Dr. Philip R. Alper,Fellow at the Hoover Institution,in a recent column in Internal Medicine World Report expresses concerns about ACP's recent efforts to- in their own words- "quickly engage[ed]to ensure that the interests of internists are represented in this national issue" The issue is the intersection of quality of care and pay-for-performance.Visible evidence of this adroit move is the "partnering" of ACP with AAFP,and AHRQ(Agency for Healthcare Research and Quality) and America's Health Insurance Plans.This union of collaborators is called AQA ( Ambulatory Health Quality Alliance). Let me quote and paraphase some of Alper's concerns.
The AQA announced a "starter" set of 26 clinical performance measures.Dr.Alper wonders if the starter set is 26, how many will we finally have to deal with. Evidence changes constantly and therefore the measures would have to be in constant flux but there is always a lag-sometimes a long lag-between changes in evidence and re-adjustments of guidelines.He says "few if any authoritative advisory systems can be trusted without question, let alone applied blindly to individual patients." He asserts that "the real driver behind the quality movments 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 out of the doctor's pocket". These two sentences are what it is all about.ACP will function to supply the veneer of concern for patient care to the process and will become an even more powerful controller of who gets to be and to continue to be an internist.
Dr. Alper is also skeptical of ACP motives."...the eagerness of the ACP to seek a place at the quality table may do more good for the ACP that for its members of their patients". He says we already have clinical quidelines to spare "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".
Alper asserts that the power base of ACP is in large institutions while most internists are scattered in small practices and that ACP has made a business of medical education and maintenance of standards. Whose interests will ACP represent as they swim with the sharks of the insurance industry?