Members urge lawmakers to protect internal medicine
From the July-August ACP Observer, copyright © 2007 by the American College of Physicians.
By Jessica Berthold
In the last four years, Margaret Adam, FACP, a Seattle general internist, has lost a third of the 21 colleagues in her group practice. Frustrated by an inadequate and complex payment system, the group's primary care doctors have left to become hospitalists, work for pharmaceutical companies or take an early retirement.
Primary care is in trouble, with fed-up doctors abandoning ship and medical students choosing more lucrative specialties to pay down school debt faster, Dr. Adam told an aide to Rep. Brian Baird (D-WA) during this year's Leadership Day on Capitol Hill. Indeed, about 21% of physicians who were board certified in the early 1990s have left internal medicine, compared with 5% of doctors in internal medicine subspecialties, a 2005 Annals of Internal Medicine study found.
Brindusa Truta, Associate and chief resident at St Mary's Hospital & Medical Center Program in San Francisco, talks to Rep. Pete Stark (D-CA) about the declining number of residents going into primary care medicine. Looking on is Donald C. Balfour III, FACP, a hematologist/oncologist in San Diego.
The good news, Dr. Adam said, is that there are things Congress can do to stem the exodus of doctors from primary care, like implement the patient-centered medical home model (PCMH), which would pay doctors to coordinate all aspects of their patients' care.
"So much of what we do as primary care doctors occurs outside the actual visit," Dr. Adam said. "The (PCMH) would really give hope and help to those of us who are in the trenches."
Dr. Adam was one of 303 College members from 42 states and the District of Columbia who visited Capitol Hill in May to lobby their senators and representatives on issues important to internal medicine. One-third of those in attendance were students or residents.
Many College members asked their lawmakers to support initiatives that bolster the PCMH concept. Other requests included:
- replace cuts to the sustained growth rate (SGR) formula, which is used to calculate doctor's Medicare fees, with increases;
- expand and improve access to care for low-income persons through new legislation and existing programs like the State Children's Health Insurance Program; and
- support student debt relief programs that would encourage aspiring doctors to go into internal medicine.
A focused approach
College members stayed focused on a few key issues—a necessary approach, since Congress has its hands full with a budget deficit, the presidential election cycle and the Iraq war, said Leadership Day keynote speaker Norman J. Ornstein, PhD, a resident scholar at the American Enterprise Institute and a Roll Call columnist.
"It's going to get very difficult to get a focus on policy process right now," Dr. Ornstein said. "If you aren't in field goal range by the August recess, you'll have very little chance of making something happen."
William E. Fox, FACP, a general internist in Charlottesville, Va., gives Rep. Virgil Goode (R-VA) a sheet explaining the College's position on Medicare's sustained growth rate (SGR) formula. "I'm a small business owner," said Dr. Fox. "I can't sustain a 10% cut in payments and stay in business."
After hearing a large group of Florida internists speak about patient care coordination and the dwindling numbers of residents going into primary practice, Rep. Allen Boyd (R-FL) opined that "all our money is going to Iraq. We've got a systemic budget deficit as far as the eye can see. The first programs to be cut will be Medicare."
Internists were bolstered, however, by indications from several aides and legislators that a scheduled SGR cut of 9.9% isn't likely to occur next year. "I'm optimistic about stopping the Medicare cuts this year and next year," Rep. Virgil Goode (R-VA) told three College members during a meeting in his office.
What happens with the SGR in the long term remains to be seen. College members would like to see it repealed eventually, with positive updates in the years leading up to the repeal. If that doesn't happen, and the threat of cuts continues, problems with access to care will persist and worsen, said David Peach, FACP, an Anchorage, Alaska gastroenterologist.
"People are having a harder time finding doctors, and the main reason is pay. The SGR has fallen behind the times. Every year there are more doctors who decide not to see Medicare patients anymore," Dr. Peach told Rep. Don Young (R-AK). "My partner just retired at age 68. He was the primary care physician for 300 Medicare patients, and they are all looking for a doctor."
Fewer primary-care residents
Uncertainty about reimbursement has led residents and medical students to steer away from primary care, several College members told lawmakers. In 2006, only 24% of third-year internal medicine residents intended to pursue careers in general internal medicine, down from 54% in 1998, College research shows.
"I'm in medicine to improve the access and quality of health care through primary care, and about half my classmates have the same goal," Theresa Cruz Mangahas, a second year medical student at the University of Washington and ACP student member, told Rep. Baird's aide. "However, medical students graduate roughly $150,000 in debt and a primary care doctor's salary is much lower than other specialties, so it takes longer to pay the debt back. This is a key reason why most of my classmates are choosing specialties instead of primary care."
The trend is especially alarming at the University of Washington, which has been ranked as the #1 primary-care medical school by U.S. News and World Report for the 13th straight year, noted Douglas Paauw, FACP, a UW professor.
"Primary care isn't just threatened, it's dying right now."
—Douglas S. Paauw, FACP
"When you see a drop like this at the nation's top school, it's scary," Dr. Paauw said. "Primary care isn't just threatened, it's dying right now."
Students and residents in Florida and California told similar tales, and urged their lawmakers to support programs offering debt relief for students. Specifically, they requested the reauthorization of the Higher Education Act of 1965 so that it includes provisions to extend the loan deferment period for residents and fellows, expands the definition of "economic hardship" and mandates full disclosure of loan terms.
They also sought co-sponsors for S. 1066, the Medical Education Affordability Act, which extends the student loan repayment deferment for borrowers who are in postgraduate medical or dental internship, residency or fellowship programs until they are finished with training.
Rep. Michael Burgess (R-TX) told internists he is working on bills to attract more primary care doctors to smaller urban areas. One bill would provide loan forgiveness payments to residents who practice in high-need areas, as well as tax relief. Another would give money to small- to medium-sized hospitals to establish residencies where they currently don't exist.
"In Texas, there aren't enough primary care residencies to keep medical students in Texas, and we tend to practice where we train. By creating residencies, we hope to retain doctors," said Rep. Burgess, who is an ob/gyn. The bills hadn't been introduced as of press time.
The PCMH incentive
Instituting elements of the PCMH also would encourage more students to go into primary care, said Michael Rein, FACP, a professor and infectious disease specialist at the University of Virginia in Charlottesville, Va.
"The reason students don't choose primary care or internal medicine isn't just financial. It's because, under the current system, they can't be internists the way they wanted to be. But the patient-centered medical home can address that," Dr. Rein told Rep. Goode.
David Winchester, ACP Associate Member, a resident physician at the University of Virginia with a patient panel at the residents’ clinic, illustrated how current payment structures stymy his ability to deliver the best possible care to a patient who is diabetic, has had several heart attacks and is on dialysis for kidney failure.
"He has two to three years to live, and the best service I can provide is to keep him out of the hospital. But I get paid to ask questions and listen to organ systems," Dr. Winchester said. "If I were paid to coordinate care, it would be of great benefit to him."
As a starting point, these and other internists urged their lawmakers to support the Geriatric Assessment and Chronic Care Coordination Act of 2007 sponsored by Sen. Blanche Lincoln (D-AR) and Rep. Gene Green (D-TX), which would link chronically ill seniors with a health professional to coordinate their care.
Concerns about access
College members also expressed concern about the roughly 15% of Americans who lack health insurance, which the Institute of Medicine estimates causes an average of 18,000 deaths per year. Several discussed the feasibility of a single-payer system, with the knowledge that such an initiative wasn't likely in the near future.
Many urged their representatives and senators to co-sponsor a new bill that is based on a College proposal: the Health Coverage, Affordability, Responsibility and Equity Act (CARE) by Reps. Marcy Kaptur (D-OH) and Steven C. LaTourette (R-OH). The measure gives a variety of financial incentives to states, small employers, individuals and insurers to provide or purchase affordable health coverage.
Rep. Young of Alaska said he would look closely at the bill. "You've got two good people sponsoring it already," he said about the Ohio representatives.
Internists also asked their representatives to reauthorize the State Children's Health Insurance Program (SCHIP), which provides coverage to more than six million children in need, and to expand the program to include more low income persons.
Replace the SGR
- Support legislation to replace the 9.9% cut in physician fees scheduled for 2008 with a 1.7% increase.
- Mandate a positive update in 2009 that reflects cost increases.
- Set a date for repealing the SGR, and during the transition, establish a process for annual increases that reflect costs.
Reward Quality Care
- Provide funding to revise Medicare's Physician Quality Reporting Initiative so that doctors can receive additional bonuses for reporting on clinical and structural measures that improve patient care—like acquiring the systems needed to deliver patient-centered care and manage chronic diseases.
Support the Patient Centered Medical Home
- Co-sponsor the Geriatric Care Management Act, which would give a monthly Medicare payment to doctors who provide ongoing care coordination to patients with chronic disease or dementia.
- Pass legislation to provide grant funding in the SCHIP reauthorization bill for states to provide a PCMH to recipients with special needs, chronic diseases and obesity.
- Co-sponsor the National Health Information Incentive Act of 2007 (H.R. 1952), which gives incentives to doctors in small practices to acquire health information technology.
Expand Coverage for the Uninsured
- Reauthorize the State Children's Health Insurance Program (SCHIP).
- Urge House members to co-sponsor the HealthCARE Act, which expands coverage in steps, and ask Senators for similar legislation.
- Support efforts to encourage states to organize their state programs, like Medicaid and SCHIP, around the PCMH.
Relieve Student Debt Burden
- Reauthorize the Higher Education Act of 1965 and include provisions to extend the loan deferment period for residents and fellows, expand the definition of "economic hardship" and mandate full disclosure of loan terms.
- Co-sponsor the Medical Education Affordability Act (S. 1066), which extends student loan repayment deferment for borrowers in postgraduate medical or dental internship, residency or fellowship programs through the duration of their training.
Robert McLean, FACP, a general internist in New Haven, Conn., won the Key Contact of the Year Award at Leadership Day 2007, which honors exceptional grassroots efforts to advance the College's policy agenda. In addition to staying in close contact with members of his local media throughout 2006, Dr. McLean seized a rare opportunity to speak at length with an interested lawmaker about the Patient Centered Medical Home—to great effect.
While at a dinner meeting with former Rep. Nancy Johnson, R-Conn., in February 2006, the Congresswoman asked Dr. McLean if the College had a proposal to improve health care while reducing Medicare costs. The physician enthusiastically spoke with her about the PCMH, then provided her with a copy of the College's policy paper on the spot.
Several weeks later, former Rep. Johnson included discussion of the PCMH in congressional hearings, and by December 2006, pilot testing of the model had been mandated in Medicare legislation.
"I'm here because I've been lucky and opportunistic," said Dr. McLean, in accepting the award. "So many ACP policies and suggestions are rational and altruistic. You just need to find a legislator who will take the time to listen."
Dr. McLean also frequently submitted letters-to-the-editor to Connecticut newspapers, including one about the need for comprehensive health care that was published in the New Haven Register in February 2006. A few months later, during Leadership Day 2006, Dr. McLean contacted the Register's Washington D.C. correspondent, which resulted in an A section story about how fewer students are training to become family doctors. He authored a March 2007 article about access to health care, as well.
The Connecticut Chapter's "advocacy success was largely a summary of Dr. McLean's accomplishments," concluded David L. Bronson, FACP, Chairman of the Board of Governors, in presenting the award.
Other Members who received Key Contact special recognition at Leadership Day included:
- Dawn E. Clancy, FACP (Johns Island, S.C.)
- S.A. Dean Drooby, FACP (Oklahoma City, Okla.)
- Jacqueline W. Fincher, FACP (Thompson, Ga.)
- Richard W. Frieden, Member (Chico, Calif.)
- Sharon C.H. Mead, FACP (Glen Head, N.Y.)
- Kay M. Mitchell, FACP (Jacksonville, Fla.)
- Lawrence M. Phillips, Member (Floral Park, N.Y.)
- Mark W. Purtle, FACP (Des Moines, Iowa)
- Susan E. Sprau, FACP (Santa Monica, Calif.)
- Robert G. Strickland, FACP (Albuquerque, N.M.)
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