The ACP Will Survie, But Will You And I

Internal Medicine World ReportJune 2005


on June 3, 2005, the American College of Physicians (ACP) unveiled “an unprecedented effort

led by the ACP” in an article titled, “Ambulatory Care Quality Alliance Approves

Uniform Starter Set of Performance Measures” (

revitalization/am_care.htm). The motivation for the ACP to throw its

hat into the ring delineated by the intersection of the evidence-based medicine and the

quality-of-care and pay-for-performance movements is as follows: “The College recognized

that the proliferation of performance measures potentially will have a major

impact on internists’ reimbursement and on practice operation, and quickly engaged to

ensure that the interests of internists were represented in this national issue.”

In doing so, the ACP joined with the American Academy of Family Physicians,

America’s Health Insurance Plans, and the Agency for Healthcare Research and

Quality (AHRQ). This resulting Ambulatory Care Quality Alliance, or AQA,

announced a consensus on a uniform starter set of 26 clinical performance measures.I must confess to reading this announcement with some incredulity. To begin with,

the coupling of 26 performance measures with the word “starter” conjured up an

image of an unlimited number of quality indicators by which physicians and their

practices may be measured. Starting with process and moving on to outcomes, virtually

everything in medicine can be measured and judged against the weight of present

evidence. Of course, evidence changes constantly, so the clinical performance measures will have to constantly be reassessed and updated even as new one are being continuously added. Presumably, practitioners will be expected to conform at

every point, disclaimers notwithstanding. If this portrayal seems exaggerated, just

consider persistent asthma, where there is now some evidence that daily steroid

inhalations, one of the more widely used quality markers, may be unnecessary in some cases and, considering the potential harm, even undesirable. How the quality

marker is handled while this is being sorted out will be one of the more interesting test cases for the entire quality effort. In addition, I know from my work in industry

that creating action-oriented databases is far simpler than maintaining them; few if

any authoritative advisory systems can be trusted without question, let alone applied blindly to individual patients. Teaming a privately funded organization

like the ACP with AHRQ, a tax-supported federal government agency that is a division

of the Department of Health and Human Services, also suggests 2 things.

First, that the work will never end (consider that one federal agency charged with designing bridges was more than a century ahead of present needs at last count).

Second, that when “my” representatives go head-to-head with the government, even if

at the moment it is in the glow of creativity and good fellowship, the relationship will be problematic. The inclusion of health insurance plans, while democratic, also ensures that agendas will quickly become quite murky. But this is only the beginning. The real

drivers behind the quality movement are the payers. Thus only as much quality as

Medicare or private insurers are willing to pay for will get done—unless of course it

is to come entirely out of the doctor’s pocket. In the case of private insurance, it

is really the employer’s bottom line that is the driver. This has been clear for several years, so

that when the current announcement by ACP speaks of becoming “quickly engaged to ensure…the interests of internists,” I can only shake my head in wonderment.

Likewise, the increasing unrealism of the leaders of the quality movement is not

reassuring in terms of practical implementation. Since, for a “quality” person,

there can never be enough quality, Donald Berwick, MD, president and

CEO, Institute for Health Care Improvement, Boston, is now speaking of “ultrasafe”

health care and the 5 barriers to its achievement, suggesting that medicine

may evolve into a 2-tier system of (inferior) safe care and (desirable) ultrasafe care (Ann Intern Med. 2005; 142:756-764). I have previously described how John Wennberg, MD, of the Center

for the Evaluative Clinical Sciences at Dartmouth Medical School, who discovered

small area variation on which much of the quality movement is based, suggested

at an ACP regional meeting that primary care physicians take 1 day off per

week to study how their performance measures up against quality standards.

Both of these gentlemen seem to follow the academic dictum to never let the practice

get in the way of the theory. A combination of narrow focus and a

disinclination to identify the points beyond which zeal in a good cause becomes harmful

already exists and is likely to get worse before it gets better. Consequently, the

eagerness of the ACP to seek a place at the quality table may do more good for the

ACP than for its members or their patients. Clinical guidelines already abound and

have been widely adopted, including in pay-for-performance programs. But knowing

how to keep performance measure implementation from turning physicians

into compliers rather than thinkers and robbing us all of the ability to recognize a

sick patient remains to be determined. Managers of physicians will tell you that, as

a group, we can be counted on to go for “A” grades whenever quantitative measures

are put before us. So we are at risk. Practicing physicians always worry how

well the organizations that represent us serve our interests, both professional and

financial, and how well they understand the frequent linkages between the 2. Do our

leader/colleagues keep our needs paramount once they begin to “move up,”

whether in the hospital, the medical association, or elsewhere? Did so-and-so sell out?

Or were there factors we didn’t know about? Given human frailty, there are always a few individuals who do things that are ethically questionable. But more often, doctors themselves

have trouble facing unpleasant realities or putting up their money to support their

rhetoric. The demise of the American Society of Internal Medicine (ASIM), an organization

that was devoted both to high standards of practice and to the socioeconomic

well-being of internists, was due to lack of adequate physician support. But before we blame ourselves for that, one must also ask if that failure itself wasn’t rational because of ASIM’s

ineffectuality in combating the major forces that began to reshape medicine during

its tenure. Now it’s ACP’s turn. Frankly, I think it remains an uphill fight. And the work won’t

be made any easier by the need for our leaders to work harmoniously with numerous

interested parties who do not view physician welfare as in any way connected to

either patient welfare or their own. Significant conflicts of interest within

ACP will also make things harder. Subspecialists are well funded and will focus on

standards. Beleaguered primary care physicians will fear both the time and financial

costs of implementation. ACP represents both. ACP’s power base is in large institutions,

especially academic ones. But the vast majority of physicians are in small, scattered

practices. ACP also makes a business out of medical education and the maintenance of

standards. Will that sway organizational thinking? The agenda is daunting.

So I would feel more comfortable if the ACP did a little less preening and self-congratulation.

And I would like those at the helm to exhibit the kind of strength that would make me want to be their shipmate if caught in a storm in a small boat. Character and wisdom, more than professional excellence, are likely to be the qualities that are needed in the conflicted times ahead.

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