Behind the scenes at ACP, policy can improve patient care

An ACP member from Maine found herself troubled by a directive from her health care system administration. Based on the advice of an external regulatory body, the administration was asking medical assistants to administer a pain scale to all outpatients. The member and her colleagues felt this made no sense and was detrimental because it reinforced some patients' tendencies to unduly focus on their pain, rather than becoming more active and addressing any underlying psychological issues.

ACP was able to help. By carefully crafting evidence-based policies, the College can influence regulatory agencies and advocate for better patient care.

ACP is governed by a Board of Regents, which is its main policy-making body. The Board of Governors, consisting of leaders elected by individual ACP chapters, advises the Board of Regents and provides an important link to the ACP membership at large. Five councils also provide representation to both boards based on specific membership characteristics: students, residents, and fellows, early-career physicians, international members, and subspecialty societies.

The work done at all levels of the College is guided by standing goals, supplemented each year by specific priority initiatives that can be found online . Goals are developed in a joint planning process by the Board of Regents, the Board of Governors, and senior staff. An additional source of guidance comes from the grassroots members in the form of resolutions developed by 1 or more chapters, which ask the Board of Regents to develop a policy or take some sort of action. Such resolutions are vetted by the Board of Governors and passed on to the Board of Regents for final approval.

Usually, the Board of Regents assigns a resolution to a particular committee either for implementation or for study. It is at the level of committees where College staff and ACP members work together to translate pertinent priority initiatives and assigned resolutions into fleshed-out policy papers and initiatives to take back to the Board of Regents.

To illustrate how ACP can address problems faced by members, consider the Maine Chapter's reaction to required use of a pain scale. The Maine Chapter wrote a resolution titled “Limiting the Use of the Pain Scale to Support a Move Away from Excessive Narcotic Prescribing” and submitted it for consideration at the spring 2015 Board of Governors meeting. It requested that the Board of Regents work toward limiting the use of pain scales in outpatient medicine except in postoperative settings and hospice care and discuss the pain scale issue with The Joint Commission and CMS to encourage them to base chronic noncancer pain treatment on maximizing function.

The resolution was approved by the Board of Governors and passed on to the Board of Regents, which then referred the first clause to the Performance Measurement Committee and the second clause to the Medical Practice & Quality Committee for implementation. The 2 committees worked together and formed a short-term workgroup including members with experience in patient management and the author of the resolution. One of the committee staff then reviewed the relevant literature and found evidence-based support for the resolution.

Letters were drafted, approved by the workgroup, and sent to The Joint Commission and CMS. Depending on the response to the letters, further follow-up with those entities will be pursued. Thus, an idea from an ACP member has been carefully vetted, supported by evidence, and translated into ACP policy that can be help advocate for better patient care.

Resolutions are but a single avenue to policy development. Much of ACP policy is developed on the initiative of the various policy committees. The main committees involved in these efforts are the Health & Public Policy Committee, the Medical Practice & Quality Committee, the Education & Publication Committee, and the Ethics, Professionalism & Human Rights Committee. Each of these committees establishes an annual agenda of policy development work under the guidance of the Board of Regents. Among the many efforts currently underway are influencing the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), advocating for reform of the Maintenance of Certification process, advocating for the College's “Patients Before Paperwork” initiative, stemming the escalating cost of prescription drugs, and revising the College's Ethics Manual.

After reading this “deep dive” into policy development, some may wonder why ACP devotes so much effort to the process. In my view, it assures our credibility and the power of using evidence-based policy in our advocacy. When ACP is asked to take a position on an issue, we don't base our response on the opinion of our President or a vote of the membership. Rather, we look to our policy compendium to see whether we have a previously developed and vetted policy. If no relevant policy is found, we stay silent until such time as we do have Board-approved policy. It is this careful and deliberate approach that adds weight to our recommendations. It enhances the influence of ACP in matters of advocacy.

An important part of my activities this year as Chair of the Board of Regents includes attending committee meetings and getting to look behind the scenes to watch policy, clinical guidelines, and educational products come to fruition. Space limitations preclude covering all of the more than 25 committees and subcommittees here, but ACP's website does describe them all online .

My involvement with committee members and talented staff has greatly increased my appreciation and admiration for their work in enhancing both patient care and the profession. I hope this brief look at some of the less visible work at ACP will give you another reason to value your membership in the College.