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How Georgia is paving the way for physician advocacy

The state’s medical association recently took the Blues to court and won. It’s just one of several ‘firsts.’

From the March 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

In 1997, Georgia physicians received some bad news: Blue Cross and Blue Shield of Georgia (BCBS), the state's largest insurer, was changing its physician fees.

Instead of continuing to base fees on charges for privately insured patients, the insurer planned to adopt a formula that would use physician average reimbursements and include lower Medicare and Medicaid rates. Even worse, the insurer refused to disclose either the fees or the formula it would use to set them, leaving physicians in the dark about how much they'd be paid. That led the Medical Association of Georgia (MAG) to sue the insurance giant for the information.

This January, the Georgia Supreme Court weighed in. Blue Cross and Blue Shield of Georgia will have to disclose its physician fee schedules and the methodology it uses to calculate them. Analysts say that the victory is the first of its kind, one that could lead to fee schedule disclosures across the country.

At the Medical Association of Georgia's "Doctor of the Day" medical station, J.R.B. Hutchinson, MD, examines State Rep. Jimmy Lord.

"We think it's a landmark case," said Paul L. Shanor, the state medical association’s executive director. "It should apply to every insurance company in Georgia, so we're going to be working with the insurance commissioner to get that enforced across the board—and hope other states do likewise."

As College members travel to Atlanta this month for Annual Session, they are headed to a state where managed care is on the rise. Yet they will also be seeing a state with some of the most aggressive—and effective—physician advocacy in the country.

Over the past decade, Georgia physicians have fought for fee disclosure, prompt payment and the protection of prescribing privileges. In the process, they have amassed an impressive track record of successful activism that other medical groups around the country are trying to emulate.

Political clout

The victory over the Blues was not Georgia physicians' first taste of success. In the 1990s, they persuaded state legislators to enact the nation's strictest prompt-pay law.

Georgia insurers and health plans have 15 working days to pay clean claims, compared to 30 or 45 days in other states. And while many prompt-pay laws in other states aren't enforced, Georgia’s state insurance commissioner, John W. Oxendine, has levied roughly $1.5 million in fines against slow-paying health plans since 1999.

Those protections have "made a difference in the mindset" of Georgia physicians, explained Chapter Governor Joseph W. Stubbs, FACP.

"Some primary care physicians don't know if they have the cash flow to pay employees from month to month, so prompt pay definitely impacts their practices," Dr. Stubbs said. "And the Blues ruling will help us better evaluate our contracts."

The state also has the nation's second patient protection bill, including HMO liability and the right to independent external review for treatment denials.

And Georgia physicians have successfully fought off a host of scope-of-practice bills in the state legislature that would allow other professions to provide independent patient care. So far, they've held the line against optometrists, nurse practitioners and psychologists who want prescribing privileges; pharmacists who want to do lab tests; and physical therapists who want direct access to patients without physician referrals.

What is the secret to their political success? Some say that it starts with stable medical practices and high esteem for physicians, both hallmarks of rural states.

As a general internist in south-central Georgia for 26 years, for instance, William R. Grow, FACP, a former co-chair of the chapter's health and public policy committee, has cared for as many as five generations of patients from some families.

"Our profession still receives a great deal of public respect in this state," Dr. Grow said, "and that translates into political clout." (The fact that Dr. Grow’s patients include a state senator and a state representative also helps.)

Yet physicians say major credit must be given to MAG, the state medical association. Dr. Stubbs explained that the College chapter “uses public policy resources much more efficiently when we coordinate with MAG and work under its umbrella.”

He pointed out that part of MAG's effectiveness is due to its grassroots efforts, including some that target physicians. Its "Blast Fax" program, for instance, sends a fax message to its 8,000 members the morning of an important legislative vote and reminds physicians to call their congresspersons.

MAG also enlists the help of the public. In a direct-mail campaign last year, it asked the public for its views on giving prescription privileges to nonphysicians. It then used the response to fight scope-of-practice bills and to build a database of respondents who lobby general assembly members when those issues are being considered.

The association also relies on coalitions with consumer groups. According to executive director Mr. Shanor, one consumer alliance led to increased Medicaid rates for physicians. MAG also maintains a firm policy of internally resolving conflicts between specialties so that medicine can speak with one voice in the state. And it creates opportunities for interactions between physicians and legislators: Under its "Doctor of the Day" program, a different member-physician every day staffs a medical station at the state capitol for general assembly staff and members during the legislative session.

Many Georgia physicians also believe that part of MAG's effectiveness is due to GAMPAC, its political action committee (PAC). "Our legislators make it loud and clear that that is one of the things that gives us access," said Glenn Carter, FACP, the College chapter's vice president and MAG's current secretary.

Having seen the success of GAMPAC, Dr. Carter said, a substantial majority of Georgia Chapter members supported establishing an ACP-ASIM PAC and remain disappointed that the College did not do so.

A politicized chapter

Georgia physicians saw their political stock begin to rise in the early 1990s. That's when the state was singled out as a pilot site for a Medicare utilization review program to be run by HealthCare COMPARE Corp. HCFA wanted the company to control costs by managing Medicare Part B reimbursement and decided to test the program in Georgia before taking it nationwide.

As Georgia physicians’ Medicare reimbursements were choked off by reduced codes and denied claims, they organized letter-writing campaigns and media coverage. Physician protests led to federal hearings, and then-Governor of the College’s Georgia Chapter, Robert B. Copeland, MACP, testified on behalf of the state’s physicians.

"Basically, we denied HealthCare COMPARE the cover of darkness," Dr. Copeland said. "From that experience, we learned that we could make a difference." As a result, the company's Georgia contract wasn't renewed, and the program was shut down.

The state medical society was instrumental in ousting HealthCare COMPARE, as was the ASIM’s Georgia society, which also helped wage battles over prompt pay and scope of practice. General internist Jacqueline W. Fincher, FACP, said that the addition of ASIM activists from the ACP-ASIM’s 1998 merger was a real plus.

While the chapter continues to work with the MAG on advocacy issues, it is also stepping up its own efforts to improve patient care. Medical practice in the state is complicated by poverty, particularly in rural areas. And Georgia is firmly situated in what Janice Herbert-Carter, FACP, an associate professor of medical education at Atlanta's Morehouse School of Medicine, called the nation's "stroke belt."

"Hypertension, cardiovascular disease and cerebral vascular disease are basically epidemic," Dr. Herbert-Carter said. "Poverty doesn't cause those illnesses, but the lack of access make treating them much worse."

In a report published in the Oct. 4, 2000 issue of the Journal of the American Medical Association, Georgia was ranked 47th among all states for the quality of care under Medicare. That ranking set the College’s Georgia Chapter in motion.

"As internists, we need to step up to bat and take that challenge," Dr. Fincher said. "We're the primary physicians taking care of Medicare patients."

The chapter has formed a task force with both the state's Medicare peer-review organization and the regional affiliate of the American Heart Association—another first for Georgia's physicians. This June, the task force will launch an ambitious campaign to familiarize all Georgia physicians with diabetes and heart disease clinical guidelines to improve care for Medicare patients.

MAG also has a full agenda of its own. It is now lobbying against the proposed acquisition of BCBS by the California-based WellPoint Health Network. And this year, it has thrown its weight behind two bills that seek to regulate physician practices. One would set rules for office-based surgery. The other would put information about the state's physicians, including convictions or malpractice settlements, on the Internet.

"It's part of our responsibility as physicians to appropriately self-police," said David A. Cook, JD, MAG's general counsel and director of government relations. "Part of being progressive is regulating ourselves."

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