yesterday, today, and tomorrow
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ARTHRITIS & RHEUMATISMVol. 54, No. 4, April 2006, pp 10291033DOI 10.1002/art.21791 2006, American College of Rheumatology
ACR PRESIDENTIAL ADDRESS
Yesterday, Today, and Tomorrow
Elizabeth A. Tindall
After beginning private practice in rheumatologyin 1982, I began my volunteer career at the AmericanCollege of Rheumatology in 1989. I served on theCommittee for Rheumatologic Care and representedthe ACR on the American Medical Associations Physi-cian Payment Review Commissions Advisory Subcom-mittee evaluating physician work. In 1992, I wasappointed to the ACR Board of Directors, of which Ihave been a member for 11 of the past 13 years. Fromthese experiences, I would like to share my reflectionson rheumatology and the ACR from 1992 through 2005.
The way we were
In 1992, a membership survey was sent to 4,300US and Canadian ACR members, to which 1,489 re-sponses were received. The breakdown of the respond-ers was as follows: 58.2% rheumatologists in privatepractice, 23.2% in medical school settings, 7.1% inhospital settings, 3.6% in government employment,1.7% in pharmaceutical industry employment, 2.8%employed in HMO settings, and 2.4% in other areas.Only 2.8% of the responders were not performing somepatient care.
The median age of ACR members in 1992 was 46years; 17% were female and 27% were in solo practice.The percentage of ACR members who provided ancil-lary services included 35% with office x-ray, 8% withbone density measurement equipment, 15% with in-
office occupational/physical therapy, and 13% perform-ing or interested in performing office-based needlearthroscopy. In the early 1990s, the ACR providededucational programs on office-based needle arthros-copy and published a position statement supportingperformance of this procedure by rheumatologists andrecommending appropriate reimbursement.
Reimbursement for cognitive medical specialtiessuch as rheumatology declined significantly in the 1990s.Physician reimbursement was still based on historical,rather than actual, costs of providing office-based ser-vices. The resource-based relative value scale, orRBRVS, did not come into law until 1992, and not until2002 had those changes in reimbursement completelytransitioned to include physician work, practice expense,and professional liability insurance. Traditionally proce-dural specialties were better compensated than cognitivephysicians, even though much of the overhead costsassociated with procedures were absorbed by hospitals.
In 1992, rheumatologists were profiled as generalinternists by Medicare and other third-party payers. Thespecialty designation UPIN (unique payer identificationnumber) of 66 was not granted to rheumatology until1991. This meant third-party payers, as well as Medicareand Medicaid, considered rheumatologists to be outlierswhen compared with other primary care providers:performing too many joint and trigger point injectionsand billing for higher levels of evaluation and manage-ment services. In a 1994 New England Journal of Medi-cine editorial (1), Kassirer stated: Specialists are moreexpensive not only because they charge more, but alsobecause they use more health resources in general forcomparable clinical conditions. . . .It seems likely thatfuture studies will detect only small differences in qualityof care between generalists and specialists.
Rheumatology reimbursement was also adverselyimpacted by the institution of the Stark Laws (I and II),
Presented at the 69th Annual Scientific Meeting of theAmerican College of Rheumatology, November 16, 2005.
Elizabeth A. Tindall, MD: Portland Medical Associates andOregon Health and Science University, Portland, Oregon: President,American College of Rheumatology, 20042005.
Address correspondence and reprint requests to Elizabeth A.Tindall, MD, 6640 SW Redwood Lane, Suite 301, Portland, OR 97224.E-mail: email@example.com.
Submitted for publication January 24, 2006; accepted January24, 2006.
Arthritis & RheumatismAn Ofcial Journal of the American College of Rheumatology
www.arthritisrheum.org and www.interscience.wiley.com
which became effective in 1992. These laws were de-signed to prevent self-dealing and self-referral by physi-cians with respect to clinical laboratory and other ancil-lary services in which a physician may have ownershipinterest. Essentially, the Stark Laws prohibited physi-cians from providing almost all ancillary services inlaboratory, imaging, and physical and occupational ther-apy. The expansion of managed care in the 1990sseverely discouraged specialty referrals from primarycare providers. Estimated physician manpower needs foran HMO of 450,000 patient lives/900-bed hospital, in-cluded 225 primary care providers, 208 hospital-basedphysicians, and only 91.2 other specialists, which in-cluded ophthalmology, otolaryngology, dermatology,pathology, hematology and oncology, neurology, gastro-enterology, allergy and immunology, pulmonary medi-cine, nephrology, rheumatology, endocrinology, infec-tious disease, and plastic and reconstructive surgery (2).
Prashker and Meenan published a 1991 article inthe Annals of Internal Medicine entitled SubspecialtyTraining: Is It Financially Worthwhile? (3). The au-thors analyzed average before-tax net incomes in 3specialties in 1988, which included gastroenterology,internal medicine, and rheumatology. Their analysisshowed that, despite 23 years of additional subspecialtytraining beyond that of general internal medicine physi-cians, the average rheumatologist was not adequatelycompensated to recoup short-term or long-term earn-ings. The average before-tax net annual income for aninternal medicine specialist was $115,825, with totalcareer earnings being $512,952. Gastroenterologistsearned an average of $210,875, with career earnings of$1,101,863. Rheumatologists earned an averagebefore-tax income of $118,056, with total negative careerearnings of $92,467. The authors concluded that,When considered exclusively as a financial decision,
fellowship training in a cognitive-oriented medical sub-specialty such as rheumatology is a poor investment.
The average debt carried by 1984 medical schoolgraduates was $22,000 for public school and $26,500 forprivate school. By 2004, the debt had increased to$105,000 for public school and $140,000 for privateschool, and only about 20% of medical students gradu-ated with no debt (4). Students with high medical schooldebt are less likely to pursue family practice and cogni-tive specialties, and instead seek specialties with higherincomes.
A Graduate Medical Education National Advi-sory Committee (GMENAC) study projected that by1990, only 1,900 rheumatologists would be needed in theUS workforce. The GMENACmodel indicated that only22.5% of patients with rheumatoid arthritis should betreated by a rheumatologist and underestimated thevolume of patients with osteoporosis and fibromyalgia.This study directly led to a decrease in AccreditationCouncil for Graduate Medical Educationaccreditedrheumatology training programs. The actual number ofUS rheumatologists practicing in 1990 was 3,200. TheACR conducted a detailed needs assessment study ofrealistically projected rheumatology manpower numbersbased on 19 diagnoses, and estimated that the idealnumber of rheumatologists needed for optimal care in1990 was 3,619 (5).
The cumulative effects of these variables pro-duced significant declines in the number of adult andpediatric training programs and the number of trainees.These numbers reached a low point in the mid-1990sand increased thereafter, but only very slightly, as shownin Tables 1 and 2. The actual number of rheumatologistsentering the US workforce was less than depicted in thetwo tables, as many of the international medical gradu-ates returned to their countries of origin.
Table 1. Trends from 1996 through 2000 in adult rheumatology training programs and number offellows*
19961997 19971998 19981999 19992000 20002001
ACGME accredited programs 114 107 106 105 107Total positions available 329 357 351 358 368No. completing program 116 113 120 105 122% IMGs 52 58 63 59 45
* Refs. 811, 16, and 17. ACGME Accreditation Council for Graduate Medical Education; IMGs international medical graduates. Total positions available, projected for the next academic year. Completed training in previous academic year. Total positions filled as of current academic year.
In addition, the ACR projected a dramatic de-cline in membership due to retirement of the babyboomers, peaking in 2016 (Figure 1). With the largenumbers of rheumatology practitioners retiring alongwith the declining numbers of trainees, rheumatologyappeared to be a specialty headed for extinction.
From 1998 to the future: saving rheumatology
There is no single action credited with turningaround the subspecialty of rheumatology. Rather, aseries of positive steps culminated in improved therapiesfor inflammatory arthritis, improved reimbursement for
rheumatologists, increased fellowship support and post-doctoral training, and reorganization within the Ameri-can College of Rheumatology.
The most important changes in the specialty ofrheumatology in the past 10 years are due to neweffective therapies for arthritis. The first wave of inno-vative nonsteroidal antiinflammatory drugs (NSAIDs)was launched by the discovery of 2 distinctive cyclooxy-genase enzymes, COX-1 and COX-2, and the release of3 COX-2 inhibitor drugs, celecoxib, rofecoxib, andvaldecoxib. A large influx of pharmaceutical funding forrheumatology was suddenly available for researchers,
Figure 1. Projected decline in American College of Rheumatology membership via retirement. Heavy line shows the projectednumber of new trainees entering the US rheumatology workforce (100 per year).