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Washington Perspective

How ACP-ASIM plans to strengthen advocacy at state and chapter levels

From the June 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

For those of us who make our living in Washington, it is convenient to think that all power flows through the federal government. After all, the more power that resides in the nation's capital, the more you need us to help you.

But the truth is that Washington is not as powerful—or important—as we like to think. While it is true that Congress and federal agencies have much influence over health care, decision-making power in health care is dispersed and diffused throughout the country.

Managed care organizations, state governments, insurance carriers and local employers all yield a great deal of power over health care. Power is exercised every time a health plan decides to deny a hospital admission and every time a state legislature expands the scope of practice of nonphysicians.

In addition, federal programs delegate a substantial amount of power to state organizations. Medicare, for instance, depends on carriers in each state to develop local medical review and coverage policies. Decision- making authority for the Medicaid program is squarely divided between federal and state authorities.

The diffusion of power creates numerous channels for internists to influence decisions. But it also presents a great challenge: With so many decision-makers, who do you call to get things changed?

Gaining influence

Helping internists gain influence over the power brokers outside of Washington is a top priority for the ACP-ASIM. We are pursuing the following strategies:

  • Creating a strong advocacy arm in every ACP-ASIM chapter. With so much happening at the state level, it is essential that every chapter learn to effectively advocate for internists.
  • Giving chapters resources. Chapters have limited resources—volunteer leader time, limited staff support and small treasuries—to apply to advocacy. They are willing to do what they can, but they need help from the national organization.
  • Empowering physicians. Right now, physicians are at a decided disadvantage in negotiating with insurers. They can negotiate one-on-one with insurers, but anti-trust laws generally preclude them from joining together to negotiate as a group over issues that affect patient care. Empowering physicians to bargain collectively with health plans would help level the playing field.

Chapter advocacy

One of the first steps toward effective chapter advocacy is establishing a state health and public policy committee. These committees provide a venue for volunteer internists to work together to develop policy recommendations on issues that are important to physicians in their state. Some chapters have also established a state medical services committee to address problems with Medicare carriers, managed care organizations and other payers.

Several larger states have hired full- or part-time staff to coordinate advocacy activities and represent the chapter's interests in state capitals. A few have even created a separate membership organization to direct lobbying and advocacy efforts.

There is no "right" way to organize a chapter's advocacy functions. What works in California or New York may not work in Montana. What is important, however, is that every chapter make a commitment to effective advocacy, using whatever approach works best locally.

Help for chapters

ACP-ASIM helps its chapters become effective advocates in several ways. Cathy Sullivan, the Washington office's Associate for State Health Policy, regularly communicates with state health and public policy committees and chapter Governors. She provides them with information on national trends, the status of particular bills being considered in their state legislature and case studies on how other chapters have influenced similar issues. She also organizes a forum during Annual Session to facilitate discussion among these committees' members on how to become more effective advocates.

The College's Department of Managed Care and Regulatory Affairs is also developing resources to help chapters establish an effective third-party-relations program. For instance, all Medicare carriers are required to establish a Medicare carrier advisory committee (CAC) to review proposed local medical review and coverage policies. By appointing a representative to serve on a CAC, chapters can have direct input into carrier decisions. ACP-ASIM can help CAC representatives by providing them with expert analysis of proposed medical review policies, suggesting strategies and helping them exchange information with CAC members from other parts of the country.

In many cases, a combination of state and national advocacy is required to bring about change. When chapters in Texas and Florida asked for ACP-ASIM's help in challenging mandatory hospitalist programs in their states, ACP-ASIM organized a joint letter from both chapters that protested the practice. Twenty three medical organizations signed the letter, which was sent to managed care trade associations. The pressure brought on by the letter—coupled with strong chapter advocacy—has led one of the plans to abandon its mandatory hospitalist program. In addition, the American Association of Health Plans, one of the recipients of the joint letter, has asked to meet with the College to discuss internists' concerns about mandatory hospitalist programs.

Collective bargaining

Even with effective advocacy at the chapter and federal level, internists will continue to be at a disadvantage in negotiations with health plans. Unless they are directly employed by a health plan, antitrust laws generally prohibit physicians from joining together in collective negotiations with health plans. An individual internist can object to a provision in a health plan contract and refuse to sign it, but if two or more internists together decide to refuse to sign a contract unless an objectionable provision is changed, they can be sued for violating antitrust laws.

ACP-ASIM is supporting federal legislation that would allow physicians to negotiate with health plans over issues that affect the quality of, or access to, care. (Such issues might include mandatory hospitalist policies or unreasonable requirements on how many patients an internist must see each hour). The College is supporting only such legislation that would prohibit collective actions that could limit or deny care to patients or result in price-fixing and other anti-competitive actions.

Combined efforts

ACP-ASIM's objective is to be an effective advocate for internists wherever decisions are made. Strong advocacy in Washington will continue to be important, since no one expects Congress and federal regulators to keep their hands off health care. Some problems—such as reducing the number of uninsured—will demand a federal response.

But advocacy is a game that cannot be played in Washington alone. It must be played in every state and community across the country. It is ACP-ASIM's role to make sure that we are fielding the best players for internal medicine, wherever the game is played, and that they are prepared with a winning strategy before they ever take the field.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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