In April, I will complete the best professional year of my career as an internist. To be the president of the College has truly been an honor and a privilege. As I reflect on the year, it is remarkable that over the 101 years of the College, it has remained the premier and most respected organization in medicine for its contributions to the principles and practice of medicine in education, advocacy, professionalism, and ethics.
Though much has been accomplished, many challenges remain. There are eight top priorities in meeting these challenges, primarily involving you as a member becoming involved. There are numerous paths to participate, including becoming active in your chapter, joining the chapter council or committees, serving on national committees, participating in Leadership Days, engaging in special interest groups within the College, or even running for a Governor position.
Affordable Care Act
The primacy of high-quality, affordable, and universal health insurance coverage as a human right remains strong. The Affordable Care Act of 2010 created a private/public health insurance marketplace where patients could purchase affordable coverage, could not be denied coverage due to pre-existing conditions, and could keep children on their parents' insurance until age 26 years, all with no annual or lifetime coverage limits and no cost differential for chronic conditions and gender, among other provisions.
In addition, the act supported development of innovative models in care delivery and payment. It has resulted in more than 20 million more people being insured, with the lowest rate of uninsured population in history, at 8%. There are challenges, including setting the proper level of subsidies and tax credits for affordability, managing high deductibles and co-payments, and keeping it affordable for all Americans.
Attempts to repeal the act without a viable replacement that addresses these issues will result in millions of Americans being once again without health care coverage. The College advocacy staff in Washington, D.C., and I have been very active by writing letters to Congress, encouraging grassroots efforts from members, generating national media coverage in 32 markets, visiting Capitol Hill, and speaking at state rallies to implore Congress to retain the act, while working to improve certain elements.
Prescription drug costs
The cost of prescription medications has reached a tipping point. As we know, our patients tell us daily about paying several hundred dollars per month for medication with no affordable alternatives, including generics, which have also seen escalating prices. We all benefit from advances in basic science research and drug development, and we agree that the pharmaceutical industry deserves a reasonable return on investment, but the skyrocketing costs are difficult to justify. I testified before the Senate Judiciary Committee about this issue, and we are working with U.S. Sen. Amy Klobuchar of Minnesota and other members of Congress to step in and regulate an unfettered free market.
The opioid dependence and overdose crisis results in more than 30,000 deaths per year nationally. As a profession, we need to recognize our responsibility in enabling dependence on opioids with indiscriminate prescribing and the need to change these practices. We also need to adequately fund research and support programs that decrease the rate of addiction and protection against overdose.
Maintenance of Certification
The College has been working diligently with the American Board of Internal Medicine (ABIM) to develop a program of lifelong learning and assessment. In 1990, the ABIM made a paradigm shift in the meaning of "board certification" by instituting a "Maintenance of Certification" (MOC) requirement. For those who initially certified after 1990, there is a 10-year, secure, written examination, a continuing education requirement, and, until last year, a practice improvement module.
ABIM recently announced an alternative pathway to MOC that includes a two-year secure exam with retake options without loss of certification.* A third medical society pathway is currently being evaluated by the College and ABIM. The College pathway envisions a Medical Knowledge Self-Assessment (MKSAP)-based learning module format with pass requirements and completion deadlines. The College is hopeful that we can collaborate with ABIM in offering such a product. The next few months will be critical to potentially moving ahead with this joint venture.
Medicare Access and CHIP Reauthorization Act (MACRA)
The most significant legislation since the Affordable Care Act has been MACRA, which developed two pathways for a transition to quality-based payment, the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). CMS reports that it has signed up over 250,000 physicians for one of these two programs to date.
MIPS payment is adjusted up or down based on quality measures and practice improvement while retaining a fee-for- service structure. APM uses accountable care organizations and/or patient-centered medical home models to increase quality and take financial risk for the cost of care. Concerns about the feasibility of small to medium-size practices' ability to develop and maintain the needed infrastructure are real, and the College has been advocating for simplification and decrease in the number of measures to be successful in either model.
CMS has agreed to exempt those physicians with less than $30,000 per year in payments or fewer than 100 patients. This exempts 384,000 physicians, mostly in practices of 10 physicians or fewer. The College supports these initiatives and others from the Center for Medicare & Medicaid Innovation (CMMI), including Comprehensive Primary Care Plus, an advanced medical home model to strengthen primary care through multipayer payment and delivery reform. It was launched last year with a nationwide panel of 20,000 physicians. There will be an opportunity this year to enroll in this five-year program. All of these models do require use of an electronic health record with collating and reporting functions and the potential to be interoperable. They also require office infrastructure and workflow, along with clinical nurse managers to manage acute and chronic disease.
ACP's Patients Before Paperwork Initiative aims to develop an evidence-based, comprehensive approach to better address the administrative issues most affecting ACP members, such as electronic health record usability, quality reporting, and dealing with insurance companies. ACP's strategies for this initiative include the following:
- 1. Identify and prioritize which complexities are of the top concern for ACP members and their patients.
- 2. Educate ACP members, other physicians, consumer advocates, and policymakers on what makes up administrative complexities.
- 3. Implement the most effective advocacy, stakeholder engagement, and practice support approaches to help mitigate or eliminate the top-priority complexities and to help ACP members (and other physicians) address those complexities that cannot be eliminated.
- 4. Achieve results that reduce physician burnout, help restore the joy of practice, and reinvigorate the patient-physician relationship.
In addition, ACP is developing a paper that will set a public agenda and outline broad policy recommendations for how to define and address administrative complexities. A toolkit is also under development for use by ACP Chapters to facilitate the discussion of these issues and help identify solutions.
Global climate change and health
I have been speaking nationally and internationally about the health effects of global climate change. They are serious and include heat-related effects, drought and disruption of food supply, flooding and infectious disease, an increase in vector-borne disease, mass migration, air pollution and exacerbation of allergies, asthma, chronic health conditions, and effects on mental health.
The College has developed an action plan to mitigate these effects, including recommendations for conversion to renewable energy. Fortunately, economic forces seem to be dictating a move away from fossil fuels as wind, solar, and battery technology continue to improve and become more cost-effective. There is much that you can do as an individual through practice and education of your colleagues, the lay public, legislators, and policymakers. Please contact me or the College for resources.
Medical liability reform
The College's efforts on medical liability reform continue to focus on patient safety and prevention of medical errors. In addition, health courts with "no fault" administrative processes, limiting noneconomic damages, and safe harbor protection for following clinical guidelines and best practices are of interest to the College, the new administration, and the Secretary of Health and Human Services.
The new Congress and administration present new opportunities and challenges. Where there is common ground, the College will work with all parties to improve health care. But we will stand strong with our principles and values of patient-centeredness, nondiscrimination, health care as a fundamental right, high-value care, and a competent and satisfied internal medicine workforce. I hope that like my predecessors and successive leaders, we will continue to move the needle on improving health care in the 21st century.