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Governor's Newsletter, Summer 2001

Eldon V. Gibson, MD, FACP
Governor, Oklahoma Chapter

Governor's Column

• Leadership Day 2001 attracted 120 ACP-ASIM Chapter Leaders, including our own Susan Harmon, MD. Leaders from 35 states converged on Washington, D.C., to meet with Senators and Representatives and to learn how to effectively advocate on behalf of their patients and profession.

• Attendees participated in a half-day of training including expert panel briefings on the Medicare Education and Regulatory Fairness Act (MERFA), legislation to reduce Medicare hassles and tax credits to increase access to health insurance. The session included workshops on "Working with the Media to influence elected leaders" and "Rx for ongoing advocacy." Dr. Harmon has summarized, in this newsletter, some of her thoughts from her participation in the Leadership Day Conference.

• The Council on Graduate Medial Education recently released Financing Graduate Medical Education in a Changing Health Care Environment, a report that highlights key issues in financing Graduate Medical Education (GME) and provides useful insight into how sufficient financing can be achieved under a system in which all health care payers share in the costs of Graduate Medical Education.

• The recommendations are generally consistent with ACP-ASIM Core Principles for financing Graduate Medical Education, which also call for a system in which all-payers share in the financing of GME. The College supports the accompanying recommendations for addressing current critical funding issues and alleviating burdensome supervision and documentation requirements for teaching physicians. However, the College does not support recommendations for reducing Federal Financial Support for GME until alternative sources of funding are assured. The report identifies important areas for further research and provides informative guidance for achieving and appropriate future physician workforce.

• For the young physician I would encourage you to take advantage of materials provided by ACP-ASIM to assist you in many phases of your professional development. A few of the newer publications include a new Preventive Services Pocket Guide and an updated version of its Practice Management Guide for Young Physicians.

• The 25-page Young Physician Practice Management Survival Handbook provides resources to help physicians who are entering practice do everything from get credentials from payers to practice cross-cultural medicine. The updated booklet also provides a basic shopping list to help physicians set up a medical practice.

• The ACP-ASIM Pocket Guide to Selected Preventive Services for Adults lists recommended frequencies and target populations for more than two-dozen common screening, immunization and counseling services. The guide also includes clinical guidelines for treating hypertension and high cholesterol, as well as diagnosing and treating diabetes mellitus. ***For free copies of either publication, call Jean Elliott at 800-523-1546, ext. 2692.

• We have all heard stories of "burned-out" internists who left their practices, or of young residents who chose a field other than Internal Medicine because they heard of the long hours, bureaucratic hassles, and declining incomes associated with our field. Several of us serving on the Board of Governors have spent the last several months developing a list of resources that could be used by anyone dealing with these issues. The Board of Governors reviewed a variety of speakers, websites, organizations, books, articles, and College publications, and chose resources they would personally recommend to their colleagues. This material has been collated and posted on ACP-ASIM Online, in the Careers Section. If someone you know is looking for a better balance or a path to renewal, there may be something on this list you can recommend.

Make Plans to Attend

Oklahoma Chapter
Annual Scientific Meeting
October 19 - 20, 2001
Renaissance Hotel
Oklahoma City

Learning Objectives-Participants will be updated on:

• Causes and prevention of errors in medical practice.
• Recent advances in the management of patients with infectious diseases and pulmonary diseases.
• Recent guidelines of acute coronary syndromes and cardiac resuscitation.
• The effective use of the Internet in current practice of medicine.
• Management of patients with severe renal disease.
• The use of autoantibodies for diagnosis of rheumatological diseases.
• Medicare projects of Oklahoma and how the information from these projects can be applied to practice.

This meeting has been approved for 11 CME hours. Registration materials are included on pages 7 and 8 of this newsletter.

Internal Medicine Loses a True Friend

On February 25, 2001, C. S. (Burr) Lewis, Jr., MD, MACP was recognized at the 1st Presbyterian Church in Tulsa for 47 years of service to his church and to medical missions around the world. On June 5, 2001, his life was remembered in a final celebration. He would have been 81 years old on July 19.

Dr. Lewis served as the 12th President of the Oklahoma Society of Internal Medicine in 1971-72 and the 6th ACP Governor for Oklahoma from 1975 through 1979. As Governor, he initiated the creation of the Oklahoma Chapter of ACP, which functioned as a joint organization with OSIM. He went on to serve on the Board of Regents of the College and eventually was selected as Chair of the Board before his election as President of the American College of Physicians. Dr. Lewis is one of only 2 Masters of the College from Oklahoma.

In addition to medical politics, Dr. Lewis has given himself to the enhancement of medical work in Presbyterian mission hospitals around the world. His work has included ward rounds, patient care, clinical teaching, and lectures in hospitals located in India, Nepal, Pakistan, Thailand, Ethiopia, Cameroon, Kenya, Sudan, and Malawi.

HCFA'S new name: Centers for Medicare and Medicaid Services

At a June 14, 2001, press conference, HHS Secretary Tommy Thompson announced that HCFA will be renamed the Centers for Medicare and Medicaid Services. Thompson said that the new name reflects the agency's increased emphasis on responsiveness to beneficiaries and providers, and on improving the quality of care that Medicaid and Medicare beneficiaries receive.

To that end, Thompson outlined the following reform efforts: 1) Launching a media campaign to give Seniors more information to help them make decisions about their healthcare choices; 2) Enhancing the 1-800-MEDICARE information line to a daily, 24-hour a day service; 3) Restructuring the agency around three centers that reflect the agency's major lines of business; 4) Reforming the contractor process to improve the quality and efficiency of the claims processing services; and 5)Instilling a new culture of responsiveness. Thompson says this is just the beginning.

Subspecialty Advisory Group on Socioeconomic Affairs (SAGSA) Information

ACP-ASIM recently developed a formal mechanism for Subspecialty Societies of Internal Medicine to provide input to the College on socioeconomic policy issues-many of which involve highly technical coding and reimbursement matters. Chair of this new group is M. Douglas Leahy, MD, FACP of TN. SAGSA will report directly to the ACP-ASIM Medical Services Committee, which is responsible for charting College policy and advocacy on coding, coverage, and Medicare payment issues. SAGSA will facilitate communication between ACP-ASIM and internal subspecialty societies on technical socioeconomic policy issues; primarily Medicare payment, coding, and resource-based relative value scale (RBRVS) issues. This process is designed to create a formal mechanism for input to the College's MSC, which will enhance timely two-way communication between ACP-ASIM and the subspecialty societies.

Third Party Relations in Oklahoma
Scott Owen, MD, Chair

Oklahoma's ACP-ASIM Third Party Relations Committee meets monthly with Medicare Services to exchange information, influence policy and represent the interests of our Members. Medicare Services completed their new computer systems conversion in early June. Claims submitted in this new system must now include a corporate provider number (instead of an individual provider number) in order to be paid. In addition, Medicare Services is now in the process of developing specific policies to address reimbursement for laboratory testing to monitor for toxicities of specific drugs. In the meantime, it is recommended that one of the following codes be utilized to ensure cleaner claims processing:

• V58.69-Long-term (current) use of other medications (high risk medications)
• V58.83-Encounter for therapeutic drug monitoring

Finally, I would like all of our Members to be aware that in 2001, Medicare Services now reimburses physicians for reviewing and signing plans of care for patients receiving home health care services. Following are the codes to be used for this purpose:

• GO180 - for initial Certification
• GO179 - for subsequent Recertification

Please contact any Member of our Committee if we can be of any service to you with your Third Party payer issues.

Managed Care Plans

In its next term, the U.S. Supreme Court will weigh in on the constitutionality of state laws that require managed care plans to wait for an independent second opinion before denying coverage of a medical procedure. In the case, an Illinois woman sued her HMO after it refused to pay for a shoulder operation that her doctor believed she needed and that a second outside doctor also recommended. According to an Associated Press report, two other doctors consulted by the health plan recommended against the surgery. The insurer eventually had the case moved to Federal Court so it could challenge the Illinois State Law that guarantees an independent external appeal. Currently, 37 states have similar laws, AP reported.

Legislative Update

After nine days of debate, the Senate passed a Patients' Bill of Rights Friday, June 29 by a vote of 59-36. The bill that passed was an amended version of S. 1052, the "Bipartisan Patient Protection Act," introduced by Senators John Edwards, D-NC, John McCain, R-Ariz., and Edward Kennedy, D-Mass. The Bill would guarantee a federal floor of protections for patients in managed care plans, ensuring the right to sue HMOs in state court for denial of benefits or quality of care issues and in federal court for non-quality of care issues.

None of the approved Amendments made changes to the core patient protection provisions of the Bill-provisions such as access to specialists and the prohibition of "gag clauses." Rather, the majority of the Amendments were related to external appeals, liability, and scope. Key Amendments include language to: ensure physicians are not inappropriately held at increased risk of liability; require patients to exhaust a health plan's internal and external appeals processes before filing a lawsuit in state or federal court; establish that State laws could supercede a Federal Patient Protection Requirement through a certification process; provide for caps on attorneys' fees; and repeal the liability provisions if a study shows that more than one million individuals lose their health insurance during the first year that the law is in effect. An Amendment by Sen. Jon Kyl, R-Ariz., which would have weakened the definition of medical necessity, was defeated. The debate now turns to the House. It is likely that Reps. Greg Ganske, R-Iowa, and John Dingell, D-Mich., the sponsors of the companion measure to the McCain/Edwards Bill in the House, will substitute their Bill with the Senate-passed measure when the House begins its debate sometime during mid-July.

ACP-ASIM will likely reaffirm its support for the House version of the McCain-Kennedy-Edwards Bill (the Ganske-Dingell Bill.) How the support of some of our sister medical organizations for the GOP Leadership Bill will play out remains to be seen, although it would seem to create the risk of sending a mixed signal to the Hill on what physicians would consider to be an acceptable outcome for us to declare victory. One risk is that if the GOP Leadership moves its Bill to the floor for a vote and wins, we may never get a vote in the full House on the Ganske-Dingell Bill. The differences between the House GOP Leadership Bill, and the Senate Bill may then be great enough to allow opponents to try to kill the Bill or make unacceptable changes in a subsequent House-Senate conference committee. We need to continue our efforts to get the best possible bill voted on by the House of Representatives.

• On June 26, Reps. Nancy Johnson, R-CN.; Ernest Fletcher, R-Ky.; and Collin Peterson, D-Minn., introduced patients' rights legislation with the backing of President Bush, House Speaker Dennis Hastert, R-Ill., and the chairmen of the three committees that have shared jurisdiction over patients' right legislation. The American Medical Association, however, opposes the Bill and in a press statement called it a "step backwards." The Bill, H.R. 2315, has attracted the support of 61 cosponsors, including nine Republicans who voted for the Norwood-Dingell Patients' Rights Bill that passed the House in 1999. President Bush maintains that he will veto the Senate-passed Bill if it reaches his desk in its current form over objections to the HMO liability provisions.

• Led by Sen. Bob Graham, D-Fla., a bipartisan group in the Senate has introduced the Medicare Reform Act of 2001. The Bill combines elements of Medicare reform bills introduced last year as well as some new provisions. Among the reforms included in the Bill is a voluntary prescription drug benefit. The benefit, which would have a $250 annual deductible and premiums estimated to initially be $52 per month, would pay 50 percent of beneficiaries' drug costs of $3,500 or less, 75 percent of costs up to $4,000, and completely cover costs of more than $4,000. Premiums would be tied to beneficiaries' annual incomes. The Bill Summary (http://graham.senate.gov/pr062801.html) includes the formation of a new scientific commission to establish national coverage policies and allowances for CMS to use purchasing, contracting, and quality improvement techniques that have been successfully used in the private sector.

What's Going On in the States?

The following are highlights from the Health Policy Tracking Service's (HPTS) recently published Snapshots and Issue Briefs. They indicate the importance of state activity and its impact on the National Agenda, specifically the Patient Protection Debate.

• The National Conference of State Legislatures (NCSL) has prepared a package of information that includes a side-by-side chart of the current House and Senate proposals and state statutes for the various provisions in the bills, along with charts and maps. The package was provided to each Senate office.

• This year Alabama, Kansas, Oregon, Virginia and West Virginia all enacted Legislation involving either Direct Access to a specialist, standing referrals or continuity of care.

• Provider Claims-Thirty-three states identified prompt pay provisions as a priority for 2001 and eight states enacted legislation-Alabama, Arkansas, Indiana, Iowa, Oklahoma, South Dakota, Utah and West Virginia.

• 30 States took action on Medicaid Coverage to low-income women with breast and cervical cancer. Ten states have waivers approved by HHS .

• Granny Cam Legislation-A growing number of states, currently at least nine, are considering allowing residents to electronically monitor their care in order to protect the vulnerable nursing home population against abuse and neglect.

• Chronic Pain Management-Tennessee has enacted the Intractable Pain Treatment Act. The new law contains a "Pain Patient's Bill of Rights" that establishes a patient's right to request or reject treatment for chronic intractable pain, including the option of using opiate medication without first undergoing an invasive medical procedure.

• Physician Assistants-A new law in Oklahoma expands the prescriptive authority for physician assistants to include schedule II drugs. A PA may write an order for a Schedule II drug for immediate and ongoing administration on site.

• Illinois, Rhode Island, California and West Virginia are all looking at legislation to provide parity for reimbursing the treatment of mental illness, alcoholism and drug addiction.

• Louisiana's Kid Care program was granted permission to offer health insurance coverage to children in families with incomes up to 200 percent of FPL.

• Oklahoma City-The high cost of prescription drugs, and many Oklahomans' lack of insurance coverage for medications, are the subjects of a couple of interim legislative study requests. Former Speaker Loyd Benson requested a joint House/Senate study into the feasibility of developing a statewide prescription drug program, "Because many Oklahomans are not covered under a prescription drug plan..." One reason is that Oklahoma has relatively high numbers of elderly and indigent citizens, and another reason is the high price of drugs, the Frederick Democrat said. Medicare was established in the 1960's before prescription drugs became such a critical component of health care. Prescription drug costs for the Oklahoma Health Care Authority have risen 20 percent each year for the last four years. The Agency's prescription drug program expenditures are projected to climb to $191 million this year.

Leadership Day 2001

Susan Harmon, MD, delegate to ACP-ASIM's Leadership Conference.

Recently, I traveled to Washington D.C. to represent you at the 2001 ACP-ASIM Leadership Conference. I arrived on the Saturday prior in order to spend sometime with my son, Michael, who is helping to keep democracy safe by working as an aeronautical engineer at the Naval Surface Warfare Center at Indian Head, Maryland. Michael was to be my transportation to and from BWI. Due to various complications with his schedule, I was forced to alter my appointment times with our Congressional Delegation. I was able to utilize the assistance of John Montgomery's secretary to do this. (John is the OSMA lobbyist in Washington D.C.)

The actual conference started on Tuesday, May 8th. We spent the afternoon being briefed on the major issues to discuss the next day. The issues included the Medicare Education and Regulatory Fairness Act (MERFA, S.452/H.R868), which would reduce Medicare hassles; patient protections via the Bipartisan Patient Protection Act (S.283/H.R.526); access to care via the REACH Act (S.590); patient safety by establishing a confidential reporting system for medical mishaps and close calls and by improved funding of AHRQ; and Medicare modernization including a prescription drug benefit and funding for health programs especially primary care training programs.

Tuesday evening we had a dinner and an entertaining speaker, Stuart Rothenberg, a political analyst for CNN. He discussed the current political atmosphere and, after reviewing our agenda, said, "The only thing we would get from the present Congress was legislation on access to care-specifically the REACH ACT or something similar that gives tax credits for purchasing insurance." We all became very gloomy but he cheered us on and told us to ask for what we want and need because that is what democracy is all about.

On Wednesday morning we heard from Senator Frist of TN, a physician and chair of the Subcommittee on Public Health and Safety. He is also the Senate's Liaison to the White House. He is working on legislation to address patient safety, which he hopes to introduce later this year. He would like to set up a system that is similar to that used by the FAA-reporting confidentially to a non-punitive agency. He dislikes the current Bipartisan Patient Protection Act because he thinks it opens the door for the trial lawyers to bring suits against the insurance companies. The ACP-ASIM is not opposed to legislation that limits liability but thinks that is a separate issue. We, of course, are already liable. Patients need protection now! We also heard from Representative Shelley Berkley of Nevada who is married to a physician and helped write the MERFA Legislation. She is definitely an ally. She was amazed when she learned that there are 135,000 pages of Medicare regulations and wants those in the medical provider area to be protected from prosecution for honest mistakes when we accidentally fail to comply with one of these regulations.

The rest of Wednesday was spent lobbying. I managed to meet face-to-face with Representatives Wes Watkins and Frank Lucas who seemed very interested in discussing healthcare and its continuing turmoil. I spoke with the aids of Senator Inhofe (Julie Waring), Representative Carson (Karen Campbell), and Representative Istook (Dr. William Duncan, PhD). I actually discussed every issue outlined above. I made a point of stating that the REACH Act was just a beginning in getting the uninsured insurance since the tax credit is only $1000 for a single person. There is nothing even close to that to purchase if you are an uninsured 50 year old with hypertension!

Only time will tell if I had any effect. I do know that if you all write or call your Representatives and express your views in support of these issues it will definitely help in our efforts to help our patients. If you need more information on any of these issues visit the ACP-ASIM web site.

Recertification: The dialogue with the ABIM

Dr. Herbert Waxman
Senior Vice President, Education, ACP-ASIM

It's about a year since there began a serious dialogue between the College and the American Board of Internal Medicine (ABIM) about the many concerns the College had with the ABIM's plan to implement the proposed Continuous Professional Development (CPD) process for recertification. The core concerns of the College are as follows:

• The process of recertification should be clinically relevant, not excessively burdensome, and not redundant of things that are already being done in physicians' practice environments (e.g. patient and peer evaluation, practice measures and improvement plans.) College Members have expressed very strong feelings about this.

• There should be a clear delineation of the responsibility for high stakes evaluation (ABIM) and education, including self-assessment (ACP-ASIM and other professional societies.)

• There should be a clear articulation of the fact that maintenance of competence requires more than just evaluation periodically. It should also encompass relevant continuing education of the individual physician.

A Joint ABIM-College Committee on Recertification was set up, with three high-level governance members and a staff person representing each party. The College sought resolution of the above concerns; the ABIM sought endorsement by the College of the proposed CPD recertification process.

Thus far, the dialogue has resulted in agreement in principle by the ABIM of the need to resolve the College's concerns. However, the devil is in the details, and there haven't been proposed details that have been perceived to satisfy the needs of the College and its members.

At the meeting of the Board of Regents at the Annual Session in Atlanta, five resolutions pertaining to recertification were communicated to the ABIM, addressing the need to respond to the College's concerns and including a deadline for meaningful progress to have taken place. The Board has instructed its Members of the Joint Committee to recommend in July whether the College should endorse CPD or refuse to endorse the process.

In response, the ABIM requested detailed information about what we want specifically. In a letter from Drs. Bernard Rosof and William Hall (our Board fo Regents Chair and our President, respectively) to the ABIM leadership, we presented our requirements. In short, we are insisting that a physician's participation in a self-assessment program (such as MKSAP) or in patient or peer evaluation or in practice performance measures in his or her own hospital or health system be allowed to satisfy the corresponding requirements of the self-evaluation modules of the recertification process. Recertification should not impose on the physician requirements of what is already being done well in many physician's practices.

ACP-ASIM has not taken a position opposing the formal examination of medical knowledge. The College believes that such an evaluation is appropriate for documentation of maintenance of certification and is something the ABIM is skilled and experienced in doing.

Meanwhile, our Research Center has carried out a telephone survey of over 600 College members, most with time-limited certificates. The results confirm what we have been hearing as strongly expressed individual opinions: The concept of recertification is supported, but the support for CPD is much weaker. Of the self-evaluation components of CPD, the patient peer evaluation module is viewed most negatively. There is a clear sense that the costs of recertification and of the educational programs to prepare for recertification are much greater than the perceived benefit.

Supporting anecdotal reports, a high proportion of respondents are carrying out in their practice environments most of the functions embodied in CPD. For these physicians, the CPD modules would be redundant and therefore represent an excessive burden. We're now waiting to hear how the ABIM responds to the demands outlined in our letter. Based on that response, there will be a final decision made by the College on whether or not to support the ABIM's proposed CPD process. Of paramount importance to the College is that, one way or another, the strongly felt and legitimate concerns of our members be satisfactorily responded to. Stay tuned!

Oklahoma Chapter

Meeting Agenda

Page updated: 06-24-03

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