By Christopher Guadagnino, Ph.D.

Published July 2008

JH: NJ Physicians is a multispecialty, statewide advocacy association for physicians. We were conceived about 18 months ago by a core group of physicians who came together because of concern that existing medical organizations have been unable to stop the steady erosion of physician influence in the health care system, and with the belief that a new strategic model, capable of moving quickly, efficiently and effectively, was necessary to avoid continued diminution of the role of physicians.

The organizers built a model based upon the idea that physician advocacy should be more inclusive and collaborative, and that physicians should leverage relationships with like-minded stakeholders to achieve better results. To that end, NJ Physicians has been meeting with labor and business leaders, representatives of hospitals, the pharmaceutical industry, AARP and others to identify common goals. On the business side of things, it has become increasingly difficult to operate a successful medical practice in the state. We launched in September 2007 and we currently have 1,100 members. We would like to hit the 2,000 member mark by the end of 2008. We have a Leadership Council composed of about 30 physicians from across the state who hold leadership positions on their medical staffs or in other specialty societies, who come together quarterly in a virtual setting to discuss the advocacy priorities of the organization. We have an Advisory Council of influential business, labor, community and political leaders that serves as an information exchange – to let people in New Jersey who have influence in health care know what we’re doing, and obtain their feed-back as to whether we are on the right track. We plan to start our first round of Town Hall meetings this September, focusing on a dialogue among members on issues that our Leadership Council identifies as important. We have also cultivated a Medical Malpractice Defense Panel of about 25 defense attorneys from across the state who have agreed to help us shape our agenda with regard to tort reform and other issues.

NJ Physicians recently sponsored a health care summit where a number of the state’s most influential leaders shared views on pressing health care issues. Keynoting the event was Senate President and former Acting Governor Richard Codey. An ensuing panel discussion included influential physicians and Commissioner of Banking and Insurance Steven Goldman. As the chief regulator of managed care companies in New Jersey, Commissioner Goldman has been open to a continuing dialogue with NJ Physicians on how best to address issues impacting physicians and their patients. High on the list of issues is managed care’s continued encroachment on physician decision-making – from determining the best medication for their patients to requiring costly preauthorization for common procedures.

JH: As a very new organization, I believe that it’s tremendously important to maintain a narrow focus on what we can achieve, and not get bogged down in too broad a scope of issues that affect physicians. Our main advocacy focus is to maintain clinical decision-making in the hands of physicians and patients. We are very concerned that others, most notably managed care carriers, have the ability to dictate how clinical decisions are made, almost always without seeing the patient. We are working with the Department of Banking and Insurance on this issue and we have an open and active dialogue with the leadership there. Similarly, as these issues are affected by the Department of Health and Senior Services and by the Board of Medical Examiners, we reach out to those groups to let them know of our concerns. If we don’t think the law is strong enough for those regulatory bodies to act, we have open dialogue with the leadership in the legislature to try to correct that.

JH: That scenario cuts across all issues, not just medical decision-making. That is the very reason we’ve adopted a collaborative and inclusive model. If we go to policymakers by ourselves, in our white coats and with our stethoscopes, that’s not as powerful as going hand-in-hand with other constituencies: the pharmaceutical industry; hospitals in the state; other providers – nurses, dentists, podiatrists. As a physician group, we are not going to agree on all issues with all parties all of the time. We recognize that. But when we disagree, we want to do it in an open and cordial fashion. We don’t want those disagreements to prevent us from working together on things we do agree on. For instance, the pharmaceutical industry is on the same side as physicians on the preauthorization issue most of the time. It also shares our goals in tort reform. Indeed, due to a collaborative effort with the pharmaceutical industry, the Governor recently pocket vetoed an extension of New Jersey’s wrongful death statute which, according to some estimates, could have doubled medical malpractice premiums. We have also been working closely with a number of the state’s medical malpractice carriers. Together we have instituted a medical malpractice defense panel to interact with our Supreme Court on court rules, model jury instructions and other issues which can impact on medical liability issues. Senior citizen groups share our efforts to maintain affordable access, and to keep medical decision-making in the hands of physicians. Labor leaders share our frustration with managed care organizations that add another layer of bureaucracy and cost to an overburdened system. Working together we can realize more victories than working alone. As a result of the relationships we have built with our state’s regulators, we have been able to provide the regulators with information which, we believe, caused one major insurer to reverse its decision to require preauthorization of echocardiograms, and another to stop paying for anesthesia services for endoscopy and colonoscopy.

JH: We’re thinking about expanding the registry. It was originally conceived to document bad outcomes, and is largely dependent on physicians going onto our website and saying there was a delay or denial of a treatment that caused a bad outcome. Many times it is hard to connect the dots in those situations and establish that those delays and denials played a large part in producing bad outcomes. What is a little easier is tracking the volume of preauthorizations and the administrative burden that we believe is placed on physicians unnecessarily. We want to add those data to physician reports of delays and denials and raise the question, "Who should be paying for that?" These issues come to us weekly. We’re looking at an issue with Suboxone, where a payor has determined not to pay for it. We’re looking at an issue with an injectible in oncology where a payor is issuing what is tantamount to a "step-edit," which is illegal in this state. There are ways that payors try to require de facto step therapy – for example, by using preauthorization to make it difficult to use certain drugs for a patient before less expensive ones are used.

JH: In addition to our advocacy issues, we are focusing on helping physicians better manage their practices. Small practices, in particular, have no ability to negotiate meaningful discounts with suppliers. We are poised to launch a group purchasing plan – we’ve signed contracts with several medical supply and equipment vendors, and with discounted banking, lending and payroll services, to offer a comprehensive buying solution for our member practices, where they can save money and reduce their costs. Similarly, we have an electronic medical record initiative in which we believe our members can attain high-quality EMRs at a significant discount. We plan to launch both of those initiatives in September. We are also exploring the formation of risk purchasing groups to offer reduced medical malpractice premiums, which are now allowed in NJ. Now that we have more carriers in the state, and it’s a more competitive market, we believe that doctors need to constantly revisit their malpractice insurance policies and try to shop for the best price on a more regular basis. We offer to each of our members a medical malpractice premium evaluation. We offer a litigation support service through which we try to get malpractice claims dismissed within 180 days. Under the current law, if you get a claim dismissed within 180 days, your malpractice insurance carrier cannot raise your premium. A lot of times, the carrier’s counsel is busy and has a large caseload, so it’s important for members to reach out to us as soon as they get the claim, so that our counsel can work with the carrier’s counsel collaboratively to get that claim dismissed in that time frame.

JH: Physicians in NJ would be wise to consider the power of numbers, be that in an association, a larger practice or a multispecialty practice. There are new discussions with regard to the laws governing negotiating with payors. There might be innovative ways to leverage volume so that physicians are getting reimbursed at a more equitable rate. We’re looking at those as they come to us.

JH: While the legislature authorized this, the regulations which were ultimately promulgated make it almost impossible to take advantage of this legislation. As such, this is, unfortunately, not a viable option at present. It will require a change in the antitrust laws, at the federal level, to realize this ability. However, as physicians come together to form larger, more integrated practices, their ability to engage in meaningful negotiation will increase. NJ Physicians is working with physicians to help them merge into these business models.