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Rhode Island Internist

May, 1997

In this issue:

PRESIDENT'S MESSAGE: Mitchell Pressman, MD
Lead Dog Learns Value of ASIM

It has been two years - 14 in dog years - since Immediate Past President Sewell Kahn, MD, handed me the responsibility of leading the Rhode Island Society of Internal Medicine (RISIM). Following his lead was a daunting task; I became the lead dog. The quote, "life is like a dog sled - if you ain't the lead dog, the scene never changes," came to mind. My first task as president was to identify the originator of this quotation. The ASIM Annual Meeting in Washington, D.C. presented my first lead. A speaker used the quote and attributed it to Sergeant Preston of the Yukon. When I challenged him to prove the source, he admitted he wasn't sure, but thought that Sergeant Preston at least sounded authentic! A close friend led me to the scent of Buddy Ryan, former coach of the Arizona Cardinals, as the originator. I had Matt Cavanaugh - ex-quarterback and then-coach of the Arizona Cardinals - ask him directly. Buddy quickly refused credit for the quotes. He admitted using it frequently, but did not know the source. I checked all of the quote books at Barnes & Noble. The trail was cold! I searched the World Wide Web - search engine after search engine - and yes, I even resorted to "chat lines!" Finally my doggedness, bordering on obsession, led to an answer! I attribute this success to persistence, an unwillingness to take "I don't know" for an answer, calling as many people as I could - many of them strangers - and howling about cold trails.

Why do I repeat these trials and tribulations? This is what ASIM has taught me! ASIM has honed my leadership skills. I used to go along with the pack. Medicare and Medicaid issues forced me to take a lead role. I not only learned to express my own opinions, but also those of my component society. I learned how to call senators and representatives and made appointments with them in Washington. Soon, those legislators started calling my office for opinions, and ASIM leadership called, too. ASIM has given me a competitive edge. All ASIM members have this opportunity - not only in leadership roles, but on all levels. ASIM's newest tool is the Effective Medical Management Self-Assessment Program (EMM-SAP). Its goal is to provide the knowledge and skills necessary to improve patient satisfaction and patient outcomes, increase practice productivity and gain a competitive advantage in this new dog-eat-dog medical marketplace.

All RISIM members need to become active. We need new ideas, new faces, new energy and new meat on our council. Please contact President-Elect Yul Ejnes, MD, at (401) 946-6200 or Yul_Ejnes@brown.edu; or me, at (401) 435-5533 or mitchell_pressman@brown.edu, and we'll throw you a bone to make you the "lead dog." It is time to pass the dog sled and team to Yul for the next two years. I want to thank the RISIM membership for allowing me the opportunity to be the lead dog and the staff at ASIM for all of the encouragement provided over the years.

Lastly, in case you were wondering, it was the late Lewis Grizzard who coined the phrase.

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Council Examines Latest State Legislation - Dennis Krauss, MD

On April 23, the RISIM council met with Steve DeToy, the Rhode Island Medical Society (RIMS) director of government and public affairs to review recent strategic changes in RIMS.

House Disbands

The most important change is the increase in size of the RIMS council with the additions of numerous specialty society representatives and geographic representatives. To eliminate redundancy, the house of delegates will be asked to disband thus referring policy decisions to the council. This would make Rhode Island only the second state medical society to disband a house of delegates.

For-Profit Hospitals Ignite Debate

Dominating this year's legislative scene has been the debate over "for-profit hospitals," reported DeToy. RIMS submitted a statement of principles regarding crucial standards that the society says need to be applied to hospitals in the state. DeToy expected that the hospital bill likely will pass and that the criteria developed will apply to both Columbia and Tenet. He noted that last year's Zainyeh bill - which should take effect by June 1 - has become a national model for insurance regulation. This bill was profiled in the December issue of The Rhode Island Internist.

The council also reviewed the status of about 18 bills that RIMS is tracking (see DeToy's column, "View from the Rhode Island Hill.").

In general, RIMS prefers to prevent the passage of legislation concerning the micro-management of physician practices. The society has not taken many defensive postures this year since RIMS has helped shape most of the for-profit health care legislation.

RIMS also has been active in community initiatives such as promoting bike helmets for children; a "tar wars" fifth grade project on smoking; and raising funds through a golf tournament on Oct. 6. To participate on the links, call RIMS at (401) 331-3207. The medical society also will provide waiting room posters - detailing the society's activities and providing information to help patients choose health plans. The ongoing internship program, in which a community leader spends day with a physician, will continue to provide a strong link between community leaders and medicine. DeToy also reviewed the status of the Rite Care program (see next article) and the probable involvement with the newly licensed Tufts insurance program.

Rhode IsIand is also one of 19 states suing the Health Care Financing Administration (HCFA) to enforce the "qualified Medicare beneficiaries" rules which date back many years but hopefully will cover the 20 percent co-pays for Medicare/Medicaid patients. As DeToy said, "This ain't your father's medical society anymore."

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United HealthCare CEO Responds to Internists - Yul Ejnes, MD, RISIM President-Elect

The February meeting of the RISIM Council featured a discussion with Richard Migliori, MD - the new president and chief executive officer of United HealthCare of New England - in which he presented a "new" United HealthCare that strives to build a more positive relationship with the physician community. Dr. Migliori is a Rhode Island native who graduated from the Brown University program in medicine, and following his surgical training found himself in the Minnesota's Twin Cities. In Minneapolis, Dr. Migliori led a large multispecialty group practice and later joined the United HealthCare staff in the Minneapolis home office. Last fall, Dr. Migliori accepted an opportunity to return to Rhode Island and run its second largest health insurance plan.

The council raised several issues with Dr. Migliori, and he brought news about changes at United to the meeting. The council wanted to review United's controversial "preferred" laboratory policy, under which physicians could earn a 2.5 percent fee increase or a 2.5 percent fee cut - depending on where they referred patients for laboratory testing. Late last year when the plan was unveiled, several local laboratories, mainly those operated by the hospitals, were not on the list of 'preferred' labs because of their relative expense compared to the other labs. By the time the council met, much of the discussion was moot since all of the United participating labs were in the "preferred" category. Dr. Migliori attributed this change to the pressures placed on the more expensive "non-preferred" labs following the initial announcement, which forced these labs to renegotiate their fees and earn the "preferred" classification. The council asked Dr. Migliori if the 2.5 percent fee increase for the use of "preferred" labs would still be in effect, since all of the labs now are "preferred." He said that as a result of the "positive" changes, all United physicians will receive the increased reimbursement for their United commercial patients. Subsequent mailings from United confirmed this.

Council members expressed their concerns about the manner in which United handled this effort to change referral patterns - specifically that it appears physicians are receiving payment for referrals. Because patients had no incentive to use a particular lab, physicians were placed in the unethical position of having to refer patients to possibly less convenient laboratories for economic, not clinical, reasons. Dr. Migliori pointed out that the original policy allowed limited use of nonpreferred labs, to account for special circumstances.

Rite Care Reimbursement Changes

Dr. Migliori also discussed the fate of United's participation in Rite Care and the plan's 20 percent rollback in physician reimbursement to help cover operating losses. He announced that as a result of changes in utilization patterns following the announcement of the fee cut, the operating deficits were reduced, and that soon, the physician reimbursement rates will be restored. Once this occurs, it is possible that additional savings in the program will be used to bring Rite Care fees closer to commercial fees (currently, United pays less for a given service in Rite Care than it does in its commercial products). Dr. Migliori acknowledged that reimbursement for Rhode Island physicians versus institutions is among the nation's most disparate. As the council members reminded him of the Rhode Island physician community's good-faith effort in participating in the Rite Care program, Dr. Migliori assured doubters that United intends to continue its activities with the program.

New Policy Proposes Risk Sharing

Dr. Migliori also presented United's new proposal on sharing risk with physician groups. Later this year, United will be able to contract with groups of physicians that are willing to share risk and manage a population of patients. These "groups" need not be merged practices, nor even independent practice associations, which to date have been the only types of physician organizations participating in risk contracts. A group of physicians in a building, or members of a hospital staff, could qualify as a group. Risk sharing would work as a form of a budgeted capitation in which the physicians are at risk for no more than an amount withheld from their reimbursement, but they are eligible to share surpluses in not only physician services, but also hospital and laboratory budgets. Perhaps as significant as the details of the new product is the change in approach that Dr. Migliori described, with a shift away from working exclusively with hospitals or hospital-affiliated organizations and toward working with groups of physicians. Dr. Migliori said he hopes to further explain the new product to a larger audience of Rhode Island physicians later this year.

The council also broached such issues as: laboratory and X-ray facilities in physician offices, which United has in the past excluded from its network; United's historical efforts to exclude specific hospitals from its network; and the general tone of United's past interactions with the physician community. Dr. Migliori indicated a willingness to take another look at the office lab issue and signaled United's new, more "physician-friendly" approach.

More Effective Representation with RISIM

Whether Dr. Migliori's comments herald a "new" United HealthCare or just the old one with new window dressing remains to be seen. The RISIM Council will interact with you and will continue the dialog with Dr. Migliori. RISIM's continued priority is to cultivate positive working relationships with the "movers and shakers" in Rhode Island's health insurance community. These relationships enhance RISIM's effectiveness in representing you whenever a controversial issue arises and in providing internists' feedback about more "routine" issues to payers. Ideas for discussion topics begin with our members. If you would like the Council to address an issue that affects your practice and/or your patients, please call me at (401) 946-6200 or e-mail Yul_Ejnes@brown.edu.

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View from the Rhode Island Hill: For-Profit Hospital Is Key Issue in General Assembly
- Steve DeToy

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 debate over the proposed sale of Roger Williams Medical Center to HCA/Columbia clearly is the key health care issue in the 1997 General Assembly session. If it is approved in the regulatory process, this would become the first "for-profit" hospital in Rhode Island. Also waiting in the wings is the Tenet Group which has a memorandum of understanding to take over the Landmark Medical Center in the northern part of the state.

At the State House, the question of transferring ownership of a traditionally non-profit facility to a for-profit corporation sparked a flood of legislation. The proposals have run the gamut from an outright prohibition, to a moratorium, to bills to increase the regulatory oversight of various state departments including the attorney general.

The state's largest hospital holding company, Lifespan, has spent hundreds of thousands of dollars attempting to keep competition out of the market. Labor unions wary of HCFA's labor reputation have joined this effort. Lifespan has done much to undermine its own fight, however, and those activities have not escaped the notice of the legislators. Lifespan may have seriously diluted its own arguments by going across state lines to form an agreement with New England Medical Center in Boston and by having several for-profit subsidiaries.

On the regulatory front, the Health Care Accessibility and Quality Assurance Act continues to make significant progress through the Rhode Island Department of Health. Most of the issues have been amicably worked out, but it would be foolish to think that Blue Cross and Blue Shield of RI will not continue to oppose it at every turn. The first public hearing on the proposed regulations will be in mid-May.

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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RISIM Welcomes New Members:

Gilbert J. Altongy, MD - Central Falls
Raymond F. Chaquette, MD - Providence
Nelson J. Chu, MD - Greenwich
J. Russell Corcoran, MD - Wakefield
Patrick R. Daly, MD - Narragansett
Joseph A. DiLorenzo, MD - Cranston
Reginald Y. Gohh, MD - Providence
Ely Gordon, MD - Providence
Suh D. Hahn, MD - Pawtucket
Pamela A. Harrop, MD - Bristol
Steven M. Kempner, MD - Providence
Sree H. Kesan, MD - Riverside
Anthony J. Lombardi, MD - Cranston
David A. Marcoux, MD - Providence
Kathleen O. Morton, MD - Providence
James R. Myers, MD - Providence
Philip J. Opalenski, MD - Cranston
Paul W. Roderick, MD - Cranston
Kenneth H. Salzsieder, MD - Warwick
Charles Felix Samson, MD - Warwick
Mohamed A. Sharif, MD - Warwick
Richard S. Shulman, MD - Providence
David M. Steigman, MD - Providence
David Q. Williams, MD - Providence

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RISIM Officers

Mitchell Pressman, MD
450 Veterans Memorial Pkwy, Bldg 6
East Providence, RI 02914
(401) 435-5533
Fax: (401) 431-2556
E-mail: mitchell_pressman@brown.edu

Yul Ejnes, MD
75 Sockanossett Cross Road
Cranston, RI 02920
(401) 946-6200
Fax: (401) 275-1992
E-mail: Yul_Ejnes@brown.edu

Immediate Past President
Sewell Kahn, MD
250 E. Centerville Road
Warwick, RI 02886
(401) 739-7380
Fax: (401) 737-7558

Membership Chair
Paul McKenney, MD
470 Tollgate Road
Warwick, RI 02886
(410) 738-6544

Newsletter Editor
Dennis Krauss, MD
49 Seekonk Street
Providence, RI 02906
(401) 351-7103
FAX:(401) 751-6179

Meeting-Program Coordinator
Harold H. Horwitz, MD
49 Seekonk Street
Providence, RI 02906
(401) 351-2280

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