American College of Physicians: Internal Medicine — Doctors for Adults ®

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Policy Briefs

ACP-ASIM works to support meaningful patient bill of rights

Patient Bill of RightsThroughout the summer, the College worked with legislators in the Senate and the House to convince lawmakers to support a meaningful patient bill of rights.

In the days leading up to the Senate's passage of the Bipartisan Patient Protection Act of 2001 (S. 1052) at the end of June, ACP-ASIM staff and officials took a multi-pronged approach to convince senators to support the legislation. The bill calls for an independent and timely appeals mechanism for patients who are denied access to necessary services.

While the bill was in the final stages of debate, ACP-ASIM President William J. Hall, FACP, spent the morning in the Senate reception area outside of the Senate chambers talking to senators about the merits of the legislation. He wore a white coat and stethoscope so senators would recognize him as a physician, not a lobbyist.

The College also sent letters to senators urging them to focus on quality and consumer protections; successfully opposed an amendment that would have allowed managed care organizations to escape accountability for medical decision-making; and mobilized members of the College's Key Contact network to contact their senators by phone, fax and e-mail. Once the Senate passed the bill, ACP-ASIM officials turned their attention to the House. In a July 11 letter, ACP-ASIM President William J. Hall, FACP, urged the House of Representatives to support the House version of the patient rights bill already passed by the Senate. Dr. Hall explained that the Ganske-Dingell-Norwood-Berry bill (H.R. 2563) was the only proposal that translates general patient rights principles into the full measure of legal protection that patients require.

In early August, when the House passed a version of that bill with weakened liability provisions, the College contacted legislators responsible for working out a compromise between the House and Senate bills. In an Aug. 8 letter to legislators who will try to draft legislation acceptable to both the House and Senate, the College said that accountability provisions in any final provision must not pre-empt stronger state laws that already give patients their day in court.

At press time, Congress was expected to convene a conference committee in early September.

Medicare may be forced to release information without doctors' permission

Peer review organizations will soon have to release information about individual physicians without their permission when they investigate complaints from Medicare beneficiaries.

On July 10, a federal district court judge ruled that peer-review organizations must disclose their findings when they investigate Medicare beneficiary complaints about the quality of care they received. The ruling overturns current policy, which states that physician-specific information can only be released to a complainant with a physician's permission.

The judge ordered the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, to notify peer review organizations about the new policy by July 30. CMS, however, sought and was granted a stay on the court order while it decided whether to formally oppose it or comply. At press time, it was unclear if and when the new policy would take effect.

The ruling was prompted by a lawsuit filed by the consumer advocacy group Public Citizen Inc. The group filed the lawsuit on behalf of David Shipp, who had complained about the care his wife received in early 1999. Mr. Shipp's wife died of cancer in June 1999.

The peer review organization investigating the complaint was able to release information to Mr. Shipp about one of three physicians involved in his wife's care because that physician had given his permission. (Investigators found no problems with that physician's care.)

Two other physicians, however, refused to allow the peer review organization to release information about them to Mr. Shipp. The peer review organization explained that CMS policy restricted them from releasing the information. It also noted that its inability to release information about the two physicians did not imply that it had found any problems with the care they provided. The judge found that the CMS policy requiring physician consent violated the intent of the law that created the peer review organization program.

Both the Clinton and Bush administrations had defended Medicare's policy protecting the privacy of physicians involved in peer review organization investigations. Consumer advocates, however, have argued that patients have the right to know the results of investigations into their physicians.

In a July 20 letter to HHS Secretary Tommy G. Thompson and CMS Administrator Thomas A. Scully, the College said the decision could "undo years of slowly built trust" between physicians and peer review organizations. The letter also said the decision could "place fear and punishment above the much nobler goal" of improving the quality of care for Medicare beneficiaries. (The College's letter is available online at www.acponline.org/hpp/scully_pro.htm.)

College: Medicare drug benefit must meet certain conditions

ACP-ASIM supports a Medicare prescription drug benefit that does not threaten the solvency of the program or current benefits, covers beneficiaries most in need and protects patients from abuses by pharmacy benefit managers.

In a July 20 letter sent to members of the Senate Finance Committee, College President William J. Hall, FACP, said that two bills in the Senate take important first steps in reforming Medicare.

The letter also said that any Medicare drug benefit should be financed through additional revenue and should not threaten the fiscal health of Medicare or reduce existing benefits. The College also stated that the highest priority should go to making prescription drugs more affordable to those most in need.

In terms of how a Medicare drug benefit would be administered, the College said that it supports the use of pharmacy benefit managers, but only as long as the legislation contains strong patient protections. ACP-ASIM also said that it supports the use of formularies, but it added that decisions to include a drug must be based on the drug's effectiveness, safety and ease of administration, not just cost.

The text of the letter is available online at www.acponline.org/hpp/fincom_letter.htm.

College says E/M guidelines still flawed, too complex

After complaints from groups like ACP-ASIM, the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, has put on hold some efforts to streamline its evaluation and management (E/M) guidelines.

CMS had been using a contractor to develop "clinical examples" that would help physicians better understand how to use Medicare's E/M guidelines. The College and other medical organizations, however, said that the efforts were further complicating matters.

In a June 29 letter to CMS Administrator Thomas A. Scully, the College joined 38 other medical organizations in urging CMS to re-examine the guidelines. The letter explained that many of the "clinical examples" being developed were inconsistent and irrelevant to physician-patient encounters. The letter also said that the clinical examples inappropriately used clinical terminology, put too much focus on mid levels of service and don't represent typical patient encounters.

ACP-ASIM followed up with a July 3 letter to the contractor developing the clinical examples, critiquing problematic examples. The College pointed out that several of the clinical examples actually undercoded physician work, called for excessive documentation and involved atypically complex problems.

In early July, CMS announced that it had temporarily suspended its efforts to develop clinical examples.

College continues to support Medicare reform legislation

Throughout the summer, the College took actions to support the Medicare Education and Regulatory Fairness Act, known as MERFA,(S. 452 and H.R. 868), to streamline the federal health program.

In a June 14 letter to Thomas A. Scully, administrator of the Centers for Medicare and Medicaid Services (CMS), formerly HCFA, the College and 48 other medical organizations outlined revisions to the bill that would allay concerns of the HHS Office of Inspector General (OIG). That office has expressed concern that the MERFA bill would compromise its ability to detect and combat Medicare fraud.

The letter proposed revising language in the MERFA bill to clarify that it does not intend to hurt the OIG's ability to fight fraud. The letter stated that "the real purpose of the bill remains addressing abuses by Medicare contractors in their procedures for identifying and recovering alleged overpayments due to inadvertent errors and honest mistakes." (The letter is online at www. acponline.org/hpp/support_merfa.htm.)

In a July 30 letter to the Chairman of the House Ways & Means Committee, the College joined a group of medical organizations and urged legislators to "establish a set of due process protections" for physicians faced with post-payment audits. In part, the letter said that physicians should not have to pay Medicare contractors for alleged overpayments until they have exhausted all their appeals and that they should be entitled to repayment plans for large amounts.

PMC releases publications on Medicare compliance, new rules

The ACP-ASIM Practice Management Center (PMC) has released three new publications to help busy internists understand a variety of Medicare topics.

  • "The Good Business Approach to Medicare Compliance: A Road Map for Internists" shows internists how doing what is good for business-in terms of high patient satisfaction, employee contentment and timely claims payment-can also help them meet Medicare compliance requirements. The publication outlines practical steps to focus compliance activities and achieve optimal results, including a compliance self-assessment checklist.
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  • "Medicare Compliance Action Plan: A Good Business Approach for Smaller Practices" helps internists identify areas they most need to remedy and allows them to track improvement over time. By using templates, internists can keep a record of identified compliance risk areas, corrective actions and follow-up actions.
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  • "What Internists Need to Know About Medicare Changes for 2001" explains why internists received a 5% increase in aggregate Medicare payments for 2001. It also lists Medicare payment rates for certain E/M services and explains how Medicare determines rates. The publications are available to College members at no charge online at www.acponline.org/pmc/ or through Customer Service at 800-523-1546, ext. 2600.

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