Reader feedback.

Dear editor.

In regard to the article in the 1998 September/October Physician Executive, entitled "A Centralized Verification System," I agree with the author that there needs to be some kind of centralized verification system for primary source verification, but I don't feel that legislation to this effect will make a major impact on hospital credentialing. Primary source verification is just a small part of hospital credentialing. Hospital accreditation standards require that current competency is established as well as ability to perform privileges requested.

The way many hospitals determine competency is by sending out a copy of the privileges requested by the applicant to his or her training program director, personal references, and current and past hospital affiliations. This process is completed by trained medical staff services professionals. often certified through the National Association of Medical Staff Services. Hospital and hospital medical staffs have a responsibility to the community to do all they can to assure that only qualified practitioners are allowed to provide patient care. Courts have held hospitals liable for corporate negligence for failing to exercise reasonable care In selecting and reviewing the competency of the medical staff. I don't feel that medical staff services professionals will feel comfortable with getting credentialing information solely from a 'single centralized verification system.

I have been doing credentialing for 12 years. The 'bad eggs" are few and far between, but they do exist. I agree that the credentialing process presents a paperwork nightmare for providers applying to managed care plans and hospitals, but I feel that the protection of the patient is the most important issue here. Let's not cut corners where that is concerned.

Sincerely,

Kathy Matzka, CMSC, CPCS 

President, Greater St. Louis Area Chapter

Missouri Association of Medical Staff Services

Memorial Hospital

Belleville. Illinois

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The PPMC debate

You recently featured an article entitled "The PPMC Debate" (July/August 1998, volume 24, issue # 4). My impression was that the four PPMC executives were trying to convince Professor Reinhardt and Dr. LeTourneau that physician practice management companies were going to sweep across the country and become wildly successful. I don't think Professor Reinhardt bought into the idea.

Since your article was published. I have seen Advanced Health, whose CEO took part in your panel discussion, collapse and fail miserably in central New Jersey. I know physicians who were being managed by them, and they were bitterly disappointed with their brief relationship with Advanced Health, Physician groups have fired them, and their stock value has plummeted. Because I felt that the ACPE was endorsing PPMCs by giving them a platform, I think that you should also investigate and run another article explaining why suddenly PPMCs seem to be failing. Professor Reinhardt seems to have the ability to discard the hype and explore the real issues.

Sincerely yours,

Joseph A. Catapano, MD

Cedarbrook Cardiology

Plainfield. New Jersey

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Is leadership born or made?

I enjoyed William R. Fifer's article entitled, "Is Leadership Born or Made?" (The Physician Executive, volume 23, issue # 8). For the past 20 years, I have seen an increasing number of articles about leadership in health care. Most describe what leadership is or how you develop leadership. Behind these articles is a presumption that there is a lack of leadership. Has anyone raised the question of why there is a leadership vacuum in health care in the first place? I have also often heard that physicians are trained to be independent thinkers and leaders. With everyone being so independent and every doctor being a leader, is true leadership even more difficult to achieve? Or has there been a fundamental flaw in their training?

Sincerely,

Steve McDermott

Executive Director

Hill Physicians Medical Group, Inc.

San Ramon, California 

Suffering is optional

As one uninformed about the work of Viktor Franki, I was not immediately grabbed by the title of Earl Washburn's recent article on "The Physician as Logotherapist" (July/August 1998, volume 24, issue # 4). Fortunately, I began to read it and I just wanted to write a note of thanks for that wonderful piece.

I am a cardiologist working as a Medical Director of American Physicians Network that develops carveouts at the IPA or health plan level for cardiovascular care. I have seen firsthand the sense of entitlement and resistance to change by our fellow physicians. I have quoted Dr. Washburn's article recently in several presentations I have made to physicians about the implications of managed care and change in health care.

I would add two quotes from the Buddha that complement Logotherapy:

1. "Pain is inevitable; suffering is optional."

2. "In life, we cannot avoid change, we cannot avoid loss. Freedom and happiness are found in the flexibility and ease with which we move through change."

Again, thank you for Dr. Washburn's wonderful article, I have ordered Man's Search for Meaning and look forward to reading it.

Warm regards,

Neil W. Treister, MD, FACC 

Medical Director

American Physicians Network

San Diego, California 

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A consistent, scientific assessment approach

I want to compliment Derek van Amerongen, MD, MS, on his well-written article, "A Guide for Approaching Controversial, High Tech Procedures," in the November/December issue of The Physician Executive (volume 24, issue # 26). It was of great interest to me personally, as I formerly sewed as a physician consultant prior to 1996 in the Anthem BC/BS medical policy and transplant units. I couldn't agree with him morel While I do think that external review panels are a great idea, I wonder how well they will do overall in practice. My experience with various panels over the last seven years has taught me that they rarely use a consistent, scientific assessment approach, and still tend to render decisions "off the cuff," rather than offering evidence or literature that the decision was based on.

Has Dr. van Amerongen found any panels that work? Under the President's Commission, did they set up any standards for the panels to follow? "Peer review" is often touted, yet when the "peers" fail to review properly, the system hind of falls flat on its face.

His book, Networks and the Future of Medical Practice, was great, too.

Ronda Wells, MD

Consulting Medical Director

Centris Risk Management, Inc.

Indianapolis, Indiana

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Derek van Amerongen's response

Thanks for your kind comments. You are absolutely correct that external panels must perform at a high level to be credible, as well as useful. The traditional external consultant was always the semi-retired MD who was doing this in his or her spare time for extra money. The kind of consultation needed now is by experts, preferably with regional or national reputations, who are actively practicing in the exact area under discussion. The opinions must be detailed, with documentation of supporting studies from the literature, and may often need to address such issues as how a procedure or treatment fits within a definition of experimental or investigational.

I personally think that if such reviews become the norm in complex, high technology cases, we will see a diminution of the mistrust many have with managed care. This mistrust has come from a sense that decisions are being made within black boxes, and are inherently unfair. If the process is open and well defined, one may disagree with the decision (as physicians often do), but one should also be able to agree that it was fairly done.

Again, thanks for your comments. I am also happy you found my book relevant and useful.

Best wishes,

Derek van Amerongen, MD,

MSNational Medical Director

Anthem Blue Cross and Blue Shield 

Mason, Ohio

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The physician executive of the future

I was delighted to find John Goldener's article, "After the Revolution: The Physician Executive of the Future," as I recently tried to catch up on my journal reading (volume 24, issue # 4). The catalogue of skills he recommends are just those I am trying to acquire myself. I recently completed the first Carnegie Mellon Capstone of the American College of Physician Executives and I enter into the Masters in Medical Management phase in February. I had been slated to go to Tulane, but decided to wait for Carnegie Mellon, as I hoped there would be a greater emphasis on informatics.

Many thanks to Dr. Goldener for his cogent and insightful article in The Physician Executive.

Thomas V. Whalen, MD

Associate Professor of Surgery & Pediatrics

Head of the Division of Pediatric Surgery

Robert Wood Johnson Medical School 

Camden, New Jersey 

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Supercilious critique of the VHA?

In Dr. Corder's supercilious critique of the VHA ("Veteran's Health Care: Time for a Change?" volume 24, # 6), he forgets one critical issue: We take care of the patients who are too ill, too poor, too socially compromised, and with too much co-morbid mental and substance pathology to be attractive to him and his private sector colleagues.

If the wholesale back-pedaling away from Medicare patients by HMOs is any indication of how the private sector will handle other older, more ill populations, it is likely that the VHA will need to continue to play a critical niche role in American health care--and will do so proudly and efficiently.

Mark S. Bauer, MD

Chief, Mental Health and Behavioral Sciences Service

Providence Veterans Affairs Medical Center

Associate Professor

Department of Psychiatry and Human Behavior

Brown University

Providence, Rhode Island 

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