I have been immersed in SGIM’s health policy efforts over the past two months. Our Health Policy Committee (HPC) has been especially active due to the Centers for Medicare & Medicaid Service (CMS) Calendar Year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule, and their request for comments.¹ Between preparing SGIM’s comments for CMS and managing requests from like-minded organizations (e.g., Primary Care Collaborative) to sign on to joint comments, the HPC has been quite busy. This is in addition to other requests for SGIM to participate in letters, amicus briefs, and consortia related to reproductive rights; diversity, equity, and inclusion; decreasing firearm injury; and challenges to Medicare’s ability to negotiate prices for some high-cost prescription drugs.

This flurry of work prompted me to review my personal advocacy goals for my mid-year column and reflect on my journey. When I wrote these goals, I knew they were ambitious. (Yes, I have been accused of tilting at windmills.) I also knew that I had a lot to learn before I could work to advance advocacy at the Society level.

I had three goals:

1. Articulate a vision of a thriving general internal medicine practice and why it is important to our patients and the health of populations.
2. Build relationships at regional and state levels for eventual national coalition building.
3. Support institutional, local, and state advocacy efforts by SGIM members.

Articulating a vision. Articulating a vision of a thriving general internal medicine practice solidified the “what” I would ask others to support and prompted me to gather key articles that I could use to help others learn more about why generalist internists’ care is important.

I wrote about my vision of general internists’ work and why it’s important in my Forum column, “The ‘4Cs’ of a Generalist’s Care” in the October 2023 issue.² Listening to the discussion at the 2023 Hess Institute and knowing about the work ACLGIM is doing to address the three top recommendations from the Institute confirmed my own vision and helped me see the variations of that vision due to local patient populations and organizational structures.

Building relationships and learning from others. I have had many discussions about improving primary care practice and educating trainees in primary care settings over the past 18 months. These usually end at the barriers of finding resources to support change and physician payment. At the start of my president-elect year, I reached out to John Goodson, SGIM’s expert on the Medicare Physician Fee Schedule (MPFS), knowing I had a lot to learn. He has been a wonderful teacher and advisor. This is a very short synopsis of what I have learned.

The MPFS is a complex system used by CMS to determine reimbursement rates for healthcare services provided by physicians and others who participate in the Medicare program. It is frequently used as a starting point by private insurers when setting rates. The foundation of the MPFS is the Resource-Based Relative Value Scale (RBRVS), a system that assigns relative values to various medical services based on the resources required to provide them. These values are divided into three components:

• Work RVUs (Relative Value Units) represent the time, skill, and effort required to provide a specific service. This is what almost all organizations use to determine physicians’ salaries, as you likely know already.
• Practice expense RVUs cover the overhead costs associated with providing a service (e.g., rent, equipment, staff salaries).
• Malpractice RVUs account for the cost of malpractice insurance associated with a service.

Historically, work RVUs have rewarded procedural care and undervalued cognitive care, the type of care provided by primary care physicians. We use the outpatient evaluation and management (E/M) service codes to bill for our cognitive care. The E/M service codes have not been well reimbursed; while at the same time, the cognitive work we do has expanded. Defining and setting the payment rates for work RVUs is a process that is not transparent, and it has been swayed by strong political pressure from organizations representing specialists who benefit from the procedural codes. The result of this longstanding imbalance in the RVU system and the expansion of the care generalists are expected to provide to our patients is well described by Goodson’s article,³ the recent Washington Post opinion piece by Rosenthal,⁴ and Berenson’s recent viewpoint article.⁵ I urge you to read these articles so you are informed of the issues driving the work SGIM’s HPC is doing on our behalf and for the patients we serve.

During my president-elect year, I also reached out to my colleagues active in the Oregon American College of Physicians (ACP) state advocacy efforts. I asked if I could listen in on their planning meetings and participate in their Advocacy Day at our state capital. I wanted to learn how the Oregon ACP Chapter does this work and whether there might be opportunities to have SGIM regions collaborate in these efforts. I am an ACP member. The Oregon ACP Governor knew my goal was to learn how SGIM and ACP members in a state might do advocacy work together and welcomed my participation. Through this activity, I got to know our ACP Governor and an Oregon member of the ACP’s Board of Regents. Both are general internists in Portland.

We found we shared the same concerns and desires to advocate to improve primary care. John Goodson provided us with information about the MPFS and ideas for advocacy since one of our Senators is Ron Wyden, Chair of the Senate Finance Committee. Senator Wyden cares deeply about Medicare and its solvency because of his position and earlier years working for the Gray Panthers, a grassroots advocacy network fighting ageism and supporting older people. Lisa Rubenstein—an Oregonian, former SGIM president, and health services researcher—joined our discussions. The four of us learned from each other. We shared research studies, ideas, and anecdotes; we knocked on legislators’ doors in Oregon; and we used each other as sounding boards about our “asks.” These relationships have been enriching for me, as well as motivating me to do more personal advocacy.

Supporting institutional, local, and state advocacy. Andrea Christopher, a SGIM member in Idaho, gave a rousing advocacy talk at the Northwest Regional meeting in 2023. Her advice was, “don’t get mad, advocate!” I took this to heart as I thought about the 2024 SGIM Annual meeting and the theme, “Strengthening Relationships and Valuing Our Differences.” This year, we started the meeting planning with an advocacy focus: decreasing the burden of firearm injury. Although this is the focus, the 2024 Annual Meeting committee is putting together a program that will help you develop your skills and strategies for your own advocacy work and to build and strengthen relationships to advance that work.

If you want to join the four of us in Oregon advocating for the Senate Finance Committee to support the CMS CY 2024 proposed rule, submit comments to your state senators, especially those of you who have senators on the Senate Finance Committee. Ask them to support CMS’ efforts to evaluate the current method for developing the MPFS and consider other transparent, evidence-driven methods for doing this. Finally, I want to thank our HPC members, Francine Jetton, SGIM staff for the HPC, and Erika Miller, our lead policy consultant from CRD Associates, for their work on the MPFS and other policy issues pertinent to SGIM members. They have played the long game, and my hope is the relationships they have developed will move our efforts forward to make changes in the MPFS.