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Rhode Island Internist

Fall, 1997

In this issue:

President's Message: Yul D. Ejnes, MD
This Duck Ain't Lame

By now, most of you know that ASIM's House of Delegates (HoD) approved the principles for the American College of Physicians (ACP) and ASIM to merge. The new organization, ACP-ASIM, will start operating next summer.

The decision to merge was no great surprise. Few disputed the need for internal medicine to speak with one voice to avoid competing for members and duplicating efforts. Yet in spite of the inevitability of the decision, the HoD spent two and a half hours asking questions and sharing their feelings and fears about the merger.

The sentiments expressed fell into a few categories: optimism that ASIM's mission would continue in the new organization; insistence that our grass-roots spirit will continue in ACP-ASIM; grief over the loss of familiar customs and institutions resulting from the merger; and relief that a decision soon would be made and that every effort would be made to make the merger work. When delegates voted the following day, I heard only one "nay" vote. Following the vote, the HoD went on with business, no less enthusiastic than in previous years, without any concession that this was the final meeting.

There's Work To Be Done

Which brings me to the main point of this column: there still is business to address while merger details are completed and even more to do afterward. ASIM just enjoyed its most successful year ever with dramatic victories in Congress bringing fairness to Medicare's payment system, and RISIM's efforts were recognized with the 1997 Component Society of the Year Award (see page 2). We're not finished yet.

RISIM will continue its activities throughout the upcoming dues year and beyond as the same component society of ASIM through the summer, then as part of the Rhode Island chapter of ACP-ASIM. Our agenda is packed, including: continuation of our efforts to make the RI Medicare Carrier's new rules on specific diagnoses for laboratory tests more reasonable and less of a "hassle"; further discussions with the "movers and shakers" in RI's health insurance community; follow-up dialogue with our congressional representatives on the issues that affect our patients and our profession; and creating - with our friends at the RIACP chapter - a strong organization that represents the professional interests of Rhode Island internists.

Joining Forces in Rhode Island

We are fortunate to have an excellent working relationship with the leadership of the ACP's Rhode Island chapter. For years RISIM and RIACP have held an annual joint general meeting. Members of both groups work together, trained together, trained each other, and/or share friendships outside of their professional work. This is a fringe benefit of living in a small state with one university system, and it makes the task of merging much simpler than it will be in other states. I've had several discussions with RIACP Governor Michele Cyr, MD, and in mid-October I attended a meeting of the RIACP Council - of which RISIM Past President Sewell Kahn, MD, has been a member for many years. Already, the two organizations joined forces on one issue when RIACP supported RISIM's efforts to preserve Medicare funding for the chief medical residency. Dr. Cyr and I plan to hold a joint meeting of both councils and soon will begin discussing how to build the new organization. If you have any ideas or suggestions, please contact me at 401/946-6200 or Yul_Ejnes@brown.edu.

RISIM has a busy year ahead and plans to proceed with its agenda, and ASIM is committed to delivering the publications, support services, and advocacy that you're accustomed to receiving for another year. For this to continue, dues support is vital. Please renew your ASIM membership when you receive your dues statement this month. Nonmembers who are part of the Affiliate Program should strongly consider converting to "active" membership. If you are not an ACP member, this is the time to join as an ASIM member and avoid the long approval process that nonmembers will go through after the merger. Without the support of our members, the quality and quantity of services to members will drop, and ASIM will become a "lame duck" organization.

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Why You Should Pay RISIM/ASIM Dues This Year

* To fund an appropriate transition to ACP-ASIM. We need you to continue your full dues support so that we can enter into the new organization standing tall and proud...not bankrupt for the sake of a few dollars saved by each member.
* New benefits in store for members in 1998. Early in 1998, ASIM's Center for a Competitive Advantage will launch several new programs. (See more on this in the December and January issues of The IM Advantage.)
* No lapse in aggressive advocacy for IM. Yes, you will get the benefit of advocacy without paying dues. But ASIM will be weaker as a result.
* Timely information for members only on the latest developments in Washington and in the managed care marketplace that affect practice.

Please remember that in 1998 no other organization will be addressing the important practice issues mentioned above in the distinctive - and proven effective way - that ASIM addresses practice issues on behalf of internists. We need your continued support one final time.

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Bringing Home the Trophy

Your component society received its highest honor when it won ASIM's 1997 Component Society of the Year Award at the 41st Annual Meeting in Washington, D.C.

In making the presentation, ASIM President M. Boyd Shook, MD, said, "One component in particular stands out for its excellence across the board in every single aspect that makes a state society successful. What's even more amazing is that it has thrived with no staff support."

Rep. Robert Weygand (D-2nd) also honored RISIM by attending the awards luncheon and received a standing ovation from the delegates.

The award will be displayed at the February and May general membership meetings, next to the Special Recognition Award that this newsletter won three years ago.

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View From the Rhode Island Hill: Information Access Grows for Patients - Steve DeToy, Director of Government and Public Affairs, Rhode Island Medical Society

Editor's Note: Working with RIMS is the most effective way to bring internists' concerns to the state legislature. Following is an update of the RIMS legislative agenda.

The Health Care Accessibility and Quality Assurance Act - the topic of discussion in several previous editions of this newsletter - now has been joined in the law books by a physician profiling law that will provide health care customers with access to information, nearly all of which is currently available to the public under RI law regarding physicians. This new act is a hybrid of legislation passed last year in Massachusetts and is a logical extension of the insurance disclosure bill. Rhode Island health care consumers are unique. No other state has passed legislation that gives consumers access to information about their health care insurance and their physicians, provides for utilization review (including external appeal), and provides parity coverage for biologically based mental health diagnosis. All of these laws originated in the medical community and clearly place Rhode Islanders in a class by themselves when facing important health care decisions.

One legislative issue of particular note to some internal medicine subspecialities will be the licensure of telemedicine practitioners. RISIM and the Medical Society remain committed to protecting the public health by forcing the Department of Health to either exercise its existing statutory authority or, if necessary, enacting legislation to mandate that any practice of medicine on a Rhode Island citizen be performed by a physician licensed in Rhode Island.

Any questions on legislation or regulatory issues may be directed to RIMS Director of Government and Public Affairs Steve DeToy at 331-3207, fax 751-8050 or e-mail rims@ids.net.

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Working for You at ASIM's Annual Meeting - Dennis S. Krauss, MD

Your Delegates Visit Congress

Yul Ejnes, MD; Mitch Pressman, MD, and I arrived early Wednesday morning to prepare for congressional visitations. ASIM drafted several talking points to discuss with our members of congress and further explained how to present them in a political effectiveness workshop that morning.

We relayed our problem with excessive documentation requirements and emphasized the need for fraud and abuse statutes to be implemented forcefully. We assured them that physicians are willing to do their part to stamp out fraud and abuse within their own ranks. We each provided some bad experiences with medical equipment suppliers, commercial labs and home health agencies, and also questioned the excessive documentation and paper requirements for physicians.

We also addressed the Clinical Laboratory Improvement Act. There is a bill in Congress that would eliminate some of the excessive burdens in the current law. We emphasized the unnecessary bureaucratic pattern of physician office lab re-inspections and the need to ease inspection to make the law less expensive to follow. We concluded discussions with physician payment reform. We expressed our thanks for Congress' role in supporting the practice expense "down payment" compromise of the Balanced Budget Act of '97 and were especially thankful for its support of a single conversion factor and the Medicare fee schedule. There have been rumors that the surgeon coalition will try to reopen the negotiations and try to have the down payment of $390 million funded through an across-the-board cut in all nonprimary care procedures. This would hurt primary care physicians as opposed to having the resources taken directly from surgical procedures. We emphasized that should the agreement be broken, the entire practice expense package would have to be reopened for examination. It was most interesting that every office we visited commented that the chest surgeons had preceded us and made an extremely forceful case on their behalf!

We also met with Rep. Patrick Kennedy (D-1st), Rep. Robert Weygand (D-2nd), and Sen. Jack Reed (D-RI). We exchanged cards at each meeting and essentially established a personal line of communication for future issues.

Breaking Down the Budget Act

Robert Reischauer, PhD, gave the opening address in which he analyzed the Balanced Budget Act of '97. Dr. Reischauer is the former director of the Congressional Budget Office and is now a Senior Fellow at the Brookings Institution. Although he hailed it as a "bipartisan victory," he traced how Medicare's spending had been cut significantly through "reducing the growth of payments to providers." He reviewed the significant structural changes in the Medicare program that should slow the growth of spending over the next decade.

Learning From the Experts

The afternoon plenary session titled, "A Medical Degree Just Ain't Enough Anymore" featured representatives from the AMA Quality Assurance Project and the director of the American Board of Internal Medicine (ABIM). The AMA program seeks to centralize physician credentialing to avoid filling out repeat applications for different organizations. Also, we heard about plans for the ABIM's educational approach toward recertification.

A highlight of the meeting was Dr. Ejnes' "Finding and Creating Homes in Cyberspace" in which he taught colleagues from across the country how to access the Internet for medical purposes. Dr. Ejnes is seen as ASIM's national expert on the topic and has spoken at several state society meetings.

Later, at the President-Elect's Luncheon, Kenneth Shine, MD, president of the Institute of Medicine, provided a provocative talk about the need for a patient-physician partnership. He emphasized the expectation that today's patients have and shared observations on the insurance crisis that the next recession will bring. In addition, Dr. Shine made a novel pitch to call our specialty "Adult Medicine" so that patients and the public understand who we are.

Local Delegates Shape National Policy

In response to a recent decision by the Rhode Island Medicare carrier to terminate funding for the PGY-4 chief medical resident in state internal medicine teaching programs, RISIM submitted a resolution for consideration by the HoD (see story, below). The resolution asked ASIM to lobby for continued funding for the chief medical residents and passed overwhelmingly as part of a larger resolution covering graduate medical education.

As a first time delegate, I was extremely impressed by the dedication of all the delegates and ASIM staff. The term "grass roots" is not an exaggeration in describing the central importance in policy making and action that always have characterized ASIM. Until one experiences this firsthand, however, the power of this concept is not obvious. Even though membership is one-fifth that of ACP, it is clear that our socioeconomic expertise and commitment will make us more than equal partners. For further details on ASIM's 41st Annual Meeting, see the November issue of The IM Advantage and the next issue of Today's Internist.

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Council Guides Local Actions, Clarifies Policy

At the last council meeting, we learned that the Rhode Island Medicare carrier had decided to terminate funding for the PGY-4 chief medical residency position (see article above). In response, we decided to draft a letter outlining our concerns to Parker Staples, MD, the medical director for Medicare. We contacted ACP to see if it would be interested in joining us in the sponsorship. Robert Crausman, MD, medical education director at Memorial Hospital, gave us background during the meeting on the funding cuts for the PGY-4 chief medical residency. When Dr. Crausman left, we essentially had established another network contact for issues affecting Rhode Island internists.

Clarifying a Burdensome Policy

The council has asked our Medicare carrier to clarify a burdensome policy that requires specific diagnoses for CBC lipoprotein panels and TSH levels. After brainstorming on "missing diagnoses," which included such obvious things as diabetic nephropathy, hypothyroidism and chronic renal failure for CBC testing; Dr. Ejnes used this information to draft a letter to Dr. Staples which concluded with the statement, "it is RISIM's preference that documentation of medical necessity in the medical record be the only requirement for payment of tests, but if HCFA insists on screening claims based on ICD-9 codes, we insist that the policies be clear and complete."

The council agreed to hold the 1998 joint RISIM/RIACP meeting on Wednesday, Feb. 11.

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RISIM Council Meetings

(All Council meetings will start at 6:30 pm at Coastal-Renaissance, 75 Sockanossett Cross Road, Cranston)

All members are invited and encouraged to attend.

* Thursday, Dec. 4, 1997
* Wednesday, Jan. 7, 1998
* No Council meeting in February (Joint RISIM/RIACP meeting, Wednesday, Feb. 11, 1998)
* Thursday, March 5, 1998
* Wednesday, April 1, 1998
* No council meeting in May (RISIM Annual Meeting, Friday, May 8, 1998)
* Thursday, June 4, 1998

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