Congress Punts – SGR patched, not fixed

The Senate passed yet another “patch” to the SGR today, for the 17th time i the last 11 years. This is disappointing in a year that appeared to promise bipartisan support for a permanent solution to the flawed formula that dictates Medicare payments. President Obama is expected to sign the bill into law tonight, postponing the designated cuts in Medicare payments to physicians until march 2015.

There are two other provisions of the bill. One is a delay in the implementation of ICD-10. While this might be welcome for some physicians, ACP notes that many physicians have already expended significant time and resources to meet the existing October 2014 start date, and this does not nearly offset failure to act on SGR. Another provision repeals limits on deductibles for small group health plans, with the idea of giving small businesses flexibility similar to that in the individual markets. Essentially, this means that insurance carriers could offer small group coverage with any deductible up to the maximum out-of-pocket limits that were established for health savings accounts.

You can read a statement from ACP President Molly Cooke here. Included is a call for us to tell our legislators that this can’t be this Congress’ final word regarding SGR.

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Have you registered for MOC yet?

Starting this month, the ABIM has implemented its revised rules for Maintenance of Certification (MOC). If you haven’t done so yet, log in to the ABIM website to find out how to proceed to obtain the designation “Meeting MOC Requirements”. You will be introduced to a new page, called myMOCStatus. You will be given a list of requirements and deadlines. In general, you must complete one activity every two years, and there is a need to earn 100 MOC points every 5 years, with at least 20 points in medical knowledge and at least 20 points in practice assessment. In addition, you will need to fulfill a patient safety and a patient survey requirement. The points earned every two years count toward the five-year total. The points earned every two years will count toward your five-year requirement, and also count toward the milestones for the certifications you are maintaining. The requirement to pass an exam every 10 years still exists as well.

If you were already enrolled prior to January 1, you remain enrolled and you will not incur additional fees until your current enrollment period expires.

We will continue to offer the opportunity to participate in courses where you can complete a medical knowledge module at our annual chapter meeting – and stay tuned for more to come!

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World AIDS Day

The first World AIDS Day was held in 1988. I guess it is a marker of how long I have been around medicine that I remember the approval of AZT; I remember ICUs full of people with Pneumocystis pneumonia; and I remember how patients with AIDS became a relative rarity on the inpatient medicine service with the advent of HAART. It has truly been remarkable to witness HIV infection go from death sentence to manageable chronic disease.

Now, for the sobering facts:
1.1 million people aged 13 and older are living with HIV infection in the US; nearly 1 in 5 of these people is unaware of being infected (2010 data from CDC);
Men who have sex with men account for over 60% of the new cases, and the number of infections increased 12% between 2008 and 2010;
African Americans and bear a disproportionate share of the disease.

The 2013 theme for World AIDS Day is “Shared Responsibility: Strengthening Results for an AIDS-Free Generation.” CDC has initiated several campaigns that are aimed at educating our patients about HIV infection
Resources from the State of Connecticut Department of Public Health are here:

Remember that testing is recommended at least once for everyone between ages 13 and 64, with annual testing for those at higher risk.

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One month into the ACA, trouble looms

When will the dust settle around implementation of the Affordable Care Act? It’s hard to say. The well-publicized technical issues will probably (hopefully?) be overcome. One wonders if the real issue is the sheer complexity of healthcare financing. Determining who qualifies for which of a myriad of different existing government-run programs (Medicare, Medicaid, Tricare, etc) and a variety of other insurer’s plans could of course be avoided by having a single-payer system. Discarding that musing momentarily, I feel it is imperative to avoid a “rush to judgment” about the failure of Obamacare. Of course, recent news about insurance companies canceling existing individual plans, contrary to President Obama’s consistent message that people could keep their current plan, is adding fuel to the fire upon which opponents would toss the ACA. In point of fact, many of those people who are being instructed to seek insurance through the exchanges instead are finding more affordable plans – but the news focuses on those who were hard done by, having to substitute their existing plan for a less affordable one and understandably, these people are upset. What is the breakdown of those who suffered versus those benefiting – we’re not yet sure. Regardless, it appears the President was perhaps misinformed or unprepared for the response of the insurance companies (I hate to think disingenuous). Nevertheless, this too shall pass.

However, one of the things that will soon be thrown into sharp relief is the shortage of primary care physicians. Congress’ failure to fund several provisions of the ACA, such as the National Workforce Commission and the Primary Care Extension Program, makes the threat of insufficient access even greater. It has been difficult to push for these things at the national level given the current fiscal environment, although truly the amounts involved are relatively small; there is even bipartisan agreement in principle, however simply because these are provisions of the ACA, political lightning rod that it is, there is no progress to be had. Shame.

Locally, this coming shortage provides more ammunition for the Connecticut APRN Society to push for an expansion in scope of practice. Legislators will be tempted to address the issue by granting this expansion. How do we counter? Are the primary care physicians of Connecticut ready to handle the potential increase burden of patients? Will more be demanded of already overburdened safety net practices? Let’s hear your voice in this debate.

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Dynamic Clinical Care Teams

The Fall Board of Governors Meeting coincided with the publication of ACP’s Position Paper on dynamic clinical care teams. There was lively debate during the creation of this policy statement, but in the end ACP has taken the stance of trying to move forward towards models of care that are most likely to benefit our patients. The paper outlines four general areas – professionalism, licensure and regulation, reimbursement and compensation, research – with definitions and principles that should guide development of clinical care teams. [Link to article].

The Professionalism section defines clinical care teams as the various health professionals “with the training and skills needed to provide high-quality, coordinated care specific to the patient’s needs and circumstances” (emphasis mine). A “culture of trust” is called for to ensure maximum effectiveness, including establishment of shared goals, respect for each member’s particular skills, and quality communication. The paper also reiterates the Institute of Medicine definition of primary care: “The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community”.

The authors also point out that viewing primary care as a single type of care, uniformly provided by a single type of practitioner, is overly simplistic. They outline a spectrum of care that can be viewed in the familiar terms secondary or tertiary, basically from wellness and minor illness to comprehensive care for complex and multiple serious conditions. A guiding principle is that assignment of specific clinical responsibilities within the team should be based on what is in the best interest of the patient. Another principle is the importance of having access to a personal physician trained in the care of the whole person and who has leadership responsibilities for the team, as previously outlined in the Joint Principles of the Patient-Centered Medical Home.

There are three editorials that accompany the piece. Predictably, the American Association of Nurse Practitioners objects to any statement that does not affirm the equality of nurse practitioners as team leaders. The editorial by Thomas Huddle of the University of Alabama at Birmingham School of Medicine points out that there is some ambiguity in the message about team leadership. I agree with his comments on professionalism; the requirement that the professional with the most expertise should be responsible for the approach to care and that it is professionalism that limits practitioners from operating beyond the sphere of their competence. Connecticut internist Anna Reisman also provides important insight; that while the position paper could not be expected to quell the scope of practice debate, continued quarreling over this issue could prevent us from getting where we need to go. Also, she highlights the importance of leadership training to ensure highly functioning teams.Overall, while the paper is likely to draw criticism from practicing physicians as well as from the nurse practitioner community for its nuanced take on team leadership, I applaud ACP for moving the conversation in the right direction and focusing on what is in the best interest of the patient.

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Developing the Next Generation of Leaders

“I start with the premise that the function of leadership is to produce more leaders, not more followers.” —Ralph Nader

The ACP has a program for Early Career Physicians called the Leadership Enhancement and Development Program (LEAD). Participation in this program helps to provide physicians with the skills and experiences needed to be a successful leader. Involvement in a series of qualifying activities makes one eligible to receive the LEAD certificate; these include such things as attaining Fellowship in the ACP, attending leadership activities at Internal Medicine 2014, participating in chapter and national committees, getting involved in advocacy activities and demonstrating leadership by involvement at the community level. The Connecticut Chapter wants to support and encourage its future leaders. Please visit the ACP website to learn more about the qualifications for a LEAD certificate, and contact me if you have an interest in participating in chapter committee or advocacy activities.

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Effort to Reduce Prescription Drug Abuse

Did you know that Connecticut is one of 17 states where the mortality rate from unintentional drug overdose, primarily from prescription opioids, exceeds the death rate from motor vehicle accidents? Thankfully a team of Connecticut public officials led by ACP Fellow and CT DPH Commissioner Dr. Jewel Mullen is now collaborating with other states and the Association of State and Territorial Health Officials (ASTHO) to address this problem. The other physician on the team is Dr. Daniel G. Tobin, an Assistant Professor of Medicine at Yale University School of Medicine and a member of our chapter’s Governor’s Council; Dr. Tobin has made the study and teaching of prescription drug abuse an area of academic focus. Together they recently attended an ASTHO-sponsored interstate summit in Washington D.C. to discuss challenges and best practices in the hope of reversing the scary statistic cited above. CT ACP members can familiarize themselves with the issues and learn how to help address the problem by reviewing an excellent article just published in the CT Mirror about the team’s efforts which can be accessed at this link.

Members looking for more education about prescribing opioids for chronic pain should consider attending the CME course sponsored by the Connecticut State Medical Society on September 25. You may have already received an announcement about this conference in the mail, but I have attached it here.

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