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Southern California Region II - Governor's Newsletter Summer 2002

Melvyn Sterling, MD, FACP
Governor, Southern California Region II

Governor's Column

For those who have lost track of the government alphabet soup, the Health Care Finance Administration, tacitly acknowledging its reputation for abuse of physicians, changed its name last year to CMS.

In a speech whose title could have been "the CMS loves you", he promised a spirit of cooperation and togetherness that I have not heard from CMS since the last time one of their ambassadors spoke to us. The question immediately comes to mind, can (will) they "walk the walk as well as they talk the talk?"

Amazingly, the answer, over the last two years, seems to be yes!

In a conversation that I had almost two years ago with Tim Hill, the head of "Program Integrity" for HCFA (now CMS), he stated that the egregious practice of "extrapolation" was terminated; except in cases of repeated allegations of inappropriate billing. Extrapolation, you may recall, is the government's practice of extracting a huge sum of money from a physician based on a small sample of charges that the carrier has arbitrarily decided were incorrectly billed. The money was extracted from the physicians BEFORE they had a hearing before an Administrative Law Judge. The change in the extrapolation guideline was confirmed by the Medical Director of our local CMS fiscal intermediary, Dr Arthur Lurvey. Based on the lack of reports of this abuse from our members, it is indeed the case.

All it took for CMS to diminish its harassment of our members was an intense lobbying campaign, initiated by the California Medical Association, then joined by the AMA and the ACP-ASIM. This led to the introduction of a series of bills, the first by Representative Toomey from Pennsylvania, then followed by other bills and their supporters in the Congress. Those bills did not exactly say "I'm mad as Hell and not going to take it anymore", but the message was clear; government harassment had reached a point that exceeded our tolerance.

Although the documentation issue is far from settled, this disease seems to be in remission at the moment. That means that the physicians that can still afford to take care of Medicare patients will feel less threatened by the CMS bureaucracy. That is the good news.

The bad news is that the number of physicians that can/will take care of Medicare patients is declining in both the short term and in the long term. In the short term, fewer physicians are accepting new Medicare patients. Although the data is sparse among internists, a recent study by the Academy of Family Practice revealed that 17% of family practitioners are no longer accepting new Medicare patients. The long term is even more worrisome for elderly Americans; fewer medical students are choosing internal medicine as a career.

Why? The projected 17% decrease in Medicare reimbursement over the next 4 years (according to the government's Sustainable Growth Rate (SGR) formula that is used to determine Medicare reimbursement), plus the conservative estimate of a 3% annual inflation over that same four year period, leaves us with almost 30% lower reimbursement than we have today. In fact, our reimbursement will be lower in 2006 than it was in 1991!

That brings me back to Ruben King Shaw and brotherly love. He asked that we supply data that show there is a lack of access impacting a significant number of Medicare patients. Our President-Elect, Dr Sarah Walker, responded, "If you wait until that data is available, it will be too late. The doctors who have stopped taking new Medicare patients will have changed their practice pattern, medical students will have stopped entering programs that serve large numbers of Medicare patients, it will be too late!"

This is like a tidal wave; if we see it coming we don't suggest waiting to see how many have drowned, we counsel rapid retreat.

What can be done? Go to our website, www.acponline.org , and follow the instructions to communicate your feelings about the 5.4% cut and the flawed SGR formula that it is based on to the White House. There are proposed solutions emerging in Congress that may mitigate this disaster. You might send a message of appreciation to your congressional representatives if they are supportive of corrective action; or a reminder that you are a voter and an opinion leader in your community if they were not.

One final note with respect to Medicare: the committee that Health and Human Services has charged with review of the Medicare Evaluation and Management Documentation Guidelines has recommended that they be abandoned! That recommendation goes to Tommy Thompson now for his decision. Meanwhile, the Current Procedural Terminology Panel is reviewing the E and M code descriptions. Stay tuned; by the end of 2002 CMS will probably make some decisions on E and M documentation.

How about some good news? Check out the PIER program, an innovative, online, clinical reference for internists. Want the differential diagnosis of hyperporcelainemia? Want to know the optimal management? This is currently free and appears to be very useful. Approximately one third of the modules of PIER have been completed so far so if what you are looking for is not there today, it will probably be there in the near future. I would value your input regarding PIER (or anything else that impacts your practice); my email is melvynsterling@hotmail.com.

And from the State Chapter... The Presidency of the California Chapter (our three Southern California plus the Northern California Region all constitute the California Chapter) has changed hands. Douglas Hegstad following in the footsteps of Jeremiah Tilles, continued the process of developing our statewide organization.

Our new President is Glenn Littenberg. Glenn is on the Current Procedural Terminology Committee that advises CMS on coding issues. He is a nationally known expert in this area. Glenn practices gastroenterology and general internal medicine in Pasadena.

For those who may not be aware of it, our state chapter monitors legislation in Sacramento and responds to bills that impact us and our patients and helps to educate state agencies regarding health care. Our Health and Public Policy Committee has a monthly telephone conference in which we discuss the socio-economic aspects of health care in California.

We also meet with legislators and administrators of state agencies as well as Medicare's fiscal intermediaries.

Issues that we have addressed include: Elder Abuse legislation, pharmaceutical/vaccine shortages, mandatory translators at the doctor's expense with a prohibition of billing either the patient or a third party, the above-mentioned Medicare hassles, the loss of the toll-free Medicare billing line with a shift to a long-distance toll call, mandatory CME, the role of the physician in the response to a disaster....

We have an attorney with extensive experience in legislation that impacts medicine who analyzes legislation as it is introduced (sometimes before it is introduced) in Sacramento. The State Chapter also coordinates our work with the California Medical Association. The hardworking and insightful chair of our CMA delegation is Susan Sprau, a pulmonologist from Region I. Our Region II representative is Gary Stewart. Gary, a gifted writer and persuasive speaker, is a member of the Executive Committee of the Specialty Delegation to the CMA.

Melvyn Sterling, MD, FACP
Governor, Southern California II Region

Associates and Students Corner

"The Associates and Students are the future of the College and Our Profession" - The associates and students of our region had several activities at University of California, Irvine (UCI) and Loma Linda University (LLU) and at the regional scientific meeting; an update/review course, abstract/poster competition, and career planning workshop in addition to an active internal medicine interest group (IMIG) at UCI.

Our Region continues to send winners to the national meeting; we have again been a winner of the poster competition. Our congratulations to the winners themselves as well as Dr's Roman and Amin, the dedicated mentors of our Associates and Internal Medicine Interest Groups.

On October 14, 2001, the 2001-abstract/poster competition for the associates and students was conducted and the winners were:

Lymphoid Enhancing Factor 1 (LEF1) Expression in Breast Cancer Nguyen AV {Internal Medicine Resident, UCI}, Milovanovic T, Waterman ML, Hope C, Planutis K, Holcombe RF

NSAIDs Inhibit Hypoxia Inducible Factor 1-Alpha In Human Gastric Cancer Cells And Gastric Endothelial Cells And Abolish Hypoxia-Induced Angiogenesis In Vitro Contreras B {Gastronenterology Fellow, UCI}, Soreghan, B, Pai R, Jones M K, Tarnawski, A S

A Case of Metastatic Prostate Cancer Presenting with Spontaneous Bleeding Secondary to Chronic Disseminated Intravascular Coagulation Teruya B {Senior Medical Student, LLU}, Choi Y, Roman M

Is It Time To Redesign Residents' Work Hours, Models for Change! Sherard T {Internal Medicine Resident, LLU}, Kelly J, Roman M

  • The winners presented their research at the national ACP-ASIM meeting in Philadelphia in April 2002. We congratulate Dr's Contreras, Soreghan, Pai and Tarnawski for their win in Philadelphia - another national winner!

Internal Medicine Interest Group (IMIG)

At the University of California, Irvine we had another great turnout of over 50 medical students who attended our IMIG activity on Primary Care versus Hospitalists based careers in Internal Medicine. The following physicians served on our panel and were a great inspiration and resource to our future physicians:

Melvyn Sterling, MD - Private Practice (Primary Care)
Carole Ward, MD - Kaiser (Primary Care)
Nancy Gin, MD - Kaiser (Hospitalist)
Lloyd Rucker, MD - University of California, Irvine (Academic Primary Care)
Jane Abdelhadi, MD - University of California, Irvine (Academic Primary Care)
Alpesh Amin, MD - University of California, Irviine (Academic Hospitalist)

Maher Roman, MD, MBA, FACP {Loma Linda University}
Associates' Council Chair
Phone: (909) 422-3176
E-Mail: DrMAR2000@aol.com

Alpesh Amin, MD, MBA {University of California, Irvine}
Associates' Council Co-Chair
Phone: (714) 456-3785
E-Mail: Anamin@msx.ndc.mc.uci.edu

Congratulations also to Sumeet Subherwal who was elected as Pacific Region Representative to the National Council of Student Members.

Fellows

The College has a tradition of recognizing members who have distinguished themselves by making significant contributions to internal medicine, the College and the community by awarding them the title of Fellow of the American College of Physicians (ACP-ASIM) is understood. I want to recognize the following new Fellows from our Region:

Fellows elected January 2002

Catherine Diamond, MD - Orange
Gary M Annunziata, DO - Rancho Mirage
Dennis P Haghighat, MD - Mission Viejo
Luc S Nguyen, MD - Santa Ana
Carlos R Canizales, MD - Upland
Mark P Miller, MD - Santa Ana
Krishna G Reddy, MBBS - Upland
Morris Hassan, MD - Orange

Fellows elected July, 2002

Weston G. Chandler, MD - Laguna Niguel
Daniel I. Kim, MD - Anaheim
Onkar N. Mehta, MBBS - Huntington Beach

Opportunity for Leadership!

Prior to the merger of the ACP with the ASIM, there was an organization known as the Orange County of Academy of Internal Medicine. We were loosely affiliated with the California Society of Internal Medicine. We met nine times a year for dinner, social intercourse and a clinically focused CME program. That organization became dormant after the merger due to a problem with CME credit. That issue has been resolved and we are exploring the possibility of resuming our CME programs in concert with Region I, which adjoins us on the north. We are seeking members who have energy and leadership skills to become the President, Secretary-Treasurer and Program Chair for this entity.

We are soon to have a radical hyphenectomy and revert to the prior name of American College of Physicians. The Board of Governors passed a resolution calling for a reversion to the name American College of Physicians. It was acknowledged that the merger with the American Society of Internal Medicine had added tremendously to our work on socio-economic and regulatory issues. Most of the testimony on this issue came from prior ASIM members who felt that it was no longer necessary to keep ASIM in the name of the College and it created a communication problem that would be remedied by reverting to the ACP name.

New E-Newsletter for Members to Replace College Update

A new monthly electronic newsletter for College members will replace College Update. The newsletter will cover new College programs, products and services, and will also keep members updated on ACP-ASIM's advocacy efforts on behalf of internists. The nearly 50,000 members who have provided the College with their e-mail addresses will receive the newsletter the first Wednesday of each month; recipients will have the opportunity to opt-out of receiving the publication at any time. The newsletter will provide brief articles (two to three paragraphs) about College activities and services that directly affect members. Readers who wish to learn more about a particular topic will be referred to more information on the Web (when available). Members who do not have e-mail may also access the newsletter on ACP-ASIM Online. For more information please contact Allison Ewing at 800-523-1546, ext. 2649 (aewing@acponline.org).

New Patient Education Brochures Published

ACP-ASIM recently published two new brochures on diabetes and headache as part of its patient education series. The brochures are written in language suitable for the layperson and are designed to help educate patients on the different aspects of the illnesses. The headache/migraine brochure supports the College's recent migraine guidelines. It helps patients understand the three most common types of headaches (tension, cluster and migraine), defines the three types in lay terms, and lets patients know that many new treatment options are available. The diabetes brochure introduces the various types of diabetes, but focuses on type 2 diabetes and its risk factors and symptoms. It encourages patients to talk to their internist if they have risk factors and/or symptoms, and to eat correctly and live a healthy lifestyle. It also comments on the link between diabetes and heart disease and high blood pressure. Free samples of both brochures were available at the Doctors for Adults booth at the College Island at Annual Session 2002. The colorful tri-fold brochures are available in shrink-wrapped package of 100 for $20 (includes S&H). The two new brochures join the five existing brochures in the series (depression, heart disease and stroke, adult immunization, antibiotic resistance, and obesity), all of which may be ordered by calling ACP-ASIM Customer Service at 800-523-1546, ext. 2600. (Headache brochure product code #700100220, diabetes brochure product code #700100120.) The brochures are also available for free download on the Doctors for Adults Website.

Bioterrorism Resource Web Site Updated

The College's Bioterrorism Resource Center has been revised for easier navigation, and features new clinical information, images, and support tools. The site has received praise from the Centers for Disease Control and Prevention and other viewers for its comprehensiveness and content. Recent additions include new support tools on cutaneous and inhalation anthrax, self-assessment questions on biological and chemical agents, and new information about biotoxins, nerve agents, and toxic gasses. Physicians are urged to visit the site to increase their knowledge of bioterrorism agents and to learn how to deal with a suspected bioterroristic attack.

Random Access

Arthur Silk MD FACP

Some medical musings for the summer months

Without the right medicines to treat the sick our best diagnoses are academic exercises. Yet prescription costs keep rising. Should ACP-ASIM assume a higher profile in the drug cost war? Or might we at least develop promotional materials informing our patients that in almost all cases generic drugs are as effective as the much higher brand names. My patients especially those with medical insurance have the impression that the brand is always best.

Our battle against big tobacco is won and we deserve credit. Perhaps it is time to turn out attention to nutrition. Obesity related illnesses are fast approaching the morbidity of tobacco and alcohol related ills. More specifically, there were 500,000 deaths attributed to tobacco related ills in the last sentinel year. But obesity related deaths were at 300,000 - -rapidly closing the morbidity gap. By contrast illicit drugs caused 40,000 deaths. Question. Should our organization develop a more aggressive strategy to combat the ingestion of high fat high salt fast foods?

Have you wondered why there are always enough Congressional appropriations for battleships and bridges but a constant alarm lest Medicare go broke? The social security "lock box" was a wonderful campaign slogan but cynical. There is no escrow fund for Medicare. Why can't health care costs be met from general taxes like battleships and bridges?

No matter how you feel about the AARP, it talks to a huge number of older people. In a recent issue it reveals that "the drug makers", (read PhARMA the umbrella organization for the pharmaceutical industry) "spent more money than any other industry -nearly $200 million in Washington in 1999-2000 alone".

They also analyze the statistics that suggest that Medicare reimbursement is so miserly that many doctors are avoiding Medicare patients. Is this really true? With a near monopoly in the care of seniors in this country, access for even the affluent may well be impacted. How should ACP-ASIM the primary care providers for almost this entire group proceed?

Thinking about boutique care for your Medicare enrollees? Better think again. The Equal Access to Care Act (sponsored by Senator Nelson of Florida) might make this illegal. Further CMS is investigating the legitimacy of a surcharge for any Medicare covered service.

Can your prescription writing preference be bought by a free lunch? Or even a trip to a spa? The Council of Ethical and Judicial Affairs of the American Medical Association (CEJA) thinks maybe so. They have opined that a free stethoscope is acceptable but free golf balls are not. Free medical books are allowed provided the cost is not substantial. Most books I buy have a price tag of about $100+. To me that's substantial. But CEJA has ruled that a gift certificate from a bookstore is OK. My loyalty to a brand or a product can't be bought with a lunch at Morton's or even a trip to the Riviera. How should we react as an organization?

Have a pleasant summer.

Medical Students Working to Make a Difference

Sumeet Subherwal

There are approximately 12 million children in the United States without health insurance. A few years ago, the federal government established the Children's Health Insurance Outreach Program (CHIP), also known as Healthy Families in California, to help address the issue of uninsured children. The Healthy Families program was created to provide low-cost health insurance to children whose parents earn too much money to qualify for Medical but cannot afford private insurance.

Last year, the California Medical Association Medical Student Section's Governing Council (CMA-MSS GC) decided to adopt a statewide service project to raise CHIP awareness among medical students and the community. Medical students at UC Irvine have participated in various activities to promote this program. Last year, we assisted enrolling children for the Healthy Families program at several local health fairs sponsored by the Orange County Coalition of Community Clinics. We also organized an informal lunchtime class for all UC Irvine medical students, in which a Healthy Families representative taught students the basics of the program. We are planning to hold a similar educational class for the new incoming class. Furthermore, buttons with the logo "Healthy Families-Ask Me/Pregunta Me" printed on them will be distributed for all medical students to wear on their white coats. These buttons have been distributed to all medical college campuses in California through funding from the AMA and CMA. The goal of the CMA-MSS GC is to have first and second year students throughout California wearing the buttons and to be educated on the basics of Healthy Families by the end of the school year.

Annual Regional Scientific Meeting August 9th, 10th and 11th

Mark your calendars; this will be the first, (that I recall), Joint Scientific Program of Southern California Region I and II. The meeting will be held at the Westin Hotel in Long Beach, concurrently with the Long Beach Jazz Festival.

Those of you who attended the 2001 meetings will recall just how interesting and helpful those meetings were. Dr's Maher Roman and Chester Choi and I met in Philadelphia to plan the combined August meeting. We plan to follow the same formula of presenting information that is immediately useful and relevant to our practices as we assemble this year's program. In addition to clinical updates in cardiology, radiology, augenblick dermatology HIPAA (King Shaw from CMS said "if you do not understand HIPAA you are going to be in a lot of trouble"), we will again have an up-to-the minute review of how government impacts your practice. We will respond to the requests from those members who missed Dr Gray Stewart's workshop on the bedside evaluation of peripheral vascular disease, offering that as one of the concurrent workshops. Other workshops will include: patient communication techniques, pain management, cardiology, joint aspiration/injection, office geriatric assessment and prevention of falls. For those of us who feel that the government has some impact on the practice of medicine, you will find our panel discussion of this topic timely and very informative. For a real treat, plan to join us for dinner on Saturday night, August 10th when internist Assemblyman Dr Keith Richman will present the perspective of an internist-assemblyman as he looks at the interface between health care and government.

The meeting will be held at the Westin Hotel, within walking distance of the Long Beach Aquarium and many fine restaurants and shops. Members will receive first priority for registration so sign up early.

2002 Southern California Regions I and II Chapter Scientific Meeting
August 9-11, 2002
Westin Hotel
Long Beach, California

For additional meeting information and registration information, please contact:

Julie Flamenco
1310 West Stewart Drive, #608
Orange, Ca 92868
Telephone: 714-997-7431
Fax number: 714-997-7296
Email: jmf_acp@yahoo.com