Chair of the BOG Report: Chair of the BOG Report: Equity, Affordability and Quality- The Indispensable Role of Payment Reform
Dear Fellow Governors,
ACC leadership including Dr. Fred Bove, Dr. Ralph Brindis, Dr. Jack Lewin and I recently attended the American Board of Internal Medicine Foundation Summer Forum in Santa Ana Pueblo, New Mexico. This meeting was entitled: Achieving Equity, Affordability and Quality- The Indispensable Role of Payment Reform.
At the Forum, over one hundred and forty physician leaders, consumers, patient advocates, purchasers, payers, policy makers, and other stakeholders convened to discuss values and develop shared principles to guide physician payment reform and to support physician professionalism.
The Forum began with a discussion on the values espoused in the Charter on Medical Professionalism which was published by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation and the European Federation of Internal Medicine in February 2002 Annals of Internal Medicine:
http://www.annals.org/cgi/content/full/136/3/243
The Charter encompasses a set of principles to which all medical professionals should aspire. It focuses on physician efforts to ensure that the health care systems and the physicians working within them remain committed to patient welfare and social justice.
The Charter is based on the concept of professionalism and states: “…Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession...” The Charter has been described as the new Hippocratic Oath and contains three fundamental principles:
1. Primacy of patient welfare.
2. Principle of patient autonomy.
3. Principle of social justice.
The Charter anticipates some of the issues raised by our flawed payment system and exemplified in the recent New Yorker article by Dr. Atul Gawande: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Quoting from Dr. Arnold Relman in the New England Journal of Medicine from 1985, 313,749: "The medical profession in this country has always had its entrepreneurs and hustling businessmen, but until recently they were on the fringe…physicians concentrated on providing or supervising services to their patients, and their professional income was largely limited to the fees or salaries paid for such services. Lately, however, a new entrepreneurial fever has begun to affect the profession, and…seems to be moving into the mainstream…"
The Charter concludes with this statement: “…These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society….”
The stated goals of the ABIM Summer Forum were to:
* Develop a set of principles and recommended actions for physician payment reform that assures equity, affordability and quality of health care and reflects the values of the medical profession.
* Learn how different stakeholders define the purposes and aims of the health care system – and how to optimize value derived from expenditures on health care.
* Discuss the implications for how services are paid and organized. Explore how delivery systems, physicians and other stakeholders can advance changes in physician payment and how medical professionalism can be fostered by these changes.
Discussants called for physician leadership in payment reform discussions realizing the huge role that physicians play in relentless rising costs of health care. Various physician payment systems were reviewed including comparative international approaches.
Quoting James C. Robinson from the University of California at Berkeley: “…There are many mechanisms for paying physicians; some are good and some are bad. The three worst are fee-for-service, capitation, and salary. Fee-for-service rewards the provision of inappropriate services, the fraudulent upcoding of visits and procedures, and the churning of "ping-pong" referrals among specialists. Capitation rewards the denial of appropriate services, the dumping of the chronically ill, and a narrow scope of practice that refers out every time-consuming patient. Salary undermines productivity, condones on-the-job leisure, and fosters a bureaucratic mentality in which every procedure is someone else's problem…”
Participants agreed that policy makers need to focus on reforming physician payment to help achieve the goals of high-quality health care. The proposed payment system should support care coordination and integration, smoother transitions and team-based care, reward quality and foster patient- centered care. Reducing disparities and providing universal access was also highlighted as part of any health reform effort. Healthcare reform approaches enabling alternatives to fee-for-service (FFS) payment, including bundled and episode-based payment, hybrid models and shared savings models were discussed. These will require ongoing evaluation and technical adjustments, including determining the appropriateness of services, how to define episodes, and how to pay for multiple episodes, among other issues. Meeting attendees were given descriptions of potential new payment models to improve FFS payment. Background information was provided regarding the Resource Based Relative Value Scale Use Committee (RUC) process (which is charged with making recommendations to Medicare about how to value services). Payment reform models that accommodate innovations in the delivery of care, such as medical homes and accountable care organizations were also discussed. Pay for quality initiatives were also discussed.
The political climate of healthcare reform was also highlighted in light of the heckling of HHS Secretary Kathleen Sibelius and Senator Arlen Specter (D PA) at the National Constitution Center in Philadelphia on Sunday, August 2nd. Some 500 people crowded in to ask questions about healthcare reform efforts. Sibelius took the opportunity to point out that the country desperately needs to train more doctors, nurses and other medical personnel as well as add more medical facilities in underserved areas.
A detailed briefing report from the ABIM Summer Forum will be distributed to the Board of Governors when available. ACC leadership then moved on to the Board of Trustees Retreat at the Broadmoor Hotel in Colorado Springs. Next weeks BOG report will provide a detailed update from the BOT meeting.
JOHN GORDON HAROLD, MD, FACC
“That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.” George Bernard Shaw, The Doctor’s Dilemma, 1911
2009-2010 Board of Governors Steering Committee Membership:
John Gordon Harold, MD, FACC (Chair), California: john.harold@cshs.org
Jane E. Schauer, MD, PhD, FACC (Past Chair), New Mexico: janeschauer1@msn.com
Richard J. Kovacs, MD, FACC (Chair-Elect), Indiana: rikovacs@iupui.edu
José Rivera Del Río, MD, FACC, Puerto Rico: joseriveradelrio@gmail.com
J. Chris Higgins, MD, FACC, Vermont: jch6@mac.com
Oscar R. Jenkins, Jr, MD, FACC, North Carolina: oscarj@avlcard.com
Margo Minissian, ACNP-BC, MSN, CNS, California: Margo.Minissian@cshs.org
Thad F. Waites, MD, FACC, Mississippi: twaites@netdoor.com
Michael Widmer, MD, FACC, Oregon: michael@heartdoctorsnw.com
Action Items
BOG Meeting and Legislative Conference
Sunday, September 13, 2009
7:30 a.m. - 5:00 p.m.
Heart House Multi-Purpose Room Washington, D.C.
BOG Meeting at Legislative Conference
7pm Legislative Conference Start
Draft agenda
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BOG Steering Committee Highlights
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