Nassau County Medical Society - News Bulletin

President's Message

Daniel J. Nicoll, M.D.

It is not easy being a physician, and it was not particularly easy becoming a physician.

When you become a licensed physician you are granted very special privileges and accept awesome responsibilities. You can ask any question and examine any part of a human being, as long as your efforts are directed at benefiting the patient. You can write prescriptions for thousands of potent medications, order invasive and non-invasive tests and perform surgical procedures that, if performed by anyone else would be a battery. You accept the fact that part of your life is no longer your own. "On call" or not, when an emergency arises or a colleague calls for help you are there.

Why did society grant us these very special privileges? As I watched my daughter begin her medical career as a first year medical student, the answer became clear. We undergo the most demanding and rigorous training of any profession and we earn the trust and honor we receive from society.

Various other professionals with "training and experience" would like to share our tights without the training and responsibilities. The legislature is considering bills to expand the scope of practice of various licensed professionals. These are bills to:

Allow physical therapists to treat patients without a referral from a physician
Allow creative arts therapists, mental health counselors, psychoanalysts and marriage and family therapists to treat any mental illness with no input from a physician
Allow psychologists to treat any mental illness, including serious mental illnesses, without input from a physician
Allow pharmacists to administer vaccines under patient specific or non-specific regimens
Expand the dental scope of practice to include the maxillofacial area
Allow optometrists to prescribe oral medications

And that doesn't include the movement for independent practice for nurse practitioners, nurse midwives and nurse anesthetists.

Whether we went to medical school in Brooklyn, Britain or Bangladesh or whether we have an MD, DO or MB degree, we share the common experience of extraordinary studying, training and working to become a physician. Whether we trained at Massachusetts General or Massapequa General, our mental and physical endurance as well as our dedication were tested, and we prevailed.

I have been told that physicians don't know anything about nutrition, but the sales clerk in the health food store is an expert. I have been told by a CSW "therapist" that physicians don't understand psychoactive and addicting drugs. And I have been told that optometrists can "co-manage" post-op cataract patients as well as an ophthalmologist. Although I don't believe any of this, the public mood is swinging in that directions.

So what can we do to restore the respect and discretion of physicians?

We must respect ourselves and our profession. We should proudly encourage young people to seek a career in medicine, both as a calling and as a living
We must vigorously fight to protect the public from inferior care, not for our own parochial interests, but because we know the danger to the public
We must clearly articulate the unique value of a medical education both from a didactic and ethical perspective. We must support medical education at the hospital where we practice and at the medical school where we studied

We can succeed. The question "are you a real doctor?" still means "are you a physician?" But we must work as tirelessly to protect our unique privileges as our opponents are working to take them away.

Daniel J. Nicoll, MD

MSSNY to Protest New JCAHO Ruling on Reporting Errors

MSSNY's Council voted on July 19, to send a formal letter of protest to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) regarding standards going into effect July 1, requiring that within the hospital setting, "The responsible licensed independent practitioner or his designee clearly explain the outcomes of any treatments or procedures to the patient and, when appropriate, to the family, whenever these outcomes differ significantly from the anticipated outcomes".

JCAHO President Dennis O'Leary, MD, acknowledged that reporting of hospital errors was almost nonexistent but said there was a need to create a culture of safety in hospitals with errors being openly discussed. The new standard, according to a JCAHO press release, "will require hospitals to initiate specific efforts to prevent medical errors and to tell patients when they have been harmed during their treatment."

MSSNY is strongly opposed to this and efforts are underway to have JCAHO reconsider implementation of this requirement.

Medicare Must Disclose Findings to
Patients' Families

A federal judge has ordered Medicare officials to instruct Peer Review Organizations (PROs) to disclose findings when they investigate beneficiaries' complaints that doctors or hospitals provided "poor Quality" care or made medical errors that injured patients, the New York Times reports.

The ruling issued by Judge Ellen Huvelle of the Federal District Court in Washington, DC, overturns a more than 20-year old policy that has prevented Medicare beneficiaries from obtaining data on physicians. Current rules state that PROs may only disclose information about a physician "with the consent of that practitioner," effectively limiting medical error disclosure to patients. Although the Clinton and Bush Administrations had supported the policy, Huvelle ruled that the policy violated the federal Medicare statute.

Huvelle ordered HHS Secretary Thompson to send a letter within 20 days to PROs that investigate Medicare complaints, telling them that they must disclose the results of investigations to beneficiaries who file complaints.

Patients also may use the information in medical malpractice lawsuits, the Times reports.

Justice Department lawyers said that the "final disposition" provision on the Medicare statute "meant simply" that PROs must inform patients that investigators had "disposed of" -- received and investigated -- complaints, "without necessarily disclosing any details of the findings." However, Huvelle said that the government's interpretation of the law would "nullify the intent" of Congress, "since the beneficiary will learn nothing of value."

MSSNY's Council, which met on July 19, directed MSSNY General Council, Donald Moy to urge the HHS to re-appeal the decision.

Guidelines for Teen Physical Exams

The American Academy of Pediatrics has issued new guidelines that doctors conducting annual physical exams of adolescent patients ask if the teens have ever been sexually assaulted and that doctors be prepared to offer psychological support to victimized patients and refer them to counseling.

The guidelines come in response to new data showing that adolescents between the ages of 12 and 19 have the nation's highest rates of rape and sexual assault, more than double those of victims 25 and older, a discrepancy attributed primarily to the rising use of date-rape drugs and changes in legal procedure.

Some of the specific recommendations for doctors who treat adolescents are:

They should "screen for both past sexual history and sexual victimization during teens' annual checkups or other office visits" and allows them to describe any incidents "in their own words."
They should familiarize themselves with local sexual-reporting requirements and community services for rape victims.
They should offer "preventive counseling," such as advising teenagers to "avoid late-night drinking and drug use that could lead to sexual assault," as 40% of incidents involving teen victims or assailants stem form drug or alcohol use.
If pediatricians learn of a recent attack on a patient, they should arrange for forensic tests and be aware that DNA technology allows for a forensic exam beyond the previous 72-hour cutoff.

Dr. David Kaplan, Chair of the Academy's Committee on Adolescence, said that despite doctors' potential anxiety, "The rewards can be tremendous if you really find something that has been bothering the adolescent."

The full guidelines are available at: www.aap.org/policy/re0067.html.

Mental Health Therapy Bills Pending in Senate

Just a reminder that bills to allow creative arts therapists, marriage and family counselors, and psychoanalysts expanded scopes of practice are still active in the New York State Senate and could be voted on at any time.

Members are encouraged to call their state Senator at 518-455-2800 to voice their opposition to passage of these bills.

AMA EVP Dr. Anderson Terminated

The AMA Board of Trustees announced that it has terminated the contract of its EVP and CEO E. Radcliff "Andy" Anderson, MD, pursuant to the terms of his employment agreement. Dr. Anderson filed a lawsuit against the AMA on June 18, charging the association with defamation and breach of contract.

Robert W. Gilmore, MD will continue his current role as the AMA Deputy EVP as the AMA launches a national search for a new EVP.

Nationwide Shortage of Td Vaccine Reported

Due to the on-going shortage of adult tetanus diphtheria (Td) vaccine, the nation's only manufacturer, Aventis Pasteur, has announced that they will no longer be taking orders for Td vaccine from private physicians' practices. However, hospitals will still be able to order small quantities. The nationwide shortage is expected to last at least until the end of 2001.

To assure vaccine availability for priority indications, the Centers for Disease Control and Prevention (CDC) recommends that all routine Td boosters in adolescents and adults should be delayed until 2002.

For the duration of the shortage, the priority circumstances for which Td vaccine is recommended are the following:

Persons traveling to a country where the risk for diphtheria is high
Persons requiring tetanus vaccination for prophylaxis in wound management
Persons who have received <3 doses of vaccine containing Td
Pregnant women who have not been vaccinated with Td within the preceding 10 years

Influenza Vaccine Alert for the 2001-2002 Season

The Centers for Disease Control and Prevention (CDC) advise that the manufacturers on influenza vaccine estimate that there will be delays in the distribution of influenza vaccine this year: 64% of the vaccine is projected to be available by the end of October; the remaining vaccine should be completely distributed by the end of December with distribution occurring throughout November and December. The total amount of vaccine that will be available (83.7 million doses) is estimated to be more than was distributed in either 2000 or 1999.

Based on the available projections, the Advisory Committee on Immunization Practices (ACIP) has recommended that providers target persons at increased risk of influenza complications and health care workers for influenza vaccine in September and October. Individuals not in these high risk groups should continue to be vaccinated through December and later, as long as vaccine is available. The ACIP recommends that mass immunization campaigns should be conducted in late October and/or November when the vaccine supply is assured.

The ACIP recommends influenza vaccine for the following persons:

Persons at Increased Risks for Complications

persons aged >65 years
residents of nursing homes and other chronic care facilities that house persons of any age who have chronic medical conditions
adults and children who have chronic disorders of the pulmonary or cardiovascular systems
adults and children who have required medical follow up or hospitalization during the preceding year because of chronic metabolic diseases, renal dysfunction, hemoglobinopathies, or immunosuppression
children and teenagers (aged 6 months to 18 years) who are receiving long term aspirin therapy and therefore might be at risk for developing Reyes syndrome after influenza infection; and
women who will be in the second or third trimester of pregnancy during the influenza season

Persons Aged 50-64 Years

Vaccination is recommended for persons aged 50-64 years because this group has an increased prevalence of persons with high-risk conditions. Persons aged 50-64 years without high-risk conditions also receive benefit from vaccination in the form of decreased rates of influenza illness, decreased work absenteeism, and decreased need for medical visits and medication, including antibiotics

Persons Who Can Transmit Influenza to Those at High-Risk

physicians, nurses, and other personnel in both hospital and outpatient-care settings, including emergency response workers
employees of assisted living and other residences for persons in groups at risk
employees of nursing homes and chronic-care facilities who have contact with patients or residents
persons who provide home care to persons in groups at high risk
household members (including children) of persons in groups at high risk

West Nile Update

As of July 3, the Nassau County Department of Health has had no positive reports of West Nile Virus (WNV) in humans, mosquitoes, or birds this year. In 2000, none of the 103 NC patients investigated, tested positive for WNV. In 1999, 6 of 70 NC patients tested positive for WNV.

The NC Department of Health would like to remind healthcare providers of the need to remain alert to potential human cases and to consider WNV in the differential diagnosis of patients presenting with clinical symptoms suggestive of viral encephalitis or meningitis.

To report, please call the Nassau County Department of Health, Division of Disease Control at 571-3471. After regular business hours you may leave a recorded message or follow instructions for medical consultation. Cases can also be reported via fax at 571-1537.

A recorded 24 hour West Nile Virus information line is available at 516-571-2500.

Information is also available on the County web site at www.co.nassau.ny.us.

MDs Should Urge Governor to Sign No-Fault "Intox" Bill

The Senate and Assembly have passed legislation that would require an automobile insurance company to reimburse a physician or other provider for care rendered to a person injured as a result of driving while intoxicated within the first 48 hours after an accident. Current law permits insurers to disclaim coverage in these instances. MSSNY strongly supports this legislation.

It is likely that the bill will be delivered to the governor shortly.

Because the auto insurance industry has voiced strong opposition to this bill, it is imperative that the Governor hear from the physicians why it is important that he sign this bill into law.

Physicians may send a letter of support to the Governor in Albany or call his office at 518-474-8390.

Update on Risk-Transfer Regulations

MSSNY has submitted its most recent comments to the State Insurance Department expressing the physician community's continuing concern with Proposed Regulation 164, a regulation that would establish standards for financial risk transfer arrangements between HMOs and IPAs.

MSSNY's concerns with the IPA reserve requirements included in prior versions of this regulation have been substantially addressed.

Nevertheless, MSSNY continues to have very serious concerns with the inclusion of a provision within the regulation that would prohibit, under any circumstances, the participating providers of any IPA from seeking recourse against the HMO if the IPA goes into default, even if the default was the result of the practices of the HMO. MSSNY has argued repeatedly to the Insurance Department that it is often the actions of the health plan through its action or inaction in maintaining control of the management of the risk that causes the IPA to go into default. Therefore, it is unfair to prohibit, under any circumstances, the ability of the participating providers of an IPA to seek recourse against the HMO.

The Insurance Department has advised that the proposed regulation is likely to go into effect August 28, should no further changes be made to the regulation.

MSSNY will continue to take the necessary steps to ensure that its concerns as identified above, be addressed before this regulation is permitted to go into effect.

We ask that individual physicians contact the New York State Department of Insurance at 518-474-4567 or 212-480-2301 to voice their opposition to this part of the proposed regulation.

HCFA to Rate Hospitals and Doctors

The federal government is planning for the first time to issue detailed ratings of the quality of care provided by nursing homes, medicare health plans, dialysis centers and eventually hospitals and doctors, a senior Bush administration official recently announced.

HCFA, using newspaper advertisements, the Internet and toll-free telephone numbers, plans to release numerical scores for every medicare provider four times a year based on a half-dozen criteria, ranging from medical credentials to staffing levels, the Washington Post reported.

"Collecting data and publishing it changes behavior faster than anything else," Thomas Scully said in his first speech as head of the agency that oversees Medicare and Medicaid.

Representatives of health care groups, however, questioned the plan, saying the government's data could be misleading because it fails to take into consideration factors such as whether facilities treat a sicker patient population. For such reasons, groups representing doctors, hospitals and other health care providers have long opposed the release of such ratings.

The federal government now spends about $300 million a year collecting information on the thousands of health care providers that serve the 70 million people in Medicare and Medicaid. But the data has never been presented in an easy-to-understand way, the Washington Post reported.

"HCFA already collects a fairly substantial amount of data," Scully said, predicting the agency will settle on a list of criteria "fairly quickly and start using it." He hopes to add ratings for hospitals within a year and for physicians after that.

Carmela Coyle, Senior Vice President for policy at the American Hospital Association, warned that any quality data must be given in the proper context. She noted that several years ago, the government published hospital mortality rates. But the rates did not factor in whether a hospital served a high-risk population, such as those in poor neighborhoods, or performed experimental treatments - both of which could elevate the rates.

Scully said the ratings plan is part of a broader effort to overhaul his agency. By the end of June, he and HHS Secretary Tommy Thompson plan to revamp virtually every aspect of the agency, from its name to how it markets programs.

Members Making News

Narendra K. Hadpawat, MD, director of Medicine at Peninsula Hospital Center in Far Rockaway, was recently elected President of the medical board. Dr. Hadpawat joined the medical staff in 1981 and was appointed Director, Division of Cardiology in 1993. In 1999, he was promoted to the position of Director of the Department of Medicine. He is board-certified in internal medicine and subspecialty cardiovascular diseases. He is a Fellow of the American College of Cardiology, the American College of Chest Physicians, and the New York Cardiological Society, and the board of directors of the American Heart Association, Long Island Chapter.

Paul A. Pipia, MD, has been named Medical Director of Nassau University Medical Center. Dr. Pipia has worked in the Department of Physical and Rehabilitative Medicine for eight years and also served on the hospital's board of trustees for 3 1/2 years. He currently serves on the Society Executive Committee and is Chairman of the Membership Committee.

Holds National Databank Hearing

July/August 2001

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