Governor's Newsletter, Fall 2000
Harmon H. Davis, II, MD, FACP
Governor, Wyoming Chapter
We have completed six months of work in the Chapter. The Chapter Council has been busy. Dr. Lanier put on a very successful Scientific Meeting September 22nd and 23rd in Laramie. Though it was not well attended by the membership, all that did attend felt that it was a great meeting. We all enjoyed ourselves, particularly interacting with the WWAMI students. Our plan is to put on a similar meeting in Laramie next Fall and hopefully have the students in attendance throughout the meeting. Our goal will be to have 8-10 hours of CME and to have it on a football weekend. We will keep you informed as the arrangements are made.
During the Scientific Meeting, one of the things that was discussed at length was the importance of the Chapter Meetings and our opportunity as a Chapter, to contribute resolutions to the College. A point that should be made is that we have the same representation at the College level as any other Chapter, including states such as New York or California, where the membership is obviously much greater. I can be reached at 1200 East 20th St., Cheyenne, WY 82001, or on the Internet at email@example.comI look forward to hearing from you.
The Fall Board of Governors Meetings was very interesting. Multiple resolutions were recommended for adoption, probably the most contentious was whether or not Associate Members should have a vote. The resolution that was sent to the Board of Regents was that Associate Members who have completed two years of training could become voting members, thus allowing Fellows to vote like a full member. The hope is that this will maintain subspecialty membership within the ACP-ASIM.
Other issues discussed that are important to the Wyoming membership included member computer skills and usage. The prioritization of educational goals carried out by the members of the Education Committee in February, was compared to those carried out by the same committee a month prior to the Fall meeting. There was good concordance except in two areas. The committee placed strong emphasis on programs preparing physicians to use computer based programs as resources for CME, journal and textbook content. As a result, the entire Annals of Internal Medicine is now published online as well as in print. There have been programs that have been successfully identified and new programs have been reviewed, which include integration of an Annual Session on informatics concurrent with mainstream medical sessions at the Annual ACP-ASIM meeting and development of family and self-assessment guides on high priority curriculum topics for dissemination through a number of print and electronic venues.
An in depth discussion was had with regard to the initiatives on patient safety in response to the IOM report, "To Err Is Human." Dr. Mottur-Pilson reviewed the contents of the IOM report, its mandate for professional societies and the patient safety domains within educational programs that might be developed. Prioritization of the domains by the Education Committee members led to the following: 1) Systems influence over error rate; 2) Medication errors, followed by; 3) Communication breakdowns; 4) Diagnostic errors and lowest priority; 5) Patient education shortfalls; 6) Non-adherence to best practices. Also emphasized was the importance of distinguishing institutional, that is, hospital or other institution environment from ambulatory practice site. The distinction between physician decision makers and practitioners in the former was identified. The impact of the individual practitioners on the systems in the latter was stressed. With respect to educational programs and identification of topics is to be addressed and educational venues likely to effect physician practices and patient outcomes are the next steps.
To guide these efforts, the formation of a Patient Safety Work Group was proposed. The outside experts to be invited were proposed by the staff and approved by the Education Committee. They are: Stephen Shortell, PhD (UC, Berkeley); Gilad Kuperman, MD, PhD (Partners/Harvard); Brent James, MD (Intermountain); George Isham (Health Partners); and Michael Cohen, FASHP (Institute of Safe Medication Practices). It was proposed there be several committee members on the Work Group and Drs. Baker and Hornbake, who are members of the Education Committee, will serve as representatives from the College. A final member will be a Governor with a background as a practicing general internist. The Work Group will meet and is expected to produce a specific educational program to be presented at the Board of Governors Meeting next year.
Another important point of information provided at the Board of Governors Meeting was that the Clinical Education and Application Program guidelines, which are called "CEAP" guidelines, will be released in the near future for the use of the College members. The newest ones are the management of acute exacerbation of COPD, which was developed in partnership with the American College of Chest Physicians, along with the judicious use of antibiotics in the adult acute respiratory infections, which was funded in part by the CDC.
One of the important developments from the Marketing and Communications Committee was the authorization to pursue a physician job search and placement service on ACP-ASIM Online and also to provide an online discount book store for members with expansion of the "virtual" Annual Session, with sponsorship from pharmaceutical companies and other various special member offers for products related to physician practice.
Last but not least, there was a heated discussion at the Board of Governors Meeting with regard to recertification, especially after the presentation by representatives of the ABIM. It is my impression that the overall tenor was that recertification needs to be carefully evaluated and perhaps significant changes made. A Task Force comprised of ACP-ASIM and ABIM representatives, has been created to address this important issue and Dr. Barbara McGuire, Governor of New Mexico, is one of the College's representatives. She is soliciting comments regarding recertification and can be reached at firstname.lastname@example.org Please feel free to contact her with your opinions regarding the recertification process and any problems that you may have had.
I would like to solicit your participation to make our Chapter more active. As I started this missive, I noted that we have the same representation as other Chapters and I think it is our obligation to participate in the College business. I look forward to representing you, as do the following members of my advisory council:
Dan Klein, MD, FACP- Immediate Past Governor, Wyoming Chapter; Medical Student Liaison;
Chair, Health and Public Policy Committee
John Beckman, MD, FACP- Chair, Credentials Committee; Website Manager
Eric Wedell, MD, FACP- Chair, Membership and Awards Committee; Chair, 2001 Scientific Program
Robert Lanier, MD, FACP- Chair, Community Based Teaching Committee; Assistant Chair, Scientific Program
Please contact a council member or myself if you are interested in participating in Chapter activities.
Enclosed is a review of advancement to Fellowship. It has been published by the Governor of Texas Southern, Dr. Marc Shabot, and is presented for your perusal (see page 4.) I would hope that all of our members desire to become a Fellow of the College. This represents not only an honorary title, but documents obviously that you have completed certain tasks making you eligible for this title and that you are committed to lifelong learning and professional development.
Harmon H. (Bud) Davis, II, MD, FACP
Governor, Wyoming ACP-ASIM Chapter
UPDATE FROM HCFA ON E/M CODING and
PRACTICE EXPENSE CALCULATION
The ACP-ASIM's Medical Services Committee (MSC) met with HCFA officials, Terry Kay and Paul Rudolf, regarding the proposed new E/M Documentation Guidelines and Practice Expense Refinement. A summary of the proposals for documentation guidelines has been prepared by Brett Baker on the College staff and can be found on the College's website www.acponline.orgSome key points that were discussed included the fact that HCFA now proposes to restore the 10% reduction in its 2000 Medicare fee schedule for the CPT critical care codes now that a revised definition of critical care work has been agreed to by the medical societies and HCFA. HCFA is proposing the use of medical decision making (MDM) as the key component in selecting a level of E/M service. The ACP-ASIM opposes this and because of input from the MSC's Third Party Relations Payment and Coding Subcommittee, believes that the components of history and examination are too important to be relegated to secondary status. HCFA is proposing to establish two new "G" codes to describe Care Plan Oversight. One will be for initial certification of Medicare covered services by a home health agency, and the other will be for recertification. HCFA proposes to assign the code for initial certification the same work RVU assigned to CPT 99213 (level 3 established patient office visit) and the code for recertification the same work RVU assigned to CPT 99212.
HCFA will need physicians to pilot these new guidelines; however, at this time it is not willing to provide immunity to physicians participating in the pilot tests. The MSC commented to the HCFA officials in attendance that the College could not recommend or encourage physicians to pilot these guidelines without assurance that they will not be audited and potentially investigated for fraud and abuse. HCFA has also indicated that they do not intend to pilot test the College's proposal to give physicians the option of using encounter time with basic documentation as an alternative to using history, examination and medical decision making to select a level of E/M service. Members of the MSC questioned HCFA officials about this, and were told the cost of such a pilot test would be very expensive and before embarking on such a test, the physician community as a whole would need to indicate a greater buy-in into the concept. HCFA's proposed timeline for implementing these guidelines is as follows: July-September 2000- Establish Clinical Vignettes to exemplify proper E/M coding; October- March 2001- Conduct various pilot studies with physicians using the guidelines; April-December 2001- Analyze results of pilot studies and train physicians and reviewers regarding the guidelines; January 2002- Implement the new E/M guidelines.
MEETING WITH THE OFFICE OF INSPECTOR GENERAL
One of the most important items that the Medical Services Committee addressed was the draft OIcompliance program for individual and small group physician practices. This draft appeared in the June 12, 2000 edition of the Federal Register. We provided to the Office of Inspector General written comments about their proposal, and also on July 27, several of the committee members met with Larry Goldberg, who is responsible for coordinating OIG's role in the investigation, audit, and resolution of health care fraud and abuse cases, and with Kimberly Brandt, who is largely responsible for drafting and monitoring this current compliance plan guideline. In both our written and verbal comments, we expressed our overall general concern that the physician community will react negatively to these compliance guidelines viewing them as overly complex, legalistic, unrealistic, and intimidating. Further, the guidelines will likely heighten physician fears of increasing governmental intrusion in the practice of medicine serving to drive away the very audience for which the guidelines were intended. We particularly emphasized in our written comments and at our face-to-face meeting that the draft guidance was more conceptual than hands-on, forcing physicians to guess what compromises an "effective" compliance plan. This will unnecessarily create among physicians anxiety that no matter what they develop it will not be good enough. While OIG officials were receptive to both our written and verbacomments, they gave little indication that they plan to make the significant types of changes that we, as well as other organized medical groups, suggested.
The feeling of the Medical Services Committee is that in all likelihood, the final version of the compliance guidelines will look similar to the current draft and our new task will be to see what the College and its staff can do to provide tools and templates for its members who are in solo and small group practices to fulfill their requirement of the OIG's compliance plan guidelines.
FELLOWSHIP ADVANCEMENT MADE EASY (FAME)
By Marc Shabot, Texas Southern Governor
- ABIM, RCPSC, or AOBIM certified*
- Licensed practitioner
- Formal training completed, Member at least 2 years, in practice or teaching for at least 2 years
- Proposed/seconded by 2 Masters/Fellows
- Commitment to lifelong learning and professional development
* May be waived in extraordinary circumstances
Then, Qualify by 1 of the 4 Pathways*
Pathway 1- Academician
- Holds academic appointment as teacher, researcher, administrator, writes scientific papers, scholarly reviews, book chapters, etc.
Pathway 2- The Scholar/Teacher/ Multiple Certification
- Active in community as teacher in Continuing Education and Professional Development activities
- Re-certified or dual boarded, or MKSAP for score
Pathway 3-The Active ACP-ASIM Member
- 10 years membership in the ACP-ASIM
- Active in ACP-ASIM meetings and Committees at local and national level
Pathway 4- The Senior Physician
- May have been a longstanding Member or have joined ACP-ASIM later in life
- Has demonstrated longstanding professional activity in the community, in teaching, in patient care or in service;
acts as a role model for other physicians and health professionals
Note: Community service, especially the voluntary provision of medical care, and ACP-ASIM activities significantly enhance the likelihood of advancement, under all four pathways.
*Pathways are not mutually exclusive; "combinations" are permissible.