of the American Medical Association. If this kind of improvement saves insurers, private or public, money on health care, no apology is necessary. We need more efficient methods of collecting, organizing and utilizing the enormous amount of data required to provide quality patient care.

Harold Weiss, FACP


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