By Christopher Guadagnino, Ph.D.

Published February 1999

• React to this article in the Discussion Forum.

PND: Can you explain how your past experiences prepare you for this position?

RM: My past experiences fall into several categories: clinician, primary care physician and teaching physician. I have been actively involved in sports medicine. I also have experience in administrative medicine. I’ve held positions as an associate medical director within an HMO and have been a medical director within an integrated point of service unit and other managed care products. I’ve been involved with quality management committees, credentialing committees and have had to be involved in decisions as to whether or not certain services should be covered, whether the plan should pay for services and understand the workings within the managed care environment. My most recent experience is within the Medicare program, which has made me very keenly aware of the political and social and economic impacts of medical decisions.

PND: Provided your nomination is confirmed by the Senate, what are your main priorities as Physician General?

RM: I think it’s important to recognize that the Physician General’s primary responsibility is to act as an advisor to the Governor and the Secretary of Health. It will be important for me to work within the administration on the agenda that they have set based upon input that I receive from the provider and the health professional communities. Having said that, I think it’s also important to note that during the interview process Governor Ridge asked me what I felt were the important areas and where I would like to focus some attention. The first would involve the health and welfare of children. This could be broken down into two areas. One would be in the preventative health area. For example, I think it’s great that we have made progress in enrolling more children in the CHIP program. I think we now need to go the next level and insure that these children not only get enrolled but also receive the care that they need such as immunizations. The second area within children’s health care would involve the overall management and education processes for children with chronic diseases, such as asthma.

The second area would be preventive health and screening for adults. This would include breast cancer screening, colon cancer screening, prostate cancer, smoking cessation. The third area involves our senior citizens. As more seniors are looking to extended care and nursing facilities, I think that there are things that can be accomplished to make sure that, not only do they receive the care that they need and that it is quality care, but that they also recognize that they still are valuable and can be important to our society even though they’re not as young as they once were.

PND: What specific approaches do you foresee taking to address these priorities?

RM: I really have not had the opportunity to sit down to review the administration’s agenda in great detail. For me to try to develop any form of an opinion or a plan would be very premature.

PND: What is your view of the role of Physician General?

RM: The Physician General has to be an effective communicator, not just to the Secretary of Health and to the Governor and the administration. I think it’s critical that the Physician General meet with and regularly keep in touch with the professional community—physicians, hospitals and other entities that are involved in the health care and well being of Pennsylvanians. An important role is to take a lot of this information and relay it to the administration in a way that is easily understandable. I think the health care industry has become increasingly complex, not only for physicians and patients, but also for administrators and for government agencies that have to oversee some of these programs. So I think an important role is to make sure that the issues are explained in understandable terms so that those individuals who have the responsibility and the authority for making decisions, for enforcing laws are making those decisions based on timely and accurate information and that they understand the ramifications of those decisions.

PND: Your predecessor, Wanda Filer, M.D., resigned in part because of a lack of access to the Governor, to cabinet meetings. What level of access and authority have you been told the position will have?

RM: During the interview process it was made very clear to me that I will have the opportunity to voice my opinions on issues. Already I have had some experience with having my ideas and recommendations being heard and also followed through on. It’s been clear to me that the people I have met with who have interviewed me are very open to my ideas and I think there’s no doubt that will continue. The Physician General carries no specific authority from the standpoint of making decisions. The Physician General’s role is to make recommendations and to be an advisor. My sense is that, if there is an issue which I feel very strongly about, my voice will be heard and that I’ll have every opportunity to make sure that the issue is understood along with the ramifications of whatever decision is ultimately made.

PND: What would you do if you were told that you couldn’t speak out on an issue you felt was vital to Pennsylvanians?

RM: During the course of the interview process that issue was discussed. I think that if an issue like that came up, I would have to work very closely with the administration to make it clear to them not only what I felt but why I felt that way. I would also want very much for the administration to be able to explain to me their position. Without knowing exactly what the issue is it would be very difficult to say what the ultimate outcome would be. My sense is, based upon some very preliminary discussions, that, while that may happen, it’s not something that I see happening on any type of a regular basis.

PND: You mentioned that a primary role of the Physician General position is to advise on health policy and public health issues. How would you propose to improve access to health care for Pennsylvania’s uninsured?

RM: I think it’s important to me, hopefully upon confirmation, to be able to sit down with all of the parties that are involved, to hear all of the issues. At that point I think I’d be in a much better position to be able to voice an opinion. That issue impacts not only providers. It involves hospitals. It involves insurance companies. It involves physicians. All of those things can become very complex and I think it would be premature for me to try to articulate a particular plan or proposal.

PND: If the incoming Health Secretary is not a physician, you would be a member of the State Board of Medicine. What is your view on scope of practice issues, e.g., whether nurses or pharmacists should be allowed to prescribe drugs?

RM: Those types of issues cross several boundaries, including medical and legal aspects. I don’t have enough of the details to tell you exactly how I feel about each and every one of them. However, I think it’s important for me to point out that, as a physician administrator not only in managed care but also in the Medicare industry, I have had a great opportunity to work with not only physicians but a lot of other health care professionals. Within the Medicare program we have a carrier advisory committee that includes optometrists and chiropractors. The Medicare program involves providers such as certified registered nurse practitioners, nurse anesthetists, clinical social workers. I have a much better understanding than I did previously with regard to how these providers render care and I think that will enable me to better understand a variety of issues that involve these types of health care practitioners and better enable me to make recommendations and give advice.

I have found that the current laws that are in place seem to be working very well. If there are changes to be made, I think they have to be looked at very closely. I think there needs to be input from all parties before any ultimate decisions are made.

PND: What is your view on the telephone nurse triage program being used by Highmark Blue Cross Blue Shield, given the objections raised by the Pennsylvania Medical Society in tandem with the Allegheny County Medical Society?

RM: I think it’s important to point out the type of role that I play within Highmark. I am the medical director with Xact Medicare Services. While we are affiliated with Highmark, we are really a separate entity within Highmark. And frankly, because we have a federal contract, we have to keep rather a good separation between us and the private side of our business. For example, if I received a call from a managed care product that is owned and operated by Highmark and they were requesting information relative to the Medicare program, I would have to treat that request just as I would a request from one of Highmark’s competitors, whether it was Aetna U.S. Healthcare, HealthAmerica or whomever.

Therefore with regard to the Blues on Call program, I have not been intimately involved with the implementation of that program. I understand the position and concerns of the Medical Society. I think that, to an extent, their concerns are valid. What I would also be interested in is the opinion of the physicians whose patients are being directed or who are receiving direction through these nurses. Frankly, I don’t have enough of that information to be able to say whether they’re pleased or they’re not pleased with the way things are currently being managed. I think it’s important that the physicians who render care to the patients be involved in that process. I’m not sure to what extent they have been, but that’s one area I have not seen a great deal of detail.

PND: Pennsylvania has had the largest non-profit hospital bankruptcy in the nation, and another hospital in southeastern Pa. has recently filed. Insurance companies have reported financial difficulties. We’ve seen huge consolidations among hospitals and among insurance companies. Do you feel that this transformation of our health care system requires any changes in the way the state regulates health care?

RM: That’s a big question. I recently had a discussion with Secretary Hoffmann on this very issue. I think that some of these changes could reflect the economic environment. For example, it just may be that the forces of supply and demand are causing or at least are partly responsible for some of the changes that we’re seeing. With regard to the role of the Department of Health or the government on these issues, I believe that becomes in part a legal opinion. But I believe there at least could be a role for some form of intervention if it could be shown that there is a problem with access to care and also with regard to quality of care. As we’ve all read these reports, clearly there are significant impacts on individuals with regard to their employment status.

PND: What can we do to prevent the next Allegheny from happening?

RM: Quite frankly, I’m not sure. I think that people who are contemplating similar types of mergers are now aware of the risks that may be associated with such mergers. It gets back to the reality that this is a dynamic industry. Things are changing rapidly. Patients who were once hospitalized for several days are now able to receive outpatient care. As a result, the need for inpatient versus outpatient management, home services is rapidly changing. All of those changes have to be taken into account when one starts to envision such mergers and consolidations.

PND: Do we need stricter controls on health care organization mergers and acquisitions or on for-profit conversions?

RM: At this point I really don’t know. It has been argued that there already are regulations that need to be enforced. Whether or not we need new regulations I think is yet to be determined. If it can be shown that existing laws do not adequately address access and quality, then there may be a need to consider new regulations.

PND: The Department of Health needs to write regulations for Act 68, the HMO law. What is your view on what sort of regulations make sense for the managed care industry?

RM: I have not had an opportunity to go in detail through Act 68. I think that each managed care organization is going to have to evaluate how that Act is going to impact them and take the necessary steps to insure compliance.

PND: As a clinician and a physician executive with experience in the managed care industry, you’ve had first hand access to many of these issues. What kinds of regulations do you think make sense for managed care?

RM: First of all, I’m not 100 percent sure that the answer rests solely within a regulation. I think there are a variety of issues that we are confronted with relative to managed care. When I say we, I mean patients, doctors and insurance companies. I think physicians need to feel that they are part of the process. I think patients need to better understand how the process works. Much of the frustration that I have seen has been the result of people feeling as if they are being impacted without having any say or input. To the extent that physicians can become a part of the process and patients can better understand or perhaps even have more choice with regard to their health care coverage, we may see greater acceptance of managed care. I’m not sure, at this point, of specific regulations that I could articulate that would address each of those issues.

PND: Do you think it’s realistic to expect that physicians will have the leverage to influence large and powerful health insurance companies without additional regulation of the industry?

RM: It’s difficult to say because it really depends upon what is the issue, what is the impact of the issue. Perhaps in some situations a regulation may be ultimately deemed appropriate. How will that regulation be enforced? What will be the penalties of those regulations? Those are all questions to which right now I don’t have answers. We’ve seen where physician societies have become more involved in both a political and legal aspect. That represents one avenue that they have. Often, when one takes that avenue it’s not necessarily viewed as working with, but rather in defense of. My hope would be that one of the roles I can play as a Physician General is to work with the physician community, to work with the medical societies, to work with the health insurance industry. To perhaps be a facilitator of information so that all parties understand what the issues are and then articulate that information to those individuals who in fact are in a position to make decisions whether they be legislative or other.