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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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