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New York State AFP Works All Avenues to Mold Legislation, Traditions
Multi-pronged Advocacy Efforts Pay Off
By Matt Brown
Enactment of I-STOP makes New York the first state in the nation to mandate that physicians consult a database containing patients' prescription histories before prescribing most controlled substances. It also makes New York the largest and only the second state to require real-time reporting by pharmacists when such prescriptions are filled. Finally, the legislation makes the state among the first to schedule a universal mandate of electronic prescribing for controlled substances by December 2014.
According to NYSAFP President Philip Kaplan, M.D., of Manlius, I-STOP represents a well-intentioned goal that will, unfortunately, be borne partly on the backs of physicians throughout the state. Still, he added, although the legislation is cumbersome and the technology needs to be ironed out, the new law is much more manageable for prescribing physicians than its original incarnation -- thanks, in large part, to the NYSAFP.
- Although the New York State AFP (NYSAFP) wasn't able to completely derail the Internet System for Tracking Over-Prescribing Act (I-STOP), which stands to create further administrative burdens for physicians, it was able to change the makeup of the bill to make it more palatable to family physicians.
- The NYSAFP has effected other behind-the-scenes changes, such as convincing one key medical liability carrier in the state to agree to extend excess liability coverage to physicians who might otherwise be unable to procure it.
- Finally, the chapter worked to help remove the extra waiting period international medical graduates historically had to undergo between completing residency and getting their medical licenses.
"After that, the bill was picked up by Gov. Cuomo's office, and, surprisingly, about three months ago, we were invited to Albany to talk to his counsel team and further address our concerns. So while we didn't get our first wish -- throwing the bill out entirely -- they did listen to our concerns and make adjustments that we think will make the new regulations more palatable to our physicians."
The original bill, explained Marc Price, D.O., of Mechanicville, a member of the NYSAFP Board and chair of the NYSAFP advocacy committee, required physicians and pharmacists to consult the database and report on 15 different fields before being able to complete a prescription. That portion was deleted entirely.
In addition, the original language required that doctors and pharmacists do all of the data entry themselves, prohibiting other staff from being involved in the process altogether.
"While it still means physicians will have to pay staff to check the website and do data entry, at least that practice is no longer forbidden in the new language," Price said. "So they did listen.
"The problem going forward will be using a cumbersome system that is currently not in real time and not integrated with electronic health records. We will continue having an open dialogue with Albany to make sure the changes and upgrades that need to be made are made."
"Our experiences over the last few years make us confident that our dialogue with Albany -- being part of the process of developing legislation -- is an approach that will produce a regulation that we can be optimistic about," Kaplan said. "For instance, the 2008 roll out of NYSIIS (the New York State Immunization Information System) was not easy, but because we developed a personal relationship with the people behind the system, we were able to create a much more supportive regulation, rather than a punitive one."
"The same goes for the recently adopted HIV testing law," said Kaplan. "The NYSAFP convinced the (New York State) Department of Health that requiring an HIV test at every office visit was unreasonable within the practice of medicine, and so it is only required at the first annual wellness visit and is only given after that if judged pertinent by the doctor. So, with regard to the I-STOP legislation, while we would rather have seen a different outcome, we believe we have reason to be hopeful about how the law is implemented because we have earned the respect of both the offices of the attorney general and the governor."
Defending Medical Liability Pool
When word got out that Gov. Cuomo's 2012-13 budget contained provisions that essentially cap the excess liability pool, potentially forcing some doctors out, Grasso said NYSAFP members started to voice concerns that hospitals could apply selection criteria that put primary care physicians at a disadvantage.
"I think there is a potential for hospitals to give preference to those specialties that generate the most admissions and business for the hospital," Grasso said. "And that is not good for primary care."
NYSAFP leadership acted to clarify the situation and find alternative markets for those who stood to be excluded from participating in the pool, contacting Healthcare Professionals Insurance Company (HPIC), one of the companies that writes the secondary coverage. Kaplan said a June 19 letter from HPIC President and CEO Mark Morris should calm fears.
"HPIC is now on record as providing the option of self-pay for the excess layer (of liability coverage) without a lapse in coverage for any physician ejected from the pool, retroactive to July 1," Kaplan said. "We do not all agree on the value for such coverage, but I prefer to spend a little to protect the low-probability, high-severity exposure of personal assets.
Facts About the New York State AFP
Number of chapter members: 4,341
Date chapter was chartered: June 3, 1948 (as New York State Academy of General Practice)
Location of chapter headquarters: Albany
2013 annual meeting/scientific conference date/location: June 22-23, Hilton Garden Inn, Troy, N.Y.
Kaplan said the commitment also should bear fruit with New York's five other such carriers. He said that the NYSAFP will send a letter to the other carriers requesting they issue the same or similar statements.
"The HPIC letter should be the impetus for them to respond similarly," said Kaplan. "The point here is that the access provided by being organized is exciting. As the spokesman for (thousands of) physicians, residents and students, I had access not otherwise available to an individual physician."
Kaplan explained that the New York State Education Department, which licenses physicians, requires extensive documentation of training and experience, and IMG residents often have difficulty securing the necessary documentation from foreign sources, which delays action on their licensure applications. Thus, IMGs in New York typically cannot get their licenses until several months after completing residency, which oftentimes leads these physicians to set up shop in more IMG-friendly states, such as Michigan.
"That's great for them, but it is bad for us," said Kaplan. "We are training doctors that we need here in the state and sending them elsewhere because of bad policy."
Acting on a resolution brought by a resident member of the chapter's board and adopted by the NYSAFP Congress of Delegates in 2011, NYSAFP's leadership met with New York State Commissioner of Health Nirav Shah, M.D., M.P.H., to enlist his support for the chapter's proposed solution.
Specifically, the NYSAFP asked that the state's education department accept letters from residency program directors as early as 60 days before graduation that indicate a particular resident is in good standing and is likely to graduate on time. This would allow the department to begin processing applications while residents continue to gather documentation verifying their educational and training experiences, rather than waiting until the application is complete before processing it.
"After all of that, we were told that it was all very interesting, but that the (New York State) Board of Regents hadn't passed on the issue yet, so we thought we were dead in the water," said Kaplan. "But I just heard yesterday that the writer of the resolution -- a resident in Schenectady -- learned that several of her fellow IMG residents have their licenses before graduation, which has never happened before."
What makes this exciting, he added, is that this was not a matter of law, but one of tradition.
"So without rewriting any laws or any regulations, we were able to point out that there is an issue of fairness and health care manpower and they made a change in practice," Kaplan said. "I find that almost more exciting than seeing a law change on the front of the paper. An organized effort produced an opportunity to have access because of the rational nature of the request."
Kaplan said it is concrete proof that paying one's dues to the NYSAFP equals results.
"It makes one realize that lobbying isn't all about bags of money being dragged into a room by … folks who are (trying to) buy favor, but that there is actually a commerce of ideas," he said. "It isn't about wasting money on millions of dollars' worth of political campaigns. If you put together a cogent argument, there are reasonable, honorable people in Albany who are going to listen."
AAFP Chapter Spotlight series
NYSAFP Works to Mold Legislation, Traditions