At Leadership Day, payment issues, IT, top busy agenda

From the July-August ACP Observer, copyright © 2005 by the American College of Physicians.

By Janet Colwell

Sidebars:

Hematologist/oncologist Margaret Lewin, FACP, is feeling a lot of frustration in her private New York practice.

Because of reimbursement changes, she no longer accepts new Medicare patients. As a result of reduced rates for office-administered drugs, she stopped offering patients chemotherapy in her office, sending them to nearby hospitals instead.

As far as practice hassles and paperwork, "I'm overwhelmed," Dr. Lewin told a legislative aide on Capitol Hill in May. "I have to keep one full-time person on staff who just pulls and files charts." And as for electronic health records, investing in a system right now is out of the question, she said. Instead, she'll hold off until she sees more standardization across the industry. Dr. Lewin was one of the record number of College members who came to Washington for ACP's annual Leadership Day event in mid-May. All told, 260 members—including 61 Associates and 19 student members—arrived from 43 states and the District of Columbia to meet with their elected officials and discuss key legislative issues.

Fixing the payment formula
Internist Cheryle D. Southern, FACP, of ACP's Indiana delegation, told legislators about the need to fix the flawed physician payment system. Dr. Southern was one of a record number of College members from 43 states and the District of Columbia who attended this year's Leadership Day and met with elected officials.


Topping members' agenda were physician payment reform, better access to health information technology and reducing student debt. Although College members found support for the idea of reforming physician payments, legislators and health care officials sent their own strong message: Future pay fixes must be tied to quality improvement and the adoption of information technology.

Moving toward pay for performance

One official delivering that message was Mark McClellan, FACP, administrator of the Centers for Medicare and Medicaid Services (CMS), who was presented with ACP's Joseph F. Boyle Award for Distinguished Public Service during the event. Briefing College members, Dr. McClellan applauded them for coming to Capitol Hill.

"It's more important than ever for physicians to be involved in health care policy," he said, "because so often, decisions are made by people removed from medical practice." (See "Key Contact of the Year: Jeevan Paul, FACP."

He made it clear, however, that the CMS intends to move away from fee for service and toward rewarding physicians who can successfully manage disease and keep medical costs in check. Toward that end, Medicare is offering beneficiaries incentives for participating in clinical studies and demonstration projects that test new therapies and models of care.

"We're not just going to pay the bills on complications anymore," he said. "We want to work with patients to keep them healthy."

Medicare reform
Sen. Charles Grassley (R-Iowa), chair of the Senate Finance Committee, talked about Medicare reform and physician reimbursement during a Leadership Day briefing with ACP members on Capitol Hill. Sen. Grassley was a key figure in developing the new Medicare prescription drug benefit and has championed provisions that improve funding to rural health care systems.


Elected officials who briefed College members included Rep. Michael C. Burgess, MD (R-Texas), member of the House Energy and Commerce Committee; Rep. Rahm Emanuel (D-Ill.), member of the House Ways and Means Committee; and Sen. Charles Grassley (R-Iowa), chair of the Senate Finance Committee.

Access to care
The problems of the uninsured and of universal coverage were high on the agenda for Rahm Emanuel (D-Ill.) at a Leadership Day breakfast briefing. Rep. Emanuel, who serves on the House Committee on Ways and Means, also addressed tort reform, saying that change is unlikely in the current political climate.


Sen. Grassley, an architect of the 2003 Medicare reform legislation, told attendees that finding a permanent fix to the dysfunctional payment system was one of his key priorities. Instead, he said, Congress has approved a series of temporary increases to avoid the high cost of major reform, "but every time we do that, we put off finding a reasonable solution."

But he also bluntly echoed Dr. McClellan's message about rewarding quality improvement. "Instead of just paying bills, we need pay for performance," he said.

Fixing the SGR

On the Hill, College members asked lawmakers to support legislation that would halt physician fee cuts for at least two years, replacing the projected 4.3% cut in 2006 with the 2.7% increase recommended by the Medicare Payment Advisory Commission.

Members also lobbied for long-term payment reform. They asked legislators to cosponsor the Preserving Patient Access to Physicians Act of 2005 (H.R. 2356/S. 1081), which would base future fee updates on the actual costs of delivering services. The bill would repeal the sustainable growth rate (SGR), which bases fee updates on fluctuations in the gross domestic product.

Without any change to the SGR, physician fee cuts would represent a $10 billion loss to the New York state economy over the next 10 years.

A delegation of New York members meeting with Ann Gavaghan, legislative aide to Sen. Hillary Rodham Clinton (D-N.Y.), noted that without any change to the SGR, physician fee cuts would represent a $10 billion loss to the New York state economy over the next 10 years.

Dr. Lewin, the New York hematologist/oncologist, pointed out that engaging in pay-for-performance programs will be almost impossible without computerized medical records. And, she said, the major financial benefit of these records won't go to doctors, but to payers.

"That's why we are asking HMOs and the government to carry the costs of standardization," she said, "and to heavily subsidize physicians' purchases of systems."

The group also emphasized the importance of health information technology for patient safety. John D. Calico, ACP Associate, described a "disconnected health care system" where time is often wasted or mistakes made because physicians cannot access the right information quickly.

Rep. Heather Wilson (R-N.M.), told ACP members from her state that getting electronic health records into rural areas is a top priority for her. Barbara J. McGuire, FACP, pointed out that pay-for-performance programs likely will help motivate physicians to invest in information technology.

"However, with single-practice systems costing about $100,000," she said, "many physicians will need help getting started."

Graduate medical education

Many Associates and student members spoke about the need to support graduate medical education (GME) and relieve student debt.

"None of my colleagues is going into primary care," said Abinash P. Achrekar, ACP Associate, a resident at the University of New Mexico in Albuquerque who was among those who met with Rep. Wilson. "They have a lot of debt coming out of training, and primary care has lower compensation than many other specialties."

The New York delegation told Sen. Clinton's aide that 80% of residents training in the state were likewise choosing subspecialties over general practice. Eliyahu S. Kopstick, ACP Associate, said he faced more than $140,000 in loans when he graduated from medical school two years ago.

Ms. Gavaghan pointed out that legislators from other states don't always recognize the need for better funding for states like New York, which has a number of medical schools and training hospitals.

Boosting funding is a matter of convincing other legislators that training is a public good, Ms. Gavaghan noted. "If you have colleagues trained in New York and living elsewhere," she suggested, "tell them to talk to their representatives about the importance of GME funding."

The Illinois contingent also stressed the need for higher GME funding to Rep. Danny K. Davis, PhD, (D-Ill.), a civil rights advocate who previously worked in health education and administration. Vineet Arora, ACP Associate and Chair of the Council of Associates, noted the drop in internal medicine graduates from schools in the state, including Northwestern and Loyola Universities.

Rep. Davis agreed that higher GME funding was needed to attract physicians to internal medicine and to maintain quality health care in the Chicago area. "Chicago has," he said, "one of the best community health center networks in the country."

Political realities

The College's focus on fixing the payment system and improving access to information technology doesn't mean that other issues have dropped off its agenda. Access to care, universal coverage and tort reform are just as important—but will probably not be supported in the current political climate. (For a list of College-supported legislation, see "A roll call of important health care bills."

"Two political realities are shaping the legislative environment," said Robert B. Doherty, ACP's Senior Vice President for Governmental Affairs and Public Policy, who briefed attendees before their Capitol Hill meetings. "First, the deficit, as well as competing economic priorities and rising health care costs, are creating pressure to limit spending. Second, bipartisanship is a casualty of a highly competitive environment producing mutual anger and frustration."

Health information technology
During their meetings on Capitol Hill, members from ACP's Tennessee Chapter talked about the need for funding to help physicians transition to electronic medical records. The delegation included (from left): Robert A. Vegors, FACP; Mary Alice Harbinson, FACP; Chapter Governor Stephen T. Miller, FACP; and J. Fred Ralston Jr., FACP, Chair, Board of Governors.


Major expansions of health care coverage are unlikely due to the need to cut costs, he said. Tort reform efforts have been thwarted by an unwillingness on the part of both parties to seek compromise.

As evidenced by this year's record Leadership Day turnout, however, those tough political realities aren't discouraging College members. "The greater the obstacles," Mr. Doherty observed, "the more important it is that members of Congress hear from their constituents."

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Key Contact of the Year: Jeevan Paul, FACP

In December 2002, the Executive Committee of the Board of Governors approved a goal of doubling the number of ACP Key Contacts nationwide over the next two years. That goal would require every chapter to enroll about 4% of its members. (ACP's 4,500 Key Contacts agree to communicate with their members of Congress on issues of importance to internists and their patients, and report results back to the College.)

As the deadline loomed last year, the Minnesota Chapter—with a total of 1,954 members—had 42 Key Contacts still left to recruit to meet that threshold. Some chapter members worried that the target was out of reach—until Jeevan Paul, FACP, stepped in.

Dr. Paul, who passed away earlier this year, single-handedly recruited 123 Key Contacts at the chapter's 2004 annual scientific meeting, more than doubling the chapter's enrollment in the program. Under Dr. Paul's leadership, the chapter went from 41 Key Contacts in 2003 to 171 in 2004—equal to about 9% of chapter membership.

That achievement was a "testament to his personal warmth and contagious passion for the issues," said ACP's Chief Executive Officer, John Tooker, FACP, who presented Dr. Paul's posthumous Key Contact of the Year Award at this year's Leadership Day event.

Increasing access to care for underserved communities was the cause closest to Dr. Paul's heart, said Dr. Tooker. A general internist, Dr. Paul spent most of his career working at a community health center in St. Paul, where he worked to break down barriers to care for low-income patients.

Until his death, Dr. Paul served as the chapter's Federal Legislative Coordinator. He also was an active supporter of the nonprofit Doctors Without Borders.

Ten other Key Contact members received special recognition for their efforts last year. They were:

  • Dawn E. Clancy, FACP (Johns Island, S.C.)
  • Sarah Corley, FACP (Annandale, Va.)
  • Robert Englund, FACP (Munsonville, N.H.)
  • Stella Hines, ACP Associate (Chicago)
  • Craig Kitchens, FACP (Gainesville, Fla.)
  • Robert Lebow, FACP (Southbridge, Mass.)
  • Eric Mazur, FACP (Norwalk, Conn.)
  • Robert M. McLean, FACP (New Haven, Conn.)
  • Richard Neubauer, FACP (Anchorage, Alaska)
  • Susan Sprau, FACP (Santa Monica, Calif.).

Dr. Hines, the first Associate to receive special Key Contact recognition, is part of a small but growing group of young physicians getting involved in advocacy.

The Vice President of the Illinois Chapter's Council of Associates last year, Dr. Hines was recently appointed to the College's national Council of Associates as a representative from the Western Zone. (She recently moved to Denver to begin a pulmonary and critical care fellowship at the University of Colorado.)

She attributes her interest in advocacy to mentors who she met during medical school at Texas A&M System Health Science Center College of Medicine in College Station, including James Rohack, FACP, a past president of the Texas Medical Association and current board chair of the American Medical Association.

According to Dr. Hines, education is the key to getting more young physicians involved. "Most residents are so focused on their work in the hospital, they have no time to realize what is going on across town, much less in Washington," she said. "But if people are educated and concerned, they will act."

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A roll call of important health care bills

The College has identified the following legislative bills as priorities in its advocacy efforts on Capitol Hill:

  • Preserving Patient Access to Physicians Act of 2005 (H.R. 2356). The bill would replace the SGR with a formula that bases fee updates on actual costs of physician services. A companion Senate bill (S. 1081) would replace the projected 4.3% cut in 2006 with a 2.7% increase in 2006 and 2007.

  • National Health Information Incentives Act (HR 747). The bipartisan bill aims at creating information technology standards and incentives for small and rural practices.

  • HealthCARE Act of 2005 (H.R. 1399). The bill would reduce the number of uninsured.

  • Patient Safety and Quality Improvement Act of 2005 (S. 544). The bill provides for confidentiality protections to encourage reporting of medical errors.

  • College Loan Assistance Act of 2005 (H.R. 1338). The bill would allow physicians to refinance medical student debt more than once to take advantage of lower interest rates.

  • Higher Education Affordability and Equity Act of 2005 (H.R. 1380). The bill would expand the tax deductibility of student loan interest and increase the income eligibility level for receiving deductions. The bill also excludes scholarships, grants and fellowships from taxable income.

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