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Governor's Newsletter Summer 2002

C. Scott Smith, MD, FACP
Governor, Idaho Chapter

ACP-ASIM Fellowship: "Bearers of the Ring"

In his Annual Session 2002 Convocation Address William Hall, MD, FACP, compared ACP-ASIM Fellowship to Tolkien's Fellowship of the Ring. Both are a group of trusted comrades with varied strengths and weaknesses that have to represent the ideals of a community while carrying on its hard work. I thought he expressed clearly why you might want to consider becoming a fellow of the college. The following are excerpts from Dr. Hall's convocation address:

One of the most gratifying experiences I have had this past year is the privilege of meeting so many Fellows of the College in their own home settings at regional meetings around the country. I have come to call them my heroes—men and women of extraordinary talent and accomplishment in communities large and small. As the year has gone by, I have tried to celebrate a few of these individuals in my monthly columns and identify a number of attributes that these successful internists share, because underneath our diversity we share some common traits. Tonight I'd like to highlight three characteristics that seem to be quite universal and highly predictive of success. I suspect most of you share these qualities.

First, these internists have a distinct clinical style, something we used to call "bedside manner," but might more appropriately be termed the art of healing. In a poem by the same title, W.H Auden said, "Healing is not a science, but the art of wooing nature." Wooing nature; I love that term. These internists have learned how to patiently deal with the vagaries of chronic illness, rarely, I suppose, "curing," but always bargaining with nature to improve the quality of their patient's lives. It is a unique partnership, and it lies at the very core of what a good internist does. These healers are easy to spot at local meetings and Annual Session. While they are not necessarily at the podium professing, some are. They are predominantly the internists in the audience who share their insight, wisdom and kindness in conversation. They have taught me a valuable lesson: You cannot heal from the pulpit, but only from the pew. It is not surprising that these internists are well represented in the ranks of Fellows in the College. The lesson here is that Healers not only practice exemplary medicine, but they also powerfully influence others who want to emulate them. Unfortunately, the increasing pressures of clinical practice make this style of practice increasingly difficult. But you, many of whom share this attribute, must continue to teach by example. Do not underestimate your power to create good by doing what you do best. It is an enormous treasure, and the health care system and the College needs you.

Secondly, in a society that increasingly seems to value less and less any sort of group activity, these internists are constantly investing in what some observers call "social capital." That is to say, they are joiners—in ACP-ASIM activities and in various causes in their communities. They, like Frodo, recognize that if you want to change the world, it is prudent to involve some trusted colleagues for the journey. They spread their enthusiasm among their peers. They recognize how appreciative we all are when a highly respected colleague seeks our counsel. In this way, their impact on their colleagues and communities—and their elected representatives—is nothing short of astonishing. So continue to lead in your communities by finding time to devote to worthy causes, and always try to involve others. You will be surprised how favorable people respond!

The final attribute is the most important and most basic. It is sometimes referred to as Character, but I've learned that a better term might be "Virtue." In classical philosophical terms, virtue describes a set of personal values developed by years of self-reflection and mentoring by family and respected colleagues. It is the inherent tendency to intuitively do the right thing. When transposed to our clinical world, virtuous personal values allow us to easily establish trust and confidence with our patients. Virtue is the basis of professionalism. In my experience, Fellows in this College know themselves very thoroughly and have more satisfying relationships with their patients as much by who they are as by what they know. Virtue is a trait worth recognizing and preserving in your careers. Your colleagues, especially younger ones, will recognize this trait and seek you out. Bring them into the fellowship.

PIER Update

As of Annual Session 2002, the College opened the Physicians' Information and Education Resource (PIER) Web site to all College members. Members can use it to access clinical information in the patient care setting and at other times as a practical medical knowledge resource. As of April 11, 2002 members can sign on to PIER by going to (http://pier.acponline.org) and using their College membership identification number.

The College opened this preview period with 130 modules, covering both common and uncommon diseases and will soon add modules on important topics such as congestive heart failure, osteoarthritis, asthma, depression, and chronic obstructive pulmonary disorder. In addition, ACP-ASIM is introducing modules on prevention and screening, legal and ethical issues, complementary/alternative medicine, and procedures. PIER's body of knowledge will continue to grow, in part based upon input from members.

The College is counting on feedback to make PIER better. Please be aware in urging fellow members to use PIER and in doing so yourselves, of the "Contact Us" link found at the bottom of each web page in PIER. It can be used to suggest new topics, to send comments or to report technical problems. PIER will be constantly growing and changing, and there will be much to comment upon. In addition, the College plans to introduce a brief electronic questionnaire requesting additional feedback.

Medicare audits

(Thanks to Don Norris, MD, Carrier Medical Director, CIGNA, Idaho for his help with this article and his advocacy of the PCA audits)

In the past, providers of care to Medicare beneficiaries have lived in fear of Medicare audits. There were, in effect, three types of audits performed on Medicare providers. The Office of the Inspector General of the Department of Health and Human Services did one type of audit. The Benefit Integrity Unit (BIU) of CIGNA Medicare performed another. Both these audits involved many documents that were primarily documentation of services provided to Medicare Beneficiaries. The purpose of these audits was to identify fraudulent or abusive billing practices in the Medicare program.

In Idaho, the third type of audit was a CIGNA Medicare Part B audit. Previously, there were two types. These were called Comprehensive Medical Review (CMR) and Focused Medical Review (FMR). FMR audits were performed over many providers to identify overpayment for a specific billing code. CMR audited the practice of a single provider to identify aberrant billing practices. Both these audits focused on reclaiming monies and returning those monies to the Medicare Trust Fund.

In October, 2000, The Centers for Medicare and Medicaid Services (CMS), formally known as HCFA, directed their Carriers (CIGNA in Idaho) to change the focus of their audits to identify errors in claims and to educate the provider community on the correct way to bill for Medicare services. These new audits are called Progressive Corrective Action (PCA). The purpose of these audits is NOT to recoup dollars for Medicare but to facilitate the payment to the providers of care for appropriate services to Medicare beneficiaries.

These new audits involve fewer medical records for the individual provider (usually 20 charts) or even fewer charts when the audit involves a large number of providers using the same service code (usually no more than 5 charts for each provider).

Although monies that are overpaid must still be recouped, there is no longer a projection over the universe of the provider's practice. Also, if there is under coding, providers will be informed. Providers will also be educated about any erroneous billing practice identified in the audit to improve on the errors identified.

As many of you know, I work at the VA and am insulated from "Medicare hassles". However, in my town hall meetings around the state I have discovered that they are at the top of the dissatisfaction list for some communities. What I am beginning to see is a pattern—a pattern based on anecdotal evidence, but compelling nonetheless. In the communities where BIU audits occurred, there seems to be widespread Medicare paranoia. Every local physician has heard some version of the story. Dissatisfaction is high. Fewer practices take Medicare, and "Medicare dumping" is more rampant. In communities that have experienced the PCA audits, this does not seem to be true.

Why do I bring this up? First, to ask you if this perception is true for you and your community. Second, to ask you to get involved. As always, an easy way to make your elected representatives aware of your views is to go to the College web site. Let them know that you support a collaborative approach to Medicare like the PCA.

Patient Safety

Here is an interesting bit of trivia that I picked up at Annual Session-the risks of serious injury or death for various activities. In the rarer-than-hens-teeth category (< 1/100,000) were scheduled airline travel, European railroad travel, and the nuclear power industry. In the moderate category (1/1000 to 1/100,000) were diving, chemical manufacturing, and chartered airline travel. In the risky category (> 1/1000) were mountain climbing, bungee jumping, and medical care! We learned from James Bagian, a doctor-engineer-astronaut who led the Challenger O-ring investigation, that the key to high reliability organizations is guiltless reporting of "close calls" coupled with redundant, fault-tolerant systems not designed to eliminate errors, but to provide safeguards that keep them from leading to harm. ACP-ASIM's safety advocacy initiative is on the College web site.

Recertification News

The spring Board of Governor's meeting held a special reference committee just to cover the many resolutions dealing with this issue. We also received a letter from the President of the ABIM that reflects significant progress in the negotiations between our two organizations. In summary, the ACP-ASIM is requesting:

  • A recertification partnership between ACP-ASIM and ABIM
  • Multiple pathways to recertification
  • All pathways meet the criteria of sensitivity to cost and time, elimination of redundancy, relevance to a variety of practice settings, and accommodation to different learning styles
  • All pathways are subject to continuous testing and validation

Washington Watch

The 9/11 disaster has re-aligned our National priorities and put much of our hard-won legislative progress from the spring and early fall of last year on Congress' back burner. Our main focus now is Medicare reform and access. The 5.4% cut in Medicare reimbursement is just the beginning. Projections for the decrease in reimbursement over the next four years are in the 20-30% range! At that rate, it will actually cost some of your practices to see Medicare patients, and you will be forced to limit or eliminate them. Your elected representatives need to hear what that will do to your practice and your community. An easy way to make your elected representatives aware of your views in these areas is to go to the ACP-ASIM Key Contact Program.

From our Associate Representative

Marcia Witte, MD, second year medicine resident in Boise

All physicians face increasing challenges, such as the difficulty of adhering to Medicare billing requirements and the financial implications of recent cuts in Medicare reimbursement. Primary care physicians may be particularly affected because their services are often less well reimbursed than those of more procedure-oriented specialties. One question these issues bring to mind is whether they influence the career choices of new physicians. Recently I spoke with a small number of internal medicine residents who are spending the second year of their residency in Boise about their thoughts on this matter. These residents are part of a primary care track and presumably at some point had had intentions of entering a career in primary care.

As one of these residents myself, the responses I heard from my peers were not surprising. In answer to the question about a career in primary care medicine, the answer from most was a resounding, "I don't know." Almost everyone I spoke with had, at one time or another, been committed to the field. However, this commitment had waned over the course of their training for various reasons. For most people, the reasons were not concerns over adequate reimbursement, but rather a matter of defining the career that would be the "best fit" in terms of medical interests, skills, and quality of life. The reasons mentioned for persistent interest in primary care reflected deeply felt values, such as the importance of continuity of care and the satisfaction of being integrally involved in a patient's life. Interestingly, the residents who were most likely to have been directly exposed to the larger issues of billing and reimbursement, because they had spent a substantial amount of time in a private practitioner's office, were also the most likely feel that this was just "part of the job" rather than a deterrent.

For my part, I have to echo the sentiments of my colleagues. Acquiring a sufficient body of knowledge and learning how to condense a myriad of problems into a 15-minute appointment are much more salient issues at this point than thinking about how to pay for support staff salaries and the electricity bill. And while on the one hand it may seem na´ve to ignore the latter issues, on the other hand it's probably an appropriate attitude at this stage in our careers. If those of us who eventually decide to pursue a career in primary care do so with a philosophical conviction of the value of the field rather than a careful weighing of the financial issues, hopefully we will also be committed to joining the legislative debate that inevitably shapes the practice of primary care.

Chapter News

Congratulations to Chris Nielson, MD on his advancement to Fellowship.

Congratulations to Marcia Witte, MD. She is an internal medicine resident at the Boise VA and is the new Associate Representative on our council. She will become a member of the Washington council upon her return to Seattle in July.

This year we established an Idaho Outstanding Internal Medicine Student Award. Congratulations to an Idaho WWAMI, Catherine Wheeler, who is the first recipient. She will be doing her Internal Medicine residency at the University of Washington

Contact Information

Banu E. Symington, MD, FACP
Governor, Idaho Chapter
Twin Falls, Idaho

Kelly Hess
Executive Director, ACP Idaho Chapter