Proposals by the American College of Physicians to improve health care quality and reimbursement---is the devil in the details?

Last year the American College of Physicians (ACP) warned of the collapse of primary care. This year they have proposed a series of reforms to help solve the problem, which they say will improve reimbursement and quality.

I have more than a few concerns about the proposals. They’re supposed to shift compensation incentives from procedures to comprehensive care. But haven’t we heard this before? The resource based relative value scale, conceived in the 1980s, was supposed to improve compensation for “cognitive” services. It wasn’t long, though, before physicians realized that RBRVS stood for “real bad reimbursement very soon.”

Worse yet, the proposals are another failure of the ACP to reclaim the identity of internal medicine. In defining the way internists fill the primary care role the proposals make no distinction from family practice. Is it any wonder there is a growing perception that the only way to be an internist is to be a hospitalist? Laurence Wellikson, M.D., CEO of the Society of Hospital Medicine, said it well: “General internal medicine had a chance to define itself as physicians who are master diagnosticians—the only doctors capable of handling the complexities of comorbidties, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with family practitioners and nurse practitioners to be the traffic cop for resource use and burgeoning specialization.” I have expressed this same view, though not as eloquently, here, here and here.

To me the proposals read like a mixture of physician DRGs, capitation, discounted fee for service, gate keeping, P4P and quality gamesmanship. They don’t make general internal medicine look very appealing.