E-DMN - September 17, 2007

September 17, 2007

Editor's Column: A Bounty Of Belonging
Educational Facility Key To Future At WSU SOM
'Shoot For A Cure' With HFHS
Immunization Update
Blue Cross Blue Shield Settles In 'Love' Case
Dem White House Hopefuls Debate Health Care
Patient Care Quality Summit

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Editor's Column: A Bounty Of Belonging

By JOSEPH WEISS, MD
Page through the Fall 2007 schedule of MSMS Conferences and Seminars. You will gain a perspective on the full range of issues of importance to Michigan’s medical community.

Conferences include Pain Management with a session on the current legal climate surrounding pain control. There is a Capitol Checkup seminar that will focus on the status of the Medicaid budget, and what proposals for state health regulation are in the offing. A Best In Medicine conference will discuss reimbursement in medical practices, update health information technology and highlight innovation in the state’s health care.

The Retreat for Women Physicians includes the topics of advances in understanding depression in women and the considerations particular to women in financial planning. The Bioethics Conference in Traverse City will look at stem cell research as it impacts Michigan today, and a discussion of the implications of mandating HPV vaccine.

You can attend a one-day seminar on the question: Can Incentives Drive Quality or on another one-day discussion hear about health information technology including an update on electronic medical records.

For physicians concerned with daily practice, MSMS offers its ongoing series on E & M documentation, medical records and the law, negotiating contracts and strategies for office efficiency.

In a review of this column, Dr. Susan Adelman suggested that a comparison of what MSMS offers now with what the Society provided in education 25 or 26 years ago would be of interest. MSMS provided the Wayne County Medical Society with a Bulletin of the Educational Programs for 1982.

Several of the names of programs are the same, but issues are far different. For example, in 1982 MSMS hosted a Women in Medicine conference, but the session focused on how to make the presence of women physicians known to the Medical Society and state legislature. The description emphasized that the main purpose of the conference was to allow women physicians to meet other women physicians and develop “a liaison of similar interests.” A Best in Medicine conference concentrated on patient satisfaction, disease management, and quality, issues that would draw a crowd today.

The Fall 1982 brochure also announced a fall conference by he MSMS Public Affairs/Leadership committee. That program presented Your Practice and the Changing World of Medical Economics, a presentation by James Sammons, president of the AMA, on Medicine’s Priorities, and a panel discussion on Market Forces Affecting Hospitals and Physicians. Sounds like we could hear from that group today. The Fall Education brochure of 1982 concluded with information on a Sports Medicine review and the topics of the MSMS Scientific Meeting scheduled for Hyatt Regency Dearborn in October. That was all the education considered, the total number of programs was less than half of what MSMS offers in 2007.

Today, MSMS serves the medical community not only in the big issues such as Medicare reform, but in ways that touch on our daily working life. The breadth of MSMS education efforts parallels the expanded responsibility facing physicians today and the widening perspective of our professional lives. Make use of the opportunity MSMS brings to take in what is practical, essential, interesting and even vital.

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Educational Facility Key To Future At WSU SOM

The creation of the Richard J. Mazurek, MD, Medical Education Commons (MEC) is the highest priority for the Wayne State University School of Medicine. Larger class sizes and new medical school accreditation requirements have made this facility absolutely essential. The MEC will almost double the number of existing class rooms to enhance small group learning sessions. In addition, it will include an advanced technological infrastructure to facilitate up to date electronic resources for improved teaching and learning experiences.

The 53,000-square-foot, three-story complex will be the nucleus of all programs for undergraduate, graduate and continuing medical education in the School of Medicine. Students will have "one-stop shopping" for all administrative, support and learning services.

Funding for the MEC comes entirely from voluntary contributions by alumni, alumni family members, parents, faculty, administration, staff, and friends who understand the essential role that WSUSOM plays in providing well-trained clinicians for the population of Michigan and beyond.

A major gift by Mr. Nick Labedz, in honor of Dr. Mazurek, changed the dream of the Commons to reality. In addition to the generous gift by Mr. Labedz, the Kresge Foundation awarded a $3 million challenge grant to support construction of the Richard J. Mazurek, MD, Medical Education Commons.

To date, contributions are approaching $25 million in contributions and pledges toward the total project goal of $30 million. The approximately $5 million balance must be raised to meet The Kresge Foundation challenge. All gifts, large and small, will help us meet this goal (and in most cases, provide tax relief!).

A groundbreaking ceremony for the MEC was held today. Contributions are still needed. For more information, contact the WSU SOM directly using the information below.

For more information about the Commons, select the link to the "Our future" video or contact Ms. Lori Robitaille or Ms. Patty Paquin

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'Shoot For A Cure' With HFHS

Shoot For a Cure, the 15th anniversary celebration benefiting research and treatment of neurological diseases at Henry Ford Hospital, will be held at 6 p.m. Thursday, Nov. 8 at the Andiamo Italia Banquet Center in Warren.

This year’s celebration will honor Bloomfield resident Penny B. Blumenstein, a long-time and devoted supporter of Henry Ford Health System.

The evening will include an auction, dinner and a performance by the Scintas, voted one of the top five groups in Las Vegas, whose act includes music, impressions and comedy.

Shoot For A Cure benefits the Neuroscience Institute, including the Hermelin Brain Tumor Center and Will Robinson Neurosurgery Fund at Henry Ford Hospital. Over the past 14 years, money raised from the event has been used to support research and treatment for neurological diseases including brain tumors, stroke, epilepsy, Parkinson’s disease, spine disorders and trauma to the brain or spinal cord.

Honorary co-chairs are Gail and Mark Kelley, M.D., of Bloomfield Hills and Nancy Schlichting of Bloomfield Township. Event co-chairs are Zelly and Tom Mikkelsen, M.D., of West Bloomfield, Pam and Mark Rosenblum, M.D., of West Bloomfield and Rosalie and Joe Vicari of Clinton Township.

Patron tickets for the event are $175 a person; Benefactor tickets are $250 a person; Gold tickets are $500 and Diamond tickets are $1,000 per person.

For more information or to make reservations call (313) 874-4088 or log on to www.henryford.com/giving .

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Immunization Update

Editor’s Note: The following is an edited message from the CDC regarding immunizations.

Get Ready for Influenza Season: Influenza vaccine manufacturers are projecting that as many as 132 million doses of vaccine will be available for this season. Three manufacturers have already begun to ship this season’s influenza vaccine, with almost all of the vaccine expected to be shipped and distributed in October and November.

On September 19, the National Foundation for Infectious Diseases (NFID), in partnership with the Summit, will sponsor the 10th Annual Influenza/Pneumoccoccal News Conference, which will be broadcast via live Web cast and telephone. More information about this event can be found at www.visualwebcaster.com/NFID-NewsConference-2007. To promote influenza vaccination and improve protection of infants, children, and adolescents, NFID recently formed the Childhood Influenza Immunization Coalition (CIIC). CIIC held a teleconference in August and will continue to coordinate efforts across partners to improve influenza immunization rates among young children.

CDC has many influenza resources available at www.cdc.gov/flu/ and a gallery of educational materials for the public and healthcare providers at www.cdc.gov/flu/gallery . Please check the CDC’s Flu Gallery for new materials throughout the influenza season.

The National Influenza Vaccine Summit -- a partnership of more than 100 stakeholders representing both public and private organizations in influenza vaccine research, production, distribution, advocacy, and administration -- has a website with additional influenza resources: www.preventinfluenza.org. In addition, the American Medical Association (AMA) hosts the Influenza Vaccine Availability Tracking System (IVATS) on its website. IVATS, a tool to assist healthcare professionals in finding vaccine to purchase, can be found at www.ama-assn.org/ama/pub/category/16919.html.

CDC encourages anyone who wants to be protected against influenza to seek vaccination, especially those at increased risk for influenza-related complications as well as those who live with or care for people at high risk – including health care providers, children between 6 months and up to 5 years of age and people with chronic diseases such as diabetes, asthma and heart disease, as well as people 50 years old and older.

While the best time for vaccination is October and November before the influenza season typically begins, vaccination can still provide protection in December and later because during most years influenza does not peak until February or later. Since influenza is unpredictable, and different types and strains of influenza circulate throughout the flu season, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommends that influenza vaccine be offered throughout the influenza season – even after influenza has appeared or begun appearing in a community.

To help get the word out about late season vaccination, National Influenza Vaccination Week (NIVW) will take place November 26–December 2. More information about NIVW will be available in future issues of Immunization Works.

The Immunization Works Database Manager can be contacted at immunizationworks@cdc.gov.

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Blue Cross Blue Shield Settles In 'Love' Case

By Daniel J. Schulte, JD, MSMS Legal Counsel
The Case
The U.S. District Court for the Southern District of Florida conditionally approved a settlement in the Love vs. Blue Cross & Blue Shield Association case on May 31, 2007. A Settlement Agreement between the Plaintiffs and the Blue Cross & Blue Shield Association (“BCBSA”), Blue Cross Blue Shield of Michigan (“BCBSM”) and 22 other BCBSA licensees (collectively the “Blues Plans”) had previously been entered into on April 27, 20071.

The Plaintiffs sought the formation of a Class Action alleging that the Blues Plans had:

1. Misrepresented and/or failed to disclose the use of edits to unilaterally “bundle”, “down code,” and/or reject claims for medically necessary covered services; 2. Failed to pay for “medical necessary” services; 3. Failed and/or refused to recognize CPT modifiers; 4. Concealed and/or misrepresented the use of improper guidelines and criteria to deny, delay and/or reduce payment for medically necessary services; 5. Misrepresented and/or refused to disclose applicable fee schedules; and 6. Failed to pay claims for medically necessary covered services within statutorily required and/or contractual time periods.

1 Several state medical societies also signed on to the Settlement Agreement. Doing so enables them to represent their members collectively in the event there is a breach of the Settlement Agreement by one of the Blues Plans. MSMS declined to join in the Settlement Agreement after comparing the agreed upon changes to the Blues Plans’ business practices to the reforms sought in the Fair Contracting Legislation currently being pursued by MSMS.

The reforms sought inthe legislation are stronger and more closely address the issues faced by Michigan physicians who contract with BCBSM.

The Settlement
Pursuant to the Settlement Agreement $128,315,907.00 will be paid into a Settlement Fund. The Settlement Fund will be distributed to members of the Class.

The Class will consist of all physicians, physician groups and physician organizations who provided services to members of a health plan underwritten or administered by any Blues Plan between May 22, 1999 and May 31, 2007. Physicians may opt-out of the Class. This is discussed below. The amount received by individual physicians who are members of the Class will be determined based on the amount of the Gross Receipts they received from BCBSM and/or the other Blues Plans between May 22, 1999 and May 31, 2007.

In addition to the creation of the Settlement Fund, BCBSM and the other Blues Plans have committed to make changes to their business practices. These changes include:

1. Basing medical necessity determinations on generally accepted standards of medical practice and clinical guidelines that are based on credible scientific evidence published in peer reviewed medical literature; 2. Subjecting medical necessity determinations to an external review process; 3. The establishment of external reviews for billing dispute resolution; 4. Investing in facilities to automate the adjudication of claims to reduce the average time taken to pay valid claims; 5. Funding initiatives to reduce the percentage of resubmitted claims; 6. Disclosing payment rules and conforming bundling and other editing practices to procedures specified in the Settlement Agreement; 7. Eliminating “gag clauses”; 8. Ensuring the payment of claims that are “complete” (as defined by the Settlement Agreement) within 15 business days if electronically submitted and 30 days for paper submissions; and 9. Making fee schedules available for review.

What Happens Next
In July, Michigan physicians identified by BCBSM as having provided services to patients enrolled in BCBSM underwritten and administered health plans between May 22, 1999 and May 31, 2007 will be receiving by mail a Notice of Class Action and Proposed Settlement (the “Notice”) and a Claim Form. In order to claim their portion of the Settlement Fund, physicians must complete and return the Claim Form no later than 90 days after the date of the Notice. Physicians will have the option of donating their portion of the Settlement Fund to certain charitable organizations (including the Michigan Health and Safety Coalition) that will be identified on the Claim Form. By choosing to participate in the settlement physicians are agreeing to release BCBSM and the other Blues Plans from any potential claim they may have relating to the allegations made by the Plaintiffs in this case. Physicians should carefully review the section of the Notice entitled “The Release and Dismissal with Prejudice” and clearly understand the claims being released. Consultation with your personal attorney to ensure an understanding of the scope of the release is advisable.

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Dem White House Hopefuls Debate Health Care

Seven Democratic presidential candidates debated health care among other issues Sept. 9. The event was aired on Univision, a national Spanish-Language television station. During the debate, held on the campus of the University of Miami, Univision news anchors Jorge Ramos and Maria Elena Salinas asked questions in Spanish, and the candidates received translations in English (Wolf/Marrero, USA Today, 9/10).

Sen. Barack Obama (Ill.) said that he has proposed a "comprehensive plan for universal health care so that all will have medical insurance."

New Mexico Gov. Bill Richardson said his universal health insurance proposal would take one year to pass and two to three to implement. In addition, he said that "we need to have everyone accessible to the best (inaudible) plan that everyone here has," reduce the age of eligibility for Medicare from 65 to 55, provide veterans with a "health card for all" and focus on preventive medicine.

Sen. Chris Dodd (Conn.) said that he supports "medical care for those who are undocumented" immigrants and universal health insurance.

Sen. Hillary Rodham Clinton (N.Y.) said that "we're going to make it possible for all to have health care; not only 47 million who are uninsured, but those millions of people who are insured who don't ... receive treatment" because of the cost.

Former Sen. Mike Gravel (Alaska) proposed a voucher system, under which U.S. residents "get a chance to choose from five insurance plans" that compete for members.

Former Sen. John Edwards (N.C.) said that federal lawmakers can no longer "negotiate with the drug companies and insurance companies, and their lobbyists" and must "face these people and change the system."

Rep. Dennis Kucinich (Ohio) promoted a bill (HR 676) he has proposed that would establish a not-for-profit, single-payer health care system called Medicare for All. He added that, "as long as we're stuck with this system where insurance companies make $600 billion a year (inaudible), spending that ought to go directly to health, we're not going to get the care we need" (Debate transcript, CQ Transcriptions, 9/9).

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Patient Care Quality Summit

The AAMSE Committee on Health Care Policy has developed a program for the Expert Summit on Quality of Patient Care III, to be held October 19-20 in Chicago, IL, intended to help medical societies as they assist their physician leaders in moving forward on quality-of-patient-care initiatives. Highlights of the Summit include the following speakers:

Brent C. James, MD, the Executive Director for Intermountain Health Care and internationally acclaimed expert in clinical quality improvement, will team with leaders from the following organizations to provide hands-on advice on how your society can get involved in their quality initiatives:

Institute for Healthcare Improvement (Joe McCannon)

AMA’s Physician Consortium for Performance Improvement (Bernard Rosof, MD, MACP, Chair)

AQA Performance Measurement Workgroup (Kevin B. Weiss, MD, MPH, FACP, Chair)

National Quality Forum (Janet M. Corrigan, PhD)

American College of Physicians (Michael S. Barr, MD, MBA, FACP)

Medical Group Management Association (William Jessee, MD)

Agency for Healthcare Research and Quality (William B. Munier, MD)

Physicians' Foundation for Health Systems Excellence (Tim Norbeck)

AAMSE membership is not required for attendance; the registration fee is $200 for the first member and $165 for additional members from the same organization. For more information please visit: http://www.aamse.org/AAMSE/Index.aspx?id=1215

American Association of Medical Society Executives
555 East Wells Street
Suite 1100
Milwaukee, WI 53202-3823

Ph: (414) 272-6071

Fax: (414) 272-6070

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