Social Issues

FRONT LINE -- April, 1995

SOCIAL & ECONOMIC ISSUES FOR THE DERMATOLOGIST IN PRIVATE PRACTICE

On April 7, Governor Zell Miller of Georgia signed the Dermatology Direct Access Bill into law. The new law states that "No health benefit policy which is issued, delivered, issued for delivery, or renewed in this State on or after July 1, 1995, shall require as a condition to the coverage of dermatological services that an enrollee, subscriber, or insured first obtain a referral from a primary care physician. "From a practical standpoint, this prevents the "gatekeeper" in any type of program from standing between the patient and the Dermatologist. The enactment of this law represents the culmination of a two-year effort by Georgia Dermatologists to enact this legislation.

American Society of Dermatology Past President Don Printz and ASD member Jerry Cooper spearheaded the legislative effort in Georgia. Dr. Cooper served as Chairman of Georgia Derm-PAC, the legislative fundraising and coordinating group. Dr. Printz testified before the various legislative committees, faxing members of the Georgia Society of Dermatologists as the bill made it past each legislative hurdle so that they could contact their own legislator at the appropriate time.

Dr. Printz noted that at every step of the way, the key to success was the personal relationship between the Dermatologist and the legislator which smoothed passage of the bill and provided a vehicle for the Dermatologist to explain the purpose of the bill.

The effort actually began in 1993 when Dr. Margaret Kopchick of Toccoa, Georgia informed her State Representative, who was also a patient, of the need for such legislation and that the gatekeeper concept was inappropriate for such a self-evident condition as skin disease. Representative Jeannette Jamieson then authored a bill modeled after California legislation authored by Dr. Michael Franzblau.

In early 1995, just prior to the current legislative session, the bill was endorsed by the Board of Directors of the Medical Association of Georgia as compatible with their previously announced position endorsing the freedoms of the patient to choose their physician. The Medical Association's support was vital in the legislative process.

The bill was opposed by all the State's major HMOs, the four leading Health Insurance Carriers, and by the State's own Department of Medical Assistance which felt their Medicaid HMOs might be adversely affected. Nevertheless, the bill cleared the key committees in both the House and Senate and passed both houses by wide margins (95-5 in the House and 48-2 in the Senate). Governor Miller endorsed the Bill enthusiastically at the signing, and concurred in the remarks of the Senate Sponsor, Johnny Isaacson, that he felt the legislation represented a reasonable approach to a patient's freedom of physician choice, even within an HMO setting. The Bill enjoyed bipartisan support; the House author was a Democrat and the Senate Sponsor a Republican. In the House, the Bill was directed to the health and Ecology Committee for consideration, while in the Senate, it came under the purview of the Insurance Committee, where the Insurance Industry generally is considered to have a stronger influence on proposed legislation. Nevertheless, it passed the key committee by a vote of 4-2 with one of the dissenting Senators stating that he voted "no" only because he was afraid it might set a precedent for other specialties and wanted stronger language in the Bill to insure it would apply to Dermatology only. (The Optometrists had tried to be added to the Bill, and the State sponsor, Senator Isaacson, stated that he would withdraw the Bill if this were attempted on the Senate floor, essentially ending any attempts to add other disciplines to the legislation.)

Georgia thus becomes the first state to have passed this legislation which guarantees direct access to all beneficiaries. Indiana had passed more limited legislation which affects only individuals in certain PPOs and includes Chiropractors, Optometrists, and other Medical Specialties as well. The Georgia legislation is comprehensive and will apply according to counsel, even to larger groups which self-insure.

Insurers retain the right to maintain panels of Dermatologists who are participants in their respective plans; Point of Service or any willing provider legislation is a different subject. The Georgia legislation removed the Gatekeeper from Dermatological care.

ASD Moves Offices
Names Interim Executive Director

At its February Board Meeting in New Orleans, the ASD Board approved moving the Society's offices to Peoria, Illinois and named M. John Hanni, Jr., CAE interim Executive Director. In making the move, the Board expressed its appreciation to Christopher W. Hayen for his services as Executive Director during the Society's formative years.

In addition to bringing Hanni's experience as a medical society executive and the resources of the Peoria Medical Society office facilities and staff, "The changes will help achieve substantial economies to free up funds for crucial ASD projects as well as permit ASD to become more responsive to the needs of the Board and the membership," said President Chester C. Danehower, M.D. "John Hanni is recognized by his colleagues for his accomplishments as a medical society executive." He will continue to serve as Executive Vice President of the Peoria Medical Society.

Before coming to Peoria, Hanni served as Executive Vice President of the Dade County (Miami, Florida) Medical Association and Executive Director of Medicine of Cleveland. He is a certified Association of Medical Society Executives and a fellow of the Royal Society of Medicine.

The Officers and Board are looking forward to increasing activity on behalf of the membership in many ways. Membership recruitment, improved communication with the membership, efforts to expand direct access programs for dermatology, continued efforts to develop methods to cope with the negative aspects of many managed care programs, continued vigilance and opposition to government programs that interfere with quality care and the doctor-patient relationship and enhancement of the practice of dermatology to the public will continue to be goals of the ASD Board of Directors.

Meet Me at Walt Disney World

ASD's Annual Meeting promises to be fun and educational for all! It will be held at the beautiful Beach Club Resort on the grounds of Walt Disney World in Orlando, Florida. This resort has lots of activities for all Epcot is a five minute walk and free transportation to the Magic Kingdom and MGM Studios is available. On the hotel grounds, there are restaurants, bars, a lagoon with a great beach, water sports and a huge pool/waterpark area.

The meeting will start Friday morning with a coding seminar by Inga Ellzey with emphasis on E&M codes. Saturday morning is devoted to dermatologic surgery and Sunday morning will have updates on state and national issues, including direct access. Afternoons are free to explore the magic of Walt Disney World!

Plan to join your colleagues for this fun and exciting meeting!

We Are Neither Powerless
Nor Too Small To Make a Difference

By Melissa Kline Clements, M.D.
President-Elect, American Society of Dermatology
Oklahoma City, Oklahoma

By many accounts managed care is the future of American medicine. We are admonished daily that if we are not ensconced upon the managed care wagon we have signed our own professional death warrants. Indeed, the hospital with which I currently maintain my primary affiliation is determined to turn the entire hospital into an HMO - the notion being to "do it to ourselves before they do it to us." While managed care in some form will likely be with us for a long while and will have increasingly deleterious effects on most of our practices and intellectual processes, it is neither the panacea to health care delivery and financing, nor ultimately will it spell the end to specialty care.

Managed care is at its core immoral and in its implementation has little to do with the market. In traditional fee-for-service medicine, the physician enters into contractual arrangements with the patient not with a third party, be it an insurance company or the government. In any managed care scenario, the physician becomes the agent of the third party upon whom he becomes increasingly dependent for referrals and income. If the physician does not satisfactorily ration services to the consumer, he is removed from the list of physicians that can participate in the care of the system's patients. The allegiance of the physician in a managed care system is to the source of his patients, not to the patients themselves. I can state the case no more eloquently than a colleague has when he likens the ethic of managed care to that of veterinarian medicine. The veterinarian is more concerned with what pleases the pet owner (i.e. the one paying for the medical care) than what pleases the patient (i.e. the pet). The fundamental difference between managed care and veterinarian care is that the pet owner is emotionally involved in the animal's care. If a pet could say, "I would like to try that new antibiotic that is more expensive, but takes only one week to work and has no side affects," the vet would say, "I will have to check with your owner." If the patient says, "I am worried that this mole is changing size and color, I know you have said watch it, but I would like to have the opinion of a dermatologist," the managed care physician would say, "Sorry, I can't authorize that. You're on your own." This is not how the market works. When a person wants and purchases goods or services, the price he pays depends upon the supply and demand of the product in question.

To date managed care has been tremendously successful in rationing care. In 1994 the HMO industry amassed profits in excess of 41 billion dollars - a quantity so immense that the industry has been able to invest the monies. Patient premiums have not declined. Services continue to be rationed. The list of covered benefits shrinks daily.

The trek of patients herded into managed care systems away from these systems and back into traditional arrangements is beginning and will increase. It is clear that the one paying for the care is the one that determines the benefits to be received. If first quality medical care is to be delivered and the frontiers of medical knowledge expanded, patients will have to have a financial stake in the purchase of their medical care and goods. Without direct accountability, someone other than the patient assumes de facto power in deciding what is to be rationed. Medical Savings Accounts are the beginning of the solution. Making insurance policies the property of the individual and not the employers is another important step. Similarly tax deductibility of insurance premiums/outlays for individuals, not employers, is necessary. Insurance plans independent of Medicare must be open to the elderly, thus increasing choice and keeping costs down. Efforts to insure patients' access to dermatological care such as that carried out in Georgia are essential. The solution to our dilemma is not single faceted. It will take time and exhaustive efforts to correct the faulty system in which we are enmeshed. This is a time to stand by our principals. We cannot succumb to the temptation of believing we are powerless to change things, or too small to make a difference. Mice have roared - they will again.

PRESIDENT'S MESSAGE

By Chester C. Danehower, M.D.
Peoria, Illinois

Most physicians complain bitterly about the climate in which they now have to practice medicine. Many are concerned about the impact of managed care on their practices and on the care their patients will receive. They wonder what will happen to the private practice of medicine in the face of an unbelievable push by government, big businesses and entrepreneurs to establish managed care as the major health care delivery system in this country Because of fear, greed or even resignation, many physicians rush to sign up for almost any managed care program. Many times they don't even bother to read the contracts or fee schedules before joining. They embrace the concept of the gatekeeper even though they are aware that this concept can readily lead to rationing of health care and that it is bitterly dividing our profession. The physicians of this country are allowing others to take our profession from us through our own complacency.

What can dermatologists do about this dilemma? We are a small specialty, and we have a great deal to lose if we sit idly by and let others act on our behalf. Unfortunately, too many of us have a defeatist attitude, and we often become negative when possible solutions are suggested. We tend to become timid at the first sign of opposition and fear that those who disagree with us will disapprove of our actions or thinking. Well, the stakes are just too high for us to be paralyzed by the fear of disapproval by others.

Even though dermatology is a very important part of medicine in our country there are many individuals, including some physicians, who feel our specialty is an expensive and superfluous luxury. Many primary care physicians and managed care administrators mistakenly feel that diseases of the skin are easy to diagnose and treat; therefore, they feel that there is a minimal need for dermatologists. If we allow their thinking to prevail, the number of dermatologists in this country will decrease significantly, and the quality of care for patients with skin diseases will rapidly deteriorate.

In order for us to solve our dilemma we must first believe that there is a solution This statement may seem simplistic; however, if we do not believe there is a solution, any attempts we implement will be doomed before we start. Unfortunately many dermatologists feel there is no solution, or if they do believe there is a solution, they will make halfhearted efforts which will surely fail. If we eliminate negative thinking, ideas will flow freely. We can then set realistic goals to save our specialty and preserve the best dermatological care in the world. Once we have determined our goals, we must pursue them with total dedication. If we fail in attaining our goals, we must not become discouraged. We must learn from our mistakes, and try repeatedly until we succeed. With this approach we can be successful!

In my opinion there are many issues we must address. The most important is that we must preserve the private practice fee for-service-system of health care at any cost. We cannot allow managed care to destroy this traditional system of health care. In the not too distant future, I believe there will be great dissatisfaction with managed care by both patients and physicians. When that time comes, patients and physicians alike will clamor for managed care's demise. Fee-for-service private practice must be a viable alternative at that time. If it is not, a single payor system will be the only remaining choice. Of course, there are many other issues dermatologists must address. OSHA, CLIA, the RBRVS, the National Practitioner Data Bank, recertification, tort reform, insurance reform, and antitrust relief are among the most important. I am sure you can think of many other areas of concern. We want your active participation in helping the ASD solve the problems that face dermatologists. The ASD is a growing and effective organization; however, we need your active participation. With your dedicated assistance, we can be successful!