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The Florida Internist

Spring, 2001

Call For Nominations

Elections for regional representatives to the Governors’ Advisory Council will be held this summer.  There are seats available in all three regions for a three year term.  If you would like to be considered for service on the Council or know of someone whose area of expertise would add another dimension to our board, please contact the Chapter office in the very near future to request a biosketch form.  The Nominations Committee will conclude their selection process in June.

The Awards Committee will also meet to select recipients of various awards for our upcoming Regional Meeting at the Renaissance Vinoy Resort in St. Petersburg.  Please review the awards and criteria outlined below and send your letter of nomination to our Clewiston office by June 1.

  • Laureate: Senior Florida Chapter physician who has demonstrated, by example and conduct, a commitment to excellence in medical care, education, or research and in service to the community and ACP-ASIM.

  • Internist of the Year:  for outstanding leadership and dedication to the practice of internal medicine.

  • Outstanding Teacher of the Year:  for outstanding leadership and dedication to medical education.

  • Community Based Teacher   for contributions to the education of medical students, residents and fellows as an office based internist.

From The Governor

Frederick E. Turton, MD, FACP
Fturton@gate.net

ABIM Recertification: A Process Run Amok

Why are you an internist or specialist of internal medicine?  I became an internist because in medical school I came to respect the internist’s commitment to scholarship.  I remain an internist and an active participant in organized internal medicine because internists reveal an unflagging determination to be the best educated, most skilled practitioners of the healing arts in our culture.  Recently the American Board of Internal Medicine (ABIM) announced a scheme for recertification of internists that is well meaning but counterproductive for the interests of individual internists and to the profession as a whole.

The process of recertification as developed by the ABIM is called “Continuous Professional Development” (CPD) and is described in detail in the Annals of Internal Medicine.  The process is modular in content, self-directed and must be begun within four years of the original certificate.  The candidate must complete a minimum of five modules covering “medical knowledge, clinical and communication skills, medical care and professionalism, and practice performance” at one to two year intervals during the ten years after initial certification and at each ten-year interval thereafter.  These are the pertinent features of the modules:

  • The first required module is essentially a take-home test.  The Board provides the candidate with a test that will require reference sources.  The candidate is allowed to take the multiple-choice test as many times as is needed for passage.

  • The second required module is a multimedia test – home or office computer required.  It quizzes the candidate in “standard physical examination and communication techniques.”

  • The third module requires the candidate to supply the Board with the names of ten colleagues and twenty-five patients.  Via a phone survey the Board then questions the doctors and patients identified by the candidate regarding the candidates “overall medical care and communication skills.”  The candidate is then given an evaluation of his performance and asked to develop a self-improvement plan.

  • The final modules, two are required, demand that the candidate evaluate his/her clinical performance in either certain “tracer” diseases such as diabetes, congestive heart failure or asthma or in selected procedures like preventive services or colonoscopy.  The candidate must perform chart reviews and then develop self-improvement strategies.  When the process is complete the candidate is then subject to random chart audits by ABIM and must be prepared to report the outcomes of quality improvement activities to the Board.

Internal medicine’s board certification should be more than a diploma that hangs on our office walls.  Board certification should be an updated standard that proclaims quality of practice, surety of results and scholarship.  Board certification should be an emblem worn proudly by each of us.  BUT, the process for achieving recertification should be relevant to the nature and scope of our practices and this is where the ABIM’s CPD breaks down.

CPD is burdensome, intrusive, redundant and expensive.  Internists are underpaid and overworked already.  Every day’s mail brings another stack of requests for practice data from insurance companies, managed care firms, pharmaceutical benefit managers, nursing homes and hospitals.  Now the ABIM wants us to spend a part of six out every ten years taking more tests, surveying our charts yet again and standing prepared to defend our practices to the Board.

CPD is not relevant to current practice.  Testimony at Board of Governors meetings, at the ACP-ASIM Annual Session and personal communication by internists indicates that the questions on the take-home test are obscure, ambiguous and unrelated to actual practice.  The busy internist deserves challenging but relevant questions, not treasure hunts through medical textbooks.

CPD is not a process that all internists can follow.  The process described by the ABIM does not take into account the fact that many internists practice in atypical environments such as within research institutions or biomedical firms.

CPD’s peer and patient questionnaires are worthless.  Who among us who was smart enough to pass the ABIM test to start with cannot find ten doctors and 25 patients who would give us a glowing review? 

CPD is not validated. Evidence that recertification is really needed and would in fact improve the care of patients is lacking.  There exists no body of evidence suggesting that recertification works better or even as well as other forms of continuous medical education.

The ABIM has been insensitive to the real world environment in which the modern internist works.  Furthermore, the paternalistic, take-it-or-leave-it way in which the process is being presented to internists is frightening because CPD threatens to further economically disadvantage internists.  The ACP-ASIM has a task force that is actively engaged in negotiations to rectify the ABIM’s position.  Until then I have one question to ask the ABIM: What part of “no” don’t you understand?

Frederick E. Turton, MD, FACP
ACP-ASIM Governor for Florida

In the interests of full self-disclosure, I was certified by the ABIM in September 1980 and will not be required to participate in the recertification process.
Annals of Internal Medicine Vol. 133; No. 3; 1 August 2000.
Annals of Internal Medicine Vol. 133; No. 3; 1 August 2000.
Annals of Internal Medicine Vol. 133; No. 3; 1 August 2000.

From The President

Kenneth R. Ratzan, MD, FACP
Kratzan@aol.com

Help is Coming, We Hope: The Medicare Education and Regulatory Fairness Act

Many of you received an e-mail from your governors announcing ACP-ASIM’s strong support of the Medicare Education and Regulatory Fairness Act (MERFA) introduced by Senators Frank Markowsky and John Carey and Representatives Shelley Berkley and Pat Tume.  This act if passed would allow physicians and their staff to spend more time treating patients and less time handling needless paperwork.

 There are over 100,000 pages of regulations which govern a physician’s relationship with his Medicare patient.  These regulations cover everything from notes in our medical charts to a request for home health care for terminally ill patients.  There is no one single place to find all Medicare regulations; indeed physicians are literally held hostage by books and books of federal and local regulations while we face intrusive audits and demands for repayments for failing to comply with these regulations.  These audits can cripple a physician’s practice. If a Medicare contractor accepts a claim and pays the physician, it can decide years later that it made a mistake and demand that the physician refund the payment.  The physician can appeal the contractor’s change of opinion, but Medicare still demands that the money be paid immediately. In short, we pay first and then we appeal.  What is even worse is that Medicare will conduct an audit of a small number of claims for a certain service, such as an office visit or a sigmoidoscopy .  When one out of fifteen claims is determined to be paid incorrectly Medicare assumes that 6.6% of all payments for that service are incorrect for a period of months or years.  One practice faced an audit that attempted to reclaim nearly $200,000 based on a review of only fifteen records.

These intrusive and unnecessary audits can essentially shut down a physician’s practice.  Receptionists cannot answer phones; instead, they are copying records.  Nurses can’t care for patients; they are flipping through charts with auditors.  And physicians are writing letters and begging for explanations of Byzantine regulations from anonymous voices, instead of caring for patients.  We hope you have not experienced such audits but all of us live in the fear that they could be coming.

The Medicare Education and Regulatory Fairness Act (MERFA) attempts to refocus Medicare’s attention on correcting the underlying issue leading to incorrect claims: the complex set of rules that creates unnecessary errors to begin with.  This act will help reduce errors by making available to physicians frequently asked questions and advisory opinions on how to bill correctly for their services.  In addition, Medicare would be required to pay its claims, without demanding more paperwork, unless there is evidence that the bill is incorrect.  Medicare would be required to actually look at all the records, rather than making an assumption that some claims were billed incorrectly based upon a statistical sample; in other words, the extrapolation process would go away.

The American College of Physicians – American Society of Internal Medicine has made passage of this bill its greatest priority.  It joined forces with the American Medical Association and the American College of Cardiology in announcing support for this legislation at a March 7, 2001 press conference.  I would urge each of you to log on to the ACP-ASIM Legislative Action Center at http://www.acponline.org/lac to e-mail, fax, or compose a letter to your legislators. Another option would be to call your legislators toll free through the ACP-ASIM grass roots hot line at 1-888-218-7770.  I think you will agree that this is critically important legislation and with your support we can make a difference.

Kenneth R. Ratzan, MD, FACP
ACP-ASIM Governor for Florida

Annual Session Highlights!

Congratulations to Dr. Sunil Joshi of the Mayo Clinic training program as one of ten winners in the Associates’ Poster Competition.  Dr. Joshi was the winner of the Associate clinical vignettes from the 2000 Florida Chapter ACP-ASIM Scientific Session at the PGA National Resort.

Congratulations to the Florida Chapter for capturing two Evergreen awards for its Legislative Program and Office Management Seminar.

Three Florida-sponsored resolutions went forward from the Board of Governors.  The first called for third party payors to include medically indicated screening colonoscopies as a covered benefit.  Another resolution asked that the ACP-ASIM call upon the manufacturers of the influenza vaccine, non-professional distributors of the vaccine, and appropriate government agencies to ensure that adequate supplies of the vaccine are made available to licensed health care providers prior to distribution to other parties.  The final resolution urged ACP-ASIM to waive any and all Annual Session registration fees for those Associates chosen by their respective chapters to participate in the formal competitions at the Annual Session]

2001 Florida Chapter ACP-ASIM Legislative Agenda

Support

HMO Improvement

  • Oppose “All Products” Clauses
  • Oppose “Hold Harmless” Clauses
  • Support holding HMO’s liable for medical decisions that they make
  • Support requiring HMO medical directors being regulated under the medical practice act and therefore being licensed in Florida
  • Support drug formulary deletions occurring no more frequently than annually.

Tort Reform

  • Expert Witness-must be actively practicing in same specialty as defendant physician
  • Allow defense attorney to talk informally with subsequent treating physician.
  • Monetary penalties for attorneys filing frivolous lawsuits.

Patient Choice

  • “Collective Bargaining Unit” legislation.
  • Increased funding for CHEC for internal medicine residencies
  • Increased access to Medicaid by its eligible population.

Oppose

  • Expansion of allied health professionals’ scope of practice such as:
    • Prescribing authority for pharmacists, ARNP’s, and psychologists.
    • Diagnostic testing authority for pharmacists.
    • Hospital privileges for optometrists.
  • Public disclosure of complaints prior to a finding of probable cause.

Family Limited Partnerships

Often Discussed and Usually Misunderstood

A family partnership provides for participation of family members in a business activity for profit.  It provides a means of diverting income and asset appreciation to family members in lower tax brackets.

The IRS has long recognized valuation discounts for gift and estate tax purposes.  These discounts range in amount, and are based on such factors as lack of marketability and lack of control.  Discounts have the effect of increasing the benefit of leveraging the annual exclusion and unified credit.

In addition to the major tax benefits of a limited partnership, there are non-tax advantages as well. A big advantage has to do with limiting liability.  While we can't eliminate attack by creditors, we can convert "desirable" assets into "undesirable" assets.

Section 703 and 704 of the Revised Uniform Limited Partnership Act limits the remedies that a judgment creditor has against the debtor's ownership interest in a limited partnership (not a general partnership interest).  The creditor's remedy is to receive a "charging order" against the debtor’s partnership interest (not the partnership itself).

If the creation of the partnership or the transfer of assets to the partnership does not represent "fraudulent conveyance" (intent to defraud a creditor), the creditor can not reach partnership income that the family member would have been entitled to receive until it is actually distributed to the debtor partner.  The creditor can not participate in management decisions or receive any right to vote the partnership interest.  Also, the creditor is treated for income tax purposes as the owner of the partnership interest, which can result in the creditor paying income tax on their pro-rata share of partnership income even though a distribution has not actually been made.

Notice that the limited partners are protected from creditors.  The general partners are not.  You could simultaneously be both a general and limited partner.  That's why in some cases it is recommend that the general partner be a corporation that you own.  That way, the liability of the general partner for the limited partnership’s debts will be limited to the assets of the general partner (corporation).  The strategy is to use a corporation with only a small amount of assets.  (The corporation can’t be a "shell" corporation. The IRS imposes certain minimum capitalization requirements.)  The general partner controls all management decisions.

Additional family limited partnership advantages include:

  • The ability to consolidate assets

  • Advantages over an "S" Corporation:

    • Unlimited number of owners
    • More flexibility in allocating profits
    • Easier to move assets in and out of partnership

  • Advantages over an irrevocable trust:

    • Ability to change the terms
    • Can use an arbitrator to resolve family disputes.  Trust law makes it difficult to substitute arbitration for a beneficiary’s right to sue a trustee.
    • Fewer restrictions as to what investments are acceptable

    If you have any questions or concerns regarding your financial planning, contact Frank Fiore, CFP at:

    Sagemark Consulting
    120 E. Palmetto Park Road
    Suite 100
    Boca Raton, FL 33432
    Phone: 561-394-4144

    This information is presented with the understanding that Lincoln Financial Advisors Corporation and its representatives are not engaged in rendering accounting or legal/tax advice.  If accounting or legal/tax services are required, an appropriate professional should be retained.

    Securities and investment advisory services offered through Lincoln Financial Advisors Corporation, a broker/dealer and a registered investment advisor.  Insurance offered through Lincoln affiliates and other fine companies.