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Governor's Newsletter, October 2000

Joel S. Levine, MD, FACP
Governor, Colorado Chapter

Governor's Corner

This is a year of transition for the Chapter.

Beginning with the Annual Spring College business meeting in Atlanta, Kelly O'Brien-Falls, MD, FACP, will take over as Governor of the Colorado Chapter. Jim Bush, MD, FACP, will start in our newly created position of Vice-president. Our leadership will be strong and effective (see example below re: re-certification). To enable that leadership to function in a way that supports your interests, we will be changing the way that our Chapter administrative function is provided.

Traditionally, the Governor would provide "hourly" administrative support from their own office. The reality was that this was more often "pro bono" than "hourly". Donna Brown has provided outstanding support for me these past 3.5 years. This sufficed when the issues at the state/national level were simpler, honorific, and took less time. It has been increasingly inadequate over the past 8 years. It is no longer possible to staff the functions of the Chapter in this manner. Whomever staffs this position should be paid regularly, have defined responsibilities and accountabilities to the Governor and committee chairs. I believe this can be done initially with a half-time FTE. This will allow consistent management of our meeting, committees, public policy initiatives, associate and medical student initiatives. As these changes engage, we will be letting you know how they will impact the service we can deliver to our membership.

Follow-up On Resolution Submitted By Colorado Chapter To College Annual Meeting

As some will remember, our Chapter's Annual Meeting in February 2000 focused on the problem of the uninsured. There was unanimous support for the Chapter to take an active role in bringing this issue back to the political agenda. However, at our Town Hall Meeting Jim Bush, MD, FACP (Fort Collins), our vice-president-elect, brought up the issue that I will paraphrase as "OK, say everyone has insurance tomorrow. Does that mean I will just have to see more patients in a fragmented delivery system that hassles me, is insensitive to the physician-patient interaction, and doesn't pay adequately for physician services rendered?" This clearly captured the interest and support of all attendees.

Working by e-mail with the Governor's Advisory Council I was able to fashion a resolution for the Spring Board of Governor's meeting that asked the College to take a proactive leadership role by developing a policy document that would define the elements of the ideal delivery system for health care. The resolution was debated with interest, but required a rescue from a negative consent calendar. The telling point was a brief floor speech from a Canadian Governor that I will paraphrase as "We listen to the anguish of the US Governors detailing effects of lack of insurance and the intrusiveness of your current health system on the practice of medicine. We are proud that all patients have insurance in Canada, but we also have problems with administrators dictating care. We strongly support this resolution." The resolution passed unanimously and was forwarded to the Board of Regents. The resolution was passed by the Board of Regents and forwarded to the Health Policy Committee where it is currently being processed.

This is an excellent example how the College can rapidly engage its resources when important problems are defined by the membership at the grassroots level. What we need is more of you taking the time to let us know about those problems.

The College Working To Reduce Hassles

Over the past 3 years I have been Vice-Chair of the College's Medical Services Committee, and recently moved to the Managed Care Sub-Committee. While at the MSC I was able to see how the College tries to protect the practicing internist and internist sub-specialist. We had multiple meetings with reps from HCFA, the Office of the Inspector General, and National Insurers. Examples of the impact the College has made include substantial change and simplification of the E&M coding guidelines that will be field tested over the next year; continued hammering at the OIG's public misrepresentation of physician fraud and "abuse" and substantial modification of their "ideal" compliance plan; and multiple meetings with a variety of large insurers. The agenda of these latter meetings always include discussion of:

  1. Clean payment issues (clean claims denied/prompt payment problems)
  2. Our opposition to "all products" clauses in physician contracts
  3. 24 hour access to binding eligibility data/preauthorization process
  4. Uniform definitions of medical necessity
  5. Reducing paperwork/administrative simplification
  6. Hassles related to prescription formularies/high cost of prescription drugs
  7. Use of mandatory hosptalists
  8. Promoting adult immunizations as plan benefits

They are listening, and little by little changing. It is a continuing battle. The more information I have about your issues the better I can represent Colorado's interests. Let me know about "hassle" issues you are confronting.

Fall Colorado Medical Society Meeting

I attended the Annual CMS meeting as this Chapter's voting delegate and also as a speaker at the educational meeting on reducing medical errors. As your representative I spoke at the Reference Committees in support of resolutions that ultimately passed asking CMS to:

  1. pursue legislation that would prevent health plans from marketing physicians as members of their network without the written consent of the physician,
  2. oppose any compaction of the current visit codes,
  3. study the impact of Hospitalists on delivery of care in Colorado,
  4. oppose all-products clauses in contracts,
  5. endorse of the voter initiative to close the gun show loophole,
  6. define measures to prevent retroactive denial of payment by HMOs,
  7. make specialty societies a part of a task force on the future of organized medicine in Colorado,
  8. encourage physicians to attain and use knowledge of palliative medicine, and
  9. oppose Tabor 205

This task was helped by the College's pro-active policy development on most of these issues, and the strong impact many Chapter members have in CMS' policy formulation. In particular, Mark Levine (Chapter Secty-Treas and CMS Board member) and Chris Unrein (Chapter Health and Public Policy and co-chair of the CMS Legislative Council). An "internal medicine caucus" was held on Friday evening. This will be an annual event at the CMS meeting and we hope to get more internists involved in our decision making as a specialty society. We are served well by the CMS' state legislative and regulatory advocacy, I encourage our members to be active in the CMS, but we need to identify when policies might be counter to our specialty's best interests.

Annual Chapter Scientific Meeting

Our meeting this year will be from February 1-3, 2001, at the Broadmoor Resort and Spa in Colorado Springs. As opposed to previous years the meeting will take place in new facilities in the South Building over the spa. I think you will find the new area an improvement as the Broadmoor continues to expand its world-class facilities. Reservations ($150/night) should be made by December 16th at 1-800-634-7711. The College Representative will be Regent William E. Golden MD, FACP, Professor of Medicine in the Division of General Internal Medicine, University of Arkansas who will be speaking on 'Advances in Quality Improvement and Medical Error Reduction for the Office Practice.' Our 2001 Laureate Award will be presented to Richard F. Bakemeier, MD, FACP.

Fall Board Of Governor's Meeting

The Resolutions submitted for consideration this fall were relatively non-controversial. One of note was the request of the Council of Associates requesting voting privileges for all Associates. The floor debate centered around the issue of non-dues paying Associates voting for the Governor-elect. A number of us were able to get a compromise resolution approved that recommended to the Board of Regents that they give Associates voting privileges after they had completed two years of internal medicine residency.

A major discussion item was "physician burnout." Although concern about the data on practice dissatisfaction, emotional fatigue, and general frustration with our current health care delivery system(s) (both US and Canadian Governors saw this as an important issue) was universally accepted, the discussion as to how the College could help clearly brought out two differing philosophical approaches. One approach ("the College as an educational institution") sought to define resources (books, a bibliography, internet sites, speakers) that could be provided to members to help in their emotional renewal. A second approach ("the College as advocate") suggested that College resources should be directed at correcting the root causes (hassles, poor reimbursement, intrusions into the patient-physician interaction, loss of professional status, etc.) of the burnout. I'm a second approach kind of guy, but it was agreed to push the College on both fronts.

An issue that occupied the entire open-forum discussion was the almost universal concern about the ABIM and its approach to recertification, which has just recently been changed. Harry Kimball, MD, MACP and President of the ABIM presented the Program for Continuous Professional Development. A program has again been introduced that is untested, may not effect quality of care, puts the ABIM into an educational role for which they have no expertise, takes a great deal of time to accomplish, and costs a lot (in these regards it wasn't that much different from the first recertification program). A College committee will be reviewing this product.

Rather than letting you know how you were represented in this matter, I have chosen to reproduce in its entirety a letter formulated by your Governor-elect, Kelly O'Brien-Falls and sent to Dr. Kimball and the College's representatives. It reflects our view of this process as currently structured. It would be helpful to hear any concerns from members in our Chapter on this issue so that we can represent your views accurately in national meetings.

Dear Dr. Kimball,

I am writing after hearing your update on the re-certification process at the September 2000 Board of Governors' meeting for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM.) Please allow me to present some concerns I had as an individual physician. This letter is not meant to represent all of the questions of the Board of Governors.

  1. Cost—while the absolute cost is not so high for a full time physician, it is going to feel costly for a two-physician family just finishing their training. Because the Board has recommended spreading the process over 5 years, many of these young physicians will be paying as they try to establish practices and pay back school loans, particularly if they have done subspecialty training.

    I have always worked part-time for non-profits institutions, as have some of my colleagues. To this group, this will feel like a substantial amount of money.

  2. The Patient Feedback Module requires feedback to the Board via a touch-tone telephone. I work, as do more and more internists, in correctional care. My patients aren't getting to a phone any time soon. In California, the Juvenile Justice Department has to distribute its literature in over ten different languages. One or two languages are no longer adequate to reach many in this country. Those physicians who work with refugee patients report that some of them are so fearful of government authorities, it limits their health care options. This will clearly limit the "touch-tone evaluation" of their physician. There are doctors working exclusively in long term and geriatric care. Most nursing home residents and many community-dwelling elderly are not going to be able to do a touch-tone survey. If we limit the evaluations to those patients able and willing to do a phone survey, we violate the very cultural competency we've been asked to achieve. This particular design demonstrates an amazing insensitivity to patients.
  3. You mentioned a time expectation of up to 15 hours per module. For some internists, that could be sixty patients, or up to 300 patients per five years. Is seeing fewer patients supposed to maintain our proficiency at caring for patients? The pamphlet supplied at our meeting refers to needing up to 120 hours over the ten year period, a potential loss of 480 patient visits. This would certainly represent an unseen cost of this re-certifying program. Also, are the hospital and HMO administrators who require re-certification to remain on staff aware of this potential loss of patient contact time?
  4. There is also a Peer Feedback Module recommended. The Board's pamphlet asks for evaluations from 20 professional colleagues. In towns with small medical communities, that number will be very hard to meet. In conversation, you said it could be ten colleagues, and they didn't all have to be physicians. This would relieve some of the burden, so why isn't that explained in the literature? You also mentioned that ten colleagues would be enough to make this an effective tool and not just a popularity contest. It is interesting that we are so effective at evaluation, it only takes ten of us to decide a colleague's future, but as individuals we need a five year process to be certified as competent.
  5. Is there evidence that this works? Your committee was unable to answer this question at the meeting. More telling, the recertification process itself has changed dramatically and continues to evolve even in the last few months. Clearly there is no evidence that this process maintains competent physicians, and there is plenty of evidence that the Board itself is not sure of the best process. Doesn''t it make more sense to start with a much simpler system, and add in steps as proven necessary, rather than start with the extensive, complicated multi-year plan being proposed?

One suggestion is that the Board require a certain amount of CME credit, followed by a secured examination. This may even be computer based to avoid the need for extensive travel. As there are still some states that don't require CME, this could help many physicians stay up to date.

Of course, it's been pointed out that currently CME can be obtained even at an industry-sponsored "infomercial". Perhaps a better use of resources would be looking at how CME is distributed­does it come from those societies and institutions we've entrusted with the education of our profession?

And why is the Board awarding CME, by the way? It was my understanding that the Board is a certifying organization. If the certifying process is so complex that the Board needs to offer CME credit to compensate, then it's time to recognize that the process is beyond complex and into burdensome and unreasonable.

The ACP-ASIM membership in Colorado is angry about the process of re-certification. It is costly, demonstrates a lack of understanding about patients, requires time spent away from patient contact to do paperwork, and changes the rules and requirements frequently and capriciously. To many of us, this sounds like an idea from the insurance industry. What a disappointment that this process has come from our own Board of Internal Medicine.

I look forward to your reply.


Kelly O'Brien-Falls, MD, FACP
Governor-elect, Colorado Chapter ACP-ASIM

New Fellows

Congratulations to the following members advanced to fellowship during the last credentialing cycle:

Hiliary L. Browne, MD, FACP - Boulder
Chester J. Dreiman, MD, FACP - Boulder
Virginia D. Sarapura, MD, FACP - Denver
Jeanne D. Seibert, MD, FACP - Denver
Isaac Teitelbaum, MD, FACP - Denver
Patrick N. Williams, MD, FACP- Edgewater

I hope that all these new Fellows (and other recently advanced Fellows who have not had the opportunity to do so) will be able to join Kelly and I in at the Convocation in the College's Annual Meeting in Atlanta March 28 - April 1, 2001. It really is a grand event that I have had the privilege to participate in for 5 years.

The Future Of Internal Medicine Will Be In Atlanta ­ March 29-April 1

Be a part of the College's vision of upholding the best traditions and creating opportunities for excellence in the future. Join us for Annual Session 2001.

Discover...The Next Generation of Multiple Small Feedings of the Mind
Back and better than before! Creative formats, short, focused presentations, and practical topics combine to make these sessions a popular favorite. Each session is based on a series of practice-derived questions related to several clinical areas that address some of the most common, yet controversial, patient-management issues.

Discover...The Most Recent Breakthroughs at the Annual Update Series
Stay current on the latest information and perspectives from the nation's foremost experts in 20 subspecialty areas. The Update series is a valuable resource to ensure that you're up on the year's most significant findings and their impact on patient care.

Discover...Meet the Professor Sessions
Go right to the source. Take this opportunity to hear the experts discuss cases illustrating controversial issues and innovative techniques in patient care. Then get up-close and personal in the new Meet and Eat with the Professor sessions. Sit down with these same experts over breakfast and lunch and get answers to your specific questions in a smaller, more intimate setting.

Discover...Interactive Learning for the Next Millennium
Hands-on learning activities are an excellent way to refresh your skills or learn new ones. Take advantage of the Learning Center to help you gain experience or refine your abilities in such vital areas as medical interviewing, physical examination, and office-based procedures. The Learning Center is also the ideal place to familiarize yourself with medical informatics software that can have an immediate impact on your daily practice.

Discover tomorrow - Register today.
Registration is available online at http://www.acponline.org/cme/as/2001/register, or by calling (215) 351-2600.

Become An ACP-ASIM Key Congressional Contact

After hearing on the evening news about a proposed change to Medicare or a problem in the healthcare system, have you ever wanted to put your two cents in on the issues? Do you care how legislation coming through Congress affects your patients and the practice of internal medicine? Is one of your friends, family members, patients, church members or civic organization members a legislator?

If you answered yes to one of these questions, you would make a valuable addition to the ACP-ASIM Key Congressional Contact Program. Recruiting new Key Contacts is an ongoing process but it will be especially important when the elections are over and the new members of the 107th Congress are selected.

The College's success on Capitol Hill depends on grassroots advocacy by Key Contacts across the country who communicate with their members of Congress on issues of importance to internists and their patients. Key Contacts usually do not have established relationships with their members of Congress. ACP-ASIM gives them the tools necessary to develop and maintain relationships.

Key Contacts receive a periodic newsletter, the Capitol Key, updating them on important legislative issues. Then, as key issues approach the decision-making stage on Capitol Hill, the College sends Legislative Alerts to Key Contacts that include all the necessary information to make informative contacts with legislators. ACP-ASIM staff is always available to provide support and answer legislative questions. Key Contacts report their contacts back to staff in the Washington, DC, office of ACP-ASIM via fax, phone, email or mail.

The College offers a Grassroots Hotline that Key Contacts can call to hear a legislative update and be matched-with and patched-through to their members of Congress at no cost. The Grassroots Hotline number is 1-888-218-7770. ACP-ASIM also offers the Legislative Action Center (LAC) website which allows ACP-ASIM members to view the most current ACP-ASIM Legislative Alerts, find out who their legislators are, and send an e-mail, compose a letter or a fax to their members of Congress. It provides the status of key legislative issues of concern to ACP-ASIM, Congress' schedule, and tips on communicating with legislators. The Legislative Action Center can be accessed through the Where We Stand section of ACP-ASIM Online, or at http://congress.nw.dc.us/acp/.

The College implemented a Key Contact Awards Program to recognize the hard work of members who go above and beyond the call of duty to contact their members of Congress. Each year, ACP-ASIM selects a Key Contact of the Year and a Top Ten Key Contact Special Recognition Winners based on the quality and quantity of responses to Legislative Alerts. The awards are presented each spring at Leadership Day in Washington, DC. If you would like to be updated on the legislation affecting internists and their patients and are interested in corresponding with your legislators a few times a year on these issues, contact Jenn Jenkins at 800-338-2746, x4536, and join the College's Key Contact Program.

Colorado Board Of Medical Examiners, Press Release

All Colorado Active and Inactive medical licenses will expire May 31, 2001.

Renewal notices will be mailed approximately 4/15/2001 to the preferred mailing address in the BOME system. This address can be verified by calling the Automated Licensing Information system at (303) 894-7434 or (303) 894-7435, or on the Automated Licensing Information system on line at www.dora.state.co.us/medical. Please be advised that a correctly completed, mandatory renewal questionnaire must be received by the BOME before your renewal is considered completed and a new license is sent to you.

Physicians will also be able to check the status of his or her license renewal using the same numbers or web site. Keep a copy of all forms sent to the BOME until the new license confirmation is obtained. I hope to see you at the Broadmoor in February.


Joel S. Levine, MD, FACP
Governor, Colorado Chapter ACP-ASIM