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Chapter Newsletter - Winter 2000 - 2001

From the Governor's Desk

Happy New Year to all members and their families!

The Fall Meeting of the Rhode Island Chapter of ACP-ASIM was held in Newport, Rhode Island on November 15, 2000. We had record breaking attendance and for the first time partnered with the Brown University Department of Medicine who were co-sponsors of our event.

Our speakers were formidable in reputation and attendees had the chance to hear them update their particular areas of expertise and then ask questions in the formal session and also during the breaks and at noontime.

The speakers and their topics were:

Lance Dworkin, MD
"Approach to the Patient with Mild to Moderate Renal Disease"

Robert J. Smith, MD
"Type II Diabetes Management: Combination Therapy for an Oligogenic Disease"

Rena Wing, PhD
"Behavioral Approaches to Weight Loss and Maintenance"

Richard Besdine, MD
"Update on Prevention for Older Adults"

Robert Crausman, MD
"Pulmonary Disease in the Elderly: Overview and Literature Update"

Charles Carpenter, MD
"Current Treatment of HIV Infection"

Jane Carter, MD
"Demystifying TB Infection: When to Screen, When to Treat"

Joseph Sweeney, MD
"Laboratory Evaluation of Hypercoagulability: 2000 A.D."

Jack Wands, MD
"Gastroenterology Update"

Additionally, Mr. Robert Doherty from the ACP-ASIM Washington Office spoke to us during our luncheon break. His topic was "What Can Internal Medicine Expect from the New President?"

Of course, by November 15th we expected to know whether George Bush or Al Gore was going to be our President, but despite the uncertainty at that time (and still as this is going to press), Mr. Doherty provided important information for us regarding what we might expect no matter who was finally elected.

During the morning session, The Milton Hamolsky Lifetime Achievement Award was presented to Dr. Richard Carleton who was unanimously selected by the Rhode Island Chapter of ACP-ASIM Awards Committee and the Governor's Council.

All who attended felt that they were treated to world class discussions in a collegial fashion in a beautiful setting and look forward to our next meeting which will our Annual Regional Meeting on Tuesday, April 17 and Wednesday, April 18, 2001 at The Radisson Airport Hotel in Warwick, R.I.

With kindest personal regards,

Fred J. Schiffman, MD, FACP
ACP-ASIM Governor for Rhode Island

Medicare to Cover Home Health Certification

Yul D. Ejnes, MD, FACP

The 2001 Medicare fee schedules contain a couple of welcome changes. Two codes have been created for certification and recertification of home health care, which is what you do when you sign the bottom of the 485 form, the three-copy form sent by home health agencies that contains the treatment plan. Here are HCFA's descriptions:

G0180 Physician services for initial certification of Medicare-covered home health services, billable once for a patient's home health certification period. This code will be used when the patient has not received Medicare-covered home health services for at least 60 days.

G0179 Physician services for recertification of Medicare-covered home health services, billable once for a patient's home health certification period. This code would be used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period.

According to the 2001 Rhode Island Medicare fee schedule, code G0180 will be reimbursed at $76.62, G0179 at $64.38. The local Medicare carrier has not yet issued specific instructions on how to bill these codes. When they are made available, we will publish them on our web page and distribute them to our members via e-mail.

Please note that these are not CPT codes and will not appear in your CPT manual. These are HCPCS Level II codes that HCFA uses for procedures not described in the CPT or those that are listed in CPT but with a definition with which Medicare does not agree. Also remember that these new codes are for use for Medicare fee for service patients only. As of this writing, BCBSRI was reviewing these new codes - they implement coding changes on April 1. UnitedHealthcare is also reviewing these codes, and as of publication had not decided whether to cover them.

These new codes follow years of discussion between the physician community and HCFA over proper reimbursement for home health care supervision. A few years ago, codes for physician oversight of home health care were created, but their use required extensive documentation and did not include time spent coordinating care with non-health care professionals (e.g., family members), so they were not used very often.

Coverage of certification and recertification coincides with efforts by HCFA and the Office of the Inspector General (OIG) to study and find ways to improve physician oversight of home health care. ACP-ASIM is participating in this process through its Medical Services Committee, which meets regularly with officials from both agencies. Part of this effort includes taking a look at the 485 form itself to see if it can be simplified.

Please also note that if you're one of the few people using the two codes for care plan oversight of home health care that I referred to above, HCFA created two G codes to take the place of the CPT codes currently in use. This was because the AMA's CPT committee expanded the definition of these services to include time spent communicating with non-health care professionals. HCFA objected, so it created codes G0181 and G0182 to take the place of CPT codes 99375 and 99378, using the 2000 CPT definitions and the same relative values.

For updates on the new codes, check the chapter web page at http://www.acponline.org/chapters/ri or submit your e-mail address to us at RIACPASIM@att.net.

Young Physicians Subcommittee

The Young Physicians Subcommittee (YPS) wants to hear from young physician members of the College about the practice environment today. Your frank comments will, through the Subcommittee, have a direct impact on you and your colleagues. Visit www.acponline.org/private/committees/yps/ and let us know what's on your mind.

We'd like to know how you feel about recertification, establishing a practice, coping with stress, and time constraints. Would you like a copy of the YPS Practice Management Survival Booklet? An E/M coding card? A curbside consultation about and evaluating and improving a practice via the College's Center for a Competitive Advantage? If you answered "yes" to any of these questions, the web site can also be used to request this information. ALL e-mails will be answered.

If you have any questions, please contact Jean Elliott, YPS Staff Liaison at (800) 523-1546, ext. 2692

Commentary: Recert Woes

Yul D. Ejnes, MD, FACP

Before I start, I must issue a disclaimer. I was ABIM certified in 1988. Therefore my certification is not time-limited. However, as you will see, any bias that might result from my status will be hard to find in this column.

Recertification is becoming another "four-letter word." There is little disagreement with the concept that as professionals, physicians should remain current in their field and continuously strive to improve their knowledge and skills. We achieve these goals in different ways, individualized according to our time demands, practice settings, financial resources, and learning styles. The American Board of Internal Medicine has decided that it knows how to get there better than anyone else, and if you're one of the growing number of internists with a time-limited certificate, it's their way or else.

The ABIM calls its current version of recertification "Continuous Professional Development (CPD)" and describes it fully in the Annals of Internal Medicine 2000;133:202-208. This process consists of open-book modules, a traditional board-type exam, chart reviews, and, most interestingly, peer and patient evaluations of the candidate. CPD itself is under continuous development, as it is not yet complete. When finished, the recertification process is intended to span the entire ten year cycle between certificates, and provide not only the prized ABIM certificate, but the candidate's continuing medical education.

Why should internists recertify every ten years? According to the ABIM, the public demands some kind of accountability. The Board had hoped to address this with voluntary recertification, but that idea was a flop. Apparently, few practicing internists wanted to part with several hundred dollars to spend two days in a hotel conference room answering multiple choice questions about things that they haven't thought about since the second year of medical school. So, the ABIM decided that some type of compulsory reassessment was needed, and beginning in 1990, issued ten-year certificates. However, the ABIM realized that physicians out of training for several years were a more sophisticated bunch than those just out of residency, so the test had to more closely reflect what real doctors seeing real patients needed to know. Hence what is now called CPD.

Criticisms of the ABIM's plans fall into two categories. There are philosophical questions raised by many leaders in internal medicine, and practical concerns raised by the internists who have recertified or are in the process of doing so. Does recertification result in better physicians? Surprisingly, there is no evidence that this is the case; in fact, the ABIM plans to study the issue after data is collected over several years of CPD.

Isn't part of CPD redundant, since other entities, notably the insurance companies, already review our charts and ask our patients to evaluate us (some practices already do this on their own as well)? ABIM has responded by saying that it may accept externally-collected data rather than require candidates to complete the CPD portions that duplicate what others are already doing, provided that the outside information is compatible with ABIM's data collection. What are the implications of choosing not to recertify? Board certification is required by many hospitals, insurance companies, and group practices. The ABIM has stated that no one should be penalized for not recertifying, yet it has raised the profile of recertification in the public's eye such that any organization would be reluctant to change its standards and not require certification. At the same time, the groundswell of opposition to CPD is such that there may be many internists with lapsed ABIM certification in the near future, so the institutions will have to deal with this issue.

Finally, should the ABIM be in the business of providing continuing medical education, which it claims as one of the goals of CPD, while at the same time serving as the certifying body? Professional organizations such as ACP-ASIM, medical schools, and hospitals provide thousands of hours of quality CME. With the considerable time commitment required for CPD, there will be an impact on many of these other CME providers. As publisher of MKSAP, the College may be greatly affected.

Most important, however, are the concerns raised by the internists who must go through the recertification process. Already, we are hearing from members who report time away from family and practice far in excess of what the description of the program estimates. Many question the relevance of the content of the CPD examinations and modules to their everyday practice, even though the ABIM claims to have made an effort to make recertification examination more relevant to practice than is the initial certification examination. The financial impact of this process is not insignificant; add to the $800-900 paid to ABIM the cost of the day away from practice for the one-day examination and the cost of completing other parts of the program, including the chart reviews, not to mention time taken from patient care to prepare for the examination. And if you're certified in both internal medicine and a subspecialty (or two), multiply the above. There are many other criticisms both philosophical and practical, but by now you must get the general picture.

In fairness to the ABIM, they stated a willingness to listen to our concerns, both directly and through a joint working committee with ACP-ASIM. They may accept patient evaluation and chart review information from outside entities if it is compatible with their data collection protocol. The leadership of the ABIM is going through CPD itself (though none are in danger of losing their jobs if they fail, I suspect). Even though CPD is overly burdensome, lacks relevance, and is an unproven means of ensuring quality medical practice, the goal of the program is noteworthy.

The ACP-ASIM Board of Governors discussed CPD at its fall meeting, and College President Sandra Adamson Fryhofer, MD, FACP published a letter on the issue in the ACP-ASIM Observer. While not disagreeing with the principle of periodic evidence-based reassessment, all view the ABIM's plans with concern and encourage individual members to write the ABIM or contact their College Governor with personal experiences or opinions.

Future of Internal Medicine Will be in Atlanta March 29-April 1

Be a part of the College's vision of upholding the best traditions and creating opportunities for excellence in the future. Join us for Annual Session 2001.

Discover... The Next Generation of Multiple Small Feedings of the Mind

Back and better than before! Creative formats, short, focused presentations, and practical topics combine to make these sessions a popular favorite. Each session is based on a series of practice- derived questions related to several clinical areas that address some of the most common, yet controversial, patient-management issues.

Discover... The Most Recent Breakthroughs at the Annual Update Series

Stay current on the latest information and perspectives from the nation's foremost experts in 20 subspecialty areas. The Update series is a valuable resource to ensure that you're up on the year's most significant findings and their impact on patient care.

Discover... Meet the Professor Sessions

Go right to the source. Take this opportunity to hear the experts discuss cases illustrating controversial issues and innovative techniques in patient care. Then get up-close and personal in the new Meet and Eat with the Professor sessions. Sit down with these same experts over breakfast and lunch and get answers to your specific questions in a smaller, more intimate setting.

Discover... Interactive Learning for the Next Millennium

Hands-on learning activities are an excellent way to refresh your skills or learn new ones. Take advantage of the Learning Center to help you gain experience or refine your abilities in such vital areas as medical interviewing, physical examination, and office-based procedures. The Learning Center is also the ideal place to familiarize yourself with medical informatics software that can have an immediate impact on your daily practice.

Discover... Annual Session and Beyond at the Many Special College Events

Get in the spirit of Annual Session. Meet fellow internists from around the globe. Share your discoveries and learn from one another. Annual Session is more than a time for learning, it is a time to honor our colleagues ' achievements at Convocation, to find out about the latest College initiatives at the Annual Business Meeting, and to meet old friends and make new ones at Regional and Chapter receptions, plus a variety of other events.

The View From the Hill

Steve DeToy

The 2001 Rhode Island General Assembly session will open with a new leadership team in the Senate and with the specter of reapportionment and legislative down-sizing looming. The health care market in our state is already down-sized to a two-player market and the specter of a large hospital conglomerate dominating the market has disappeared.

The Rhode Island Medical Society and its 20 component specialty societies, including ACP-ASIM, will be pursuing a focused agenda seeking legislative assistance in protecting and enhancing the delivery of health care service to Rhode Islanders.

At the top of the agenda is an ambitious bill to utilize existing federal anti-trust law to provide RI health care providers with a "state action exemption" that would allow for meaningful negotiations between providers and the two insurers. RIMS has brought together a broad-based coalition of providers to mount an unprecedented effort to pass what has been dubbed the "Health Care Fairness Act," (HCFA). Among the bill's supporters is the Attorney General.

This large scale effort will include direct mailings to all providers in the state asking them to personally join the effort, a creation of a data base to keep those providers up to date on the developments around the bill, a substantial media effort, in-office hand-outs to engage patients in the process, and other strategies that have not been seen in health care legislative efforts in the past.

Also, health care providers will continue to support legislation to require that the two insurers process claims on a timely basis. This bill recognizes the difficulties that 39 other states have had with a "prompt payment" law, and requires simply that all claims be processed in a timely fashion. This RI approach will provide for quicker payment of claims by forcing the two insurers to end the practice of "pending" claims or denying claims without full explanation.

The Rhode Island Medical Society's legislative agenda is crafted by its Public Laws Committee, which has representation from all specialty societies that have seats on the RIMS Council. The efforts of the Public Laws Committee are supported by the active participation of the Rhode Island Medical Political Action Committee, RIMPAC. All physicians have an ethical and professional obligation to support the work of these two committees.

If any ACP-ASIM members have any questions on the workings of these committees or on legislative issues, they are encouraged to contact RIMS's Director of Government and Public Affairs, Steve DeToy at 401-528-3283 or by e-mail at sdetoy@rimed.org.

Steve DeToy is Director of Governmental Affairs and Public Policy for the Rhode Island Medical Society.

Survey on Health Care Reform

Yul D. Ejnes, MD, FACP

Regular readers of this newsletter will recall that in the Spring issue we included a survey of reader attitudes towards several options for reforming the health care system. The return rate for the survey was quite poor (only fifteen out of a mailing list of several hundred), but the results, while not statistically significant, were quite illustrative of the diversity of opinions among those members who did respond.

Readers were asked to rate several proposals for health care reform based on their description (we avoided labels such as "single payer" or "voucher system" but most readers will recognize the proposals). A summary of each proposal from the original survey is listed, followed by the results, using the following scale:

Readers are invited to draw their own conclusions from the results. If one lumps together the "strongly support" and "support" columns and the "strongly oppose" and "oppose" columns, it might be possible to say that there is general opposition to any proposal that involves a single private insurer; interestingly, the same group of respondents was split on the proposal most closely resembling a government-financed and run single payer system. The proposal for individual ownership of insurance seemed to garner a favorable response from this group of members, using the same analysis.