Report from the Governor's Desk

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Governor's Message
Parting Shots – Five Basic Tenants for Health Care Reform: universal access, computerized health information integration, rational payments to hospitals and physicians, overhaul/replacement of the medical malpractice system, and rational rationing.

As this is my final column as your Governor, I thought that I would invoke your forbearance and exploit the "bully pulpit" of both my position and this newsletter to present you with my personal thoughts about health care reform. I do not pretend to know how to pragmatically solve the health care crisis nor do I feel that I have discovered a new blueprint for the future. Rather, after many years involved in medical leadership and political advocacy, both at my hospital and through the ACP, I have developed some ideas, hopefully informed, about the fundamental principles upon which I believe an efficient, high quality and functional health care system should be structured. Unfortunately, I have to concede at the outset that from a political perspective and taken together, these principles are completely impractical. Given the positions of the two major political parties in the United States, I do not see a realistic, politically pragmatic path to reach the goals that I am about to enunciate. Nevertheless, I cannot help but articulate the principles, however politically naive, with the hope that the political landscape will change at some time in the future and that which is politically impossible today becomes feasible in the future.

Firstly, with health care expenditures currently totaling 16% of the United States GDP, I think that it is safe to assume that there are sufficient dollars currently being devoted to health care in the United States to create and sustain a truly excellent universal health care system. Japan, with the longest average life expectancy in the world (83 years) and the second lowest infant mortality (2.8 per 1,000 live births) spends only 7.9% of its GDP on health care, only half of the U.S. rate. In absolute dollars, Japan's annual per capita health care spending is only 38% ($2,690) of that in the United States ($7,026). The United States leads the entire world both in the percentage of GDP and the annual per capita dollars spent on health care and yet our overall health outcomes rank in the middle. While it is also true that the United States leads the world in medical research and technology, research costs consume only 2% of the health care dollar. Therefore, I do not think that it is necessary to add more money to the "pot" to achieve a quality, universal system. I would suggest that if we restructure our health care system on the following five pillars, that system would be capable of providing excellent care to all of our citizens and yet still maintain our leadership in research and technology and require no increase in the level of funding. These fundamental principles are:

Universal Access:
We simply must provide (and appropriately fund) universal access to health care for all of our citizens. Since I believe that we have agreed as a society that health care is an inherent right and not a privilege, the principle of universal access is the simplest and most basic. In our current system, all patients ultimately do receive care, but the care that they receive is neither high quality nor timely nor efficient. We have evolved a hodgepodge of disparate mechanisms to provide care for the underserved, mechanisms that actually serve them quite poorly and cost us substantially more than a universal system. Our dysfunctional and piecemeal approach forces us to provide care during the most expensive, acute exacerbations and end stages of disease, disease that often could and should have been managed chronically or even prevented. Also, currently hospitals must charge their commercial payers substantially more than their costs in order to cross subsidize the care of their uninsured and the Medicaid poor (who are not even covered at a break-even point by Medicaid payments). Private physicians eschew Medicaid patients (for which payments also generally do not cover office costs) and reluctantly care for many of them on a pro bono basis in under funded, poorly organized hospital-based clinics. In order to maintain their bottom lines, hospitals are forced to develop and market high margin clinical programs and services, chosen primarily on profit potential rather than social good. It should not be the responsibility of hospitals and physicians alone to figure out how to take care of the poor. The current reality results in parochial, ad hoc, inefficient and incomplete solutions. It is the responsibility of all of us, as a society and as a country, to shoulder this responsibility. This means developing a health insurance system that provides universal access (and adequate funding) for every member of our society. The problem of the uninsured has been "pushed down" onto the health care providers, exploiting our professional ethics and using the tools of unfunded legislative mandates and regulatory requirements. However, access cannot be solved by providers at the front lines; we must address this issue together, as an informed and progressive society, at the highest level of our government.

Computerized Health Information Integration:
This is the "simplest" pillar of health care reform, one on which everyone appears to agree. The potential value of computerized health information integration is obvious to all of us who take care of patients – less duplication of testing, the availability of a complete medical history and accurate medication list, fewer errors, lower costs etc. However, my concern is the means by which the insurance industry and the federal government are attempting to capitalize information technology implementation within the health care system. Like the problems of the uninsured and the underserved, this issue is being "pushed down" directly onto health care providers, expecting us, in this severely resource constrained environment, to fund the creation of a $156 billion technology infrastructure and support annual operating costs of $48 billion (Kaushal et al., Ann Int Med 143: 165-173, 2005) out of the very limited positive margins we are currently achieving. Computerized health information integration will provide a social good that accrues to the entire society. It is therefore also a societal responsibility and society (i.e. government) should fund it. It has been estimated that physicians who install electronic medical records in their offices will reap only 20% of the financial benefits of such a system. However, physicians (and hospitals) are being asked to bear nearly 100% of the costs. This is not fair, it is not right and it is not economically realistic.

Rational payments to hospitals and physicians:
Internists realize, perhaps better than anyone, how irrational and inequitable our current payment system is. An internist consulting on a complex elderly patient with multiple chronic, life threatening diseases will be paid, for an hour's worth of difficult cognitive work and thoughtful patient/family interaction, only a small fraction (i.e. 10-20%) of what a radiologist or proceduralist will be paid, for the same amount of physician work and time. Hospitals receive from Medicare approximately 30 fold more reimbursement (exclusive of the equipment cost) for the placement of an intra-cardiac defibrillator than for providing a patient with comprehensive diabetes education over 10 one hour sessions with a trained diabetes nurse. It is no wonder that medical students are choosing radiology over general internal medicine for their specialty training and that hospitals are choosing to develop imaging centers, bariatric surgery programs and interventional cardiovascular centers rather than geriatrics and diabetes programs. Indeed, the free market works and we have created a medical marketplace in the United States that rewards procedures and technology while discouraging cognitive services, longitudinal disease management and face-to-face patient contact with physicians. This dysfunctional payment system, as an unintended consequence, undermines the availability of desirable and very necessary clinical services (geriatrics, psychiatry, primary care etc.) as well as threatens the future composition of the physician workforce. We must rationalize payments to hospitals and physicians to create effectively a flat "playing field" in which no program or service or procedure is inherently more profitable than another, and in which an hour of physician's time reading images or performing procedures is reimbursed at a rate comparable to an hour performing cognitive work. Were we to do so, I believe that we as a society would purchase more of those elements of health care (i.e. specific services) that are really required to serve the public good (and generate positive health outcomes) and fewer of those that are largely driven by high margins of profit.

Overhaul/replacement of the medical malpractice system:
Politicians and the public are tired of hearing about "rich doctors" who complain about rising and/or excessive malpractice premiums. Earlier in my career, I too was a bit of a cynic, believing that "defensive medicine" was overstated as a significant driver of unnecessary health care expenditures. However, as I have matured, I believe that I have witnessed a fundamental transformation in the perspective through which we as physicians approach the delivery of patient care, a transformation driven by the necessity to mitigate the pervasive risk of medical malpractice. During the past 25 years, there has been an insidious change in clinical practice by physicians who have shifted from doing that which we genuinely feel is best for our patients to frequently basing our clinical decisions (i.e. testing, hospitalization and even therapy) on that which first and foremost reduces medico-legal risk. Despite unambiguous research indicating that malpractice awards are driven largely by poor clinical outcomes rather than by physician negligence, politicians and the public continue to insist that access to essentially unlimited malpractice awards is required to keep us physicians "honest, i.e. to assure physician quality and reduce the risk of medical error. While for many years I had difficulty accepting the "lottery mentality" of excessive malpractice awards driven largely by the emotions of jurors, I have gradually come to accept our implicit societal decision that an adverse medical outcome should be mitigated by some sort of financial remuneration. However, I would propose that such remuneration should be provided through a society-wide, no fault insurance system program (similar to Workmen's Compensation) rather than a medical negligence / malpractice system that punishes the involved physician. Some would argue that without the opportunity to prove medical negligence, the individual and society lose the opportunity to control the quality of medical practice and to hold physicians accountable for their clinical decisions. I would suggest that we separate the administrative system that regulates physician quality and clinical practice from that which rewards adverse medical outcomes. Regarding the former, I would have no problem supporting a much more rigorous system for medical licensure and licensure renewal; one which requires physician-specific quality reporting and review, recurrent testing and limited licenses (for those who do not maintain the level of quality necessary for independent practice). It is difficult to argue that we as physicians should not be completely qualified and competent throughout our careers. However, the medical malpractice system is working neither to assure physician quality nor to reduce medical error. It is only inexorably driving up the total costs of health care to a level that some Stanford economists (Daniel P. Kessler and Mark McClellan MD, 1996) estimate to be 5 to 9% of the entire health care budget. What a waste of money!

Rational rationing:
Finally, we get to the "R" word – rationing. Rationing is the "third rail" of health care reform - no one wants to touch it. Nevertheless, rationing is a necessary and inevitable component of any universal health care system for which there are finite societal resources available and in which the demand for services is functionally unlimited. For most products and services, rationing is not required because demand is constrained by an individual's personal capacity to purchase those products and services. However, we as a society have agreed that health care is a "right" and that everyone should have access to all necessary health care services regardless of their personal economic circumstances. In our society, there is effectively no personal economic consequence for choosing to purchase health care services. While a lot of free market economists believe that creating personal accountability for the purchase of health care services will effectively limit the demand for health care, I do not agree. I believe that the "average" individual has neither the knowledge nor the temperament to routinely make the best (and most cost effective) health care decisions on their own behalf. The health care marketplace will never be rational and consumers are not capable of judging quality or effectiveness. Rather, I believe that we as a society, aided by physicians, health care analysts and politicians, can and must address health care rationing publicly and make overt allocation decisions – prospectively, transparently, scientifically and effectively, on the basis of social "good". We have to recognize that rationing is already taking place in the United States and among the other developed countries around the world. In the United States we ration passively and irrationally, allowing services to be allocated to our citizens based upon a mishmash of insurance products and an individual's age, employment and economic situations. In Canada, health care is rationed by limiting access and centrally budgeting health care resources, producing long queues that reduce the utilization of many high demand and expensive services. Neither of these approaches allocates health care services rationally and thus neither serves its public well. Given the vast amount that we are already spending on health care in the United States, I do not believe that the rational rationing of health care will reduce anyone's access to necessary and effective procedures and services. But, we have to critically evaluate that for which we do and do not provide funding, investing in only those procedures and services that truly improve meaningful health outcomes. We as physicians observe the squandering of health care resources every day – hundreds of thousands of dollars of ICU care for the tenth and terminal pneumonia of an elderly, malnourished COPD patient; demented, wizened patients sustained on dialysis because their families cannot make the decision to let them die; third line complex chemotherapy or extraordinarily expensive biologic therapy for the patient with metastatic adenocarcinoma of the lung and essentially no prospect for incremental quality survival; complex back and disc surgery for pain that otherwise would have resolved with time and, countless other examples. Our society, focused intensely on the "rights" of the individual, is loath to make decisions that overtly restrict an individual's right to choose anything on the health care menu, regardless of how expensive or ineffective. I believe that we cannot allow our cultural orientation towards the "rights" of the individual to undermine our capacity to create an affordable (and equally effective) health care system that serves our entire society. The right to effective health care should not be translated into the right to all possible health care or the right to cost ineffective and futile health care. The alternatives to rational rationing are our current approach of de facto irrational rationing and/or financial insolvency of the health care system. We must accept that rationing is an inevitable, necessary and inherent part of all universal health care systems. Let's ration deliberately and overtly, so that the choices we make are active and not passive. Let's ration rationally, such that the rationing optimally benefits every one of us and results in universal access with quality, meaningful and effective health care for everyone.

So, there you have it – my personal prescription for the principles on which health care reform should be based. Pie in the sky? You "betcha"! Politically impracticable? Absolutely! But, sensible and reasonable? I think so. Creating a universal system of health care at realistically achievable costs that provides quality outcomes for all is definitely within our reach and clearly within our budget. However, it will require major concessions from both sides of the political aisle and a change in how we as individuals view the balance between our personal "rights" and societal benefit. We are at the beginning of a new political era – let us hope that our leaders have the courage to think "out of the box" and are willing break new ground in leading the United States to our shared (and elusive) goal of the best health care system in the world.

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Abstract Presentations at the 2008 Connecticut Chapter Annual Scientific Meeting October 8, 2008
The resident abstract presentations again proved to be the cornerstone of the annual meeting. An overwhelming total of 208 abstracts were submitted by residents from across the state of Connecticut. Residency programs selected one abstract for oral presentation and 10 such abstracts were presented in simultaneous sessions. The remaining abstracts, detailing either a resident's original research work or an instructive clinical vignette were presented as posters. Each resident was permitted to serve as first author on only one abstract. The judges and attendees remarked again that this year's research presentations were excellent and judging proved to be exceptionally difficult. Awards for the best three oral presentations went to Dr. Harm Feringa (Griffin Hospital), Dr. Olumuyiwa Adeboye (St. Vincent's Medical Center) and Dr. Deepak Kadiyala (St. Mary's Hospital). The best overall clinical vignette poster was awarded to Viktorija Overiene (UCONN Primary Care) entitled "Pseudopseudohypoparathyroidism" and the best research poster was awarded to Dr. Pia Ajero (Danbury Hospital) entitled "Management of Hyperglycemia in Non-Critically Ill Patients Admitted to Danbury Hospital".

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Annual CT ACP Awards
Each year, the Connecticut Chapter of the ACP selects a few distinguished internal medicine physicians (and/or subspecialists) from across Connecticut to honor at our statewide annual meeting (scheduled for Friday, October 30, 2009). This year, we are seeking to significantly broaden the nominations process and solicit recommendations from our ACP Members throughout the State. Three awards are to be presented.

The Connecticut Chapter Laureate Award "honors those Fellows or Masters of the College who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education or research, and in service to their community, their Chapter, and the American College of Physicians".

The Connecticut Chapter Volunteerism and Community Service Award "honor(s) members of the Connecticut Chapter who have distinguished themselves in voluntary service in the area of medicine. Awardees must be Masters, Fellows or Members of the College. …The service must have been performed on a voluntary basis and not required for the completion of teaching, training or position requirements. Volunteer work must have been done as a physician and be medically related".

Finally, the George F. Thornton Award "is given to an individual in recognition of outstanding contributions to medical education. It recognizes the individual's excellence in clinical teaching as well as his or her motivational impact on students, residents and attendings". Nominees for the George F. Thornton Award need not be ACP Fellows or Members, but non-members will be provided their first year of ACP membership upon selection as the award recipient. Given our interest in promoting diversity within our State Chapter, we are particularly interested in identifying female and minority candidates for these awards. If you are interested in submitting a nomination, please draft a letter of support for the nominee, fully explaining why he or she is appropriate for the award. Please submit that letter, as well as a current copy of the candidate's C.V, either electronically or by hard copy, to Nancy Sullivan, Executive Director, E-mail: ctacp@comcast.net, mail: ACP Connecticut Chapter, 30 Dwight Drive, P.O. Box 464, Middlefield, CT 06455. Nominations should be submitted to Ms. Sullivan by March 1, 2009. Your participation is essential to ensure that worthy.

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Program Committee Robert Nardino, M.D., Chair
Once again, the annual Connecticut Chapter Scientific Meeting, "Internal Medicine 2008", was a tremendous success. Held October 8, 2008 at the Aqua Turf Club in Southington CT, the meeting provided meaningful CME while also showcasing the scholarly activity of internal medicine residents from the state's thirteen residency programs. Resident abstract presentations and outstanding lectures on state-mandated CME topics delivered by Alan Kliger, MD, FACP (Patient Safety) and Anne Flitcraft, MD (Domestic Violence) got the meeting off to a great start. Frederick Turton, MD, FACP, representing the ACP Board of Regents, then provided the College's perspective on Fostering Excellence in Internal Medicine. The afternoon featured the eighth installment of our popular "Multiple Small Feedings of the Mind" (MSFM) program, which was in essence a mini-symposium on the metabolic syndrome provided by Thomas Lane, MD, FACP, Carl Malchoff, MD and Joseph Rosenblatt, MD, FACP, followed by a primer on office electronic medical modulerecord systems delivered by council member Stephen O'Mahony, MD, FACP. Simultaneously, we provided two ABIM self-assessment modules, a well-received offering we began at the 2007 meeting to aid internists with the recertification process.

We were also pleased to honor Andre Sofair, MD, MPH, as recipient of the George F. Thornton Award for outstanding contributions to medical education, Steven V. Angus, MD, FACP as recipient of the Chapter Laureate Award for contributions to the ACP, and Kevin Dieckhaus, MD as recipient of the Volunteerism & Community Service Award. Congratulations to these outstanding role models.

Be sure to save the date for the 2009 Chapter Meeting: Friday, October 30, 2009. We look forward to seeing you next year!

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Health & Public Policy Committee Report Robert McLean, M.D., FACP
With the recent national election, we can expect the federal government to address health reform in ways not considered since 1992. What exactly will happen? Health reform is clearly a priority for the new Obama administration, as signaled by the choice of former Senate Majority Leader Tom Daschle as new Secretary of Health & Human Services.

Health legislation pertaining to Medicare generally originates within the Senate Finance Committee. The ACP has been glad to see that Committee's chairman Senator Max Baucus released a "white paper" describing his goals for health reform, which recognized the crucial importance of primary care by proposing increases in Medicare payment rates for primary care physicians and expansion of the Patient Centered Medical Home.

As the Congressional term wound down before the election recess, an ACP-sponsored bill was released: the "Preserving Patient Access to Primary Care Act H.R. 7192". Our CT Chapter delegation discussed this bill with legislators and staff in D.C. this past May and hopes to enlist formal co-sponsorship over the next couple months.

Will more meaningful reform come from the federal government or through our state? That is truly difficult to know. Last year's most promising legislation was a bill to establish a "Connecticut Healthcare Partnership" designed to allow municipalities, small businesses, and non-profits to voluntarily join the state employee health insurance plan, sponsored by Rep. Chris Donovan. To recognize his initiative and leadership in promoting this legislation, our Chapter awarded him our 2008 Legislator of the Year Award at our Chapter meeting in October.

Rep. Donovan will be the new Speaker of the House for the next session in January, and we look forward to supporting similar initiatives. His bill passed both the House and the Senate but was then disappointingly vetoed by Governor Rell. This upcoming term, both the House and the Senate have veto-proof Democratic majorities, and so this legislation will likely be re-introduced.

Many legislators in Hartford want to reform our dysfunctional health delivery system, but the question is how? Should we follow the lead of Massachusetts in mandating universal health insurance, but then not ensuring enough primary care providers in the state to handle the increased demand? The legislature in June 2007 set up 2 "authorities", the HealthFirst Authority and the Primary Care Access Authority, to study the issues involved with primary care access and providing universal health insurance access, and expect reports back with recommendations over the next few years. Such deliberate action is a hallmark of the slow pace of change in our state.

Where is the role of our ACP Chapter in all this? The ACP has developed and promoted excellent policy around universal health insurance and the crucial role of primary care in an efficient well-functioning system (as embodied in the Patient Centered Medical Home model), and we are trying to ensure that appropriate legislators and policymakers are familiar with ACP policies. We should forge alliances where appropriate with other organizations to promote primary care based health system reform, especially with the other physician groups in the Patient-Centered Primary Care Collaborative, the American Academy of Pediatrics and the American Academy of Family Physicians.

In your practice, you will likely encounter patients who ask your opinion on the almost-daily topic of health reform in the news. It is in the interest of our profession to have our patients understand these issues, and that requires at least some familiarity with health policy on our individual parts. Therefore, I urge you to try to understand some of the major issues. A great place to start is to actually read the health policy blog written by Bob Doherty, our ACP's point man on Government Relations & Public Policy , which is a wonderful summary of the really important issues circulating around Capitol Hill. There's a new e-mail newsletter "The ACP Advocate", which will provide updates on the rapidly changing news over the next several months.

Put on your seatbelts, because we may be in for a fast ride to some significant health reform in the near future. I, for one, think we need it and look forward to an exciting ride.

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Internal Medicine at Yale Medical School Napur Garg, Medical Student
The Yale medical student ACP Chapter, aka Internal Medicine Interest Group (MIG), has been enjoying a successful start to the new academic year.

During orientation in September, an activities fair was held to showcase all the different student groups at Yale to the first years. About 50 new students signed up for the Internal Medicine Group. They all received information on events for the year and ACP membership guidance. In October, as a part of National Primary Care Week, IMIG hosted an event in which the Chair of the Internal Medicine Department at Yale, Dr. Jack Elias, moderated a panel on "What is Internal Medicine?" The panelists included Dr. Stephen Huot, Director of Primary Care Residency Program, Dr. Grace Jenq, Director of Geriatric Education for Medical Residents, and Connecticut ACP's Governor-elect, Dr. Robert McLean. The discussion ranged from the organization of the residency years to international/preventative health to making tough career choices at the right time. There were about 40 students present ranging from 1st years to 5th years. A mixer with Internal Medicine staff and students was held in December. Future events include an Internal Medicine Resident's Panel, Diverse Careers in Internal Medicine Panel, Students who matched in Internal Medicine Panel, and the traditional Pizza & Politics discussion.

If you are interested in participating, please contact Napur Garg, Yale School of Medicine Class of 2011 at napur.garg@yale.edu or Barry J. Wu, MD, FACP at bwu@shrs.org.

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CT ACP to Launch Diversity Task Force Call for Participants
At the ACP Connecticut Chapter's Governor's Council on December 2, 2008, the Council discussed prioritizing efforts to increase the diversity of the ACP membership and participation throughout the Connecticut Chapter of the ACP. As the ethnic and cultural makeup of the country becomes more diverse, as medical schools and residency programs work to attract bright culturally diverse students, those of us who practice internal medicine welcome increasing the diversity of our ranks as well. By making it a priority to attract physicians from minority groups into the CT ACP, we are also hoping to impact on the important issue of disparities in the delivery of health care services and outcomes as well as attending to cultural sensitivity. To this end, Eric Mazur, the Governor, has called for establishment of a Connecticut ACP task force to address diversity. This task force will be charged with developing and implementing initiatives designed to increase the participation of women and minorities in all levels of the Connecticut ACP. We are particularly seeking the participation of young minority physicians who have not previously been active in the ACP to help get this task force off the ground.

If you are interested in leading or serving on this task force, please contact Ms. Nancy Sullivan, Executive Director of the Connecticut ACP Chapter. She can be reached by e-mall at: ctacp@comcast.net or by mail at the Connecticut Chapter-ACP, 30 Dwight Drive, Middlefield, CT 06455.

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CT Chapter's Council of Young Physicians Rebecca Andrews, M.D.
The Connecticut Chapter Council of Young Physicians has had a full year with several well-attended events. The most recent event was an information session on advancement to fellowship with Dr. Mazur as guest speaker. Topics discussed included fellowship and its benefits, provider burnout, and the future of primary care. The attendees represented general internal medicine, hematology-oncology, nephrology, and rheumatology. The meeting was held at L'Orcio in New Haven. Continuing to alternate sites, the next event after the holidays will take place in the Hartford area. This event will focus on networking amongst members. Members with specific topics of interest should contact Rebecca Andrews at doctorbecca@aol.com or Jeanette Tetrault at jtetrault17@yahoo.com.

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Internal Medicine 2009
When: April 23-25, 2009
Where: Pennsylvania Convention Center
Registration Online

Philadelphia, PA plays host to ACP's annual scientific meeting. Choose from over 260 sessions providing comprehensive coverage of internal medicine, its subspecialties, and issues in practice management and healthcare policy.

Join your colleagues throughout the internal medicine community at this exceptional experience. Register by February 13, 2009 and save up to $70 on registration fees!

Page updated: 1/5/09

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Contact Information

Robert McLean, MD, FACP
ACP Governor, Connecticut Chapter

Nancy Sullivan
30 Dwight Drive, Middlefield, CT 06455
Phone: (860) 349-8995
Fax: (860) 349-3004 or
E-mail: ctacp@comcast.net