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Rhode Island Internist

In this issue:

PRESIDENT'S MESSAGE: Mitchell Pressman, MD


On Feb. 29, I received a telephone call from ASIM Executive Vice President Alan Nelson, MD. This immediately reminded me that ASIM is a down-to-earth organization, as I regularly receive phone calls from the Society. ASIM listens to our needs and has assisted Rhode Island Society of Internal Medicine (RISIM) members in their battle with a third-party insurer to define and recognize primary care providers. Dr. Nelson encouraged RISIM to participate in the ASIM affiliate program. This program helps component societies attract new members, regain past members and keep existing members. Without membership growth, ASIM--and its component societies--could have difficulties providing its members and policymakers with the same top-notch information it currently offers.

I think it's important to explain some of the things ASIM has done and is doing for RISIM. ASIM is a grass-roots organization and represents all internists. The strength of the organization is its membership. This strength has helped ASIM establish and maintain a very loud voice in the socioeconomic arena. The Society has six principle goals:

* To promote the discipline of internal medicine, its value and the role of internists.

* To serve as an advocate for internists' patients and the health of the public.

* To increase the effectiveness of the internist.

* To increase the efficiency of the internist.

* To improve the practice environment of the internist.

* To increase the strength and effectiveness of ASIM and its component societies.

Each component society has a responsibility to set the Society's agenda through a democratic process governed by ASIM's House of Delegates. ASIM is extremely active in advocating for internists' needs with Congress and federal agencies, and the managed care marketplace. In addition, ASIM leads the way in forming coalitions and helping its component societies fight local battles.

ASIM also has a role in medical education with its foundation, the Internal Medicine Center to Advance Research and Education (IMCARE). IMCARE publishes updates on medical care research, promotes internal medicine residency training and develops medical practice guidelines.


The 1996 RISIM/ASIM Annual Meeting will be held in May. The subject will be "Walk Through the Web,"--members will learn what's available to them on the World Wide Web. You will be receiving additional information in the mail soon.

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Bing Lu- Providence

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On Nov. 30, RISIM held an open forum titled "Will You Be Left Out?" at the Rhode Island Medical Society (RIMS) auditorium. The purpose of this event was to enlighten members on selection into health maintenance organization (HMO) panels.


Steven Schoenbaum, MD, medical director of Harvard Community Health Plan (HCHP), led off the discussion by tracing the evolution of this organization from a closed-panel HMO to an evolving open-panel independent practice association (IPA) in association with Pilgrim Health Plan. This "HMO without walls" requires participating internists to be board certified or board eligible. HCHP participates in the National Committee for Quality Assurance Program (NCQA), which has its own standards for participation. NCQA standards are available through Dr. Pressman's office (call 435-5533). Dr. Schoenbaum recommended that, to participate in HCHP in the future, get in early and join a group. He noted that HCHP does not use economic profiling for the credential process.


Peter Hollmann, MD, of HMO of Rhode Island (HMO-RI), discussed his organization's participation requirements. HMO-RI requires that physicians have hospital privileges with three years of training and prefers that members are board certified. His organization also participates in the NCQA accreditation program, which is open to all internists. Dr. Hollman also suggested that physicians can gain clout by joining a group, but added that it is not a requirement for his plan. HMO-RI allows participating specialists to be listed in their own specialty, as a primary physician or as both. HMO-RI's list of participants is available to the public.


Anthony Kazlauskas, MD, medical director of United Health Plan (UHP), discussed his organization's efforts in joining the NCQA accreditation program. He emphasized that physicians need to begin thinking about patient satisfaction. UHP does various surveys and if individual physician scores do not meet their standards on quality measures, the plan works with physicians to improve their scores rather than taking punitive actions. They plan to make physician compensation more positive--giving physicians extra payments for demonstrated quality areas like administrative issues and medical management (i.e., patient satisfaction and office hours). UHP plans to retain its broad physician network, without narrowing physician services. There seemed to be a general consensus among all the speakers that capitation contracts, while late in coming to Rhode Island, will appear within the next three years.

Before signing any HMO contract, ask an expert! To receive reduced-fee, comprehensive legal advice from ASIM's Medical Advocacy Services, Inc.-- ranging from contract evaluations to negotiations and representation--please call (800) 338-2746, ext. 272.


As the editor of the RISIM newsletter, I regularly have the opportunity to review sample newsletters from other state component societies. Here are some ideas I have gleaned.

1. A coding column- This would provide helpful suggestions and answers to questions for common coding issues. The possibility to increase revenue from more accurate coding could be an obvious inducement.

2. Residents' corner- Medical residents are the life-blood of our not too distant future. Residents would have access to our national office resources and be able to verbalize issues of concern to his or her colleagues.

3. Op/Ed- As we have done in the past, a forum would be available for members to share whatever medical issues they would like to discuss directly with our membership.

Please contact me at 351-7103 if you are interested in any of these important--and hopefully enjoyable-- initiatives.-DK

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The RISIM Council devoted its January meeting to a discussion of the recent merger of three local insurers: Pilgrim, Harvard Community Health Plan (HCHP) and Health Advantage. Executives from all three organizations were the council's guests.

The new entity that resulted from the merger is known as Harvard Pilgrim Health Plan (HPHP). According to the speakers, while the corporations are merged, the insurance products remain separate-- although there are plans to integrate them. Current patients enrolled in the HCHP HMO must still be seen at HCHP health centers or by affiliated groups. Eventually, patients will be able to see any physician participating in the plan. Because of the eventual transition into a single insurance product, HCHP's efforts to affiliate with primary care groups in the community is on hold.

The largest discussion centered around Health Advantage. This plan, which experienced tremendous growth in its few years of existence, decided it needed a new partner to continue expanding. After looking at a few local insurers, it chose Pilgrim, which at the time had not yet merged with Harvard. In December 1995, the agreement was finalized and Harvard Pilgrim acquired Health Advantage.

Pilgrim is offering a new option through Health Advantage allowing physicians to share risk through the physician hospital organizations (PHO) of the Health Advantage hospitals (Lifespan, Kent, Memorial, Butler and Women and Infants). To participate in the joint venture, a primary care physician must declare himself or herself a member of a risk pool--usually the one affiliated with his or her primary hospital's PHO. The joint venture uses "budgeted capitation," in which the overall budget is determined per patient and claims are submitted on a fee-for-service basis with a "withhold" taken out. If, at the end of the year, real expenses are below budgeted expenses, the risk pool members share in the surplus. If expenses exceed the budget, the withholds will be used to make up the deficit to a certain degree, and then the insurer picks up the rest.


An area of concern exists for internists who practice a subspecialty and also provide primary care services to their subspecialty patients. According to the speakers, a physician in this situation has several options: choosing to be designated as a primary care physician (PCP) in the risk pool of one of the hospitals to which he or she admits patents (this would allow them to participate in the risk pool, and to accept referrals for subspecialty care from other primary care physicians). Or, these physicians could be designated as subspecialists only, participating in as many risk pools as there are hospitals. Claims for subspecialty services would be charged to the risk pool which the patients' PCP participates. Under this scenario, the physician would not be able to function as a primary care provider.

A troubling point for some subspecialists is that declaring as a primary care provider means he or she will be listed in the provider manual as a PCP accepting new primary care patients. This does not adequately address the situation. While a physician traditionally has acted as a PCP for subspecialty patients, he or she does not seek new primary care patients, but wants the right to continue as a PCP for existing patients. The HPHP representatives said they would find a way to make the system work.

The discussion included technical details of how the risk pools work as well as a summary of the advantages of participating in the joint venture with the PHOs versus through the traditional Pilgrim IPA. Please call your RISIM Council members to answer any questions or help you to find the appropriate staff person at HPHP.

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This year's RISIM joint annual meeting with the Rhode Island Chapter of the American College of Physicians was held March 6 at the Providence Marriott Hotel. Dr. Pressman explained to the approximately 60 members and their spouses that council members--who felt it was time for a respite from the usual lecture format--decided to have a nonacademic, political or economic medical topic. Bob Colonna (a member of the Trinity Rep acting company), was joined by Colleen Mahan (a student at the Trinity Rep Conservatory), and Linda Kamajian (a local actress) in entertaining the crowd with excerpts from 12 literary pieces. Topics ranged from the comedy of Carl Reiner and Mel Brooks ("The 2000-Year-Old Man"), to a satirical poem of Lola Haskins ("A Note on the Acquisition by the American Medical Schools of Skeletons from India"). The selections ended with a touching poem by Marcia Lynch (Peau D'Orange) describing the human emotions behind a physical finding. "Medicine on Stage" was a delightful and informative reflection on how literature views our scientific facade.--DK

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From a health care viewpoint, the 1996 session of the Rhode Island General Assembly would be best characterized as the year of managed care. Gov. Lincoln Almond's office (RI Department of Health), Rep. George Caruolo (D-East Providence), majority leader of the House of Representatives, a wide range of legislators, and consumer groups and interest groups such as RIMS introduced a total of 13 pieces of legislation pertaining to managed care.

The governor's package would make needed changes to the utilization review statute, revamp the state's certificate of need (CON) process and establish Rhode Island Department of Health's regulatory oversight over those entities who administer managed care plans. The utilization review proposal would remove existing loopholes that allow some insurance companies to avoid utilization review oversight for medical and surgical services. The CON proposal would begin the dismantling of the process for reviewing and approving major expenditures by health care facilities. The managed care organization bill would institute state reviews of agents who contract to administer health plans for self-insurers or other entities.


Managed care issues also are at the top of the legislative agenda for the House leadership. Rep. George Caruolo has targeted certain aspects and techniques of managed care:

* Prohibiting "gag" rules (which prevent physicians from openly discussing the terms of the patients' managed care coverage);

* Establishing physicians as the final authority in "medical necessity;"

* Clarifying deceptive practices;

* Prohibiting hold-harmless clauses (which relate to the costs or liabilities resulting from a breach of the obligations of the contract);

* Defining of "emergency services;"

* Prohibiting improper financial incentives for limiting services

* Requiring a minimum percentage of premium dollars that must be spent on direct patient care (90 percent).

The most interesting bill was one which would prohibit the insurance industry's practice of obtaining additional discounts from providers and not passing the resulting savings onto consumers. This issue has been the subject of numerous lawsuits around the country and a local lawsuit may be forthcoming.

RIMS also has been very active in bringing managed care legislation to the General Assembly. RIMS' pending bills include: direct access to annual, routine gynecological care; a prohibition on hold-harmless and contingency clauses in provider contracts; a standard for the substitution of generic drugs; and a bill mandating the state to require that insurance companies which participate in RIte Care reimburse physicians at the same rate as for commercial patients.

Finally, a major piece of consumer-oriented legislation that passed in the House last year has been re-worked by a special legislative commission in the past six months. The bill provides for full disclosure-- with standardized definitions of the key aspects--of how a health plan operates, requires large employers (more than 50 employees) who do not pay 100 percent of the cost of their employees' health care to offer at least two different health plans. It also protects consumers from discrimination by the health plan via prohibiting the de-selection of providers "without cause." At this time, two of the state's major insurers, United Health Plan of New England and HPHP are supporting this legislation--which was introduced by Rep. George Zainyeh (D-Warwick). It has a real possibility of becoming law this year.

[Editor's Note: RISIM has been meeting on a regular basis with Mr. DeToy--RIMS's chief lobbyist--to discuss and offer advice on these managed care issues.--DK]

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