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Governor's Newsletter, October 1998

Governor's Corner

The focus of this month's newsletter will be CHANGE. I expect it will not be the last time it is my 'theme.' Some more observant will note the change in the Chapter's letterhead, codifying the merger of the Colorado Chapter of the ACP and the Colorado Society of Internal Medicine. Some who are more tactile than visual will note the increased weight of this newsletter. I decided to wait an extra month before writing, so that I can describe the 'new' organization in action, at least as viewed from the September Board of Governors meeting in Chicago. Unfortunately, too much has been happening too quickly, outstripping both my reportorial and observational skills. I will limit the 'Corner' to my observations, and try to encompass the more factual areas separately.

I have been very impressed by the high level of collegiality, intelligence, thoughtfulness, hard work, and willingness to collaborate in the change process of our new organization. Unless Governors happened to be wearing a different color ribbon on their name tag, I could not tell the difference between 'transitional (AKA ASIM)' and 'traditional (AKA ACP) governors. Important issues over a wide-spectrum (see below) of physician, societal, and physician-patient interactions were raised, studied, consensus developed, and efficiently balloted. The receptiveness of our 'new' colleagues to recognize the importance of the College's historical strengths in scholarship, education, and policy analysis has been unfailing. This has been mirrored by the traditional leadership of the College's excitement over the changes in advocacy and direct member services that the ASIM has brought to the table. I want to give two small 'vignettes' of the latter for our 'traditional' membership who were not involved with, and knew little about, the ASIM.

HR 4006 - The Lethal Drug Abuse Prevention Act, suddenly appeared on the legislative agenda in early summer. The bill was intended to prevent physician-assisted suicide, had strong political backing by the Right to Life Movement, and had strong political appeal to conservative members of Congress. Sound bites were easy and plentiful. Unfortunately, as written, the unintended consequences of the bill would make the prescription of narcotics for pain control at the end of life a potential felony. The new ACP-ASIM has been a juggernaut in Congress attempting to defeat or significantly modify the consequences of this legislation that forcefully intrudes the federal government, in the form of the Drug Enforcement Agency, between the physician and the patient.

Our new Washington health policy and advocacy arm under the tutelage of Alan Nelson, MD, FACP the former executive VP of the ASIM, responded immediately. Getting a buy off of the Board of Regents and a sense of the Board of Governors, our representatives in Washington have put together a highly polished grass-roots advocacy campaign that would put to shame the Trial Lawyers Association. A bill that appeared to be a slam-dunk in Washington, suddenly had co-sponsors withdraw, hearings that highlighted the potential disastrous consequences, and a 54 member opposition coalition (created from scratch and led by us) created that included patient advocacy groups and providers.

First we saw delay, than increasingly vocal opposition. Our President, Harold Sox, MD, FACP, has been in and out of Washington on this issue. A new grassroots toll free number has been created that directs your call to your representatives so that you can give immediate impact to advocacy with little time and no expense. DIAL 1-888-218-7770. You will be asked for your ACP-ASIM member number (on the cover of the Annals) and your zip code. You will than be routed to your legislator. I will have a phone available at the Annual Meeting to let you try this out.

At this moment I cannot predict the outcome of the legislation. It will not pass as a free-standing bill, but may be added as an amendment to an appropriations bill in the Senate. I can state that without doubt this legislation would have passed already if not for the new ACP-ASIM. If it is defeated you and your patients will owe a great deal to this organization's commitment to advocate for our profession in Washington.

The Center for Competitive Advantage, is something that you need to know about, and begin to use as a member benefit. I recently had an opportunity to speak with Carl Cunningham, MBA who is the Director of the Center. The Center functions as a clearing house for new products that can help you run a more efficient office. Want to know a group of the best patient management programs for Windows? Call Carl. Want to know whether a contract sounds right? Call Carl. Want to know the best industrial carpet to install in an office (literally a recent question)? Call Carl. If he doesn't have the answer he will track it down for you. In addition the Center has developed a number of its own products that can be used in the office to assess patient satisfaction. This is a terrific, new member benefit for old ACP-types. We will be sure to have printed materials available at our Annual Meeting in the Broadmoor.

Carl Cunningham can be reached at (202) 261-4553 or 1-800-338-2746 or Email at ccunningham@acponline.org.

Change - Chapter By-Laws

Our new by-laws are in the process of legal review. Four members selected by the Chapter and four members with traditional CSIM Component Society background met on July 29th. Over three hours of excellent participation the new Colorado ACP-ASIM was fashioned. Our intent is that they will be available for approval at our Annual Meeting at the Broadmoor (see below). My sincere gratitude needs to be expressed to Christopher Unrein, DO, FACP, Herbert Rothenberg, MD, FACP, Kelly O'Brien-Falls, MD, FACP, Stephen Kroger, MD, FACP, Robert Gibbons, MD, FACP, James Bush, MD, FACP, and David Abbey, MD, FACP for their hard work.

A fundamental tenet of the new Colorado Chapter will be the need for greater participation by the Members in the workings of the organization. If you want us to be successful we cannot continue to work top-down. Therefore I am going to take the liberty (while I still have the power to do so) to reformulate the membership of several of our Chapter's Committees. I will be calling a number of you personally to ask your help in this process. If we are to truly represent the needs and values of Internal Medicine in this State we will need to get out and be involved. There are many threats to our role within the health care system, they will not be resolved by ignoring them. I look forward to your help in this regard.

Change - Board of Governor's Meeting - Resolutions

FIFTY THREE resolutions were submitted for discussion, approval, approval with change, or rejection. Please note that there had been a TOTAL of 132 resolutions in the ACP in the previous 12 years! I believe I was able to be an effective spokesperson for this Chapter because a number of our members were willing to study the Resolutions and provide rapid feedback. Not only was I able to transmit consensus support or rejection of resolutions but was ready to offer amendments that improved (or made passable) important resolutions.

This was a remarkable meeting, masterfully conducted by the Chair of the BOG, Mehandr Kochar, MD, FACP of Wisconsin, and Rick Latos, MD, FACP Governor from West Virginia who is Chair of the Resolutions Committee. The level of debate was high, the level of hyperbole low, and we were kept on pace. The following are the substance of approved resolutions which will now be forwarded to the Board of Regents for discussion and either approval or denial. The resolutions passed SUPPORT:

  • Private contracting under Medicare (with patient protections)
  • Medicaid coverage of smoking cessation programs
  • Monitoring of conversions of not-for profit health care entities to for profit entities
  • Collaborative, but not independent, practice by nurse practitioners
  • Expedient appeals processes in MCOs for denied services and that such denials can only be made by a physician licensed in the State
  • An update of ACP-ASIM policies concerning the privacy of medical records
  • Marshaling ACP-ASIM resources to return universal access to affordable health insurance to the national agenda
  • ACP-ASIM advocacy for national legislation that will preserve and expand sources of funding for research and education
  • A study of the outcomes of the Oregon Health Plan Model
  • ACP-ASIM continuing to take an active role in the development of E&M documentation guidelines and the clarification of federal and state fraud and abuse laws to ensure that physicians are not inappropriately punished
  • Good samaritan legislation that protects volunteer physicians
  • The ACP-ASIM petitioning HCFA to proptly restructure its guidelines for reimbursing newer, in-office, injectable medication
  • Assessment of the validity of medical symptom assessment and triage provided by insurers through telephone contact
  • The ACP-ASIM taking appropriate action to prevent Medicare-HMO intermediary contracts with physicians to contain any clause that would prevent the physician from billing other governmental and commercial insurance carriers
  • Establishment of an ACP-ASIM policy compendium with review and 'sunset' provisions
  • Making volunteer/community service an enhancing criterion for advancement for Fellowship
  • A study of whether the ACP-ASIM can develop a program to aid Internists in their purchase and implementation of Computerized Patient Record Systems
  • The establishment of a Political Action Committee that is fiscally separate from the parent organization
  • Publishing pending resolutions 3 weeks prior to the BOG meeting
  • The ACP-ASIM assume an advocacy position for improving the representation of African Americans, Hispanic Americans, and Native Americans in the medical profession
  • The promotion, development, and advocacy of programs that reduce the morbidity and mortality caused by violence
  • The adoption of a policy that would allow a more flexible interval (e.g. 11 months rather than 365 days between mammograms) between screening exams
  • Advocacy for universal immunization of college students
  • Studying the creation of a membership category for senior and/or retired physicians

An issue of importance to this Chapter, making State dues mandatory, was tabled and deferred to the Membership Committee for study and return to the BOG at the Annual Meeting (New Orleans, April 20-25, 1998). The issue related to putting the national membership at risk when not getting local dues paid. Everyone was supportive of witholding local rights and privileges on this basis.

Change - Board of Governor's Meeting - Task Force Recommendations

The BOG was presented with the recommendations of four task forces that were put in place after the merger. The process for discussion was somewhat truncated because the recommendations were not discussed at a reference committee, but rather at a plenary session of all the Governors. However, most of the recommendations developed a general consensus. They will now be passed on to the BOR. The task force recommendations were;

Structure and Function Task Force - BOG voted against changing the length of Governor's tenure to 3 years. However they supported that: further discussion needed to be engaged on the role of Governors in policy development visa vie the BOR, the current internal leadership structure of the BOG should remain the same, Governors should be active participants in all of the College's committees, that vice-chairs of committes (always a Governor) need to be assertive and active in their committees, that Governors should have adequate time to comment on public policy papers from the College, that the Chapters Subcommittee report directly to the executive committee, and that the chair-elects of the Council of Associates and Council of Medical Students be invited to sit with the BOG as voting members.

Resolutions Task Force - BOG voted to support the recommendations that: Davis' Rules of Order will be used, each approved resolution have a time line for action and follow-up, each College body will be required to provide a report to the BOG one-year after the resolution is approved and a compendium will be kept as a tracking mechanism, resolutions shall be posted on acponline.org with a response form for members to comment on each resolution (responses will be compiled and the results given to the governors and the resolutions committee prior to the hearings, a policy should be developed to accommodate late resolutions, and a sunset provision shall be instituted. The BOG did not approve having only one resolutions hearing/year. All agreed that the structure of the meetings will need to be modified to accommodate the large number of resolutions.

Electronic Communications Task Force - BOG agreed that the College needed to move towards an era in which electronic communications would be preferred, and the resources would need to be identified to accomplish this task.

New Regions Task Force - The merger agreement stated that there would be 8-10 more Governors. Although there was much discussion of the recommendations no consensus could be reached. The Task Force will meet again and reshape the recommendations based on the input from the BOG.

Change - Volunteerism - Community Service

Always stated as a value for the College, the idea of crafting novel ways to recognize and foster community service by Members originally emanated from the Council of Associates. They created an award that was won by a Colorado Associate last year. The BOG agreed that this should be a priority, and passed a resolution that volunteerism/community service should be a criteria that amplifies the advancement to Fellowship. There is also talk of establishing an award of recognition, much like the Laureate Award, that would be given each year at the Chapter's Annual Meeting.

I don't think that we should wait for the BOR to decide on this issue. Such an award would recognize fundamental values of our profession and should be part of what we are about in Colorado. Therefore I will ask our Nominations Committee to develop criteria for, and consider awarding, a Community Service Award to a deserving Member in 1999.

Change - Progress in E&M Documentation Guidelines

After the April 1998 'fly-in' to Chicago at which time the ACP-ASIM not only presented its objection to the documentation guidelines, but also made specific recommendations for improvement, the CPT coding committee created a 'new framework' for documentation. However, in June 1998 the AMA House of Delegates passed a resolution that forbade any guideline system that was 'quantitative.' This, predictably, was followed by a letter from HCFA stating that the guidelines were meant to be audited, and therefore quantifiable, or they would create their own guidelines (so there!). Two weeks ago the AMA Executive Committee agreed to restart negotiations with HCFA, keeping the quantifiable components to a minimum.

The good news is that the point of departure of those negotiations are the June 1998 'new framework' guidelines which are better than any of the previously created guidelines. They shorten the documentation substantially by allowing 2/3 history areas instead of all three, simplifies physical examination criteria, and simplifies the medical decision component. When a history cannot be obtained in critically ill patients a simple note recognizing this fact will still permit the history to be deemed 'comprehensive.' Much more can be done to improve the guidelines, allowing the June 1998 framework to be the base is a major improvement. Any new guideline will be field tested before being applied nationally, so that it is unlikely that such will happen for at least 2 years.

Change - Associates and Medical Student Members of the Colorado Chapter

As we move into the future, we need to integrate our newest Members into the institutional governance of our Chapter. Therefore, after discussion with the members of the By-Laws Committee, I have decided to assure that Associates and medical students will have an opportunity to participate and contribute to our Chapter activities. I will attempt to have at least one Associate or medical student as a voting member on each of our standing committees.

Change - Structure of the Colorado ACP-ASIM Chapter Annual Meeting

Robert Swaney, MD, Chair of the Program Committee, and his colleagues on the Committee (Kelly O'brien-Falls, MD, FACP; Jean Kutner, MD; Lisa Kettering, MD; Jeff Gori, MD, Tom Perille, MD, FACP; Jim Adams, MD; David Abbey, MD, FACP) have put together their usual excellent scientific session for our upcoming Annual Meeting at the Broadmoor February 18-20, 1999. Topics will include: using the computer to find medical information, new concepts in the management of venous thrombosis, diagnosis and treatment of anxiety disorders and PTSD, management of chronic pain, diagnosis and management of Parkinson's disease, management of female urinary incontinence, herbal medicine, appropriate use of new antibiotics, nonivasive testing for diagnosis and surveillance of CAD, and a panel on hospitalists and hospital medicine. All have excellent speakers and offer the potential for all attendees to bring something of value back to their practice.

In addition, we will be fortunate in having a number of outstanding guest speakers. These include:

  • Harold Sox, MD, FACP President of the ACP-ASIM. Dr. Sox is Chairman of the Department of Medicine at Dartmouth-Hitchcock Medical Center and an internationally recognized expert in disease prevention. He will be giving a lecture on controversies in screening but also will be addressing the Chapter during lunch on Saturday February 20th.
  • John D. Stobo, MD, MACP President of the University of Texas Medical Branch at Galveston. Dr. Stobo, previously Chair of the Department of Medicine at Johns Hopkins Medical Center, will be coming as part of a joint program from the ACP-ASIM and the ABIM (on whose Board he is a member). He will be giving a lecture on Professionalism in Medicine, and will have time reserved on Saturday afternoon to talk about the ABIM's current certification/re-certification initiatives, answering questions from attendees.
  • Winthrop Whitcomb, MD Co-President of the National Association of Inpatient Physicians. Dr. Whitcomb will participate in the panel discussion of hospital medicine and hospitalists.

This type of thoughtful blending of current topics of practical interest is what we have all come to expect of our Annual Meeting and our Program committee. But again the topic this month is CHANGE. There will be a number of clearly evident changes in the structure and content of the meeting. These will include:

  • Although there will be a hosted reception on Thursday night February 18th, it will be our merged chapter, not the CSIM, that will be the host.
  • Prior to the start of the scientific meetings on Friday and Saturday, we will make available rooms for breakfasts for any groups with special interests ( e.g. women's group; members wishing to know more about how they can qualify for, or need help in filling out the forms for, advancement to Fellowship; computer's in medicine; community based teaching, health policy, Associates) whom I can convince to organize and become more active within the Chapter.
  • The business meeting will be moved from the end of the meeting to lunchtime Friday February 19th, will have a request for proposal for resolutions, will approve the new by-laws, and be expanded in time to two hours. This will replace the previous report from the ASIM representative.
  • We will try to make available some specific activities for spouses during the day.
  • The black-tie optional banquet, that is part of our small (miniscule?) registration fee, will be maintained. However, we will be asking everyone to let us know whether or not they and guests are actually coming since the Chapter typically loses $2000 each year for meals it has to pay for when no one comes.
  • We will be quite strict this year in expecting members who do not pay State dues, and non-members, to pay a higher registration fee that more truly reflects the cost of the meeting.

Enough already. I'm tired and you have other things to do. We'll talk again soon.