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Friday, June 12, 2009

American College Physicians (ACP) endorses house bill that allows NP lead Medical Homes

Note this is a republication of an earlier version with a new headline and some introductory remarks..As pointed out by Bob Doherty in a comment to my earlier posting ( I am not sure that comment will survive this editing but that reflects my lack of mastery with blogger rather than an intent to silence his criticism) that the earlier headline was "demonstrably wrong". It said " The American college of Physicians endorses independent NP practices." To avoid misleading anyone I should have said what the current headline says namely that ACP has endorsed a house bill that does allow NP lead medical home practices.The ACP does not endorse NP lead practices in general only in the context of what is outlined in the house bill, ie in the context of the medical home practices.. Although my earlier headline is arguably technically accurate, it could be misleading and I hope my correction will satisfy Mr. Doherty's concerns. Judging from comments on Bob Doherty's blog I am not the only internist who has serious concerns about the issue of ACP going along with this element of the House bill and the ACP's support for what they do support is bad enough without me implying they are endorsing something worse. So here is the rest of the posting without any changes.

The American College of Physicians is endorsing a bill before the house that would enable NPs to practice independently in the context of the ACP sponsored "Medical Home". Further they seemingly welcome the opportunity to take part in a contest using certain quality measures to see who is the better provider.The bill,HR2350,can be read in all of vagueness and details yet to worked out here.

Go here to read what the ACP's man in Washington, Bob Doherty, has to say about how real practicing internists should enthusiastically get on board and strive to follow the appropriate quality driven guidelines to prove to the world that an internist provides better medical care that a RN with an extra two years Master degree that qualifies him as a NP.

Doherty says that the leaders of the ACP are endorsing this proposal because they are so pleased with the other elements of the bill, which include more training slots for general internists and some very modest increases in reimbursements from CMS and it furthers promotion of their highly touted Medical Home proposal. With these and other elements in the bill they are willing to endorse it even though the NP provision "goes past" what they had previously supported.

Doherty argues that if internists really were confident in their superior training they would welcome the opportunity to show they are better than folks with significantly less medical training. They should relish the opportunity to play a game even those it will likely be with rules that not disclosed (those devils in the details will be worked out later) and are likely to be written by folks who may well have an agenda which would be well served by either a victory for NPs or even a tie, which would also be a victory for the NPs . Go to the proposed bill and see if you can find what will be the rules of the comparison game between doctors and nurses.They are to be worked out later. So we should agree to a contest with rules to be worked out later?

Go here to read from the virtual pen of DrRich of the situation facing the general internist and his views of this "capitulation" of the ACP in his commentary that laments the now official nature of the death of the general internists even if the bill is not passed. (With the current state of the Republican party left toothless since the last election just about any democratic sponsored bill will be passed.) By virtue of their current stand the ACP has already stipulated that NPs are for practical purposes equivalent to internists.HR 2350 may set up more general internal medicine training programs but as DrRich points out what medical students with any modicum of cognitive function left would choose to enter a field of medicine that its professional organization has publicly stated that its members are equivalent to other health care providers with much less training. What does that about what the ACP thinks of an internist training and worth? What good will the Medical Home be to internists or the ACP when its Medical Home becomes a NP run organization?

The assertion that internists will prevail in a head to head who-gives -the- best- care contest seems to me to be naive or hypocritical. Does anyone really believe that such a comparison would be based on anything other than the usual "quality" measurements of compliance with easy to account guidelines and/or coarse grained outcomes too crude to show a difference in the short run.

If you think that it is not possible for this development be spun as a good news-bad news story read the second related commentary by DrRich. Go here for that. He suggests that this ACP capitulation could be taken as a opportunity for internists to get out of this "primary care" farce and become retainer docs leaving what primary care has become to a few internists who may just want to run the clock out and the NPs and whatever level of provider that the NP lead practices may devolve into.

This type of internist he and I trained to be may find professional satisfaction in a retainer practice ( at least before medical "reform" deems that to be illegal) or by becoming a hospitalist . The primary care environment that the internist turned officist now faces is-for many of us-not worth doing.


Bob Doherty said...

I recommend that people actually read the ACP poicy on NPs and primary care rather than relying on this blog's inaccurate and misleading description of our policies. The headline for his blog, that ACP endorses independent NP-led practices, is demonstrably wrong. Here is what we really said:


The policy clearly states that NPs and internists have complimentary but not equivalent skills, that patients have the right to be informed about the credentials of the person providing care, and that patient-centered medical homes are best led by a pphysician.

The legislation that I blogged about does not--I repeat not--pre-empt state laws on NPs scope of pracice. In fact, it specifically says that NPs can lead PCMHs only to the extent authorized by state law and that they have to meet the same standards as physician-run practices. Both payments and evaluation metrics for a PCMH will be risk adjusted, to take into account the more complex mis of patients typically seen in an internist-led PCMH.

Further, the best studies on physician workforce, including the Colwell study in Health Affairs, project shortages of primary care physciains for adults of more than 40,000, even after taking into account increased numbers of NPs.

ACP coninues to have confidence that PCMHs led by internists will be shown to have the vest value in American health care.

Bob Doherty

james gaulte said...

I thank Bob Doherty for his comments.
I will admit the headline could be interpreted as indicating a more global endorsement by the ACP that is indicated by their endorsement of a specific house bill which I explain more precisely in the body of the blog. In the body of the blog I correctly state that the house bill allows nurse lead practices to exist in the context of the medical homes.I correctly state that this bill is endorsed ("strongly endorsed") by the ACP. I believe this is a mistake. I never suggested that state laws would be preempted nor did I deny the shortage of primary care doctors although Mr. Doherty saw fit to comment on these topics as if that somehow refuted my comments.I am a bit surprised and maybe a bit complemented that anyone at the ACP actually reads a blog from a retired internist whose views frequently are at odds with some policies of the ACP.We will have to agree to disagree on both the endorsement of the bill and the wisdom of taking part in a "quality" contest between internists and NPs.

james gaulte said...

Bob Doherty,

Your comment was saved.I hope the new headline will not be considered misleading.