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General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.
General Internal Medicine (GIM) has entered a challenging period. After several years of national attention and growth, interest has waned. The number of physicians choosing to practice GIM in a primary care setting has decreased by 50% in the past 5 years, and many physicians who have been practicing GIM are now abandoning it. Some academic medical centers are eliminating primary care from their organizations altogether. Why is General Internal Medicine perceived by trainees and experienced by practitioners to be so undesirable? Can anything be done to improve the perception and the Practice of General Internal Medicine?
Paradoxically, this exodus and contraction is occurring at a time when well-trained, well-supported Internists are more essential than ever. Health care has grown more complex: more patients have more chronic illness that requires coordination by a highly trained specialist in adult medicine. In 2005, 133 million Americans (45% of the population) had a chronic condition; approximately 60 million (24% of the population) suffered from multiple chronic conditions, and this number is projected to increase to 81 million (25%) by 2020. 1,2 Care for this type of patient is complex and expensive. Total yearly medical expenditures for a person with a chronic condition ($6,032) are more than 5-fold higher than for a healthy person ($1105) (Fig. 1). 3 From a national perspective, direct medical costs of chronic diseases were $510 billion in 2000 and are expected to rise to more than $1 trillion by 2020, and nearly 80% of this is apt to be spent on patients with chronic illnesses.4 Health care spending for a person with one chronic condition is 2 1/2 times greater than spending for someone without any chronic condition, while spending is almost 15 times greater for someone with 5 or more chronic conditions, translating into more than $15,000 per beneficiary annually (Fig. 3). Thus, care for patients with multiple chronic conditions demands a level of support and a working environment that is vastly different from that required for less complex acute care or prevention.
The care of such patients has become progressively more fragmented as specialists, who make up the preponderance of the physician workforce, attend to only 1 disease or 1 organ system. Although most General Internists report that demand for their services far outstrips their capacity, decreasing reimbursement for their services coupled with excessive administrative burdens are making this discipline unattractive, if not untenable, for many highly trained physicians.
It is unlikely that this situation can be sustained for many more years before the fabric of health care in the United States begins to rapidly and visibly disintegrate. Health care in the United States is extraordinarily expensive, consuming nearly 15% of the United States gross domestic product in 2002 and projected to grow to more than 18% in 2013, with annual expenditures of $3.4 trillion.5 Despite this vast expenditure, the health care received by most Americans is at best mediocre compared with the rest of the developed world. In a study of approximately 4,600 randomly selected adults from 12 U.S. cities, only slightly more than half received recommended preventive, acute, or chronic care.6 Moreover, these deficiencies respect neither ethnic nor socioeconomic boundaries and are equally pervasive throughout the population. There is substantial evidence that the delivery system is inefficient and wasteful, as illustrated by the fact that 1 in 7 hospital admissions is prompted by poor access to a patient’s medical records, 12% of physicians’ orders are not executed as written, and 20% of laboratory tests are requested because prior results are not readily available.7
Many experts attribute these problems to a fragmented health care system that lacks the structure and tools to genuinely improve quality. Almost all financial incentives favor volume over quality and high-tech procedures over personalized care and prevention.
The care of complex patients with multiple chronic illnesses requires careful management by thoughtful physicians who have the scope of expertise and are able to devote the time to understanding all of the active problems and how they interact and affect the patient. As opposed to physicians who spend most of their time performing procedures, these physicians are often referred to as cognitive specialists because they devote most of their time and effort to interviewing, examining, treating and counseling patients. The environment for these cognitive specialists, who include primary care physicians (General Internal Medicine, Pediatrics, and Family Medicine), non-procedural medical subspecialists (e.g., Endocrinology, Rheumatology, Genetics, and Infectious Diseases), and other medical fields (e.g., Psychiatry), is becoming increasingly hostile. The demands of this type of clinical practice have increased dramatically, while remuneration has steadily declined in relative terms. During the period 1995–2005, physicians spent an increase amount of time on direct patient care, which is defined as face-to-face contact with patients, patient record keeping and office work, travel time connected with seeing patients, and communication with other physicians, hospitals, pharmacies, and others on a patient’s behalf.
As a result, the number of physicians entering these fields has dropped precipitously, and serious shortages of such physicians are predicted (Fig. 2). Conversely, physicians in specialties that entail performance of technical procedures have experienced dramatic improvements in their practice environments and have been able to effectively limit their working hours while incomes have risen more briskly. Correspondingly, procedural specialties are now viewed as more appealing than cognitive specialties and are attracting record numbers of trainees. Even within Internal Medicine, the number of physicians entering the higher paid procedural specialties such as Interventional Cardiology, Gastroenterology, and Nephrology has steadily risen over the past decade, whereas that entering cognitive specialties such as Endocrinology, Infectious Diseases, and Rheumatology that provide long-term care to patients with serious chronic diseases such as diabetes, HIV/AIDS, and rheumatoid arthritis, has been slowly decreasing, as has the number of medical school graduates electing to enter General Internal Medicine.
The major reason for this shift has been a system of reimbursement that rewards the diagnosis and treatment of disease with procedures and devices rather than primarily with careful examination and management. Between 1999 and 2003, payment for imaging services grew by 45%, and in 2004, the cost of imaging to all payers was approximately $100 billion, equivalent to $350 per person in the United States.8 For reading an ultrasound image, the radiologist, who may never actually see the patient, is paid as much or more than a cognitive specialist who thoughtfully interviews and examines the patient, determines the need for and orders the ultrasound examination, and ultimately, crafts a treatment plan. Although the rationale for this disparity may be that procedures and devices are easily counted and controlled, the net result is increasingly to drive the medical care system toward an impersonal, technological, and expensive approach to care.
General Internal Medicine is a prototypical cognitive specialty with few procedures and has suffered declining fortunes along with the others. Disparities in financial rewards coupled with high levels of indebtedness plus a higher perceived job satisfaction and better lifestyle in other medical specialties are the major factors driving trainees away from primary care. High-tech proceduralists are paid vastly more than physicians whose work is mainly cognitive, and trainees have taken notice. The national average compensation of a Dermatologist is twice that of a General Internist or a Family Physician, while that of an Orthopedic Surgeon is nearly 2 1/2 times higher. In some community settings, the disparity can be much greater, with proceduralists earning up to 6 times as much as a cognitive specialist. This is not necessarily to argue for parity, but to highlight explicitly the power of the incentives that are presently operating in the medical marketplace. Moreover, although in real terms the income of physicians has declined in recent years, that decline has been much more severe for physicians engaged in primary care practice (Fig. 3).
It should be noted that in some countries, England, for example, the incentives are tilted in precisely the opposite direction. Generalist Physicians there are now paid on average more than specialists to attract the best and brightest into general practice and reward efficient, high quality care.
Many cognitive physicians in the United States, such as General Internists, practice in settings in which it is difficult to deliver optimal health care to patients over time. Heavy demands for productivity, micromanagement by insurers, and limited practice support have eroded continuity and opportunities for truly personalized care. Performance of Generalist Physicians is measured in terms of numbers of visits, patients, or relative value units (RVUs), rather than results or quality. Current attempts to address these problems, such as typical disease management programs, that are external to the physician’s practice rather than integrated with it, may produce targeted improvements but also lead to more fragmentation and disease-centric care. These circumstances can easily lead to higher use of medical services (including procedures), lower quality, and higher costs. It is for this reason that every other developed country in the world has a health care system that links each patient to a generalist provider. Accumulating evidence supports the model of care where the patient has a strong relationship with a primary care physician as improving quality of care and lowering costs. Continuity of care is a prime determinant of patient satisfaction.9 Ironically, wealthier patients have recognized these problems and now often seek out “boutique” physicians who have divorced themselves from the systems that pay for disease care and offer a more comprehensive model focused on maintaining health. This reflects the fact that practically no patient wants production line, generic care, and that when substantial economic incentives exist, personalized, continuous care is available.
The United States has reached a crossroad. Unless the decline in cognitive specialists is reversed and new approaches to care for chronic illness are made readily available to all who need them, our health care system will continue to disintegrate and grow unaffordable to the majority of Americans. Patients will undergo an endlessly growing number of expensive procedures for a diminishing benefit. The elderly, who use most of the health services in this country, will continue to find themselves increasingly adrift in a complex system, required to shuttle on their own between single system specialists, each armed with a procedure. Rather than simply accept this inevitability, the alternative is to create a rational system in which all components of care are sensibly integrated within a highly functional environment that is strongly anchored by a skillful Generalist Physician who is able to match the medical needs and personal preferences of individual patients to the complex array of available tests and therapies. This physician is truly a specialist in managing complex, chronic illness. Although only a limited number of highly integrated systems such as the Veterans Health Administration and group-model health maintenance organizations have begun to move toward this goal, it is possible to envision other settings in which this type of care could readily be provided. Achieving this goal will require vision and commitment by the medical profession and by policy makers as well as a serious restructuring of the current methods of paying for health care.
In the remainder, we highlight principles of effective care for patients with chronic illness and suggest a potential strategy forward. We also address the special role of academic General Internists in addressing this impending crisis.
For the past three decades, the predominant approach to delivery of routine health for most Americans has been a primary care model. Several groups, including the Institute of Medicine, have carefully delineated the essential attributes of effective primary care. Although these remain thoroughly relevant to the provision of high quality health care, they are general attributes and do not provide detail about how they might be effectively translated into the delivery of care in real world settings such as that described above.
More recently, professional organizations such as the American College of Physicians (ACP) and the American Academy of Family Practice (AAFP) have issued very thoughtful and forward thinking position papers that address the current plight of Generalist Physicians. These statements also set forth potential solutions that might help to resurrect the important role of generalists. The ACP has proposed the concept of the Advanced Medical Home consisting of a competent team, including a physician specialist in complex, chronic care management, and coordination and active involvement by informed patients.10 To facilitate this initiative, ACP has called for:
AAFP has also issued policy statements supporting the notion of a medical home.11
We applaud and endorse these efforts and hope that the efforts of Society of General Internal Medicine (SGIM) will support and bolster those of our colleagues in those other organizations. We now propose a set of adjunctive principles that are intended to supplement the work of other organizations by establishing an approach that will sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the provision of coordinated, longitudinal care of adult patients with acute and chronic illness. These principles address critical components of health care delivery such as clinical support, organization, information management, and access. We discuss the implications for training and for future research.
In the early 1970s, it was recognized that the rapidly increasing specialization of physicians was leading to care that was fragmented and focused on specific organ systems rather than whole patients. Furthermore, the care was expensive and lacked sufficient emphasis on prevention. The primary care movement was established in response to these circumstances. Over the ensuing three decades, however, the term primary care has come to subsume several types of health care that include:
Although all of these types of care share certain elements such as a focus on prevention and provision of first contact care, they also differ in important ways. GIM, in particular, focuses on providing care to patients with multiple chronic conditions. For the purposes of this report, we concentrate on the demands of providing effective, high-quality care to adults with multiple chronic conditions. Management of these patients represents a special type of primary care that is very different from the episodic care for acute illness and prevention that otherwise healthy individuals require. Because of these differences, we refer to this type of health care as Coordinated Care as distinct from the more general term, Primary Care. Coordinated Care is also very different from the disease-based approach to care that is encouraged by our present system of payment. Coordinated Care embodies a true system of care in which continuity, coordination, comprehensiveness, and patient-focus, as a whole, are the goals.
The key to providing high caliber coordinated care by a General Internist will be to create a practice environment that incorporates improvements in workflow and information management, but still retains the essential characteristics of primary care models such as maintaining a trusting, long-term relationship with the patient. In the new model, the pre-appointment, intra-appointment, and post-appointment work are designed to maximize the quality and efficiency of the patient care encounter and to optimize the satisfaction of patients, staff, and physicians. The specific components of the new model are described in terms of clinical support, medical information management, and scheduling. Such seemingly mundane issues are vitally important to provision of excellent health care. It has become increasingly apparent that how systems of care are structured and operated is as or more important than the expertise or decisions of individual physicians. To take good care of patients, General Internists need a viable practice model.
There are numerous ways in which the office or clinic of a General Internist might be restructured to facilitate coordinated care. The physician might work side-by-side with one or more clinical assistants who are not independent clinicians but have substantial training and experience in clinical settings. For each patient, a clinical assistant completes an initial intake, reviews medical records, assesses the patient’s status, solicits agenda items, obtains vital signs, and performs any necessary point of care testing. The clinical assistant confers with the physician to review this information and joins the physician with the patient. The physician confirms and supplements key aspects of the history in an efficient and directed manner. During this process, the patient, clinical assistant, and physician formulate a plan and the clinical assistant simultaneously completes documentation. The physician then moves on to the next patient while the clinical assistant works with the patient to implement the plan and provides further education/explanation. If the patient calls later in the week with a question, she/he can be confident that this clinical assistant works closely with the physician and is personally familiar with the patient’s situation. The clinical assistant is continually learning in this environment, and like the physician, is rewarded by close interactions with patients.
Alternatively, routine interval visits could be scheduled with a nurse practitioner or physician assistant. The physician could visit briefly with the patient at the end of the encounter. The patient would understand that his or her physician remains firmly engaged and can look forward to a one-on-one appointment with the physician in the future. In larger practices, the services of pharmacists, health educators, nutritionists, and others may be warranted by the size of the patient population. In some clinics, pharmacists now initiate insulin therapy and titrate dosage or adjust antihypertensive medications.
The typical Generalist Physician still depends heavily upon paper records and forms that are inefficient to complete, store, access, and transmit. Moreover, it is difficult and expensive to use paper records for effective quality improvement or measurement. EHRs overcome many of these limitations, but despite their increasing adoption, their potential for improving the health of patients remains relatively untapped. Even in settings in which extensive EHRs have been deployed, the system is typically used in the same fashion as a paper record, i.e., simply for documentation, and most of the data are not systematically used for quality improvement. This is not only because of limitations of EHRs themselves, but also to the fact that physicians are too busy and poorly trained for such efforts.
In the setting of high quality coordinated care, the General Internist becomes the expert in the use of the EHR, not only in caring for an individual patient but also in managing a large number of patients within a practice. Moreover, the EHR is specifically designed to support this model of practice. When collecting and compiling clinical data, a clinical assistant is easily able to assemble prespecified reports that display all relevant information about patients, irrespective of the source (e.g., history, laboratory results, procedures, etc.) in a readily understandable, standardized format. This facilitates information exchange and eliminates time that would otherwise be spent searching through multiple sections of a record. Data in the record automatically link to context-sensitive resources such as clinical practice guidelines or alerts about newly recognized drug toxicities. The EHR also automatically links to other useful resources, such as patient education material and community resources. Patients can access and enter relevant information that is then available to the health care team.
The EHR in this setting also supports systematic methods for ensuring that patients receive a consistently high quality of care. The staff routinely devotes time each day to reviewing regular reports that identify patients who are due to receive indicated services such as cancer screening tests. Patients with certain parameters that are out-of-range, such as blood pressure, low-density lipoprotein (LDL)-cholesterol, or creatinine are identified, and plans to address these problems are devised. Patients can be confident that important results and findings do not slip through the cracks.
Because most medical errors reflect problems in information gathering and display, the EHR has the potential to play a critical role in improving efficiency and quality. The EHR should assist the physician in managing and using information. It must support physicians’ “thought-flow” as well as work-flow. To achieve this goal, however, the EHR must meet critical performance standards including:
The potential of the EHR to improve the efficiency of longitudinal care and the health of patients has barely been tapped. Realizing this potential, through the design of interfaces, implementation and application of the advanced EHR should become the province of physicians who specialize in coordinated care and assume responsibility for the oversight of patients’ overall health care.
The modern General Internist must simultaneously manage three basic sets of issues: evaluation of acute symptoms, management of chronic illness, and disease prevention. The typical practice relies mainly on routinely scheduled visits plus a variable number of acute or drop-in visits, although some practices are beginning to commit a substantial proportion of visits to open access. Advance planning for either type of visit is often minimal, but in a setting in which coordinated care is practiced, the staff carefully manage schedules to optimize efficiency. In the Coordinated Care model, staff assembles necessary data from other providers or the laboratory before the visit to facilitate management of chronic illnesses and to provide opportunities to enhance preventive health. Many offices would continue to provide same-day access for acute problems, but simultaneously dovetail provision of preventive services to potentially obviate routine scheduled visits in the future. In general, routine tests are ordered according to predetermined protocols and accepted clinical practice guidelines. This process is aided by the EHR, which tracks and recommends indicated tests and procedures and functions to reduce unnecessary or duplicative procedures. In this way patients can be automatically contacted at prescribed intervals for tests and visits.
When preferred by the patient and the physician, preventive care can be provided at a dedicated visit that provides sufficient time for the physician and staff to properly assess and counsel the patient. The intelligent EHR relieves the physician and staff of many routine tracking and scheduling tasks and permits them to focus on gathering critical information directly from the patient. The patient has confidence in the system because she/he has come to expect that necessary tests, and treatments are accomplished in a timely and predictable fashion.
Implicit in all of the foregoing discussion is that few, if any, of these changes can occur without a change in the method of paying for care. The present evaluation and management system reinforces an inefficient and expensive care delivery system that rewards piecework yet ignores the finished product. Unless and until the payment system is revamped, providers will be motivated to provide high volumes of visits without investing the time, energy, or resources into improved approaches to delivering health care to all people, but especially those who are chronically ill. In particular, there must be a mechanism to fairly reimburse physicians who provide leadership to teams that deliver high quality coordinated care. Payers must recognize that teams can provide better care than individuals and provide a mechanism to reasonably support this type of care. By furnishing a mechanism to provide coordinated, longitudinal care, payers will ultimately reap benefits by avoiding preventable complications and unnecessary care. As advocated by ACP, CMS should fund pilot programs to develop better practice models. Some of these should be conducted in academic settings so that the next generation of physicians can furnish leadership in moving toward coordinated care.
As the premier organization for academic General Internists, SGIM has a critical role to play in discussions regarding the future of GIM and the role of General Internists in caring for patients in the 21st century. In particular, SGIM must lead the way by:
The authors are grateful to Barbara J. Turner, MD, Msc, immediate Past President for initiating this project and providing incisive criticism of the draft report, to Robert Centor, MD, President, for exceptional support and leadership and to the SGIM Council for their thoughtful criticism and feedback.
Potential Financial Conflicts of Interest None disclosed.
This paper was developed by the Blue Ribbon Panel of the Society of General Internal Medicine. Its authors include Stewart F. Babbott, MD; JudyAnn Bigby, MD; Susan C. Day, MD; David C. Dugdale, MD; Stephan D. Fihn, MD (panel chair); Wishwa N. Kapoor, MD; Laurence F. McMahon, Jr., MD; Gary E. Rosenthal, MD; and Christine A. Sinsky, MD. It was approved by the SGIM Council on July 14, 2006.