Improving the practice environment and payment reform

ACP advocacy can be thought of as a 2-sided coin. One side is our advocacy on broad societal issues that affect public and individual health; the other is our advocacy to improve the practice environment for internists and their patients.

Recent examples of the former include our positions on reducing health care disparities for lesbian, gay, bisexual, and transgendered people; preventing injuries and deaths from firearms; and calling for immigration policies that do not compromise the health of vulnerable persons. Admittedly, such stances are controversial. In as much as the College is considered to be “the conscience of American medicine,” they are an essential part of its commitment to access and quality for all. Sometimes overlooked, though, is the College's work to improve the practice environment for internists and their patients, an even more important part of our advocacy.

Here are some examples and accomplishments of ACP advocacy toward improving the practice environment:

Increasing payments to internists. In an extraordinarily comprehensive and thoughtful 47-page letter to the Centers for Medicare and Medicaid Services, which I shared with all members in September and which is online, ACP called for Medicare to begin payment for the work internists do that falls outside of the usual office visit. We urged the agency to begin paying for e-mail and telephone consultations. We commended the agency for proposing to pay for advance care planning starting next year but argued that this should be done on a national basis, for all Medicare patients, instead of leaving it up to local Medicare carriers to decide if it would be covered in their areas.

Building on our successful effort to get Medicare to begin paying for chronic care management (CCM) services as of the first of this year, we urged Medicare to provide additional payment for CCM codes that require more time and to reduce documentation and other barriers to using the existing codes. And, let's not forget, ACP played a key role in repealing the Medicare sustainable growth rate formula earlier this year and ensuring that the new law provides opportunities for internists to earn higher payments, especially if they are in a patient-centered medical home practice.

ACP also is urging Congress to continue the Medicare Primary Care Incentive Payment Program, which pays internists and other primary care physicians a 10% bonus on their office visits and other designated services, beyond its scheduled expiration at the end of the year. We continue to advocate for restoring Medicaid primary care parity, which would increase Medicaid payments for primary care to no less than the applicable Medicare rates.

Reducing administrative burdens. Last year, we announced an important new advocacy initiative, called Patients Before Paperwork, to eliminate or mitigate the most intrusive, costly, and time-consuming “hassles” for members. Since then, we have researched the top “hassles,” electronic health records (EHRs) and meaningful use, quality reporting, and interactions with health plans, and are advocating solutions to each.

In a pioneering paper on clinical documentation issued at the beginning of this year, ACP reminded policymakers that the purpose of clinical documentation in EHRs is to allow physicians to provide the best care possible, not to meet regulatory mandates. The paper proposed specific ways to ensure that clinical documentation meets this objective. ACP already has achieved big improvements in EHR meaningful use rules by eliminating a requirement to report use of Stage 2 measures and by reducing the 2015 reporting period to 90 days from a full year.

Also, we were the first physician membership organization to urge CMS not to go forward with Stage 3, a recommendation that has been supported by key members of Congress. ACP advocacy played an important role in an agreement reached a couple of months ago to create a grace period to protect physicians from being unfairly penalized for mistakes in using the new ICD-10 codes. The agreement states that, for a 1-year period starting Oct. 1, Medicare claims will not be denied or audited solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes.

Promoting continuity of care and access to physicians. ACP has urged the U.S. Department of Health and Human Services (HHS) and the National Association of Insurance Commissioners (NAIC) to strengthen “network adequacy” and continuity of care protections for qualified health plans under the Affordable Care Act. HHS, as recommended by ACP, is requiring that insurers provide “real-time” access to accurate “provider” directors and has strengthened the rights of patients to continue to receive current medications and to appeal prescription denials when they switch to a new qualified health plan. NAIC is expected to release model network adequacy legislation in October.

Reducing the costs of prescription drugs. Earlier this year, ACP joined and became a leader in the Campaign for Sustainable Rx Pricing, a multi-stakeholder coalition working for solutions to skyrocketing prescription medicine prices.

When ACP joined the coalition in January, the College noted that its members work on the front lines of the health care delivery system and have witnessed firsthand the harm caused to patient health and personal finances by unsustainable pharmaceutical drug prices. We made it clear that exorbitant drug prices deny patients access to life-enhancing medicines and result in higher out-of-pocket costs, premiums, and taxes. To prevent our health care system from going bankrupt, we need to establish a drug pricing structure based on value and data-driven evidence and balance between the interests of innovative drug manufacturers and those of society and our health care system.

“Many patients and clinicians express concern that the pricing of specialty drugs increasingly lacks transparency and rationality,” I recently told a reporter. We're seeing the introduction of many patent-protected drugs with near monopolistic pricing power that fail to demonstrate a relationship between their price and the value to the health care system. Although many of these medications offer great promise, their high price tag can put them out of reach for some patients.

Other examples. In September, ACP released a policy paper that supports the expanded role of telemedicine as a method of health care delivery that may enhance patient-physician collaborations, improve health outcomes, increase access to care and members of a patient's health care team, and reduce medical costs when used as a component of a patient's longitudinal care. We also recently released a position paper on behavioral health and primary care. The paper proposes specific ways to better integrate mental health with the care provided by primary care internists. We also recently issued a paper that addresses retail health clinics and how our patients may utilize this new practice modality as a backup alternative to the establishment of a strong relationship with a primary care internist.

These are just a few examples of the College's work to improve the practice environment and maintain the relevancy of primary care for our patients. These are my key priorities as your president.