PHILADELPHIA — Officials at the American College of Physicians are proposing major changes in the way general internists practice, get paid, and are trained.
The recommendations are outlined in three new policy papers aimed at addressing reform of the payment system, a national workforce for internal medicine, and redesign of internal medicine training programs.
The Medicare payment system is one of the principal reasons that physicians are abandoning primary care, said Robert B. Doherty, ACP senior vice president for governmental affairs and public policy.
ACP officials are recommending changes to the current payment system to improve compensation for general internists, but say that more sweeping reforms are needed. Proposed changes to the Medicare Resource-Based Relative Value Schedule (RBRVS) include increasing the work relative value units (RVUs) for evaluation and management services, reexamining the methodologies used to derive the practice expense RVUs, and establishing a process to identify potentially misvalued RVUs.
If recommendations by the RVS Update Committee—the group of physicians that recommends changes in the payment level for new and revised CPT codes—to increase payments for evaluation and management codes are accepted, the changes would take effect on Jan. 1, 2007, he said.
ACP also is seeking separate Medicare payments for services that contribute to coordinated care. For example, ACP is calling on CMS to provide a separate payment for e-mail, telephone, and related technology that can reduce the need for face-to-face visits for nonurgent care. CMS should also develop specific codes for care coordination activities, such as intensive follow-up, the use of patient registries and population-based treatment protocols, and disease management training, according to ACP.
In addition, ACP officials would like CMS to provide an add-on payment when office visits include the use of health information technology, such as electronic health records, electronic prescribing, or clinical decision support tools.
On pay for performance, ACP maintains that potential rewards should be substantial enough to allow for continuous quality improvement. Also, positive incentives should be used rather than penalties.
In the long term, Congress should replace the Sustainable Growth Rate with a formula that would provide adequate and predictable payment increases for all physicians, ACP said in its position paper. And ACP officials want to work with Medicare and other payers to design a new model for health care financing that would build on the concept of the advanced medical home.
Reforms to the education of medical students and the training of internal medicine residents also are needed. The ACP position paper, “Redesigning Training for Internal Medicine,” was published online and will appear in the June 20 print edition of Annals of Internal Medicine.
Rethinking Internist Residency Training
The ACP position paper on training for internal medicine outlines six revisions to the current model for graduate medical education:
▸ Defining the design model for residency training. ACP is calling for the creation of a 3-year model for residency education that would include 2 years of core training and 1 year of customized experiences tailored to the career goals of the trainees. For example, someone interested in becoming a hospitalist would spend more of the third year in the hospital, while others would spend more time in ambulatory care settings.
▸ Integrating educational and service needs. Such a change would move away from excessive workloads for residents, which currently meet the needs of the institutions but not of the residents or patients.
▸ Enhancing ambulatory training. When possible, residents should train in office settings that use advanced technology, such as electronic health records, and that have a team approach to care, according to ACP. In addition, the time spent in ambulatory settings should be structured so that residents do not view it as a distraction from their inpatient duties. Ambulatory training has been the “poor stepchild” of graduate medical education, Dr. Weinberger said, and usually is conducted in settings that make it difficult to practice and learn.
▸ Utilizing team-based care. Training should incorporate team-based care that includes nurses, social workers, case managers, and midlevel providers, according to ACP. In addition, residents can be paired together or with faculty so that one member can provide inpatient care while the other cares for ambulatory patients.
▸ Developing faculty models. Training programs should also consider creating a “core faculty,” a specialized group of clinician educators, who would receive sufficient time, money, and status to train and mentor residents. “We don't have the right faculty models,” Dr. Weinberger said.
▸ Stressing professionalism. The core values include patient-centered, culturally sensitive, evidence-based care.