Governor's Newsletter, Summer 1999

National News

Included below are up-to-date news items that will potentially affect all practicing Internists and their patients.

Universal Health Coverage: A Call to Action from America's Internists

Whitney W. Addington, MD, FACP, (newly elected president of the ACP-ASIM) has declared health care coverage for all Americans the "central focus" of his presidency. He points out that ACP-ASIM had long-standing programs and policies aimed at increasing access to the health care system. He plans to build on that foundation. Dr. Addington believes that the College has both the responsibility and opportunity to make universal coverage a public debate in the upcoming presidential elections.

Tax Credits to Insure More Americans Gain Support in Congress

On April 7, 1999, ACP-ASIM's Governmental Affairs and Policy Division invited all House and Senate legislative staff members to a briefing about the growing problem of the uninsured and ACP-ASIM's proposal to expand health insurance through tax credits. Whitney Addington, MD, FACP, discussed the importance of universal coverage as a determinant of public health and why the assurance of it is critical to physicians and their patients. Plans are now being developed for the use federal tax credits and a portion of the budget surplus to fund health insurance by both parties and the ACP-ASIM. The plans were presented at the briefing.

ACP-ASIM's plan for tax credits is gaining support and has received praise for its comprehensive approach. The plan:

• Calls upon Congress and the President to dedicate 12.6% of the budget surplus over the next five years expanding health coverage to low to moderate income Americans;
• Asks for the enactment of an adequate refundable tax credit for Americans with incomes up to 150% of the poverty level to pay for the cost of standard health insurance coverage;
• Calls for expanded Medicare coverage to all Americans of poverty level and outreach programs for enrollment; and
• Provides for federal subsidies for unemployed workers to pay for the cost of premiums under COBRA coverage.

Physicians Discuss Universal Care in Annals

In the April 20, 1999 issue of Annals of Internal Medicine, a policy brief by Donald Light, MD, of the University of Pennsylvania Health System, argues that "Managed care's cost cutting tactics have created a market in which pernicious managed care edges out good clinical managed care. Several programs have tried to patch the existing system, but Congress and medical societies continue to call for patient and physician protections, enhanced care for the terminally ill and increased privacy. The current voluntary system, however, ties medical choices to reimbursement, pitting the salary of the providers against their clinical judgement with administration costs three times greater than a universal system."

"Concern exists among internists that efforts to raise standards for patient rights without the guarantee of universal health insurance will only increase the number of uninsured." Dr. Light concludes, "Without universal coverage, all players are rewarded for gaming the system and exploiting the most vulnerable."

In the same issue of Annals, Frank Davidoff, MD, editor of Annals of Internal Medicine, and Robert D. Reinecke, MD, Professor of Ophthalmology at Jefferson Medical College, propose another solution to the current U.S. health care: a Constitutional amendment guaranteeing equal access to basic and essential health care. Knowing that it would be difficult to pass such an amendment, the doctors note, "That Americans have a Constitutional right to assistance of legal counsel, but not the assistance of medical practitioners. There has to be a better way."

ACP-ASIM Views Gun Violence as a High Priority Public Health Issue

Amid intense public discourse in the aftermath of the tragedy in Colorado, ACP-ASIM supports a number of policy initiatives deemed effective in reducing preventable injuries, unnecessary loss of life and the consumption of health care resources caused by gun violence.

In a news release dated May 3, 1999, Whitney W. Addington, MD, FACP, called for forceful national and local legislation to restrict gun sales to minors and adopt design features that make it difficult for children to operate firearms. "Reducing the exposure of children and young adults to firearms is clearly a preventative action that can help save lives," said Dr. Addington.

At the invitation of the American Medical Association, ACP-ASIM took a proactive stance with allied medical societies, proposing an Organized Medicine's Summit on School Violence. The summit intends to explore critical questions about the multi-dimensional factors that contribute to school violence. The six-month study will produce a comprehensive report of conclusions and recommendations for families, communities, schools, governments and public policy advocates, as well as physicians and their organizations. Surgeon General David Satcher and the American Public Health Association are sponsors of the effort. The Office of the Attorney General also agreed to participate.

The summit was announced May 10, 1999 at a highly publicized first meeting in Washington, DC with President Clinton and First Lady Hillary Rodham Clinton in attendance. It is seen as an important opportunity for America's physicians to assist in a time of profound national concern that has caused our nation to seriously question the social environment in which our children are raised.

College Strongly Supports Conquering Pain Act of 1999

ACP-ASIM strongly supports a bill that was launched on May 3, 1999 in both the House and the Senate, which recognizes a federal responsibility for legislation to ensure the best possible care, both short- and long-term, for terminally ill patients in need of pain management. The bill, sponsored by Senators Ron Wyden (D-OR) and Connie Mack (R-FL,) holds the health care plans and hospitals accountable for responding to the concerns of chronically ill patients and improving pain treatment. It also coordinates the federal government's funding and activities on pain research.

Immediate past President Harold C. Sox, MD, MACP, pledged College support for the bill in a letter to Sen. Wyden. Dr. Sox explained, "Far too many Americans suffer from severe pain. This is particularly true for patients with terminal illnesses. That's why the enactment of the Conquering Pain Act is crucial. The bill will go a long way toward helping patients get the care they need and policy makers develop long-term solutions."

Senate "Patient Bill of Rights" Falls Short of Expectations

Associate Executive Vice President Alan R. Nelson, MD, FACP, represented the view of ACP-ASIM to Sen. Jim Jeffords (R-VT,) Chairman of the Health, Education, Labor & Pensions Committee, regarding S. 326, named the Patient Bill of Rights in a letter dated March 15, 1999. Dr. Nelson outlined ACP-ASIM's support of the following provisions:

A requirement that managed care plans offer point-of-service options, allowing patients to obtain from physicians outside the network:

• Prudent layperson standards for emergency room coverage determinations;
• Information for enrollees to a health care plan enabling them to compare quality measures and indicators;
• A prohibition of restrictions on communication between physicians and patients; and
• requirement of timely review processes and the opportunity for appeal by an independent physician.

However, the letter expressed the College's concern that, while the bill provides some patient protections, the bill omits other important health care rights and protections or covers only "those individuals who are insured by large employers under ERISA." The letter states that the bill is missing the following provisions:

• Holding health plans accountable in a court of law for medical decisions that may result in death or injury to the patient;
• Granting network physicians a central role in the development of utilization review and quality improvement protocols;
• Rules to ensure physicians call make decisions regarding the necessity and appropriateness of treatments; and
• Requirements on plans to maintain ongoing internal and external quality assurance programs.

ACP-ASIM's greatest concern about the bill is that S. 326 does not adequately ensure access to affordable health insurance coverage. ACP-ASIM calls upon the Congress to guarantee the most basic right of all Americans - the right to insurance coverage.

Call for Greater Disclosure and Participation in Medicare Decisions

ACP-ASIM submitted a statement to the Committee on Ways and Means Subcommittee on Health Care Financing Administration (HCFA) on May 7, 1999. The statement congratulated the Subcommittee for holding hearings to examine the processes available to physicians and seniors to appeal Medicare Coverage decisions, especially those made by Medicare carriers. However, ACP-ASIM noted in its statement that HCFA's processes failed to address local coverage decisions and called for reform. The College is suggesting the following recommendations:

• HCFA's Office of Clinical Standards and Quality should oversee local medical review policies (LMRP) to maintain accurate information;
• Carriers should lengthen the review and public comment period to sixty days for all proposed policy changes;
• Require carriers to state, in writing, the decisions made in framing the final policy;
• HCFA should provide "best practices" guidelines to local carriers;
• Establish a uniform process for appealing and modifying LMRPs after they are implemented;
• Require carriers to access the long-term financial/cost benefit impact of LMRPs that are enacted;
• Require HCFA to inform beneficiaries that LMRPs that deny or restrict coverage will cause their out-of-pocket costs to increase; and
• National medical societies should have input into "model" LMRPs.

Merger Opposed as Threat to Quality Care and Choice

Twenty-nine medical societies representing nearly a half million physicians, including the College, expressed concern about the recent merger of Aetna U.S. Healthcare with Prudential in a letter dated March 25, 1999 to Assistant Attorney General Joel I. Klein in charge of the Antitrust Division of the Department of Justice. The organizations are concerned that vigorous protections against the control of market conditions are not applied to the national insurance companies, resulting in a significant control over health care being vested in a few companies. In their view, merger activities will interfere with patient choice and for physicians' ability to provide needed care to their patients.

The medical societies ask Klein to review the following areas of concern in the merger and challenge its anti-competitive and effect:

• Pre-merger, Aetna controls one-third of the market in nine of the most populous states and encompasses 40% of the Fortune 1000 companies nationally;
• With growth, Aetna consistently restricts physician networks, particularly for specialist care and interferes with primary care doctors' ability to make referrals to specialists;
• Historically, Aetna produces complex and lengthy approval processes for care, some of which have needed legislative redress for timely payment, even with pre-approvals;
• Aetna consistently defines medical necessity as "least costly alternative," and the market power of this insurance company limits physician options to collectively negotiate for reasonable medical policies on behalf of patients;
• Mergers create "dislocations" of care that jeopardizes the continuity of patient care and creates backlogs of claims approval; and
• With the merger, Aetna will require Prudential patients and physicians to adhere to the Aetna business philosophy stated above.

Mandatory Programs are Denounced by Physicians and Hospitalists

A coalition of 24 medical societies, led by ACP-ASIM, are publicly criticizing some of the nation's leading managed care companies for their mandatory hospitalist programs. Mandatory hospitalist policies require that a patient's primary physician transfer complete responsibility for patient care to a hospital-based physician upon entering the hospital. Florida, Maryland, Missouri and Texas have established these programs.

In a letter of protest, the coalition denounced mandatory policies, demanding an end to the practice. "The coalition does not oppose hospitalists, as long as their use is voluntary," said ACP-ASIM immediate past president Harold C. Sox. "Patients must have the opportunity to discuss potential advantages and disadvantages of hospitalist programs with their physicians and must be free to choose doctors."

The National Association of Inpatient Physicians (NAIP) also expressed their opposition to mandatory programs in a May 3 letter to Blue Cross/Blue Shield, the American Association of Health Plans and Health Insurance Association of Health Plans. John R. Nelson, MD, and Winthrop F. Whitcomb, MD, Co-Presidents of NAIP wrote, "We oppose, in the strongest terms possible, the imposition of mandatory hospitalist programs by such organizations on patients and primary care physicians." The letter continues to say that the success of hospitalist systems depends upon the endorsement of the primary care physicians who refer their patients and the patient's opportunity to discuss choice of care options.

Jamie S. Barkin, MD, FACP, Governor of the Florida Chapter, and members of the Florida chapter, are actively opposing the Florida program and are planning to introduce a new bill in the legislature next year.

On May 4, 1999, Dr. Sox received a reply to the coalition's letter from Karen Ignagni, President and CEO of American Association of Health Plans (AAHP). Ms. Ignagni states, "You made a number of compelling points that should be discussed more broadly by the health plan and the provider communities." In response, she offers to host the first meeting of key individuals from both communities at AAHP and pledges to facilitate and ensure a productive dialogue.

Managed Care and Palliative Care Guides Available

At the April Board of Regents meeting, a position paper entitled "Medical Ethics, Professionalism and the Changing Practice Environment" was approved. This paper, under the direction of the College's newly formed Center for Ethics and Professionalism, presents the model and general principles for papers to be developed on the theme of professionalism and on managed care ethics issues by the Ethics and Human Rights Committee.

A series of papers from the Consensus Panel on End-of-Life Care, chaired by Bernard Lo, MD, will be appearing in the ACP-ASIM Annals of Internal Medicine over the next year. Launched May 4, the series comprehensively addresses issues about caring for the dying for physicians and clinicians. First in the series was a guide for discussing palliative care with terminal patients. End-of-life care for patients who lack decision-making capacity was also published in May.

The ACP-ASIM Center for Ethics and Professionalism is a member of Last Acts, a national effort to bring together health professionals, educators, advocates and patients to improve the care of dying patients. Results of their research are available for physicians in their publication and online forum, Innovations in End-of-Life Care.

ACP-ASIM Confronts HHS Fraud and Abuse Campaigns

In an exchange of letters and news releases, ACP-ASIM confronted questionable assertions from the Department of Health and Human Services' investigation of physician waste, fraud and abuse in Medicare claims and in their campaigns geared to the elderly.

An April 1, 1999 letter from Executive Vice President Walter McDonald, MD, FACP, questions actions of the OIG and other government officials that imply the billings of all physicians are suspect despite claims by the OIG that it is not interested in prosecuting physicians who make honest mistakes. The letter asserts that a recent campaign launched by HHS and AARP entitled "Who Pays? You Pay," creates mistrust between physicians and their elderly patients.

ACP-ASIM previously proposed comprehensive ways physicians and government could work together to reduce waste, fraud and abuse to the Inspector General, but was rebuffed in attempts to meet a second time.

Inspector General June Gibbs Brown refuted ACP-ASIM's allegations, but "welcomed the opportunity to meet with representatives of the ACP-ASIM to discuss issues of mutual interest." ACP-ASIM now sees the opportunity to propose recommendations to the OIG.

Local Happenings

Dan Duffy, MD, MACP Addresses Wisconsin ACP-ASIM Council on Recertification

Dan Duffy, MD, MACP and a member of the American Board of Internal Medicine, started out with giving some historical data about organizations that started recertification requirements. The American Board of Family Practitioners started with the requirement for recertification every seven years ever since they were formed. The surgeons added recertification in the mid-seventies. The pediatricians added the requirement for recertification at some point in the 1980s. In 1986, the ABIM board decided that internists would also need to recertify. So all given out since 1990 are only ten-year certificates; hence requiring recertification. Everyone prior to that time was given a lifetime certificate and that is not to be rescinded. It is expected that many internists will voluntarily go through recertification, but it will not become required by the ABIM.

In the near future, the ABIM will come out with its new recommendations for recertification. It will have three parts. The first part will be a self-assessment in which an internist will have to answer 60 questions from 5 different modules in the field that they are recertifying in. It is open book multiple-choice test. It deals with difficult controversial questions and answers and the individual must pass all five modules. Resubmission of a particular section can be done several times in case they don't pass particular modules. The second part deals with communication skills and will not be multiple choice. The physician will need to select 40 patients who will be called by ABIM representatives to give feedback in regard to the communication skills of the physicians. Additionally, the physician will have to select 20 peers and similar process of questioning by the ABIM will be performed. Feedback will then be given to the physician in regard to the response of those interviewed. There will also be a portion of it that will be a practice performance review in which 60 patient charts will be for practice principles such as prevention. The third portion of recertification will be the requirement for passing the final exam. The test will be reasonable information that should be in the head of practicing physicians. It is felt that if they don't already know it then they would be inefficient. There will be 180 questions total and it will be a proctored exam.

The cost of recertification will be $855. If a physician is recertifying only in a subspecialty area, they do not need to recertify in the field of General Internal Medicine. Discussion then pursued among the council members in regard to our Wisconsin Chapter taking some kind of stance that deals with employer organizations that are actually requiring board certification as an eligibility for employment. It was decided that we should definitely relegate some time at our state meeting to discuss the recertification issue as well as advancement to fellowship and that there be readily available materials and knowledgeable persons to answer the questions.

Wisconsin Chapter ACP-ASIM Regional Meeting
September 16,17 & 18, 1999
Pfister Hotel, Milwaukee, WI

I would like to invite you to join me and your colleagues in internal medicine at what will be this year's most important medical meeting in your field - the 1999 Scientific Meeting of the Wisconsin Chapter of the American College of Physicians - American Society of Internal Medicine.

Join us at the Pfister Hotel for timely and topical discussions of the medical, economic and political issues that internal medicine faces today - and in the future. At this year's meeting, you'll hear noted colleagues share the latest on:

• Resident Poster Session and Clinical Vignettes;
• New Pharmacology for Internists; and
• Legislative Update on Medical Issues.

I particularly want to invite you to join us at our annual Town Meeting and Business Meeting. You'll learn more about the activities of our Chapter and have a better opportunity to contribute in areas of particular concern to you. We are pleased to have Sara E. Walker, MD, MACP, at our meeting to talk with us about College-related issues. Don't miss this chance to make your voice heard by College leadership.

Between scientific sessions, be sure to stop by the College display for an update on new programs and services for members. Information will be available about new subspecialty MKSAPs, postgraduate courses, books and the upcoming Annual Session.

Last, and certainly not least, I encourage you to bring your family. There is always free time to enjoy numerous recreational activities and sightseeing that will make your attendance at our meeting enjoyable for all.

Don't delay! Mark your calendar now and send in your registration today. I am sure you'll agree this meeting with colleagues in our Chapter is an exciting, informative passport to the future in internal medicine.

Scientific Program and Special Events

Thursday, September 16, 1999

6:00 AM - Golf Tournament

12:30 PM - Registration Opens

2:00-4:00 - Residents' Poster Session
Kesavan Kutty, MD, FACP, Chair

6:30-7:30 - Welcome Reception

Friday, September 17, 1999

6:30 AM - 5K walk/run

7:00 - Registration Opens

7:30 - Wisconsin Chapter, ACP-ASIM Town Meeting and Business Meeting
Frank M. Graziano, MD, PhD, FACP, Governor

Presentation by College Representative
Sara E. Walker, MD, MACP

8:45 - Asthma Pharmacology
Robert K. Bush, MD, FACP
Section of Allergy/Immunology
University of Wisconsin Hospital and Clinics

9:30 - Arthritis Pharmacology
Paul B. Halverson, MD, FACP
Section of Rheumatology
Medical College of Wisconsin

10:15 - Break
Visit exhibits and College display

10:30 - Diabetes Pharmacology
Gregory C. Doelle, MD, FACP
Department of Endocrinology and Metabolism
Marshfield Clinic

11:15 - Middleton Memorial Lecture
Richard E. Rieselbach, MD, FACP
"The Education of Internists for the Next Century"

12:15 PM - Luncheon and Presentation of Laureate Award to Richard E. Rieselbach, MD, FACP

1:25 - Residents' Clinical Vignettes

6:30 - Chapter Banquet and Awards

Saturday, September 18, 1999

8:00 AM - Continental Breakfast

8:30-9:30 - Russell Quirk Memorial Lecture
Mark A. Kelley, MD, FACP

9:30-10:15 - The Physician Assistant's Role in Wisconsin
Tim Gengembre

10:15-11:45 - Legislative Update

12:00 - Council Meeting

Governor's Note

This year's chapter meeting in Milwaukee will be an opportunity to learn and discuss new and exciting therapeutics for important disease processes affecting our patients. It will also be a time to discuss important issues affecting all of us in the practice of medicine. We look forward to seeing you September 16-18 in Milwaukee.

In addition to this newsletter, you'll find a brochure entitled "How Satisfied Are Your Patients?" Through the patient satisfaction survey, you'll be able to gauge your practice on physician interactions, service convenience and staff interpersonal skills. You'll also learn how your patients regard the quality of their office visits and get tips for improvement through this invaluable survey service.

For additional brochures, please call ACP-ASIM Customer Service at (800) 523-1546, ext. 2600. The brochure is a product of the ACP-ASIM Center For A Competitive Advantage.

Any questions concerning the meeting or other concerns contact the Chapter office at 600 Highland Avenue, H6/368, Madison, WI 53792-3244 or call (608) 263-3457 or e-mail fmg@medicine.wisc.edu.

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