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Chapter Newsletter - Fall, 1998

From the Governor's Desk

Greetings, ACP-ASIM members!

Since taking on the RI ACP-ASIM Chapter governorship, much of my early effort has been expended on merger-related issues. Some organizational housekeeping matters were put in order at a meeting of the Chapter's Executive Council in July. Council subcommittees were formed, the activities of which - at least initially - will be directed by temporary chairs: IMG Subcommittee (Munawar Azam, MD); Education Subcommittee (J. Russell Corcoran, MD and Michele Cyr, MD); Associates Subcommittee (Mark Fagan, MD); Communications Subcommittee (Yul Ejnes, MD); Health and Public Policy Subcommittee (Frederick Crisafulli, MD); Membership Subcommittee (Pamela Harrop, MD). Minutes of the meeting have been distributed to Council members, and copies are available to Chapter members by request. Just call the Chapter's Administrative Assistant, Nancy Baker-Hobin, at (401) 444-8537. If you are interested in subcommittee leadership or membership, please contact Yul or me.

We are fortunate to have engaged Nancy Baker-Hobin to manage the myriad details associated with Chapter administration, events and services. During the term of the Immediate Past Governor, Michele Cyr, Nancy was instrumental in bringing form and function to the complexities inherent in our evolving professional organization. She is committed to helping raise the bar of excellence in Chapter administration.

Yul and I attended the national ACP-ASIM Board of Governors meeting in Chicago on September 25. The deliberations of that body are summarized elsewhere in this newsletter.

On October 6, Newport was the scenic backdrop for a highly successful Chapter scientific meeting. My personal thanks to our top-notch speakers - Jim Hennessey, Rochelle Strenger, Michele Cyr, Joseph Sweeney, Steve Opal and Tim Flanigan - all of whom provided clinical updates in their respective areas of expertise. Bob Doherty, Vice President of Governmental Affairs and Public Policy in the ACP-ASIM Washington office, presented health and public policy issues that promise to influence the future practice of medicine.

Plans are afoot for the Chapter's annual regional meeting at the Radisson Airport Hotel in Warwick, April 6 and 7, 1999. Traditionally, regional conferences are Associate-focused and feature oral presentations and poster exhibitions of medical resident research abstracts. Additional features of past meetings have been panel discussions and meet-the-professor sessions. While future spring regional conferences will retain their resident research emphases, your suggestions for program enhancement are most welcome. You may contact me directly, or one of the Education Subcommittee chairs, whose telephone numbers are listed in this newsletter.

As RI Chapter Governor, one of my objectives is a balanced, member-driven organization where the unique, varied interests of its consolidated membership are fully represented. But to achieve this, I will need your help. Let me have your thoughts and ideas.

Best personal regards,

Fred J. Schiffman, MD, FACP
Governor, RI Chapter, ACP-ASIM

Report On the ACP-ASIM Board of Governors Fall Conference Chicago, September 24-26, 1998

Fred J. Schiffman, MD, FACP
Yul D. Ejnes, MD, FACP

The American College of Physicians-American Society of Internal Medicine Board of Governors Fall Conference was held in Chicago, Illinois from September 24-26, 1998. We attended as Governor and Transitional Governor of the Rhode Island Chapter of ACP-ASIM.

Meeting highlights:

Presidential Message: ACP-ASIM President Dr. Harold C. Sox recounted his activities directed towards preventing a bill (HR-4006 in the House, S-2151 in the Senate) currently in Congress from becoming law. This bill would "clarify Federal law to prohibit dispensing of controlled substance for the purpose of causing or assisting in causing the suicide or euthanasia of any individual."

Besides ACP-ASIM, other organizations, including the AMA, have also taken exception to the bill. If enacted, the bill could seriously harm patient care by intimidating physicians into not prescribing needed high doses of narcotics. It could also threaten a patient's right to privacy since the ground rules for review process would require physicians to disclose details of patient care that should be held in confidence. Additionally, it could usurp a state's authority to regulate the practice of medicine.

If enacted, this bill would intrude on the rights of states to determine acceptable medical practice, threaten the confidentiality of patients' medical records, and harm patient care.

Further details regarding this bill and how our membership can work for its defeat are available at ACP-ASIM Online. In addition, the College has set up a toll-free number that links members directly to their Representatives or Senators. Call 1-888-218-7770 and follow the prompts (you'll need your ACP-ASIM member number, which is printed on your Annals mailing label). We encourage members to be in touch with our Congressional delegation often, not only on this issue but on others that affect our patients and our profession.

Resolution Reference Committee Hearings: The Reference Committee hearings were of great interest. Two Reference Committees heard testimony on resolutions submitted by the Chapters. The Committees were charged with considering the testimony and developing a list of recommendations for action on the resolutions (such as to accept or to reject) by the Board of Governors at its business meeting two days later.

More than fifty resolutions were presented to help guide ACP-ASIM policy. The most interesting, and perhaps defining, dealt with establishment of an ACP-ASIM political action committee (PAC) since the current one will be dissolved in November, 1998. Nevada, North Carolina, and Pennsylvania chapters presented a resolution to establish a PAC to further the agenda of our new organization. The issue elicited spirited comment, both from those who did and did not support the resolution. The notion of providing funds to elected representatives to gain access to them on matters of interest to the ACP-ASIM, and health care subscribers, is anathema but felt to be a necessary evil. Until campaign spending reform and other "tainted" practices are addressed, the PAC would seem to be in keeping with our need to be heard. The strong presence in Washington developed by the ASIM, it was felt, would be eroded without such entree to Congress. Those who spoke against PAC's believed that it would put us on a "slippery slope" which was financially and perhaps ethically "impure." Additionally, if we preferentially supported selected politicians, it might close off access to others who could help us in the future.

Workshops: Workshops that we attended included: "Structuring the Chapter for Success" - a useful session that outlined methods that other chapters have successfully used to utilize chapter offices and staff support, streamline chapter finances, increase activity, plan meetings, and provide advocacy for members.

Washington Report: Alan Nelson, ACP-ASIM's Associate Executive Vice President, and Robert Doherty, Vice President for Government Affairs, provided a "Washington Report" for the group on the second day of the conference (Mr. Doherty was a keynote speaker for the October 6th Chapter meeting in Newport). The details of this discussion are available from Fred Schiffman's office and include an update on efforts to defeat the lethal drug bill, discussed above, and Medicare user fees and E/M documentation.

AMA Executive Vice-President: The AMA's Executive Vice-President, Cliff Anderson, discussed how the AMA and ACP-ASIM could work together on some of the issues discussed by Mr. Doherty.

Transitional Governors' Workshop: Later that afternoon, a Transitional Governors' workshop was held. College leaders met with the Transitional Governors to make certain that all was going well in their respective states as well as at their first Fall Conference. The Transitional Governors reported that they felt comfortable in their roles and their integration into the College leadership structure was proceeding well.

Interest Group Discussions: On the last day of the meeting, "interest group" breakfast discussions concerning access to health care, clinical themes, hospitalists, nurse practitioners, and E/M documentation. Each group reported back to the Governors at the business meeting that followed.

The session that I (YE) attended included a lively discussion of hospitalist physicians. This issue, just starting to appear in Rhode Island, has rapidly developed elsewhere. It raises concerns about continuity of care, further fragmentation of the specialty of internal medicine, and the rights of patients and primary care physicians to determine if a hospitalist will provide care. Several of the participants had worked with hospitalist systems for years, and shared ways to avoid the potential pitfalls.

The final session was a Business Meeting. It included approval of minutes, task force recommendations, and reference committee recommendations, as well as new business, followed by a "Town Hall."

Business Meeting: The Board of Governors discussed four task force reports plus the Reference Committees' recommendations on the 56 resolutions. The meeting was conducted using parliamentary procedure, which takes a bit of getting used to (at times it was hard to keep track of whether we were discussing an amendment to a resolution, the resolution itself, or neither). The process of presenting resolutions at the Board of Governors' meetings goes back several years and was introduced as a means of ensuring input from the grassroots in policy formation. Chapters submitted resolutions covering College policy, points of view to be communicated to the government or insurers, and the operation of the Board of Governors itself. The number of resolutions was significantly higher than in past meetings, in part due to the merger with ASIM, but also because the ACP Governors were already making greater use of this process.

The Board of Governors' recommendations to the Board of Regents are posted on ACP-ASIM Online for your review. Among the resolutions supported by the Board of Governors were:

  • A resolution recommending establishment of a political action committee, which essentially continues the PAC that ASIM ran prior to the merger. As noted above, this was perhaps the most controversial issue of the meeting, due to mixed opinions about the College's association with a PAC (as part of the merger between ACP and ASIM, it was agreed that the PAC would not be supported after the present election cycle). Others cited the advantages of PAC's in furthering the College's mission and enhancing the advocacy efforts that benefit our patients. In the end, the resolution passed overwhelmingly following an amendment that called for the PAC to pay its own administrative expenses, so that members would not be forced to support operation of the PAC with their dues dollars.
  • A resolution reaffirming the collaborative relationship between physicians and nurse practitioners, and opposing initiatives for nurse practitioners to practice independently, unless physician supervision was not possible (such as in rural or inner city areas).
  • Resolutions calling for third party insurers to provide 24 hour access to a medical director to discuss denials of coverage, and for the 24 hour availability of information on covered and non-covered services for patients.

We strongly encourage you to visit the College's web site so you can review the past and recent resolutions. You should consider whether you would like the Chapter to introduce resolutions on areas of concern to you at future meetings (the next one is in April, just before ACP-ASIM Annual Session in New Orleans).

Town Hall: The meeting ended with a "Town Hall" question and answer period where all agreed that this first meeting of the new organization went remarkably well. ACP-ASIM Executive Vice President Walter McDonald rated the progress of the merger at "nine out of ten" at the beginning of the meeting, but by the end, that score was up to "9.5."

The Board of Governors' Fall Conference was a great educational opportunity for us. The informal networking with our colleagues and discussions about chapter innovations and problems will be, we believe, greatly beneficial.

We have a great deal of additional information regarding the meeting which we would be happy to discuss with any individual member.

CAC - An Opportunity For Input Into Local Medicare Policy

Yul D. Ejnes, MD, FACP

Medicare carriers (ours is Blue Cross & Blue Shield of Rhode Island) are required to have a Carrier Advisory Committee (CAC) that meets regularly to discuss changes in the Medicare program and its policies, and to collect feedback from physicians.

Our CAC is chaired by the Medical Director of Rhode Island Medicare, Parker Staples MD. The CAC's members include representatives from specialty societies, the private insurers that offer Medicare HMO's, and Rhode Island's peer review organization (which is Rhode Island Quality Partners). Members of the carrier's administrative staff also attend.

For about one year, I've been the internal medicine representative to the CAC. The committee meets three or four times per year and usually covers a varied agenda which includes new policies that are about to be adopted (a 45 day comment period begins when these policies are brought to the CAC, after which the policy becomes effective, sometimes with modification based on comments from physicians), information on coding patterns, news from the regional and national HCFA offices, and opportunities for physician groups to express their views regarding any of the above.

The most recent meeting of the CAC was held on September 15. The highlight of the meeting was the discussion of HCFA's plans to pay skilled nursing facilities on a prospective basis, similar to the DRG's that determine hospital reimbursement. Prospective payment is to be phased in slowly over the next several months. When a patient is admitted to a SNF, a prospective payment is determined, based on information obtained at the time of admission to the SNF. This payment is used to pay for all room charges, testing, ambulance travel, and facility fees, but not physician fees. The inclusion of facility fees in the prospective payment has potential implications for physicians who deliver care in special units such as an outpatient endoscopy suite or a radiation therapy office. The facilities in these cases, though usually owned by the physician or physician group, would have to get paid by the SNF, not by Medicare directly, as would be done for the professional fee.

Many of the physicians present expressed strong reservations about this feature of prospective payment, as it would require physician-owned outpatient facilities to develop contractual relationships with SNF's and essentially put the SNF's in the position of a third party payer. This could have the effect of restricting a patient's choice of physician.

Another issue discussed with potential implications on patient care is the policy on ambulance transfers, which will be published in an upcoming Medicare Memo. Medicare will cover only medically necessary ambulance transfers to a facility that can take care of the patient's medical needs. No longer will it cover ambulance transfers for patients who are unable to easily use other means of transportation (wheelchair users would be required to use lift vans if available, for example) for non-emergency visits to doctors offices or other facilities. Nor would hospital-to-hospital transfers be covered, unless a patient could not get a required service at the hospital where he or she was located. Transfers for the purpose of moving a patient to a hospital where the primary care physician has admitting privileges would not be covered, even if such a transfer is in the patient's best interest.

On occasion, CAC members receive proposed policy changes with a request for comment. I will try to forward these documents to members with expertise in the affected area and ask for comment that I can present to the CAC. Our comments in the past have resulted in changes to the list of "approved" diagnoses for certain tests, for example, and could have a more significant impact in other areas.

If you have any questions about the Medicare CAC or want to volunteer to review policies, please contact me at Yul_Ejnes@brown.edu or at 275-1991.

ACP-ASIM Medical Services Committee Meets For First Time

Yul D. Ejnes, MD, FACP

In early October I attended the first meeting of the ACP-ASIM's Medical Services Committee (MSC). The MSC is a new committee that complements the longstanding Health and Public Policy Committee and is charged with developing policy in the areas of private and public physician reimbursement, government regulation, and managed care, as well as advising on practice management and productivity-enhancing products and programs for members. This is a twelve member committee that is chaired by ACP-ASIM Regent Cecil Wilson, who visited with us a couple of years ago as the ASIM Trustee assigned to Rhode Island. The other members include leaders from ACP-ASIM who have an interest or expertise in these issues.

The first meeting had an ambitious agenda that covered recent developments in the E/M documentation story, efforts to develop national rules for documentation of medical necessity for laboratory tests (an issue near to the hearts of Rhode Island internists for the past two years), HCFA's plans for addressing the "Y2K" (Year 2000) problem, and updates from ACP-ASIM's Government Affairs division and the Center For a Competitive Advantage. A deputy from the Health Care Financing Administration met with the MSC for ninety minutes to discuss a variety of issues, including some listed above.

I am honored to have been appointed to this committee, which will enhance our ability to strongly advocate for our patients as well as for the profession. My participation on the MSC provides members of the Rhode Island Chapter with an additional opportunity to participate in development of College policy as well as in that of HCFA policy, given the College's influence on other organizations as the largest specialty organization in the world. From time to time, I'll post developments from the MSC on our Web page, or in this newsletter, and some of you may get calls from me requesting your input into matters that the Committee is considering.

Rhode Island Chapter of ACP-ASIM Executive Council

Fred J. Schiffman, MD, FACP - Governor (1998-2002) (401-793-4035)
Yul D. Ejnes, MD, FACP - Transitional Governor (1998-2000); Chair, Communications Subcommittee (401-275-1991)
Michele G. Cyr, MD, FACP - Immediate Past Governor, Co-Chair, Education Subcommittee (401-444-4765)
Mitchell A. Pressman, MD, Member - Treasurer (401-435-5533)
John R. Audett III, MD, Member
Munawar Azam, MD, Member - Chair, IMG Subcommittee (401-456-3000)
James Burrill, MD, FACP
J. Russell Corcoran, MD, FACP - Co-Chair, Education Subcommittee (401-783-0084)
Robert S. Crausman, MD
Frederick S. Crisafulli, MD, FACP - Chair, Health and Public Policy Subcommittee (401-331-8555)
Mark Fagan, MD, Member - Chair, Associates Subcommittee (401-444-5344)
Edward Feller, MD, Member
Neal Galinko, MD, FACP
Reginald Y. Gohh, MD, Member
R. Scott Hanson, MD, Member
Pamela Harrop, MD, Member - Co-Chair, Membership Subcommittee (401-253-8900)
James V. Hennessey, MD, FACP
Harold M. Horwitz, MD, Member
Sewell I. Kahn, MD, FACP
Janice Kizirian, MD, FACP
Dennis S. Krauss, MD, FACP
Edward Lally, MD, FACP
Paul F. McKenney, MD, Member
Anthony Mega, MD. Member
Harold Sanders, MD, FACP
Karen Stevenson, MD, Member
Dominick Tammaro, MD, FACP
Alan Weitberg, MD, FACP

Administrative Assistant

Nancy Baker-Hobin
Division of General Internal Medicine
Rhode Island Hospital
593 Eddy St.
Providence, RI 02903
401-444-8537 (voice)401-444-4730 (fax)

Attention AMA Members: Don't forget to designate ACP-ASIM as the specialty society that will represent you in the AMA House of Delegates. You can do this on the form mailed to you by the AMA this fall or by visiting the AMA's Web site at www.ama-assn.org