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Blues Execs promise
improvements in service
MSMS to ‘watch closely’
By PAUL NATINSKY
Managing Editor
Top brass from Blue Cross and Blue Shield of Michigan
promised a physician audience of more than 100 June 8 in Novi
that the health care corporation will work to improve its relationship
with doctors.
"It is a fundamental, driving imperative for us to have a good relationship
with physicians," said a Blues spokesman.
To do that, the health care corporation will have to solve myriad problems,
including high rates for claims rejections, inappropriate payment delays,
unannounced coding changes and computer problems, said MSMS Board Chair
Michael Sandler, MD.
The meeting, dubbed the Blues Summit, was attended by company CEO Richard
Whitmer, Medical Director Thomas Simmer, MD, and other Blues executives.
Various speakers from the panel told physicians that BCBSM is hard at
work fixing problems. The effort includes sending Blues executives into
the field to "feel providers' pain."
The Blues' Susan Barkell said the company's Provider Affiliation Strategy
contains a number of vehicles to solve problems with physicians, including
regular meetings with MSMS staff on coding issues and other difficulties.
She said in the past the Blues used measurements it speculated were correct
to establish codes, now the company sends employees into the field to
get data.
Dr. Simmer said, "If we want to get consistent answers, a standardized
system is the only way." He said a nationally supported system could
yield compatible answers to provider questions, but he did not say that
such a system is likely anytime soon.
In an eight-page handout distributed at the Summit, the Blues listed
four "key elements of change" to improve dealings with doctors:
1. Prompt and accurate claims payment;
2. Consistent, and responsive service;
3. Timely and effective communication;
4. Partnerships to promote and facilitate better health care.
"The proof of the pudding is in the eating," said Dr. Sandler. He said
MSMS will watch the process closely. He said the Blues and MSMS leaders have
had several recent meetings characterized by a "candid tenor."
Dr. Sandler said there are several things physicians can do to help.
He said, "If you have claims issues, now is the time to let us know." MSMS
provided forms for that purpose at the event and has a section on its
Web site, www.msms.org, set aside for
gathering complaints. The Payer Solutions Network (PSN) is the e-mail-based
system located at the MSMS Web site. Having your e-mail address on file
with MSMS automatically registers you for the network. MSMS would like
to collect the e-mail addresses of office managers, billers and other
physician office staff who might benefit from being part of the network.
MSMS also offers a Reimbursement Advocate who has direct access to every
health plan in the state and has helped doctors recover as little as
$30 and as much as $50,000. Members can contact Stacie Saylor at (517)
336-5722 or ssaylor@msms.org for
more information.
Dr. Sandler added that specialty societies supported by MSMS can be of
assistance in supporting physicians who have difficulties with the Blues.
MSMS President John MacKeigan, MD, who is also Vice Chair of the Blues
Board, said that "physicians were once viewed by BCBSM as a nuisance,
but that has changed." He said "nothing distinguishes the Blues
from other insurers - they must address these issues to distinguish themselves.”
Liability, Medicare are front and center at AMA
By NARINDER K. SHERMA, MD
WCMS
The 153rd Annual meeting of the AMA House of Delegates was
held at the Hyatt Regency in Chicago, June 12-16, 2004. WCMS
was represented by Drs. Kahkonen, Sawhney (Delegates) and Amirikia,
Sandler, Andaya and Sherma (Alternate Delegates). Also present
were Adam Jablonowski, Drs. Brooks Bock, Kamran Moghissi, Michael
Benninger, Richard Smith and Ron Davis. The announcement for
Ron Davis's reelection bid for second term to AMA Board of trustees
at the 2005 meeting was co-sponsored by your WCMS.
The House opened with an address from one of its most dynamic outgoing
presidents. Dr. Palmisano highlighted the victory on the Medicare bill,
implored the AMA not to rest until it finally fixed the medical liability
problem and found a permanent fix to the flawed Medicare formula that
continues to threaten physician reimbursements and patients’ access to
care. He closed his remarks strongly urging AMA to see this race to the
end and to shatter the barriers that tell us "it can't be done."
Michael D. Maves, AMA's EVP/CEO told the story of AMA in numbers. AMA
has the bragging rights in terms of our advocacy efforts. Our PAC has
been described as the number one health care related PAC by several Washington
organizations. AMA, for the first time had a year to year increase in
membership, 5,251 more members when compared to June 2003.
AMA's advocacy agenda was unveiled at this meeting. "Healing the
System: A Plan to Rescue US Medicine" outlines AMA's themes on reforming
the medical liability system, strengthening Medicare, expanding health
care coverage and choice, financing medical care for low income patients,
improving managed care and enhancing patient safety.
Many educational forums were held. Space will not permit mention of all.
The Organized Medical Staff section presented "A Tale of a Stalwart
Medical Staff: A Lesson in Self-Governance" about the Community
Hospital of Ventura County California and "The Widening Gulf Between
Hospitals and Medical Staff," a really intriguing outcome-based
presentation by a professor from the Wharton School of Business. The
Council on Medical Education celebrated its 100th anniversary. The Council
on Ethics and Judicial Affairs, Minority Affairs Caucus, International
Medical Graduates Section, Medical Students, Residents and Fellows, Young
Physicians, Women Physicians, Senior Physicians, Group and Faculty Practice,
OSMAP, Surgical Caucus, Litigation Center, Tobacco Control Coalition
and AMA Action Team on Elimination of Underage Drinking all held their
deliberations.
The AMA confronted OBESITY at this meeting by holding an Open Forum and
adopting several new policies targeting obesity and unhealthy eating,
including the role of obesity in the lives of racial and ethnic minorities.
The AMA called for a revision of the Dietary Guidelines for Americans
and Food Guide Pyramid, educating physicians, urging restaurants to provide
information on nutritional content of food items and making healthy food
options available in hospitals, schools and work cafeterias.
Incoming AMA President John Nelson called for a comprehensive bipartisan-supported
health care campaign,"Healing the System," and reiterated the
need for significant changes in Medicare to keep pace with advances in
clinical medicine and a burgeoning population reaching retirement age.
Dr. Nelson is from Salt Lake City, site of the last winter Olympics,
where he held one of the Olympic lanterns. He did so again in Chicago
and promised to "Light the fire within our organization" during
his term.
J. Edward Hill of Mississippi, was elected president-elect defeating
Herman I. Abromowitz of Ohio. William Hazel from Virginia was elected
to Board of Trustees; Mohamed Khan, previously from Michigan, was elected
to the Council of Scientific Affairs. The Michigan delegation reelected
Cathy Blight as chair; Willard Stawsky as vice chair and Dominic Federico
as secretary.
The House deliberated on myriad issues through various committees and
set policies. For the first time, the meeting was shortened by one day
and despite everybody's nervousness about it business was conducted rather
smoothly. Some of the important issues in various committees were as
follows:
Minority Affairs Caucus was given their longstanding right to a voice
in the house of medicine when the HOD adopted a board report recommending
a delegate. Society of Infectious Diseases was also inducted into the
HOD.
AMA is to adopt policies that ask physicians who testify in malpractice
cases to voluntarily sign an affirmation that they will adhere to AMA
principles; express concerns to President Bush and the Department of
Justice regarding subpoenas to disclose certain medical records of women
who had a third-trimester abortion; support legislative efforts to allow
co-adoption of a child by same sex partner or unmarried opposite sex
partner; support service learning in medical school and residency curricula;
creation of a national training network for National Disaster Life Support
Program; survey the effects of work hour rules; reaffirm policy against
discrimination in residency selection; support "R" rating for
films with tobacco use; restriction on the sale of tobacco products to
tobacco specialty stores and a smoking ban in casinos; support FDA reconsideration
of OTC contraception pills for emergency use; study the impact of specialty
hospitals; and maintain editorial independence of JAMA and Archives.
AMA will encourage national legislation that would strengthen the rights
of the hospital medical staff to self-governance, prohibiting unilateral
changes in bylaws-rules and will continue to work with JCAHO to improve
patient safety; will develop and/promote legislation to eliminate the
sale-without a legitimate prescription -of prescription drugs over the
Internet.
The Michigan delegation introduced 13 resolutions on behalf of MSMS members.
Seven were adopted as introduced; four were amended and adopted and two
were referred to the Board. WCMS's resolution asking for reappointments
to medical staffs every four years rather than two was adopted and AMA
was directed to work with JCAHO and if necessary the federal government
to achieve that. Our last year's resolution on "Impact of HMOs" was
the subject of Board of Trustees report that was adopted by the House
of Delegates.
Please visit the AMA Web site (www.ama-assn.org)
for details on the meeting and other issues or contact one of your AMA
delegates or alternates who will be happy to answer any of your questions.
Letter: Fended In Pigs Are Easy Prey
Now that so many physicians have been herded into PPOs,
HMOs, etc. I’m frequently reminded of my favorite story:
A city slicker in a big truck pulled into a gas station in the hills
of Tennessee. As his truck was being serviced, the city slicker asked
the elderly attendant where he could find the wild pigs around there.
The attendant said, “Down the road a piece and to the right. Why do you
want to know?” The city slicker replied, “Well, I have this big truck
and I want to take some back to the city to sell for meat.”
As the city slicker drove off, the old man shook his head and thought, “Those
pigs have been there for years and it will take more than a dummy like
him to catch them.”
A few days later the same truck drove into the station going in the opposite
direction. The back of the truck was loaded high with dead pigs. The
elderly attendant couldn’t believe his eyes. “How did you do it?” he
asked the city slicker. “It was easy,” was the reply. “When I was in
here last I had a load of corn in the truck. It wasn’t just any corn;
it was the best corn I could buy. I went down there where the pigs were
and threw out some of my corn. At first, they wouldn’t have anything
to do with it. Then some of the young ones came to eat my corn. They
started to bring their friends and families. That good corn was better
than rooting for roots and insects. Then I started to put a fence around
them -- one board at a time. Every day more pigs came and enjoyed the
corn -- and every day I put another board in the fence. They never noticed
the day I put in the last board.”
-- Arthur M. Clark, MD
County, city approve Public Health Authority
After much delay and deliberation, the Wayne County
Commission and Detroit City Council last month gave their approval
to a proposal for a Public Health Authority for Detroit and Wayne
County.
WCMS and MSMS lobbied aggressively for the approval, as did local health
care leaders, including DMC CEO Michael Duggan.
The Authority is expected to provide a structure, gather and organize
resources to provide health care to the poor and uninsured in Detroit
and Wayne County. The Authority is partially modeled after successful
public health authorities operating in Chicago and Denver.
A committee drafted a plan for the Authority and the state approved it
several months ago.
-- Paul Natinsky
Editorial: Should We Maintain What Cannot Be Sustained?
By JOSEPH WEISS, MD
Editor
Physicians today may know more about the SGR than about
the EKG. The medical community hears every day that the Sustainable
Growth Rate (SGR) formula whereby Medicare determines our reimbursement
is better called the Unsustainable Growth Rate Formula. The best
that could be said of the SGR is that it reflects good intent,
but is a bad tool.
The SGR equation includes drug prices over which doctors have no control,
and considers every examination, even those now mandated by Medicare
as being the basis for reimbursement penalty. The SGR does not need a "fix," which
is the popular terminology on Capitol Hill, the SGR needs to be abandoned
and replaced.
It is unfortunate that in the matter of reimbursement for medical services
we have gone so far and deep into insurance payments that we are well
beyond returning to the marketplace to set the price of medical services.
Today, a party other than physicians and patients will determine what
we will earn. Since such is the case, let that determination reflect
the elegance and simplicity that characterizes a good equation. That
means the formula used to pay us should contain all the elements necessary
(elegance) and nothing in greater proportion than its contribution (simplicity).
Costs, incentives to innovation, and acknowledgement of excellent care
all need recognition in a proper reimbursement formula. These considerations
need to be coupled to individuals in the medical community whose background
and experience would allow them to develop an economic reimbursement
model. Certainly, we could expect one superior to what we have with the
SGR.
To date, no major medical organization such as the AMA, American College
of Physicians, or the Centers for Medicare and Medicaid Services have
made an effort to bring people together to discuss an improved model.
Rather all efforts are directed to getting a short term change, a fix,
such as the last minute 1.5 percent Medicare reimbursement increase recently
thrown into the Medicare Modernization Act.
We need to ask our parent organization to end its lobbying for patches
and instead support innovation and initiative. Furthermore, the alternative
to the SGR should be a single measure that the medical community agrees
upon. Only a single proposal with wholehearted support from all of medicine
can take on the effort needed to get innovation in reimbursement through
Congress.
We need our leaders both to change their course and merge their agendas
with others.
Editorial: Health Savings Accounts
By GILBERT BLUHM, MD
Associate Editor
Recently, the Michigan State Medical Society House of Delegates
considered a Resolution for the Society to support Universal
Health Coverage (UHC) in the US. About 10 years ago there was
considered to be 37 million people who lacked health insurance
coverage, but now that number is estimated to have reached 44
million. The health coverage policy of the AMA supports UHC through
a pluralistic delivery system, but not a single payer system
(SPS). Among different approaches to health coverage, the Medical
Savings Account (MSA) for individuals and/or families was supported.
The State of Michigan legislated MSAs in this State in the mid 1990s
before the federal government legislated a pilot study about a year later. Blue
Cross Blue Shield of Michigan was to service (sell) the coverage and
National Bank of Detroit (NBD) was to handle the money for those who
were eligible and wished to use MSA for health coverage. If none or only
part of the yearly dollar amount deposited was spent, the residual plus
its investment earning would carry over from year to year. Not many used
MSA in this state, probably because it wasn't publicized by BCBS (which
was the only company to write and service it); and the MSA was difficult
for potential customers to understand. However, the Mellon Company
in Pennsylvania was able to use MSAs successfully.
This year, the US Government legislated the use of Health Savings Accounts
(HSA) without restriction as a pilot project. The major criticism seems
to be that only healthy patients are expected to utilize such coverage.
If accurate, a decrease in the "healthy" insurance pool is
projected to result in higher premiums. However, any unused HSA dollars
accumulate with interest. The surplus of unused sums that occurs year
after year may be used in an emergency or for retirement. Catastrophic
health insurance coverage is required as part of the HSA.
Perhaps the HSA will appeal to the uninsured young and healthy, and assist
in lowering some of the uninsured 44 million. However, the critics of
HSA may succeed in preventing a fair trial as happened with the MSA in
Michigan.
Supreme Court rules in favor of HMOs in battle over patient
lawsuits
By PAUL NATINSKY
Managing Editor
The Supreme Court said June 21 that patients who claim their
HMOs wouldn't pay for recommended medical care cannot sue for
large medical malpractice damages, a development viewed by physicians,
trial lawyers and patients’ advocates as a blow to patients’ rights
when they are denied treatments and procedures.
A unanimous court said that two HMO patients in Texas cannot pursue big
malpractice or negligence cases against their insurers in state court,
as they claimed a Texas patient protection law allowed them to do.
Congress has repeatedly failed to pass a national patients rights law.
Protections afforded patients by various state laws vary.
The court ruling moves cases against HMOs from state courts, which are
generally sympathetic to defendants, to federal court.
The court based its ruling on the language of the 30-year-old Employee
Retirement Income Security Act or ERISA. HMO patients, such as those
who brought the suit, are now forced to sue only in federal courts.
AMA President John C. Nelson, MD, MPH, expressed extreme disappointment
in the Supreme Court’s ruling, which, he said, denies patients the right
to hold managed care plans accountable in state court for negligent health
care treatment decisions. Managed care plans, said Dr. Nelson, now have
very little incentive to approve expensive but medically necessary treatments.
“By reserving the right to decide what is -- and what is not -- medically necessary,
managed care plans can now practice medicine without a license, and without the
same accountability that physicians face every day,” said Dr. Nelson. “While
the AMA appreciates those managed care plans that put patients ahead of profits,
[the] Supreme Court action significantly erodes patients’ ability to obtain medically
necessary care by placing patients at the mercy of managed care plans that play
doctor.”
The insurance industry had argued that ERISA trumps state patient protection
laws or other state laws that allow medical negligence suits in local
courts, and lower courts were divided on the issue.
The court ruled against a hysterectomy patient, Ruby Calad, who had claimed
that Cigna Healthcare of Texas essentially evicted her from a Houston
hospital after only one day of recovery.
The HMO would not pay for a longer stay, even though her doctor recommended
it.
She was back in the hospital a few days later, suffering complications
she claims could have been avoided had she remained hospitalized longer
after surgery. She later went to court, seeking to make the HMO pay a
price for what she called negligent care.
The Supreme Court did not rule on the coverage questions contained in
the case, but did rule on where the case could be filed.
In the Calad case and a companion one involving post-polio patient Juan
Davila, insurers tried to pull their lawsuits out of state court and
then sought to have the complaints dismissed in federal court.
Davila took what he claims was inferior but cheaper pain medication,
instead of the Vioxx his doctor had recommended, because his Aetna Health
plan would not pay for the more expensive drug right away.
The cheaper medication caused bleeding ulcers, and he almost had a heart
attack, Davila told the Associated Press.
Texas and nine other states regulate HMOs, making decisions about whether
treatment is medically necessary, state attorneys general backing Calad
and Davila argued in a friend of the court brief. Other states have passed
some form of consumer protection from HMO decisions, and still more states
are considering such laws, the state lawyers wrote.
Arizona, California, Georgia, Louisiana, Maine, New Jersey, Oklahoma,
Washington and West Virginia have laws similar to Texas.
The cases are Aetna Health Inc. v. Davila, 02-1845 and Cigna Healthcare
of Texas Inc. v. Calad, 03-83.
American Academy of Otolaryngology - Head and Neck Surgery
honors Michigan Oto-Laryngological Society
The Michigan Oto-Laryngological Society (MOS) is this
year's recipient of the Board of Governors (BOG) Model Society
Award. This society and its 200 members have effectively worked
to address issues that affect their patients and the specialty.
In the past year, MOS has exemplified a BOG model society by
its advocacy, education, and carrier relations activities.
Before this year, Michigan was one of only two states that did not license
audiologists. MOS leadership was instrumental in enacting SB 206, Michigan's
new audiology licensing law. This more than two-year collaborative effort
resulted in legislation that balanced the overdue need for audiology
licensure with appropriate patient protection to ensure quality care.
SB 206 protects both the audiology profession and the public from untrained
or incompetent practitioners and brings Michigan law into line with that
of most other states. MOS Past- Presidents Michael Seidman, MD, and Jeffrey
Weingarten, MD, were the driving force behind this legislative initiative,
dedicating countless hours developing and promoting a model bill for
the best interests of patients. In addition, MOS members wrote numerous
e-mails and letters to legislators voicing their opinions on the legislation.
On May 7, 2004, this hard work culminated with Gov. Jennifer Granholm
signing SB 206 into law.
MOS is also involved in furthering its members' continuing education.
The Society holds quarterly meetings that offer attendees up to eight
CME credits. These meetings update members on new developments in the
specialty and allow participants to cultivate professional relationships
with colleagues. Recent topics discussed include childhood hearing loss,
cranial facial surgery, and new concepts in rhinoplasty. Through these
programs, the society meets the critical continuing education and professional
development needs of its members.
In addition to its continuing education programs, MOS works to educate
its members and their office personnel about ever-changing reimbursement
procedures. At its annual meeting, MOS offers a coding seminar for both
its members and their office managers. During this seminar, a leading
coding specialist addresses issues that commonly affect a medical practice.
The seminar introduces attendees to a unique approach to understanding
coding and provides an open forum for presenting new ideas and answering
coding questions. This event is yet another example of the society responding
to member concerns and keeping them informed.
MOS has also been successful in facilitating a dialogue with Blue Cross
Blue Shield of Michigan (BCBSM). Through letter writing campaigns and
meetings, the society has fostered a working relationship with BCBSM.
This relationship has allowed MOS to effectively communicate with BCBSM
about its reimbursement policies, including the bundling of uvulopalatopharyngoplasty
and tonsillectomy.
The MOS continues to be actively involved in the AAO-HNS through participation
in programs and meetings. Additionally, MOS members serve as AAO-HNS'
board members, including Journal Editor Michael Benninger, MD, and Practice
Affairs Coordinator Charles Koopmann, MD. The following MOS members should
be applauded for their leadership: Carol Bradford, MD, President and
BOG Governor; Michael Rontal, MD, President-Elect; Dennis Bojrab, MD,
Secretary-Treasurer; Robert Stachler, MD, Program Chair and BOG Legislative
Representative; Arthur Rosner, MD, Immediate Past President; and Kathleen
Yaremchuk, MD, BOG Public Relations Representative.
The Michigan Oto-Laryngological Society's achievements are a testament
to its commitment to exhibiting effective leadership, instituting AAO-HNS
programs and furthering AAO-HNS goals through active participation in
the BOG. The Model Society award will be presented to MOS during
the 2004 Annual Meeting & OTO EXPO's Opening Ceremony in September
2004, New York, New York.
MSMS questions rationale of new UAW PPO provisions
The UAW and the Big Three autos negotiated new health care benefits,
which include moving all UAW members previously covered under the Traditional
Plan to new PPO structures, administered by Blue Cross Blue Shield of
Michigan through the existing PPO Trust Network.
MSMS is extremely concerned that the General Motors PPO, Traditional
Care Network, restricts physicians to billing PPO network rates for office
visits. Unlike Daimler-Chrysler, which has a $5,000 catastrophic deductible,
the GM plan does not include a deductible for office visits.
MSMS is requesting answers from UAW, the autos and BCBSM as to why these
discounted fees were incorporated into a contract in which office visits
are a non-covered "benefit," and notifying lawmakers about
our concerns. MSMS legal counsel is analyzing the Trust Agreement, and
advises physicians to comply with the rules as stated in BCBSM's "The
Record" (PDF format) until additional information is available.
Watch for further detail for MSMS members and their office staff through
these MSMS Payer Solutions Network e-mail alerts, on the web site (www.msms.org/bsyp),
and through Medigram.
For more information, contact Julie Novak at MSMS at (517) 336-5768 or jnovak@msms.org.
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