Officials from the American College of Physicians (ACP) presented the internal medicine organization's annual State of the Nation's Health Care briefing on Feb. 20, detailing a strategy they said would make the U.S. healthcare system better and reduce barriers to the patient-physician relationship.
The ACP report noted that the Affordable Care Act (ACA) will soon make affordable health coverage available to nearly all legal U.S. residents – an unprecedented circumstance accompanied by a record slowdown in healthcare cost increases. However, ACP also warned of vulnerable patients being left behind in states that refuse to cover their poor under Medicaid; the threat to public health and access if an across-the-board budget cut (sequestration) is allowed to occur; the continued obstacles to high-quality care created by Medicare’s Sustainable Growth Rate (SGR) formula; and the unacceptable toll of deaths and injuries from firearms.
At the same time, ACP officials said, a growing shortage of primary care physicians for adults will increase costs and reduce access. They added that many physicians report growing concern over intrusions on the patient-physician relationship.
ACP issued the following recommendations to make the health system more effective:
- Renew commitment at both the national and state levels to effectively implement the coverage expansions and related policies under the ACA, with particular attention to ensuring the poorest and most vulnerable patients have access to affordable coverage.
- Urge Congress and the administration to reach agreement on a plan to replace across-the-board sequestration cuts and future potential future disruptions in funding for critical healthcare and instead enact fiscally and socially responsible alternatives to reduce unnecessary healthcare spending.
- Pressure Congress to enact legislation to eliminate Medicare’s SGR formula and support the medical profession’s commitment to transition to new payment models.
- Institute policies to recruit and retain primary care physicians.
- Reduce firearms-related injuries and deaths by improving access to mental health services, supporting research on the causes and prevention of violence, and enacting reasonable controls over access to firearms that do not infringe on constitutionally protected rights.
David L. Bronson, MD, FACP, president of the ACP, then turned the discussion to what he termed "the unrelenting day-to-day intrusions on the patient-physician relationship."
Bronson explained, "As a practicing physician and a mentor to future physicians, I’m steeped in the same daily morass of barriers on the patient-physician relationship that are encountered by patients and physicians. These barriers constantly undermine the patient-physician relationship, the very foundation of good medical care."
He specifically cited lack of time with patients; "unnecessary and unproductive" administrative tasks; electronic health records (EHRs) that "do not meet clinicians' and patients' needs; performance measures that can have unintended adverse patient care consequences; "growing and excessive" mandates on physicians enforced by penalties; a "dysfunctional" medical liability system; and laws that "dictate [what physicians] can say to their patients."
"The inevitable result of the unrelenting assault on the patient-physician relationship is physician burnout, causing many physicians to leave their beloved profession," said Bronson. "It especially is causing many physicians to view primary care as a less desirable career choice, exacerbating a growing shortage of primary care physicians, because a disproportionate share of the burden of reporting on measures, health insurance transactions, and pressure to spend less time with patients falls directly on primary care physicians and their patients. "
ACP provided the following recommendations intended to reduce intrusions on the patient-physician relationship:
- Public and private policymakers and payers must ensure that any payment reforms explicitly allow physicians to spend more appropriate clinical time with their patients.
- Payment and delivery reforms that hold physicians accountable for the outcomes of care (measurable performance on quality, cost, satisfaction and experience with care) should concurrently "eliminate the layers of review and second-guessing" of the clinical decisions made by physicians.
- The Centers for Medicare & Medicaid Services (CMS) should harmonize (and reduce to the extent possible) the measures used in different reporting programs, and work toward overall composite outcomes measures "rather than a laundry list of process measures."
- CMS should provide more clinically relevant ways to satisfy the requirement that physicians must transition to using ICD-10 codes for billing and reporting purposes.
- Congress and CMS should work with physicians to encourage participation in quality reporting programs by reducing administrative barriers, improving bonuses to incentivize ongoing quality improvements for all physicians, and broadening hardship exemptions. If necessary, Congress and CMS should consider delaying the penalties for not successfully participating in quality reporting programs, if it appears that the vast majority of physicians will be subject to penalties due to limitations in the programs themselves.
- The government, the medical profession, and standard-setting organizations should work with electronic health record vendors to improve the functional capabilities of their systems, to improve the ability of those systems to report on quality measures, and to ensure that those systems "improve rather than add to workflow inefficiency."
- Medicare and private insurers should move toward standardizing claims administration requirements, pre-authorization and other administrative simplification requirements in advance of -- and in addition to -- the simplification rules included in the ACA.
- Congress should enact meaningful medical liability reforms including health courts, early disclosure errors and caps on non-economic damages.
- State and federal authorities should avoid enactment of mandates that "interfere with physician free speech and the patient-physician relationship. On this point, ACP explained, "Several states have proposed or adopted legislation and/or regulations that interfere, or have the potential to interfere, with appropriate clinical practice by (1) prohibiting physicians from discussing with or asking their patients about risk factors that may affect their health or the health of their families; (2) requiring physicians to discuss specific practices that in the physician’s best clinical judgment are not individualized to the patient; (3) requiring physicians to provide diagnostic tests or medical interventions that are not supported by evidence or clinical relevance; or (4) limiting information that physicians can disclose to patients. Of particular concern are laws and regulations that require physicians to provide care not supported by evidence-based guidelines and/or not individualized to the needs of the specific patient."
“System-wide efforts to improve the health care system won’t succeed on their own in improving access and quality if the physicians that the system is counting on to deliver are over-hassled, over-stressed, harried, hushed and rushed,” said Bronson. “ACP views necessary strategic health reform improvements and results not from a partisan or ideological perspective, but from the standpoint of what the evidence tells us will be the most effective course of action.”