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Public Health
Authority gets underway
The Aug. 18 inaugural meeting of the Detroit Wayne County
Health Authority capped an 18-month odyssey of planning and
politics and began a coordinated effort to address the
growing health care crisis in Detroit and Wayne County.
"The ball has been handed to the Detroit Wayne County
Health Authority to be the model in the nation for how we
can coordinate and provide care," said Gov. Jennifer
Granholm at the first public meeting at the Cabrini Clinic
in the Detroit’s Corktown neighborhood.
"This cooperation in health care is
unprecedented," said Gail Warden, former CEO of Henry
Ford Health System and the person who helped guide the
health authority as it formed. "This is the first time
I've felt all the players were talking to each other with
the same goal in mind."
The health authority originated with a joint task force
Granholm established in April 2003 to prevent two Detroit
hospitals from closing. The task force's recommendations
resulted in a $50-million public bailout for Detroit
Receiving Hospital and Hutzel Women's Hospital. But city and
state officials, along with local health care leaders
recognized the fix was just a stopgap measure. Structural
reform was deemed necessary.
A separate group was formed to investigate long-term
solutions to the crisis. The governor, mayor of Detroit and
Wayne County executive entered into an agreement
establishing the health authority in December. After much
internal wrangling, the Wayne County Commission and Detroit
City Council approved the agreement, setting the stage for
the authority’s launch.
The authority will be financed by a $500,000 federal grant
and $600,000 from foundations and charitable organizations
during its first year of operations.
Doctors want voice in coverage decisions
By MICHAEL SANDLER, MD
Chair, MSMS Board of Directors
The Aug. 1 newspaper story, "Blue Cross cuts 1,350
doctors in network," is just the tip of the iceberg
about how poorly Blue Cross Blue Shield of Michigan is
treating its participating physicians and our patients.
Ironically, Blue Cross Blue Shield recently held three
"summit meetings" to seek a better relationship
with physicians, while making unilateral contracting
decisions that infuriate physicians and could disrupt
patient care.
Two recent examples highlight the disrespectful nature of
Blue Cross's unfair business practices.
In early July, Blue Cross sent recontracting letters to
physicians in Blues Preferred Plus giving them a matter of
days to reply or be disaffiliated. The reimbursement
schedule was not even included. As the story noted, it also
plans to cut up to 10 percent of the physicians in this
plan, forcing thousands of patients to find a new medical
home.
What other business could behave in such an arbitrary and
capricious manner to the people on whom they depend for
their very existence?
Ford, DaimlerChrysler and GM's recent United Auto Workers
settlement also is disheartening. Autoworkers were taken
from the traditional plan and put into a preferred provider
organization, a false label since none of the autos have
contracted with any physicians.
Blue Cross and the autos also misuse the term "covered
service" by saying it includes office visits, even
though they are subject to 100 percent co-payment. What else
in the future might be called a "covered service"
that UAW members will pay out of their own pockets?
If physicians do not comply with the unilaterally discounted
office visit fee, it's clear they will be disaffiliated from
UAW plans, as well as other Blue Cross PPO plans, further
disrupting patient care. Even if physicians agree to this
reduced reimbursement, the autos and Blue Cross intend to
cut many doctors from the UAW networks next year anyway, so
UAW members' freedom to choose their own physicians will
become further limited.
The goal of the Michigan State Medical Society is to provide
high-quality care to our patients. We understand controlling
health care costs is important. We simply want an equal
voice in how it is done.
1010 Antietam Road, Detroit 1958-2004
The longtime headquarters of the Wayne County
Medical Society was sold to the Detroit Entrepreneurship
Institute, Inc., on July 29, 2004. The building at 1010
Antietam Road was the only headquarters building known to
many members. In 1958, when the Society moved from the
Whitney House to Antietam Road, the new WSU School of
Medicine was across the mall in Shapiro Hall and a number of
hospitals were within walking distance. Over the years
changes occurred, the hospitals are now in close proximity
to one other within the DMC, the WSU School of Medicine is
housed in Scott Hall on Canfield St. and the Society is a
suite of offices at New Center One on West Grand Blvd.
The Detroit Entrepreneurship Institute, Inc., established in
1990, is a non-profit licensed proprietary school and has
provided business training, technical assistance and
start-up capital for 14 years.
Our best wishes to the DEI for years of success.
Members in the News
Krishna Sawhney, MD, was named President of the
American Medical Association Foundation for 2004-2005. Dr.
Sawhney is on the staff of Henry Ford Wyandotte Hospital
and serves as Chief of Surgery, Downriver Region, for the
Henry Ford Health System in Detroit. He also is a Clinical
Associate Professor of Surgery at Wayne State University
School of Medicine.
Sophie Womack, MD, Sinai-Grace Hospital’s
(SGH) Chief of Neonatology, has been named the new President
of the Detroit Medical Center Medical (DMC) Staff. Dr.
Womack will oversee all matters related to the physicians
and allied health professionals within the DMC.
EDITORIAL: Being Blue Or Being Preferred
By JOSEPH WEISS, MD
Editor
I am referring to the announcement you have already
heard: BCBS intends to drop a good number of physicians from
its Blue Preferred Plus (BPP) network. The number originally
was 700 primary care physicians, though newspaper articles
set the goal as 1,350 doctors. (In the local 21 counties
there are 8,000 physicians in the network with the number of
primary care physician representing one-half to two-thirds
of the total).
According to BCBS the criteria they will use has four
aspects: (1) cost/patient, (2) prescription costs, (3)
patient satisfaction scores, and (4) measures of quality
based on HEDIS (Health Plan Employer Data and Information
Set). BCBS states that it has the data on hand on each
physician in the Blue Preferred Plus network to profile each
physician and on the basis of points, decide who among
doctors will continue to be preferred, and which doctors
will be dropped from the network.
What reason is there to drop any doctor? The Blues reply
that they are the messengers, the message came from the auto
companies. Each of the big three - Ford, GM, DaimlerChrysler
- eventually came to an agreement that the Blue Preferred
Network should downsize to include only the most efficient
"providers."
While the Blues state there are four criteria for inclusion,
the feeling in the medical community is that by far the
greatest weight will go to criterion of the physician's
cost/patient. If that physician is high, he or she will be
out, and if low, will continue in the network.
Neither the Big Three nor BCBS offer a rationale explaining
why fewer doctors would mean less cost. To date, no analysis
exists as to how many high-cost doctors are in BPP, how much
higher their cost is compared with the average, or what
price BPP pays by shifting an increased patient load to the
doctors who remain in the network. No one has thought out if
the tradeoff is worthwhile if doctors are overworked, and
patients are underserved.
The Michigan State Medical Society has responded as follows:
-Asked for the weight BCBS will give to each of its four
criteria.
-Requested a written appeal process available to doctors who
wish to dispute BCBS conclusions or actions on
participation.
-Continues to gather its own data to respond to BCBS's claim
that the elimination of 700-1350 physicians will mean no
loss for autoworkers in terms of access to care, its
timeliness, or personal quality.
As if dropping physicians and doing so with no prior warning
by either contract or letter wasn't bad enough, the new
contract tells doctors to do more work and guarantees them
in return less remuneration.
More woe to primary care physicians: more criticism, more
scrutiny, and now welcome to the world of day labor.
CORRECTION
An error appeared in the editorial in our June 2004
newsletter. Dr. Weiss stated that "Rep. Howell will be
opposed by Dr. Roger Kahn, a Genesee cardiologist." Dr.
Kahn is a cardiologist in Saginaw County. In addition, he
will not be running against Rep. Howell, who is not running
for state representative.
The Rising Tide Of Health Care Costs Doesn’t Raise
All Boats
By GEORGE SHADE, MD
Chief, Department of Obstetrics and Gynecology
Sinai-Grace Hospital-Detroit Medical Center
This is the first time I have heard a balanced
perspective on this whole health care issue. The Big Three
are responsible for capitulating to the UAW for years
offering the "Rolls Royce" of health care benefits
to its hourly employees. The cost of everything is going up!
In striking contrast, however, the percent of the health
care dollar that goes to physicians for direct patient care
has continued to go down. I think doctors have been squeezed
to their limit from all sides: insurances, government, and
professional benevolence in the form of pro bono service.
Hospitals are closing or cutting back on staff and services,
doctors are leaving the City of Detroit, Wayne County, the
State of Michigan or just choosing to revamp their life and
how they practice medicine. I saw a dermatologist patient of
mine recently who says that she no longer accepts any kind
of insurance as payment for her professional services. She
is tired of the litany of paperwork, onerous regulatory
requirements from the government, and ever-rising overhead
expenses.
Just by eliminating insurance headaches, she has been able
to reduce her office staff and overhead expenses by 60
percent with little or no impact on her gross receipts.
The industry leaders need to direct their frustration where
it should be focused: on pharmaceuticals, laboratory
services and durable medical supplies.
It is absurd when the cost of a single prescription is
sometimes three times the cost of the doctor's visit. One is
paid significantly more to run a lab test than to take
direct care of a sick patient. The issue of durable medical
supplies, where vendors are becoming millionaires supplying
oxygen, bedpans, walkers or other items at rental rates that
are sometimes greater than four times the cost of buying the
product outright, is almost as ridiculous as what the
military pays for its supplies.
Everyone one who is lower on the food chain is actually
feeding better than the primary sources of health care in
America.
MSMS scrutinizes
new UAW/PPO provisions
By JESSY SIELSKI
Chief of Communications, MSMS
In the June 2004 edition of The Record, Blue Cross Blue
Shield of Michigan released details of the General
Motors/Delphi UAW PPO benefit structure. DaimlerChrysler
implemented their version of a new UAW PPO, called the
"Standard Care Network," on April 1, 2004. The GM
version of the new PPO, titled "Traditional Care
Network," was implemented July 1, 2004, and has subtle
but important differences from the DaimlerChrysler UAW PPO.
Ford is now anticipated to implement their version on Sept.
1, 2004. All of these PPOs were implemented to enroll those
auto company employees currently covered under the auto
companies' traditional insurance programs. BCBSM has
committed those physicians who have entered into a Blue
Preferred Plan (Trust) Professional Provider Agreement (the
"Trust Network Physicians") with BCBSM ("PPA")
to provide office visit services to the PPO enrollees for
new fee schedule amounts.
Like DaimlerChrysler, General Motors expects that Trust
Network Physicians will bill the PPO enrollees new fee
schedule amounts that are less than what Trust Network
Physicians have been charging for these office-visit
services. Although Trust Network Physicians are allowed to
bill the patient at the time of the visit, General Motors
also expects Trust Network Physicians to submit a claim to
BCBSM so that it can generate a voucher and an explanation
of benefits that will confirm the member's financial
responsibility. Since it is unlikely that there will be a
condition under which the member will not be responsible
(the DaimlerChrysler UAW PPO has a $5,000 annual deductible
applicable to office visits and the GM UAW PPO has a 100
percent co-payment requirement for office visits), the need
for this paperwork is not apparent.
MSMS legal counsel reviewed the Physician Participation
Agreement and is seeking answers and information from BCBSM
and/or auto company representatives prior to giving a formal
opinion as to whether Trust Network Physicians are obligated
to bill only the fee schedule amount for office visit
services. Trust Network Physicians are not obligated to
accept a fee schedule rate for office visit services without
a contract obligating them to do so. BCBSM seems to be
relying on the PPA as this contract. However, an examination
of the PPA raises several questions/issues:
-The Trust contract references certificates, riders and/or
benefit plan descriptions issued by BCBSM. These would
outline covered services and specify the obligations of the
Trust Network Physicians. BCBSM staff has stated that there
are no certificates or riders because this is an
administrative service contract. How can physicians be
obligated to rules that are not specified in the manner
referred to in the contract? How can BCBSM exert what is
virtually an "all products clause" by obligating
physicians to accept all PPO products if they want to
participate in the Trust network?
-If the contract obligates physicians to accept the Trust
fee schedule for covered services, how can services that
have 100 percent patient co-pay or an unreasonably high
deductible be considered covered services?
-With few exceptions, fee schedule changes cannot be
implemented until after 60 days written notice. Very broad
details on the DaimlerChrysler and Ford PPOs were published
in the January 2004 edition of The Record, but MSMS had to
make inquiries in March to find out what office visits were
included and to get written verification of the catastrophic
deductible before the April 1, 2004, implementation date. GM
PPO program details were not released until the June 2004
edition of The Record, and the program was implemented July
1, 2004. Why was appropriate notice not given?
-The Trust contract states that physicians should only seek
payment for covered services from BCBSM. How does this
reconcile with the instruction that physicians collect
office visit fees directly from patients?
MSMS notified members about concerns with this program
through a Payer Solutions Network e-mail message on June 24
and will provide updates on a regular basis. MSMS is also
educating legislators about the concerns they may be hearing
from physicians in their districts. For more information,
contact Julie Novak at MSMS at (517) 336-5768 or jnovak@msms.org.
Doctors’ suit against Blues continues, judge says
A federal judge has rejected Blue Cross Blue Shield of
Michigan's request to dismiss a class action lawsuit by
several Oakland County doctors over reimbursement practices
at the state's largest health insurer, reported the
Associated Press.
US District Judge Bernard A. Friedman ruled that portions of
the case should remain in federal court while one portion
dealing with timely reimbursement should be dealt with
through other channels, such as the state insurance
commissioner., according to the report.
The doctors’ assert that the Blues intentionally delayed
payment for services rendered.
Blue Cross officials said they were pleased with the ruling
on prompt payment, while attorneys for the doctors say they
were glad that a charge that Blue Cross violated the federal
Racketeer Influenced and Corrupt Organizations Art remained,
reported the AP.
``This lawsuit is misdirected and without merit and we are
pleased that the court has already dismissed one of its
counts,'' Blue Cross spokeswoman Helen Stojic told The Daily
Oakland Press of Pontiac.
Linda Watson of the Troy law firm of Cox, Hodgman and
Giarmarco that represents the doctors told the AP that Blue
Cross violated federal statutes when in 2002 it changed
billing codes for gynecological services.
She said Blue Cross then routinely denied payment on
legitimate claims on the false grounds that the codes
submitted by physicians were incorrect.
Dr. Susan Adelman and her art
I would like to bring to the attention of the membership,
that Dr. Susan Adelman's latest work is now on display at
the Charach Gallery, at the Jewish Center (Drake Road, just
north of Maple Road) and will be there through Sept. 29. She
will also have a show at the Southfield Public Library
(Civic Center Drive near Telegraph) that opens Thursday,
Sept. 2 from 6-8 p.m. DMN readers are invited to the
opening.
We know Dr. Adelman as a pediatric surgeon who also wielded
an incisive and witty pen. However her talent ranges in art
to painting, sculpture and jewelry design. The two showings
exhibit the range of her skills and reveal that her incisive
mind and eye retain their vigor.
I have seen the Charach Gallery show and was impressed with
her range of subjects and the statements she makes on the
people and scenes she paints. As always, it continues to be
worth your while to pay attention to what Susan does, her
work and artistry can enrich each of us.
— Joe Weiss, MD
Blue Preferred Plus reduces network, MSMS seeks
appeal process for physicians
By JESSY SIELSKI
Chief of Communications, MSMS
Blue Cross Blue Shield of Michigan is revising the
payment arrangement for the Blue Preferred Plus (BPP)
program, a smaller auto PPO network established in 1994.
Previously, physicians contracting with BPP were paid at the
TRUST fee schedule with a 15 percent withhold. The withhold
return was determined by the cost of the plan versus
patients enrolled in the Traditional program. The autos
specified that BPP had to be less costly than Traditional
for the withhold to be returned, so it was based on
aggregate measures, not individual performance. Because
sicker patients were attracted to the program for the more
generous office visit coverage, and because the autos froze
the program size and did not let new patients enroll, BPP
inevitably became more expensive, and the withhold was not
returned for the last several years.
BCBSM now is revising the program at the request of the auto
companies. The payment will now be 10 percent under the
TRUST fee schedule, with no withhold. They are also reducing
the size of the network by eliminating 700 primary care
physicians this year. New contracting letters are being sent
to physicians over the next several weeks. The 700 that will
not be invited to rejoin the network represent a 5 percent
reduction of the network and were chosen based on profiles
conducted by Blue Care Network, which does some of the
administrative work for the network. The measures used
included economic profiles, quality data (HEDIS
performance), pharmacy prescribing patterns, and patient
satisfaction. MSMS is asking that BCBSM address the
need for an appeal mechanism for physicians that are dropped
from the network. BCBSM intends to address reduction in the
number of specialists when they have better data to measure
them by, possibly in 2005.
For more information, contact Julie Novak at MSMS at (517)
336-5768 or jnovak@msms.org.
MSMS Board takes action on automaker PPO issue
A series of strategies to address concerns raised by the new
United Auto Workers PPO contracts with the Big Three
automakers was approved by the MSMS Board of Directors
during its July 25 meeting.
The collective bargaining negotiations last fall resulted in
moving all UAW members previously covered under the
Traditional Plans to so-called "PPOs" created by
each of the auto companies that are administered by BCBSM.
Instead of creating a real PPO by contracting with
physicians, hospitals and others necessary to provide the
covered services the auto companies have represented to
their employees that the BCBSM TRUST Network is required to
provide services at the TRUST fee screen rates.
MSMS Legal Counsel specifically asked BCBSM if charging
other than the TRUST fee screen would be a breach of the
TRUST Network Agreement.
BCBSM wrongly believes that the TRUST Network Agreement
obligates physicians to charge the fee screen amount rather
than the amounts historically charged for office visit
services. This interpretation of the TRUST Network Agreement
by the auto companies and BCBSM is based on their erroneous
conclusions that an office visit is a "covered
service" even though it requires a 100 percent patient
copayment (or a deductible that has been set so high, e.g.
$5,000, that it will never be met) and that the benefit plan
descriptions issued by the auto companies have somehow been
"sponsored" by BCBSM.
MSMS Legal Counsel also specifically asked what would be the
consequences of such a "breach" of the TRUST
Network Agreement.
BCBSM officials have been clear that physicians who do not
comply with the office visit discounts will be disaffiliated
from the TRUST network after an "educational"
phase.
After a thorough review of the TRUST contract and discussion
with BCBSM officials, MSMS Legal Counsel does not believe
that the TRUST contract requires physicians to charge only
the fee screen amount for office visit services provided to
enrollees in these "PPOs."
The TRUST Network Agreement only requires physicians to
charge the fee screen amount for covered services provided
to patients (i.e. services that are actually covered) that
are cited in a certificate, a rider or benefit plan
description issued by BCBSM or under its sponsorship. This
would only include patients enrolled in a BCBSM PPO plan.
BCBSM has said that in order to stay in the TRUST Network,
physicians must participate in all programs offered by BCBSM,
including these new "PPOs" (which are really just
self-funded employer plans and not PPOs). In other words, if
physicians do not accept this unilaterally imposed fee
reduction, they will become an "out-of-network"
provider for any patient enrolled in a BCBSM PPO product.
"Based on action taken by the MSMS Board of Directors,
MSMS is currently pursuing every possible avenue to reach a
resolution with BCBSM about this onerous provision in the
UAW PPO rules," said MSMS Board Chair Michael A.
Sandler, MD. "MSMS Legal Counsel has been instructed to
explore all possible legal remedies if a resolution cannot
be reached. MSMS also is educating legislators about the
impacts of this violation of generally accepted business
practices, including possible disruption of patient
care."
What can you do? MSMS has developed a sample letter to help
physicians explain this situation to their UAW patients.
This letter can be downloaded from the MSMS Web page at http://www.msms.org/bsyp/news/LettertoPatients.doc
and printed on your office stationary.
You also can go to the MSMS Action Center to send messages
to Blue Cross officials or contact your legislator. The Web
address for the action center is: http://capwiz.com/msms/issues/alert/?alertid=6215766&type=CU&azip=48823&bzip=2605.
To reach your legislator, use: http://capwiz.com/msms/mail/oneclick_compose/?alertid=6214336.
BCBSM expects to have 3 million (or 75 percent of its
covered lives) enrolled in its PPOs by the end of 2004. In
addition, the patients who see an out-of-network physician
are sanctioned with fines and increased copays and
deductibles. DaimlerChrysler and General Motors have already
implemented the new PPO structures; Ford will begin
implementation on Sept. 1, 2004.
For more information, contact Julie Novak, MSMS Director of
Medical Economics, at (517) 336-5768 or jnovak@msms.org.
Blues policy changes bring more questions than
answers
From Dr. Federico Mariona:
Following the efforts of MSMS the deadline for
"new" provider contract return to the Blues was
extended to Aug. 31. That said, time is running short to
activate further steps to protect the involved physicians.
First, we don’t know to this day who the disinvited are.
Are they those who do not receive the new blank contract to
sign? Who has the list ? We really dont't know for certain
how many are not going to be "invited back" into
the new product. The numbers given by the blues are
confusing. Are those 1,200 or so part of the total number of
participating physicians in the state or part of the
participating Primary Care Physicians?
If the latter is the case as I believe it is, the impact on
practices and hospitals may be variable according to the
distribution of subscribers per affected physician and the
number of PCPs per hospital in any area. Some practices and
hospitals, especially in Southeast Michigan may have a major
impact if their volume is large and patients are required to
change PCP AND hospital at the same time.
Further, whatever (Blues Medical Director) Simmer has said
is also suspect since it is Blue Care Network that
administers the program, therefore it is probably in the
hands of Kevin Seitz.
I am probably not up-to-date in the activities and new
strategies of MSMS, however, I believe that once Aug. 31 is
gone those disinvited physicians will be out of the loop
with no recourse other than some request for
"reconsideration" or activating the
"appeal" process, which we all know how long it
takes and what the possible results will be.
I am rhetorically asking: Are MSMS and the regional
societies ready to strongly support physicians in this new
attempt by the monopolizing insurer to restict their
professional activities ? We know which language those
insurers understand the best. Your thoughts and updates will
be appreciated.
MSMS Response:
Yes, MSMS is continuing to pursue this issue vigorously. I
am including questions that we sent to Blue Cross, and we
were promised answers shortly. Please know that MSMS legal
counsel has read the existing and new BPP contracts, and has
advised us that no one can be dropped from the network until
they have received a separate letter giving them 60 days
notice. We intend to make sure that they live by the rules
of the existing contract on this issue. We have already
insisted they set up an appeal mechanism, so that those that
are targeted for disaffiliation can examine the data that
are being used and pursue a reconsideration.
Here are the questions we sent, putting BCBSM and BCN
administrators on alert that we expect these issues to be
resolved quickly. We have asked that the list of physicians
being targeted for disaffiliation be released to us and to
physician organizations. Our legal counsel will have
additional analysis and recommendation when we receive their
response, or if we do not get complete answers.
1) Please confirm for me the next steps in this
process and the exact timelines for what will occur next.
2) The date for returning the contract was extended to
:Aug. 31 after MSMS expressed concerns. What will happen to
physicians that do not return the contract by that date?
3) When exactly will you be mailing letters to the 700
PCPs you plan to disaffiliate from the BPP network? When can
I see a draft of the letter that is going out? Our
understanding is that the old contract requires you to give
60 days notice in that letter.
4) You and I spoke several times about the need for an
appeal process for physicians that you are disaffiliating.
Please tell me what that appeal process will be, and confirm
that it will be outlined in the letter that will go out to
physicians.
5) We have heard from group practices that have only
received contracts for some physicians in the group. This
obviously would create coverage problems if a patient needs
to be seen when the contracted physician isn't available.
How do you intend to address this?
6) Some of the large PO groups are struggling to understand
who is in and who is out, particularly since you have yet to
notify the 700 you plan to drop. When you notify the 700, we
would like to have a copy of the list and ask that you
provide PO groups names of physicians in their area that are
being dropped. We are wasting a lot of your and our time
talking to people that weren't in BPP before, because they
are confused about whether this issue applies to them. This
could have been avoided if people receiving contracts had
been given appropriate notice and had timely access to fee
schedule information. Instead we had to fax and e-mail
everyone so that they knew the deadline had been extended.
If your relationship with the autos doesn't allow fair
notification and complete information for physicians before
they must make a contracting decision, then it will be hard
to sell the wonders of the Provider Affiliation Strategy to
our members.
7) I have had calls from several practices that contacted
the phone numbers included in the letter (BCN Provider
Affairs), and have either not gotten return calls or can't
seem to get the information they want. We have been
referring our members to Provider Consulting, since this is
a Blue Cross PPO product and we expect that PCS staff will
follow up with physicians or refer them to the right people.
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