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Governor's Newsletter

SPECIAL ISSUE—The 2000 Rhode Island Chapter Regional Meeting

From the Governor's Desk...

As many of you know, a major theme of our regional meeting in Warwick on April 27 and 28 will be the emerging issue of antibiotic resistance. The topic was selected by our Education Subcommittee because it is both a matter of international concern and an ACP-ASIM clinical theme project. Dr. Munsey Wheby, College Representative for our regional meeting and Chair of the ACP-ASIM Board of Governors, has been closely involved with the project. He will have much to contribute to our regional meeting on this topic.

Initiated in September of 1999, this ACP-ASIM clinical theme project will continue through April of 2000. Its goals are to (1) increase physician and patient awareness concerning appropriate uses of antibiotics, (2) modify physician and patient attitudes concerning the use of antibiotics, (3) raise public consciousness about appropriate uses of antibiotics, and (4) amplify the College's efforts through collaboration with governmental and civilian agencies. Organizations currently collaborating with the ACP-ASIM include the American College of Chest Physicians, the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the American Academy of Family Physicians.

Members of the latter organizations, under the leadership of the ACP-ASIM's Dr. Herbert Waxman, formed a working group to develop a curricular outline encompassing the dimensions, causes, impact, biology and mechanisms of antimicrobial resistance; laboratory methods for identifying resistance; and strategies for combating the problem. The outline will be available to physicians at our regional meeting.

This spring, the ACP-ASIM's Annual Session in Philadelphia will highlight antimicrobial resistance in meet-the-professor sessions, panel discussions, workshops, distinguished lectures, at the learning center, and with a virtual annual session. In 2001, Annual Session will offer specific topics related to antimicrobial resistance.

Guidelines are under development for the management of infections caused by antibiotic resistant organisms, such as sinusitis and COPD. Also under collaborative development are guidelines entitled "Principles of Judicious Antibiotic Use for Adult Acute Respiratory Infections," which address such conditions as acute bronchitis, sinusitis, pharyngitis and URI's. Patient guidelines will be disseminated through physicians' offices in English and Spanish, and will be broadcast via web sites and televised spots. Another vehicle for physician education will be the MKSAP, with clinical problem-solving cases and multiple choice questions.

The ACP-ASIM will help to focus chapter educational programs by recommending specific clinical themes, faculty and relevant materials. Governors will be involved with measuring the effectiveness of theme-related initiatives.

Multimedia resources will disseminate important information: ACP-ASIM Observer, Books Program, ACP-ASIM's web site (www.acponline.org), Annals of Internal Medicine, and the journal Effective Clinical Practice. The ACP-ASIM will support federal legislative and regulatory efforts to educate physicians and patients on the risks of over-prescribing antibiotics. A comprehensive project communications plan is currently under development to include partnering with the pharmaceutical industry and developing televised public service spots. The effectiveness of these activities will be evaluated and reported by ACP-ASIM. However, the breadth and scope of the evaluation will be governed, at least in part, by the $50,000 budget available for the project. The final impact report will be made available in December, 2002.

As you can see, our organization is hard at work addressing the important issue of antibiotic resistance. Please attend our regional meeting on April 27 and 28 to hear more from a panel of experts, including Dr. Munsey Wheby, Chair, ACP-ASIM Board of Governors; Dr. Antone Medeiros, Epidemiologist, Division of Infectious Diseases at The Miriam Hospital; Dr. John Lonks, Staff Physician, Division of Infectious Diseases at The Miriam Hospital; Dr. Leonard Mermel, Medical Director, Department of Infection Control at Rhode Island Hospital; and Dr. Timothy Flanigan, Director of the Immunology Center and Division of Clinical Immunology and Geographic Medicine at The Miriam Hospital and Director of the Infectious Disease Division at Brown University. There will be ample opportunity for audience participation.

I look forward to seeing you in Warwick in April.

With kindest personal regards,
Fred J. Schiffman, MD, FACP
ACP-ASIM Governor for Rhode Island

From The Editor

Yul D. Ejnes, MD, FACP

This issue of the Governor's Newsletter features a preview and background materials for the 2000 Rhode Island ACP-ASIM Chapter's Regional Meeting, to be held on April 27 and 28 at the Radisson Airport Hotel in Warwick. In addition to resident abstracts and posters, a message from our visiting College Representative, Munsey Wheby MD, FACP, and the presentation of the Irving Beck Laureate Award, there will be two panel discussions on topics of paramount importance to practicing internists and their patients. The morning panel will focus on emerging antimicrobial resistance and highlight the College's Clinical Topic for 2000. Fred J. Schiffman, MD, FACP, Governor of the Rhode Island Chapter, writes about this in his Governor's Message. The afternoon panel will discuss the health care crisis in Rhode Island and is entitled "What Next, Rhode Island?"

The term "crisis" is perhaps overused, but the current situation is not far from one if we're not already there. One major insurer that provided high-quality care in this market since the 1970's went out of business last year; another acclaimed insurer withdrew from the market, as its parent also entered the world of "state receivership." The two survivors, forced to end their price wars or risk the same fate as the others, increased premiums by double-digit amounts, with further increases likely next year.

Seniors enrolled in Medicare+Choice plans were greeted with reductions in their benefits, increases in their premiums, or termination of their plans. And not even $1500 in yearly prescription coverage was enough for them to afford their drugs!

With few exceptions, Rhode Island's hospitals lost large amounts of money again in 1999. Physician practices were also hard hit by the failure of Harvard-Pilgrim and delays in payments from the other insurers. Reimbursement either decreased or remained the same, while costs, most notably health insurance premiums, increased.

All this while 100,000 Rhode Islanders remain uninsured.

Against this backdrop leaders from the health care industry, government, and business have stepped forward with calls for change to the system. Some of them have criticized the failings and deficiencies of the existing system, while others have made specific suggestions for change. In our panel discussion on April 28, as well as in these pages, some of those ideas will be presented.

Our panel will include Lieutenant Governor Charles Fogarty. Mr. Fogarty has several ideas for reform in the system, including using proceeds from the tobacco settlement solely for health care issues, an idea that the Chapter formally endorsed last year.

On our panel with Lt. Gov. Fogarty will be Mr. Ronald Battista, President/CEO of Blue Cross and Blue Shield of Rhode Island. Mr. Battista will share with us his company's vision of the future health care system. Psychiatrist Michael Ingall, MD will join our other panelists to discuss a proposal that he made in a column in the Providence Journal in January, 2000. In it, he recommends that a single-payer system based on the Medicare program be adopted for all Americans. Ms. Tricia Leddy of the Rhode Island Department of Human Services will present a proposal for expanding the role of the State of Rhode Island in reducing the number of uninsured through its RIte Care program.

We hope that you come to the Regional Meeting prepared to listen, to think, and to share. The format of the panel discussion will be interactive. I'll roam the audience with a wireless microphone and hope that you'll be prepared to not only ask panelists questions, but to challenge them as well as each other. We need to hear your ideas as well, because the medical profession must develop an approach to the crisis that it can take to the public and to legislators. Otherwise, as they say, someone else will "fix" the problem for us.

Chapter Resolution on Individual Ownership of Health Insurance

Yul D. Ejnes, MD, FACP

The Rhode Island Chapter Executive Council submitted the following resolution for consideration at the 2000 Annual Meeting of the ACP-ASIM Board of Governors:

WHEREAS ACP-ASIM policy calls for universal health care based in part on employer-sponsored health insurance and for the exploration of alternatives to employer-based insurance as the mainstay of our system of coverage, and

WHEREAS employer-based insurance insulates the consumer of health care from the cost of health care, thereby promoting inefficient use of resources; interferes with the portability of health insurance when employees change jobs; and unfairly distributes the burden of financing health insurance; therefore be it

RESOLVED that ACP-ASIM promote alternatives to employer-based insurance as the basis of our health care system; and be it further

RESOLVED that ACP-ASIM actively promote solutions to the problems of universal access and coverage that call for individual ownership of health insurance.

Rationale: At this time, one sixth of Americans, including 12 percent of Rhode Islanders, are uninsured. The number of uninsured Americans is expected to increase to 53 million by 2007. And, according to Consumers Union, as many as 31 million Americans could be underinsured, many of them employed.

For years, the foundation of the system that finances health insurance for most non-elderly Americans has been employer-provided insurance. According to the Health Insurance Association of America, nine out of 10 Americans with private insurance get it from an employer. In Rhode Island, 77 percent of businesses provide their employees with health insurance. Commentators at both ends of the political spectrum have criticized employer-provided insurance on the following grounds:

  • by insulating individuals from the cost of most of their care, employer-based insurance encourages increased health care spending.
  • since insurance is tied to employment, loss or change of jobs can mean loss of insurance.
  • since employers purchase the insurance, they also determine how much coverage is provided, who provides the coverage, and how much of the employee's compensation will be spent on health care.
  • while one of the advantages of insurance is the spreading of risk among large numbers of people, the current system spreads risk within smaller groups of employees, thereby losing the benefits of pooling of risk.
  • current tax treatment of employer-paid insurance subsidizes such coverage with over $100 billion in tax breaks, in contrast to coverage that is not employer-paid, which receives little or no tax benefit.
  • premium increases will make it increasingly difficult for small businesses to provide insurance without increasing employee contributions, which may increase the number of uninsured Americans as employees choose to opt out of employer-provided insurance.

Current ACP-ASIM policy supports a system of universal access based on employer and publicly-sponsored insurance coverage. Our resolution asks the College to change its position. A shift to individually-owned health insurance is compatible with many current proposals for health care reform, from Medical Savings Accounts to government-purchased or subsidized coverage. It allows employers to continue to contribute to their employees' health insurance, but puts ownership and greater responsibility in the hands of the employee. It raises the status of health coverage from one of fringe benefit to that of fundamental right.

In submitting this resolution, the Rhode Island Chapter does not endorse one proposed "solution" over another, but encourages a paradigm shift that will permit us to make meaningful changes in the system. These changes will secure insurance coverage for the currently employed and make it easier to expand coverage to those who are now uninsured.

(Data sources available upon request.)

Other Chapter News

Yul D. Ejnes, MD, FACP

The Rhode Island Chapter's Health and Public Policy Subcommittee (HPP) has been active on several fronts. In February, HPP hosted a meeting with Steven Schoenbaum, MD, FACP, the former President of Harvard-Pilgrim Health Care of New England (HPHC-NE). The meeting was attended by Candace Dyer, MD, President of the Rhode Island Medical Society (RIMS), and Michael Macko, MD, President-elect of RIMS. The topic of the meeting was a look back at what happened with HPHC-NE and what lessons could be learned from the experience.

Another HPP activity was a meeting in February with Blue CHiP Medical Director Peter Hollmann, MD, and representatives of Pharmacare, the pharmacy benefits manager for the Blue Cross& Blue Shield plans. The meeting was in response to a letter that I sent Pharmacare protesting its burdensome process of formulary management, which involves the completion of forms for the approval of medication changes. Several proposals for simplifying the process were discussed, as was the possibility of compensating physicians for the time spent on the additional paperwork.

The Rhode Island Chapter of ACP-ASIM recently joined several other specialty societies, the Rhode Island Medical Society, managed care organizations, the hospitals, the State Department of Health, and Rhode Island Quality Partners in an initiative called Take Care Rhode Island. This program is designed to study and improve the quality of care for five conditions: myocardial infarction, congestive heart failure, atrial fibrillation, stroke, and community-acquired pneumonia. Participants will share data and best practices, thereby reducing the duplication of effort resulting from each group's collecting data and communicating with physicians separately. For more information on Take Care Rhode Island, contact Rhode Island Quality Partners at 401-528-3200.

The View From the Hill

Steven DeToy

The Rhode Island General Assembly has begun its 2000 session in a political environment where health care issues dominate the landscape. However, due to the uniquely Rhode Island flavor of many of the health care issues, it is unclear how the legislators will proceed. The issues of affordability and accessibility of health insurance, the uninsured and other "national" oriented issues are in the Rhode Island context that includes the demise of Harvard Pilgrim and Tufts, the statutorily mandated expansion of RIte Care, the shrinking commercial health insurer market and the looming specter of a merged hospital system.

There are currently at least four "official" groups studying the current health care situation or crisis depending on one's perspective. The House passed legislation in 1999 creating a special study commission, the Senate leadership has convened its committee chairs and select other senators, and the Governors Advisory Council on Health (GACH) has been busy collecting and analyzing information for the past two years. The three convene once a week to in a bipartisan, bicameral effort to identify and to eventually address issues.

The Rhode Island Medical Society (RIMS) has developed a legislative agenda that speaks to the issues of changing relationships between insurers, hospitals and physicians. This agenda is intended to empower physicians and to level the "playing field" to enable physicians to continue to advocate on behalf of their patients.

The most significant bill in the RIMS armamentarium would provide an exception to federal anti-trust law to allow providers to collectively negotiate with insurers. Corporations Chair William Irons (D-39), introduced the bill 00S-2747 in the Senate. Rep. William Murphy (D-39) introduced the House bill 00H-7952. Another RIMS bill would mandate prompt payment by insurers, 00H-7390 by Rep. Suzanne Henseler (D-44) and in the Senate by Sen. Elizabeth Roberts (D-11).

RIMS has also introduced a bill to ban "all-products" clauses in insurance contracts, 00H-7521 by Rep. Steven Costantino and legislation to prohibit hospitals from making staff privileges contingent upon physicians not admitting patients to other hospitals, 00H-7161 by Rep. Nancy Benoit (D-64) and 00S-2519 by Senator Roberts.

For physicians wishing to more closely monitor activity at the State House there are two pertinent web sites: the official General Assembly site at http://www.rilin.state.ri.us and the site created by the Secretary of State's office http://www.sec.state.ri.us. You may also feel free to contact Steve DeToy directly at the Medical Society, 401-331-3207.

Steve DeToy is Director of Governmental Affairs and Public Policy for the Rhode Island Medical Society. His The View From the Hill columns summarizing activity in the Rhode Island State House will appear from time to time in this newsletter.