Pay for coordinating care tops internists' wish list

General internists, frustrated by the growing number of barriers to practicing medicine and the declining interest in their specialty from U.S. medical students, are the second group in three months to sketch out a plan for revitalizing their specialty.

The Society of General Internal Medicine put forth a summary of its plan in the April 20 issue of the Annals of Internal Medicine. It follows the April release of the Future of Family Medicine project by the American Academy of Family Physicians.

"We heard from practitioners just how hard it was to do their jobs," said internist Eric Larson, MD, MPH, chair of the SGIM task force commissioned to draw up a strategy to revitalize the discipline and director of the Center for Health Studies at Group Health Cooperative in Seattle. "We need fundamental reorganization."

Taking a look at reimbursement

The top priority is changing the fee-for-service reimbursement system that has become a barrier to providing the type of care generalists do best -- coordinating the care of chronically ill patients.

Graduate medical education is also targeted. The SGIM sees a broad and deep knowledge of medicine as critical, along with a mastery of informatics, management and team leadership.

The task force's recommendations cover instituting new technologies to help doctors better partner with patients, increase the efficiency of care and ultimately improve outcomes. Leadership skills are important because generalists need to manage the continuous care of patients with multiple, complex, chronic diseases that require treatment from other physicians and health care professionals.

JudyAnn Bigby, MD, SGIM president, said restructuring physician reimbursement was a hot issue.

"Doctors are paid for doing procedures," she said. "They're paid for ticking off a series of boxes of what they did for patients. They're not paid for coordination or supporting patients through illness. The system rewards them for seeing patients every 10 to 15 minutes. They aren't satisfied to do that, and patients aren't, either."

The SGIM will focus on bringing about the recommended changes.

Dr. Larson said a reimbursement fix could come in several forms. Doctors could be reimbursed for the time they spend supervising long-term care, managing teams and providing phone and e-mail consultations. Or, payment, either on a fee basis or salary, could include incentives for quality and improved outcomes.

Gail Wilensky, PhD, senior fellow at Project HOPE and an expert on health policy and financing issues, said physicians need to be savvy if they want to get beyond wishful thinking. "It's all very nice to say you'd like to get paid for things you aren't paid for now, but in the current climate that isn't very fruitful."

Bundling could be one approach, where one fee is paid for a number of services. Medicare, for example, does this with nursing home care. paying the nursing home a specified sum per day. If physician fees were paid in a similar manner, coordination of care or patient counseling could be factored into the total charge.

Linking reimbursement with quality could be another avenue to pursue, she said. Doctors might not get paid exclusively for phone calls or e-mails, but if these efforts improved outcomes, physicians would, in effect, be reimbursed for them.

Dr. Larson said these recommendations are vital if barriers to patient care are to be torn down and the internal medicine profession kept healthy. If the status quo remains, "patients will miss the benefits of the best quality care. You're going to see very fragmented care, and I think there will be a significant risk of increased errors. Care today is very complicated, and if you don't have it well-organized and coordinated, you'll have problems."