E Presidential Address—1992

AISIGIE Presidential Address-1992 Assuming the presidency of the American Society for Gastrointestinal Endoscopy (A/S/G/E), I looked forward to an exciting year, continuing many of the projects begun by my predecessors, initiating new ones, and dealing with national issues of importance to our membership and our profession. There were exciting new technologies that warranted position papers to assess their place in clinical practice based on the best available evidence: to guide physicians until controlled trials documented their efficacy. Additional practice guidelines were to be developed in a newly expanded format, with broader input and more indepth documentation from the literature, thus conforming with new government guidelines in order to achieve wider acceptance and utilization. Innovative interactive educational techniques were evolving that needed to be adapted to endoscopic training and their development funded as a major tool to be utilized to help resolve the otherwise apparently insoluble problem of post-fellowship endoscopic training. First-ever grants were to be awarded for outcomes and effectiveness research proposals, and a cooperative project with the American Gastroenterological Association and a large midwestern health maintenance organization promised to provide an opportunity to assess the effectiveness of implementation of A/S/G/E practice guidelines on patient outcomes. I knew that interaction with government was inevitable, as soon as the Health Care Financing Administration (HCFA) published its rules for the new Medicare fee schedule for physician reimbursement. But in that area, I listened to Albert Einstein, who said, "I never think of the future. It comes soon enough." I wasn't too worried. Just before my term began, believe it or not, a Sunday supper fortune cookie said, "Executive ability is prominent in your make up." I wasn't even disheartened by the one 2 weeks later that quoted Confucius as saying, "Top of ladder nice place ... but very lonesome." However, neither I nor the fortune cookie maker could have predicted what lay ahead, starting with HCFA's preliminary rules on reimbursement published in the fall that threatened rejection of payment for all medical care for 90 days following any endoscopic procedure through implementation of a global fee schedule, and presented work relative value units (RVUs) that must have been calculated for the parttime employee behind a fast food counter. HCFA's Resource Based Relative Value Scale (RBRVS) reminds me of Isaac Asimov's story about the gigantic generator that had stopped running, causing the work of an entire vast industrial plant to grind to a halt. Distraught engineers did their best to start it again, but without success, and every minute it was idle cost the firm thousands of dollars. 630

Finally, an expert on generators was brought in from outside. Cooly, he walked the length of the generator, studied its dials, and pondered. At last he said, "May I have a small hammer?" One was handed to him, and he walked up to a certain pipe, felt it delicately, located a particular point, and tapped that point sharply with the hammer. Instantly, the generator sprang into action. "Your fee?" asked the gratified head of the firm. "$505," said the expert. The other's eyes opened wide. "$505 for just hitting the pipe with a hammer?" "For that," said the expert, "$5.00. For knowing where to hit, $500." So A/S/G/E assessed and spelled out the inequities, and HCFA staff turned to A/S/G/E for suggestions on how they might rectify them. To quote Winston Churchill, "I was not the lion, but it fell to me-and A/S/G/E-to give the lion's roar." But no sooner had A/S/G/E addressed these issues, encouraging RCFA to recant the global fee concept for endoscopy and to revise many of the endoscopic RVUs, than the new CPT codes for Evaluation and Management (E/M) Services were published. These days, it takes longer to figure out how to code a patient's visit than to diagnose and treat his medical problem. As Shakespeare says in King Lear, "Striving to better, oft we mar what's well." Now a new source of hassles has appeared. All over the country, local Peer Review Organizations (PROs) have begun to demand that every patient undergoing endoscopy have a complete history and physical examination with the endoscopy record, including the patient's temperature and an assessment of his mental status. That a patient's temperature and mental status have no bearing on his gastrointestinal endoscopic procedure appear to be irrelevant. Nor do the local PROs have the power to temper their demands. These too are HCFA rules to be enforced regardless of their rationality. Obviously, the individuals at HCFA responsible for these rules are unaware of the earlier ones that refused reimbursement for E/M services on the day of a procedure on the grounds that physicians in their survey usually provided them at an earlier time. A/S/G/E has begun to address this issue as well. A meeting with the American Medical Peer Review Association (AMPRA) is planned, and we have established contact and will be meeting with the relevant individuals at RCFA as well. The new buzz words in the hallowed halls of Washington-and among those in organized medicine as well-are "outcomes" and "effectiveness." But whose outcome and for whose benefit? Those are the questions you and I have to address. Government, through its newly created Agency for Health Care Policy and GASTROINTESTINAL ENDOSCOPY

Research, plans to spend several million dollars to create practice guidelines and to assess the effectiveness of different approaches to the diagnosis and management of medical problems to determine which most effectively achieve beneficial outcomes. It will be up to us to ensure that the patient's outcome, not government's, insurers', and investors' bottom line, remains the primary concern. It was Oregon's application of traditional cost-effectiveness theory that produced a prioritized list of health care services for Medicaid reimbursement in which dental tooth capping took precedence over a life-saving appendectomy for acute appendicitis or surgery for ectopic pregnancy, despite the virtually 100% effectiveness of these procedures in treating otherwise generally fatal conditions. To economists, the goal is to maximize health benefits within society without regard for individual welfare. The obvious absurdities sent the Oregon Health Services Commission back to the drawing board to factor in the powerful human proclivity to rescue endangered life, dubbed the "Rule of Rescue" by Jonsen, who also recognized the difficulties it posed for resource allocation planning. Moreover, although the Rule of Rescue may be most compelling in the context of lifesaving interventions, it is also a factor whenever a patient is in need of treatment that may be costly but is clearly most effective for that individual. Our obligations will be: (1) to ensure that quality does take precedence over cost in the care of our patients; (2) to monitor outcomes and effectiveness research closely to be sure that the premises upon which it is based are valid; and (3) to continue to lead in practice guideline development and assume leadership in the evaluation of their effectiveness and impact on medical practice. There were times this year when I felt like the little Dutch boy with his finger in the hole in the dike. Confucius was wrong though. I have not been lonesome. I feel like I know most of the 5000 members of AISIGIE from the letters I have sent to you, the hundreds that I have received personally, and the copies of correspondence to HCFA and Congress that members have sent to me. I have shared your anger and frustration as well as your gratitude for the successes we have achieved. Your communications have helped to bolster my resolve to continue the battle. Now, Dr. John Bond, your assignment, should you choose to accept it, is to continue to lead the fight in all these spheres with your usual flare and determination. Thank you all for your support. Barbara B. Frank, MD Haverford, Pennsylvania

VOLUME 38, NO.5, 1992

From the Rostrum

Advanced endoscopic training: teaching us older dogs some new tricks The primary responsibility of the governing board of a professional medical society is, of course, to respond to the stated needs of its membership. Recognizing all of the highly successful current and recent A/S/G/E projects and programs, we must confess that one of the most frequently cited priorities of our members has not yet been successfully addressed-how can A/S/G/E members obtain hands-on training to perform endoscopic procedures which either were not taught during formal training, or were developed after graduation from formal training? A correlative of this question is how can members obtain hands-on training with an experienced teacher to improve their performance of basic endoscopic procedures they already perform? The A/S/G/E has been a leader among professional gastrointestinal societies in establishing standards for training and credentialing. The bottom line appropriately has been the greatest benefit for patients with digestive disorders. As these standards and guidelines have been promulgated, however, many conscientious and skilled endoscopists have been caught between the completion of their fellowship training and the rapid development of new, highly technical advances in our specialty. Our training standards rightfully declare that acquiring competence in new techniques, or major extensions of established procedures, requires not only didactic course instruction, but also hands-on training under the supervision of a skilled and experienced teacher. What we haven't yet solved, however, is the frequently asked question, "Okay, but where do I go to get such required training?" An informal query of training programs conducted by 631