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Governor's Newsletter, Summer 2000

Joseph G. Weigel, MD, FACP
Governor, Kentucky Chapter

Governor's Column

As I'm sure it is with you, the older I get, the faster the time seems to go. It seems as if it was only weeks ago that the Annual Session was in Philadelphia, and it is only 2 months until our Scientific Session meets again in Louisville in conjunction with the Kentucky Medical Association's Annual Session. We have worked diligently to begin a new approach to these Scientific Sessions by involving the Departments of Medicine at the University of Kentucky and the University of Louisville more so than ever before. This year the University of Louisville is largely responsible for the meeting content and for the speakers. It is my hope that strengthening the relationship between the medical schools, the departments of medicine, and our College Chapter will help everyone in the long run.

Let me know your thoughts about this and please make every effort to attend. We seem to have the same persons year after year, and new faces are always welcome and sought after.

Please find next a copy of our meeting agenda and a sign up form to mail or fax in to register for the meeting.

1:00 REGISTRATION
1:10 INTRODUCTIONS
Joseph G Weigel, MD, FACP
Governor, KY Chapter ACP-ASIM
1:15 ASSOCIATE PRESENTATIONS
2:15 ACP-ASIM UPDATE
College Representative
Captain, Stephen C Beuttel, MD, FACP
2:45 BIOTERRORISM: WHAT THE INTERNIST NEEDS TO KNOW
Charles M Helms, MD, PhD
3:15

CARDIOLOGY
Marcus Stoddard, MD

2 Most Important Articles in Cardiology 1999-2000 Pressing question of interest to general internist in Cardiology

3:45

MEDICAL INFORMATICS
Phil Bressoud, MD
The General Internist and the Internet

4:15

ENDOCRINOLOGY
Steve Winters, MD (Chief, Endocrinology, University of Louisville)

2 Most Important Articles in Endocrinology Pressing question of interest to general internist in Endocrinology

4:45

GASTROENTEROLOGY
Steve McClave, MD

2 Most Important Articles in Gastroenterology Pressing question of interest to general internist in Gastroenterology

5:15 ADJOURN
6:15

COCKTAILS, DINNER & AWARDS PRESENTATIONS: Pendennis Club

After Dinner Talk Dr. Clifford Kuhn: The Laugh Doctor

7:30

TOWN MEETING
College Representative

 

It seems hard to believe, but my term of office is already well past half over. Later this year a Governor-Elect will be selected from our membership.

CAN YOU DO THIS?

Your vote counts! Exercise your right to vote and have your voice heard this fall when ballots are mailed to elect the next Governor for the chapter. Candidates willing to serve your interests, represent your thoughts and positions on nationwide issues, and support local activities that will expand and enhance the chapter are running for office.

You are empowered to guide the College's leadership into the new century. It all starts with one little checkmark. Ballots will arrive in November to all eligible voters (Masters, Fellows, and Members), including brief biographical information on the candidates as well as vision statements from them. If you don't receive your ballot by the end of November, look in the Member Connections section of ACP-ASIM Online, located at www.acponline.org/private/mbrconn to check that the mailing address listed for you is correct. If you did not receive a ballot, you can request that one be sent to you by contacting Joy Christ at 800-523-1546,ext. 2722.

Support the best your chapter has to offer and take a few moments to review the ballot. It's easy. When the ballot arrives, just check off one name and return it in the envelope provided. It's that simple. And you can make a difference.

The College continues to work diligently to reduce factors many times outside individual practitioners control which make the daily practice of medicine much more difficult.

 

ACP-ASIM's EFFORTS TO REDUCE THE HASSLE FACTOR

The ACP-ASIM's Department of Managed Care and Regulatory Affairs Department has compiled a comprehensive list, which outlines the College's efforts to reduce the hassle factors faced by physicians. From meeting with the staff of the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) to influencing pending legislation on physician-assisted suicide, the ACP-ASIM is dedicated to fighting the hassle factor battles for its members.

The following is a sampling of the College's efforts as prepared by its Department of Managed Care and Regulatory Affairs Department (March 2000). For the complete list, log on to ACP-ASIM Online at www.acponline.org/hpp/hassles.htm.

1. Easing Evaluation and Management (E/M) Documentation Requirements:

  • Urged the Medicare Payment Advisory Commission (MedPAC) to recommend that E/M documentation requirements be made less burdensome; ACP-ASIM's recommendations were included in their March 2000 report.

2. Simplifying Claims Processing and Credentialling:

  • Reached agreement on a process that will allow ACP-ASIM leaders to meet regularly with policymaking representatives from the BCBSA and the Health Insurance Association of America (HIAA). Both HIAA and BCBS have recently announced initiatives to reduce hassles affecting physicians. ACP-ASIM has been invited and agreed to participate in both efforts.

3. Opposing Imposition of Mandatory Hospitalist Programs:

  • Persuaded United Healthcare to withdraw its mandatory hospitalist plan in Rhode Island; influenced MCOs in Florida and Texas to withdraw their mandatory programs and make them voluntary.

4. Simplifying Billing for Laboratory Tests:

  • Participated in the negotiated rulemaking committee to develop standard Medicare policies for 23 clinical laboratory tests with the goal of reducing the administrative burden physicians' face when ordering lab tests and to eliminating Medicare carrier policy variability. New proposed rule has been published for comment that incorporates the rulemaking committee's recommendations, including most of ACP-ASIM's concerns.

5. Addressing Concerns about Fraud and Abuse:

  • Achieved revisions in OIG's "Who Pays, You Pay" campaign materials that are more physician friendly, and that direct patients to resolving billing issues with their physicians first, rather than calling the OIG Fraud Hotline. The revised materials note that most physicians are honest and want to work with patients to resolve questions about bills.

6. Improving CPT Codes for Care Plan Oversight Services:

  • The CPT Editorial Panel agreed to an ACP-ASIM proposal, submitted jointly with the American Academy of Family Physicians, that would allow physicians to bill for the time they spend communicating with family and other care decision-makers regarding coordination of care for home health and hospice services.

7. Reducing Other Hassles:

  • Made numerous recommendations aimed at promoting fairness in the way Medicare audits physicians and seeks recoupment of money paid to physicians based on those audits. Met with an independent auditor that prepared a report on ways to improve Medicare's review processes. ACP-ASIM's recommendations also aim to eliminate the elements of the current process that coerce physicians into accepting settlements on Medicare's terms.
  • Provided guidance to HCFA so the agency can ensure all of its Medicare carriers are not
    restricting patients' ability to be evaluated by an internist (or other physician) prior to surgery.

8. Empowering Physicians to Influence Third Party Payers:

  • Lobbying for comprehensive patient bill of rights legislation (Norwood-Dingell bill) that will provide physicians and patients with greater rights to influence and appeal inappropriate denial of payments. The bill would also prohibit gag clauses, assure that physicians-not MCOs-define what is medically necessary, and allowing recourse to the courts when self-insured plans deny needed benefits. Norwood-Dingell bill was passed by the House of Representatives last year. The College is currently influencing House-Senate conferees to report legislation based on Norwood-Dingell, rather than a weaker version passed by the Senate.

9. Helping Internists Cope with Hassles:

  • The College's Department of Managed Care and Regulatory Affairs and ACP-ASIM's Center for a Competitive Advantage have developed numerous educational resources to help internists cope with requirements from Medicare and private payers in the least burdensome manner possible. Resources include a guide on compliance with federal fraud programs and Medicare audits, a laminated list of ICD-9 codes typically used by internists, and a pocket guide to coding for E/M services.
  • The Department of Managed Care and Regulatory Affairs authors a monthly column in the
    Observer on coding, coverage and payment policies.
  • ACP-ASIM maintains a toll-free hotline to enable internist-members to get personal assis-
    tance in resolving problems with Medicare and other payers. The hotline number is
    800-338-2746, ext. 4533.

LEADERSHIP DAY

Leadership day was attended by Dr. Lela Maynard of Pikeville and Dr. Phil Bressoud of Louisville. The following is from Dr. Maynard.

Dear Fellow ACP- ASIM Member:

It was my pleasure to represent you in Washington DC, on May 17th for "LeadershipDay on Capitol Hill 200." Dr. Phil Bressoud, an Internist from the University of Louisville, and I were the two representatives from Kentucky, along with one-hundred Internists from across the country on leadership day.We met with members of Congress and/or their staff to discuss many important health related issues. (Copy follows for your review.)Dr. Bressoud and I hope that this will encourage each of you to discuss these topics with your representatives.

Sincerely,

Lela C. Maynard, MD, FACP

 

ACP-ASIM PRIORITY ISSUES IN THE 106th CONGRESS

The American College of Physicians-American Society of Internal Medicine (ACP-ASIM), the nation's largest medical specialty organization representing 115,000 physicians of internal medicine and medical students, commends the 106th Congress for working on many important health-related issues this year. ACP-ASIM encourages Congress to take action on the following issues that affect the internists and their patients.

Access to Care/Uninsured

  • Co-sponsor the bipartisan access to care tax credit bill S. 2320, sponsored by Senators Jeffords
    (R-VT), Breaux (D-LA), Frist (R-TN), Lincoln (D-AR), and Snowe (R-ME) and H.R. 4113, sponsored
    by Representatives Armey (R-TX) and Dooley (D-CA).

  • Support proposals to expand the Medicaid and S-CHIP programs to cover all low-income adults.

  • Work towards long-term solutions that would provide coverage to all Americans.

Patient Safety

  • Support creation of a Center for Patient Safety within AHRQ and the administration's budget request
    for funding of such a center.

  • Support further examination of how best to report and analyze data on patient errors.
  • Support limiting mandatory reporting to injuries that cause death or permanent disability with
    confidentiality protections.

 

Medicare Prescription Drug Benefit

  • Support enactment of legislation to provide a prescription drug benefit sustainable financing, with the
    highest priority going to help low-income beneficiaries.
  • Work to assure that the authorizing legislation includes consumer protections on the use of formularies
    or the role of pharmacy benefit managers (PBMs) in controlling the costs of the drug benefit.

 

Patients' Bill of Rights

  • Support legislation that includes the Norwood-Dingell provisions to individuals who are covered, liability,
    and appeals.

 

Medicare Modernization

  • Oppose the Administration's proposals for Medicare preferred provider option (PPO) programs and
    expansion of Centers of Excellence.

  • Support primary care case management (PCCM) with changes to open it up to qualified subspecialists
    and to eliminate the requirement that all referrals be made through the PCCM.
  • Support dual eligible demonstration programs to improve coordination of care for patients and assure
    that the programs are open to all physicians.
  • Oppose S. 1895 and other proposals to convert Medicare to a defined contribution program.

 

Negotiations/Anti-trust

  • Cosponsor H.R. 1304 in the House, and vote for the bill on the House floor.

  • Sponsor the bill in the Senate, urge Senator Hatch to allow consideration of the bill in the Judiciary
    Committee, and vote for the bill in committee and on the floor.

 

For more information o these issues, please contact the Washington Office at (202) 261-4500, or visit the "Where We Stand" page of the College website.

Finally, I attach an editorial for Pharos, the quarterly publication of AOA. In this day and time, when it seems that every decision we make is being questioned, many of us find ourselves wondering why we do what we do. I found the accompanying
editorial in the Winter 2000 issue to be right on point in reminding of the essence of what we do, and we still strive to do our jobs well each day.

 

PROFESSIONALISM

The Creed We Must Follow

Edward D Harris, Jr., MD (AOA,Harvard Medical School, 1962) Editor, The Pharos

The fall 1999 issue of The Pharos contained a prediction of the future for the health care system written by Robert H. Moser, MD ("Mene, Mene, Tekel, Upharsin Comes to Medicine," Pharos, Fall 1999, pp. 15-19.) Dr Moser, viewing the world from a mountain of experience formed, in part, during his tenure as editor-in-chief of the Journal of the American Medical Association, foresees the eventual evolution of a stable and mature form of medical care constructed around Single Payer Program (SPP). He predicts that "all income and expenses will be controlled by the SPP working with states, academic health centers, and the primary care providers in whatever organizational structure that evolves from the current hodgepodge of management schemes." He believes that academic health centers will be subsidized completely by the SPP, and that pharmaceutical and medical equipment manufactures will be obligated by law to subsidize them.

In what time frame will all this happen? Within ten to thirty years, predicts Moser.

While none of us would be surprised if a mature and stable medical care system did not evolve in the next several decades, it is realistic to agree with Dr. Moser that during the intervening years there will be "a period of considerable chaos before this nirvana is achieved."

There is evidence that these dark ages are already rolling in. We currently have an irresponsible reimbursement system for our extraordinarily expensive ways of taking care of the sick as well as the worried well. Do we need more evidence than the fact that the American Medical Association has been instructed by its board to support legislative approval for formation of physician unions? Another sign: A high percentage of doctors in a recent survey indicated that lying to health insurance companies or health maintenance organizations was justifiable in order to practice as their patients' advocate.(1)

Jordan Cohen, MD, president of the Association of American Medical Colleges, lists five conditions contributing to the imperfect alignment of society's needs with what our health care system provides. They are:

1. The escalation of health care costs

2. The overproduction of specialists

3. Disease and disability arising from poor health habits

4. The large number of Americans who are medically underserved

5. The erosion of trust in the doctor-patient relationship.(2)

Dr. Cohen lists these while outlining how medical schools must improve in the training of future generations of physicians, but the same deficiencies affect the daily lives of practitioners as well.

Aggravating the problem of this imperfect alignment is the recognition that , as Edmund Pellegrino has pointed out, "Societies' are not infallible in the demands that they make on their citizens or institutions."(3) Just because society wants something is not a guarantee that it fits with the long-term
principles of our profession. There are many historical episodes (Nazi Germany's "medical experimentation," for example) to remind us of this.

Well then, if societal demands linked with politics and a free market economy on the one hand, and the need to conserve or even ration resources on the other hand present us with so many diverse courses to follow, what beacon can the perplexed physician follow through these dark days?

I encourage you to read John Benson's essay in this issue of The Pharos on page four. He suggests that "professional behavior is the answer to this dilemma, in fact, an enduring answer that will out live current notions framed around market values, managed access, and even technology as the foundation of the health care system."

Dr. Benson defines a profession as follows: A profession is the repository of a socially valuable body of knowledge. Its members set standards for themselves, and enforce them, thereby guarding the privilege of self-governance. Professions must also establish principles, and guard them vigorously. And a profession that serves others must value that performance and service above personal reward.

The problem for us all, Benson points out, is that "double agency" has inserted itself in out professional lives in multiple ways. At the same time that we are advocates for the patient, we are urged, and sometimes forced, to be proxies for the health plan or PPO that we have joined. This often sets our decision about the optimal care for our patients against our plan's insistence on the form of care that costs less. And when some form of rationing comes up against the alternative of centralized, rule-based rationing.

The only appropriate course for physicians must be to serve our patients to the exclusion of other forces and pressures. We must keep this goal as the lighthouse toward which we sail. Unions are not the answer. Perhaps a good answer is to constantly renew our covenant with our profession and society, a covenant similar to the one intoned by the 1998 graduated of Harvard Medical School, quoted by Arnold Relman in the December 1998 issue of Academic Medicine.(4) This covenant is published on page five.

The profession of medicine is under siege. Our resistance must be professionalism.

References

1. Freeman VG, Rathore SS, Weinfurt KP, et al. Lying for patients: Physicians deception of third party payers. Arch Intern
Med. 1999, 159: 2263-70.

2. Cohen JJ. Missions of a medical school: A North American perspective. Acad Med Aug 1999; 74: S27.

3. Pellegrino ED. Academic health centers and society: An ethical reflection. Acad Med Aug 1999; 74: S21

4. Relman AS. Education to defend professional values in the corporate age. Acad Med Dec 1998; 73: S21

 

I hope to see many of you in September in Louisville. If you have any questions, please syntax me, or Libbey.

Thanks for your attention.

Joe