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

United HealthCare drops mandatory hospitalist plan

In part because of objections from the College's Rhode Island Chapter, United HealthCare of New England agreed in early October to drop plans to implement a mandatory hospitalist program for its Medicare managed care plans.

United already uses hospitalists in its commercial HMOs and Medicaid HMOs, but on a voluntary basis. The health plan, which serves Rhode Island and parts of Massachussetts and Connecticut, had proposed making hospitalists mandatory for patients enrolled in its Medicare managed care plans.

"We strongly felt that it should be a choice," explained Yul D. Ejnes, FACP, the College's Transitional Governor for the Rhode Island Chapter, noting that a mandatory plan could interfere with the decision to admit a patient into the hospital. If a primary care physician and hospitalist disagreed about whether to admit a patient, he said, the hospitalist's decision would prevail.

When United announced its plans for a mandatory hospitalist program in July, the chapter alerted its members, many of whom wrote to United and spoke to the plan's medical director. The chapter was joined in its effort by College headquarters, the state medical society and the Rhode Island Academy of Family Physicians.

New E/M framework is better, but other options needed

ACP-ASIM is pushing for additional changes to HCFA's evaluation and management (E/M) documentation guidelines.

While College officials agreed that the "new framework" for E/M guidelines submitted by the Current Procedural Terminology (CPT) Editorial Panel is more reasonable than earlier versions, they said it is still too burdensome for physicians.

In a Sept. 7 letter to HCFA, the College said it supported pilot testing the new framework, but suggested that HCFA simultaneously test a less complex system that takes into account the amount of time that physicians spend with each patient.

The College's letter also said that HCFA should pilot-test its new E/M guidelines in different types of practice settings around the country to determine exactly how much time and effort physicians would need to spend documenting their work. The College suggested that HCFA should allow all physicians, not just those participating in the pilot studies, to use the new framework during the pilot phase.

College suggests changes to HCFA's new fee schedule

The College has called on HCFA to incorporate its suggestions into the new Medicare physician fee schedule, which takes effect on Jan. 1.

In a Sept. 20 statement, ACP-ASIM suggested that HCFA make a number of changes to its resource-based practice expense relative value units (RVUs). The College said that interested parties should be able to review and comment on recommendations made by the contractor that is helping HCFA evaluate methodological issues. The College also suggested that HCFA create a set of standardized criteria determining exactly what type of data different specialties can submit to justify increases in RVUs.

The College also suggested changes in the use of CPT modifier-25. ACP-ASIM opposes the proposal that would require all evaluation and management (E/M) services to include this modifier when performed on the same day as a procedure not covered by global surgery rules.

The College fears that physicians who use this modifier will have their claims inappropriately denied by Medicare carriers.

BBA cuts to indirect GME should be kept to current rate

In testimony submitted Oct. 1 to the House Ways and Means Health Subcommittee, the College called for a halt in further reductions to Medicare reimbursements for the indirect costs of graduate medical education.

The Balanced Budget Act (BBA) of 1997 cut indirect medical education (IME) payments, which reimburse teaching programs for supervising residents and fellows, treating indigent patients and other education-related expenses. BBA changes were expected to reduce IME payments by $103 billion between 1998 and 2002, but analysts now say that the legislation will save closer to $191.5 billion, or 86% more than was initially projected.

The College is urging the subcommittee to freeze IME payments at the current level of 6.5%. Before the BBA, IME payments had been 7.7% and further cuts are scheduled to reduce them to 5.5% by 2001. Without adequate funding, teaching hospitals—which rely on graduate medical education to provide care to poor patients—will not be able to survive.

"These cuts will further jeopardize the survival of teaching hospitals and their programs of graduate medical education," the College said in its testimony. The College also urged Congress to correct the Medicare sustainable growth rate (SGR) formula mandated by the BBA. The SGR establishes a target for Medicare spending on physician services and then raises or lowers physician reimbursements to ensure that Medicare meets that goal.

The College has protested that physicians have been the only group subject to this target, even though physician services have grown more slowly than other Medicare benefits. The Medicare Payment Advisory Committee has made several recommendations to improve the SGR, but HCFA has said that it lacks the authority to fix errors. As a result, ACP-ASIM is asking Congress to make legislative changes to address the problem.

ACP-ASIM supports House patients' bill of rights

ACP-ASIM commended the House of Representatives' passage of the bipartisan patients' bill of rights on Oct. 7.

The bill, which was sponsored by Reps. John Dingell (D-Mich.) and Charles Norwood (R-Ga.), would permit patients to sue HMOs in state courts and appeal health plan denials. It would also expand emergency room coverage and broaden access to specialty care.

"It is clearly in a patient's interest to have medical decisions made by their personal physicians, based on the individual's particular circumstances and the available clinical evidence on the effectiveness of different treatments," said College President Whitney W. Addington, FACP.

At press time, the House bill had to be reconciled with a Senate bill that lacked key patient protections. The Senate bill would extend patient protections only to Americans covered by self-insured plans governed by ERISA, leaving all other patients without federal protections. The Senate bill would also not allow patients to sue HMOs when coverage of procedures is delayed or denied.

Rules on restraint, sedation need more input from doctors

The College is concerned about two new HCFA rules that limit the use of restraints and sedation on hospitalized patients.

The new provisions require a face-to-face physician evaluation within an hour of ordering a patient in a behavioral management setting to be restrained or sedated. The new guidelines are part of HCFA's interim final rule, which took effect on Aug. 2.

College officials are concerned that the provisions were created without appropriate consideration from the medical community. In a Sept. 17 letter to HCFA Administrator Nancy-Ann DeParle, the College's Associate Executive Vice President Alan Nelson, FACP, said that the requirement is "overly prescriptive" and "does not reflect the current nor the best practice of medicine."

While the College agrees that a timely evaluation should be performed when a patient is restrained or sedated, it maintains that a face-to-face evaluation within an hour by a physician is not always possible or clinically necessary.

Vice President Al Gore calling undecided members of the U.S. House to encourage them to vote for the bipartisan patients' bill of rights.

College to OIG: change fraud campaign literature

The Office of Inspector General (OIG) has agreed to change the print materials that are part of the campaign targeting Medicare fraud.

The College had requested the change in a letter to the OIG because it said that the print materials supporting the "Who Pays? You Pay" campaign "tear down, rather than build a bridge of trust between beneficiaries and providers." The College has asked that the revised print materials present physicians and providers as partners and allies in the government's war on fraud.

The College is also asking the American Association of Retired Persons (AARP) to change its print materials.

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