January 21, 2008

IN THIS ISSUE

Editor's Column: What Are We Measuring And Why?
Blues Hearings Start This Week
More Med Mal Reforms Needed
St. John Appoints WSU Grad Cardiology Chief
Marketplace: GM To Offer 46,000 Buyout
Students Do WSUSOM Proud At Hawaii Meeting

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Editor's Column: What Are We Measuring And Why?

By JOSEPH WEISS, MD
It is possible that we are victims of the Count. As you may  remember, he was the character in Sesame Street who felt compelled to add up everything. The Count was a clever way to introduce children to arithmetic, but Sesame Street made fun of his obsession.

The present focus on measuring performance takes on the Count’s obsession but without the gaiety of it. Counting and measuring what physicians do has a place. When used by physician organizations those measurements are purposeful. What counts is a physician’s performance compared with others in the group, what the measurements uncover is what is possible in prescribing medications, minimizing emergency visits and hospital admissions. The performance rating of the individual physician comes from the experience of the group.

In contrast, the performance criteria set up by health insurance companies and Medicare are arbitrary metrics using criteria that are easily measured but still unverified as to their meaning for the outcome of the individual patient. What these insurance companies and Medicare performance criteria have in common is metrics that drive up the cost of care.

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Blues Hearings Start This Week

By PAUL NATINSKY
Battle lines continue to form in preparation for what could be a months-long deliberation in the Michigan Senate about a package of Blue Cross and Blue Shield bills that would make rules for the Blues more like those that apply to other insurers while leaving intact BCBSM's favorable tax treatment.

The Blues, business associations such as the Small Business Association of Michigan (which sells Blues policies to its members) and some chambers of commerce support the bills and the Blues notion that it's losses for the policies it writes in the individual insurance market will increase unfairly. Also couched in this argument are predictions that the individual insurance market will increase as fewer employers offer insurance and more people are forced to buy it on their own.

On the other side are the Blues' for-profit competitors, non-profit HMOs, the Michigan Attorney General, AARP of Michigan and at least one consumer group. Their arguments press the point that the changes proposed in the legislation would be anti-competitive and ultimately raise rates across the board.

The data mining, report citing and information spinning has already begun in earnest with the issuance of a report commissioned by a coalition of for-profit insurers and created by the Anderson Economic Group indicating that the Blues reaped $130 million a year in tax breaks; a figure at odds with the Blues self-reported figure which was $48 million less. The Blues have already disputed the Anderson figure.

And so, Wednesday the games begin officially. After a rush through the House, it will be refreshing, if exhausting, to see the bills considered carefully in the Senate.

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More Med Mal Reforms Needed

By RONALD DAVIS, MD
This column was originally published in AMA eVoice on Jan. 17, 2007. Dr. Davis is president of the American Medical Association.

Last month, Medical Liability Monitor released results of its annual rate survey, which reports the medical insurance rates of the nation's major insurers of physicians. The results are a bit of a mixed bag.

First, some positive news: Medical liability rates appear to be stabilizing for the second consecutive year. According to the survey, nearly 84 percent of company—reported rates held steady or dropped in 2007. Of that 84 percent, 31 percent of rates decreased—almost triple the number of rate reductions in 2005.

Now for the bad news: Premiums in many areas of the country still are at or near all-time highs. For example, premiums in Connecticut, New Jersey, and Pennsylvania have nearly tripled since 2000. And in New York, after a 14 percent increase in rates last July, most physicians are paying as much as 80 percent more for their liability insurance than they were in 2002, bringing annual premiums for many specialists to levels in the hundreds of thousands of dollars.

Clearly, there's much to be done on this front. That's why the AMA is aggressively working to solve this ongoing problem and protect patients' access to care. One way we're doing that is through efforts with state medical associations to enact and defend strong medical liability reform laws.

Last year, the AMA provided support to the Illinois State Medical Society (ISMS) in anticipation of a legal challenge to medical liability reforms enacted there in 2005. In November, the possibility of a challenge became reality when a Cook County Circuit Court judge ruled those reforms to be unconstitutional. An appeal has moved to the state Supreme Court, and the AMA and ISMS have collaborated on these ads as part of the fight to retain these reforms.

The AMA also has helped the Hawaii Medical Association, the Medical Society of the State of New York, and the Tennessee Medical Association in the past year in their efforts to pass medical liability reforms in their respective states.

A number of states have enjoyed great success in getting reforms passed—and they're reaping the benefits. Since 1999, 16 states have capped noneconomic damages or improved existing caps, and close to 30 states now have some form of a cap in place.

Among them is Texas, where a series of reforms took effect in 2003. Since then, Texas physicians have seen their rates cut by an average of 21.3 percent, and the state has experienced a statewide increase in the number of physicians, particularly specialists. Another is Ohio, where, also in 2003, lawmakers passed two dozen sweeping medical liability reforms. That year, the state only had five medical liability insurance carriers; today, because of the stability of the marketplace and an improved liability climate, that figure is up to 15.

These accomplishments, as well as recent changes in other states that have enacted significant reforms, are supported by a growing body of economic research (PDF, 72KB) that links medical liability reforms to slower growth in indemnity payments and premiums.

Because some states have had difficulty securing effective reforms, the AMA is advocating for a federal solution based on proven state laws, such as California's Medical Injury Compensation Reform Act (MICRA). Enacted in 1975, MICRA—considered the "gold standard" of medical liability reform#151;limits noneconomic damages in medical liability cases to $250,000 and has stabilized rates in California for more than three decades.

Last year, the AMA initiated a sign-on letter in support of medical liability reform legislation that would have established a cap of $250,000 for noneconomic damages, prohibited arbitrary awarding of punitive damages, and promoted swift dispute resolution. That bill was introduced in and passed by the U.S. House of Representatives but failed to garner enough support in the Senate. Despite that outcome, the AMA remains committed to advancing federal legislation on this issue.

The AMA also continues to research alternative reforms, such as affidavits of merit, statutes of limitations/repose, and apology inadmissibility. In addition, the AMA recently adopted policy on health courts to serve as legislative guidelines in the development of a fair and expeditious system for the resolution of medical liability claims.

Only through a collective effort to spur reform can we help more states make the types of gains seen in California, Texas, Ohio, and others, and also bring about a federal solution to the nation's medical liability problem. So please learn more about what the AMA is doing to reform the system. By working together, we'll be able to present a unified front to advocate for reforms that promote access to quality care while protecting against attempts to overturn existing laws that are helping physicians and their patients.

The lighter side

In a study published in JAMA in 1997, researchers reported that primary care physicians who have had no medical liability claims against them are more likely than those who have had two or more claims against them to use certain communication behaviors in their patient interactions, including laughter and humor. Interestingly, the investigators found no difference in communication behaviors between claims and no-claims surgeons.

An article in American Medical News gave examples of the use of humor by physicians. For example, during a routine Pap test, Douglas Farrago, MD, a Maine family physician and editor-in-chief of Placebo Journal, may turn to his nurse and say: "Did you mistakenly switch the Crazy Glue with the Vaseline again?" The article pointed out that while humor can strengthen the bond between physician and patient (and thus might reduce the likelihood of the patient filing a lawsuit in the event of a bad clinical outcome), it can also harm their relationship if used inappropriately.

Do you use humor or other special communication techniques to strengthen the bond with your patients and/or reduce the chance of lawsuits? Would you be willing to share any stories of when these techniques worked well, or did not work so well?

Please send comments, questions, and replies to amaprez@ama-assn.org.

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St. John Appoints WSU Grad Cardiology Chief

St. John Hospital and Medical Center has named Thomas LaLonde, MD, as division chief of cardiovascular diseases. Dr. LaLonde assumes his new role after serving as interim chief for the last year.

Dr. LaLonde has been an active staff member at SJH&MC since 1989, and the vice chief of cardiology since 2005. He was president of the medical staff from 2004-2006, and has been a member of the St. John Hospital Board of Trustees since 2000.

"We are pleased Dr. LaLonde will assume this leadership role and establish a medical leadership team within the cardiovascular service line to expand and promote cardiovascular care for our area. We are confident that Dr. LaLonde will enhance the visibility of this important product line and bring recognition to the great medical care of the cardiologists at our institution," say Louis D. Saravolatz, MD, chairman and program director, Department of Internal Medicine at SJH&MC.

Dr. LaLonde earned his bachelor of science degree at the University of Michigan and his medical degree at Wayne State University School of Medicine. He then trained as a resident, chief medical resident, and fellow in cardiology and interventional cardiology at SJH&MC. Dr. LaLonde is certified by the American Board of Internal Medicine in cardiovascular disease and interventional cardiology. He has also been recognized as a "Top Doc" cardiologist in the Detroit area for the last 13 years. He has served as director of the interventional cardiology fellowship program, and medical director of the cardiac catheterization lab at SJH&MC. He is a clinical assistant professor of medicine at Wayne State University School of Medicine.

St. John Hospital and Medical Center is a member of St. John Health and the St. John Health Heart Care Network, the leading provider of heart care in Michigan. SJH&MC is a Blue Cross Blue Shield of Michigan Cardiac Center of Excellence and has been recognized as a Top 100 heart hospital by Thomson, a national healthcare strategic information company.

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Marketplace: GM To Offer 46,000 Buyout

General Motors CEO Rick Wagoner on Thursday said that the company plans to offer a buyout package to about 46,000 employees, a move that he hopes will reduce the size of the company work force and open positions for new employees who will receive lower wages and reduced health and other benefits, the Detroit News reports (Terlep, Detroit News, 1/18).

Under a contract approved by GM and United Auto Workers last fall, the company will reduce labor costs through a two-tier wage and benefit system for noncore employees. Employees hired into the lower tier of the system will receive lower base pay and no defined-benefit pension plans or retiree health benefits. The contract also will establish a voluntary employees' beneficiary association managed by UAW that will reduce retiree health benefit liabilities for GM by about $47 billion (Kaiser Daily Health Policy Report, 10/16/07).

Wagoner said that GM and UAW have not completed discussions on the details of the buyout package, which the company plans to offer in February. GM employees who accept the buyout package would leave the company in April. GM has about 73,000 hourly employees, and analysts expect between 11,000 and 20,000 to accept the buyout package.

Reduced Costs
Wagoner said that the contract will reduce labor costs for GM by between $4 billion and $5 billion annually by 2010. According to the Detroit Free Press, although "much of the savings will come" from the VEBA, a "significant amount will come from reduced hourly labor costs," likely "sooner than many analysts expected." GM officials said that the VEBA will reduce costs for the company by $3 billion annually (Merx, Detroit Free Press, 1/18).

In addition, GM officials said that they expect pension and health care costs for U.S. hourly and salaried employees to decrease from $7 billion annually over the past 15 years to $1 billion annually after 2009 (Krisher, AP/San Jose Mercury News, 1/17).

Editorial
The plan by GM to offer a buyout package to "more than half its factory work force" will "force difficult decisions on many Michigan households and put a heavy onus on the UAW to get its new VEBA system up and running and well-funded enough to handle the health care needs of thousands more retirees," a Free Press editorial states. In addition, under the plan, "GM will be hiring a number of younger people who might not otherwise have had an opportunity to work for the auto company," the editorial states (Detroit Free Press, 1/18).

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Students Do WSUSOM Proud At Hawaii Meeting

Eleven students from the Wayne State University School of Medicine attended the 29th annual American Medical Association’s Interim Meeting in Honolulu, Hawaii, representing the School, Wayne County and Michigan.

The School of Medicine contingent consisted of students from the executive board, the AMA-Wayne County Medical Society student body, AMA national committees and from the State Governing Council. The students who attended the Nov. 7-10, 2007 conference included Pamella Abghari, Lisa Walker, Andy Moriarity, Jeanise Gorenchan, Rodney Faulkiner, Catherine Wheatley, Ryan George, Daniel King, Anthony Livorine, Mary Jacob and Kristin Ophaug.

"We were greeted with different opportunities to meet medical students and current physicians from all over, and to catch some really interesting speakers and presentations," said Ms. Abghari, AMA chapter president. "I also had the chance to share with our region this year's successful recruitment, future and past events, and our current community service endeavors."

The students had the opportunity to attend the seminars that interested them.

Ms. Abghari submitted a resolution about the handling of patients’ healthcare records, and discussed the issue with medical students from other states.

Mr. King, a national representative, served as chair of the Committee of Scientific Issues for the AMA. He put together a poster presentation competition to highlight student research from all over the United States.

Attendees also sat in on meetings about leadership and recruitment, learned about healthcare practices in Hawaii, gained more details surrounding the Covering the Uninsured Mission, and shared personal experiences about serving minorities in Detroit during a meeting about Minority Health and Health Disparities.

"We all came out together, on top, as a team," said Ms. Abghari. "We are now stronger, smarter, and wiser, with all new information and opportunities to share with our colleagues and peers."

Ms. Abghari thanked the Wayne County Medical Society and the Michigan State Medical Society for supporting the group at the meeting and for "trusting us with the mission of spreading the word about healthcare in Detroit and for discovering new ways to improve our current program."

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