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Chapter Newsletter, Winter 1999-2000

From The Governor's Desk . . .

Seasons Greetings to all members and friends.

Our Education/Annual Meeting Planning Committee has met and we have, I believe, an exciting event planned for Thursday, April 27th and Friday, April 28th.

First of all, make certain that those days are on your calendar!

On the evening of April 27th, we have planned our annual residents' clinical vignette/abstract exhibition at the Radisson Airport Hotel in Warwick, RI. This will take place from 6:00 pm to 8:00 pm with our ACP–ASIM representative, Munsey S. Wheby, MD, FACP, Chair of the Board of Governors of the ACP–ASIM in attendance.

The next morning, after registration and a continental breakfast, our members can look forward to a scientific session that will address the important clinical threat of antimicrobial resistance. Several of Brown University's Department of Medicine's distinguished faculty will participate in the presentation and panel discussion which will be directed at physicians who prescribe antibiotics (that's all of us!). ACP–ASIM believes that we must act now to prevent the dire consequences of antibiotic resistance and Dr. Wheby will speak about what is going on at the national level. Our panelists will address the scientific basis of antimicrobial resistance and what we might do to educate ourselves, our patients and modify the awful scenario which could exist in the new millennium where micro-organisms of all kinds would simply laugh at the antimicrobial therapy we would offer.

Following this, we will have Brown University and Boston University residents present papers representing clinical vignettes, case series or bench research. The Irving Beck Chapter Laureate Award presentation will follow, and during the luncheon hour, our "Meet the Professor Session" will take place with Drs. Milton Hamolsky, Steven Opal and Marilyn Weigner tentatively scheduled to participate.

A session of resident presentations similar to the morning session will take place in the early afternoon. Our meeting will then address the Rhode Island health insurance crisis (is crisis management the theme of this meeting?) with a panel discussion on proposed solutions. Panelists tentatively scheduled include Mr. Ronald Battista, President/CEO of Blue Cross & Blue Shield of Rhode Island; state government officials; and others.

The program promises to be quite a stimulating one, hopefully with educational value for everyone who participates. We look forward to seeing you there. Don't forget to save the evening of April 27th and all day of April 28th for this meeting.

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

ACP–ASIM Governor for Rhode Island

Random Thoughts

Yul D. Ejnes, MD, FACP

"Convergence" is the name of an arts event held in Providence in the summer, isn't it? Well, it's also the name of a medical event going on right now. The failure of a major insurer, recurrent delays in payments from the surviving players, increases in the cost of running a practice (most notably due to the steep rise in health insurance premiums), and a malaise among physicians are all converging to threaten the health care system in Rhode Island. Rather than throwing up our hands in disgust and claiming powerlessness to do anything about it, isn't it time that we as a physician community took action? It's time to put aside the old thinking, politics, and dogma, take off the blinders, and consider new approaches to the problem. Tinkering with the current employer-based system of insurance isn't going to get the job done. As providers, employers, and patients, we're in the best position to know all sides of the issue - let's lead the discussion. Write to the editor of the Providence Journal, open a dialogue with your local candidates, become more active in the ACP–ASIM. It's time to wake up!

Let me say a few good words about the community-based teaching (CBT) programs in our state. Many of our members are already participants in CBT, which takes residents in the local internal medicine programs and sets them up with physicians in private practice for a few half-day sessions per month, during which the residents see outpatients and enjoy one-on-one teaching from a private attending. With the changes in how hospital care is delivered, the opportunities for many of us to teach residents in the inpatient setting are slowly (or even quickly) disappearing. CBT allows us to continue this energizing activity, not to mention provide a service to medical education. There are fringe benefits, such as eligibility for faculty appointment, recognition by the residency (and ACP–ASIM) as a teacher, and achievement of one of the criteria for advancement to ACP–ASIM Fellowship. Call your hospital's residency program director if you're interested—I'm sure they'll appreciate the help.

Kudos to Education Committee chair Jim Hennessey, MD, FACP for putting together another successful Update in Internal Medicine, held in Newport this October. Thanks also to our speakers, including Bob Doherty from the ACP–ASIM Washington office.

Speaking of the DC office, let me pay a tribute to Alan Nelson, MD, FACP. Alan's career in clinical and organized medicine would take up all of this newsletter, even if summarized concisely. Most recently ACP–ASIM's Associate EVP, Alan begins the new year as "special advisor" to the EVP, which means that while he'll continue to contribute to the organization, he'll hopefully have more time to spend with his family and leisure pursuits. On behalf of the membership of the RI Chapter I'd like to thank Alan for his support through the years. On a personal note, I'll always appreciate Alan's encouragement and counsel.

Finally, yet another shameless plug for our medical societies. I won't rehash the case that I made in the last newsletter for the value of ACP–ASIM membership. As I write this column, the Rhode Island Medical Society (RIMS), in which the Rhode Island Chapter of ACP–ASIM is very active, is working hard to ease the transition for both patients and physicians as Harvard-Pilgrim Health Care shuts down. True, with the "convergence" that I described earlier, paying dues to a medical organization doesn't seem like a priority (or even a practical reality). But consider how much more difficult it will be to get through this difficult period without these organizations!

 

The RIQP Column

Edward Westrick, MD, MS

In November, Rhode Island Quality Partners (RIQP) began work under the 6th Scope of Work contract with the Health Care Financing Administration (HCFA). Our major challenge in this three-year period is to facilitate improvement statewide in 6 clinical areas (myocardial infarction, pneumonia, heart failure, stroke, diabetes mellitus, and mammography screening) on a variety of quality indicators. As a state we are already performing well on a number of these measures. However difficult it is to improve already good performance, their remains significant room for improvement. We realize that we must work more directly with the physicians that care for these beneficiaries and with the beneficiaries themselves. Since internists see the vast majority of these patients we expect to work closely with internists and see the specialty society as an important player in this work.

The physician staff for RIQP includes three internists: Raymond Maxim, David Gifford, and I. There are a number of internists on the RIQP Board: Jeff Bandola, Sheldon Lidofsky, Peter Hollmann, Richard Carleton, Neil Galinko, and Robert Baute.

We held a focus group of physicians and office staff in early November at the Rhode Island Medical Society. We received valuable feedback on some materials that we plan to share with physician practices. We also heard some good suggestions for how we can assist busy practices to improve. We expect to convene focus groups periodically throughout the next 3 years. We will continue to provide a dinner and honorarium for those who participate.

We published a Prevention Checklist in the Providence Journal in late November. It will be printed and distributed to senior sites throughout RI including physician offices, senior centers, churches, and senior housing complexes. Your patients should be coming to you for sign off on the completion of important preventive services: influenza and pneumococcal immunization; colorectal cancer and breast cancer screening; and dilated funduscopic exams, lipid profile testing, and HgbA1C testing in patients with diabetes mellitus. This is a good time to reinforce to your patients the value of these preventive behaviors.

Contact information:
Edward Westrick, MD, MS
Chief Medical Officer
Rhode Island Quality Partners
ripro.ewestric@sdps.org
528-3250 (voice); 528-3210 (fax)


Internal Medicine Interest Group

Andrea Tom, BMS IV

The Internal Medicine Interest Group had an excellent turnout for the organizational meeting in which approximately 30 people attended. There was an enthusiastic response to the many events planned for this year. We have set up a mentoring program between medical students and community physicians in which a student spends a half-day with a doctor to better understand the rewarding field of internal medicine. Planned for November was an informational session about Medicine-Pediatrics Residencies in which faculty and students from the Medicine/Pediatrics Program at Brown will attend.

Other events planned for this year include separate sessions on: medicine clerkships, the residency application process, away electives, international health opportunities, and public health and MPH programs. We also are directing students interested in public service or in attaining more clinical experience to work in free clinics.


Board Review Strategies

Patrick C. Alguire, MD, FACP
Director, Education and Career Development

The American Board of Internal Medicine certifying examination differs from most traditional examinations in that it tests overall knowledge and the application of that knowledge to solve problems, rather than simply recalling facts. To be successful, you may need to view the examination differently and prepare in new ways. The following suggestions were gleaned from the article "Taking the boards? Try these strategies for success," published in the May 1999 ACP–ASIM Observer by Christine Kelly, and the collected experiences of selected program directors.

The Format: Nearly 85% of the test questions are presented as clinical scenarios that take place in ambulatory settings. The test emphases general knowledge; if you haven't seen or heard about it during your residency training, chances are slim that it will be on the board exam. Don't worry about recent studies in medical literature. Examinations are created over a year in advance of their use, so recent material will not be tested. For a breakdown of what is covered on the examination, see the ABIM's web site www.abim.org/info/www.abim.org/info/www.abim.org/info/blueprnt.htm.

Pace Yourself: Last minute cramming for the exam is not likely to help and may hurt your chances. Despite the difficulty in motivating yourself, most residents need to begin a study program at the beginning of their second year; starting at the beginning of the third year is cutting it pretty close, and halfway through the last year is too late. Most experts recommend reading about your own patients as the basis for your study plan. In general, the frequency that you encounter certain problems during the residency program will reflect the importance they receive on the examination.

Assess Yourself: Review courses and practice examinations can help you prepare by identifying your weak areas. One of the most popular and most accurate at predicting your performance on the board examination, is the in-training examination. Residents with scores falling below the 50th percentile on the in-training examination will have the greatest probability of failing the board examination. Remediation, usually in the form of changing reading habits, can improve the likelihood of passing the board exam. In fact, and not surprisingly, there is a direct correlation on the amount of time spent reading and the ability to pass the board examination; about 5 to 7 hours per week appears to be the bottom line for success.

Study Groups: Study groups are a good method to ensure compliance with your study program. Limit the number to three or four individuals, and meet consistently - weekly or every other week. The groups can be organized by problem, organ system, or chapters in the textbook. A tried and true strategy is to have each member prepare questions based on their reading and use them to test the group's knowledge. It's not unusual to accurately guess the content areas and types of questions that will appear on the board exam.

Review Sample Questions: Trying out sample questions can help you become a better test-taker by learning strategies to increase your odds of selecting the correct answer. About 80% of residents taking the board examination use the College's Medical Knowledge Self-Assessment Program (MKSAP) as a study tool www.acponline.org/catalog/mksap/. In addition to the questions, the accompanying syllabus presents key advances in the subspecialty and general internal medicine areas for the past three years.

Review Courses: Near the end of residency training, review courses can help solidify what you have learned during training. Do not deceive yourself into believing that a review course will make up for the lack of consistent and steady study habits, but rather they tend to "tie things together" and give a sense of confidence regarding preparedness for the examination. The College offers a number of board review courses and information about them is available on line www.acponline.org/cme/acpcours.htm.

Other Tips:

When starting the exam, determine the number of questions and the amount of time available.

  • Calculate how many should be answered by halfway through the allotted time. Typically, you will need to answer a question every one or two minutes.
  • Read the stem (the clinical vignette) carefully.
  • Pick out the pertinent parts of the stem that will help you select the correct diagnosis.
  • Pick the obviously correct answer. There are no trick questions.
  • Consider race, sex and age when selecting the answer.
  • If you don't know the answer to a question, make your best guess and move on.
  • Don't change the answers to questions unless you have made an obvious mistake; first impressions are generally the correct impressions.

UnitedHealthcare Rolls Out Care Coordination

Anthony J. Kazlauskas, MD

EDITOR'S NOTE: In early November, UnitedHealthcare's announcement that it would no longer require prior authorization of health services covered under its benefit plans was greeted with considerable fanfare and enthusiasm as well as some skepticism, both nationally and locally. It also generated some questions from local physicians that are answered here by UnitedHealthcare of New England, Inc.'s senior medical director and ACP–ASIM member, Dr. Anthony J. Kazlauskas anthony_j_kazlauskas@uhc.com.

What are the major points of the new program? We call the program Care Coordination. Its goals are to:

  • eliminate the hassle associated with precertification and prior authorization;
  • keep medical decision making where it belongs—in the physician-patient relationship;
  • make it easier for our members to get the care they need by helping them navigate through the complexity of the health care system.

We are serious about our stated goal of not issuing medical necessity denials. Thus, physicians and the health plan will continue to engage in a dialogue that supports the "science" of evidence based medicine, but when a physician feels he or she needs to apply the "art" of medicine to an individual patient, there need not be a concern that the health plan will say "no". We hope our actions will help restore the joy of practicing medicine by making every UnitedHealthcare member an easier patient for the physician to treat both clinically and administratively.

Does Care Coordination mean that UnitedHealthcare will allow payment for all services that are requested by a physician?
Definitely not. Coverage decisions are based upon benefit designs and summary plan descriptions—essentially contracts between members and the health plan that define covered services. Under Care Coordination we do not intend to deny a covered medical service because we believe it is not medically necessary. However, services to which the member is not contractually entitled are not covered.

Physical therapy is a good example. A coverage certificate might indicate that a member is entitled to 20 physical therapy visits per calendar year. However, if a physician requests more than 20 visits, even if they are medically necessary, coverage is not available.

Although benefit packages vary, some common non-covered services include weight loss therapy and medications, exercise programs and cosmetic surgery. In fact, for some potentially cosmetic procedures that can be indicated for medical reasons (e.g., blepharoplasty, vein stripping, reduction mammoplasty), Rhode Island Law requires that we evaluate coverage using a "medical necessity" rather than a "benefit" review process.

Many critics are asking, "How will UnitedHealthcare control costs?" Will costs go up?
No, we do not expect our costs to rise. It is important to note that we have redirected many resources that were previously conducting prior authorization activities towards new programs that not only make the health care experience better for the member, but also reduce unnecessary costs.

An example is a program called Welcome Home! Here, health plan nurses, who were previously engaged with medical necessity review, make telephonic contact to members with selected diagnoses within 48 hours of hospital discharge. The goal is to identify "gaps in care" such as lack of understanding of discharge medications, home care needs or failure to schedule an appropriate follow up physician visit. Patients are often very vulnerable during this time period, and the interventions of our staff not only make the care experience better, but often identify valuable information that is relayed to the attending physician who can take actions to avoid a deterioration in clinical status.

It was becoming less and less acceptable to us for UnitedHealthcare to be perceived as being in the middle of the physician/patient relationship. So, as a company we had to evolve—we did—and the result is Care Coordination. The fact that we are doing much less prior authorization may mean that we will pay for a few more tests and procedures. However, we are confident this is going to be far offset by the gains made by our Care Coordination programs.

At present, the new program does not apply to drugs and mental health services. What's the story?
Requests for either mental health services or a small number of pharmaceutical products still may be reviewed for medical necessity. We are in the middle of an evolutionary process. Remember that we do not expect medical costs to rise because we have replaced old techniques with new programs. To date, we have not developed those alternative programs for either mental health or pharmacy. The company is working hard to do so, and we are optimistic this will occur.

UnitedHealthcare is gathering more and more information about individual physician practice habits. Are there plans to deselect physicians through profiling?
Our feeling is that physicians respond positively to good data. When that happens, there is no need to talk about deselection.

The industry has generally lacked good profiling tools. A good tool:

  • produces data at a low cost (which means it must rely on claims data rather than chart review);
  • has integrity (e.g., adjusts for severity);
  • identifies patient care issues or patterns of care that are actionable by the physician.

UnitedHealthcare's quality profiling tool, Clinical Profiles meets the above tests. We began distributing Clinical Profiles to internists and cardiologists in 1998 and by the end of this year, pediatricians and obstetricians will have also received reports. Clinical Profiles uses claims data to provide physicians with confidential, personalized reports about their current practice patterns in comparison to nationally accepted best practices. It is distributed every six months, and focuses on the physician's use of recommended clinical guidelines in treating or screening for common conditions, such as prescribing beta-blockers after a heart attack or inhaled corticosteroids in asthmatics. In addition, a Clinical Profile is actionable because it provides doctors with the names of their patients who might benefit from suggested therapies or tests. Also, and this is a very nice feature, if a patient is incorrectly identified as someone who did not receive a therapy, there is a mechanism whereby the physician can correct the profile for future printings. Clinical Profiles provides a very solid foundation upon which UnitedHealthcare can grow its quality profiling.

Actionable cost profiling has been hampered by the lack of tools that can severity adjust. However, we believe are on the verge of having some very powerful mechanisms available to us, and we expect we will step up our activity in this area during 2000.

Any advice to physicians?
As physicians receive information about their individual patients from disease management programs, Clinical Profiles, or other Care Coordination activities such as Welcome Home! they should take the clinically appropriate actions that are in the best interests of their individual patients. That's what we want to achieve through these programs.

Also, and this will become increasingly important, as physicians continue to receive more data about their overall practice patterns as compared to peers, they should respond to it, correct it, question it - anything but ignore it. Its purpose is to improve medical care and move the individual physician and the medical community in the direction of "best possible practice". Hopefully, physicians will use this information for both quality and cost improvement as well as an important focal point for discussion and interaction with UnitedHealthcare.

Dr. Hamolsky Receives Lifetime Achievement Award

Nancy Baker-Hobin

At the Rhode Island Chapter's Update in Internal Medicine in Newport on October 7, Milton Hamolsky, MD, MACP received the chapter's first "Lifetime Achievement Award." "This laureateship is bestowed, Milton, in recognition of individual excellence, and your distinguished contributions to the practice of medicine which have benefited the public, our patients, the medical profession and our members," announced Fred J. Schiffman, MD, FACP, Governor of the RI ACP–ASIM. "You have earned the respect of your colleagues in the community and the people of the state of Rhode Island."

Dr. Hamolsky's internationally-acknowledged contributions to thyroid research and lifelong dedication to serving the health needs of the Rhode Island community were cited, including 24 years as Rhode Island Hospital's Chief of Medicine and the past 12 years as Chief Administrative Officer for the RI Department of Health's Board of Medical Licensure and Discipline.

Dr. Hamolsky is a Master of the ACP–ASIM, an honor accorded only a small group of distinguished physicians who have achieved recognition in medicine through pre-eminence in practice or research, positions of high honor, or significant contributions to medical science.

The RI ACP–ASIM Executive Council nominated Dr. Hamolsky for the award by acclamation. Henceforth, the award will be known as the "Milton Hamolsky Lifetime Achievement Award" and will be presented to senior Masters or Fellows of the College whose achievements in the field of medicine rival those of Dr. Hamolsky.


Annual Session 2000—Philadelphia Style
The ACP–ASIM invites you to celebrate the new millennium in the Birthplace of America, at Internal Medicine's premier educational event—Annual Session 2000, from April 13-16. From recertification courses to a history of medicine series, computer workshops to subspecialty updates, Annual Session 2000 guarantees you an abundance of educational and professional opportunities.

For the first time ever, the College's governing Boards have chosen a Clinical Theme for special emphasis in ACP–ASIM educational programs—Emerging Antibiotic Resistance. Since antibiotic resistance is now a major threat to the health of people worldwide, numerous sessions will provide up-to-date information on this topic, strategies on how to reduce this threat and skills to enable physicians to resist the importuning of patients for inappropriate antibiotics for self-limited non-bacterial infections.

Other Annual Session highlights include a four-part series on the history of medicine, the ever-popular "Multiple Small Feedings of the Mind," Clinical Skills workshops and the Learning Center, as well as over 250 educational sessions.

Members are encouraged to register now for Annual Session 2000 to have the best selection of sessions requiring advance reservations, including workshops and the new "Meet and Eat with the Professor" sessions (informal breakfast and lunch sessions with distinguished faculty that provide opportunities to discuss recent advances and new developments in selected topics.) Requests are filled on a first-come, first-serve basis. For more information on Annual Session 2000, or to register, visit ACP–ASIM Online at www.acponline.org or contact Customer Service at 800-523-1546, ext. 2600. Register by January 31, 2000 and save money.


 

Yul D. Ejnes, MD, FACP
Transitional Governor (RI), ACP–ASIM
(401) 946-6200
Yul_Ejnes@brown.edu
http://users.aol.com/yde/html/home.html (last updated 11/20/99)

 

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)


"The art of medicine consists of amusing the patient while nature cures the disease." - Voltaire