Ralston: Tough Times Ahead for IMS

Internal Medicine World Report, Summer 2011, Volume 1, Issue 1

Ralston: Tough Times Ahead for IMS

A Frank Conversation with ACP Immediate Past President Fred Ralston, MD

By Ed Rabinowitz

IMWRspoke with J. Fred Ralston, Jr, MD, FACP, immediate past president of the American College of Physicians (ACP), the national organization of internists, and a practicing internist with Fayetteville Medical Associates in Tennessee, about issues facing internists today and going forward.

What are some of the key issues facing healthcare today?

If you look at it from the perspective of payers and regulators, there’s a valid concern about healthcare costs, and the projections of rising costs in the future. But there also are legitimate concerns about quality and efficiency. From the patient’s perspective, we live in a specialty-dominated world, and yet if you look at the data on cost and quality, we need to move toward a better balance between primary care and other specialties to get the best bang for the buck, and to get the best outcomes. However, if you look at the projections of specialty choice by medical students and the increased needs of the Baby Boom generation, it’s very clear that we’re going to have a significant shortage of primary care doctors. And the key is figuring out the way to change that trend. It’s going to take a lot of hard work to do that.

Why are internists unhappy over the state of healthcare today?

From the perspective of a practicing physician, and I’ll state my bias as a general internist: The world has become much more complicated. It used to be that I saw a patient, did what I could in the exam room, and then wrote a prescription. Generally, if you wrote a prescription, you didn’t get denials and need prior approval and have to rewrite everything for 90 days with 3 refills, and then have to do that again when the pharmacy benefit manager changed. The world has gotten a lot more complicated. I still love what I’m able to do for my patients; the access to specialty services for many of those patients is much better. But it’s a lot harder and a lot more difficult to do that.

Can healthcare delivery models like the patient-centered

medical home help?

You said the magic words. I really feel if you look at everyone’s perspective, and everyone’s benefit, the patient-centered medical home is something that if it didn’t exist would have to be invented. It’s an opportunity for practicing doctors to have additional resources. It’s an opportunity to blend nurse practitioners and primary care physicians together in a cooperative team-based approach. It’s also an opportunity

for using data collection to make it a dynamic process. Whenever I talk about the American healthcare system now, I use quotes around the word “system,” because “system” implies something about working effectively together. And that’s one of the elements that I believe the patient-centered medical home helps us achieve.

What needs to be done to move the patient-centered medical home model forward?

Obviously there’s much work to be done, and there certainly needs to be more work done on the payment model, because it will need to provide the proper resources to both support the clinical staff and to attract the medical students toward that specialty. If you think about an investment portfolio, you have to rebalance it from time to time. Perhaps now we have roughly 30% of physicians in the United States in primary care. And if we need to move toward 50%, then you’re going to need more than 50% of medical school classes for a number of years going into primary care. It would take a significant shift in current trends for that to become a reality. I think the patient-centered medical home gives people an opportunity to see the attractive opportunities for long-term relationships with patients. And I think that the positive benefit of primary care both to the patient and the clinician is something that will help drive more people toward primary care.

Why hasn’t there been more widespread adoption of electronic medical records (EMRs)?

I practice in an 8-person primary care group. We went ahead early on and bought an electronic health record, but our experience parallels a lot of other people’s experience. We’re glad we got it, and I think the estimates that we get 15% of the financial benefit of the record, but we pay 100% of the cost, is one of the limiting factors. Now, that’s going to change with the incentive funds, although even having had a record since 2004, we’re going to have to run through hoops and figure out all of the meaningful use aspects. And I think if somebody was actually beginning the process, to choose an EMR right now it might take them a while to get to meaningful use. But it seems like in many instances practices bought and were sold, in effect, replacements for paper charts. Either much of the capability wasn’t even there in the medical record, or the people selling it and the people buying it didn’t understand it. A lot of that quality measurement, for example, wasn’t turned on, and the companies really seemed to focus more on moving to the next potential client and selling a record rather than helping people get to the next level.

What needs to happen to change that perception and increase the adoption rate?

I think if the advantages were so overwhelming of an EMR eliminating hassle factors, then more people would be attracted to it. If, for example, I have an asthma patient and I’m trying to give them either a long-acting steroid or a combination inhaler that’s clinically indicated, there may be 2 or 3 choices that I can pick from. If in real time I’m told which one the patient’s particular insurance prefers, and also would be provided an opportunity to tell the patient it’s a $50 copay since it’s a branded medicine, all of a sudden that EMR quits being a luxury or a hassle, and those who have it tell their colleagues how great it is and how much time it saves.

How important are things like fellowships, certification, and the ACP’s Council of Young Physicians in attracting and retaining physicians?

I think they’re very important. I just attended our ACP Council of Young Physicians meeting in Philadelphia, and their chairman is a very dynamic general internist from Nashville, Ryan Meyer. They help us understand what’s coming up with the next generation. We talked about applications for the [Microsoft] Droid being very important, and that’s not something that normally comes up at all ACP meetings, for example. But we have to make those ACP educational tools, which I think most people feel are of outstandingly high quality, available to people in the formats that they need. And, we’re working hard with the Council of Young Physicians and others to make sure that happens.

One of the anecdotal things that we’re hearing with these patient-centered medical home demo projects, where people getting close to retirement age happen to be in a practice that tested out the patient-centered medical home, which is really reassuring to hear, is quotes like, “I was planning on retirement, but I’ve changed my mind. I’m signing up to continue in practice because in the patient-centered medical home, I feel like I’m doing what I wanted to do when I went into medicine. I’m taking care of patients.” I think that’s important.

I think there’s always a blend of experience and the excitement of the newly trained internists. And, it’s important for us not to lose those experienced mentors. Almost everyone would feel that at some point the incentives will be there to encourage more people to come into primary care. I don’t want to lose a generation that had an opportunity to mentor these young physicians. And I think it’s exciting with the patient-centered medical home that many people have the opportunity to continue their career. First of all, it fills positions and takes care of patients while additional physicians are being trained. But it also gives you the opportunity to have that blend where the experienced doctors learn the new ideas from the new doctors, but the newly trained doctors learn from the experience of their colleagues.