Practice Makes Perfect

Improving patient care is central to the work of the American College of Physicians. Here the ACP’s John Tooker tells Frances Davies why the organization is advocating change in our healthcare system.

For John Tooker, frequent travel is part of the job. As EVP and CEO of the American College of Physicians, he heads an organization representing 126,000 members both in the US and spread across the globe. EHM caught up with him in Chicago, where he was attending the American Medical Association (AMA) House of Delegates meeting.

Luckily, Tooker is used to changes of scenery. He has lived and worked in Colorado, New York, Maine, Washington State, and he is now based in Philadelphia, where ACP has its headquarters. Tooker smiles when asked how he would compare these vastly different environments. “Of course, I have an affinity for the state in which I was born and raised, Colorado,” he says. “But from a point of view of practicing medicine, one of the great opportunities in this country – in this world – is that the practice of medicine is very portable and there are always patients that you can interact with and help take care of.

“The US is very diverse geographically but fortunately the standard of care in all of these locales is quite similar now, so that one can easily go from one to another and feel very comfortable practicing medicine. They all have their opportunities. In terms of the best living conditions, Colorado and Maine are wonderful rural states, but I’ve also thoroughly enjoyed New York, Seattle, and now the city of Philadelphia. It does present some challenges in this work because of the amount of travel that’s involved across three time zones, but it’s wonderful to have this degree of opportunity in this country.”

Members first

As our healthcare system continues to undergo radical changes, the ACP plays an important role fostering excellence and professionalism in the practice of medicine and providing education and quality improvement opportunities to its members, most of whom are physicians practicing internal medicine. There is also a large contingent of medical students who are members of the organization, and are likely to choose internal medicine or one of its sub-specialties as their career.

The work of the ACP can be separated into two main areas: the first is the ongoing education of internal medicine physicians through a variety of resources, from textbooks to clinical journals, to a large number of web-based resources that provide current knowledge of internal medicine and guidance for patient care. Much of the work is in quality improvement – the ACP is working to help its members efficiently measure how well care is delivered and what steps should be taken to improve the quality of care when opportunities arise.

The second area involves public policy and dealing with important issues such as improving access to healthcare for patients in the US, given the large number of uninsured people. “Access is a big problem,” states Tooker. “We have a broad public policy base and ability to advocate at both the federal and the state level for patients. This requires a significant legislative and regulatory presence in Washington, so we have a pretty good-sized and talented Washington staff working on these federal issues. This work also includes the important issues of professionalism and medical practice reform.”

Adding value

Tooker describes how it is crucial for the organization to be run as a business, assigning value to everything that it does. “As we determine that value, we can assign the appropriate resources,” Tooker says. “ACP resources are very important for our members. They are paying dues to this organization and expect value for their membership.

“It is our responsibility to make sure we are fulfilling the college’s mission, in accordance with their wishes. This requires an understanding of how to participate in the marketplace of medicine. There are many commercial education and proprietary educational companies that we compete with in the open marketplace. This requires paying close attention to the marketing and promotion of our programs, products and services, and we need to make sure that we communicate well with our members.”

The ACP has a board of directors called the Board of Regents, who are responsible for the organization. They are strongly advised by the Board of Governors, a representational body from each geographic area of the country and the international ACP chapters. It is these volunteer internists to whom Tooker, as CEO, is responsible. “I, along with the wonderful staff at the ACP, use the goals that have been set by the governance, the leadership of the organization, to develop our staff structure and resources to serve our patients and members.”

The ACP implements a continual strategic planning process to determine the short and long term strategies to support its mission and long term vision. The strategic planning committee integrates input from the major policy committees, councils and Board of Governors to develop the strategic plan that is presented annually to the Board of Regents for approval.

The components that structure and describe the ACP’s strategies are: theme – high-level outcome (what it ultimately wants to achieve); objective – specific goals or results (how it will achieve the outcome); initiatives – projects/activities to achieve the objective (what it will do); and performance indicators – specific measurement strategies to assess progress.

“Each year the current themes and objectives are systematically reviewed to refocus or reaffirm the college’s strategic direction, Tooker explains. “Themes and objectives may be revised for the upcoming fiscal year, based on current events in the healthcare environment, and suggestions from the Board of Governors through the resolutions process.

“Often, more than one committee/council is working toward a single objective, and several committees/councils may be involved in the objectives for a strategic theme, necessitating a coordinated effort.”

Credit where it’s due

On the public policy front, the ACP is currently leading efforts to implement fundamental and comprehensive reforms, to repair a dysfunctional payment system, and to make internal medicine more attractive as a career choice. “The current payment system in the United States has been in existence for many years, with physicians paid for the work they do according to a sustainable growth rate, or SGR formula,” Tooker says. A committee convened by the AMA develops the physician payment codes based on a variety of factors, including the amount and the intensity of the work involved in providing a service.”

Tooker is concerned that the reimbursement for primary care is much less than for other specialties and sub-specialties. With this in mind, the ACP is working hard to improve reimbursement for primary care, in particular for those physicians practicing general internal medicine. “These internists are very important for the physician workforce in this country. Every patient deserves to have their own personal physician, if they choose to have one. The comprehensive services provided by a general internist can be organized around an emerging care model, known as a patient-centered medical home (PCMH).

The care in a PCMH is provided by a team led by a personal physician, in this case a general internist or a sub-specialist who chooses to practice according to the PCMH model. Importantly, the practice in a PCMH model would be paid for the full range of services, including care coordination. The ACP, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Osteopathic Association came together to develop a national set of principles around the PCMH model of care. These PCMH principles are the basis for the Patient-Centered Primary Care Collaborative, a coalition of major employers, consumer groups and other stakeholders who have joined with the organizations representing primary care physicians to develop and advance the patient-centered medical home.  

Patient focus

As the population increases and advances in age, patients are developing more and more chronic diseases – for example, high blood pressure or high cholesterol – which may progress to organ damage such as kidney failure or heart failure. Most patients, as they age, will have more than one chronic condition. “As a result, we need a model of care in which they will have a patient-centered medical home that will be able to manage the majority of their conditions, and will also be able to coordinate the care for all of their conditions.”

There are four principles of primary care in the patient-centered medical home, as Tooker explains. “The first of these is first contact. If a patient has a need, then the patient should be able to promptly find out exactly where they can get that care. Second, patients should be able to get care in the medical home that is comprehensive. Third, the care should be continuous. Last, the care should be coordinated for patients between all the various interactions within the healthcare system, such as office and hospital care, laboratory and imaging services, and pharmacies.”

The Wagner Chronic Care Model plays an important part in this. Developed by Dr. Ed Wagner and colleagues, this model provides for a predictably good relationship between the patient and the practice they’re a part of. “We have taken these primary care principles and the Wagner Chronic Care Model, and incorporated them into the patient-centered medical home. It’s gaining a lot of popularity, but the care model is not yet proven. It is now being piloted, including the payment model for the PCMH.”

A further difficulty with the current payment system here in the US is that the more services physicians provide in the short term, the more they are paid under the SGR formula, a volume-based incentive. But with this incentive comes a downside. “Unfortunately, from the government’s point of view, according to the SGR formula, once you exceed a certain volume of services, then the government reduces the overall payment to all physicians,” Tooker says.

IT impacts

Information technology plays a crucial role in many aspects of our lives, and medical practice is no different. Getting the right information for patients is a necessity and the ACP is working hard to facilitate this. At its recent annual meeting, the college released a position paper, “ E-Health and Its Impact on Medical Practice ”, with a number of recommendations. “In a patient-centered medical home, patients need to have access to the right information,” advises Tooker. “They need to fully participate, where possible, in clinical decision-making with their physicians. If the patient needs to have a particular test or a procedure done, the physician and the patient should be fully informed in order to help make that decision. Communication is vital.”

Tooker worries about how information exchange with patients often fails between one appointment and the next. “A lot of patients require much, much more communication in order to help manage their chronic illnesses. This means that we need to further develop other technologies, such as patient Internet portals and secure e-mail exchanges in addition to in-person visits and telephone communication. Telephone care can be used, but it’s time consuming and you have to get both parties together at the same time. The nice thing about Internet portal communication and e-mail is that they’re asynchronous, which means that both parties don’t have to be participating at exactly the same time.

“Each physician practice in the patient-centered medical home is required to generate information that goes back to the patients and informs them about the quality of care that the medical home is providing. For example, measuring diabetes – how well is the medical home providing diabetes care? This kind of information should be available to patients on an ongoing basis, but also to patients who may be deciding to choose a medical home and may have more than one choice. They need to be able to have comparative information about the quality of care they are going to receive from that medical home.

“Moving from paper-based records to secure electronic health records, where the ease of access and usability of this information for both patients and for the practice, is much better than what it has been before. Unfortunately, in this country the rate of adoption is still quite low.”