Blues Update; Oct. 4

MSMS sues Blues in PPO dispute
By MICHAEL SANDLER, MD
Chair, MSMS Board of Directors
The Michigan State Medical Society filed a lawsuit against Blue Cross and Blue Shield of Michigan (BCBSM) Sept. 9 regarding the improper way BCBSM has instituted the so-called “PPOs” for UAW members.

MSMS is seeking a declaratory judgment from the Ingham County Circuit Court stating that physicians are not obligated to charge the discounted BCBSM fee screen amount for office visit services physicians provide to UAW “PPOs.” The lawsuit was jointly filed with the Michigan Osteopathic Association.

Additionally, the complaint seeks a preliminary injunction preventing BCBSM from terminating any BCBSM  TRUST Network physician based upon that physician’s refusal to charge the discounted fee for these services.

The UAW/automaker collective bargaining negotiations last fall resulted in moving all UAW members previously covered under the Traditional Plans into so-called “PPOs” created by BCBSM for each of the auto companies. BCBSM and the automakers did not create a true PPO by contracting with physicians to provide the covered services. Instead, they told UAW members that their new “PPO” requires physicians to provide office visit services at the discounted TRUST fee screen rates.

In insinuating these “PPOs,” BCBSM wrongly believed that the TRUST Network Agreement obligates physicians to charge the discounted fee rather than the amounts historically charged for office visit services. This interpretation of the TRUST Network Agreement by the auto companies and BCBSM was 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 (for example, $5,000) that it will never be met.

By claiming that an office visit is a “covered service” (even though the patient pays 100 percent), BCBSM and the automakers argued that office visits are subject to a discounted fee unilaterally set by them.
BCBSM still requires physicians to submit a bill for the office visit to Blue Cross despite the fact that no reimbursement will come back to them.

Originally, BCBSM officials stated that physicians who did not comply with the office visit discounts would be disaffiliated from the TRUST Network. This would mean that physicians could be disaffiliated from all BCBSM PPO programs in the TRUST Network including Community Blue, Blue Preferred, MI Child, State of Michigan Health Plan PPO, Mental Health Services PPO, MESSA Choices, FEP-PPO, the new DaimlerChrysler Standard Care Network, the new GM Traditional Care Network, and the new Ford National Plan.

Over the past two weeks during discussions between BCBSM and leaders from MSMS and MOA, Blue Cross proposed changes to address physicians’ concerns. As of Sept. 7, physician leaders and legal counsels from both associations concluded that the proposals provide neither complete solutions nor long-term, enforceable resolutions and determined that filing a lawsuit was necessary.

MSMS and MOA agreed that we need to file a lawsuit because we are extremely concerned about what else in the future might be called a “covered service” for which UAW members or other employee groups will pay 100 percent out of their own pockets and what other physician fees will be unilaterally set by BCBSM.

In addition to the lawsuit, MSMS is seeking legislative remedies and is educating lawmakers 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 physician practices explain this situation to their UAW patients. This letter can be downloaded from the MSMS Web page at http://www.msms.org/bsyp/index.html and printed on the physician office stationary. You can also go to the MSMS Action Center at http://action.msms.org to send messages to Blue Cross senior management, auto company executives, newspaper editors and your legislators to express your concern about these new programs.

The MSMS Board of Directors authorized this lawsuit because this situation clearly represents a violation of the contract between BCBSM and physicians and because the market power of Blue Cross makes it difficult for any single physician to stand up against  their unilateral actions. We hope that the court will take immediate action on our request for a temporary restraining order.
For updates, watch for e-mails from the MSMS Payer Solutions Network or visit the MSMS Web page at www.msms.org. To join the Payer Solutions Network, send your name to msms@msms.org, and enter “Payer Solutions Network” in the subject line.
This is a tumultuous time in health care. We must stay united now more than ever.

Now is the time to preserve tort reform
MSMS continues to fight House Bills 5338 and 5905, which propose to amend the current law to allow a judge's discretion to determine whether an attorney could re-file or amend an improperly submitted affidavit of merit. The bills could potentially create a loophole within the medical liability laws in Michigan and expose physicians to more lawsuits. Currently, no action is scheduled. However, if these bills are acted upon, it would likely happen very quickly.

Here are a few ways that physicians can engage in preserving current tort reform laws:
(1) Send an e-mail message to senators through the MSMS Action Center (www.msms.org) encouraging them to oppose the bills. Legislators are most likely to take action on an issue if they hear from many constituents and experts on an issue. The squeaky wheel, in fact, does get the grease! 

(2) Support Michigan Supreme Court Justice Stephen Markman in his campaign for reelection to the bench by making a contribution, spreading the word to colleagues, and voting for him on Tuesday, Nov. 2. Justice Markman's record of judicial conservatism has proven that he does not legislate from the bench. Instead, he believes in upholding existing laws, which is crucial to preserving tort reform.

(3) Meet personally with lawmakers by signing up to be "Doctor of the Day" during the upcoming legislative session. This program enables physicians to engage their legislators in dialogue about important health care issues, such as tort reform. For more information, contact Brian Reuwer at MSMS at (517) 336-5788 or breuwer@msms.org.

The affidavit of merit is a key provision of the tort reform laws passed in 1993, and has been instrumental in helping to reduce the number of frivolous lawsuits filed in Michigan. The Affidavit of Merit standards are clear, and are meant to provide protection to individuals from being wrongfully named in a medical liability case. 

Unfortunately, House Bills 5338 and 5905 would unnecessarily amend the law to correct "defects" within an otherwise properly submitted affidavit.  The law already specifies what elements are necessary to properly submit an Affidavit of Merit. This proposal is contrary to virtually all of the liability reform efforts across the country. The medical liability climate in Michigan can simply not afford these types of changes. 

MSMS has prepared a new chart detailing how tort reform has fared in the legislature and our courts. Access the chart online at www.msms.org/grpa.

For more information about state legislation, contact Colin Ford at MSMS at (517) 336-5737 or cford@msms.org.

PRESIDENT'S REPORT: Members attend Dingell fundraiser
By RICHARD SMITH, MD
WCMS President
Detroit/Wayne County Health Authority
The Authority has been named. Our Medical and Public Health Issues Committee will present a report later of their review of the final report of the DWCHA Development Committee. In addition, I have 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. You will hear more about the sale in the Board of Trustees report.

Blue Cross Blue Shield
Extensive discussions have been underway 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.

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 each hospital’s staff meetings. Just this month, we will be at St. John's Riverview Hospital, Oakwood Hospital and St. John's Medical Center.

Tigers Baseball
Forty members and guests attended a Tigers game Aug. 8 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 to promote attendance next summer with a special treat that will be described in a report by Dr. Sophie Womack, our WCMSSM Secretary and Chair of the Membership Committee.

Upcoming Events:
-Primed CME, Cobo Convention Center, Oct. 7-8, 2004, Detroit.
-First Delegate Body Meeting 2004-05, Hyatt Regency Hotel, Dearborn.
-MSMS Annual Scientific Meeting, November 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.

For additional information on any or these items, contact the WCMSSM office.

EDITORIAL: Health care debate needs our participation
By H. MICHAEL MARSH, MBBS
WCMSSM Past President
The health care system in the United States is a chaotic patchwork consuming approximately 14 percent of the GDP but leaving approximately 48 million citizens (about 16 percent of the US population) uninsured. In Michigan, with approximately 1.2 million uninsured from a population of about 10 million (12 percent of the state’s population), we also have grossly underfunded the Medicaid system, which serves an additional 1.2 million Michigan citizens. This state health system provides medical services to these poorer citizens, for which the state pays less than Medicare payments, to the tune of about a $1 billion underpayment per annum. Private payers in general pay at or above Medicare rates.

The major problem with this national and regional health care system is its inherent distributive unfairness. Sufficient total money is available within the current system to provide adequate health care services to the population of the country, provided the regulation and governance of the service distribution and payment systems are significantly reorganized. This requires political wisdom, resolve and courage; qualities significantly lacking in our current leadership at all levels. Explicit, uniform health care menus citizens, with explicit, cost-based and fair payment options must be provided. Some call this rationing. They ignore the implicit rationing inherent to the current schemes, with their basic distributive unfairness. This same distributive inequality is eroding the current health care infrastructure and will gradually destroy the high quality of the existing system nationally. Regionally, in Michigan, and particularly in Detroit and Wayne County, this destruction is self evident.

What can be done? We must achieve distributive fairness and transparency in payment and cost relationships within the existing health expenditures in our communities. The population can then democratically decide how they wish to direct their hard-earned dollars toward their health care. I would suggest four significant steps:

1) Data about the state of health of citizens and of the existing health systems must be made available on a regional basis throughout the country. One could decide whether this should be an accountability for each congressional district’s representative to Washington or whether it should be a joint accountability for each ZIP code’s regional representatives for city, state and national governmental bodies to shoulder. The legislators are responsible for the public health.

2) Distributive unfairness within the existing health care system must be made explicit. To do this, existing health care costs must be made explicit and payment-to-cost ratios become publicly available, in manageable and understandable form, from each regional set of providers and payers. Administrative costs from each group of third-party payers must also be made public and clear.

3) Profiteering from the public monies, or cooperative insurance, third-party payer monies provided for health insurance must be significantly reduced or completely stopped by adequate oversight. To do this, so-called administrative costs for funds distribution and for public, not-for-profit facilities for health care management must be appropriately limited and reduced. Furthermore, not-for-profit status must be stripped from any health care entities that do not provide complete and comprehensive access to health care services to all local citizens.

The political difficulties inherent in achieving these steps toward improved health care for our citizens are obvious from the decade of inactivity since 1994 following the Clinton’s failed initiative and the last four years of shamefully irrelevant activity. Whether a public health authority in Southeast Michigan will evolve in sufficient time to address Detroit’s problem is currently questionable. National inattention is inexcusable.

What can be done by WCMSSM? We are participating in the Public Health Authority initiative, have joined with MSMS , MOA and MHA in moving a study of Michigan’s Medicaid System, and continue to participate in GDAHC. We continue our lobbying efforts at all levels and will advocate for the public health of our community. We are also appointing a public member to our board and will ask GDAHC to begin to help us with data to answer the two questions posed above. This data will be published regularly for all of our membership. We all need to keep these issues in front of our elected representatives for the next election cycle.

LETTER: The last great slight of hand...
Editor:
I find it frightening how blind society seems to be to what is going on.
There has been an ever-spiraling downward movement in the direction of health insurance as a job fringe benefit. It has gone from first-dollar coverage to ever-rising, up-front annual deductibles, deductibles plus co-pays, family coverage to employee-only coverage. The last great slight-of-hand trick by industry will be to declare that health care has become so costly that they can no longer afford the cost of the benefit for their workers. So ... alas, society is being slowly forced to chose between health care benefits or employment. The old law of economics "...guns or butter...", you can't have both.
I think no group has learned the current lesson being taught better than physicians; once something is taken away, it is never given back!

George H. Shade Jr., MD
Chief, Department of Obstetrics and Gynecology
Sinai-Grace Hospital-Detroit Medical Center

EDITORIAL: What We Are Doing Now: Necessary, But Not Sufficient?
By JOSEPH WEISS, MD
Editor
What we are doing now in the debates between Single Pay (National Health Insurance), Medicare expanded and private Medicare is discussing the merits of cost shifting. How each of us responds reflects our personal attitude and appraisal of personal profit or loss under a pattern of payment for care different from what we now work under.

The discussion of who pays does not touch upon the questions that the public receiving care considers equally or even more important: (1) how to avoid wasteful care, (2) how to minimize harm from medical errors, and (3) how to readily access care for emergencies, ongoing medical needs, and prevention of illness.

Changing who pays won't address any of the these three concerns, except that whoever pays for health services will set up barriers in front of any attempt to change care that costs another dime more. No matter what approach to reimbursement used, physicians will see that politics more than physiology will determine the adoption of the new.

One possible way to accomplish economy, availability, and safety in medicine is to bring small size to medical care in the way that such scale works in auto repair. As in health care, the person seeking repairs on his or her car is not able to determine who is the best repairman. Outcomes in car repair, as in medical care, are impossible to track.

However, certain aspects of auto repair give it a good marketplace fit. Competition keeps auto repair charges from reaching exorbitant levels. The presence of many auto repair shops makes access reasonable both for emergencies and maintenance care. While the quality of the mechanic is difficult to judge, you can, if dissatisfied, go to another mechanic the next time your car needs attention.

Medical organizations can learn from the auto repair sector; we should consider organizing in a similar fashion. The method at our disposal is the Physician Organization (PO). This approach gives the power of numbers to negotiate, but not too great to create a monopoly, and the flexibility to meet the public's requirements for efficient, safe and available care.

The PO itself has the capability to follow what members of the group are doing in quality and cost as compared with other members of the group, that is, to monitor the performance of each physician in the organization.
 
The PO governing board has both an interest and closeness to physician error and is in position to pass judgment on the quality of care.

The nation may decide on the experiment of "Single Pay" as the way of increasing access to care. But providing quality, safety, reasonable cost and efficient use of medical manpower and technology resides elsewhere: in the arena of the Physician Organization. If the PO as it is now adopts those favorable features of the auto repair sector, then the nation stands a chance to end the gap between what health care is today and what we should have tomorrow.

HEALTH PLAN PROFILES: AmeriChoice
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.

With its acquisition of Great Lakes Health Plan last February, AmeriChoice, the public sector health care unit of UnitedHealth Group, serves more than 1.2 million beneficiaries of Medicaid and Children's Health Insurance Programs in eleven states across the country. Since its founding in 1996, AmeriChoice has focused exclusively on public sector health care; every aspect of our operations has been developed to meet the unique needs of beneficiaries of government-sponsored health care programs.

AmeriChoice understands that these beneficiaries have different needs than the commercially insured. Moreover, AmeriChoice believes that health care cannot be provided effectively without consideration of the non-medical, environmental factors that affect a person's well-being. The unique AmeriChoice Personal Care Model marshals both the medical and community social service resources needed to help members achieve the highest functional status possible and improve the quality of their lives.

Central to the approach AmeriChoice brings to GLHP is a comprehensive, community-based network that is supported with cutting edge technology and business systems and the timely dissemination of data, including member profiles, best practice guidelines and evidence-based care recommendations. Included in this suite is a proprietary member tracking software application and sophisticated claims analysis programs to assist network partners in evaluating practice patterns against nationally accepted protocols. Top-ranked academic medical centers and researchers developed AmeriChoice disease management programs, and AmeriChoice was the first public sector health care company to use telemedicine in urban settings. AmeriChoice health plans are also distinguished by extensive outreach and education programs and the support of numerous cultural and educational initiatives.

Because AmeriChoice believes that compassion and respect are essential components of quality health care, we employ a diverse workforce, with varied backgrounds and extensive practical experience, and rooted in the communities we serve, to give us a better understanding of all our customers-regulators, members and physicians-and their needs.