Quality, teamwork to be key issues for internists 

Task force cites need for compensation restructure

A task force of leading internal medicine physicians is recommending significant changes to their profession and the health care industry so they can better serve patients while stemming chaos in the current health care system.

"The Future of General Internal Medicine: Report and Recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine," was published recently by the Journal of General Internal Medicine.1

The task force was chaired by Eric B. Larson, MD, MPH, director of the Seattle-based Group Health Cooperative’s Center for Health Studies. It had been tasked by SGIM — a group of physician researchers in the field — to redefine their profession in light of its uncertain future.

Quality accountable physicians’

Among the group’s recommendations were the following:

  • General internal medicine should remain true to its core values and competencies, though market forces may tempt the field to abandon them while adapting to chaos.
  • The domain of the field should remain broad and deep.
  • General internal medicine should embrace changes in information systems.
  • Postgraduate and continuing medical education should develop mastery.
  • General internists usually should work in teams and provide services through their own direct contact with patients.
  • Current financing of physician services, especially fee for service, must be abandoned, reformed, or restructured.

The task force also called for internists to be "quality-accountable physicians."

"We think that quality has the same traits that generalists aspire to — a broad concept all the way from timeliness as experienced by the patient, doctor, and nurse leading to the best possible outcomes," Larson adds.

"Along the way [to those outcomes] are satisfaction, reducing errors, care safety, and not using an excess amount of resources," he says. While the general public most likely perceives internists as primary caregivers in an office setting, the report notes that today’s internal medicine physicians play a significant role in hospital care — either as hospitalists or as internists dealing with inpatient care issues.

"The general conception of an internist being broad and deep is very important for hospitals; it’s what they like about us," Larson notes.

"We take care of a breadth of problems that are both common and unusual, and we are very good at it. Orthopedic surgeons, for example, will want an internist to take care of everything for a patient with a broken hip except the surgery itself," he says.

This vision of the future readily can be seen in the team concept. In general, it envisions the internist leading a multidiscipline team, but as Larson points out, the actual shape of that team will vary from setting to setting.

"We looked at a situation in Dillon, MT, for example," he observes. "The team includes a small rural hospital where the internal medicine physician works with everybody. You can form these teams around the patient first and foremost, but someone has to be willing to take on that organizing principle — the coach/player role.

"We think the internist is the logical person to do this," Larson continues. "You want a person who is interested in this to do it — not to command and control the team, but someone who works by cooperation."

Link pay and quality

Pay structures should be reformed to reflect quality and performance, Larson argues, although he concedes that the task force found pros and cons with many of the alternatives considered. Still, he says, they are preferable to today’s fee-for-service model.

"One obvious model is salary plus incentive. Another would be time-based, like an attorney’s compensation," he suggests. "A third is a hybrid fee for service plus a management or coordination fee. This gets really important when you talk about chronic disease care."

Quality and compensation were among the frontier issues discussed at the recent meeting of the American College of Physicians (ACP), Larson says.

"There was a lot of interest in coming up with ways to do what we know works for quality in ways that are rewarded for quality," Larson reports.

"For example, if a group of docs got together voluntarily to feed in data on their [diabetic] patients, and showed as they did this over time that the hemoglobin A1C readings improved, then incorporating incentives could allow both the patient and the provider to benefit," he says.

Other possible incentive structures might include productivity or efficiency, Larson suggests.

"The new Medicare bill has some provision for studying these issues," he notes.

The bottom line, he says, is that internists and quality professionals are on the same page when it comes to patient care. "Ideally, people would like to do good and do well," he says.

"The ACP has established a performance measurement subcommittee, charged to come up with ways to improve quality without creating distortions in the system. Any good idea needs to be carefully tested, and physician practice groups are close enough to the world of real practice to come up with some of these."

Which brings us to quality managers. "They have a real opportunity to pilot things," Larson says.

"A lot of change will occur in the future by taking things that are out in the intellectual stratospheres, trying them, and charting them," he explains.

In some of these cases, he says, the pilot programs might be underwritten by a government agency or by a private insurance company.

Of one thing Larson is sure; things must change. "One of my colleagues just got word his mother broke her hip," he relates. "He went back from Boston to Seattle, because he wasn’t sure she would get good care. This means we’ve really got to make some changes. The whole thrust [of the report] is to not sit back and wait for someone else to do it, but to make changes before the situation gets worse."

For more information, contact:

  • Eric B. Larson, MD, MPH, Director, Center for Health Studies, Group Health Cooperative, Seattle. Phone: (206) 287-2988. E-mail: larson.e@ghc.org.

Reference

1. Larson EB, Finn SD, Kirk LM, et al. The future of general internal medicine: Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med 2004; 19:69-77.