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Managed Care and the Death of Ivan Ilyich Any physician who has visited Washington, DC or Albany for a legislative meeting knows that when doctors complain about managed care it generates a sympathetic smile, but when patients complain they get action and answers. So, education our patients about the enormous challenges of practicing medicine in the current managed care environment and engendering their support is important. But the question is not if we should share our practice concerns with our patients, but when is the appropriate time to have the discussion. The patient confronted with illness is quite often anxious and at times convinced that a life threatening illness is looming. For the patient, the wish that the physician sitting in front of them be completely consumed with their health concerns is appropriate and necessary. Anything that distracts from that goal can lead to their anxiety and lead to dissatisfaction, even when good care is rendered. Over one hundred years ago, Tolstoy captured the essence of the patient's terror in the face of illness in the essay, "The Death of Ivan Ilyich." Unrelenting abdominal pain and "a queer taste in the mouth" led to a medical consultation. ...everything was as it always is. There was the
usual period in the waiting-room, and the important manner assumed by
the doctor-and the sounding and listening and questions that called for
answers that were foregone conclusions and obviously unnecessary , and
the weighty looks which implies, You just leave it all to us, and we'll
arrange matters. The fear of serious illness is far too strong a distraction to the patient at the time of your consultation to believe that an effective message relating to the politics of medicine can be delivered. I believe we need to express our concerns by reaching out more to friends, relatives and neighbors at social events and community activities. Everyone has health care and insurance related complaints, as well as, unpaid or contested bills. Many people I speak with are interested in learning about the challenges from the physician side. We also need to encourage patients to attend political fund-raisers with representatives of the medical society and support greater patient involvement in peer support groups that have active legislative agendas. We need the support of our patients as advocates for change as the managed care environment evolves. It's all about timing.
David Eskreis, MD
From the New York State Department of Health Pursuant to 1998 landmark legislation and the Department of Health's continued commitment to pain management, we are pleased to announce new regulations affecting the prescribing and dispensing of controlled substances. The regulations follow recommendations by the Public Health Council's Pain Management Committee and the New York State Task force on Life and the Law. The goal of the regulations is to promote greater accessibility of medication for the treatment of pain and related symptoms, while deterring the illegal use of controlled substances. On May 1, 2001, the New York State Department of Health will begin issuing the new single part Official Prescription Form. The new single part Official Prescription Form is purple in color and contains state of the art security features to deter alterations, color copying and scanning. The process for ordering Official Prescriptions remains the same. After April 30, 2001, all orders will automatically be filled with the new single part Official Prescription Form. Physicians may continue to utilize Triplicate Prescriptions through December 31, 2001. However, beginning January 1, 2002, only the new single part Official Prescription Forms will be valid. Please note that there will be no refunds issued for unused triplicate prescriptions. If you have any questions regarding this issue, please call the Bureau of Controlled Substances at (518) 402-0708.
Copies of the revised Nassau County Department of Health bulletin Lyme Disease and Other Tick Related Illnesses are available at no cost to health care providers for distribution to their patients. The bulletin provides information to patients about Lyme Disease and other diseases in this area that are caused by bites from infected ticks. The bulletin provides strategies to prevent disease, describes the proper way to remove ticks and lists the early symptoms of Lyme Disease, Ehrlichiosis, Babesiosis and Rocky Mountain Spotted Fever. The bulletin also includes recommendations for the use of Lyme Disease Vaccine. Health care providers can contact the Nassau County Department of Health at 516-571-2006 to obtain copies of the Lyme Disease and Other Tick Related Illnesses bulletin.
In an effort to limit huge financial losses from its failed Oxford Medicare contract, the North Shore-LIJ health care system has sharply cut its E&M code reimbursement rates for its participating physicians. The giant hospital complex has also announced that it has reached an agreement with Oxford Health Plans to terminate its 5-year risk contract after the first three years. The agreement covers 26,000 seniors in Nassau, Queens and Staten Island. A statement from Oxford says that company officials "may reassess its Medicare benefits and coverage in Nassau County for 2002." Oxford bailed out of the Suffolk Medicare HMO market two years ago. North Shore-LIJ officials have told physicians that the loss may be as high as $27 million in 2000 alone. The deal was cast, however, at a time when expanding HMO interest in Medicare managed care coincided with North Shore-LIJ's interest in gaining market share in the highly competitive Long Island market. The North Shore Physicians Organization (NSPO), which represents many physicians at North Shore University Hospital in Manhasset, the Physician Organization of Central L.I., (POCLI), which represents physicians as North Shore - Plainview and New Island Hospital, are loudly protesting the cut in Medicare service reimbursement. Physicians argue that the cuts will severely impact on the ability of physicians to adequately care for this clinically-complex population. Until now, physicians participating in the program had received 100% of the Medicare fee schedule for E&M code visits and 90% for non-E&M code procedures. Under the North Shore-LIJ fee reductions, to go into effect April 23, reimbursement will be cut to anywhere from 64% to 77% of the latest Medicare schedule. A significant added burden, according to a spokesperson from NSPO, is the added demand by North Shore-LIJ that physicians submit hard copies of a patient's records before they can be reimbursed for a Level four or Level Five service. NSPO has advised members to do a financial analysis to determine individually whether a member "can provide quality care to elderly patients at these new fees."
Senate Republicans held a press conference to announce a package of bills to reduce auto insurance fraud and auto premiums. The package was in response to the recent news that drivers in New York's ""assigned Risk Pool" would see their rates raised an average of 18%, that auto insurance fraud reports had tripled in the last four years, and that New York State was likely to overtake New Jersey as the state with the highest auto insurance premiums in the country. The proposals in the package included:
With regard to the reduction of the time frames issue, in order to ensure that physicians and claimants would not be denied payment when a claim is submitted beyond the deadline for issues out of the physician's control, the Senate stated that there would be "exemptions" for legitimate excuses that would prevent complying with a deadline. Those exemptions have not yet been defined, as no bill has of yet been introduced on this issue. The medical society will continue to argue to the Legislature and the Governor that most reasons for the delay are legitimate and not the fault of the provider. No legislation, therefore, should place unnecessary burdens on legitimate providers who are already overburdened with expensive and often meaningless regulation. The Assembly majority are likely to announce shortly their own package of bills to reduce auto insurance fraud.
New guidelines developed by a CDC-convened panel of doctors urge physicians to cease routinely prescribing antibiotics for colds, sore throats, sinus problems and bronchitis. Dr. Vincenza Snow, an internist with the Medical College of Pennsylvania who helped write the guidelines, said, "Seventy-five percent of antibiotics are prescribed for upper respiratory problems and we now know that the great majority of those illnesses are caused by viruses, so most of those prescriptions would be inappropriate." Snow added that patients with viral infections "often erroneously" believe that antibiotics make them better, but "the passage of time cured their viral illness." The panel recommendations include:
To further achieve the CDC's goal of decreasing the number of unnecessary antibiotic prescriptions and spread of antibiotic resistance, the agency is forming partnerships with state and local health departments, medical societies, managed care plans, pharmacy benefits managers and the medical industry to promote "appropriate antibiotic use".
As of March 14, Frontier Insurance Group has voluntarily stopped writing new and renewal business in New York. Although the company has many lines of insurance, medical malpractice proved to be particularly unprofitable. The company posted net losses of $113 million for the first three-quarters of 2000, which followed a net loss of $233 million in 1999. In 1999, when A.M. Best Co. downgraded Frontier from A- to B++, the company continued to write business under the Clarendon Insurance Group of New York. The company took several restructuring measures to increase reserves in the past few years but none of them were able to offset the huge loss of reserves. The New York State Insurance Department said that regulators are "pleased that the company volunteered to stop writing business." The Department is closely monitoring the company and "will continue to evaluate what actions are necessary to protect Frontier's policyholders."
Assembly Judiciary Committee Chair Helene Weinstock has reintroduced two bills, strongly opposed by the medical society, that would greatly expand liability costs for physicians in New York State. The first, A.7789, would expand the type of damages awardable in a wrongful death action to include damages for non-economic loss including pain and suffering. A same-as bill (S.793) has been introduced in the Senate by Senate Judiciary Committee Chair James Lack. The other bill introduced A.7793, would change the medical liability statute of limitations to a "date of discovery" rule, thus essentially eliminating any statute of limitations. The bill would also create a one-year re-opener provision for claims that had previously been time barred. If either of these bills has been enacted, medical liability premiums for physicians would need to be increased hundreds of millions of dollars. Given the already out of control medical liability system in New York State, with verdicts having tripled in the last 5 years (form $1.7 million in 1994 to $5.6 million in 1999), and with the uncertainty of the fate of the Excess Medical Malpractice Insurance Program after June 30, 2001, enactment of any liability expansion could create a health care crisis of monumental proportions in New York State. Physicians are urged to contact their legislators in opposition to these measures, either by telephone (Assembly: 518-455-4100 / Senate: 518-455-2800), by sending a letter via regular mail or e-mail. Addresses and e-mail addresses are available on the NCMS Web site. .
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