E-DMN - October 20, 2008

October 20, 2008

Editor's Column: Medicine At The Crossroads Means Medicine At The Mall
In My Opinion: Comments On 'Why Obama's Health Plan Is Better'
Seminar Provides Info On Serving At Free Clinic
WSUSOM Wins Grant That Could Shorten PMD Diagnosis Time
Blues Medicare Advantage Development
Best In Medicine Conference
Study Finds Shortcomings In Hospital Readiness For Terror Attack
Comment On MQIC Draft Guidelines Here

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Editor's Column: Medicine At The Crossroads Means Medicine At The Mall

By JOSEPH WEISS, MD
Both the public and physicians hear repeatedly about the shortage in America of internists and family physicians. The country’s population is rising and the number of elderly is growing rapidly; these changes clearly indicate a need for more primary medical practitioners. However, the number of medical graduates entering medical residency programs has decreased steadily since 1998, and in Internal Medicine residencies, the great majority of graduates enter specialty fellowships. Projections indicate that the deficit between need for and availability of a generalist will be between 35,000-44,000 physicians.

The immediate response is to create new medical schools and increase enrollment in existing institutions. However, medical policy analysts point out that this approach may not bring that much help to primary care. Patient visits are becoming longer as the elderly develop more needs; furthermore, there is no evidence to conclude that more doctors means more generalists.

An alternative exists to increasing the physician supply -- the retail clinic. These offices placed in stores such as Target, CVS, Walgreens, Walmart and grocery chains are seeing increasing numbers of children and adults. Estimates are that the number of these clinics will grow to 6,000 by 2012, and that eventually 15 percent of children and nearly 20 percent of adults will use retail clinics; the retail clinic industry expects 50 million visits/year by 2011.

At present 10 medical conditions represent 90 percent of retail medical clinic vists. These conditions are:

Sinusitis, immunizations, upper respiratory infections, otitis externa, Pharyngitis, conjunctivitis, urinary tract infections, screening lab/blood pressure check, otitis media and bronchitis. Likely in time this list will expand.

The average cost per clinic visit is $104. By comparison, the average physician office reimbursement is $159, and the average claim paid for an Emergency Room visit is $383, according to numbers appearing in the journal Health Affairs.

Critics of the retail clinic contend that these facilities disrupt the primary care physician-patient relationship. However, 60 percent of patients attending retail clinic report they do not have a primary care physician.

To date, proponents of the Patient Centered Medical Home have ignored the retail medical clinic. That is a mistake. The Patient Centered Medical Home as now constituted must provide all care -- both acute and chronic. That totality is the concept’s fatal flaw. Freeing the physician’s office of the acute care conditions noted above will allow the physician to spend more time on the chronic problems that come with aging. Advocates of the Patient Centered Medical Home should look to integrate the Home with the retail clinic movement.

The day may come when the voice message from the physician’s office phone will not only say: “ If this is an emergency go to the nearest hospital emergency room,” but will add, “if this is an acute or routine concern go to the Walgreens at Main Street across from City Hall.”

Response from Dr. Victor Bloom
I can't tell if Dr. Weiss favors or is against the retail clinic. My first impression is that it would make certain medical diagnoses and treatments a common commodity, adding to the destruction of the doctor-patient relationship. To me medical care is kind of sacred. I mean what if drugstores and supermarkets had little chapels for meditation (medication) and prayer? I don't think a business atmosphere is conducive for the practice of medicine. This idea, however convenient and cost-efficient it might seem, would be a slippery slope toward reducing the practice of medicine to first aid and the band aid. Costco is offering flu shots, and I was considering it for convenience. However, after reading this column, I am going to reconsider it.

Dr. Adelman’s Comments
The problems with retail clinics are significant: In many cases, the simple visits allow physicians to pick up on conditions that the patient would not have known to come in for.Episodic care, be it through an emergency room or through retail clinics, leads to simple interventions without a more comprehensive look at the patient.

The patients will presumably be seen by nurses in the retail clinics, so it will be “nursing medicine.” Whether or not you like that depends on your experience with nurses as primary care givers.

Next, these are the types of visits that pay the bills for the doctor in the office. The doctor in the office will get more for the time spent in simple visits, less for complicated visits, so the gains on simple visits pay for the losses on complicated ones.

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In My Opinion: Comments On 'Why Obama's Health Plan Is Better'

Editor’s note: The following is a commentary from Allan Dobzyniak on remarks from David M. Cutler, J Bradford DeLong and Ann Marie Marciarille appearing in The Wall Street Journal Sept. 16,2008. The WSJ piece was supportive of the Obama health plan. For a detailed description of the Obama plan, visit barackobama.com .

By ALLAN DOBZYNIAK, MD
I find it interesting that two economists and a lawyer can accurately define an improved health care system. I do believe that doctors may know at least as much about treating disease and keeping people healthy as economists, lawyers and even politicians.

1.The authors seem to have forgotten that not only to reduce the cost of health care but also of other goods and services would be to reform the runaway trial bar. The trial bar is a crushing economic societal cost both directly and indirectly. Estimates are that as much as 25-30 percent of health care expenditures are related to direct legal costs and defensive medicine.

2. Learning - Competition in free markets with the patient in charge will allow the most appropriate decisions regarding technological support for lower cost, increased access, clinical innovations, improved efficiency and market transparency. This surely has been the case in other industries.

3. Rewarding - If it is believed that the motivation of doctors and hospitals is performing procedures and not helping patients, and that insurance companies are only interested in dumping patients and not keeping patients healthy, then the conclusions of the authors are tenable. More accurately though providers are focused on their professional and ethical responsibilities and insurers do understand the value of improved health for their customers. The financial disconnect created largely by the Medicare and Medicaid monopolies have no doubt created a challenge for providers to meet their professional obligations given the onus of a largely arbitrary and politically directed reimbursement system.

4. Prevention - To a greater extent prevention is largely dependent on appropriate lifestyle choices. This is not exclusive to the traditional health care system but is an issue extending throughout society. Engagement by government and also the private sector including the health care industry could provide the necessary motivation and education to enhance improved outcomes. To single out the health care industry for criticism, reward or punishment is to miss the mark.

5. Pooling - Spreading risk is elementary. This can be accomplished through the private sector simply by allowing smaller companies or individual to join together or even the formation of purchasing cooperatives. Further, allow the negotiation to take place directly between providers and purchasers. If the additional cost created by the middle man does not add value, then dispense with it. Large provider groups can best determine what is needed to produce health care that is transparent, easily understood, comparable, innovative and value driven. Portability is mandatory.

6.Tax policy - Level the playing field by allowing individual the same tax advantages as large companies. Encourage health savings accounts.

7. Safety net - Certainly the taxpayers should conclude societal decisions regarding provision of a safety net for those who need coverage beyond afford ability for appropriate circumstances. Also it should be decided how the cost should be borne for non-citizens.

Remember, all socialized systems have resulted in some form of rationing and have been more expensive than anticipated. The population is aging with fewer tax payers relative to the expansion of health care consumption. Medicare is predicted to have a $35 trillion shortfall over the next 75 years. But, worst of all, the best and the brightest would choose careers other than medicine, and excellent doctors would retire early in frustration. There is already a doctor and nurse shortage.

Consider the catastrophic circumstance of the impending provider shortfall based on a career which is neither professionally or financially rewarding given the challenging commitment to education and lack of reasonable financial or professional

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Seminar Provides Info On Serving At Free Clinic

With the number of uninsured in Wayne County rising, the need for free clinics has never been greater. The Michigan State Medical Society is offering a seminar for physicians and other health professionals on serving at a free clinic, Friday, Oct. 24, at 8:30 a.m. to noon.

"The Free Clinic Experience" will discuss the clinical skills required to volunteer at a free clinic, the value of giving back to society through participation in a free clinic, and the legalities of working at a free clinic. Chris Bush, MD, President of the Wayne County Medical Society and Director of the Wyandotte Clinic for the Working Uninsured in Brownstown Township, will lead the seminar. Speakers include:

Sister Mary Ellen Howard, RSM, Director of the Cabrini Clinic, Detroit.
Ram Goswami, MD, Director of the MAPI Clinic, Taylor.
Nancy Zack, CEO, Associate Director, Wyandotte Clinic for the Working Uninsured.

The seminar is part of the medical society's 143rd annual Scientific Meeting, Oct. 22-24, at the Somerset Inn, Troy The course is open to all professionals who work with the health care safety net. Course registration fee is $105 for members, $135 for non-members. To register, call 517-336-5797, or visit www.msms.org.

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WSUSOM Wins Grant That Could Shorten PMD Diagnosis Time

A team of Wayne State University School of Medicine researchers have secured a $40,000 grant from the Pelizaeus-Merzbacher Disease Foundation to conduct translational research on the disorder. Their work could lead to a test that would cut diagnosis by months, and offer parents who carry the gene that causes the disorder greater awareness of their condition through genetic counseling.

Alexander Gow, Ph.D., associate professor in the School of Medicine’s Center for Molecular Medicine and Genetics (CMMG), the Carman and Ann Adams Department of Pediatrics, and the Department of Neurology; and James Garbern, M.D., Ph.D., associate professor of neurology and of molecular medicine and genetics at the Wayne State University School of Medicine, secured the grant to further their research for a faster diagnostic test for PMD.

PMD is a rare neurodegenerative disease that usually affects children younger than 1 year. The disorder belongs to a group of rare diseases called leukodystrophies. They stem from different causes but are similar in that the white matter in the brain fails to develop. Because PMD is caused by a genetic mutation in the PLP1 gene, located on the X chromosome, the disorder mainly affects boys. Girls carry the mutation from generation to generation but generally have very mild or no symptoms.

PMD can be relatively mild, with patients living into their 50 or 60s, or so severe that patients may die in their teens or 20s. There is no treatment, only palliative care. However, increased awareness over the last few decades has dramatically increased life span.

Mild forms are characterized by lower limb spasticity with gradual deterioration and eventual need for a wheelchair. The patient’s awareness is not dramatically impaired and they can attend school. Severe forms include uncontrollable eye movements, difficulty breathing, swallowing and communicating, seizures and paralysis.

Dr. Gow explained that PMD is caused by at least 3 genetic lesions: deletion of the PLP1 gene, duplication of the PLP1 gene and small mutations that change the protein encoded by the PLP1 gene. The last category accounts for approximately 20 percent of all PMD patients and is the group for which Dr. Gow and Dr. Garbern designed their test.

They have examined more than 20 different PLP1 mutations from patients in which the disease severity is known. In all but a couple of mutations their test matches the severity seen in patients. They want to examine another 10 patients to conclude their study, a goal they believe they can reach with this recent grant.

Dr. Gow explained that it usually takes many months to arrive at a diagnosis. Their test, however, takes about 2 weeks to complete.

“Once we identify the mutation in the PLP1 gene from a patient, we generate this mutation in our lab as a synthetic gene,” Dr. Gow said. “We then introduce the gene into cells growing in a culture dish and they express the mutant protein. After a couple of days we examine the cells to find out what has happened to the protein. If the mutant protein behaves similarly to the normal form of the protein (i.e. PLP1 in normal people), then the mutant protein will cause a mild form of the disease in the patient. However, if the mutant protein behaves badly in the cultured cells, then the patient is likely to develop severe symptoms.”

A problem with PMD is that “we don’t know how severe the disease will be until the patient is about 5 years old,” he added. “By then, the disease has done a great deal of damage and any treatment we come up with will not be very effective. If our test is reliable, we may be able to predict severity by 2 years of age, when the disease is at an early stage. In this case, treatments should be more effective.”

An important part of the PMD grant, Dr. Gow noted, is that it pays to bring patients to Detroit from around the world. Dr. Garbern and Angela Trepanier, a certified genetics counselor with the CMMG, schedule patients, and Dr. Garbern determines clinical severity, performs MRIs and interacts with parents to provide counseling.

“Another reason for pursuing this test is genetic counseling,” Dr. Gow said. “If a couple has a son with PMD there is a 50 percent chance that another son will also have the disease. We hope to predict disease severity to allow the parents to decide if they wish to have additional children.”

The test would not only help parents with awareness of the disorder, it will help inform mothers who are carriers about what they can expect as they age.

“Mild symptoms can occur in carrier mothers. This is more likely if the mutation causes mild disease in the son,” Dr. Gow explained. “We would then make the mother aware of the types of symptoms she may develop as she ages. Thus, the prognostic test will help us determine how to counsel the mother about any illness.”

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Blues Medicare Advantage Development

Physicians, when deciding whether or not to participate in BCBSM's Medicare Advantage PPO network, should ensure that they are familiar with the program.

- Medicare Advantage PPO will be a Medicare managed care program. BCBSM intends the program to be operational beginning Jan. 1, 2010. BCBSM intends to submit its application to CMS in early 2009.

- Unlike BCBSM's current Medicare Advantage product offerings, the MA PPO will have a contracted provider network. BCBSM has represented that there will be no guarantee that physicians who fail to join the network before the end of 2008 will be invited to join the network in the future. Patients may obtain services from non-network providers subject to increased co-payments.

- Although BCBSM is notifying physicians to sign the agreement at this time, physician participation remains subject to satisfaction of BCBSM's credentialing criteria which have not been published. Consequently, it is possible that physicians who sign and return the agreement may not be accepted into the network. BCBSM's timetable for these determinations is not clear.

- Subject to certain termination events, physician participation in the Medicare Advantage PPO network will be for a minimum term of one year through Dec. 31, 2010. After that, either BCBM or the physician may terminate on 60 day’s advance notice.

- Grounds for early termination are specified, such as a physician's or BCBSM's failure to remain licensed, etc. While BCBSM has the right to terminate on 30 day’s notice and opportunity to cure due to a physician's breach, the agreement fails to provide physicians and other providers with an express termination right in the event of non-payment or other breach by BCBSM.

- Providers have a right to terminate within 45 days of notification from BCBSM of an amendment to the agreement, which it may make unilaterally. While the agreement does not explicitly extend this right to provider manual amendments which BCBSM may make unilaterally, whether a manual amendment may qualify as an amendment to the agreement will need to be evaluated on a facts and circumstances basis. The manual has not been published, and it is not clear when it will be published.

- For 2010, BCBSM has represented that physician payments will be at original Medicare fee-for-service rates, but BCBSM may modify this methodology subject to physician termination rights. BCBM may enact incentive plans and withholds.

- As with the current Medicare Advantage program, BCBSM will be responsible to pay

providers from its own funds (BCBSM will be paid a capitated rate by CMS). Clean

claims (i.e., Medicare's definition) will be paid within 30 days of receipt. Claims paid beyond this time bear statutory interest. Claims, including adjustments and revisions, must be submitted within 365 days from date of service or they will not be payable.

- To date, BCBSM has not published or established its operational policies and procedures, utilization management program, quality program, provider manual, and credentialing requirements for the Medicare Advantage PPO network. Whether these policies and procedures will track established BCBSM requirements for its commercial products is not known. The standard for medical necessity is contractually defined from the perspective of a provider exercising prudent clinical judgment.

- Physicians who participate will be contractually obligated to comply with specified administrative, disclosure and compliance requirements (including internal compliance monitoring and auditing). In order to comply, physicians and other providers will need to adopt new compliance programs or may need to modify existing compliance programs. BCBSM agrees to assist providers as appropriate with education and training materials relating to the agreement. Other requirements include maintaining medical, financial, and administrative records for 10 years, as well as acceptable levels of any required liability insurance.

- As with its other programs, BCBSM has the right to initiate recovery of overpayments, etc., within 24 months of the date of payment, except that in instances of fraud there is no time limit on recoveries.

- A provider and BCBSM are required to indemnify and hold the other harmless for claims and liabilities arising out of or resulting from any act or omission by that party in performing its responsibilities under the agreement or arising from criminal, fraudulent, negligent or dishonest acts or omissions. While indemnification provisions are common in managed care provider agreements, they are not required by CMS MA regulations nor are they utilized by BCBSM in its traditional and TRUST agreements for physicians. As required by CMS regulations, the agreement states that BCBSM may not require providers to indemnify it against any civil liability for damages caused to a member as a result of BCBSM's denial of medically necessary care.

- The agreement contains other provisions commonly found in managed care contracts, such as a requirement that providers look solely to the plan for payment, even in the event of the plan's insolvency or failure to pay, except for co-payments payable by the patient.

_________________________

This communication has been furnished for informational purposes only to members of the Wayne County Medical Society of Southeast Michigan, courtesy of the Oakland County Medical Society and does not constitute legal advice by the WCMSSM or by Kerr, Russell and Weber, PLC. Physicians are advised to consult with their own professional advisors and to make their own individual decisions. While the information contained herein is believed to be accurate, this communication is qualified by the terms and conditions of BCBSM documents and other pronouncements made through the date hereof (Oct. 14, 2008) and which are not reprinted herein. The information contained in this communication is subject to revision or change without prior notification. For further information, contact the Oakland County Medical Society, Donna W. LaGosh, Executive Director, at (248) 773-4000, or Patrick J. Haddad, Kerr, Russell and Weber, PLC at (313) 961-0200.

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Best In Medicine Conference

Best in Medicine
Best Minds, Best Practices
The Michigan State Medical Society Foundation Presents
Tuesday, November 11, 2008
The Inn at St. Johns ▪ Plymouth
This year’s conference will provide a strong line up of important clinical and leadership issues.
AMA PRA Category 1 Credit: 6
Fees: MSMS & MMGMA Members: $150; Non-Members: $190
Meals: Continental breakfast and lunch will be provided

Small Sampling of Featured Topics & Speakers:

Planned Care in the Small Office Practice
Michael A. Zimmerman, MD, Chief Medical Officer, Affinity Medical Group, California

Cardiovascular Disease: Patient Literacy
Barbara Meyer Lucas, MD, MHSA, MSMS Board of Directors, and Health Care Consultant, Dearborn

Smoking Cessation
Linda Thomas, MS, CTTS-M, Program Manager, Tobacco Consultation Services, University of Michigan Health System

Physician and Hospital Relations
Gerard Van Grinsven, President, Chief Executive Officer, Henry Ford West Bloomfield Hospital

Emergency Call Coverage – The Florida Study
Eli Lerner, MD, FACS, Immediate Past Chairman, Florida Medical Association

Physician and PA Team Concept
John McGinnity, MS, PA-C, President, Michigan Academy of Physician Assistant
James Kilmark, Immediate Past President, Michigan Academy of Physician Assistant

4 Easy Ways to Register:

▪ Online: www.msms.org/eo
▪ Telephone: (517) 336-5784
▪ Fax: (517) 336-5797
▪ Mail: MSMS Foundation, 120 W. Saginaw St., East Lansing, MI 48823

For More Information:

Contact Kate McPherson at (517) 336-5734 or kmcpherson@msms.org

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Study Finds Shortcomings In Hospital Readiness For Terror Attacks

The findings of a new study published today in the American Medical Association's (AMA) Disaster Medicine and Public Health Preparedness journal found that emergency department physicians and nurses are deeply concerned about the ability of the nation's hospitals to deal with the medical implications of a radioactive dirty bomb or other terrorist attacks involving radioactive materials.

"Hospital emergency departments will play a crucial role in the response to any terrorist attack involving radioactive materials," said study lead author Steven M. Becker, PhD, Associate Professor of Public Health, and Vice Chair of the Department of Environmental Health Sciences, at the University of Alabama at Birmingham. "In fact, it is no exaggeration to say that the actions of hospitals will be central to the success or failure of efforts to manage a radiological terrorism attack and its health consequences."

Researchers conducted a series of 10 focus groups with emergency department physicians and nurses in hospitals in three U.S. regions – southeast, northeast and the west. Study participants discussed a hypothetical "dirty bomb" scenario and the treatment of patients affected by such an attack. Participants consistently expressed the view that medical professionals, emergency departments, and hospital facilities are not sufficiently prepared to respond effectively to a radiological attack. Key concerns of physicians and nurses include the possibility of the hospital being overwhelmed with patients, safety of loved ones, potential staff shortages, risks for hospital personnel, and a general lack of familiarity with radiation safety and treatment issues.

The study, which was funded by the Centers for Disease Control and Prevention (CDC), provides new insights into physician and nurse concerns and viewpoints, and reveals major preparedness challenges. These challenges must be addressed if hospitals and the nation are to successfully face current and future threats.

"The study has clear implications for medical preparedness and response," said Dr. Becker. "There is a need for increased information and training on managing radiological events, protecting staff, and treating affected patients. Likewise, there is a need for increased access to informational resources, such as specialized professional hotlines, pocket guides, posters and toolkits. In addition, physicians' and nurses' concerns for loved ones need to be better taken into account in preparedness planning to prevent a potential shortage of health care providers.

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Comment On MQIC Draft Guidelines Here

The formal draft guideline on office-based procedures requiring anesthesia developed by the MQIC Medical Directors has been issued and comments are due back to MQIC by October 31, 2008. The draft guideline is based on the 2007 American Medical Association's Improving Office-Based Surgery Principles and incorporates some changes based on MSMS feedback. The draft guideline is attached for your review (click here for form).

If you are interested in submitting comments to MQIC directly, complete and return the attached Disclosure Form and Guideline Feedback Form to wanderson@bcbsm.com or by fax to (248) 448-8055 by Friday, October 31, 2008.

If you would prefer that your comments be submitted through MSMS, please forward them to Stacey Hettiger via email (shettiger@msms.org) or fax (517-337-2490) by Thursday, October 30, 2008.

The following is a summary of the changes to the previous draft:

Accreditation:

Language under "accreditation" has been modified to state that physicians performing office-based surgery should demonstrate the ability to provide anesthesia services safely by meeting the key components outlined in the guideline. The key components can be satisfied by accreditation through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Accreditation Association for Ambulatory Health Care (AAAHC), or American Association for Accreditation of Ambulatory Surgical Facilities (AAAAS). (Note: This modification appears to be consistent with MSMS's recommendation.)

MQIC did not accept MSMS's recommendation to omit the last bullet, as the language has been retained in the second bullet.

The third bullet is new language.

Patient Selection:

A definition of "ASA Level III" is added as a footnote and includes the applicable Web site address (www.asahq.org) as per the suggestion by MSMS.

Informed Consent:

Second bullet modified by the addition of the word "meet" as suggested by MSMS.

Adverse Incidents:

The third bullet from the previous draft, which recommended that practices consider having a policy on apologies to patients for adverse/avoidable events, was removed.

Educational and Credentialing Requirements:

First bullet modified to require that physicians have completed an accredited post-graduate training program appropriate to the procedure performed. Second bullet, which suggested that physicians administering or supervising moderate or deep sedation or general anesthesia should have appropriate education and training, was removed.

Hospital Affiliation:

No changes.

Monitoring and Resuscitation:

MSMS recommendations adopted by renaming the component "Monitoring and Resuscitation" and by modifying the second bullet to require that both monitoring and resuscitative equipment is present or immediately available.

Anesthesia Administration:

No changes.

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