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The Florida Internist

Winter, 2001

From the Governor

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

Fellowship, It's Not Just for Academics

The question arises constantly. It is almost always asked the same way. "Should I apply for Fellowship? I practice in the community and I don't have any publications." It is an unfortunate myth that doctors need to be university-based and have produced peer-reviewed journal articles to be a candidate for FACP after their name. In fact the attributes the College seeks in candidates for fellowship are the same values you appreciate in your best consultants and most trusted colleagues. I invite you to go to the ACP-ASIM website and review the four pathways to Fellowship. It is possible that you too qualify for one of the more esteemed honorifics in Medicine.

The ACP-ASIM has established four pathways to Fellowship because it understands that we all practice in different environments and have different opportunities to leave our mark on our communities and our patients. The College stresses personal scholarly growth. For example, adding a second Board certification or obtaining one of the various added-qualification certificates such as Adolescent Medicine, Critical Care Medicine, Geriatrics, Sports Medicine and Electrophysiology indicates conviction to scholarship and is valued in the application process. Indulging in high quality CME, especially taking the MKSAP for credit, does more than improve our practices. Comprehensive CME impresses the folks at the College who award the FACPs. The stalwarts who make our hospitals work by manning the committees, assuming leadership roles, providing CME presentations and participating on all the different quality-enhancing organizations like tumor boards are doctors the College would like to honor. Community involvement, especially by delivering medical care to the indigent, is important to our cities and towns and it is valued by the ACP-ASIM when awarding Fellowships. Additionally, because community-based teaching is essential for the future of our profession, the College appreciates those physicians who teach medical students, specialty fellows and allied healthcare professionals in their offices and hospitals. Finally, doctors who have gone to bat for the profession by serving in the American College of Physicians, the American Society of Internal Medicine, the ACP-ASIM or other professional organizations are doctors we are all indebted to and the College would like to see them honored.

We are all in this together. Some serve in academia, some in the community. We all have our role and those who have served well deserve an FACP. Are you one of them? Contact Alice Sutton at the Chapter's office (800-542-8461) for an application to be considered for Fellowship. You owe it to yourself. Applications can also be obtained online at: http://www.acponline.org/college/membership/classes.htm#fellow

From the President

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

A Time to Take Inventory

As this year draws to an end it seems as it if was only yesterday that our nation and the world were preparing for the uncertainty of Y-2K. As we know now it came not with a bang but a whimper. During the holiday season from Thanksgiving to the New Year I usually take inventory of the things for which I am grateful and I thought I'd share some of these with you. I am grateful for my patients with whom I have contact on a daily basis. Despite all the machinations of managed care and government intervention, caring for patients, experiencing their gratitude, and learning so much from them about how to live life make a career in medicine well worthwhile. I am grateful to be a member of the ACP-ASIM, a leader in advocating for universal access to medical care. Our organization has been steadfast in its support of this principle and has been willing to invest a sizable amount of money to carry its cause to the public and our politicians. I am grateful for the College's stand with the Office of the Inspector General in revising the "who pays, you pay" campaign material to make it more physician friendly. The revised materials acknowledge that most physicians are honest and want to work with patients to resolve questions about bills and are not perpetrators of fraud and abuse who take advantage of their patients. Indeed, fewer than 1% of calls to the Office of Inspector General hotline involve complaints against physicians; half of which are substantiated or partly substantiated and only a handful are referred for further investigation of criminal violations. I am grateful for the College's national legislative program supporting a strong patient bill of rights, a workable and affordable drug benefit program for the elderly, and collective bargaining for physicians. I am grateful for the Florida Chapter's legislative program in Tallahassee directed by Bo Tucker which was successful in obtaining legislation to prohibit HMOs from mandating the use of hospitalists, achieving legislation which assures that HMOs are held accountable in their business relationships with physicians, that "clean" claims are paid on a timely basis, and that adverse decisions by HMO's can be appealed.

I am grateful that our nation survived the crisis surrounding the presidential election and that the judicial process was allowed to work its way to a peaceful solution.

I am grateful to have the good fortune of being associated with leaders in the ACP-ASIM such as Jim Borland who was chosen to be this years' recipient of the Alfred Stengel Award for Outstanding Service to ACP-ASIM, Cecil Wilson who was named Chair-elect of the Board of Regents, and Roger Turkington and Phil Altus who were elevated to Masters of the American College of Physicians. I am grateful to have developed a great working relationship with my co-governor, Fred Turton, who has extraordinary energy, competence, and foresight, and who will succeed me as President of the Florida Chapter next year and will serve us extremely well in that role in the future. I am grateful to Jamie Barkin, past Governor of our Chapter, who carried on the tradition of the Governors he succeeded and left our Chapter stronger than he found it. I am grateful for the staff of our Chapter. Without Alice Sutton, Dawn Moerings, and Bob Harvey we would not be able to serve our membership as effectively as we do. I am grateful to Norm Vickers under whose editorial guidance we have the best newsletter among all of the Chapters of the ACP-ASIM. And to Chris Nuland I am grateful for his leadership, counsel and wisdom in keeping our organization running smoothly and enhancing its efficacy as an advocate for our position in the Florida legislature.

Finally, I am grateful for all of you who have supported the ACP-ASIM, both nationally and locally, to make our organization the leader in scholarship and advocacy for internists.

Craig S. Kitchens, MD, FACP
New Governor-elect Designee

Florida Chapter members elected Dr. Craig S. Kitchens, of Gainesville to a four year term as ACP-ASIM Governor for Florida beginning April 14, 2002. He will take office as Governor-elect at the upcoming Annual Session in Atlanta.

With the unique governance structure of the Florida Chapter and the responsibilities of presiding over both a 501(c)3 and 501(c)6 corporation, Dr. Kenneth R. Ratzan will complete his term as President of the Florida Chapter on April 14, 2002 and Dr. Frederick E. Turton, of Sarasota will assume that office. Dr. Kitchens will become Vice-President of the Chapter. The next election for Governor will be held in the fall of 2002

Jamie S. Barkin, MD, FACP, MACG
New Regent-elect

The College has announced that Dr. Jamie S. Barkin, immediate past ACP-ASIM Governor for Florida, has been elected by the Board of Governors and Board of Regents to a three year term as Regent beginning April 1, 2001. The College is governed by the Board of Regents , which is responsible for establishing College policies and overseeing College operations.

The Board of Regents meets four times a year, including immediately prior to Annual Session. The 18 Regents elected by the members of the Board of Governors and Board of Regents are eligible for a second term

Transplantation in the New Millennium
By P. V. Caralis, MD, JD, FACP

Whether you believed it was last year or this year, the new millennium is here, bringing with it the promise of new scientific discoveries. The triumphs and defeats over disease in 2001 will be like riding a roller coaster with both excitement and danger. The dangers will include the ethical challenges we must face with new technologies. One of the most promising areas has been the field of transplantation medicine. What were once "desperate remedies for desperate patients' have transformed into almost "ordinary" interventions to treat a wide number of end-stage diseases. The range and combinations of the different organs transplanted and the array of donors and recipients for whom procedures are becoming commonplace are astounding. Whether we are health care professionals or lay people, all of us can understand the gravity of illnesses and empathize with the frequent deaths, the hope and renewal, the "breakthroughs", the despair and disappointments that donors and recipients, their families and friends and providers experience. As we watch, we see the ethical dilemmas of the human condition unfold...equality and justice...presumed consent...designated donation...living unrelated donors...retrans-plantation...commerce in scarce resources. The chronic shortage of organs drives the search for new sources and the proposed solutions have provided us a view of the current state of American moral, sociological and legal values and beliefs. In 1997, the Institute of Medicine opened the door to proposals to obtain organs from "non-heart beating-donors", who do not meet criteria of brain death, and challenged all of us to construct protocols that respect persons by forbidding organ retrieval that itself causes death. When is the patient-donor really dead, so that his/her organs may be retrieved? How many minutes without spontaneous heartbeat do you wait-two, five, ten minutes? Other advances opened up whole new worlds of organ sources: nonhuman animals and genetically engineered humans conceived and birthed solely to produce matched organ parts.

The most profound controversies ahead promise to be those that purport to change the "gift of life" into a free market procurement strategy ranging from "swapping organs" to the sale of body parts. The state of Pennsylvania planned to begin paying relatives of organ donors $300 toward funeral expenses, becoming the first jurisdiction in the country to reward donation. Is this so bad when 62,000 Americans desperately await an organ transplant yearly and over 3000 die waiting? We have two kidneys don't we? We permit the sale of other goods, plasma and sperm, why not support everyone's autonomy-the seller's right to do whatever they please with their bodies and the buyer's right to maximize their life and pursuit of happiness? Nay say the critics! The human body is not a commodity to be sold or bid on eBay! "Exploitation" and "slippery slope" cry the moralists. It would produce a society in which poor people are literally cut up to serve as spare parts for the upper classes. A decent society draws the line at this form of "slavery" and human degradation. While some programs do cross the line, is a $300 benefit really a slide down the slippery slope or simply a courageous choice to move the moral line? Are we strong enough to hold the line?

Well, in closing, I wish you the best in the New Year and new millennium and remind you to fasten your seat belts, because this roller coaster promises to be a bumpy ride!

Join us at Convocation at the Annual Session
Thursday, March 29, 2001 at 6:30 p.m. !

The College has announced that several of our Florida members are to be honored.

James L. Borland, Jr., MD, MACP will receive the Alfred Stengel Award for Outstanding Service to the ACP-ASIM. Drs. Philip Altus a former ACP Governor for Florida, and Roger Turkington will receive the prestigious title of Master of the American College of Physicians-American Society of Internal Medicine.

You're Invited ! - Florida, Georgia, Alabama, Mississippi and Louisiana Reception

Friday, March 30, 2001
6:30-8:00 p.m.
Atlanta Marriott Marquis
Ballroom II

Risk Management Seminar
April 28, 2001
Florida Associates Meeting
A one hour course in Risk Management will be offered from 11:00 a.m.. until noon on Saturday, April 28th at the University of Florida Hotel & Conference Center in Gainesville, Florida. This course will meet the mandatory requirement for first-time licensure. For information, call the Chapter offices at1-800-542-8461-1-1.

Florida Associates Meeting
April 28 and 29, 2001
University of Florida Hotel & Conference Center
Gainesville, Florida

Saturday, April 28, 2001
11:00-12:00 Risk Management,
12:30-5:30 Clinical Vignettes
6:00 Formal Poster Judging & Reception

Sunday, April 29, 2001
8:30 Your Private Practice: Pitfalls & Opportunities
10:00 "Doctors Dilemma" Competition
11:45 Awards
12:00 Adjourn

The meeting is free to Associates and Medical Students as well as members who have paid Chapter dues.

Managed Care Plans; pick one, but not any one!
By Cliff Rapp, Vice President of Risk Management, FPIC

Implementing effective loss prevention measures in their practice of medicine helps physicians avoid unnecessary liability exposure. When participating in managed care, the same approach must be taken. Loss prevention measures should begin with a careful evaluation of the managed care entity before a "Provider Agreement" or contract is signed. Concern should be focused on the plans history with regard to provider payment and should include confirmation of the overall financial soundness of the plan as well as the type of enrollees that it seeks. It is also wise to determine if other physicians affiliated with the plan are supportive of its administrative, incentive, and utilization review aspects. And specifically, plan accessibility.

After an evaluation of the organization itself has been done, physicians should further investigate the plan's payment provisions. Determine if there are provisions that will limit your compensation to the largest amount accepted for the same service by another affiliated provider. Also consider the extent and scope of quality assurance activities and how quality assurance documentation of the plan and provider will be protected from discoverability. Be cautious of ambiguous contractual language and determine how the plan defines medical necessity. The credentialing process and utilization review activities are often overlooked. An inadequate system could leave you exposed to administrative-type liability, which is not covered by most malpractice insurance policies.

An important question to ask is: What constitutes covered services? Carefully review this aspect of the plan! There have been many cases where physicians not completely aware of what services are covered, have been held financially responsible for medical care and treatment that they could not possibly provide within the confines of their medical specialty or practice setting. Alternatively, standard of care issues could arise.

Termination of the contract may not top the evaluation list right now. However, should unexpected changes in your practice or professional association take place, physicians may need to exercise their termination option or agreement. Be careful of any limitations set forth pertaining to plan termination in light of the potential exposure to breach of contract, which could include patient abandonment.

Remain cognizant of the fact that the "Provider Agreement" is a legally binding contract. It is imperative that physicians negotiate their managed care contract correctly in order to promote success of that relationship and avoid unnecessary liability exposure. When necessary, seek guidance from your personal attorney or professional liability carrier.

(Cliff Rapp is the Vice President of Risk Management with FPIC. Mr. Rapp may be contacted by calling FPIC at 800/741-3742.)

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.

Board Of Medicine Update
By Christopher L. Nuland, Esq., Chapter Counsel

The Board of Medicine met from November 30 through December 3 and dealt with several issues of vital interest to our members.

Office Surgery: Effective December 7, 2000, new regulations regarding overnight stays will go into effect, requiring at least two monitors (one of whom must be ACLS certified) until such time as the patient is ready for discharge. In addition, all Level II and III surgeons must be ACLS certified, as must one assistant.

The Board also approved additional language that will lift the current prohibition of combination abdominoplasties and liposuction. Under the newly proposed rule, liposuctions of under 1,000 cc total aspirate may be performed in combination with other procedures.

The Board also voted to amend its controversial rule that requires informed written consent for all surgical procedures, voting to exclude from that requirement minor Level I procedures.

Emergency Rule: The Board opted not to amend or rescind its previously enacted emergency rules regarding the submission of surgical logs and the prohibition of combination procedures involving liposuction. In light of the Surgical Care Committee's finding that liposuction integral to the procedure does not constitute a separate procedure, combined with the Board's decision that the ban on combination procedures involving liposuctions is not justified, it is unclear whether the emergency rule (which is scheduled to expire on February 9, 2001) would withstand judicial scrutiny.

Office Surgery Rule Lawsuits: The Board voted to reject proposed settlement offers and to appeal both of its adverse rulings to the First District Court of Appeals.

Physical Plant Standards: Recognizing that the issue of physical plant standards for physician offices is likely to be complex and controversial, the Surgical Care Committee voted to delay consideration of the issue until an undetermined future date, at which time the Committee will devote an entire meeting to this subject.

Use of Ancillary Personnel: The Board unanimously opined that only physicians, PAs, and ARNPs may perform laser hair removal and the injection of collagen.

Electrology Dispute: While the issue was not closed with finality, electrologists still are not allowed to perform laser hair removal under any circumstances at this time.