ACP: Current and future payment and practice trends in medicine

ACP: Current and future payment and practice trends in medicineA guest column by the American College of Physicians, exclusive to KevinMD.com.

In April 2011 I finished seven years on the Board of Regents of the American College of Physicians (ACP) including two years as Chair of the ACP Health and Public Policy Committee and serving during the last year as President. During that time I had the opportunity to be involved in some great discussions on health care within ACP and with a variety of people in government and the private sector. Now that I am home in my “day job” practicing general internal medicine in Fayetteville, Tennessee, I get a lot of questions from friends and colleagues about my take on current and future trends in medicine. I would like to share some of those thoughts and see how others with different perspectives view them.

We currently have a payment system that encourages episodic care and procedures. An ideal payment system will encourage efficient use of resources and pay for the right care at the right time. Of course, transitions will likely require much effort and expense, while current survival is still linked to the existing payment system.

A frequent question is about Accountable Care Organizations (ACOs.)  Should we form one now? If we don’t form an ACO what should we do to get ready? In my local area the incentives provided under the initial ACO proposals don’t make financial sense for us. However, we need to get to work to prepare for future changes that will benefit us and the patients we serve.

My advice is first to understand a few basic issues:

  1. Regardless of politics and feelings about recent health reform initiatives our current health care “system” is unsustainable. The cost curve for health care will bankrupt us and simple “across the board cuts” in the current delivery system would be painful but would not solve underlying issues.
  2. We need to encourage team-based primary care. The Patient-Centered Medical Home model should allow enhanced access and cost-effective quality care for patients and more efficient use of time and resources for medical professionals.
  3. Many physicians throughout the U.S. are in small groups. Within ACP we have understood that a key element as we move toward a more efficient system is to help these practices transition to a model where they have many of the tools used now by larger groups but at an affordable price. Doctors in small groups have seen lots of “trends” that didn’t pan out, so it is reasonable to try to find ways to share costs and expertise incrementally without having to change everything at once. It is also important for early adopters to share their experiences with peers.

For my practice and others I would aim toward:

  • Easy patient access to avoid unnecessary ER visits and hospitalizations (24/7 phone access enhanced by an electronic record and same day appointments where practical)
  • Better communication (Between patients and caregivers, among various physicians, and between inpatient and outpatient settings)
  • Better understanding of cost-effective care both within my practice and in those we refer to
  • Continuous quality improvement to allow physicians to improve the care we provide

The messages I hear recently from Washington miss the point that we have to fundamentally provide care in a different way.  In listening to 24/7 news channels it seems our two options regarding Medicare are to protect it or to place it on the table for cuts to strengthen the financial stability of our country. As typically stated, these “options” are oversimplifications of the issue for the sake of sound bites.

We must make sure our seniors, and everyone else, have access to affordable quality health care.  However, without a bend in the cost curve, the system will bankrupt us all as individuals, employers and taxpayers. Therefore, simple either/or options do a disservice to the debate.  We need to all be thinking outside our normal political discussions for creative options to achieve easy access, improved quality, and lower cost.

I would like to hear more discussions about programs such as ACP’s High Value, Cost-Conscious Care initiative, which connects two important priorities for the College: helping physicians to provide the best possible care to their patients, and simultaneously reducing unnecessary costs to the health care system.

I also hope we can encourage physicians and other health care professionals to embrace the Patient-Centered Medical Home as a key component moving forward.

We are all trying to prepare at the ground level for the future. What are your thoughts either from the local or national perspective?

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is the Immediate Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • http://twitter.com/glevin1 gary levin

    What we really need is Reform for Cost of Medical Technology. These entities should share our burden as well. If costs go down so will cost of care…..This year there was a 10% fall in general income in the U.S. across the board.

  • Anonymous

    “Many physicians throughout the U.S. are in small groups. Within ACP we have understood that a key element as we move toward a more efficient system is to help these practices transition to a model where they have many of the tools used now by larger groups but at an affordable price.”

    But larger groups tend to provide more expensive health care with no significant improvements in quality. Why should we move in that direction?

  • Anonymous

    As a newly graduated (subspeciality) medical trainee, starting out in my first full time job, I can say that my generation of physicians are fairly jaded and pesimistic regarding any hope of positive change for US healthcare. Our governemnt is over-run with a rats nest of special interest groups that it’s almost a given that money will be siphoned out of the pockets of patients, primary care MD’s, and support staff, and given to large corporate managed care companies and Pharma.

    I don’t realistically see our dysfunctional, hysterical, paranoid, and schizophrenic government leaders really prioritizing the 3 keys of a sustainable healthcare system: universal coverage for all, high quality care initiatives, and cost savings.

    To my generation of physicians, the AMA is utterly inept, and incapable of advocating for the best interests of our patients and the physicians that care for them.

    I see some hope in a ground up, market disruption from emerging medical information and practice technologies. This is through smart, streamlined, and effiecient ways to evaluate patients, collect data, appropriately share that data with other connected providers to better their care, and to rapidly respond to a patient’s changing health status.

    If a critical mass of patients sees the benefits of a connected, integrated, health 2.0 system that is armed and primed to respond to their needs, they will push their representatives harder and harder to turn their ear away from the lobbyist and to the patients.

    I agree in the we need a serious reform of the payment/reimbursment system that provides the incentives for outcome based, health driven care rather than illness based, procedural care. This will be a difficult fight. Just don’t expect Washington to be our salvation. Our representatives are too busy taking 6 months for vacation, honing their golf game, and sipping cognac on industry paid private jets.

    • http://twitter.com/PamelaWibleMD PamelaWibleMD

      EXACTLY what I am saying. Change ain’t coming for politician saviors. Those well-worn channels are bottlenecked at every pass. Change is coming from the grassroots — from patients and doctors who are collaborating at the community level to design their own ideal clinics and hospitals. So common sense.

  • http://twitter.com/PamelaWibleMD PamelaWibleMD

    Hey Fred ~ 

    I believe we miss the boat in healthcare reform if we do not put patients front and center and allow them the create/design their ideal clinics. We live in an era of disintermediation (removing the middle man) and increased transparency and citizens want direct relationships with their doc in small neighborhood practices. They do not
    want cafeteria-style waiting rooms in mega-offices. This is what I hear across the country when I lead town hall meetings. We can not afford to wait for politician saviors: http://www.youtube.com/watch?v=qztCebIU5yM

    The idea of the PCMH is a great one, but if we use the term “patient-centered” then I would want patients to actually design their own medical homes. Here is an example: http://www.youtube.com/watch?v=xoU__gsv1DI

    There are more and more doctors who are collaborating with their patients to design ideal clinics. We are actually filming a documentary this fall featuring these primary care offices across the nation. Healthcare of, by, and for the People. It s time to truly put patients in charge: http://www.idealmedicalcare.org/docs/The-Documentary.pdf

    Everyone is invited to be a part of this collaborative project. The answers that we are so desperately looking for are not coming from the top down. The answers we so desperately seek are in the hearts and souls of our own communities. We don’t need to wait for the next election cycle. . . .

    This is what I hear when I hold a megaphone up to the American people. When the people lead. The leaders will follow.

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