Table Of Content

Digitized by the Internet Archive in 2017 with funding from The National Endowment for the Humanities and the Arcadia Fund https://archive.org/details/alabamamedicinej6219medi July 1992 Vol. 62, No. 1 NAL OF THE MEDICAL ASSOCIATION OF THE STATE OF ALABAMA RARELYARE THERE EASY ANSWERS, BUT THERE ARE INTELLIGENT CHOICES. The Keystone of Your Protection .Mutual Assurance 100 Brookwood Place Birmingham, AL 35209 205-877-4400 1-800-272-6401 Alabama In This Issue Medicine JournaldtheMedicalAssociationoftheStateofAlabama Executive Director. 2 VOL. 62. NO. 1, JULY 1992 The ERISA SquirrelLaw (USPS284720) ISSN0738-4947 OFFICEOFPUBLICATION:P.O.Box 1900,Montgomery President's Page 8 Alabama36102-1900.SubscriptionPrices:member.$15.00, non-member,$30.00peryear$2.50percopy.Secondclass Complacency, Apathy, Hostility postagepaidatMontgomery,Alabamaandatadditbrudoffices. PuUishedmonthlybyTheMedicalAssociationofTheStateof A36l1a0b4a.maat19SouthJacksonStreet,Montgomery,Alabama Primary Causes ofMedicalInstability of PP.OOS.TBMoxAS1T90E0R,:MoSnetngdomaedrdyr,esAsLch3a6n1g0e2s-1t9o00A.labamaMedicine. Medicare Patients atDischarge 12 Established1931,pul^ishedbyandforTheMedicalAssociation Robert G. Sherrill, Jr., M.D., M.A., et al. oftheStateofAlabamaforopenandlespionsiUediscussionof mattenrelevanttomedicineandotherfieldsofinftresttophysi- cians.Conclusionsandopinionsexpressedhereinaredxiseofthe individualauthors.Noportionofthispublicationmayberepro- Classifieds 29 ducedinanyform,includingelectronic,withoutwrittenconsenL Putdishersreservetherighttorejectanyadvertisingwithorwith- outexplanatiorL Auxiliary 30 Copyright1992bytheMedicalAssociation oftheStaleofAlabama The First Five Minutes EDITOR QaudeL.Brown,Jr.,MD.,Mobile ASSISTANTEDITOR Newly Licensed Doctors 31 Wm.H.McDonald,Montgomery ADVERTISING&DESIGN RhondaMills,Montgomery How PRN OFFICERSOFTHEASSOCIATION:President-PeterW. Assists the Physician, the Patient Morris,M.D.(1993)**,Binnmgham;President-ElectJamesE. and the BoardofMedical Examiners .33 West,M.D.(1993)**,Anniston;ImmediatePastPresident- WilliamD.Lazenby,MD.(1993)**,Opelika;Vice-President- Physicians Recovery Network ErnestG.Moore,Jr.,MX).(1993),Binningham;Speaker,House ofDelegates- RichardO.Russell,Jr.,M.D.(1994)***, Birmingham;Vice-Speaker,HouseofDelegates -R. Bob COUNTWAY MuUins,MD.C1994)***,Valley. THE FRANCIS A. DELEGATESANDALTERNATESAMERICANMEDICAL LIBRARY OF MEDICINE ASSOCIATION(TermsexpiringDecember31ofyearshown) boston, MA 1992 Delegates*JuliusMichaclson,MD.,Foley; WilliamT. Wright,M.D.,Mobile; CarlA.(jrotc,Jr.,MD.,Huntsville. 1993Delegates-JonE.Sanford,M.D.,Fayette; KennethC. Yohn,M.D.,Eufaula.1994Delegates-JuliusMichaclson,M.D., Foley;WilliamT.Wright,MD.,Mobile;CarlGrote,Jr.,M.D., Huntsville.1992Alternates-BurtF.Taylor.M.D.,Mobile; GarlandC.Hall,Jr.,MD.,Moulton;R,BobMullins,Jr.,M.D., Valley.1993Alternates-PeterW.Morris,M.D.,Birmingham; EdgarW.Branyon,Jr.,M.D.,Annision. 1994Allcrrtalcs-Burt F.Taylor,M.D.,Mobile;GarlandC.Hall,Jr.,MD.,Moulton;R. BobMullins.Jr.,M.D,,Valley. THESTATEBOARDOFCENSORS: RichardH.Esham, M.D.,Chairman0994)*,Mobile; WflliamM.Lightfoot.MD., VMiDceChairman(1994)*. 1stDistrict,Mobfle;EUannMcQory, (1993),4thDistrict,FtPayne;GarlandC.Hall,Jr,M.D. (1993),5lhDistria,Moulton;PatrickB.Jones,Jr.,M.D.(1994), 2ndDistrict,Dothan;JonE.Sanford,M.D.(1994)*,Fayette; PinkL.Folmar,M.D.,(1996),6thDistrict,Birmingham;Robert H.Story,M.D.,(1996)*,Tuskegee;JamesH.WaJbum,M.D., (1996),7thDistrict,Tuscaloosa;JoelC.Pitlard,M.D.,(1997), Opelika;ReginaM. Benjamin,M.D.,(1997)*,3rdDistrict, BayouLaBatrc;WilliamA.Curry.M.D.,(1997)*,Carrollton. *Allarge ••Member,BoardofCensors •••Ex-OfficioMember,BoardofCens<xs STATE HEALTH OFFICER: Claude Earl Fox. M.D., Montgomery. -STAFF- EXECUTIVEDIRECTOR S.LonCemer Secretary-Tieasufcr•EmmettWyatt DEPARTMENTS Ixgal-WendellR.Morgan Education-GeorgeD.Getting GovemmcnlalAffairs-RichardC.Whitakca' PuUicRelations•HolleyMidgley Communications•Wm.H.McDonald Alabama Medicine, The Journal of MASA / 1 EXECUTIVE DIRECTOR S. LonConner ExecutiveDirector,MASA The ERISA Law Squirrel For generations, this story has long been a fixture “That’s all well and good, John, but how do you of folk politics in the South and may be apoc- stand on the squirrel law? Are you fer it or agin it? ryphal for all I know: That’s all we want to know about.” A Tennessee Congressman long ago found himself Congressman John looked over the crowd of vot- running for re-election in the midst of a local contro- ers, figuring that here was a fairly representative sam- versy over a proposed squirrel law. ple of the 50-50 split on the issue. The air was The exact details of the squirrel law escape my charged with expectation as he adjusted his string tie, memory but it had something to do with confining tossed back his silver mane, cleared his throat and squirrel hunting to certain hours of the day, etc. The began: people in the candidate’s congressional district “Ladies and gentlemen, as a statesman 1 will not appeared to be about evenly divided on the issue, a hedge or waffle. Someone once said at such a highly emotional one for proponents and opponents momentous juncture as this: ‘All is lost save honor, My alike in that farsimplerday. and that hangs in the balance.’ personal honor and That’s about all the voters had on their minds when integrity, as you all know, are more important to me the Congressman began stumping for the fall election. than my re-election. The times cry out for leadership He was naturally determined to avoid the subject like and a courageous stand on principle and I will not the plague. shirk or shilly-shally. I must be true for there are He succeeded for a time, hara—nguing the multitudes those who trust me. I must be brave for there is much on every subject under the sun except the squirrel to dare. The great people of this great state know my law. But near the close of his campaign, hecklers sterling record offearless faith as their public servant. began appearing at his rallies demanding that he For was it not I who struck the serpent from the ” decla—re himself on the squirrel law, one way or the eagle’s nest in theirbehalflong, long ago? .... other or, as they put it, “fer it or agin it?” Day after “THE SQUIRREL LAW, JOHN,” came the insis- day, the hecklers returned with their taunts. The tent voice from the back of the crowd. “FER IT OR Congressman stood mute on the issue. AGIN IT?”The crowd picked up the chant. Even the few people who didn’t care much one “Ah, yes, the squirrel law,” the Congressman way or the other were getting restive: if their con- began. “No greater question has presented itselfto the gressman couldn’t make up his mind, maybe he good people ofour fair state since it was created. The should stay at home in Tennessee next term. squirrel law is as fundamental to the rights of a free- Finally, he could evade no longer. Rumors had dom-loving people as the Magna Carta; as basic to been building for weeks that he was about to declare the liberties ofourgreat citizenry as the Bill ofRights himself. On the fateful day came the usual challenge itself; as essential to the maintenance of the character from the crowd assembled in the town square: and substance ofourproud people as....” 2 / Alabama Medicine, The Journal ofMASA Make easier life many for of your patients Humulin 70/30. Convenientand simpleto administer. No more mixing. No more mixingerrors. Allofwhichmakes hvingwithdiabetes a little easierforpatients.And compliance aloteasierto achieve. Humulin 70% human insulin isophane suspension 30% human insulin injection DNA (recombinant origin) Thepatient-friendlypremix GlobalExcellencein DiabetesCare ElIindLiilalnyapaonlids.CoInmdpiaannay WARNING:Anychangeofinsulinshouldbemadecautiouslyandonly 46285 undermedicalsupervision. HI-7905-B-249327 ©1992.elilillyandcompany . . “THE SQUIRREL LAW, THE SQUIRREL LAW, since World War 11. THE SQUIRREL LAW,” the crowd, now mutinous, Since Medicare-Medicaid, the unwritten social chanted contract has been that the private sector, business and “I will not equivocate,” the congressman said, industry, will cover working Americans and govern- equivocating: “Some ofmy friends are ferthe squirrel ment will care for the old and at least some of the law and some are agin it. I want to say here—and now poor. But now spokesmen forthe aged are saying that that my record speaks loudly on this point I’m fer their constituents are once again paying as much-out- my friends; always have been, always will be. ‘This of-pocket for health care, in constant dollars, as they above all,’ the Bard said, ‘to thine on self be true.’ did before Medicare; Medicaid covers a smaller per- Thank you all and remember your faithful servant on centage of the poor with each passing year, and the election day.” private sector says it is being forced to curtail cover- They did; he lost age and even to renege on pension plans because of The swelling national controversy over Section spiraling health care overhead and as the target of 514 ofthe 1974 federal law, the Employee Retirement much ofthe cost-shifting from othersectors. Income Security Act (ERISA), is a squirrel law in that All this is the result of many economic factors, some of medicine’s friends are fer it and some are including the cost-shifting from Medicare-Medicaid agin it. At the risk of sounding like the fearless and other prudent buyers of health care. In other Congressman, I think both sides have persuasive words, the social contract is in tatters. Everybody, it cases. seems, wants that fellow behind the tree to pay and he This is the section that permits large employers to has disappeared without a trace. self-insure, as about two-thirds already have. The Section 514 has been around for 18 years but not essential appeal is that the law permits self-insuring until recently has the controversy over its social companies to escape state insurance laws and state immunization reached critical mass. taxes earmarked for pools to provide care for the Senator Dave Durenberger, Minnesota Republican, uninsured. speaks for many in the state houses and a significant The rush to self-insurance is the result of many number in Congress when he says: “ERISA has forces, principal among them being the freedom it become a shield behind which self-insured companies gives employers to write theirown policies as a hedge can avoid social responsibilities that others must against the rising cost ofhealth care; and as an escape bear.” He is one of the leaders of the ERISA reform from the mandated state benefits legislators have been movement. — imposing on carriers requiring coverage demanded Such is the state ofthe controversy at this time that by every special interest group in the land. it seems immaterial that employers were driven to While many of these legislative mandates have self-insure by the Niagara of legislative mandates and been legitimate, some groups have succeeded in get- by the massive cost-shifting that ultimately landed at ting mandated coverage for in vitro fertilization, hair their door. By going into business as their own self- transplants, acupuncture and even, it is alleged, fees insurer they are beyond most state insurance laws and for Christian Science counseling. These and similar can reduce coverage almost without restraint. coverages are hardly ofthe kind of medical necessity Several states have already filed for congressional normally insured. Taken together, they add many mil- waivers under the act, which is the only way to get lions to the health care bill. straying employers back under the tent, short of Since the buck stops with those who pay the bills, repealing the section. Leaders of the state waiver many employers are jumping ship. Some states are movement are Florida, Minnesota and Vermont, all of howling mad that these escapees can dilute coverage which enacted health care reform this year, reform with only their consciences as their guides. They have that would not work if the big employers stayed out. also insulated themselves against taxes designed to Oregon and California are preparing to file. defray the costs oftreating the medically indigent. A lobbyist for the National Governors Association, The exodus under Section 514 also undercuts, per- Alicia Pelrine, says most states can’t move without an haps fatally, many of the proposed health care ERISA waiver. “We are caught between a rock and a reforms in Congress, along with AMA’s own grand hard place,” Ms. Pelrine says: design. Health Access America. Most of the bills in “On the one hand Congress wants to support incre- Congress are designed to build on existing insurance mental reforms in the states and on the other if busi- infrastructure that employers have been providing ness succeeds in killing any hope we might have, we 4 / Alabama Medicine, The Journal ofMASA