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Rhode Island Internist

Spring, 1998

In this issue:

State of the Society

In January, it is customary for national, state and municipal leaders to address their constituents in a "State of the Union/State/City/etc." address. RISIM's year begins in June or July, after the annual meeting, so this newsletter presents a timely opportunity for me to present the "State of RISIM."

It's been a busy year, in part because of the ACP-ASIM merger, but even without that momentous development, the RISIM council had a full plate this year. Medicare lab-ordering policies, graduate medical education financing, third-party issues, and the ASIM Annual Meeting presented us with several opportunities to work for our members.

We began the year with a review of what could be called the epitome of "hassle," the Medicare policies that require specific diagnoses for certain lab tests to be reimbursed. The RISIM council protested the existence of the policies from the beginning, but acknowledging that national HCFA policy left the local carrier with little choice, the council worked to make the existing policy more user-friendly. Many legitimate indications for cholesterol testing, complete blood counts, and diabetes testing were omitted from the original list of "approved" diagnoses. The RISIM council asked for member suggestions, reviewed the policy in a working session, and requested that the Rhode Island Medicare carrier add the diagnoses that RISIM felt should be on the list. As a result, the policies were changed to reflect RISIM's suggestions. As a follow-up to this, RISIM actively participated in the Carrier Advisory Committee that reviews policies prior to their enactment by the carrier.

In September, RISIM joined with the Rhode Island Chapter of ACP to request that HCFA continue graduate medical education funding (GME) for the chief medical residency. The leaders of both organizations drafted a letter to Parker Staples, MD, Medicare medical director, and in October RISIM introduced a resolution on GME that the ASIM House of Delegates later passed.

RISIM continued to represent internists by meeting with the "movers and shakers" in the payer community. In addition to working with the Medicare carrier, RISIM met with James Krominga, MD, senior vice president of Blue Cross/Blue Shield (BC/BS) of Rhode Island and Chief Medical Officer of BlueCHiP. We again urged the Blues to develop ways of identifying internists who deliver care to complicated hospitalized patients and reimbursing them for the concurrent care they deliver. We also expressed our concerns about the mental health provider network that BC/BS announced this winter. (RISIM hopes to meet with officials of United HealthCare later this spring.)

Our relationship with the Rhode Island Medical Society strengthened, as I continued to represent RISIM on the Medical Society's council and RISIM council member Scott Hanson, MD, sat on the RIMS Public Laws Committee. We also were honored by the attendance of RIMS President Michael Migliori, MD, and RIMS Executive Director Newell Warde at our recent general meeting cosponsored by the Rhode Island ACP Chapter. And Steve DeToy, RIMS director of government and public affairs, continued his insightful and informative contributions to this newsletter.

Further pursuing its objective of keeping members informed, RISIM, under the leadership of Newsletter Editor Dennis Krauss, MD, published this award-winning newsletter. We frequently updated RISIM's Web page (http://users.aol.com/yde/html/RISIM.html) with news about the council's activity and issues of importance to Rhode Island internists. We also developed a fax and e-mail distribution list that now includes more than 50 members.

Following the summary of accomplishments, it is customary for the "State of the Society" address to outline the upcoming year's goals. I will not disappoint you here. Everything that I described in the preceding paragraphs will continue. The merger with ACP will, if anything, make our job easier, since we truly will speak for all Rhode Island internists with a larger membership base and more resources to strengthen our influence. Our current council members will be invited to sit on the new ACP-ASIM council, as will the current ACP council members. A committee structure that will facilitate the new organization's combined missions will be developed. Within this structure, a Health and Public Policy Committee will assume responsibility for third-party activities, legislative affairs, and practice management issues. Both Fred Crisafulli, MD, our president-elect, and I will be active on this committee as well as in the new RI ACP-ASIM chapter council. In addition, the RI chapter will be privileged to have two voices on the national ACP-ASIM Board of Governors--the RI chapter governor, Fred Schiffman, MD; and a transitional governor appointed for a two-year term by ASIM, yours truly.

So, as you can see, we've been busy. We also intend to continue to work for you. I strongly urge those of you who haven't yet renewed your 1997-98 ASIM membership to do so. While your council and officers work for free, the U.S. Postal Service, local printer, and RISIM's other "helpers" do not. Your dues support is needed to keep RISIM strong and to sustain the level of activity that ASIM maintains in Washington. If you're a member of both ASIM and ACP, this is the last time you'll be asked to pay two sets of dues. If you're not an ACP member, renewing your ASIM membership will guarantee membership in the new organization. I hope that I've given you at least one reason to renew. If not, call me and I'll list several others.

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One Society and One Accreditation Plan For All - Dennis S. Krauss, MD

ASIM President Dr. Bernard Rosof addressed our annual meeting on Feb. 11, at the Holiday Inn at the Crossings. He first brought us up-to-date on the ACP-ASIM merger which should be completed on time by July 1, 1998. Dr. Rosof spoke about the merger task force adopting a basic set of principles allowing state units to merge as a cohesive unit. He noted that new bylaws would be distributed in due time. Advocacy of issues also will continue to emerge from local councils as has been the tradition for ASIM. Resident involvement will continue to be strong. He also predicted that the new organization will be the strongest competitor to the AMA for public and government agency recognition.

Dr. Rosof, who has achieved national prominence in clinical practice guidelines' studies and physician quality and performance measurement, then brought us up to speed on the AMA's new accreditation plan. The project's goal is to develop quality performance standards for busy internists who deal with a variety of credentialing plans. For example, the average internist belongs to 12.5 organizations, all of which require periodic review of the physician's qualifications. The hope would be that one accreditation plan would replace the multitude of office site visits, economic and clinical profiling. The proposed physician accreditation program standards would be set by peers, be based on known criteria, be patient-oriented and physician-friendly, and be overseen by the medical profession. In addition to relieving duplicate efforts as referred to above, the proposed plan would provide physicians with a self-assessment measure to compare to nationwide norms.

Dr. Rosof explained that the effort was not meant to be a revenue producer for AMA. AMA hopefully would develop programs that would be acceptable across a wide variety of medical subspecialty societies and physicians would not have to duplicate efforts to verify credentials with managed care organizations, the National Committee for Quality Assurance, etc. The program hopefully would be phased in by 2001 with appropriate feedback during the development phase. Currently it is operational in New Jersey and Maryland. Rhode Island has expressed some interest and Massachusetts hopes to have a program by mid-1998. The cost would be about $50 per physician. Targeted users of the program would be physicians, managed care organizations, Medicare, Medicaid, hospitals and other health care organizations, employers and consumers. The value to these constituents might include cost reduction, minimized duplication, improved relations with physicians, objective medical staff credentialing and public credibility. While the audience generally was in favor of the efforts, one physician noted that the plan's success would depend on NCQA's acceptance (Note: NCQA is involved in the planning stage).

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Annual Meeting May 27, 1998

We would like to invite all members to attend the last annual meeting of the Rhode Island ASIM Chapter! Our special guest speaker will be Dr. Edward Wing, newly appointed chairman of the Brown and Lifespan Department of Internal Medicine. Dr. Wing will present "From Pittsburgh to Rhode Island--A Perspective of a Chairman." The evening will end with a tribute to our past presidents and hopefully some historical anecdotes from them.

The meeting will be at the Holiday Inn at the Crossings in Warwick on Wednesday, May 27, at 6 p.m. More details to follow by mail.

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Blue Cross Continues Forum with RISIM - Dennis S. Krauss, MD

The RISIM council recently met with Dr. James Krominga, a family practitioner and the new chief medical officer for Blue Cross/Blue Shield. BC/BS had sought an MD for this management position which incorporates the senior vice presidency and chief medical officer of the BlueCHiP product. The Senior BlueCHiP product aims to convert fee-for-service patients to prepaid risk arrangements. Dr. Krominga speculated how groups such as Rhode Island Primary Care or Coastal would handle such a risk; e.g., in terms of deciding how to use a specialist's care on their own. He said there also could be a role for risk pools of unaffiliated physicians to see BlueCHiP patients. Dr. Krominga noted that the BlueCHiP product currently has 6,000 seniors and expects to have about 20,000 by the end of the year.

A lot of discussion centered around the mental health "carve-out" program that Lifespan and Butler Hospital are developing. The council expressed concern about interference in established mental health providers' care should they not become part of the network. As It turns out, Rhode Island has significantly higher hospitalization rates for mental health than other states. Dr. Krominga emphasized that primary care physicians could continue to provide psychiatric care for their patients and submit claims for such visits. Should patients require specialty care, however, they would have to use the new contracting network. We expressed our concern that Lifespan and the Kent/Butler affiliate groups have had more inpatient than outpatient experience going into this venture. Dr. Krominga said in closing that he foresaw other possible ventures in visual care, radiology and podiatry.

The council also discussed the society's continuing concern and impatience with the status of concurrent care reimbursement. Dr. Krominga noted that concurrent care rates, when they are paid, are about the national average. We gave numerous examples of cases that clearly required an excessive amount of work and appeals for reimbursement. He promised to get back to us about what might be done and, he did, in fact, notify Dr. Ejnes the next day that he hoped to establish an internal group to resolve the issue.

Dr. Krominga also noted that Blue Cross is looking to share administrative services with the Maine/Vermont Blue Cross group. He shared our hope that the ACP-ASIM consolidation would continue to communicate freely with him and act as a partnership.

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New Combination is a Knock-Out - Fred Schiffman, MD

As the incoming governor for the American College of Physicians in Rhode Island, it is with great excitement that my term will be starting at a time when ACP and ASIM are beginning their merger. The background for the integration of our groups is well known. It is, in large part, a grass-roots effort. Members of both organizations want it to happen. We need to have a single internal medicine membership organization to better serve our members and our patients. Policy makers will be less confused and we will have a more coherent voice with less duplication, less administrative work and more efficiency. It also seems that as both groups have evolved, we have developed similar missions and goals, albeit with different emphasis. Both groups, as a merged organization, will continue to establish standards, provide information and education, advocate for the public, our patients and members, promote research, and recognize excellence.

At our last Board of Governors meeting in California last fall, we heard from some ACP chapters about potential problems and obstacles to a successful merger. Dr. Michelle Cyr and I were surprised by some of the anticipated difficulties since all along ACP and ASIM have cooperated beautifully in Rhode Island. In fact, as you all know, the current RISIM president, Yul Ejnes, MD, has had the honor of being selected as one of 10 ASIM leaders in the country chosen for a two-year term on the ACP-ASIM Board of Governors. Together, Yul and I will address many issues of mutual concern and hope to solve whatever problems may arise on behalf of our combined membership! We have developed a tentative operating structure and anticipate that the voices of members in both organizations will be strengthened by our joint effort. We will count on the ACP-ASIM membership to continue in their current roles and to be invigorated by our new combination.

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View from the Rhode Island Hill: Managed Care vs. Patients' Rights - Steve DeToy, Director of Government and Public Affairs, Rhode Island Medical Society

In 1997, the Rhode Island General Assembly wrestled with the difficult issue of hospital conversions. Rhode Island's tradition of nonprofit, community-based hospitals was challenged by large, national for-profit hospital chains' attempts to enter the market as well as by the regionalization phenomena between and amongst Rhode Island, Massachusetts, and to a lesser degree, Connecticut hospitals. The General Assembly responded by passing the landmark Hospital Conversions Act.

This year the major health care issue for the General Assembly to consider is whether health insurers should be liable for actions that may contribute to a less than desirable medical outcome. This managed care vs. patients' rights issue is being debated among health care professionals and policy wonks across the country and is being actively considered in, at last count, nearly 20 legislatures. Not wanting to be outdone by their hometown colleagues, Congress is also considering several pieces of legislation that would help guide state deliberations at issue.

The debate began in earnest last year in Texas where the legislature decided that a patient who had experienced a bad outcome was entitled to ask the court to decide whether the actions of the health insurer contributed to the harm the patient. The bill allowing patients to bring suit against health insurers passed easily, but Aetna immediately challenged it under the guise that the new law could not be used against health insurers that claimed immunity under the infamous ERISA preemption against state actions that affect multi-state employers' health plans. That case is still in litigation. RIMS and its component specialty societies are founding members of the national Campaign for Health Care Accountability which is supporting the federal legislation to clarify Congressional intent on ERISA and allow states to regulate the quality of plans offered by ERISA-covered plans within their respective borders.

Here in Rhode Island, the issue was first raised during the 1997 session by freshman Sen. Daniel Connors (D-Cumberland); the bill died in committee. This session, five bills have been introduced to provide a specific course of action for patients. It has been argued that there is no reason why a suit against an insurer could not be brought currently. The debate will focus on two bills: 98H-8251 Henseler (D-North Kingstown); and 98S-2306 Fogarty (D-Glocester-Burrillville). These bills come with plenty of political punch as Rep. Henseler is the majority whip (third in line) in the House and Sen. Fogarty is president pro tempore of the Senate.

The Medical Society is supporting the concept of health care insurer accountability. Given the intrusive nature of managed care and its direct impact on patient care, the decision to support the legislation was not complicated. RIMS will continue to raise its long-standing concerns about the state's inequitable tort system, but will not allow those concerns to stand in the way of concerns for patients' rights to seek redress for bad medical outcomes.

The health insurers have staged a full-court press to have their cake and eat it too. They want to protect their desire to micromanage care without being held accountable. Their threats to be even more intrusive in the physician-patient relationship are somewhat facetious, and their claims that being held accountable will significantly raise premium costs contradict the only published studies on the issue.

The question is simple: Should patients have the right to ask a court to examine all of the facts in their case or should one potentially liable party and their actions be exempt from court? The answer is simple.

Any questions on legislative 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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