Resolution 1-F12. Exploring the Benefits of Establishing an ACP Council of Retired Physicians

Transcription

1 Resolution 1-F12. Exploring the Benefits of Establishing an ACP Council of Retired Physicians (Co-sponsors: New York, Colorado, Connecticut, Florida, Ohio, and Texas Chapters) WHEREAS, retired members of the College are an important constituency by virtue of their experience and perspective; and WHEREAS, these members have a high level of commitment and loyalty to the College; and WHEREAS, the College will benefit from the continued active participation of these members; and WHEREAS, these members have interests of particular significance to them, including volunteerism, mentoring, and philanthropy; therefore be it RESOLVED, that the Board of Regents explores the benefits of establishing a Council of Retired Physicians to develop an agenda of interest and relevance to our retired members.

2 Resolution 2-F12. Working with ABIM toward Reducing the Cost of Recertification (Sponsor: Florida Chapter) WHEREAS, the ABIM requires recertification for only a portion of its diplomats to prove qualification; and WHEREAS, the ABIM maintenance of certification process requires internists and subspecialists certified in 1990 or later (1987 for critical care medicine and 1988 for geriatric medicine) to spend a great deal of their time and money to continue to qualify; and WHEREAS, the ABIM s policy as such is disliked by many ACP members because it appears to have created an industry for itself and for other educational entities for preparatory and actual test administration of this segregated portion of diplomats, and not others; and WHEREAS, the ACP Mission and Goals include To serve the professional needs of the membership, support healthy lives for physicians, and advance internal medicine as a career; and WHEREAS, the cost to recertify every 10 years approximates $2, and should not be minimized especially for many small internal medicine practices struggling to survive; therefore be it RESOLVED, that the Board of Regents works with the ABIM toward reducing the cost of recertification.

3 Resolution 3-F12. Creating an Option for the 10-Year ABIM Examination (Sponsor: Florida Chapter) WHEREAS, the ABIM maintenance of certification process requires internists and subspecialists certified in 1990 or later (1987 for critical care medicine and 1988 for geriatric medicine) to spend a great deal of their time and money to continue to qualify; and WHEREAS, the ABIM s policy as such is disliked by many ACP members because it appears to have created an industry for itself and for other educational entities for preparatory and actual test administration of this segregated portion of diplomats, and not others; therefore be it RESOLVED, that the Board of Regents works with ABIM to create an option that does not require the 10-year maintenance of certification examination if continued competency can still be demonstrated.

4 Resolution 4-F12. Recognizing and Endorsing Priorities for Primary Care Payment and Practice Reform (Sponsor: Massachusetts Chapter) WHEREAS, there is a need for health care payment reform in a system that has been shown to be unsustainable, and consequently there are now numerous models of payment that are being considered, both at state and national levels, including the creation of accountable care organizations and alternative quality contracts; and WHEREAS, there is a national trend for improved access and reduced cost of care, primary care physicians will assume responsibility for improving access and reducing costs; and WHEREAS, putting forward the following policy positions are essential to achieving health care reform and require urgent revitalization and prioritization; and WHEREAS, ACP is committed to improving the quality of health care and reducing costs of care to make it more affordable for more people; and WHEREAS, ACP is committed to the maintenance of adequate reimbursement for the care provided by primary care physicians, the foundation of our health care delivery system; therefore be it RESOLVED, that the Board of Regents recognizes and endorses these priorities for primary care payment and practice reform: 1) There must be a new net investment (of money and other resources) in primary care practices to enable their transformation to high performance entities that incorporate the principles of the patient-centered medical home; the investment needs to be prospective. 2) Payment to primary care practices and its professionals should be sufficient to enable and incent achievement of desired primary care outcomes and reflect the actual value created; it should not be based on existing RVU determinations (which undervalue primary care services), though RVU-based payment may remain relevant for some specialty and procedural providers. 3) Payment for primary care should transition from fee-for-service to increasing degrees of bundled, comprehensive, or capitated payment over time and be complemented by performance-based, practice reinvestment/bonus payment for achieving desired goals in quality, patient centeredness, and efficiency as practices transform and develop the capacity to manage performance risk. 4) Any bundled, global, or performance-based payment for primary care must be robustly risk-adjusted, taking into account not only demographic and clinical factors, but also psychosocial determinants. 5) Payment reform for primary care should be offered uniformly across payers. 6) Performance metrics and standards used for payment must be scientifically validated, evidence-based, clinically meaningful, and vetted by practices before being implemented.

5 7) Loan forgiveness and other recruitment and retention incentives should be built into payment reform measures for primary care 8) Liability reform must accompany payment and practice reform for primary care. Reform should include but not be limited to: a) expert-panel pre-review of claims with a majority of panel members being practicing, same-specialty experts. b) no opt-out for claims deemed of low merit. c) a prejudgment interest rate equal to the national annual inflation rate or a similar statistic. d) safe-harbor provisions against law suits for practice of evidence-based medicine. e) cooling- off period with opportunity for non-admissible apology and communication between parties. 9) Primary care physicians and practices participating in an ACO or other integrated, risksharing care network must: a) occupy at least 50% of seats on the organization s board when its performance metrics and goals are heavily weighted towards primary care outcomes. b) choose and approve the mode of payment for primary care and have oversight authority for its implementation and ongoing operation. c) participate in the design, selection, implementation, and analysis of performance metrics. d) specify and be provided in timely fashion the systems, collaborations, and data necessary to fulfill their responsibilities within the organization. 10) Practices that choose not to join a formal ACO structure yet commit to and achieve its overall goals of high-value, patient-centered, coordinated care should not be penalized for remaining outside the ACO and should be able to interact with its participants in the delivery of care.

6 Resolution 5-F12. Recognizing and Endorsing Priorities for Subspecialty Payment and Practice Reform (Sponsor: Massachusetts Chapter) WHEREAS, numerous models of payment reform are being considered both at the state and national levels, including the creation of accountable care organizations and alternative quality contracts; and WHEREAS, there is a national trend toward putting together systems to provide comprehensive care; and WHEREAS, a particular group of internal medicine subspecialists the non-interventional fields such as endocrinology, infectious diseases, hematology and oncology do not derive their livelihood primarily through the performance of procedures, but rather add value with depth of expertise in complex medical problems supported primarily by evaluation and management (E&M) codes like primary care, in contrast to our colleagues in interventional cardiology and gastroenterology; and WHEREAS, the non-interventional medical specialists provide longitudinal and coordinated care to complex patients with chronic diseases such as diabetes, chronic renal failure, cancer, and chronic hepatitis; and WHEREAS, the care of these patients is highly complex and expensive requiring extensive specialist time and skill to optimize patient outcomes with thoughtful use of resources; and WHEREAS, many of these medical problems require not only an advanced depth of training and experience but also require complex treatments where there is a thin margin between treatment efficacy and toxicity, which results in a time consuming process of frequent testing, follow-up, medication adjustment, as well as conferring with infusion pharmacists, home nurses, and other physician specialists in dedicated patient conferences for both physicians and their professional staff; and WHEREAS, ACP is committed to improving quality of care and reducing costs of care to make it more affordable to more people; and WHEREAS, ACP is committed to the maintenance of adequate reimbursement for care to specialists who provide highly complex cognitive services and coordination of care; therefore be it RESOLVED, that the Board of Regents recognizes and endorses these priorities for subspecialty payment and practice reform: 1. There must be a new net investment (of money and other resources) in subspecialty internal medicine practices to enable their transformation to high performance entities; the investment needs to be prospective. 2. Payment to subspecialty Internal Medicine practices and its professionals should be sufficient to enable and incent achievement of desired subspecialist outcomes and reflect the actual value created; it should not be based on the recently discounted spectrum of E&M codes authorized for use by medical subspecialists as currently existing RVU

7 determinations undervalue cognitive subspecialist services. It is likely however that RVU-based payment may remain relevant for some specialty and procedural services. 3. Payment for subspecialists work should transition from fee-for-service to increasing degrees of bundled, comprehensive, or capitated payment over time and be complemented by performance-based, practice reinvestment/bonus payment for achieving focused goals in quality, patient centeredness, and efficiency as practices transform and develop the capacity to manage performance risk. 4. Any bundled, global, or performance-based payment for subspecialists must be robustly risk-adjusted, taking into account not only demographic and clinical factors, but also psychosocial determinants and the added expertise required to provide high quality subspecialty care. 5. Payment reform for subspecialists should be offered uniformly across payers. 6. Performance metrics and standards used for payment must be scientifically validated, evidence-based, clinically meaningful, limited to the actual care provided by the subspecialist and vetted by practices before being implemented. 7. Loan forgiveness and other recruitment and retention incentives should be built into payment reform measures for non-interventional subspecialists who work in medically underserved urban and rural areas and/or focus on priority public health conditions. 8. Liability reform must accompany payment and practice reform for subspecialists. Reform should include but not be limited to: a) expert-panel pre-review of claims with a majority of panel members being practicing, same-specialty experts. b) no opt-out for claims deemed of low merit. c) a prejudgment interest rate equal to the national annual inflation rate or a similar statistic. d) safe-harbor provisions against law suits for practice of evidence-based medicine. e) cooling-off period with opportunity for non-admissible apology and communication between parties. 9. Subspecialist physicians and practices participating in an ACO or other integrated, risksharing care network must: a) occupy at least 25% of seats on the organization s board when its performance metrics and goals are heavily weighted towards subspecialist outcomes. b) choose and approve the mode of payment for subspecialist and have oversight authority for its implementation and ongoing operation. c) participate in the design, selection, implementation, and analysis of performance metrics. d) specify and be provided in timely fashion the systems, collaborations, and data necessary to fulfill their responsibilities within the organization. 10. Practices that choose not to join a formal ACO structure yet commit to and achieve its overall goals of high-value, patient-centered, coordinated care should not be penalized for remaining outside the ACO and should be able to interact with its participants in the delivery of care. 11. The value of end-of-life planning discussions with their inherent complexity and teamapproach must be recognized and reimbursed as part of a bundled-payment model.

8 Resolution 6-F12. Requesting ACP Involvement to Improve the Pending ICD-10 Codes (Sponsor: Maine Chapter) WHEREAS, the proposed ICD-10 codes are extremely complicated and difficult to use; and WHEREAS, most primary care physicians do not have coders and chose the codes themselves; and WHEREAS, in many office EMR's the visit cannot be concluded and referrals and tests ordered until the code is chosen; and WHEREAS, there is a dearth of primary care doctors and if it takes 5-10 minutes longer to do an office visit because of these new coding demands this will exacerbate the access problem for patients; and WHEREAS, the proposed ICD codes are so complex they will increase errors and make the system less rather than more accurate; and WHEREAS, it is recognized that ICD- 9 codes are outdated; therefore be it RESOLVED, that the Board of Regents lobbies to delay the institution of the ICD-10 codes; and be it further RESOLVED, that during this delay the Board of Regents forms a committee to analyze how these codes can be simplified and made more accurate and reliable; and be it further RESOLVED, that the Board of Regents provides these recommendations to the government so that they can do a credible job of updating the coding system in America.

9 Resolution 7-F12. Evaluating the Impact of Medicare Contractor s Denials on the Quality of Care for Patients (Sponsor: Pennsylvania Chapter) WHEREAS, CMS Recovery Auditors, aka RAC or Recovery Audit Contractor, are denying inpatient payment to hospitals for short stay hospitalizations and demanding physicians return any payments received in these cases; and WHEREAS, Recovery Auditors are reviewing hospital admissions and second-guessing the physician's order, and making inadequate payments; and WHEREAS, the Recovery Auditor's audits are noted often to be conducted with little concern for the patient, with very little weight given to physicians notes and with little apparent reference to evidence-based medicine; and WHEREAS, physicians and hospitals have previously considered certain short stay hospitalizations as appropriate for inpatient admission; and WHEREAS, it does not cost the hospital any less to care for a patient if the hospital receives only the outpatient payment; and WHEREAS, the definition of an inpatient admission as set forth in the Medicare Benefit Policy Manual is vague and open for interpretation; and WHEREAS, CMS has not specifically clarified those services expected for an inpatient admission and has based their denial on the premise that the services provided were appropriate for the outpatient setting; and WHEREAS, greater weight needs to be given to the admitting physicians evaluation and decision; therefore be it RESOLVED, that the Board of Regents evaluates the impact of Medicare contractor denials of hospital and physician services, often without any input from the treating physicians or guidance from appropriate medical societies, on the quality of patient care; and be it further RESOLVED, that the Board of Regents determines the financial impact on patients and physicians; and be it further RESOLVED, that the Board of Regents lobbies for a transparent process wherein CMS provides explicitly, for each diagnosis-related group (DRG) under review, those services that are expected for an inpatient admission and those services which are best provided in the outpatient setting; and be it further RESOLVED, that the Board of Regents and physician societies be involved in the process.

10 Resolution 8-F12. Supporting the Immediate Adoption of a Single-Payer Health Insurance System (Sponsor: Illinois Northern Chapter) WHEREAS, the American College of Physicians recognizes the need to ensure that everyone in the United States has access to needed health care services of high quality; and WHEREAS, the ACP has recommended that the public and policymakers consider adopting a single-payer financing model as a means of achieving universal coverage, because single-payer systems are equitable and achieve high levels of patient satisfaction and high measures of quality and access with lower administrative costs compared to multi-payer systems; and WHEREAS, the Affordable Care Act, will leave many U.S. residents uninsured, expands Medicaid with its unreliable payment structure and expands expensive multi-payer private insurance coverage; and WHEREAS, a single-payer system with the above characteristics is most consistent with ACP's goal of promoting the highest clinical standards and ethical ideals; and WHEREAS, a single-payer system best promotes the value of primary and patient-centered care, as well as the medical home, concepts that ACP recognizes; and WHEREAS, a single-payer system shows the greatest potential to guide decision making through the use of evidence-based medicine, decision support, and electronic information systems in combination with an interoperable health record; and WHEREAS, under a single-payer system costs of future care would be removed from the tort system, thus allowing a decrease in liability insurance premiums; therefore be it RESOLVED, that the Board of Regents supports the immediate adoption of a single-payer health insurance system in the United States.

11 Resolution 9-F12. Developing a Position Statement on Personal Responsibility in Health Care (Sponsor: Wisconsin Chapter) WHEREAS, health care costs have been increasing at an unsustainable rate and Medicare is projected to become insolvent within the next 15 years 1 ; and WHEREAS, approximately 60% of health care costs are attributed to chronic diseases, many of which are deemed preventable based on lifestyle choices 2 ; and WHEREAS, some employers, insurance companies and state Medicaid programs encourage healthy lifestyle choices via reduced premiums, wellness programs and other incentives, most entitlement programs do not do so; and WHEREAS, the ACP in previous statements 3, has found it ethical to use patient incentives to promote behavioral change; and WHEREAS, the ACP has stated that decisions regarding allocation of health care resources are best made at the policy level, and that health care professionals with expertise in the delivery of health care services should participate in this decision making 4 ; therefore be it RESOLVED, that the Board of Regents develops a position paper outlining acceptable health care reform measures, including the use of incentive programs, that would actively engage and increase the responsibility of patients in making lifestyle choices that could positively impact their health. 1 Davis PA, Medicare: History of Part A Trust Fund Insolvency Projections Congressional Research Service - Report for Congress, May 27, Stanton MW, Rutherford MK. The high concentration of U.S. health care expenditures. Rockville (MD): Agency for Healthcare Research and Quality; Research in Action Issue 19. AHRQ Pub. No Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond. American College of Physicians Position Paper American College of Physicians Ethics Manual, Sixth Edition. Annals of Internal Medicine Supplement, January 3, 2012.

12 Resolution 10-F12. Supporting the Concept of I m Sorry Laws (Sponsor: Kentucky Chapter) WHEREAS, medicine is an inherently inexact art and science, in which medical errors will occur; and WHEREAS, medical liability reform is a critical issue that must be addressed to maintain the solvency of the U.S. healthcare system; and WHEREAS, due to constitutional limitations, tort reform is not a viable option in some states; and WHEREAS, Many studies have shown that implementing an I'm sorry policy has resulted in positive results on many levels. The University of Michigan Health System adopted a policy of investigating medical errors in 2002, and included the apology strategy. This cut their litigation costs in half and new claims declined by 40% 5. Similarly a study done by the Veterans Health Administration 6, another early advocate of the I m sorry policy at its hospital in Lexington, Kentucky, had 88 claims and paid an average $15,622 per claim (from 1990 to 1996) compared with a $98,000 average at VA hospitals without I'm sorry policies. 7 ; therefore be it RESOLVED, that the Board of Regents supports the concept of I m Sorry laws (i.e., medical liability laws that include an apology strategy) and will include this support in its efforts to enact medical liability reform. 5 Risk Management: Extreme Honesty May Be the Best Policy, Annals of Internal Medicine, Dec. 21, 1999, vol. 131, no. 12, Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program, Annals of Internal Medicine, August 17, 2010, vol. 153, no. 4,

13 Resolution 11-F12. Drafting Policy on the Risks of Non-Scientifically Based Health Legislation (Sponsor: Arizona Chapter) WHEREAS, recent legislative sessions have included federal and state laws that legislate medical education and practice; and WHEREAS, recent legislative sessions have included federal and state laws that are not scientifically sound. For example, a recent law passed in Arizona (H.B. 2036) 8 declares life to begin 2 weeks before conception; and WHEREAS, ACP, with its internal medicine specialists and subspecialists members, are charged with educating and maintaining the best interests of the patient community at all times; therefore be it RESOLVED, that the Board of Regents drafts policy on the risks of non-scientifically based health legislation. 8

14 Resolution 12-F12. Assembling a Forum to Develop Solutions for GME Financing (Sponsor: Arizona Chapter) WHEREAS, the United States is facing a critical shortage of physicians especially in primary care; and WHEREAS, medical schools are increasing their capacity to graduate students; and WHEREAS, graduate medical education (GME) programs are facing cuts and are closing; therefore be it RESOLVED, that the Board of Regents assembles a forum of constituents who benefit from GME including businesses and insurance companies; and be if further RESOLVED, that the Board of Regents charges the forum with developing creative solutions to finance GME; and be it further RESOLVED, that the Board of Regents forwards these recommendations to the Health Resources and Services Administration for consideration for funding of pilot models for GME financing.

15 Resolution 13-F12. Advocating for a National Educational Standard for All Disciplines that Grant Prescription Writing Privileges (Sponsor: New York Chapter) WHEREAS, the primary focus of physician training is the etiology, pathophysiology, diagnosis and treatment of disease and appropriate therapeutic interventions to treat disease; and WHEREAS, appropriate use of medications requires a thorough understanding of pharmacology, which in turn depends on the broad educational curriculum of medical school and residency training; and WHEREAS, certain states permit non-physicians to prescribe medications; and WHEREAS, the education of non-physicians is not as thorough or extensive as that of physicians; and WHEREAS, prescribing medications without a thorough knowledge base can result in harm to patients; therefore be it RESOLVED, that the Board of Regents advocates for a single national educational standard for all disciplines that are or will be granted prescription writing privileges.