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MSMS turns up the heat
on Blues
By PAUL NATINSKY
Managing Editor
MSMS and the Michigan Osteopathic Association (MOA) continue to respond
to Blue Cross and Blue Shield of Michigan actions that are hostile to
physicians.
MSMS Legal Counsel Dan Schulte of the firm Kerr, Russell, Weber briefed
physicians on recent developments at the WCMSSM Delegate Body Meeting
Oct. 20 at the Hyatt Regency Hotel in Dearborn.
MSMS/MOA are working to prevent the Blues from forcing physicians to
accept a fee schedule unilaterally imposed by BCBSM on physicians who
participate in the insurer’s TRUST Network. The TRUST Network is a roster
of physicians assembled by the Blues that services various patient groups.
The issue emanates from the recent contract talks between the United
Auto Workers and the Big Three automakers.
Prior to the recently negotiated contracts between autoworkers and automakers,
patient office visits were not considered covered benefits and physicians
were free to set charges for their services. The UAW contract talks resulted
in converting these fee-for-service arrangements into preferred provider
organization (PPO) arrangements complete with a fee schedule. Without
consulting TRUST Network physicians, the Blues declared that TRUST Network
physicians must adhere to a fee schedule or be removed from the PPOs
formed by the auto contract talks and any other PPO arrangements that
utilize the TRUST Network.
While the Blues declared office visits “covered benefits,” patients are
responsible for a “100 percent copay.” The result is that patients don’t
receive any new benefit and physicians are required to accept a fee schedule
and process claims, despite the fact that patients are paying 100 percent
of the cost of office visits.
Schulte said the Blues maintain that this arrangement would extend to
seven PPOs representing 3 million patients and 70 percent of the Blues’ business.
Schulte said MSMS/MOA are seeking relief in two forms. The first is an
injuction to prevent BCBSM from removing doctors from the TRUST Network
if they refuse to adhere to the fee schedule. The second is to challenge
the unilateral imposition of a fee schedule on TRUST Network doctors
as a binding contract. Schulte said that for a contract to be considered
binding both sides of the agreement must receive consideration. MSMS/MOA
argue that physicians are being forced to accept a fee schedule but are
not receiving any consideration in return.
Schulte also asserted that as an admistrative-services-only agent for
the automakers, the Blues are not underwriting payment of services to
UAW members and cannot therefore act to impose such conditions on physicians
whether legitimate or not. BCBSM must “sponsor” a plan to take that type
of measure.
In response, said Schulte, the Blues are attempting to amend definitions
within the TRUST agreement to characterize their arrangements with the
automakers as “sponsored” plans.
Rulings on the injuction preventing expulsion from the TRUST Network
and whether the new Blues-imposed rules represent a binding contract
are expected within the next few weeks.
WCSSM 2004 Holiday Party Contributors
Dr. & Mrs. Edmund M. Barbour
Dr. & Mrs. Michael E. Kosinski
Madjid Mesgarzadeh, MD
Sion Soleymani, MD
Dr. & Mrs. B.J.Woodley
Dr. Richard J. Pollard
William R. Fulgenzi, MD
Dr. & Mrs. Donald M. Ditmars, Jr., MD
Margaret Dowling
Drs. Kenneth & Deborah Granke
Thad H. Joos, MD
Gregory Utter, MD
Michael G. Taylor, MD, FACS
David W. Law, DO, FACOS
Robert J. Griffin, MD
Paul J. Sullivan, MD
Sylvia & Marvin Gordon
Downriver Pediatric Associates
Dr. Nancy Jackson
Dr. Ray and Mrs. Marcia Littleton
Kenneth P. Bartold
Claus Petermann, MD, FACP
Gregory Goyert & Marjorie Treadwell
L.C. Rivera, MD, PC
Patricia A. Kolowich, MD
Irene and Oscar Signori
Drs. Juan A. and Ilse Estigarribia
Thomas B. Coles Jr., MD
Jack A. Litwin, MD
Sheryl Wissman, MD
Andrew J. Mitchell, MD
Stephanie C. From, MD
President's Report:: No Docs on Health Authority Board; Blues
Suit Continues
By RICHARD SMITH, MD
WCMSSM President
Detroit Wayne County Public Health Authority
The Authority has been named and begun to meet monthly. No physicians
were named to the Authority Board. In addition, I have submitted a list
of the nominees to the Provider and Community Advisory Committees to
the Authority Board. We have not received any word thus far about any
of our nominees being named.
Antietam Building
The sale of the building was completed on July 29, 2004.
I signed the sale closing documents on July 29, 2004. The new
owner, the Detroit Entrepreneurship Institute has begun extensive
building renovations and intends to make full use of the space
for educational and training purposes. The building was sold
for $700,000. After expenses related to the sale and move, the
Society netted approximately $500,000.
Blue Cross-Blue Shield of Michigan
Extensive discussions have been held
between MSMS and the Blues for several months.
BCBSM deems a physician office visit a "covered
benefit" for UAW members even though
it requires a 100 percent co-payment from
the UAW members, or the payment of a deductible
amount set intentionally so high ($5,000
in the case of DaimlerChrysler) that no patient
can reasonably be expected to meet it. By
calling the office visit a covered benefit
even though the patient pays 100 percent,
BCBSM believes it can require physicians
to accept a unilaterally discounted office
visit fee. As of this date no resolution
has been reached regarding the Autos/UAW
contract provision requiring physicians to
accept the Trust payment for office services.
As you know MSMS along with MOA has filed
a lawsuit to stop implementation of this
contract provision. In addition, the Blues
in another move against physicians have begun
the disaffiliation process with over 300
primary care physicians in southeast Michigan.
A number of our members have contacted our
office and MSMS for assistance.
Congressman John Dingell
A number of our members participated in a successful fundraising event
for Congressman Dingell held at Gale Warden's home on June 30, 2004.
Mr. Dingell has always been open to meeting with and responding to MSMS
and WCMSSM.
Hospital Medical Staff Meetings
The Oakwood Southshore Hospital staff kicked off the year with its meeting
in July. One of our officers or staff will attend at least one of every
hospitals' staff meetings. Last month, we were at St. John's Riverview
Hospital, Oakwood Hospital, Ford-Wyandotte Hospital, St. Mary's Hospital
and St. John's Medical Center.
Tigers Baseball
On Aug. 8, 40 members and guests attended a Tigers game promoted by the
Membership Committee. Although the fans witnessed a home run derby, the
home team was not victorious. There is always next year, however. The
Committee intends on promoting attendance next summer with seating in
the Ilitch suite. With room for just 40 attendees, reservations will
be taken early next year.
General Membership Meeting
On Tuesday, September 21, 2004, the WCMSSM and the Detroit Medical Society
met in a joint general membership meeting at the Magnolia Restaurant,
Detroit. Our guest speaker was the President of the AMA, Dr. John Nelson.
Dr. Nelson spoke extensively about health care disparities and discrimination
toward health professionals and patients. Dr. Nelson spent two days in
Detroit visiting the Henry Ford Health System, WSU School of Medicine
and participating in editorial Board meetings at the Detroit News and
The Detroit Free Press arranged by WCMSSM. Subsequently, the Detroit
News printed a very favorable editorial, praising the AMA plan for covering
the uninsured and reforming the health care system.
Biomedical Ethics Conference
The MSMS and WCMSSM merged their committees on Bioethics a number of
years ago. Several WCMSSM members participated in the Conference held
at Traverse City Oct. 1-2. This year's meeting was devoted to "Crisis
and Opportunity: Conversations on Universal Health Care Coverage" and
included extensive discussions on the Canadian system, the Institute
of Medicine reports on the uninsured and defining a Minimum Set of Health
Services in Universal Health Care. WCMSSM is looking for more members
to serve on this Committee. If you are interested, please contact the
staff.
Primed CME
The conference was held at the Cobo Convention Center, Oct. 7-8, in Detroit
with more than 500 physicians participating from all over southern Michigan
and northern Ohio. Next year's spring meeting is scheduled for March
22-23 here at the Hyatt Regency in Dearborn. The fall dates are to be
announced.
Upcoming Events:
-·MSMS Annual Scientific Meeting, Nov. 3-5, 2004, Somerset Inn, Troy.
-·WCMSSM 83rd Annual William Beaumont Lecture, Noon, Friday, Nov. 5,
2004. This year's Beaumont lecturer is Paul Bach-y-Rita, MD on Artificial
Vision.
-·WCMS Foundation 19th Annual Holiday Party for Underprivileged Children,
Detroit Science Center, Dec. 11, 2004.
-·WCMS Foundation Rhoades Lecture - April 8, 2005, Detroit Yacht Club,
6 p.m. "Healthcare Rationing" presented by Bruce Goldberg,
MD, Administrator Office for Oregon Health Policy and Research.
-·Combined General Membership Meeting, Detroit Medical Society, Tri-County
Osteopathic Society and WCMSSM, 6 p.m., April 20, 2005, Marriott Renaissance
Hotel, Detroit.
-·MSMS House of Delegates, April 29 - May 1, 2005, Ritz-Carlton Hotel,
Dearborn.
Editorial: Formularies: Focus On Doctors, Not On Drugs
By JOSEPH WEISS, MD
Editor
The Sept. 26 New York Times carried a front-page article on the battle
between health insurers and pharmaceutical drug companies over Medicare
drug formularies.
The insurers' demand sharp limitation on the number of drugs in the formulary
and at the same time the pharmaceutical companies drive to place all
their drugs on the same list.
The skirmish comes about as a result of the recently passed Medicare
Modernization Act. The Act mandates that if insurers are to obtain government
subsidies, the insurers must offer at least two drugs in each of 146
drug classes.
Critics claim that a restrictive formulary will cost more over time.
Added admissions to hospitals and nursing homes, with their great expense,
will occur because people will not receive the best drugs for their condition.
Denying patients drugs they need and use will cause more harm than help.
Another group, mainly health insurers and medicine benefit managers,
oppose expansion of Medicare drug formularies. The insurers say that
the 146 classes are too many and could be simplified. If such is done,
then the ability of insurers to negotiate favorable prices will increase
substantially.
Nowhere in this debate are physicians mentioned nor is their advice requested.
But we know better. The choice of drugs on the Medicare formulary should
not be left to legislative fiat. Nor should such decisions on drugs be
the result of negotiations between the accountants and the business managers.
Doctors should decide. A proper drug formulary comes from discussion
by doctors who compose the panel making the drug selection. The proper
focus in Medicare should not be on drugs included but on the doctors
selected.
We need the AMA to intervene with CMS to rewrite the formulary regulations.
The best rules will be those that focus on the proper composition of
the formulary panel. Also, we should go to the AARP for support. In this
matter of formularies intervening on the doctors' behalf is acting in
the best interest of the elderly.
This controversy illustrates why the medical community needs to remain
vigilant and organized. Debates on health care without physician representation
are of questionable value. We must protest any time we are not included
whether by accident or design, in the discussion of change, criticism,
or innovation in health care.
Rob Beattie, our MSMS member services representative
The Wayne County Member Service Representative from the Michigan State
Medical Society is Rob Beattie. You can expect a visit from Rob in your
office to make sure you are familiar with all that MSMS offers. He can
provide you with easier access to MSMS services and products available
exclusively to members. Whether the topics are HIPAA compliance, coding,
member benefits, endorsed services, or liability insurance, Rob can answer
your questions. There is no charge to have him visit your office. To
schedule an appointment, contact him in the MSR Department of MSMS at
(517) 336-5776 or rbeattie@msms.org.
HEALTH PLAN PROFILE: Molina Healthcare
Editor’s Note: The following article is part of a series of profiles
of the new Medicaid managed care plans that will take over management
of Medicaid patients as a result of the recent rebidding undergone by
Michigan Medicaid.
From its modest beginnings more than 20 years ago, Molina Healthcare
has stayed true to its mission: providing quality health care to patients
in need. Founded by C. David Molina, Molina Healthcare began as Molina
Medical Centers, primary care clinics for low-income neighborhoods, which
still operates 21 clinics in California.
Molina Healthcare has continued its expertise in serving Medicaid and
low-income patients through an understanding of its members’ cultural
and societal needs. This perspective of treating “the whole person” has
provided Molina with a firm foundation with remarkable results – more
than 700,000 members are served by the company’s health plans in California,
Michigan, New Mexico, Utah and Washington.
Molina Healthcare of Michigan was granted NCQA accreditation in 2002.
Its success has been confirmed by significant improvement in its HEDIS
scores and recognition by the Michigan Association of Health Plans (MAHP).
In June, Molina Healthcare of Michigan received MAHP’s Pinnacle Award
for a pilot program targeting children with developmental delays.
Molina’s philosophy of care allows it to serve a unique combination of
rural and urban service areas in 37 Lower Peninsula counties including
Kent, Wayne, Oakland and Macomb – providing care to more than 88,000
members.
The philosophy of the company is echoed by its leadership, composed of
Michigan-based health care experts “We are committed to providing innovative
quality health care for Medicaid and low-income members,” said Roman
T. Kulich, CEO of Molina Healthcare of Michigan.
LETTER
Editor:
Dr. Mariona, nice editorial on Sept. 6. We have gone from “provider” to “supplier.” How
debased wil it become?
Marshall Blondy, MD
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