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The tragedy on September 11 affected all Americans. Physicians, however, were affected in several unique and painful ways. Physicians, throughout the region, responded to the immediate emergency. Our colleagues in Manhattan near "Ground Zero" were called upon to treat large numbers of injured victims of the attack. Many of us responded with local hospital emergency plans or volunteered to help in the hospitals and emergency staging areas set up for the expected deluge of victims which never materialized. Regardless of our training and experience, none of us was prepared for the shear magnitude of the tragedy. However, we were prepared to act in any useful capacity. Then came the sense of impotence and uselessness when we realized that most victims were killed immediately and the medical triage/emergency services would not be utilized. Like the general public, we all know people who either perished or who lost loved ones in the tragedy. Many of us lost patients. Families often looked to their physicians for physical and emotional comfort following such losses, only this time most of us really did share their pain. As physicians, we again rose to the challenge to help our patients both with the physical and emotional effects of this tragedy. Beyond the immediate effect, we realized that our world was changing too. Physicians became concerned that Empire Blue Cross/Blue Shield might not be able to reimburse physicians with profound cash flow and business consequences for many practices. Fortunately, most Empire employees escaped serious injury and we were reassured that all would be made right, with some temporary inconvenience. As we entered the second week after the tragedy, the public became more concerned about biological and chemical terrorism. Physicians then began receiving requests for prescriptions of Cipro for families to stockpile like the government as protection against anthrax. We needed to spend hours explaining that although this may or may not be effective against anthrax, it was useless against small pox and Ebola-like agents. Suddenly we were public health and safety officials discussing population concerns with individual patients. Finally came the realization that our key priorities were moved down the list by governments at all levels. It is highly unlikely that Congress will pass the Patients' Bill of Rights and the expansion of the benefits of the Medicare program this year. There were discussions of lowering the Medicare conversion factor, based upon the state of the economy, before the attack. Clearly the state of the economy is worse and therefore we certainly cannot expect anything good to come from the new calculations. The fate of the supplemental malpractice coverage in the state legislature is an open question as they contemplate whether to permit NYC Mayor Giuliani to extend his term or run again. Physicians, as always, rise to the occasion when tragedy strikes. Today, we are being asked to bear our own unique burdens and to share the burdens of all Americans. We shall overcome, as physicians and as Americans.
Daniel J. Nicoll, MD
On August 15, the Medical Society of the State of New York (MSSNY), on behalf of its 27,000 member physicians filed six separate legal actions against six of the largest managed care insurance carriers in New York. The actions were filed in New York State Supreme Court in Manhattan and request injunctive relief from a series of destructive, ongoing practices by managed care insurance carriers. In addition, six class action lawsuits have also been filed on behalf of individual physician members of MSSNY against the same six managed care insurance carriers seeking monetary damages for the alleged abusive practices. The suits brought against Aetna, Cigna, Empire Blue Cross/Blue Shield, Excellus, Oxford, and United HealthCare claim that the companies systematically harm both patients and physicians by systematically engaging in illegal practices and routinely breaching the terms of contracts with physicians. The six firms control almost half of the managed care contracts in New York. The suits specifically point to the insurance carriers' continual arbitrary denial of medically necessary care, capricious reductions in reimbursement claims, subjective downcoding and bundling of claims, as well as utilization of computer programs that deny claims based on arbitrary guidelines. In addition, the suits point to the failure of the carriers to provide adequate staffing for the volume of claims being submitted and to their failure to provide information to physicians about how claims decisions are made. Commenting on the legal action, MSSNY President Robert Bonvino, MD, from Staten Island, called the legal action "the culmination of years of intransigence by the managed care insurance carriers and their utter disregard for the rights of the patients and physicians. It is a sad comment on the way these insurance carriers conduct business." Dr. Bonvino said, "that we have to go to the court system to force them to live up to their obligations. However, our patients can be assured of continuity of quality medical care only if we address the balance of interests between profit-focused carriers and medically necessary physician decisions. The continued intrusion of insurance bureaucrats in the patient-physician relationship is destructive and must be stopped." Former MSSNY President William Dolan, MD, said the efforts over the years to seek redress through legislative and regulatory actions have failed to abate managed care abuses. "Every physician in New York State has a story to tell about managed care companies and their casual disregard for both the needs of patients and their contractual obligations to physicians. This series of legal actions is unfortunate but necessary because managed care insurance carriers have taken the position that second-guessing physicians is a business tool for cost control. This has to stop."
Medical Liability Mutual Insurance Company (MLMIC) has completed its merger with Healthcare Underwriters Mutual (HUM) of Latham, NY. The combined entities annually write more that $425 million in insurance premiums. MLMIC is the largest provider-owned medical malpractice underwriter in the world. MLMIC says that it will now be able to offer new products and services that meet the expanding needs of its policyholders. Gerald H. Cassidy, who served as President and Chief Executive Officer of HUM Group, continues on as President of the HUM division of MLMIC. Several of HUM's board members have joined MLMIC's Board of Directors. Prior to the merger, the company insured more that 20,000 physicians, dentists and healthcare professionals, as well as 29 hospitals, in New York State.
The country's largest insurer, Aetna Inc., reported a 94% drop in second quarter net income and attributed the "disappointing results" to increases in medical costs, the Wall Street Journal reports. Also, costs for the company's HMO line increased by about 185, compared to the second quarter last year, a rate "not seen since the late 1980s." Aetna said its members visited more specialists and had more prescriptions filled that the insurer had anticipated. Overall, Aetna lost $95.9 million in Q2 2001, compared to a $36.4 million profit during Q2 2000. Second quarter revenue dropped 3% to $6.54 billion, and the insured reported a net income of $10.6 million in the second quarter last year. Since September, the insurer has undergone a major restructuring to identify and correct problems. Aetna plans to increase its premiums and average of 10.4% for HMOs and 13% to 15% for its PPO products. Aetna said that other turnaround plans include:
The Nassau County Department of Health has recently revised its brochure "Lyme Disease and other Tick-Related Diseases." It is available to the public free of charge. The brochure has the latest information about how to prevent tick-borne diseases, including recommendations for the use of Lyme disease vaccine, symptoms of these diseases and recommended treatments. To receive the brochures (available in both English and Spanish), contact the Nassau County Department of Health at 516-571-2006 weekdays 9:00 AM - 4:45 PM.
Oxford Health Plans announced that they are pulling out of Medicare in Nassau County at the end of this year. It is estimated that 14,000 beneficiaries will be affected. The pull out was not a surprise as the North Shore-LIJ Health System negotiated an early termination to its risk-sharing deal with Oxford. It is estimated that North Shore was losing more than $8 million a year in the deal. In August, about 400 physician members of the North Shore Physicians Organization and the Physicians Organization of Central Long Island resigned from Oxford's Medicare Advantage Program because fees were too low, having been reduced 35% in April.
DOH anticipated mailing out on September 7, a statewide notification to physicians of the upcoming profiling system, and the requirement that physicians complete and return a profile questionnaire. This mailing will only be a notification, and will not contain the questionnaire. DOH had previously completed a sample mailing to 1,000 physicians. The September 7, mailing gave physicians the option of whether they would like to complete the profile questionnaire in writing, or whether they wish to submit data electronically. If the physician chooses to submit electronically, he/she will be required to submit a reply card back to DOH indicating this choice. The reply card will be in the September 7 mailing. The DOH will then send to that physician, a Memorandum of Understanding (MOU) that indicates that the physician has chosen the option of submitting data electronically. The physician will then be required to sign the MOU, as well a provide DOH with a copy of their driver's license (for signature verification) and other contact information. The physician will then be given a password that will facilitate the ability of that physician to submit their profile electronically. The benefit of the electronic submission is that physicians will be able to quickly update their profile, as well as receive emergency health and community health alerts via e-mail. DOH has indicated that they are hoping that most physicians will choose to submit data electronically. DOH anticipates that the MOU and the "hard copy" of the profile survey (to those who choose to submit data in writing) will be mailed to physicians at the same time, probably in late September. Physicians who choose to complete the survey in writing will be required to complete and return the survey in 30 days. Physicians who choose to submit electronically, must send back the MOU, as described above. Ten days after DOH receives the MOU, the physician may then begin to complete the survey electronically, and will have 30 days to do so. Therefore, the surveys will be required to be completed and sent to DOH by late October or early November, depending on the method by which the physician chooses to complete the survey. MSSNY will continue to keep physicians appraised of any other relevant information regarding the implementation of this new law.
The New York State Insurance Department (SID) regulations concerning risk transfer went into effect August 22. MSSNY has been in discussion with SID on these regulations for almost two years. Earlier proposed versions of this regulation would have required all IPAs and group practices that receive more than $250,000 in annual capitation payments from a particular insurer to reserve 12.5% of that amount, a requirement which would have placed a tremendous financial burden on IPAs and their member physicians. However, the final version of this regulation exempts IPAs from these requirements where the contract between the insurer and IPA is constructed so that the Per Member, Per Month (PMPM) payment from the insurer to the IPA is made on the last day of the month. Furthermore, the regulation now exempts from these reserve requirements all capitation arrangement with a group practice where the care is to be directly provided by the members of the group practice. MSSNY also expressed concern with a proposed provision prohibiting
the participating providers of an IPA from seeking recourse against the
HMO if the IPA goes into default. However, according to SID, this
provision is not required to be included in a contract where the PMPM
payment is made on the last day of the month.
A temporary restraining order (TRO) was granted on Friday, Aug. 31 prohibiting the new "Regulation 68" created by the NYS Insurance Department (SID) from taking effect on September 1. On the same day, the state filed a Notice of Appeal to an Appellate Court and claimed that in filing a Notice of Appeal, there was an "automatic stay" of the TRO and that Regulation 68" would take effect as scheduled. MSSNY and other plaintiffs asserted that there was not stay to the TRO. On September 4, the state again filed a Notice of Appeal of the TRO and once more asserted that there was an "automatic stay" of the TRO. However, on September 5, Appellate Court Justice Peter Tom granted MSSNY and the other plaintiffs interim relief by vacating any stay pending a full review of the stay issued in the Appellate Court. It is doubtful that such review will occur prior to October 5, 2001. SID issued Circular Letter no. 25 dated September 5, to insurers to inform them that as a result of the order, the new Regulation 68 is not in effect at this time. Currently, arguments on the merits of the plaintiff's legal proceeding challenging Regulation 68 are scheduled in New York State Supreme Court in Manhattan on September 27. Among the several plaintiffs are two physicians who treat a large number of non-English speaking patients and argue that even under the 90 and 180 day deadlines, it is difficult to obtain the No-Fault information quickly enough. It is asserted that physicians will be denied compensation for the care that they provide to injured victims who fail to notify the No-Fault carrier within the shortened 30-day deadline or because of the patient's inability or the physician's inability to comply with the severely shorten 45-day proof of claim requirement. The physicians also argue that the extremely shortened deadlines impose substantially increased record keeping, reporting costs and other compliance requirements on medical practices.
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