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Washington Perspective

How we keep in touch on issues like errors and drug management

From the April 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

It is common in election years for politicians to make a sport out of beating up on Washington. The accusations go along the following lines: People who work in the nation's capital are out of touch with the American people. They need to get out and meet "real" Americans. An "inside-the-beltway" mentality has taken hold in Washington that results in ridiculous rules, stupid laws and unfair policies.

Washington insiders have thick skins and rarely let the attacks get to them. They know that once the attackers get elected, they too will quickly become part of the inside Washington crowd (even though they may be loath to admit it to constituents).

The campaign rhetoric may be overheated, but there is some truth to the charge. Lawmakers, regulators and lobbyists tend to talk primarily to other lawmakers, regulators and lobbyists, often to the exclusion of those who sent them to Washington in the first place. The ACP-ASIM Washington Office, however, prides itself on resisting this temptation and making it an important part of our jobs to regularly talk with College members.

Chapter meetings

One of the most important ways we stay in touch is by attending College chapter meetings. In my view, we need to get out of Washington periodically to do the best job that we can in Washington.

Over the past six months, I have had the privilege of meeting with internists at chapter meetings in Virginia, North Carolina, Rhode Island, Nebraska and New Mexico. (Altogether, I attend about 15 chapter meetings a year, trips that are paid for by the College, not local chapters.) The four lobbyists who work in the Washington office also attend chapter meetings throughout the year. The time out of the office and the expense is considerable, but it is well worth it.

What have I learned from my recent visits? Two issues in particular were subjects of considerable discussion among College members. Internists are very concerned that politicians will use the Institute of Medicine (IOM) report on medical errors to pin the blame on physicians instead of promoting constructive solutions. Many are also angry about growing interference from pharmacy benefit managers. On both of these issues, members wanted to know what the College is doing to represent their—and their patients'—interests.

Medical errors

One ACP-ASIM member in Virginia, having heard my presentation on how the College is addressing the medical errors issue, said that the College needs to "get the word out" to members. He observed that newspaper reports characterized the IOM's conclusions much more negatively than the College, and he implored ACP-ASIM to do a better job in getting the truth out to members and the public. College members also told me that they remained very concerned that mandatory reporting of medical errors will lead to more litigation and penalties and not the quality improvement approach that ACP-ASIM favors.

What did I take home from this? First, that ACP-ASIM needs to use every available medium to provide an accurate, balanced and complete understanding of what the IOM has recommended and how the federal government is responding. If opinions about the IOM report are formed based on misleading and exaggerated accounts in the media, physicians understandably will resist the IOM's call to reduce errors.

Second, internists have a valid concern that mandatory reporting will be used in a punitive manner. While internists support the College's commitment to working with federal and state officials to reduce errors, members also want us to be strong advocates for emphasizing quality improvement instead of finger-pointing. (To date, the Clinton administration has proposed that uniform reporting to state government agencies of major errors--defined as mistakes that lead to "permanent disability or death"--be gradually phased in over the next three years, along with strong confidentiality protections.)

Pharmacy benefit managers

ACP-ASIM members in North Carolina spoke passionately about the need for the College to fight attempts by pharmacy benefit managers (PBMs) to limit the availability of appropriate medications in order to save money. (PBMs are companies hired by managed care plans to control the costs of prescription drug benefits.) Several members expressed concern that a decision by Congress to expand Medicare coverage for prescription drugs would lead to more intrusion by PBMs into physicians' prescribing decisions.

I was able to report that ACP-ASIM has recently updated its policies on the role of PBMs. Our new policies state that formularies and drug utilization review should be based on ease of administration, effectiveness and safety, and not principally on costs. Physicians should be able to prescribe off-formulary drugs based on objective evidence of effectiveness without having to go through a burdensome approval process. And patients should be informed in a timely manner about changes in formularies and how their co-payments will be affected if a prescribed drug is not on a formulary.

We are currently drafting consumer protection principles based on these policies. We will advocate that lawmakers include these principles in any legislation to expand Medicare coverage of prescription drugs. It was clear from the discussion in North Carolina, which has since been echoed in other chapter meetings, that the College is on the right track in making the issue of PBMs and their role in restricting the availability of prescription drugs a major part of our advocacy agenda.

Learning and validating

Chapter meetings help us learn what members really think about the College's advocacy efforts. We are able to validate that we are on the right track with issues like patient safety and pharmacy benefit managers, and we find out if we need to do a better job in getting information out to members on such issues. Talking to members at chapter meetings also alerts us to emerging issues that may not yet be a major part of our agenda, but will likely become so.

Attending chapter meetings isn't the only way that we hear from College members. The Washington Office has a standing policy of being available to any member who contacts us by e-mail, phone or letter. The public policy booth at the Annual Session also provides a place for members to stop by and meet the D.C. staff.

We are committed to staying in touch with College members and determined not to fall victim to the "inside-the-beltway" syndrome that affects so many others in Washington. If we should ever falter, however, it is important that you let us know. You can find one of us at most chapter meetings or at Annual Session. Or just contact me directly at 800-338-2746, ext. 4530, or send an e-mail to rdoherty@acponline.org. I'd love to hear from you.

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

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