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Governor's Newsletter, Summer 2001

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

Governor's Column I

Melvyn L. Sterling, MD, FACP, Southern California Region II

This newsletter will mark the beginning of a new approach to communication with our membership. Although we plan to continue the publication of this snail mail newsletter, we will initiate a monthly e-mail, Gigabytes, to all those whose e-mail address we have. We hope to provide you with current developments in government regulatory and payment policies as well as clinical information. Our focus will be on information that will be relevant to the practice of medicine and the health and welfare of our members and our patients.

In this newsletter you will find a sample of what is to come. I hope that you will find it interesting and useful. The e-mail version will be more timely and trade bytes for bark (as in trees). In order to receive this we need your e-mail address. Please send it to melvynsterling@hotmail.com.

Other Announcements:

Jerome Tobis will join our Governor's Council.

Dr Tobis brings his experience in physical medicine and rehabilitation, geriatrics, ethics and alternative medicine to our Council.

Congratulations to our new Fellows:

Guilherme R. Carvalho, MD, FACP
Lan T. Nguyen, MD, FACP
Mustaqueen A. Qazi, MBBS, FACP

See Dr Roman's and Dr Amin's columns regarding our Associates and Students and their accomplishments.

Mark your calendar:

Our Regional Meeting will be held on the weekend of October 13 and 14, 2001 at the Hilton Hotel in Costa Mesa. The program, now in the final stages of development, will include updates in various aspects of internal medicine, hands-on workshops, revelations about state and federal activities impinging on internal medicine..., all this in a beautiful hotel within a short walk of a world renowned sculpture garden, fabulous restaurants, the Orange County Performing Arts Center, South Coast Repertory Theater..., plus the shopping center where more money changed hands last Christmas than anywhere else on Earth ­ South Coast Plaza. You and your spouse will be able to spend all of next year's income in less than an hour!

Watch for the Program Announcement in the mail and on ACP-ASIM Online.

Governor's Column II

HIPAA, CPT, ICD, ... Practicing physicians are all too familiar with the bureaucracy that makes us responsible for detailed knowledge of coding, the necessity of finding the correct 5 digit descriptor of the diagnosis, absorbing the administrative costs of billing and other expenses associated with dealing with Medicare, Medicaid and the insurance companies.

Now add to that the new problems associated with patient confidentiality.

We are all aware of the sensitivity of the information that we gather from our patients; information that, if it fell into the wrong hands could have devastating consequences for our patients and their families. We are therefore supportive of careful control of patient information. The problem that arises is how to provide the necessary security without impeding the flow of information necessary for the care of the patient, coupled with the requirements of HCFA and the insurance industry.

Developing a solution to that problem would be difficult enough if we could work with the HCFA and other parties involved in an atmosphere of cooperation and mutual respect. Sadly, that is not the case. The relationship between insurance companies and physicians is almost a state of war. The relationship with the HCFA is even worse. Rather than mutual respect, there is ignorance and profound distrust. The distrust is self-evident; why else, almost four years after issuing the horrendous 1997 E and M documentation guidelines, would we still be unable to agree on a way to be paid for the services that we provide without the OIG's sword over our heads?

The ignorance is due to the impossibility of understanding the 140,000 pages of rules and regulations that we AND the government and the fiscal intermediaries have to understand. Is it necessary to say that such an understanding is not possible?

And that brings me to MERFA, S 452 and HR 868.

MERFA is the Medicare Education and Regulatory Fairness Act. This bill will require HCFA to pay for our services
without demanding more paperwork unless there is evidence that the bill is incorrect; it would change the outrageous practice of extrapolation. It would mandate that the carriers answer questions from us regarding billing and coding, identify the person giving that answer and then be bound by that answer. It would provide for education of carriers and physicians to help both parties negotiate the 140,00 page minefield of Medicare/HCFA requirements.

The widespread support of MERFA is evident from its bipartisan sponsorship and large number of cosponsors. The bill has over 150 cosponsors in the House and we anticipate similar support in the Senate. I was surprised though, to find that none of my legislators had signed on at the time of my visit to Congress in May. Although none were opposed to the bill they may need more encouragement to sign on and work for its passage. It would be very helpful to call or write to your Congressman/woman and Senators Feinstein and Boxer and ask them to support MERFA. MERFA will not solve the problems of ignorance, mutual distrust and inappropriate bureaucratic intrusion into our exam rooms, but it is a beginning.

"A journey of a thousand leagues begins with one good bipartisan bill."

Advocacy for Dummies (like me) - You are Going to Love This!

By Dr. Gary Stewart

1. Connect to your Internet Service Provider (e.g., I use Earthlink).

2. Open your browser (e.g, I use Netscape Navigator).

3. Type in the web address www.acponline.org, and hit Enter.

4. Double-click on "Advocacy" located in the headings on the bar at the top.

5. Double-click on "Legislative Action Center."

6. Double-click on the issue regarding which you wish to contact your representatives. (This time, I chose MERFA, the Medicare Education and Regulatory Fairness Act.)

7. Read the Action Alert information on the topic.

8. In the "Take Action Now" box, type in your Zip Code and click the GO button. {Note: You may be prompted to put in your Zip+4 or your address.}

9. Click in the appropriate boxes to Select you Message Recipients and your preferred method of communication (e-mail, fax or letter.)

10. Option: You may now elect to use the prepared message, edit it, or write your own. (I usually edit the original somewhat to make it sound more personal.)

11. Once your message is completed, you type in your name and address in the boxes provided. {Note: If you click the "Remember Me" box at the bottom, you won't have to do this step again.}

12. Click the appropriate boxes to indicate whether you wish a copy of your message to go to ACP-ASIM and/or to your own e-mail address.

13. Click "Send Message".

This may look like a lot, but to accomplish this takes me no more than 5 minutes, which includes the time to log
on. That is five minutes in order to send a personalized and knowledgeable letter, fax or e-mail free to your senators and/or representative in Washington. So next time you're going to visit EBay, check this out first. Participate! It makes a difference!

Health and Public Policy Committee

Jeremiah G. Tilles, MD, FACP

The statewide Health and Public Policy Committee developed an Annual Legislative Report Card which was sent to every state legislator and the Governor. It was also released to the national press with the help of the ACP-ASIM Washington office at the time of the Sacramento Leadership Day on February 6-7, 2001. The latter was attended by members of the HPPC of each California region (Drs. Stephen Colucci, Gebré Gobezie, Ron Miller and Jeremiah Tilles from Region II) as well as the Governors (Melvyn Sterling) and Board of Directors (Douglas Hegstad). Presentations were made and queries answered by Joy Higa of the Department of Managed Health Care; Richard Figueroa, health advisor to Governor Gray Davis; Senator Deborah Ortiz, Chair of the California Senate Committee on Health; Scott Bain of the Assembly Committee on Health; Elizabeth Prewitt from the Washington office of ACP-ASIM; and Joan Hall (legislative consultant). Each of the attending members discussed the Annual Legislative Report Card in an individual meeting with their own senator and assemblyperson during the afternoon of February 7, 2001. The Report Card was also well received and generated many favorable comments when presented in March to the national networking meeting for the HPPC's from every state at the Annual Session in Atlanta. It should be noted that a large contingent of Southern California Region II members attended the Annual Session which had an exceptionally rich scientific program this year.

Joan Hall, the legislative consultant to the statewide HPPC, keeps a close eye on both the state government and the CMA and periodically sends us her Legislative Updates (note the latest is on the ACP-ASIM California Chapter web page at http://www.acponline.org/chapters/ca/ and in the statewide newsletter.) Gary Stewart is a member of the ACP-ASIM delegation to the Specialty Delegation of the CMA. This year the ACP-ASIM delegates again attended a briefing session by Joan Hall at the onset of the CMA Annual Session in Reno. They then shepherded two ACP-ASIM resolutions through the Specialty Delegation and the House of Delegates where both were approved. The resolutions would require favorable amendment of the elder abuse law and disclosure of fee schedules by managed care organizations. Frank Straus from Southern California Region I was elected secretary of the Specialty Delegation and our own Gary Stewart was appointed Delegate at Large to the Executive Committee. Darin Latimore from the Northern California Region became a member of the Council on Legislation and Mel Sterling was asked to join the Council on Scientific Affairs.

This year Washington Leadership Day was held May 8-9, 2001. A group of 12 delegates including Melvyn Sterling, Doug Hegstad, and Jeremiah G. Tilles made a whirlwind trip in which they attended presentations by Stuart Rottenberg, Senator William First, and Congresswoman Shelley Berkley. They then met with 50 of the California congresspersons or staff and the two California Senators to give the internists' perspective on reducing Medicare hassles (MERFA), access to care (REACH Act), the Bipartisan Patient Protection Act, and patient safety.

Associates and Students Corner

"The Associates and Students are the future of the College and Our Profession"

University of California, Irvine (UCI) Report

By Alpesh Amin, MD, MBA

Internal Medicine Interest Group at University of California, Irvine

It has been a very exciting and dynamic year for our Internal Medicine Interest Group (IMIG) which had 3 group activities this past academic year. These meetings were coordinated by the IMIG student President Lianne Wener (senior med student at UCI) and Alpesh Amin, MD (IMIG faculty advisor) and were attended by 20-30 medical students from UCI.

The first two IMIG meeting were about careers in Internal Medicine. Our first meeting was in October, 2000 and focused on Primary Care and Hospitalist Medicine with a panel of physicians that included:

  • Primary care physicians in private practice: Dr. Jane Curtis and Dr. Melvyn Sterling
  • Primary care physician in HMO practice: Dr. Carol Ward
  • Hospitalist in private practice: Dr. Raymond Casciari
  • Hospitalist in academic practice: Dr. Alpesh Amin and Dr. Chong Kim

The second IMIG meeting occurred in February, 2001 and focused on subspecialties in Internal Medicine with the following physician panel:

  • Dr. Reza Movahed (Cardiology)
  • Dr. Solomon Liao (Geriatrics and Palliative Care)
  • Dr. Tom Vovan (Pulmonary and Critical Care)
  • Dr. Luan Do(Nephrology)

Our third IMIG meeting was last May 2001 and discussed residency programs in Internal Medicine looking at academic versus community programs. It included a panel of interns and recent senior students who matched in Internal Medicine programs across the country. I was also very fortunate to facilitate this meeting serving in my role as the Assistant Program Director for UCI Residency Program. The students received tips on preparing their applications for residency, interviewing suggestions, and determining strengths and weakness of various programs.

The IMIG activities have been well attended by our medical students and these activities should be even more exciting next year. It has gained a considerable amount of student support with 6 future senior medical students wanting to be President of IMIG at UCI next year.

1st Annual Abstract/Poster Session at University of California, Irvine

This past January 2001, I was given the honor of coordinating the 1st Annual Abstract/Poster Session for the Department of Medicine at the University of California, Irvine (UCI) in conjunction with ACP-ASIM Southern California Region II. The following Associates' abstracts were selected for oral presentation at the Department of Medicine Grand Rounds which was televised to three hospitals (U.C. Irvine Medical Center; Long Beach VA, and Long Beach Memorial) and the UCI Campus:

MAP (ERK-2) Kinase ­ A Key Target For Nsaid-Induced Inhibition of Gastric Cancer Cell Proliferation and Growth> by Hussain SS, Szabo I, Pai R, Soregham B, Tarnawski AS

Role of Caspases in T Cell Proliferation by Empedrard R, Gollapudi S, Gupta S

Fractured Kirschner Wire Causing Hemoptysis by Kim J

Distal Colonic Polyps As A Predictor of ProximalNeoplasia by Atay S, Katz K, Kidao J, Black J

The winner of the Oral Abstract Presentation was Dr. Sayeda Hussain (fellow in the Division of Gastroenterology at UCI) on her work on MAP (ERK-2) Kinase.

Among the posters that were presented, the winning poster was presented by Lianne Wener (senior medical student at UCI) on:

Student Teaching Rounds: A Novel Concept in Medical Education by Wener LS, Kim CU, Amin AN

Congratulations, Dr. Sayeda Hussain and Lianne Wener on your excellent research!!! Both Dr. Hussain and Ms. Wener won trips to this year's national ACP-ASIM meeting in Atlanta, Georgia to present their research sponsored by ACP-ASIM Southern California Region II.

A special thanks to our judges for the oral abstract/poster session: Dr. John Longhurst, Dr. Lloyd Rucker, Dr. Ellis Levin, Dr. Murray Korc, Dr. Melvyn Sterling, and Dr. Alpesh Amin.

Loma Linda University (LLU) Report

By Maher Roman, MD, MBA

On December 15, 2000, the 2000-abstract/poster competition for the associates and students of Loma Linda University (LLU) was conducted at Loma Linda VA Medical Center. The winners were:

First Place Winner:
Juan Lin, MD, PhD
Eosinophilia Associated with Hepatocellular Carcinoma

Second Place Winners (a tie):
Michelle Cao, DO & Aneta Marlowe, MD
A Case of Miliary Tuberculosis in an Elderly Woman

Michael Woo, MD
Role of Diagnostic and Therapeutic ERCP in Adolescents and Children as Performed By Adult Gastroenterologists

The winners presented their research at the ACP-ASIM national meeting in Atlanta, Georgia (March 2001). Dr. Lin's poster was a winner there as well. This is the second year to have a winner at the national competition from our region. Last year, there were two local students' winners who presented their research at the national meeting; Roger Seheult and Derek Helton, both of them are currently internal medicine residents. Dr. Helton's poster was a winner at the national meeting of 2000 in Philadelphia.

We would like to congratulate the winners on their scholarly achievements and wish them continued success. We would also like to thank our distinguished physicians from the different specialties of internal medicine who served as judges namely, Douglas Hegstad, MD, FACP, George Isaac, MD, Leonard Specht, MD, Terry Lewis, MD, Philip Roos, MD, and Ray Wong, MD, FACP.

Future Associates and Students Activities

Third Annual Internal/Adult Medicine Review and Update Course

The course will be conducted at Loma Linda VA Medical Center, Loma Linda, in early August 2001. If you are interested, please e-mail Maher Roman at DrMAR2000@aol.com.

The Regional Meeting Associates and Students Program

The program is a part of the scientific meeting for Southern California Region II that will be held in October. The program activities include:

1. "The 2001 Abstract/Poster Competition"

2. Career planning workshop, The Transition From Training to Practice; Thriving Not Just Surviving

3. Interactive panel discussion on The Future of Internal Medicine

In Southern California Region II, we believe that our associates and students are not only the future of the College, but also the future of our profession! Thank you for your involvement. We look forward to your participation in our future activities. If you have questions or ideas for other activities that may benefit the associates and students please feel free to contact us.

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

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

Nobody Asked Me, But...

By Arthur D. Silk

Several well publicized tragedies have prompted a clamor to ban the use of cellular telephones in automobiles. All the reports of cell phone induced accidents are as yet unquantified and anecdotal. Has any one actually counted the mishaps caused by quarreling children or applying makeup or tuning the radio or drinking a cup of coffee while driving? Car makers supply lighted cosmetic mirrors and who has not seen them used by drivers while en route?

Perhaps a driver can pull over to make a call but some emergency calls can be incoming.

And the latest upscale gizmo to add to the cacophony is the installation of mapping screens to print out data from global positioning satellites. Looking at that screen will really force a driver's eyes off the road.

It has been the position of this organization to demand evidence before making sweeping medical decisions.

As physicians we should continue to advocate careful responsible driver behavior but banning the use of a device
simply because it can be mis-used is a hysterical premature response which we should reject.

Mark Your Calendars

October 13-14, 2001
ACP-ASIM Southern California Region II Scientific Meeting
Costa Mesa, CA

October 13, 2001
ACP-ASIM Northern California Chapter Annual Meeting
Canterbury Hotel, San Francisco, California

November 16-18, 2001
ACP-ASIM Arizona Chapter Annual Scientific Meeting
Sheraton El Conquistador Tucson, Arizona

April 11-14, 2002
ACP-ASIM Annual Session
Philadelphia, PA

Award to Dean Cesario

To his always growing list of honors, indefatigable Dr. Thomas Cesario, Dean of Medicine at the University of California, Irvine, has added the prestigious Physician of the Year award bestowed by the Orange County Medical Association on that physician adjudged by the organization to have best met the goals of advocate, educator, motivator, and servant of his patients.

To these merits Dr Cesario surely adds proven professionalism and involvement with the community and with the
medical society.

We are proud that he is of us and with us.

Medicare Moments

Arthur N. Lurvey, MD, FACP

Pre-operative evaluations: HCFA has issued a new regulation clarifying reimbursement for pre-operative testing. Pre-operative services consist of evaluation and management (E/M) services that are not included in the global surgical package and of diagnostic tests performed for the purpose of evaluating a patient's risk of perioperative complications and optimizing perioperative care. These services will be reimbursed if they are medically necessary and meet the documentation and other requirements for the care given. The level of E&M code selected should be based on the medical necessity of the situation, whether the patient is new or established, and whether the service is a visit or consultation.

Pre-operative diagnostic tests are reimbursed if they are considered medically necessary for the particular patient. The nature of the surgery and underlying medical conditions will usually dictate which tests are considered reasonable and necessary.

Claims for preoperative medical examination and preoperative diagnostic must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84). Additionally, the appropriate ICD-9 codes for the condition(s) that prompted surgery must also be documented on the claim. Other diagnoses and conditions affecting the patient should also be documented on the claim, if appropriate. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84).

Some patients are seen one to two weeks before minor surgery more to stabilize their clinical disease state and monitor chronic medical conditions than to perform pre-operative assessments. In those situations, regular office visits with typical outpatient coding

Evaluation and Management Documentation Status: Aspen Systems has been collecting vignettes of actual medical charts sent in from different states and in different specialties. Charts included were those where the physician and Medicare reviewer both agreed on the code submitted. These charts were then de-identified, abstracted into a common format (by system examined), and broken into "physician exam" and "decision making." Medicare Contractors and specialty societies have been sent these records for comment as whether these vignettes are good examples for the codes used.

The current model under consideration breaks examinations into three categories: brief, detailed, and comprehensive depending on the number of systems evaluated (in the multi-system model), and number of specialty items evaluated (in the single system model). Decision making also consists of three levels: straightforward, moderately complex, and highly complex. Newer Items (such as number of chronic conditions, underlying diseases, and medications taken) all figure in the complexity equation.

Additional vignettes are being collected from some specialties not completely represented, and the opinions of the Contractors and specialty societies are being assessed. Ultimately (probably in 2002) some form of pilot testing will be undertaken. We will keep you informed in developments in this area.

PRIT Activity from HCFA: The PRIT (Physicians' Regulatory Issues Team) is a 24-member HCFA committee actively evaluating physician hassle factors. Chaired by Californian Dr. Barbara Paul, this committee is working with the Practicing Physicians' Advisory Council (a group of 15 selected physicians) to support the ability of physicians to care for patients. Among those issues physicians are most concerned about include: Advance Beneficiary Notices, difficulty with Medicare Bulletin complexities, claims resubmission, follow up visits for cancer patients, diabetic monitoring supplies, certificates of medical necessity, etc.

For more information on PRIT, there is a Government Internet site: http://www.hcfa.gov/medlearn/pubs.htm.