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Report from the Governor's Desk
June 2009



FEEDBACK NEEDED: ACP Chapter Questionnaire





Leadership Day 2009

In mid May our ACP Rhode Island Chapter spent two days in Washington DC being briefed on the legislative landscape and visiting with our two Representatives and two Senators. The members of our team were Dr. Kristin Anderson, Dr. Yul Ejnes and Dr. Nitin Damle.

In this time of “health care reform” we focused on four principles:

  • Ensuring that all Americans have access to affordable health care coverage.
  • Legislating significant payment reform to bring primary care in line with subspecialty medicine.
  • Broaden the pilot tests of the Patient Centered Medical Home within the Medicare program and developing sustainable funding mechanisms for comprehensive, continuous and complex care.
  • Establishing a national workforce policy to ensure a sufficient supply of primary care and other physicians, recognizing the importance of payment reform in setting policy.

We gave specific examples of the difficulties of recruiting physicians in Rhode Island and the dearth of internal medicine residents who will be staying in the state to practice primary care. We then asked for specific support from our legislators on several bills in the House and the Senate that address the above issues.

A particular bill that encompasses many of our concerns is the Preserving Patient Access to Primary Care Act, H.R. 2350 sponsored by Representative Allyson Schwartz. This bill is already co-sponsored by Representative's Kennedy and Langevin and we thanked them and reiterated the importance of this legislation.

Our success occurred on the Senate side. Senator Cantwell of Washington had introduced a similar bill but was looking for a co-sponsor. We spoke with Senator Reed and Whitehouse about its importance and were ultimately able to persuade Senator Whitehouse to become such a co-sponsor. This bill has now been introduced in the Senate.

Advocacy can work for our patients and our profession. I think the strongest vehicle for its delivery is through organized medicine. We welcome your involvement at any level of participation. Please contact me, if you would like to get involved and even attend Leadership Days in 2010.



June Chapter Scientific Meeting

On June 4, 2009 we had the best attended meeting in years at the Radisson Hotel in Warwick RI. We had a series of excellent lectures from “Fostering Excellence in Medicine,” to ankle and foot problems, imaging of the abdomen, obesity and bariatric surgery, dermatology and a series of topics on the aging heart, end of life issues, bio-defense and universal precautions.

Robert Doherty, Vice President of Governmental Affairs for the College gave an informative talk on the political landscape in Washington in this year of health care reform.

We gave three distinguished awards: Governor's Award to Pamela Harrop MD ; Irving Addison Beck Memorial Award to Nicholas Califano MD FACP ; Milton Hamolsky Lifetime Achievement Award to James Crowley MD FACP ; and we had over seventy five Associate Posters and six podium presentations from the Boston University and Brown University Teaching Programs.

The Program Committee is already planning an excellent meeting for next year. Please plan on attending. It is a good means to get CME credits, hear new and exciting advances in medicine and connect with friends and colleagues.



Chapter Award Recipients

Warmest congratulations go out to the following individuals who were recipient of chapter awards this year. We salute and honor them.

2009 Laureate Award Recipients:

The Irving Addison Beck Memorial Award and the Milton Hamolsky Lifetime Achievement Award honor Fellows and Masters of the College who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, or research and in service to their community, their Chapter, and the American College of Physicians.

2009 Governor's Award Recipient:
Pamela A. Harrop, MD - 2009 Governor's Award
Governor's Awards were initiated to honor members who have distinguished themselves as true humanitarians to be honored for their contributions in medicine.

2009 Senior Medical Resident Award Recipients:

  • Patricia Jimenez-Mendez, MD, representing Roger Williams Medical Center and the Boston University School of Medicine
  • Saba Asad, MD, representing Memorial Hospital of Rhode Island and the Warren Alpert Medical School of Brown University
  • Lyuda Ryaboy, MD, representing Rhode Island Hospital/The Miriam Hospital, and the Warren Alpert Medical School of Brown University
  • Elizabeth Lo, MD, representing Rhode Island Hospital/The Miriam Hospital, and the Warren Alpert Medical School of Brown University




Rhode Island Medical Society Council - Meeting Highlights June 1, 2009 by Newell Warde

The RI Health Insurance Commissioner, Christopher Koller, explained the new mandate he is giving to the health plans to control cost and promote quality: over the next 5 years the plans must double (from 5.5% to 11%) the proportion of premium they expend in support of primary care, and they must do so in ways that do not have the direct effect of increasing premiums.

The Commissioner believes these goals can be accomplished by adjusting patterns of utilization, over which physicians have significant control. He does not favor boosting rates of payment for primary care services at the expense of subspecialists, a strategy he believes would be destructive; rather he envisions an overall shift of resources proportionally from institutions to physicians.

More specifically, Mr. Koller wants the health plans to find ways to strengthen the infrastructure of primary care in RI, encourage the growth of the Chronic Care Model Medical Home, encourage the adoption of EMR, and “work toward comprehensive payment reform across the delivery system.” (The vision of “payment reform” remains inchoate, but such reform would likely include more bundling and broader use of per-member-per-month.) Mr. Koller called upon the professional community to foster a culture of population-based health care delivery that promotes optimal utilization. He asserted that appropriate utilization both serves patients and promotes system affordability.

Mr. Koller described the limits of his powers as Commissioner and noted two areas that frustrate him: lack of a definition of one of his four key charges, namely “fairness to providers,” and the elusiveness of truly comparable data that could be used to benchmark premium and payment levels in Rhode Island against those in other jurisdictions. However, he did not dispute the fact that Rhode Island providers are disadvantaged by a persistent regional disparity in payment, and he confirmed that interstate disparities tend to be greater for RI physicians than for RI hospitals.

Mr. Koller urged members of the Council to visit www.ohic.ri.gov and to offer comments on the current requests of BCBSRI and UnitedHealthcare for double-digit rate increases; he noted that the insurers project paying 45% of the premiums they collect to hospitals; changes in utilization could appropriately reduce that proportion, he suggested.

The CEO of BCBSRI, Mr. James Purcell, told the Council that his company is in general agreement with the rationale and goals of Mr. Koller's mandate. Indeed, BCBSRI has already embarked voluntarily on a parallel track to boost primary care infrastructure, the Medical Home and EMR in order to control cost and promote quality. Mr. Purcell said that soon after he became CEO 5 years ago, BCBSRI recognized that the company's relationship with physicians is of primary importance. Since 2004 BCBSRI has improved aggregate reimbursement levels for physicians from 84% of Medicare to 113%; this year BCBSRI will achieve regional parity for those primary care physicians who use EMR (124% of Medicare).

Mr. Purcell asserted that the fee-for-service system has been “the root of all evil” in creating a quantity-based health care system and fostering distortions and inequities.

One inequity repeatedly noted was the fact that larger entities command better payment than smaller ones by virtue of their greater market clout, not by virtue of greater value, quality or efficiency. Further, the prevalence of private contracting renders many payment relationships opaque, even to the Commissioner. Greater transparency would serve the public interest, as would a regulatory framework within which greater value could compete successfully against greater market leverage.

BCBSRI Medical Director Augustine Manocchia, MD, reviewed BCBSRI's efforts to boost primary care (e.g., the ongoing series of fee enhancements, the “Quality Counts” pay-for-performance program, EMR/infrastructure funding, loan forgiveness, Chronic Care Sustainability initiative, integrated behavioral health). He noted the company's plans to build upon these programs and to extend EMR support to subspecialists.

ELECTIONS The Council elected Dr. Nitin Damle Vice President, effective immediately, to serve out the unexpired term of Dr. Gillian Pearis. Dr. Marlene Cutitar was elected to serve out the unexpired term of Dr. Damle as Councilor-at-Large.

The Council accepted the Report of the Nominating Committee as presented. Accordingly, the following will take office in September 2009: President, Vera DePalo, MD; President-Elect, Gary Bubly, MD; Vice President, Nitin Damle, MD; Treasurer, Jerald Fingerut, MD; Secretary, Alyn Adrain, MD; Councilors-at-Large, Andrew Dowd, MD, Martin Papazian, MD; Marlene Cutitar, MD; and Steven Fera, MD; Adjunct Councilors, Joel Kaufman, MD, and Ira Singer, MD. Michael Migliori, MD, was reelected to a 2-year term as Delegate to the AMA. Standing committees, committee chairs and Directors of the RIMS Insurance Brokerage Corporation where also elected in accordance with the Bylaws.

OTHER MATTERS The Council's discussions with its three guests displaced other agenda items, which otherwise would have included at least the following:

  • An update on the Society's lawsuit against the State to nullify provider taxes.
  • An update on a new loan repayment program for primary care physicians.
  • An update on efforts to establish a training program for Physician Assistants in RI.
  • A review and update of the Council's 2006 long-range planning exercise.

Council members were encouraged to visit www.rimed.org to review the latest changes and enhancements in RIMS' website, including new pages devoted to individual subspecialty organizations that are represented on the RIMS Council.


Rhode Island Patient-Centered Medical Home pilot up and running!
Patient-Centered Medical Home??? by Thomas A. Bledsoe, MD, FACP

As you may remember from the previous newsletter, Rhode Island is home to the first large scale multi-payer pilot of the patient-centered medical home (PC-MH), an innovative approach to both primary care and principal care. Recognizing that the current funding and practice delivery model has become untenable (both unsustainable in terms of professional satisfaction and unable to deliver and demonstrate quality care despite well-meaning, well-educated, hard-working physicians), the Rhode Island pilot was given the name CSI-RI; the Chronic Care Sustainability Initiative. The idea is based on the chronic care model developed by Ed Wagner and his colleagues that it takes a team to deliver quality primary or principal care, with a goal of “productive interactions between an activated, informed patient and a prepared, proactive practice.” The American College of Physicians has been integral in developing this concept and helpful in providing background assistance to the Rhode Island pilot.

“Patient-Centered Medical Home” as a name has been snatched up and used widely and generically for the way health care should be delivered in the future, but officially from the ACP's perspective it is an interesting concept worthy of study. In Rhode Island, we are at the forefront of that study with a pilot project supported heavily by BCBSRI, UHC and the state's Medicaid program. According to the ACP, there are six components of a patient-centered medical home: each patient has a personal physician, physician leads a team of health care providers, the practice uses a whole-person orientation, care is coordinated and integrated, quality and safety are priorities, there is enhanced access to care and payment supports these elements. We have all worked very hard to provide care along the lines of the first six of these principles but have previously lacked the financial backing to make it happen.

The Rhode Island pilot of this concept was officially launched on October 1st, 2008 for a two year trial period based in five clinical sites: two small private practices, one large private practice, one large practice nested in an academic faculty practice and a community health center. The practices are receiving $3 PMPM from BCBSRI and UHC for each of their members and up to $30 PMPM for more complicated patients from Medicaid to support building the infrastructure needed to support the required practice enhancements. In addition, each practice received a half- or nearly full-time “nurse care manager” to support the enhancements on both an individual patient and practice level as well as significant logistical support from Quality Partners and the Health Department.

NCQA Certification
On the advice of the national ACP leadership, the pilot needed to determine what would be necessary for a practice to be designated as a “patient-centered medical home.” After much debate, the project decided to adopt standards being put forth by the National Committee on Quality Accreditation (NCQA), a national non-profit organization dedicated to improving health care quality. These standards are now being suggested as national standards for what constitutes a PC-MH by insurance organizations and others with an eye toward making them a requirement for certification as a patient-centered medical home. In fact, we are also piloting the NCQA's certification process.

The NCQA certification process is both costly and time-consuming. Each of the participating pilot sites was contractually required to do a self-assessment related to the NCQA standards by January 1st of this year and file a formal request for certification by March 1st. This certification was to “Level 1” (of four), with an upcoming requirement to achieve “Level 2” later in the pilot project. Scoring occurs on a complicated grid with many components and certain “must pass elements”. Components include such things as access and communication, patient tracking and registry functions and others (see figure). All five of the pilot sites were able to submit the necessary documentation on time and, as of this writing, all are still waiting to hear whether they will be certified. As it is likely that certification along these lines will be required of all practices seeking enhanced reimbursement and other support in the not-too-distant future, I'd recommend that we all take a look at our current practices to see how we'd do on these measures. The NCQA standards are available on their website (www.ncqa.org , look for “Patient-Centered Medical Home).

What the pilot sites are doing
Each of the five pilot sites has undertaken a series of practice transformation efforts with the assistance of Quality Partners, the Rhode Island Chronic Care Collaborative from the RI Department of Health and others. These efforts are partially funded through the PMPM payments. Targeting the chronic diseases of diabetes mellitus, coronary artery disease and depression as well as smoking but also looking broadly at how the practices function, changes to phone answering protocols to registry population management, to group visits with certified diabetes educators, pharmacists and co-located psychologists have been implemented. A meeting of all providers and staff from the pilot sites recently over dinner provided a dramatic demonstration of the changes that are possible over a short time but with concentrated effort and financial support.

What the pilot sites are finding
Of note, as the practices start to measure and track quality markers, they are finding that both on a practice level (“How are our HgbA1c's?”) and on an individual level (“Whatever happened to that beta-blocker I started you on last year?”), there is significant room for improvement. Just measuring quality on a practice level is yielding improvements. Additionally, by involving the whole office, both physicians and office staff have found greater professional satisfaction. We've seen the first inklings that the “physician-led team” will have beneficial effects on the three main outcome measures for the pilot project: Physician professional satisfaction, patient satisfaction and quality of care measures.

Rolling it out
Initial conversations have begun on how this project could benefit all who practice in Rhode Island. Both UHC and BCBSRI (and now Tufts) are at the table with these conversations. Whether the efforts spreads piecemeal to a few more practices or really take hold more generally is still up in the air. In my opinion, it is the only way to save primary care as a specialty and the most promising option for improving care for those with chronic illnesses, both areas where traditional fee-for-service financing has failed so miserably. ACP members who are preparing for negotiating with payers in the near future would do well to look at the standards and be prepared to discuss what such a practice transformation would require in terms of financial support. Not just primary care!

While the CSI-RI project is centered on primary care, the national ACP model includes “principal care” in the planning. Sub-specialists who provide care for patients' principal medical problem would also do well to consider how performing to these standards would benefit their practices and their patients. Certainly, all will learn valuable insights from our very own Patient-Centered Medical Home pilot project, the Rhode Island Chronic Care Sustainability Initiative.

More details to follow!
NCQA standards: Access and communication
Patient tracking and registry functions
Care management
Patient self-management support
Electronic prescribing
Test tracking
Referral tracking
Performance reporting and improvement
Advanced electronic communications



…at the Department of Health (ACP Primary Care Physician Advisory Committee update)
- by Thomas A. Bledsoe, MD, FACP

Since its inception in 1992, the Primary Care Physician Advisory Committee (PCPAC) has advised the Rhode Island Department of Health on programmatic and policy issues impacting primary care in Rhode Island. PCPAC consists of primary care physicians representing each of the four primary care academies (family medicine, internal medicine (American College of Physicians), pediatrics, and obstetrics/gynecology), the medical society, primary care residency programs in RI, Community Health Centers, hospital-based primary care clinics, and large and small private practices. I serve as the ACP representative on the committee (and currently chair it).

The committee has become a valuable source on information, consultation and feedback for the director of the department (Dave Gifford, member) from the primary care community. Recently, for example, all CON requests that are processed by the department are vetted by the advisory committee as to how the multimillion dollar project would impact and benefit primary care in the state. Topics addressed this past year include a review of the Health Department's legislative agenda, broadening the (generally highly successful) centralized flu vaccine program, loan repayment programs for primary care programs and how the RI global Medicaid program would affect primary care. Additionally, many of you received an email from me related to the recent swine flu outbreak as the department sought to use the PCPAC as a two way conduit for flow of information related to an active public health issue.

If you are interested in joining this committee (once monthly, hot topics, a chance to have serious input to a person in power who listens!!), please send me an e-mail. While we are still looking to refine communication, please also feel free email me with any input related to our past or future topics at thomas_bledsoe@brown.edu.


FEEDBACK NEEDED: ACP Chapter Questionnaire

As we move forward in these difficult economic times, we would like to make sure that we are providing you with the services that you expect. The biggest service that the chapter provides is the scientific meeting with an Awards Reception and Banquet. We would like to get some feedback on a proposed Chapter Awards Dinner separate from the meeting as well as any other suggestions. Below is a short questionnaire which should only take a few moments of your time, but will guide the Council in making plans for meetings in 2010 and beyond. Please, take a few minutes to provide us with this essential information. The questions are numbered. Please copy and paste these questions in an email to respond. We would appreciate it if you would send replies directly to the Chapter Governor, Nitin S. Damle, MD, FACP at nsdamle@scim.necoxmail.com.Thank you for your help and time.

1) What new services or benefits would you like to see the ACP offer at the Rhode Island Chapter level?

2) Have you ever attended a Chapter Meeting?
- If yes, what was the year of the last meeting you attended?

Should the Chapter meeting . . .
3) Should the meeting move around the state or be at one central site each time?

4) Would you suggest a new venue for the meetings that you would be most likely attend?

5) How long should the Chapter meeting be? (1/2 day, 1 full day, 1 ½ day, 2 days)? Do you prefer a weekend day or a weekday?

6) Would you like to see activities such as spouse/child program, golf, college athletic events, music, outdoor activities, cooking classes, photo classes, etc? If so, which one?

7) Would you attend an annual dinner that would honor our Chapter Award Recipients separate from the Chapter Meeting? We would host it at a restaurant or club. (Yes or No)

8) Would you be willing to pay a fee to attend this dinner.

9) If so, would you prefer the Awards Dinner be planned for early spring or fall?

Additional Thoughts: ______________________________________________________________________

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