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Chapter Newsletter, Fall 1999

From The Governor's Desk

It has been an exciting and demanding three months since our last Newsletter. As you see from the enclosed articles, our Chapter has been active on several fronts—most especially facing the challenge of mandatory hospitalists.

The accompanying articles recount what local our Chapter and what our national organization has done and will be doing to live up to our mission which is: "To enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine."

I have just returned from the Fall 1999 Board of Governors' Conference held in Asheville, North Carolina. The agenda was varied and of great interest. Elsewhere in this newsletter, Yul Ejnes will give an overview of the conference. Our membership should be aware that Yul has already achieved a high level of respect and leadership in our newly combined organization. Both ACP and ASIM physicians hold Yul in high esteem and he has been and will be called upon to assume leadership roles himself and will undoubtedly have greater visibility and influence at a national level.

There were two agenda items at the meeting, which I found quite compelling and noteworthy. One is the College's effort to confront the real threat of antimicrobial resistance in the United States and the world today. I am pleased that the College is taking on a leadership role for its own members and patients. It will educate us about the best way to prescribe antibiotics so that multi drug resistance does not develop in some of the most virulent organisms we know. This will require careful strategies on several fronts and will require both local and national assertiveness as we attempt to grapple with this growing concern. You will be receiving more concrete information about what we all can do in the very near future.

One of the other agenda items which was especially appealing and gripping for all present was a session called "Being a Doctor." This panel discussion was chaired by Dr. Faith Fitzgerald. Participants included Christine Laine, MD, PhD as well as Drs. Warren Furey and Donna Sweet. Dr. Laine's presentation included a discussion of "On Being a Doctor" articles which have appeared in the Annals of Internal Medicine. She is a deputy editor for the Annalsand reviews all such submissions. She divided her presentation into categories, which included presenting distressing narratives on death and dying, seeking absolution, conflict between professional and personal life, physicians or someone close to them becoming patients and maintaining professional distance. She also spoke about the joy of practice of medicine, the fascination of science and physiology, the doctor as a teacher, the magic or the power of the profession and getting to know patients as people. The audience was truly moved by these readings and I hope to make available to our local chapter a bibliography, which she distributed. Dr. Furey and Dr. Sweet then described patient encounters they experienced which were emotionally stirring to them and others.

In the question and answer discussion period which followed, there was consensus that "Being a Doctor" should be a part of every Board of Governors' Meeting. I heartily agreed.

The foregoing, I believe, illustrates how much the College is doing for its membership at many levels. We should be proud to be part of this organization and work together to encourage others to join!

With kindest personal regards, Fred J. Schiffman, MD, FACP

COMMENTARY: "What Have You Done For Me Lately?" The Mandatory Hospitalist Issue

Yul D. Ejnes, MD, FACP

The title of this column will be familiar to veteran readers of the old RISIM and ASIM newsletters. Given the significant dues dollars that our members pay each year, the question is legitimate and should be answered from time to time. This column will not be a "pledge week" pitch, although if it inspires you to renew or to urge a colleague to join ACP-ASIM, that's fine.

In July, United Healthcare of New England (UHCNE) announced to participating physicians that it planned to introduce a mandatory hospitalist program as a means of improving the quality of hospital care and controlling costs. It cited the financial jeopardy of the Medicare managed care product as a major reason for this action.

Immediately, a coalition of medical organizations led by the RI Chapter of ACP-ASIM expressed its strong opposition to the mandatory hospitalist program on the grounds that a mandatory program was an intrusion into the physician-patient relationship by the insurer. While ACP-ASIM supported the concept of hospitalists as one that has potential benefits, it strongly felt that the use of hospitalists must be decided by the primary care physician and patient rather than by an outside entity. The National Association of Inpatient Physicians shared this view.

The program was due to begin on September 1. Due to regulatory requirements, the start date was delayed until UHCNE could obtain the necessary approvals from Health Care Financing Administration (HCFA) and the Rhode Island Department of Health. On October 5, UHCNE sent a letter to participating physicians stating that the hospitalist program was to be voluntary for all its products, including Medicare. The reason for the change of heart: overwhelming physician opposition to mandatory hospitalists. (A chronology of the events following the original letter from UHCNE is available at our website at http://www.acponline.org/chapters/ri.)

A "behind the scenes" look at our opposition to this program will hopefully convince you that your dues dollars are well-spent (better yet, reinforce that view). After the initial letter from UHCNE was received, our leadership mobilized the Chapter's Health and Public Policy Committee and it discussed the issue almost daily by e-mail. The Chapter sent out broadcast faxes and e-mails to members alerting them to the program and soliciting their views. We also contacted the Rhode Island Medical Society and the Rhode Island Academy of Family Physicians (RIAFP) to coordinate efforts. E-mails were sent to the Washington office of ACP-ASIM, which had dealt with similar attempts to implement mandatory hospitalist programs in four other states.

As a result of those early measures, a multifaceted approach to this issue was developed. Our Health and Public Policy Committee, with RIAFP president Dr. Michael Fine in attendance, met with Anthony Kazlauskas, MD, UHCNE's Medical Director, in August to formally discuss the program and to express ACP-ASIM's opposition. The meeting was cordial, but the discussion was frank. While it ended with no change in UHCNE's position, it did get across to Dr. Kazlauskas our reasons for opposing the mandatory hospitalist program and our intention to pursue the issue further. Regulators at RIDOH were informed of the medical community's opposition to the program by our members and other concerned physicians. Several of you sent letters to Dr. Kazlauskas expressing opposition.

In addition, the ACP-ASIM Washington office wrote letters to Dr. Kazlauskas and to the United Healthcare corporate office in Minnesota, discussed the issue with HCFA, and established a dialogue with the United Healthcare's national Medical Director Lee Newcomer, MD. The Washington office also provided us with samples of draft legislation used in other states and support in the development of a media campaign if one were necessary.

The result of this team effort speaks for itself.

The practicing physician is often far-removed from the activities of his or her specialty society. Getting the Medicare documentation requirements changed, advocating for universal access, and raising the bar in the areas of quality care and education are worthwhile goals that impact all members, but they may not be "backyard" issues for all. However all of them require the efforts and resources of active members and staff, working together. The mandatory hospitalist hit home as no other issue has in years. In my opinion, our members and even non-member internists were beneficiaries of an advocacy effort that would be difficult to pull off as individuals or even small groups. We caught the attention of United Healthcare, federal and state regulators, and other professional societies in Rhode Island as an organization that will act on behalf of its members and their patients. And while we were persistent in our efforts, we pursued them in a professional and reasoned manner that allowed us to make our point while avoiding an atmosphere of confrontation and hostility that would jeopardize future activities with UHCNE or other third parties on areas in which we do agree.

So, to answer the title of this column, that's what we've done for you lately.

Chapter Vital Statistics

The preliminary draft of the 1998-1999 Chapter Profile Report was released in September and contains several interesting facts about our chapter. We have 680 members, of which 254 are associates (residents and fellows) and medical students. Three of our members are Masters and 124 are Fellows. Over 50% of the state's Board-certified internists are members of ACP-ASIM. Almost two-thirds of our members are under 45 years old. Women represent over a quarter of our membership. These numbers are not very different from the national statistics or those for similarly-sized chapters.

HPPC Report

The RI Chapter's Health and Public Policy Committee (HPPC) began its series of meetings with local insurers this summer. In August, the Committee met with Anthony Kazlauskas, MD, a member of ACP-ASIM and Senior Medical Director of United Healthcare of New England (UHCNE). The focus of the meeting was UHCNE's proposed mandatory hospitalist program, which ACP-ASIM opposed. (The mandatory hospitalist issue is detailed on page 2 of this newsletter.) Because other important issues could not be covered, the HPPC and Dr. Kazlauskas agreed to meet again at a later date, hopefully with UHCNE's new CEO, Budd Fisher, joining us.

In September, the HPPC met with Steven Schoenbaum, MD, FACP, President of Harvard-Pilgrim Health Care of New England (HPHC-NE). Dr. Schoenbaum is also a member of our HPPC, but that evening he wore his HPHC-NE hat and discussed recent events at his health plan. This summer, HPHC-NE's parent company announced that as part of a financial reorganization, it will take several actions to reduce the size of its operating deficit. In addition to improvements to its billing system, which should provide welcome relief to physicians who have experienced delays in payments from HPHC, the most significant part of the deficit reduction is the planned sale of the Rhode Island subsidiary of Harvard-Pilgrim. Both the group practice based at the five health centers as well as the insurance business, known collectively as Harvard-Pilgrim Health Care of New England (formerly RIGHA) will be sold. These developments will have a great impact on patients and our members and will be watched closely.

The HPPC plans to meet with representatives of Blue Cross & Blue Shield of RI, Lifespan, and other "movers and shakers" in health care in the coming months. It will also lead the Chapter's activity in promoting universal access to health care during the 2000 election cycle. If you would like to participate on the Chapter's HPPC, contact Committee Chair Fred Crisafulli, MD, FACP at 401-331-8555 or BPCFSC@aol.com.

Editors note: At press time, the Rhode Island Department of Business Regulation assumed supervision of HCHP-NE, which involves oversight of major business decisions, including the sale of the company, but day-to-day management continues to be performed by HCHP-NE staff.

Clinical Performance Measurement

Edward Westrick, MD, MS

Clinical performance measurement is becoming an increasingly important issue in today's health care delivery system. In this column I provide some historical context, a conceptual framework, and a report on progress at the state and national levels. This is an abbreviated version of the column that appeared in the August 1999 issue of Medicine and Health / Rhode Island.

Clinical performance measurement has essentially two purposes: quality improvement and accountability. Performance measurement for accountability can be used for public reporting. Performance measurement for quality improvement is used by organizations to improve their processes. RIQP uses performance measurement exclusively in the quality improvement context.

The framework for health care quality measurement was proposed by a physician, Avedis Donabedian, more than 30 years ago: categorizing measurement into structures, processes, and outcomes. Structures are the people, places, and things in health care. Processes are the verbs in health care, what the structures do. Outcomes are the results of structures doing processes.

In Rhode Island, we are currently working with the Department of Health, Medical Society, Hospital Association, JCAHO, and HCFA to develop a health care quality performance measurement and reporting program for licensed health care facilities. This effort was directed by state legislation. The national perspective has been included in an attempt to create a measurement system that satisfies the major accreditator and regulator concerns.

Nationally, three organizations are leading performance measurement in health care: JCAHO in the hospital setting, NCQA in the MCO setting, and AMAP in the physician office setting. These three organizations recently formed the Performance Measurement Coordinating Council (PMCC) with the goal of minimizing discordant measurement across settings of accreditation. Medical specialty boards are likely to develop physician performance measures in the near future.

Contact Information:
Edward Westrick, MD, MS
Principal Clinical Coordinator
Rhode Island Quality Partners
ripro.ewestric@sdps.org
(401) 528-3250 voice
(401) 528-3210 fax

Congratulations to New Fellows

The following members were elected to ACP-ASIM Fellowship in by the Board of Regents in July:
Robert S. Crausman, MD - Pawtucket
Raymond O. Powrie, MD - Providence
Mitchell A. Pressman, MD - East Providence
Josiah D. Rich, MD - Providence

Members should review the qualifications for advancement to Fellowship, available at the ACP-ASIM Online web site (www.acponline.org), or from the Chapter office. There are several "pathways" to Fellowship; not all require publication. We strongly encourage qualified members to apply for Fellowship.

Fall Governors' Meeting Highlights

Yul D. Ejnes, MD, FACP The ACP-ASIM Board of Governors (BOG) met in late September in Asheville, NC. Fred Schiffman and I attended and, as usual, enjoyed meeting with fellow Governors from across the US, Canada, and Latin America as well as members of the College staff. Full details of the meeting will appear in an issue of ACP-ASIM Observer in the late fall. Fred shares his perspectives on the meeting at the beginning of this newsletter.

Since the Spring BOG meeting in April, the joint negotiation/collective bargaining issue has taken off, with the AMA voting this summer to establish a collective bargaining unit. While it has no plan to establish a similar organization, ACP-ASIM has developed a policy position that parallels the AMA's. This was discussed at length at the fall BOG meeting.

ACP-ASIM's policy states that physicians "should have the right to negotiate jointly with health insurance plans over issues that affect the quality of, and access to, patient care..." These issues include payment policies that adversely impact access and quality. However, the position paper goes on to note that the College opposes any collective denial or limitation of services to patients (such as strikes or slowdowns) as well as actions that result in price fixing. So, while ACP-ASIM supports the right to negotiate patient care issues jointly, it does not support the use of this right solely for physicians' economic gain nor does it endorse actions traditionally used by labor unions. While the lay press characterizes recent developments in this area as "physicians seeking to form labor unions," the above distinctions should make clear that this is not the case.

The position paper includes statements on joint negotiating issues for resident physicians and how a joint negotiating unit should be set up (voluntary membership for members, no non-physician providers included).

Discussion of the position statement and the topic in general by the governors was quite robust, with several points of view expressed, ranging from support of joint negotiations to disgust over the idea. My sense was that the governors who expressed an opinion generally favored some form of joint negotiations. Fred and I would like to know your opinions on the right of physicians to negotiate jointly. The position paper is available at http://www.acponline.org/hpp/pospaper/negotiations.htm. Please e-mail us at RIACPASIM@worldnet.att.net with your thoughts.

Another subject that generated discussion was the College's initiative to reduce the inappropriate use of antibiotics. This campaign will be rolled out at the 2000 ACP-ASIM Annual Session in Philadelphia. We heard a presentation of data that indicated that the emergence of resistance to broad-spectrum antibiotics will is attributable to overuse of antibiotics, and that we often treat non-bacterial illnesses such as colds with antibiotics. The success of this project will depend on our ability to get the message out to our colleagues as well as our patients. As part of the program, ACP-ASIM will develop tools that will facilitate that process.

Sharing ideas, successes, and failures with fellow governors is always a highlight of these meetings. It seems that every chapter is dealing with issues of low attendance at chapter meetings, increased demands to provide advocacy services for members, and the challenge of energizing students, residents, and young physicians about the specialty of internal medicine. We learned a few things from our colleagues and hopefully returned the lessons. Over the next several months, Fred and I will put those new ideas into practice. As always, no offer of help is turned away at the Rhode Island Chapter. So, if you're interested in contributing ideas or your time towards making the RI ACP-ASIM a better organization, please let us know.

CT/MA/RI Regional Meeting?
We Need Your Opinion

The Governors of the Connecticut, Massachusetts, and Rhode Island Chapters of ACP-ASIM are discussing the possibility of a regional meeting for their chapters. This would be a scientific meeting featuring national and local speakers on a variety of internal medicine topics, modeled on the national ACP-ASIM meeting, with opportunities for the individual chapters to meet and discuss issues of local importance. The proposed regional meeting would be held over a weekend at a resort, with Foxwoods, Newport, and Sturbridge, MA mentioned as possibilities, and would be geared toward families, with a spouse/guest program, social functions for all attendees, and ample time for all attendees to enjoy the local attractions. A date for this meeting has not been proposed, but the fall of 2000 or 2001 would be possibilities.

Before we work on this major project, we would like feedback from members as to whether they would attend such a program. The member response form at the end of this newsletter has a question on this proposal. Please complete it and send it to the Chapter office. Or, if you prefer, e-mail us at RIACPASIM@worldnet.att.net.

ACP-ASIM Launches Legislative Action Center

ACP-ASIM Staff

To make participation in grassroots advocacy easier for its members, ACP-ASIM launched in August the new Legislative Action Center (LAC), which may be accessed from ACP-ASIM Online. The LAC allows you as an ACP-ASIM member to view the most current ACP-ASIM Legislative Alerts, find out who your federal legislators are, and send e-mails or faxes to your members of Congress. It also provides you with the status of key legislative issues of concern to ACP-ASIM, Congress' schedule, and tips on communicating with your legislators. ACP-ASIM encourages you to try the LAC by sending an e-mail to your members of Congress in response to the current Legislative Alert posted on ACP-ASIM Online.

You can access the Legislative Action Center through the "Where We Stand" section of ACP-ASIM Online at http://www.acponline.org/home/policy.htm, or by going straight to the LAC at http://congress.nw.dc.us/acp/. To send a message to Congress, you are prompted for your zip code and are zip-matched to your federal legislators. You will then be asked for your name and address (so that congressional offices can identify you as a constituent). ACP-ASIM encourages you to send a message based on the sample points posted for you, with your own personal anecdotes added. If you have any questions about the LAC or contacting your federal legislators, please contact Jenn Jenkins, Associate for Grassroots Advocacy, at jjenkins@acponline.org.

Final Y2K Reminder

By the time you read this newsletter, it will not be too late for you to get ready for "Year 2000" but it will be really close. If you haven't already done so, check your equipment for items that will not operate properly after December 31, 1999, and either upgrade and replace them. If you use a computerized billing system, check with your vendor to make certain that you can continue to bill for your services after the new year begins. Develop contingency plans that will allow you to continue to practice even if your computerized equipment does not operate (for example, prepare for the possibility of elevators not working, disruptions in cash flow, and unavailability of certain equipment).

For more details on how to prepare for Y2K, visit the ACP-ASIM Online website, which has a special section on Year 2000 preparedness. But hurry!

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 (401-444-4765)

Mitchell A. Pressman, MD, FACP
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

Robert S. Crausman, MD, FACP

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
Chair, Education Subcommittee

Harold M. Horwitz, MD, Member

Sewell I. Kahn, MD, FACP

Janice Kizirian, MD, FACP

Dennis S. Krauss, MD, FACP

Paul F. McKenney, MD, Member

Anthony Mega, MD, Member

Harold Sanders, MD, FACP

Diane Siedlicki, MD, Member

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)
NBaker-Hobin@lifespan.org (email)

Yul D. Ejnes, MD, FACP
Transitional Governor (RI), ACP-ASIM
(401) 946-6200
Yul_Ejnes@brown.edu
http://www.acponline.org/chapters/ri/