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Phone: (916) 446-5054
Message: (561) 873-8335
Fax: (916) 446-0500
|American Society of Dermatology, Inc.
A Voice for Private Dermatologists Since 1992
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
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
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
Plan to join your colleagues for this fun and
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
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.
By Chester C. Danehower, M.D.
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
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
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!