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

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Primary care’s collapse tops agenda on Leadership Day

Members visited Capitol Hill to convince lawmakers that payment reform is critical to primary care's future

From the July-August ACP Observer, copyright 2006 by the American College of Physicians.

By Janet Colwell

WASHINGTON—Jacqueline Fincher, FACP, a general internist in rural Thomson, Ga., is all for linking physician payments to quality of care. But she worries about the cost to small practices.

She and her three partners recently installed an electronic health record system for $200,000—representing one-sixth of their total budget. This scenario is being played out across the country, she told an aide to Rep. Sanford Bishop (D-Ga.) during this year’s Leadership Day on Capitol Hill. But small practices are "being squeezed" by a payment system that not only doesn’t help physicians invest in technology but actively discourages the coordinated, long-term care of chronically ill patients.


Jacqueline Fincher, FACP, points out to legislative staff that her practice now limits the number of Medicare patients it treats.



Another consequence of bad payment policies: She and her colleagues have had to limit their Medicare patient enrollment to 42% of their practice, down from 70% a decade ago. “It’s hard when we have to turn people away,” she told the health care aide, “but if we didn’t limit our Medicare patient load we’d go out of business.”

Dr. Fincher was one of 264 College members from 42 states and the District of Columbia who converged on Capitol Hill in May to lobby their senators and representatives on issues important to internal medicine.

One major issue was payment policies and other factors contributing to the looming collapse of primary care. ACP members outlined the problems with the Medicare payment system and urged repeal of the sustainable growth rate formula (SGR) used to calculate physician fees.

They proposed some short-term fixes, including replacing scheduled pay cuts with modest increases and boosting the Medicare work relative values for evaluation and management services by shifting dollars from specialty procedures to cognitive services. They also explained to lawmakers the College’s "advanced medical home" concept of care delivery, which would put internists at the head of teams delivering physician-led, patient-centered care.

A primary care crisis

Some of the most sobering discussions with policy-makers were led by medical students and residents. They gave first-hand accounts of why so few medical graduates are going into primary care.

They presented startling numbers: Only 20% of third-year internal medicine residents surveyed in 2005 planned to pursue careers in general internal medicine, compared with 54% in 1998. At the same time, only 13% of first-year residents planned to go into primary care.

Andrew P. Seaman, ACP Medical Student Member, a second-year medical student from Alaska, told Sen. Lisa Murkowski (R-Alaska) that more than half of his classmates would like to go into primary care—but only if payment issues are resolved.


Andrew P. Seaman, ACP Medical Student Member (speaking, photo left) tells Sen. Lisa Murkowski (photo right) that payment issues would have to be resolved before his classmates would consider primary care.



“There have to be some incentives,” said Mr. Seaman, who will face $150,000 in loans when he graduates. “If we have to limit appointments to 10 or 15 minutes, we aren’t getting what we wanted out of being primary care doctors, which is time with patients.”

Julie A. Ake, ACP Associate Member, a third-year internal medicine resident in Seattle, told Sen. Murkowski that she “doesn’t know anyone” among her colleagues who is going into primary care. She added that rotations during the third year are an eye-opener about the realities of primary care.

“We see older doctors who are frustrated and on a treadmill, providing fragmented care,” she said. “Then we see specialists who have more time to spend with patients.”

As residents of Alaska, Dr. Ake and Mr. Seaman both pointed out the difficulty of attracting young physicians to underserved areas. Students and young physicians must train in more populated areas, where many eventually get attractive job offers.

Sen. Murkowski noted that Alaska’s shortage of primary care physicians is already far worse than in other states. “It would take 500 more doctors,” she said, “to get Alaska on a par with the rest of the nation.”

Abinash P. Achrekar, ACP Associate Member, of Correales, N.M., told an aide to Sen. Pete V. Domenici (R-N.M.) that he had initially planned to go into primary care—but changed his mind.

“Even though I support primary care, I am going to specialize,” Dr. Achrekar said. “None of my colleagues is going into primary care because we see a crisis coming in the next five years if nothing changes.”

Roadblocks to reform

While staffers and lawmakers alike agreed that the payment system is flawed, all expressed concern about the potential costs of reform. Estimates ranged from $8 billion to $11 billion just to avert scheduled decreases over the next five years and freeze physician payments at their current level.

Another problem, some staffers pointed out, is that there is no logical piece of legislation to tie an SGR reform bill to. In 2003, for example, the temporary payment fix to scheduled SGR payment cuts was linked to Medicare prescription drug benefit legislation.

Unless Congress acts to repeal the SGR, ACP members told officials, the Centers for Medicare and Medicaid Services (CMS) is projecting a 4.6% cut in 2007 and a total of 34% in cuts through 2015. Such cuts would force many general internists out of business and discourage even more students from going into primary care. ACP is recommending that Congress implement an SGR alternative system that would not be linked to fluctuations in the economy, as is the case now. Ideally, any new formula would reflect practice costs and include resources to support quality improvement.

Information technology (IT) was another major concern voiced by many physicians. Several gave reports similar to Dr. Fincher's on the high costs for small practices—and said they feared they would have to join larger groups or hospitals to make information technology a reality.

James W. Sawyer, FACP, a general internist at the Diagnostic Clinic of Longview, Texas, said he worries that practices such as his own will be forced to ally themselves with hospitals in their community to afford an electronic conversion. But “we don’t want the one that our local hospital is encouraging,” he said, “and we don’t want to tie our clinic tightly to the hospital.”

John F. Schneider, FACP, a general internist from Chicago, echoed those concerns. “The hospitals want IT that supports their operations,” he said. “They will sell it to us but that ties us to them.”

While legislative staffers were sympathetic, they stressed that any financial assistance for information technology would have to be tied to quality improvement.

Updates from the Hill

Before their meetings on the Hill, College members heard from Rep. Nancy L. Johnson (R-Conn.) and Sen. Ron Wyden (D-Ore.) on priority health care issues.

Rep. Johnson, chair of the House Ways and Means Health Subcommittee, acknowledged that the physician payment formula is outdated. “We can’t just keep putting more money into physician payments,” she said. “We need a change in thinking.” Rep. Johnson last year introduced the Medicare Value-Based Purchasing for Physicians' Services Act of 2005 (H.R. 3617), which calls for basing Medicare payment updates on quality measurements.

Rep. Johnson also said she is “very interested” in the College’s advanced medical home model and its emphasis on health care teams. “It’s about how we combine resources that already exist,” she said. “The view now at the CMS is how to move to a preventive health management mode and still deliver the level of treatment necessary.”

Sen. Wyden, who serves on the Senate finance and budget committees, told attendees that he “strongly supports” repealing the SGR.

“We’re spending enough money but it’s not in the right places,” he said. “It has to be on the front end with primary care.”

The biggest point of contention between the political parties on the Hill is whether the health care system should be driven by the individual or by government.

“We need something in between,” Sen. Wyden said. “We need the government to share a bit of the risk for very large bills so that small business can afford to provide general coverage without being wiped out by one catastrophic bill.”

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ACP in Washington: priority issues

Support primary care

  • Increase the Medicare work relative value units (RVUs) for undervalued evaluation and management services.
  • Develop a better process for identifying overvalued work RVUs to increase the pool of dollars for other services.

Advocate for advanced medical home

  • Ask officials to work with the College to develop and/or support legislation that would direct the Centers for Medicare and Medicaid Services (CMS) to design, implement and evaluate a new model of physician-guided, patient-centered care.

Link payment to quality

  • Have Congress authorize the CMS to implement a phased-in program to reward physicians who voluntarily engage in quality improvement and care coordination, based on CMS’ Physician Voluntary Reporting Program.

Reform the SGR

  • Support legislation to replace the 4.6% cut in physician fees projected for 2007 with a 2.8% increase.
  • Repeal and replace the SGR with an alternative method of updating physician fees that would not be connected to measures of per capita gross domestic product. A new payment system should reflect true physician practice costs and be aligned with incentives for quality measurement and reporting.

Foster information technology adoption

  • Support the bipartisan National Health information Incentives Act (H.R. 747) that facilitates the adoption of information technology standards and incentives for small practices.
  • Support funding of the office of the national coordinator for information technology and increased technology research funding by the Agency for Healthcare Research and Quality.

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Low-tech approach yields high rewards for Key Contact winner

Four days a week, Murli Manohar, FACP, an allergy and infectious diseases specialist in Canton, Ohio, goes about the typical routine of running a solo practice. But on Wednesdays and Saturdays he closes his doors to patients, lays his stethoscope aside and changes the sign on his door to the "Center for Health Care Policies and Planning."


Murli Manohar, FACP



Physically, it’s the same office, said Dr. Manohar, who opened his Canton practice in 1980. But as director of the center, which has its own official letterhead, he switches from direct patient care to tending to the larger political issues shaping U.S. health care.

He’s had considerable success since 1984, when the center opened its doors, forging longstanding relationships with senators and representatives, especially in his home district. In May, he received the College’s Key Contact of the Year Award, given to an ACP member who has been instrumental in supporting the College’s grassroots agenda.

A force in his community

Dr. Manohar is a well-regarded political force in his hometown, known for his support of immigrant and indigent population issues. He worked closely with a former Canton mayor in 1992 to co-found the city’s free clinic, which is now supported by more than 50 volunteer providers.

After realizing that fear of malpractice suits was hurting the clinic’s ability to recruit volunteer physicians, he helped develop legislation, later adopted in Ohio, that gives malpractice immunity to physicians working in free clinics. He supported several other malpractice bills that were later passed by the state legislature, including limiting noneconomic damages to $350,000 and extending peer-review protections to non-hospital settings, such as physician offices and ambulatory surgical facilities.

In 1996, Ohio’s then-Gov. George Voinovich (now a U.S. senator) appointed Dr. Manohar to the state commission on minority health, a volunteer post he used to champion issues related to health care for the poor. He’s also served as a paid consultant to the state and city departments of health--part of a resume that gives him clout with political leaders.

Low-tech, high touch

Surprisingly, Dr. Manohar has successfully forged these political alliances without using a computer. While fellow advocates have latched onto the power of the Web, e-mail and even blogs to broadcast their message to ever-wider audiences, Dr. Manohar still relies on phone calls and faxes.

Old-fashioned networking underlies his successful formula, said Dr. Manohar, who describes the center as a “public-private think tank.” Whenever a health care bill comes forward he calls upon a local network of advisors ranging from doctors and lawyers to chief executive officers, patients and patient advocates.

He forms an opinion based on his own research and his advisors’ input and “that’s what I pursue,” he said. “I might write a letter in support of a bill or go to the Hill or state capital to testify for or against it.” He makes two to three trips every year to Washington and another one or two to the state capital.

He first became active in politics in medical school, he said, and is convinced that physicians can't really separate clinical practice from political realities.

Important issues are always worth a fight, he said, no matter what the outcome.

“I win some and lose some,” said Dr. Manohar. “You get a bloody nose sometimes, but you move on.”

Other Members who received Key Contact special recognition at Leadership Day included:

  • Robert L. Allison, FACP (Pierre, S.D.)
  • Dawn E. Clancy, FACP (Johns Island, S.C.)
  • S.A. Dean Drooby, FACP (Oklahoma City)
  • Jacqueline W. Fincher, FACP (Thomson, Ga.)
  • William E. Fox, FACP (Charlottesville, Va.)
  • Glenn D. Littenberg, FACP (Pasadena, Calif.)
  • Robert M. McLean, FACP (New Haven, Conn.)
  • Richard L. Neubauer, FACP (Anchorage)
  • Susan E. Sprau, FACP (Northridge, Calif.)
  • Sara E. Walker, MACP (Columbia, Miss.)

Special Advocacy Awards for Leadership Day 2006:

  • Vineet Arora, ACP Member (Chicago)
  • Kerry Donegan, ACP Student Member (New York)

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