The ACP’s Cognitive Dissonance

Brian Klepper

Relative to their specialist colleagues, primary care physicians have been generally passive about the politics that shape their professional lives, and they have been big losers. It is important for them to consider whether their societies are genuinely acting in their interests. I believe the evidence overwhelmingly reflects poor judgment by the societies that has diminished primary care’s prospects and, more importantly, caused significant harm to patients and purchasers.

Over at the ACP Advocate Blog on Wednesday, ACP Senior Vice President of Governmental Affairs and Public Policy Bob Doherty took me to task for asserting that the American Academy of Family Physicians is the only “pure” primary care society. He’s right, of course, in the sense that the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) have done yeoman’s work in the past few years in promoting the value of primary care. He’s also right, and I stand corrected, on my statement that AAFP is the largest society. The information on Wikipedia shows that ACP has 130,000 members while AAFP has less at around 100,000.

As though any of this matters.

Source: Medscape Physician Lifestyle Report 2012,

The deeper point is that under the leadership of all the societies that profess to be primary care advocates, primary care has declined precipitously. There’s little debate that, over the past 20 years, the duration of primary care office visits has declined, the referral rates to specialists have increased, the income of primary care physicians relative to specialists has dropped precipitously, and we now face an impending primary care labor crisis because only the most idealistic medical students are willing to endure a career making far less.

This last point is critical, especially to Mr. Doherty’s argument, because it highlights the difference between motion and action, between good intentions and effectiveness. If ACP is an ardent and effective advocate for primary care, why did the rate of medical students choosing general internal medicine plummet from 9% to 2% between 1990 and 2007.

A core problem here is cognitive dissonance. ACP (like AAP and AOA) serves multiple masters. Mr. Doherty sees no conflict in representing the opposing interests of ACP’s general internal medicine and internal medicine sub-specialist physicians, because we need them all. In an email to me yesterday he said:

…we represent all internists, primary care and more specialized, and that the demand for primary and specialty care is so great that health policy needs to recognize the roles of all involved in taking care of patients, especially those with complex and chronic diseases–general internists, family physicians, pediatricians, and IM subspecialists.

Of course, it is impossible to not agree that health policy “needs to recognize the roles of all involved in taking care of patients.” On the other hand, it is very difficult to advocate for a shift in the balance of power when you’re representing both sides. And ACP’s stripes are most clearly apparent in their choice of a delegate to the AMA’s RVS Update Committee (RUC). Since 1994, ACP has been represented by J. Leonard Lichtenfeld, MD, an oncologist who serves as Deputy Chief Medical Officer for the American Cancer Society. (By contrast, and to the main thrust of Dr. Doherty’s post, AAFP is comprised only of primary care physicians and its RUC representative represents only primary care. So it is “pure” and not conflicted, at least on this point.)

Mr. Doherty pooh-poohs the influence of the RUC on the plight of primary care reimbursement, saying that there are a host of external  factors that are really the culprits.

Budget-neutrality adjustments by CMS, volume increases in other categories of services, lower primary care conversion factors by private insurers, high debt, high administrative costs and burdens … there is a long, long list of factors that have contributed to the under-valuation of primary care outside of the RUC’s decisions.

And he says that abandoning the RUC isn’t the way to go.

We have recommended improvements in the RUC and CMS’ processes for establishing relative values (including endorsing MedPAC’s recommendations for an independent expert panel to identify misvalued codes). We don’t think that a “do it my way, or we take the ball home and won’t play anymore” approach to the RUC” is productive in achieving the necessary changes.

Mr. Doherty asserts that, due to ACP’s advocacy, the RUC has recognized the value of primary care by adding two new primary care seats.

ACP has also worked diligently to reform the RUC, and we have achieved a large measure of success, with the RUC’s decision to add another seat for primary care and another seat for geriatrics, which will add to the existing seats for AAFP, ACP, AOA, AAP and a rotating seat for IM subspecialties.

After 20 years of mostly ignoring primary care’s concerns, the RUC suddenly voted to add 2 new seats – a permanent one for Geriatrics and a rotating one for primary care. What’s the most logical explanation for that? That after a lot of media and legal pressure, the RUC decided to convey the illusion of course correction to the court? Or that the RUC suddenly saw the error of specialty-dominating ways, listened to primary care societies, and did the right thing.

And did this great act buy primary care anything? As Paul Fischer MD and I described in more detail here, the balance of power still remains heavily weighted in favor of the specialists. There is no more transparency in the ways that valuations are reached. There is no change in the bogus valuation methodologies. As a practical matter, nothing has changed, and the RUC, an institution with overarching influence over the public interest but constituted specifically to promote the special interest, maintains business as usual.

As many reputable critics have documented over the past 5 years, the RUC is a key driver of excessive health care and cost. Medicare’s sole advisor on medical services valuations, its recommendations have been accepted more than 90 percent of the time without further due diligence, and then are often generalized into the fee schedules of commercial health plans. Most importantly, as David Kibbe MD and I recently documented, unlike other federal advisory bodies, it operates outside the requirements of the Federal Advisory Committee Act, which are designed to ensure that the formation of federal regulation is in the public rather than then special interest.

Good intentions notwithstanding, the overwhelming desire of the leadership of primary care medical societies to remain at the AMA’s table has had disastrous real-world consequences for patients, purchasers and primary care physicians. In March I excoriated the American Academy of Family Physicians for acquiescing to the RUC’s refusal to meet most of its demands, and by doing so becoming complicit with the RUC’s actions. (This was the same article, by the way, in which I characterized the AAFP as a “pure” primary care advocate.) As this brief interaction with Mr. Doherty shows, there is a similar problem with ACP, which may have some laudable official advocacy positions, but whose political expediencies have often worked against the interests of rank-and-file general internists.

All this raises another issue. Do these realities call for a new all-encompassing primary care society, that unites and leverages the highly fragmented primary care community, re-calibrating the sensibility that primary care’s leadership projects into the policy environment? But that will have to be the subject of another post.

3 thoughts on “The ACP’s Cognitive Dissonance

  1. This is a brilliant argument and totally fits my observations of the current realities of medical practice. The very poor reimbursement to primary care has a whole cascade of implications beyond those described in this article. Because primary care is so poorly compensated it is very difficult to start a new primary care practice and a real challenge to keep a private group practice with an established reputation going. As a consequence, 85% of primary care physicians work for hospital systems today. Why do hospitals want to control the primary care force? Once again, we need to just follow the power and the money. I see no evidence that primary care practices are being bought to improve outpatient management of chronic diseases to improve health and reduce costs. Everything that I see tells me that hospitals are willing to pay a premium for these practices to preserve their volumes of high-priced procedures and tests. All of these realities will impair our ability to improve our national health cost crisis.

  2. In a letter published in the May 2, 2008 issue of the Annals of Internal Medicine I suggested that the demise of Internal Medicine as we then knew it was near. I post that correspondence below. I am neither prophetic nor clairvoyant but predict that the era of the ambulatory care Internist is over.
    The Internist must concede the ambulatory care arena to family medicine and retreat to the hospital and medical subspecialties.
    Training programs must be redesigned for the new realities.

    A thoughtful editorial (1) bemoans a decline in the number of practicing internists but admits to a paucity of information in literature and among physician workplace researchers to explain its causes. I have previously made comments (2) relevant to this problem. Thirty years of practice as an internist allow me to make further observations.

    Academic medicine is the carpenter that fashioned the coffin of internal medicine. Instead of reengineering internal medicine to accommodate change, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment, and the latter blurred distinctions between internists and those without medical degrees who practice in ambulatory care settings.

    Medical subspecialties that are nurtured in the ivory towers of academia have further reduced the stature of the internist. Effective lobbying by their affiliated societies and by commercial manufacturers of the medical devices they use assured them disproportionately higher reimbursement than that of their generalist colleagues. Absent an identity, the internist’s only remaining role is thought to be that of provider of ambulatory care to the chronically ill whose medical problems are beyond procedural intervention and lucrative compensation.

    A continuing decline in professional stature and income, when coupled with deteriorating working conditions, makes the continued existence of internal medicine untenable. I am pessimistic that current political and professional interests will allow significant change to resuscitate internal medicine. Would it then not be opportune to draft an obituary for internal medicine and commission a requiem to its memory?

    1. Adaftary accurately describes the decline of internal medicine and points to the important role internists must play in the focused management of chronically ill patients. These patients have created the lion’s share of the increase in medical costs over the last two decades. We are in this position because the recommendations from the Institute of Medicine to redesign our systems of care for patients with priority chronic conditions have been ignored. We are in this position because of a failure of medical leadership that rivals that seen in the banking industry that lead to the housing bubble. Most premature chronic diseases in this country are caused by unhealthy foods, physical inactivity, and cigarette smoke. All of these factors inappropriately activate common core signaling pathways and epigenetic mechanisms that produce multiple chronic diseases. On the other hand, life style interventions, statins, ACE inhibitors, ARBs, metformin, and spironolactone have benificial effects on multiple chronic diseases including diabetes, hypertension, high cholesterol, kidney failure, heart failure, heart attach, stroke, amputation, blindness, atrial fibrilliation. All of these conditions share a common causation. The well trained internist who is a student of nutrition and molecular biology is best suited to coordinate managing these patients. Internists should be the most valuable primary care doctors over the next several decades. The well-trained generalist can best deliver this care. The new science that shows that strokes, heart attacks, and kidney failure are all caused by the same molecular biology make the siloed approaches of neurology, cardiology, and nephrology less valuable. The best management will come from generalists who manage all of these conditions in a coordinated way.. Partialists will never solve the medical quality and cost crisis facing our families, industry, and government at all levels. Internal medicine may be dying, but medical leadership that works in the national interest and patient’s interest is already dead-all the more reason to start all over with a new primary care society that will truly empower generalists to fulfill their critical role in providing better care at lower costs.

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