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



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

Surviving Medicare Part D

Your excellent advice on surviving Medicare Part D needed to include one more tip: Have the patient make an appointment. ("Part D hopes and hassles begin to play out," May ACP Observer, page 1.)

Every time we receive a request for a formulary change from a patient or pharmacy, my staff is instructed to ask the patient to make an appointment, come in and discuss the change. Then I can review the change with patients and complete, in their presence, a formulary exception form if necessary. I also document the discussion and schedule a follow-up appointment to assess their response to the new medication.

This allows patients to be properly informed about the risks and benefits to medication switches—and makes them aware of the many administrative hassles physicians face every day. It also allows me to be properly compensated for the time spent by myself and my staff.

Ronald L. Hirsch, FACP
Elgin, Ill.

Your recent article on Medicare Part D is fraught with an ironic twist that went unacknowledged by your excellent overview.

ACP has advised internists not to counsel patients on their specific plan choice, despite the large numbers of patients who seek my advice. However, the same article reports on a Pittsburgh-based company that, for a $19.95 fee, will provide an individual analysis of a beneficiary's options and associated costs.

Doesn't the fact that one of the company's principals represent several large national insurers that offer Part D plans bother someone other than myself—and highlight how difficult the benefit is for the average senior to understand?

Clifford F. Feiner, FACP
Jamaica, N.Y.

ACP's Washington office responds: Dr. Feiner’s letter reflects two key points about the new Part D benefit: the enrollment decision is very complicated for many beneficiaries, and primary care physicians are often one of the first sources enrollees look to for advice.

In previous ACP Observer articles the College has suggested that physicians not refer patients to specific plans. Instead, physicians should provide objective information on the type of features to look for in a plan based upon patients' medication needs. Physicians were also strongly encouraged to direct patients to sources supported by the Centers for Medicare and Medicaid (CMS), including the 800-MEDICARE hotline and web site, as well as their local state health insurance assistance program. (You can locate that program by calling 800-677-1116.)

In its marketing guidelines, the CMS also has strict limitations on direct plan referrals from physicians who are contracted with a Part D plan or related entity.

Outsourcing trends

I was disturbed by several issues raised in the Q&A with Robert M. Wachter, FACP, on the outsourcing of medical services, including radiology and intensive care unit (ICU) monitoring. ("Beaming images overseas sparks controversy at home," May ACP Observer, page 13.)

First, there is no such thing as “lower-cost, around-the-clock providers,” either in the ICU or elsewhere in medicine—because watching a bank of monitors is not practicing medicine. Monitors cannot replace the cognition that goes into the on-the-spot troubleshooting of problems or the comprehensive management of cases long-term.

Plus, the notion of dividing a colonoscopy into "smaller components" with technicians doing the insertion strikes me as dangerous. With no physician onsite during the procedure, who will handle or treat complications—such as perforation or respiratory depression—or even recognize when complications occur? How can you separate the person performing the procedure from the one responsible for that patient's care?

And to the question of “how can we ensure quality,” Dr. Wachter claims that the same “digitized" system can also “measure and monitor care." Does he really think the offsite system that records and delivers care can measure and monitor itself?

The College advocates for ensuring quality through maintaining board certification. Why would we want to send radiologic studies overseas to be interpreted by physicians whose training, care standards and expertise are impossible to judge?

Frances Parisi, ACP Member
Lancaster, N.Y.

Dr. Wachter responds: On-the-spot troubleshooting by a real-live intensivist sounds attractive, but hundreds of hospitals can’t find or afford one—making the tele-intensivist an appealing alternative. Having a gastroenterologist perform all parts of every GI procedure feels right, unless some components could be performed safely at half the cost.

The bottom line is that health care will be judged on value: quality divided by cost. At this very moment, the denominator of that equation is bankrupting hundreds of American companies and tens of thousands of its citizens. It is immoral not to seek ways to provide high quality care at more affordable costs.

Dr. Parisi asks: How can we ensure quality? As a board member of the American Board of Internal Medicine, I have witnessed the board’s powerful commitment to ensuring the quality of care. But the days of testing such quality solely through a one-time exam are gone. Patients, payers and policymakers now expect us to tap into actual clinical data to assess a physician’s quality of care.

I suspect that, once we truly figure out how to do that, the additional challenge of assessing the care of the radiologist in Bangalore vs. Bangor, Maine, or of the remote vs. onsite intensivist will not prove insurmountable.

I enjoyed the interview with Dr. Wachter on controversial outsourcing innovations. However, both the interview and Dr. Wachter’s original New England Journal of Medicine article failed to point out another outsourcing trend: patients going to India for surgical procedures.

The business of patients going abroad for medical interventions is known as medical tourism. While it is not yet common in the U.S., it is well established in Europe.

The process is being driven in the U.S. by several factors: India is giving tax incentives to the industry; American academic medical centers are establishing business or professional relationships with Indian hospitals; the Joint Commission on Accreditation of Healthcare Organizations is accrediting Indian hospitals; and, most importantly, there is an approximate 10-1 cost difference between care in the U.S. and India.

If medical tourism becomes common here, what niches could it fill? It may allow managed care to reduce costs, provide a refuge for our many uninsured Americans or help patients avoid the hospital-acquired resistant infections that are increasingly common here.

Medical tourism would also "commoditize" the practice of surgery. Dr. Wachter pointed out that primary care doctors are the most immune from the changes brought by the Internet to medical care, and I agree. But if surgery becomes an international commodity, can internal medicine be far behind?

Frederick E. Turton, FACP
Sarasota, Fla.
The comments expressed here by Dr. Turton, who is a College Regent, are solely his own and do not represent an official position of ACP.


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