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The End Of Internal Medicine As We Know It



January 14th, 2011

Editor’s Note: In the post below, Caroline Poplin takes a skeptical look at Accountable Care Organizations (ACOs) and the trends they represent. For more on ACOs from various perspectives, readers can consult the January issue of Health Affairs, released on Thursday, January 6, titled “Accountable Care Organizations: Making Them Work.”

Physicians have doubtless been issuing jeremiads since before Jeremiah.  We are overworked, underpaid, and underappreciated.

But today, general internists have a real problem.  And it is our leaders who do this to us.  As summarized in the Annals of Internal Medicine:

To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change.  The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.  The most successful physicians will be those who collaborate with other providers to improve outcomes, care productivity and patient experience.

In the future envisioned by the health policy community, including the leadership of the Amercian College of Physicians and the American Medical Association, patients who want a personal physician, someone they know and trust, who understands and cares about them as individuals will have to pay extra for “concierge” care.  Everyone else will migrate to team care from large “Accountable Care Oranizations” (accountable to whom, one may ask—certainly not the patients).  These teams may well improve patients’ blood pressures, glucose control, lipid panels, maybe even weight, and indeed improve the outcomes of patients whose outcomes can be improved.  Their care will be efficient: providers (yes, providers) who do not see enough patients, whose patients do not improve adequately, who order too many tests, do not meet the fifteen criteria for meaningful use of EHRs, or do not continuously pursue quality improvement projects, will see their incomes fall.

Perhaps the new organizations will provide better care for some patients and some conditions.  Will other patients — those with poor prognoses, bad attitudes, complex or ill-defined diagnoses, multiple complications, cognitive limitations, even just morbid obesity — be lost in the shuffle.

And whether this radical overhaul of the health care delivery system will reduce health care costs overall, ostensibly the point of the exercise, is unknown.  The cost of multiple layers of highly paid managers (including multi-million dollar executives) and the extensive information technology infrastructure on which these elaborate systems depend, is not trivial.  Indeed, modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions that pay serious attention to suggestions from production workers and those who deal directly with customers. What little evidence we have on cost savings from ACOs is largely anecdotal and equivocal.

I am a Board-certified general internist.  I worked for many years for just such an Accountable Care Organization.  It was factory work: we were interchangeable cogs in a vast machine.  The people who saw patients, especially “primary care providers” like me, were at the base of the pyramid and the bottom of the pecking order.

The future is clear.  The management of the ACO — professional administrators, and physicians who see few if any patients — will schedule every moment of every primary provider’s day, critique every decision, continually scrutinize and evaluate every aspect of one’s practice.  At my ACO, yes, we were on teams, but given no time to communicate with one another. We were forced to complete clunky electronic records we had no time to read.  Despite years of training and experience, we had no input to the system that controlled our lives. We were not respected as professionals.  It was demoralizing.

If one is concerned about a “shift work” mentality in medicine, surely it develops not in residents who get more sleep, but in physicians who can only survive by meeting ever-higher “performance goals” set by others.

So far, specialists seem to have largely escaped these problems. There seem to be fewer performance measures for them, less pressure to adopt “meaningful use” of electronic health records, less concern about supervision and efficiency.  The community still respects them.

Is it any wonder that medical students and residents are signing up for specialties, voting with their feet?

Contrasting The United States And Europe

What has baffled me throughout this process is the logic of the reformers, physicians and non-physicians alike.

After all, the European countries, including those that are avowedly socialist, have achieved better outcomes than we, at far lower cost, with conventional, decentralized delivery systems and fee-for-service-type payment practices.  Yes, many have electronic medical records, but I understand that European systems are primarily designed to provide a doctor with information about her patient, not “feedback” about her performance.

In Europe, some 50 percent of physicians practice primary care.  Here, 70 percent of physicians are specialists, and, given the situation, we can only expect that number to climb.

The Cost Drivers: Insurers And Technology

Everyone agrees that the biggest problem in American health care today is its outsized accelerating cost, already 17 percent of GDP despite the fact that many uninsured people receive no care at all.

From my vantage point, the two principal drivers of cost in our system are the insurance industry and excessive expensive technology. The insurance industry – which will no longer be allowed to manage risk — cannot manage care, and manages cost by requiring discounts from providers, which the companies pocket. We should pay insurers for processing claims, period.

Also, we have disproportionate incentives in our system for ever-costlier technology, particularly specialty procedures requiring high-tech equipment, as well as expensive imaging, tests and pharmaceuticals.  Yes, there is competition, but rarely on price, since manufacturers are reimbursed for whatever they charge.

Nevertheless, health care reformers have largely ignored insurers and manufacturers, trusting, without much evidence, to future market competition.  Instead, the policy elite has targeted primary care.  They believe it is poor.  We do not work hard enough to keep our patients healthy, we neglect important preventive measures, and our patients therefore develop costly avoidable illnesses and require too many expensive hospital admissions.  We do not coordinate with others.

Misdiagnosing The Ills Of Primary Care By Ignoring Internists

Fair enough, perhaps.  What is troublesome is that the reformers never think to ask why primary care in this country isn’t better.  Certainly they never ask us.

The health policy elite appears to have concluded that the crux of the problem is primary care practitioners, internists included, who are largely ignorant, lazy, and indifferent to their patients’ welfare, and oppose change of any kind.  We do not know or care that a diabetic’s hemoglobin A1C should be below 7.

Therefore, we need tight supervision, complex systems of financial incentives and penalties, and frequent “feedback” about our deficiencies.  We need electronic records to remind us that our female patients are due for mammograms, that we should advise smokers to quit. And we must reach our goals efficiently, using the minimum number of those expensive tests, and managing large panels of patients.  (So we can’t spend much time with anyone.)

The experts decry traditional fee-for-service.  And there is no question that fee-for-service encourages development and overuse of expensive procedures, such as frequent endoscopies to follow Barrett’s esophagus, or CT angiography to screen for coronary artery disease (no evidence basis for either).  But instead, policymakers are concerned about excess office visits.

Therefore, our fees are to be “bundled” with the hospital and the ACO.  You can imagine, after the hospital has taken its share — for services it performed or money it “saved” — and senior management has helped itself, what will be left for the providers who actually see the patients.

In part, internists have done this to themselves.  Back in the day, there was no “primary care.”  There were general practitioners, who treated routine medical problems, and there were internists, who followed adults with more complex conditions.

As the expansion of medical knowledge accelerated in the last thirty years or so, no individual physician could keep up with it all.  Multiple problems had to be handled by multiple specialists.  At the same time, fees for evaluation and management, the bread and butter of general internal medicine, fell, partly because small practices had no leverage against large insurance companies. To make a living, a practicing internist had to step up her volume, seeing twenty, thirty patients or more a day.  It is daunting, sometimes even dangerous, to try to deal with complex issues or multiple chronic conditions in ten minutes.

In the meantime, general practitioners were disappearing.  So internists picked up their work: routine physicals, minor acute complaints, and isolated chronic problems — uncomplicated hypertension, for instance –easier to deal with in ten minutes.  We became “primary care physicians.”

But one doesn’t need seven years of medical training for this sort of practice: less expensive mid-level professionals — nurse practitioners and physician’s assistants — can provide it just as well.  This new competition increased downward pressure on fees, and turned us into “primary care providers” suitable to staff the bottom rung of the ACO.  Many general internists outside the hospital are not practicing at the top of their capacity, but nearer the bottom.

The current fee structure in our fee-for-service system is designed for the medicine of the 1950’s, when most illnesses and injuries were discrete and acute.  Single acute conditions (the “chief complaint”) that present with many symptoms and physical findings generate maximum fees. The more elaborate the history and physical, the more one is paid: these two elements account for two thirds of the fee. Everything else — reviewing glucose records, specialists’ reports, developing a differential diagnosis, reviewing alternative treatments, and treating conditions beyond the “chief complaint” — accounts for just one third.

Following Medicare, payers pay little or nothing for anything done outside the visit.  Doctors are supposed to make telephone calls, respond to emails, review records, consult with specialists, visiting nurses and family—all for free.  Is it any wonder our system is not coordinated?

The Proper Role Of Internists In The Health System

Internists are not Luddites.  We understand that American health care has become increasingly dysfunctional as medicine has advanced.  We appreciate that midlevel professionals and specialists are indispensable to the care of modern complex patients, and that electronic health records can be invaluable if they provide us with convenient, real-time, comprehensive information on our patients.  It should be the internist’s job to coordinate care, not by ensuring that patients get their colonoscopies, but by integrating the information provided by our midlevel colleagues, specialists and tests, in order to help our patients understand problems and tradeoffs and make decisions on treatment, as internists in the hospital (so-called “hospitalists”) do.

We welcome assistance.  But we should not be forced to surrender our autonomy to ACOs.  We know what our patients need: we don’t need highly compensated management to tell us.  Doctors would happily adopt electronic records (particularly if they were cheap and interoperable) if we thought they could help us take care of patients. Clearly, the profession, which in general embraces high technology, doesn’t find the current EHRs (largely designed to gather information about the physician performance and statistics for research) useful; that is why the government had to define and mandate “meaningful use”. 

There is a vital role for the general internist in modern medicine, but it is not on a virtual assembly line at the bottom of an ACO.  Better electronic information systems and a fee structure suited to modern medicine, one which pays more for what we do with our heads (even when the patient is not present), less for what we do with our hands, that pays a provider more for treating more complex patients, could go a long way towards improving co-ordination and reducing cost without disrupting the entire delivery system. 

It is also worth remembering that the last time Americans saw managed care—for an ACO is an HMO by another name–in the 1990s, they resoundingly rejected it.

Internists are professionals. We want the best for our patients. We have much to offer, but we expect respect.  The policy elite can either do things with us, or to us.  So far they have chosen the latter.

Despite the most strenuous prevention measures, there will always be sick patients. And there will always be doctors.  But outside of the hospital, the American general internist may go the way of the general practitioner before him: the medical world of the future may consist of midlevel professionals, and specialty physicians.  Maybe this care will be cheaper and better — or not.  We will see.

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6 Responses to “The End Of Internal Medicine As We Know It”

  1. Christopher Langston Says:

    While we can all feel sympthy for how beleagerd primary care physicians feel (family AND internal medicine), this post seems to miss the mark on both diagnosis and the interventions proposed by reform.

    The notion that leaders want everyone to pay for concierge care unless they are willing to accept faceless, impersonal, industrial and (worst of all) not necessarily physician led care is without merit or foundation. Regardless of whatever else you think of the leaders of the AMA and ACP, they are loyal to their salt and work to advance the interests of their members above all else.

    Moreover, part of the very notion of ACOs and Medical Homes is that people will get concierge level care without having to pay out of pocket for it. In the Medicare Medical Home demonstration that is still floating around out there somewhere, the plan was to pay fully capable practices $50 per person per month for any Medicare beneficiary who had a chronic condition (all 81% of them). This corresponds to a concierge fee of $600 annually for a primary care physician also getting standard fee for service.

    In the ACO concept, primary care physicians are also in the driver’s seat. An ACO is defined at minimum as a physician-hospital organization that gets to share in the “savings” versus hypothetical spending levels overall (e.g. Medicare part A and B) spending is reduced. The beneficiaries for whom an ACO is accountable are the patients of the primary care providers contracted to be part of the organization. If primary care providers refuse to participate, an ACO is DOA. The emerging approach to reducing spending seems to be to send extra non-fee-for-service subsidies to primary care practices to get them on board and to enable them to prevent utilization of expensive (i.e., hospital) services.

    All of this comes on top of a 10% E&M payment bonus that the PPACA provides to primary care providers who receive the bulk of their reimbursement through E&M codes. Far from wanting to end GIM or Family Medicine, PPACA and health reform in general is predicated on strong primary care systems.

    The rest of this argument is similarly flawed. It assumes without evidence that EHRs that meet the new “meaningful use” criteria are largely about performance measurement rather than delivering good care. Of course what EHR have most often really been about is billing.

    It implies that the current redesign efforts are without physician input while in fact they have been dominated by the efforts of the AAFP and the ACP, the work of TransforMed and others around medical homes.

    And, most infuriatingly, while admitting that physicians are overqualified for much of primary care work and agreeing that some can and should be ceded to nurse practitioners and physician assistants, the author equates team care with faceless impersonal care. This seems more about physician’s loss of control than the interests of patients (who would not want a whole team?) Physicians need to on health care teams, not in charge of them.

  2. John Ballard Says:

    Such a grim picture. Unfortunately it’s not far from reality. As a retired layman who has been following this debate for several years I am convinced that we are not on the way to less expensive medicine but a system which does what America does best: those with the most assets get the best of whatever they want and those at the economic bottom settle for whatever elected officials decide will be the least they can get away with to get re-elected. The trend of providers not accepting Medicare is not new and at least anecdotally seems to be accelerating.

    Concierge practices are a growing trend. One of my children, a dental assistant, said she used to schedule doctor’s appointments for Friday (dentists typically work Mon-Thur only, Fridays off) but an increasing number of doctors are also taking three-day weekends. This tells me the fee-for-service and concierge models must be generating a pretty good revenue stream.

    Not soon, but over the next several years I’m expecting a shakeout, with vast numbers of ordinary people getting middling attention until they reach Medicare, then even more middling attention unless they can afford the Cadillac supplements that the insurance industry is certain to have available. There will be market, and for those who can pay, surcharges and taxes will make little or no difference.

    Outcomes? It appears they are already not all that good and most people really don’t care. At the moment the Veterans Health System seems to be getting better AND getting better outcomes. Medicaid is a duke’s mixture depending on different states, some of which do excellent and others are a disaster. Keep me out of Arizona Medicaid if I need an organ transplant.

    PPACA has new and better mechanisms to reduce fraud and abuse. We can hope they make a difference. Every time I see one of those damn commercials advertising “free” motorized scooters and chairs I want to scream. I am a senior care-giver (non-medical) in my post-retirement job and I see unused, un-needed durable medical equipment all over the place. At least one client authorized for wheel-chair rental was informed when returning the chair to keep it… the rent had paid for the chair and he would not likely get approved for another one anyway.

    Mental health care since deinstitutionalization in the Sixties has been okay in a some localities but overall is a monumental failure,resulting in a growing number of mass killings (all “isolated” incidents, you know). I am not optimistic that this trend will improve. We can expect another such “isolated incident” in future, likely before a year is out.
    http://www.csgv.org/issues-and-campaigns/guns-democracy-and-freedom/insurrection-timeline

    The writer is correct that ACO is just the old HMO writ differently. I didn’t work when it was first tried because insurance companies, not doctors, were making treatment decisions based on profit projections rather than best medical practices. Insurance are in the business of risk management. Providers are in the business of medial care. The two are at cross purposes.

    From what I can tell, the goal of ACO, Medical Home and all those other neologisms is to replicate the handful of places that have been getting good outcomes at lower costs so that the country will not crash economically as the consequence of health care inflation, which for years now has run ahead of ordinary inflation and GDP. The US spends something like seventeen or eighteen percent of GDP for health care with tens of millions uninsured, and other countries furnish nearly everyone with medical care for much less. Last I read, Canada only spends eleven percent of GDP for health care.

    If places like Mayo, Cleveland, Geisinger, some of the kaiser places and the examples that Atul Gawande wrote about in the New Yorker can do what they do, a way needs to be found to replicate their results more widely. I think that is the goal. And the professional infighting, nagging and turf wars do nothing to advance that goal. Individually most providers do a good job. But collectively, thanks to a litany of problems, what is routinely called the Best Health Care System in the World is an economic and social train wreck. And when I read columns and comments threads like this one it makes me depressed.

  3. CB Says:

    While a skeptical viewpoint about ACOs is one that’s needed for the industry’s dialogue, I have little sympathy for the complaint that physicians’ actions and decisions will be measured and scrutinized more closely now and going forward. (Referring to “The future is clear. The management of the ACO — professional administrators, and physicians who see few if any patients — will schedule every moment of every primary provider’s day, critique every decision, continually scrutinize and evaluate every aspect of one’s practice.”)

    Most educated professionals in most every other industry have been having their actions and decisions monitored, critiqued, and measured for quite some time. Take for example my spouse who works in finance as a Certified Financial Planner. Every phone call he has is recorded, every email is reviewed and his company compiles and monitors stats such as number of phone calls answered per day, growth of his clients’ portfolios compared to the market average, and client satisfaction scores on a quarterly basis. His stats are compared to all of his peers in the same position. He is a person with post-graduate degrees and certifications and more than a decade experience in the industry, not so dissimilar from the background of a physician.

    I have other examples of friends and colleagues in other industries as well that are very similar, this type of monitoring of work-related actions and decisions is not unique to finance.

    Yes, it’s painful to go through change as a professional when you’ve had much autonomy and will likely have less so in the future. Yes, it’s more stressful knowing that every decision is watched and critiqued and therefore your job or livelihood is at risk. But that’s what most non-physicians are dealing with today and have been for the last 5-10 years as computers have become more sophisticated and prevalent.

    Other industries have greatly benefited from measuring and tracking of employees actions and decisions and overall it has improved the quality of products and services, and also made them more cost-effective. Thus, I believe it is important for physicians’ actions and decisions to be monitored and evaluated for the purposes of providing higher quality, more cost-effective care. But, I also believe it should be done fairly to physicians, especially those in primary care.

    Separately, I have much respect for primary care physicians, they do work hard and are underpaid for their dedication. My hope is that going forward they will be treated more equally to specialists when it comes to compensation.

    Additionally, I agree with the author that while ACOs may improve the care of some patients, I worry that others will receive worse care. Patients with less common conditions, conditions for which there is little medical evidence to support treatment options, or conditions that affect multiple organ systems, are those I worry about most since so much attention will be paid to improving the care of common conditions like diabetes, asthma, heart disease, etc. What will happen to those patients as we move forward in the transition that has just begun?

  4. medicalcontrarian Says:

    The first thing that has to go is the CPT system which has created a barrier for developing novel ways to fulfill patient needs. The fact that the most important functions that non-procedural problem solvers do outside the face to face patient encounter have no home in the CPT menu means that those represent volunteer work. The idea that what represent a service and value will need to be redefined and that this will require scrapping of the current payment system will be very unpopular with the AMA since it serves as its major source of revenue via licensing agreements.

    Any communication from the AMA regarding the payment system should include a conflict of interest disclaimer.

  5. Barrett Says:

    I agree with Dr. Poplin and indeed hope that health care reform changes Internal Medicine – I expect it will be for the better, as the current is pretty dismal.

    If we all agree the system is broken, no one should have the expectation that their part of the system doesn’t get changed in whatever fix comes along – rest assured I have heard similar laments from every health care sector of under appreciation and dismal working environments. Just about all of them are true.

    Within the PPACA is this mythical beast of a Medicare ACO (Medicare Shared Savings Program). And while the policy types do indeed want “shared decision making” at the governance level, there is no need for a hospital to be a willing participant if the doctors – either in group form or network of independent physicians – take the initiative. If anything this offers a very bright prospect of maintaining independence.

    I don’t confuse insurance reform with health reform (not saying Dr. Poplin did – just most do). In the PPACA there is insurance reform in the commercial sector and their is an optional payment reform in the Medicare sector that requires health care reform in order participate in the payment reform.

    These reforms, in my humble opinion, are expanding the influence of the PCP. The Medicare ACO (Shared Savings Program) in the PPACA requires PCPs, the qualifying metric is PCP based (attribution of patients in PCP activity) , it appears that all but 2 or 3 of the quality metrics are PCP metrics – that sounds like a lot of influence and control to me. The reform also includes the “accountability” of a peer group establishing just a bit more precisely when a patient should be cath’ed or the development of a major joint guidelines of when, how, and if a serious of joint injections of lubricant/pain relief are appropriate. It is the accountability back to the peer group that is worthwhile: Insurance company, patient and government are either too inexperienced and removed from the clinical decision making to be of real value.

    Savings created by the PCP for exerting this influence are then shared back with the Medicare ACO. Let us remember that less than 15% of the population visits the hospital in any given year – we make the most improvement and savings away from the hospital – an admission neither costs or is of poor quality if it doesn’t need and doesn’t happen….

    Who gets how much is very much dependent on who initiates the effort. If the physicians want to organize and initiate the effort, they will have the preponderance of influence. There are several groups – including mine – that would be very interested in helping these organizations form as truly physician centered and empowered.

    The “good old days” are part of the broken system, and most likely weren’t all that good anyway. The new days will require change from all of us.

    I don’t think PCPs should surrender their autonomy – I don’t see collaborative guideline and best practices education and development as a surrender of autonomy. I wonder why a well intended physician would either not want the education or not pass on their knowledge?

  6. American Medical Assn Says:

    The AMA is helping physicians who chose to do so prepare to lead and participate in new models of care, including ACOs, which can improve care coordination and quality for patients. Not all physicians provide services in the hospital, nor should they. New AMA principles on ACOs emphasize that they must be physician-led, place patients’ interests first, ensure voluntary physician and patient participation, and enable independent physicians to participate. The physician-led ACO model injects competition into the market by eliminating the need for consolidation under a hospital system. The AMA believes care coordination is vital, and physicians can work together with a health care team to keep patients healthy while maintaining independent medical practices. The AMA is encouraging CMS to adopt policies that facilitate physician-led ACOs and do not inadvertently bias participation in favor of large health systems and hospitals.

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