David L. Bronson, MD, is immediate past president of the 133,000-member American College of Physicians—the largest medical specialty group in the nation.
During an interview Monday, Bronson, who also is president of Cleveland Clinic Regional Hospitals, explained why he thinks attendance was up at the organization's annual meeting this month in San Francisco. He also discussed what he views as internal medicine's biggest concerns.
HLM: This year's ACP conference was better attended than ever. Why was this meeting the biggest? Arguably we are just coming out of a major recession that hurt medical conference attendance throughout all specialties.
DB: People are trying to figure out where we are, and how we respond to health reform changes that all of us in American medicine are facing.
HLM: Do you get the sense that no, there's a realization that things will move forward, the Supreme Court has affirmed the legality of the Patient Protection and Affordable Care Act and the Obama administration is committed to moving ahead? That push has now come to shove?
DB: That's exactly right. The ACOs are forming across the country, and there's a lot of pressure, even outside these ACOs, in terms of financial stressors in the states, and small businesses that affect (health plan) contracts. So people are trying to figure out, how do we get ready for this, and respond?
HLM: Last year, you had the idea to have ACP convene a meeting for professional specialists in Washington, D.C. I hear that you sent out 64 invitations and 63 responded. What was the meeting about?
DB: Yes. It was a summit meeting, and 63 said yes, and did come. It was to talk about some areas of common concern, and how we work together as specialists to be more effective both with advocacy and collaboration.
HLM: Can you be more specific?
DB: There are challenges in interprofessional relationships, about who is going to take responsibility for doing what when you're caring across a spectrum of patient illness. For example, coronary disease. What should the internal medicine specialists be doing and what should the cardiologist be doing. We have to be more efficient, especially as baby boomers start needing more and more medical care. We don't want to waste peoples' time, both the doctors and the patients.
For example, we don't want both the general internal medicine doctor and the cardiologist managing a patient's cholesterol. Someone should, but it shouldn't be both.
HLM: That doesn't sound efficient. Is that the way doctors have been practicing?
DB: Too often, in the era of disconnected paper medical records, there's often been a lack of clarity for the generalist or specialist.
HLM: It occurs to me that in the effort to keep costs down, we have an even bigger effort with multiple specialties involved in the American Board of Internal Medicine's "Choosing Wisely" campaign. How is that impacting the internal medicine doctor's practice? I imagine that doctors might be spending as much time talking patients out of getting worthless care that might do harm as they do talking patients into doing something, or having something done where there's evidence it can help them.
DB: Yes absolutely. I think there's a responsibility to help patients understand when something is not useful, like a test. Or even when something might cause potential harm. We have an ethical responsibility.
HLM: Hasn't that always been the case? What's changed?
DB: We have always had the responsibility, but now it's affecting the bottom line, for example, in an ACO, or whatever structural organization you might have for shared savings. We want patients to get the right care at the right time, and no more than necessary. I think there's a shift in thinking on this issue. There's a lot more realization we have to be prudent with resources. We have to get rid of the things that add no value in healthcare.
The payers are paying attention to this too. They're saying no when there's no indication for a screening test.
I don't recommend some of the tests I used to recommend, also, because science has come along and said, gee, we thought that was more useful than it ended up actually being. The PSA (prostate specific antigen) test for prostate cancer is one example.
HLM: I understand that an awful lot of doctors are aging, and may not be on board with some of these changes. What do you say to them?
DB: Everything's a tough sell for a doctor who doesn't want to change.
HLM: A few years ago, we were hearing some scary stories about the shortage of doctors, especially as more people would be insured, and baby boomers would start needing more medical attention. Is this still the case?
DB: The supply of doctors has increased. The number of residency positions in medical schools has increased, mostly because of private funding. But there's going to be a need for more physicians.
HLM: Internists can expect a pay raise of 4%, which includes 3% for transitional care management services. So that's a good sign that primary care is being recognized.
DB: Yes, and hopefully soon, [the federal government] will implement the provisions of the ACA that raise payment for Medicaid patients' evaluation and management services so it is equivalent to what we're paid for taking care of Medicare patients. It varies from state to state, but in some states, it could be almost a doubling, from $40 to about $70. It's going to be the difference between losing money and being able to cover your costs.
This, of course, is being done to assure there will be enough physicians to care for the expanded numbers of Medicaid patients next year.
HLM: How else do you see internists working with hospitals when hospital care is to be avoided?
DB: You try new ideas to prevent utilization of expensive resources. A good example is after a total joint replacement, you get the patient home as quickly as possible with home physical therapy. That's more efficient than keeping them in the hospital for an hour of physical therapy every day for a week, and then sending them home."
HLM: How has your view of healthcare changed in your year as ACP president?
DB: I've never been more optimistic. People are frightened by change. But we have a lot of people working hard across lots of specialties to get this right. Does it mean everything will be smooth? No. It's going to take time to get the wrinkles out, and we'll make some mistakes.
HLM: What's the most important lesson you've learned in the last two years?
DB: That you have to play the long game, because you don't win every time. You have to recognize people will disagree, but you have to keep your eye on the long-term goal and don't destroy a relationship; just respectfully disagree and keep working on the same issues, pushing and trying, and get better science.