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Governor's Newsletter, March 1998

Governor's Corner

I have sent this letter to our 8 congressional representatives. I believe it represents accurately the sentiments I have been hearing from our members. If any of you have concerns about this communication please let me know. If you agree with the sentiments, take the time and let your own legislators know in writing.

An open letter to Colorado's Congresspersons:

I am sending this letter on behalf of the Colorado Chapter of the American College of Physicians, representing over 1000 Internists (Specialists in Adult Medicine), to express our concerns regarding the proposed Evaluation and Management (E&M) documentation guidelines for Medicare. After careful review of these materials we feel that the requirements have little to do with the provision of quality healthcare to seniors, represent arbitrary fixed standards (not guidelines) that intrude on the doctor-patient relationship, and were developed solely to provide a mechanism for non-health care professionals (e.g. accountants) to audit a medical chart in the same way that they can audit an IRS form.

As a profession we view being able to care for our rapidly aging population as a privilege. As a specialty, Internists, Internist sub-specialists, and Internist-Geriatricians provide a large portion of the day to day care of this and the next generation of the elderly. This is a population for whom modern health care has been able to extend productive life-spans into the 80s. As previously fatal diseases are deferred or prevented, the diagnosis and management of chronic debilitating diseases (arthritis, diabetes, heart failure, respiratory insufficiency, etc.) have become a more common, and difficult, part of our practice. We do not cure these problems, we attempt to maintain function. The best of us listen, try to understand, and help our patients to cope with the use of life-style changes, medicines, and at times surgery ... in summary we take time.

We may take an hour to help a patient understand how to live a more full and functional life and not document that we have examined "all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems. (Proposed HCFA guidelines for E & M documentation)" Another patient might be given the same amount of time but have 10 body areas examined (one at no extra charge!) because it is medically appropriate to do so.

We would pose questions for you.

"Is it appropriate for Medicare/HCFA rules to tell doctors what the exact content of their medical examination must be every single time a complex patient is seen?" Illness/culture/health does not = accounting standards for a business.

"Is it appropriate for Medicare/HCFA to describe these interventions as 'guidelines' (variance allowed, learn from your mistakes) when in point of fact they are being audited as 'standards' (consistent variation of any degree = fraud)? I am a gastroenterologist (digestive diseases sub-specialist). How would you (or your parent or your uncle) feel if you came to see me in consultation for chronic diarrhea that had impaired your ability to work, I had blocked out an hour to review your records, understand your problem, get to know you as a person, perform an appropriate examination, and explain how I am thinking about your problem in the context of your overall health; but have to limit the time that I can do those things because I have to spend 10-15 minutes fulfilling my documenta-tion requirements so that I am not accused of fraud! Who other than OIG accountants win in that setting?

We are not na´ve. We recognize that a very small portion of practicing physicians may willfully try to defraud Medicare/Medicaid. We will never defend such activities. For most doctors, however, the 'documentation deficiencies' that the GAO has identified as the most common source of 'fraud' reflect historical patterns of medical charting developed when their only concern was transmitting the kernel of the medical interaction (for themselves, another doctor, or to prevent being sued) and moving on to the next patient. Certainly when Dr. Hsiao developed the current Medicare Resource-Based Relative Value System for the Medicare fee schedule he did not take into account the documentation burden that has been added subsequently.

We recognize that our government needs to protect itself against true fraud. However, the 'solution' conceived in HCFA (with the help of the AMA I'm sorry to admit) throws out the baby with the bath water, and potentially threatens the quality and content of the services delivered to the elderly and the poor (these rules will apply to the children seen under Medicaid as well). The well documented pernicious and reckless auditing practices and enforcement by the States Attorney General and the Office of the Inspector General (currently under litigation in California) of similar 'guidelines' among the Schools of Medicine in the United States does not suggest that we can expect a 'fair hearing' when it is our turn.

We petition you and your staff to get a better understanding of the threat that interposing IRS-like rules and auditing policies is having on the physician-patient relationship. The consequences to your constituents (both doctors and their patients) are far reaching and unpredictable. There must be a better way of protecting the government against true fraud. Our Chapter, and the national American College of Physicians (over 100,000 members) are willing to take part in a dialogue that leads to a better outcome for both the payer (all of us) and the patient.

We thank you for your consideration of our issues.


Joel S. Levine, M.D., FACP
Governor, Colorado Chapter
American College of Physicians

Colorado Chapter/CSIM Component Society Annual Meeting

Those of you who could not get to the Annual Meeting at the Broadmoor in Colorado Springs, missed a large (103 attendees), scholarly (11.5 credits of solid, practical information for your office practice), rowdy (we have really started to talk about the substantial issues facing our profession), collegial (Laureate Awards given to two nominees submitted by the Chapter and the Component Society), and entertaining (cave dwellings at the banquet) meeting at one of the premier hotel-resorts in the country. Meetings of such quality don't just happen, they are the result of the time, effort, and contributed resources of many. I want to take this opportunity to recognize:

Donna Brown - Without whom I would have self-destructed long ago. Donna has been doing a spectacular job as our part-time Chapter administrator.

The Program Committee - Chair and ACEL Robert Swaney, M.D. and his committee put together a terrific scientific program. The members of the committee are:

Alan Aboaf, MD, FACP
Ray Blum, MD
Jim Bush, MD, FACP
Brian Dwinnell, MD
Mark Earnest, MD
Susan Fixman, MD
Brownie Flesche, MD, FACP
Kelly O'Brien-Falls, MD, FACP
John F. Steiner, MD, MPH
Robert Swaney, MD

As we become the ACP/ASIM I expect the overall content of the meeting to be expanded to include more policy/business functions, but our core educational program will continue, possibly with some structural changes. If any of our members are interested in taking part in next year's program committee, please contact Donna Brown in my office.

Our Local Faculty Who Have Given of Their Time and Expertise

Dan Bessessen, MD - Assistant Professor Division of Endocrinology, Denver Health Medical Center, UCHSC spoke on "Obesity - What to Do After Fen/Phen."

Mark A. Earnest, MD - Assistant Professor Division of General Internal Medicine, UCHSC spoke on "Precepting in the Medical Clinic."

Bryan R. Haugen, MD - Assistant Professor Division of Endocrinology, UCHSC, spoke on "Evaluating Thyroid Disease in the Office."

Edward P. Havranek, MD, FACP - Associate Professor of Medicine Division of Cardiology, Denver Health Medical Center, UCHSC spoke on "Primary Prevention of Coronary Heart Disease."

Steven D. Kick, MD, MSPH - Assistant Professor of Psychiatry and Medicine UCHSC, spoke on "Depressive Disorders in the Medical Setting"

Allan V. Prochazka, MD, MSc - Associate Professor of Medicine Division of General Internal Medicine, UCHSC, New Developments in Smoking Cessation."

Jane E. B. Reusch, MD - Assistant Professor of Medicine Division of Endocrinology, UCHSC, spoke on "The New Diabetes Drugs"

John F. Steiner, MD, MPH - Associate Professor of Medicine and Biometrics, UCHSC, spoke on "Critical Appraisals of New Therapies."

Sally E. Wenzel, MD, Associate Professor of Medicine Division of Pulmonology, UCHSC, spoke on "Approach to the Management of Asthma."

Our Visiting Faculty

David Folks, MD - Chair of the Psychiatry Department at Creighton University spoke on "Pharmacologic Management of Alzheimer's Disease."

Cyril (Kim) Hetsko, MD - Current Trustee of the ASIM and Clinical Professor of Medicine at the University of Wisconsin, Madison spoke on "Antibiotics, New Developments."

Kimberly A. Yonkers, MD - Assistant Professor of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, spoke about "Premenstrual Dysphoric Disorder: A Treatment Update"

Our Associates Presentations

All were well prepared and presented

Rhonda G. Whittie, MD UCHSC, spoke on "Management of Hyperlipidemia."

Elizabeth Sebestyen, MD HealthONE, spoke on "Axillary Vein Thrombosis."

Kathryn L. Lynch, MD St. Joseph Hospital, spoke on "Hemobilia Presenting as Gastrointestinal Hemorrhage."

Visiting Representatives of the ACP/ASIM

We appreciate the time that both representatives took participating in our meeting and speaking informally with the attendees.

Andrea Kielich, MD, FACP - Trustee of the ASIM and now Governor at Large of the ACP/ASIM gave an update on the current status of merger negotiations.

Rowen K. Zetterman, MD, FACP - Regent, American College of Physicians; Professor of Medicine, University of Nebraska Medical Center, spoke on "Update on Treatment of Hepatitis C," and provided an update from the ACP.

Our Banquet Speaker

Henry Claman, M.D. Professor of Medicine UCHSC spoke about paleolithic cave artists, providing a most entertaining conclusion to our honors banquet. I'm thinking of inviting him back for our next meeting to continue his insights into art history.

Our First Colorado ACP/ASIM Laureate Award Winners

Our Chapter and the CSIM Component jointly agreed that this year only one type of honorary award should be given at the Annual Meeting. We have abandoned our historically separate awards and will honor our joint membership who "have demonstrated by their example and conduct and abiding commitment to excellence in medical care, education, and research and service to their community" the qualities that exemplify this years recipients of the Laureate Award.

Barry W. Frank, MD, FACP - Denver, Colorado

J. Stephen Kroger, MD, FACP - Longmont, Colorado

The Industrial Sponsors of Our Meeting

Through their willingness to provide unrestricted educational grants the following firms should be recognized for their support of continuing education for internists in the State of Colorado. Let your representatives know that we appreciate their

Abbott Laboratories
Glaxo Wellcome
Kaiser Permanente, Denver
Roche Laboratories
TAP Pharmaceuticals, Inc.


To Robert McCartney, MD, FACP on being selected one of the Regents of the ACP that are coming from the pool of ASIM Trustees.

To Robert Gibbons, MD, FACP and immediate past-governor of this Chapter on being elected as a Regent of the ACP. Colorado is going to be well represented in the ACP's main decision making body.

To Christopher Unrein, DO, FACP who has been elected the President of the CSIM.

To our colleagues who have advanced to fellowship during the past year:

Alan Aboaf, MD, FACP

To our colleagues who have become members of the ACP

To all 77 of our members (and non-member internists) who have received the ACP recognition award for their community based teaching. Your certificate, suitable for framing and hanging in a prominent place in your office will be arriving shortly. For those who qualify but have not applied please contact Lorraine Adams

To MD, ACP Associate, Resident in Internal Medicine at St. Joseph's Hospital for her recognition by the ACP

To the EIGHT Colorado Associates whose clinical vignettes have been selected for presentation at the Annual Meeting in San Diego.

Speaking of San Diego a reminder to all of the Annual Meeting from April 2 to April 5. An excellent collection of practical CME.