NCVHS Standards and Security Subcommittee: Alternative Link Testimony

May 30, 2002

Opening Comments

• Good morning, Mr. Chairman, members of the National Committee on Vital and Health Statistics’ Standards and Security Subcommittee (NCVHS/Subcommittee) and others here today.
• Alternative Link appreciates the invitation to report on recent interactions with the American Medical Association (AMA). These interactions were mandated by the Designated Standard Maintenance Organizations (DSMOs) and the Subcommittee, and facilitated by a staff member of the Centers for Medicare and Medicaid Services (CMS).
• Our understanding from the April 10th public hearing and, especially, from a separate meeting with NCVHS staff, CMS staff and the AMA later that day, was that this mandate had two distinct elements. The AMA was to:
  • review the functionality and value of the market-ready ABCcodes and establish a business agreement on a mutually acceptable approach to the situation and any relevant intellectual property issues; and,
  • on the basis of that business agreement, collaborate to integrate the functionality of ABCcodes and CPT codes in a manner that supports public health, health industry business needs and congressional intent under HIPAA.
• During this testimony, Alternative Link will:
  • describe the challenges of trying to collaborate with the American Medical Association, even with expert facilitation by Subcommittee and CMS staff;
  • review the AMA’s mixed history of public health achievements and political behavior;
  • stress the urgency of the code set situation, emphasize the life-saving potential of the ABCcodes and report on the hundreds of thousands of human lives that could be lost as a result of further delays in code set availability;
  • highlight benefits and functionality offered by ABCcodes for alternative medicine, nursing and other non-physician interventions; and
  • use an analogy from the grocery industry to illustrate why stakeholders benefiting from an existing supply chain infrastructure should not have control over coding for new technologies.

Recent Experience with the AMA

• Alternative Link found the AMA to be unreliable, self-serving and predatory in its approach to the mandated collaboration.
• The AMA’s newly proposed alternative therapies CPT coding initiative establishes the AMA as a direct competitor to, rather than a collaborator with, Alternative Link.
• Although the AMA may—at this point in time—have some legitimate intentions in the monopolistic role it is proposing for itself, this stance will also position the AMA to:
  • delay code set availability and keep alternative medicine, nursing and other non-allopathic physician practitioners disenfranchised from mainstream healthcare;
  • manipulate code assignment to make difficult head-to-head scientific comparisons of conventional/physician and non-conventional/non-physician interventions;
  • reverse engineer Alternative Link’s intellectual property; and
  • enhance the political strength of allopathic physicians by dominating a critical element of the healthcare infrastructure.
• In our view, the DSMOs, the NCVHS Subcommittee and the DHHS as a whole did not intend to give the AMA the authority to behave as a monopoly. The AMA’s monopolistic stance is, however, an unfortunate byproduct of the mandate to collaborate. This is particularly disturbing because DSMO and Subcommittee leadership assured Alternative Link that DHHS believed the AMA would be more collaborative than it had been in past interactions. We were told that the AMA had been counseled to be cooperative, transparent, impartial and socially responsible—clear duties of a designated standard.
• In a separate meeting on April 10th (following the Subcommittee’s directive to the AMA and Alternative Link to try to work together), Subcommittee and CMS staff advised the AMA to address two things in collaborating with Alternative Link:
  • First, seriously consider the immediate functionality and value of the 4,000 market-ready ABCcodes and—depending on the significance of these codes to public health, health industry business needs and congressional intent under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)— come to an agreement about how best to make use of the codes, and establish an appropriate business relationship, including an acceptable approach to any relevant intellectual property issues.
  • Second, with code set merits and intellectual property issues settled, collaborate on a code set integration processes that serves public health, business needs and congressional intent under HIPAA.
• The AMA agreed to follow this directive.
• Based on the DSMO and Subcommittee assurances—as well as the AMA’s own statements about their new leadership and collaborative approach to the industry—Alternative Link laid aside a long history of negative experiences with the AMA and agreed to collaborate with “a new and improved AMA.”
• In the past six weeks—in marked contrast to its presentation in the April 10th hearing and its commitments in the separate meeting that followed—the AMA exhibited aggressive competitive behavior.
• In particular, the AMA:
• withheld a non-disclosure agreement it agreed to generate that would have facilitated more meaningful discussions about the market-ready ABCcodes and their ability to contribute to public health, address health industry business needs and satisfy congressional intent under the HIPAA;
  • proposed a crosswalk from ABCcodes to CPT codes—something it had obstructed in prior years—and asked Alternative Link to refocus our business on claims edit/scrub applications.(1)
  • showed virtually no interest in examining the characteristics, development and maintenance process, functionality and/or value of the ABCcodes, and then argued that no basis existed for a code integration-related business relationship or an intellectual property agreement;
  • canceled two meetings that were jointly scheduled on April 10th, the first one scheduled for May 1st and intended to cover intellectual property, and the second scheduled for May 14th and intended to cover code set integration processes; and
  • when Alternative Link reminded the AMA of its commitment to first address business and intellectual property issues, flatly stated that the AMA would establish an Alternative Therapies Workgroup and develop competitive CPT codes with or without Alternative Link’s involvement.
• Disregarding its duty and pledge to be a cooperative, transparent, impartial and socially responsible code set authority, the AMA is now in a position to:
  • delay code set availability and keep non-conventional/non-physician practitioners disenfranchised,
  • manipulate code assignment,
  • reverse engineer Alternative Link’s intellectual property, and
  • use a critical component of the healthcare infrastructure to exercise a monopoly and advance allopathic physician interests.

The AMA’s History Prior to the DSMO and Subcommittee Directives

• From its inception in the mid-1800s, the AMA has protected physician interests both legitimately—by supporting meaningful public health initiatives—and illegitimately—by suppressing potentially competitive providers under the guise of protecting public health.
• While the AMA has undertaken many inspiring public health initiatives, it is undeniably a political organization:

1849: AMA establishes a board to analyze quack remedies and nostrums and to enlighten the public in regard to the nature and dangerous tendencies of such remedies.

1925: AMA Propaganda Department becomes Bureau of Investigation.

1943: AMA opens office in Washington DC. AMA Council on Medical Service and Public Relations is established.

1948: AMA launches a campaign against President Truman's plan for national health insurance.

1961: The American Medical Political Action Committee (AMPAC) is formed to represent physicians'… interests in health care legislation.

1966: AMA publishes first edition of the Current Procedural Terminology (CPT), a system of standardized terms for medical procedures used to facilitate documentation.

1983: AMA and the Health Care Financing Administration (HCFA, now CMS) sign an agreement requiring the use of CPT in federal programs for the reporting of physicians' services, as part of the administration's common procedural coding system (HCPCS). Subsequently, HCFA in 1986 extended the requirement to state medical agencies using the Medicaid Management Information System.

1991: AMA proposes reform of the U. S. health care system (Health Access America) to include expansion of health insurance coverage.

1995: AMA encourages Office of Alternative Medicine of the National Institutes of Health to evaluate the safety and effectiveness of alternative therapies.

1998: The AMA… implement(s) an aggressive campaign to bring needed changes to HCFA’s revised Documentation Guidelines for Medicare Evaluation and Management Services. This campaign include(s) web-based information for physicians and aimed at protecting them from unwarranted fraud and abuse penalties.

1999: Addressing the national trend toward consolidation among large health insurance and health care providers, the AMA increase(s) its advocacy efforts, ensuring the protection of U.S. physicians and their patients.

2000: In an effort to help physicians provide the most trusted and comprehensive resource for health care information to their patients on the Internet, the AMA, in partnership with six of the nation’s leading medical societies, implemented its newly created electronic health network, Medem.(www.medem.com)(2)

• The AMA’s commitment to its allopathic physician membership is common knowledge in the healthcare industry and is referred to on the AMA’s own website:

“The AMA is much more than an organization of physicians. We are …the physician's voice(3)… the nation's most influential medical organization(4)…the leading advocate for physicians.”(5)

• With only a few “bad apples” deviating from a largely civic-minded mission, a trade association that serves allopathic physicians and is a designated code set authority could easily withhold, or continue to introduce biases into, code development:
  • to limit the scientific collection and analysis of healthcare data needed for head-to-head quality and cost comparisons between conventional/physician and non-conventional/non-physician interventions; and
  • to restrict public access to non-conventional/non-physician interventions.
• Alternative Link recognizes that the AMA’s Board of Trustees is committed to “the art and science of medicine and the betterment of public health.”(6)
• That notwithstanding, the AMA itself has expressed proprietary interest in maintaining control over coding of allopathic care and gaining greater control over the coding of alternative medicine, nursing and other non-allopathic physician interventions.
• For example, in a presentation to the AMA Board of Trustees on December 4, 2000, the AMA Board Chair(7) stated,

“You may have never realized the huge investment physicians have in (coding)—not in terms of dollars—but an investment in physician autonomy… AMA administration of a physician-driven process… (coding) has given…(us)…a cohesive voice in… health care delivery—a voice that makes us stronger and louder than we are as individuals... In an age where physician autonomy is in danger of slowly being chipped away, how did the AMA secure a physician-driven standard used to describe medical services, not only for payers, but also for all of the health care industry? … Certainly, physician control of a uniform code has not always been the norm.”

• The AMA is a politically astute organization. Its members are politically active and strategically placed.
• The AMA has been well represented on the DSMOs (with the AMA permanently chairing one of the DSMOs, the National Uniform Claims Committee, and holding a seat on the National Uniform Billing Committee).
• Conventional allopathic physicians have been serving in DHHS and on the NCVHS Subcommittee.
• Conventional allopathic physicians are also in leadership positions in the Health Insurance Association of America (HIAA) and other organizations with significant influence in code development and maintenance.
• With this level of advocacy, the AMA has maintained a position of control over this critical component of the healthcare infrastructure, despite well-known weaknesses in the CPT code set and the CPT Editorial Process. (As early as 1993, the NCVHS reported that the AMA's code development process was flawed and was widely believed to favor AMA membership. That notwithstanding, the AMA’s CPT code set was named a designated standard under HIPAA.)
• The AMA CPT Editorial Panel is almost exclusively conventional medical doctors, as is the CPT Advisory Committee. (Please refer to CPT 2002, p. iv.) The Health Care Professionals Advisory Committee (HCPAC) and the newly formed Alternative Therapies Workgroup include some other practitioners, but both fail to include more than 90 specialty associations (not including over 50 specialties of nursing). Despite the advisory bodies within the AMA, final decisions are still made by a decision making body that is almost exclusively allopathic physicians.
• While AMA leadership includes some individuals who are clearly committed to cooperative, transparent, impartial and socially responsible coding, the AMA in practice has not lived up to the laudable goals put forth by the Board of Trustees. For example, as a coding innovator for alternative medicine, nursing and other non-physician interventions, Alternative Link has repeatedly approached the AMA in a spirit of collaboration. In doing so, Alternative Link has documented five years of contentious behavior by the AMA. This behavior has delayed and reduced the healthcare industry’s ability to design insurance benefit plans, manage utilization and process claims, as well as manage clinical trials, conduct health services research and perform actuarial analyses. Worse, as we will describe, it has cost thousands of lives.
• Our intention is not to vilify the AMA. The AMA has supported some of the greatest public health initiatives this country has ever known. Our intention is to say that—even under the best of circumstances—a political organization with an allopathic physician agenda will be hard-pressed to divorce itself from self-interest and demonstrate cooperative, transparent, impartial, and socially responsible behavior in code development for alternative medicine, nursing and other non-allopathic physician interventions.
• In this particular area, the AMA’s record has been less than stellar—a great shame given the impressive history of the organization.
• We ask that the Subcommittee please refer to Alternative Link’s “HIPAA-Compliant Code Set Development Timeline” and to the recent chronology of AMA and Alternative Link communications to understand the dangers of putting coding for alternative medicine, nursing and other non-physician interventions into the hands of the AMA, with its ongoing pattern of behavior.

Urgency, Life Saving Potential and Possible Death Toll

• According to the Journal of the American Medical Association (JAMA), over 100,000 patients die in the U.S. each year as a direct result of hospital and physician errors and not the diseases for which these citizens sought treatment. That number again die from negative effects of “appropriate” conventional treatments.(8) In total, nearly a quarter of a million individuals die from iatrogenic causes, including an estimated 12,000 from unnecessary surgery, 7,000 from medication errors in hospitals, 20,000 from other errors in hospitals, 80,000 from infections in hospitals and 106,000 from non-error, negative effects of drugs.(9)
• For this and many other reasons, American citizens are increasingly turning to alternative medicine, nursing and other non-allopathic physician interventions as a primary source of care. In fact, according to subject matter experts, complementary and alternative medicine (CAM) has a compounded annual growth rate of 38% and more visits are made each year to CAM practitioners than to primary care practitioners (PCPs).(10)
• Imagine the chaos that would exist in the industry today if the practices of PCPs were uncoded. PCPs would essentially be disenfranchised from mainstream healthcare. That is exactly the situation with alternative medicine, nursing and other non-allopathic physician practitioners.
  • If the AMA were granted coding authority over alternative medicine, nursing and other non-allopathic physician interventions, public health would suffer tremendously.
    
    Three reasonably probable scenarios (based on the JAMA statistics) make this clear:
    
  • Scenario #1. The AMA is politically motivated in the development of codes for non-conventional/non-physician interventions. Codes are defined with insufficient granularity or interventions are intentionally bundled and coded is such a way as to preclude the demonstration of superior outcomes for alternative medicine, nursing and other non-allopathic physician interventions when compared head-to-head with conventional interventions.
    
    Suboptimal care patterns result in a 10% increase in unnecessary hospitalizations, physician visits and other types of conventional care. The setback in actuarial capabilities costs no fewer than 320,000 lives(11)—more than 100 times the number of lives lost in the 9/11 attacks.
    
  • Scenario #2. The AMA is politically divided over the development of non-conventional/non-physician interventions and code development stalls out. ABCcodes are named a standard code set in 2010 instead of 2002.
    
    The setback in code set availability could cost 160,000 lives(12)—more than 50 times the number of lives lost in the 9/11 attacks.
    
  • Scenario #3. The AMA wholeheartedly embraces the need for non-conventional/non-physician codes and relies on the existing CPT Editorial Process—plus an Alternative Therapies Workgroup—to generate a remarkable 250 to 500 new codes per year. Assuming the AMA would somehow avoid violating Alternative Link copyrights and patents, the AMA would take no fewer than 8 years to achieve what Alternative Link has already completed.
    
    If the coded non-conventional/non-physician interventions could have prevented 10% of unnecessary hospitalizations, physician interventions and other forms of conventional care, more than 20,000 lives per year—nearly 55 per day—would be unnecessarily lost due to conventional treatment errors and known side effects of treatment.(13) Under the most favorable circumstances, with no fewer than 500 codes developed per year, by 2010, this setback in code set availability could cost 90,000 American lives(14)—more than 30 times the number of lives lost in the World Trade Center and Pentagon attacks.

• Assuming that 10% of conventional care would be made unnecessary by non-conventional/non-physician care, every two-month delay in making the functionality of ABCcodes available to the industry costs more lives than were lost in last year’s terrorist attacks.(15) Similarly, a 10% displacement of potentially harmful non-conventional/non-physician interventions by safe and effective conventional allopathic physician care could save a comparable number of lives every two months.
• The point is that the functionality of ABCcodes is needed immediately to support cost-effective, evidence-based and integrative healthcare. The cost of delays is staggering in terms of potential loss of human lives. If we also consider the dollars wasted as a result of unnecessary administrative inefficiencies—dollars that could be reallocated to generate greater prosperity or to cover the uninsured—the human toll is even more devastating.

The Benefits and Functionality of ABCcodes and Ways to Make Them Accessible

• To make possible the responsible integration of non-conventional/non-physician practitioners into mainstream healthcare, the founder and research team at Alternative Link spent seven years and millions of dollars eliciting expert support, with their assistance, developing approximately 4,000 market-ready codes for 13 categories of alternative medicine, nursing and other non-allopathic physician interventions.
• These codes were systematically developed and are maintained in collaboration with subject matter experts, academic institutions, trade associations, licensing boards and government entities. They offer hierarchic design features and alphabetic characters that allow for more than 11 million code combinations, plus greater functionality and expandability than CPT codes. In fact, ABCcodes are sufficiently robust to resolve many of the code set challenges of the healthcare industry.
• In 1998, at the government’s request, ABCcodes were added to the National Library of Medicine’s Unified Medical Language System. Today, these market-ready and ANSI ASC X12N-compliant codes are supported by detailed information that identifies who can do what in each of the 50 United States and the District of Columbia. For each code, this supporting information includes
  
  1) practitioner training requirements; 2) state statutes, administrative regulations and case law; and 3) relative value units.

• The supporting information is housed in a market-ready database that includes over 13 million units of information for accurate adjudication of claims under HIPAA, as well as numerous other essential health industry research and business processes. The contents of the database are publicly available in three publications already on the market through Delmar/Thomson Learning and Relative Value Studies, Inc.:(16)
  • The CAM and Nursing Coding Manual
  • The State Legal Guide to CAM and Nursing
  • Relative Values for CAM and Nursing
• Interestingly, in the time Alternative Link developed 4,000 market-ready non-conventional/non-physician codes and supporting scope of practice and relative value information urgently needed by the healthcare industry, the AMA developed only two codes for acupuncture and four codes for chiropractic services—these prompted by legal action.

A Coding Analogy from the Grocery Industry

• Sometimes, to get a clear picture of a situation, we need get out of the details and just hear things put simply—in a way that everyone can understand. Alternative Link believes an analogy from the grocery industry would make the point that a coding decision should not be held hostage in a political battle—especially when that battle could compromise public health, industry efficiencies and compliance with legislative intent.
• We are all familiar with Universal Product Codes, called UPCs. They are placed on retail products, such as your groceries, not only to allow for scanning at check out, but also to support efficiency of the entire supply chain, from manufacturing through wholesale and retail distribution.
• Just as a UPC on a package of Kraft cheddar cheese does not force a retailer to carry that brand in his store, an ABCcode or a CPT code assigned to a complementary healthcare intervention does not force a health plan to offer that intervention as a benefit. It simply allows that intervention to be tracked and managed.
• Kraft cheddar cheese requires refrigeration, as do most conventional dairy products. It can be thought to represent a conventional offering in the marketplace.
• Now, imagine that a European company developed a new technology that made possible the production and packaging of dairy products that could be stored at room temperature. Imagine if this technology supported twice the shelf life of conventional dairy products and delivered a better tasting product.
• Imagine that a few innovative US dairy farmers started using the new European technology to process dairy products and began to test these products in local stores and farmers markets. Imagine that, in these test markets, demand for the innovative dairy products surged because retailers and customers preferred not to have to restock their supplies as frequently and were also grappling with skyrocketing energy bills resulting from excessive use of electricity and transportation fuels.
• Imagine that the innovative dairy farmers were interested in supplying the dairy products on a national basis, through major retail chains—some of whom had already started to sell the products on a trial basis. Imagine that, in order to support an efficient supply chain and satisfy growing demand from retailers and consumers, the farmers needed the Uniform Code Council to assign this new class of dairy products hundreds of unique UPCs.
• Imagine that the conventional dairy product producers, distributors and vendors had invested considerable capital in the existing infrastructure for refrigerated dairy products and refrigerated transportation (e.g., in refrigeration equipment and supplies). Imagine, too, that these stakeholders derived considerable revenues from these sources and did not have an equity stake in the new dairy products.
• Imagine that these conventional stakeholders first initiated a political campaign and a negative advertising campaign against the new dairy products, implying that the products were a health hazard. Imagine that demand continued to surge.
• Imagine that the conventional stakeholders then initiated a series of legal actions that distracted the dairy product innovators from their innovative product development activities. Imagine that the innovators somehow managed to stay in business and continue to supply their customers.
• Imagine that the conventional stakeholders then tried to take over the Uniform Code Council so they could control whether and how codes would be issued for the innovative dairy products.
• Worse, imagine if the conventional stakeholders were named as the Uniform Code Council by the government.
• Imagine that issuance of the UPC codes supported political agendas rather than the public good.
• Without UPCs, innovative dairy product manufacturers would be unable to accurately forecast demand to support production, inventory and distribution planning. Dairy product retailers would be unable to forecast sales, efficiently stock shelves and purchase products electronically.
• Dairy industry associations and dairy research organizations would be unable to track spoilage and determine scientifically the extent to which the new dairy products extend shelf lives, offer cost savings and do a better job of meeting consumer needs.

Conclusion

• As suggested by the above analogy, medical codes are to the healthcare industry what universal product codes (UPCs) are to the retail industry. That is, codes are a vital part of the industry’s infrastructure. They support electronic communications and transactions that are essential to proper functioning of the industry. However, unlike UPCs in retail, codes in healthcare do a great deal more than support the industry’s supply chain. In healthcare, codes enable industry stakeholders to control healthcare access, quality and costs, and to manage care, claims and outcomes. Because of this, delayed and/or improper development, management and use of codes can result in lost lives.
• As the section entitled, “Urgency, Life Saving Potential and Possible Death Toll” makes clear, this code set authority issue is one of the most critical health data issues facing the nation. The NCVHS Subcommittee’s recommendation to the Secretary of DHHS, regarding ABCcodes, will impact public health for years to come. The Subcommittee will help the Secretary decide whether the AMA (a trade association which represents allopathic physicians) will control a vital component of the healthcare infrastructure and thereby gain the ability to control public access to interventions offered by other healthcare practitioners—even if those interventions offer better economic and health outcomes. This is roughly akin to giving GM control over Ford parts and service…but it affects human lives, not automobiles.
• ABCcodes are urgently needed to design healthcare insurance benefits, manage utilization and process claims, as well as run clinical trials, conduct health services research and perform actuarial analyses.
• With regard to public health, about a quarter of a million Americans die from iatrogenic causes related to conventional approaches to healthcare.(17) Non-conventional/non-physician approaches to healthcare are typically more preventive and less invasive than is allopathic physician care. Preventing diseases and thereby avoiding hospitalizations and drug interventions saves lives, but those who earn their living by treating diseases may not perceive it as “good business.”
• Some alternative medicine, nursing and other non-allopathic physician interventions are effective and some are not. Some may displace conventional allopathic physician interventions and some may be quackery. The challenge is that the scientific evaluation of these non-conventional/non-physician interventions is currently limited, since the AMA, in more than 30 years of code development, has all but ignored these approaches to healthcare. In the same period of time, the AMA has coded thousands and thousands of allopathic physician interventions.
• The AMA is proposing to control tools that are essential for scientific research, as well as the management of care, the processing of medical insurance claims and the assessment of economic and health outcomes.
• Concern about the AMA’s proposal is widespread and yet the industry’s outcry has been preempted by widespread fear of AMA retaliation.
• Alternative Link has been told by leading conventional and non-conventional practitioners, academic research institutions, trade associations and payers that they applaud our work and want our codes to become a designated standard.
• At the same time, we have been asked by many of them to keep their identities hidden. Why? Because they view the AMA as a powerful monopoly that will take retaliatory action against them.
• Practitioners fear a loss of referrals.
• Academics fear their articles will be banned from JAMA and other medical publications.
• Trade associations fear the limited progress they have made in years of negotiations with the AMA will be lost.
• Payers fear they will have difficulty with their provider contracts.
• Because our livelihood depends largely on ABCcodes, we are in the unenviable position of being David against the AMA’s Goliath.
• However, unlike David, our motivation has not been to destroy the giant. Instead, we have tried for years to collaborate with the AMA. When that did not work, we tried to avoid their attacks. When the government directed us to face them again, we set aside our concerns and approached the issue in a cooperative, transparent, impartial and socially responsible manner.
• We have not insisted that our code set be incorporated into the CPT codes, although we believe this is one of many potential solutions. In fact, our CPT application was prompted by the AMA, not conceived by us.
• Instead, as requested by the DSMOs and Subcommittee, we have repeatedly asked the AMA to evaluate the functionality and merits of the ABCcodes as a whole and—depending on the significance of these codes to public health, health industry business needs and congressional intent under the HIPAA—establish a business agreement.
• We have suggested that, on the basis of that business agreement, we could collaborate to integrate the functionality of ABCcodes and CPT codes in a manner that supports public health, health industry business needs and congressional intent under HIPAA.
• We have encountered insurmountable challenges with the AMA in the past six weeks, and the past five years.
• The market urgently needs codes for alternative medicine, nursing and other non-allopathic physician interventions.
• ABCcodes meet public health and business needs, and comply with congressional intent under HIPAA.
• ABCcodes offer a market-ready solution that will increase the industry’s ability to promote cost-effective, evidence-based and integrative healthcare.
• ABCcodes have the potential to save hundreds of thousands of lives per year.
• With human lives at stake and an industry burdened by expenditures for scientifically unsubstantiated care, a coding decision should not be held hostage in a political battle over public access to non-conventional/non-physician care.
• If the AMA gains Subcommittee endorsement in coding alternative medicine, nursing and other non-allopathic physician interventions, it will have a monopoly over a critical component of the healthcare infrastructure. From this position, it will be able to restrain trade, compromise public health, exacerbate inefficiencies in the cost-burdened healthcare industry and violate congressional intent under HIPAA.
• In contrast, implementation of market-ready non-conventional/non-physician codes will quickly separate quackery from meaningful medical interventions. It will put decisions about healthcare access back into the hands of the people, their government representatives, and the healthcare providers and insurers they select. This will ultimately support greater consumer choice, as well as more cost-effective, evidence-based and integrative healthcare.
  
  Despite the AMA’s aggressive competitive stance, in our most recent communication with the AMA, we reiterated the benefits of a collaborative approach. We continue to believe we can help the AMA in:
  • Taking an impartial approach to code development and maintenance that could reverse public, industry and legislature perceptions of trade association bias;
  • Protecting its franchise in allopathic physician code development and maintenance, while improving its relationship with alternative medicine, nursing and other non-physician practitioners;
  • Improving its product by gaining access to a hierarchic code structure and improved code set functionality that better support cost-effective, evidence-based and integrative healthcare;
  • Increasing its revenues by jointly expanding the market for code set licenses and publications; and
  • Reducing costs by reengineering its business processes based on a systematic review and appropriate adoption of ALI’s best code development and maintenance practices.
• Our goal has always been to use ABCcodes and supporting tools to bring cost-effective, evidence-based and integrative healthcare into the mainstream, and thereby support the health and welfare of the public.
• In 1999, Alternative Link established a non-profit organization to reinforce an already cooperative, transparent, impartial and socially responsible approach to code development and maintenance. The structure of the organization has been established and includes subject matter experts, academic organizations, trade associations, key categories of health industry stakeholders and government representatives. The non-profit is ready to assume authority for ongoing code development and maintenance.
• Public demand for alternative medicine, nursing and other non-allopathic interventions continues to escalate. The industry needs a code set now to help manage care, claims and outcomes for non-conventional/non-physician interventions. In light of this, Alternative Link asks that the Subcommittee carefully review the ABCcodes and, upon confirming their value, recommend them as a designation standard.
• We ask for your help in supporting the Secretary of DHHS in making a rational decision based on public health interests, critical industry needs and congressional intent under HIPAA.

Details of Interactions with the AMA

• Despite this, the DSMOs had not only issued the mandate, but had also begun to make derogatory public statements about Alternative Link, implying that Alternative Link was being somehow uncooperative. The organizers of a West Coast conference on HIPAA compliance professionally recorded at least one such statement.
• Between March 13th and April 10th, despite an encouraging tone in the discussions with the AMA, Alternative Link became aware that the AMA wanted to reverse engineer Alternative Link’s intellectual property for the AMA’s proprietary benefit.
• In our April 10th testimony to the Subcommittee, Alternative Link reported serious concern that the AMA collaboration could continue to be difficult and time consuming.
• Alternative Link noted that the AMA had encouraged Alternative Link to apply for CPT codes through the existing code application process without informing Alternative Link that this would transfer Alternative Link’s intellectual property to the AMA without compensation.
• Alternative Link also reported that the AMA had delayed providing guidance about how to address application related challenges until the day the CPT application was due.
• Alternative Link noted that—had we not anticipated these responses—we could have lost our ability to represent alternative medicine, nursing and other non-physician practitioners, and our HIPAA compliance efforts could have been stalled by three more months.
• Following our April 10th testimony—despite our candid comments about the challenges of working with the AMA—the Subcommittee directed us to continue communications with the AMA and continue to try to integrate the two code sets.
• In a separate meeting following the April 10th testimony, a group of DHHS staff members met with Alternative Link and the AMA, expressed concern that another six weeks might pass with no progress made on the collaboration and offered to facilitate meetings and discussions to assure the most positive outcome possible.
• In that meeting, with DHHS guidance, the AMA made special note of a change in the AMA’s top leadership that would facilitate a collaboration and expressed a commitment to this end. In addition, the AMA agreed to 1) draft a mutual non-disclosure/non-compete agreement typical of joint-ventures and alluded to skills in protecting intellectual property; 2) execute the non-disclosure/non-compete agreement prior to May 1st; 3) meet on May 1st to resolve intellectual property issues and come to a mutually satisfactory arrangement for moving forward with code set integration planning; and 4) meet on May 14th to initiate code set integration planning.
• Alternative Link wrote an email to the AMA shortly following this separate meeting and asked for the non-disclosure agreement, as well as an early sense of the direction the AMA planned to take on business discussions.
• In a subsequent telephone call, facilitated by Stanley Nachimson of CMS, without alluding to any review of ABCcodes, the AMA said that the AMA did not recognize the value of ABCcodes and other Alternative Link intellectual property. The AMA referred to ABCcodes as “ideas” and said that the CPT Editorial Process was government-endorsed and more legitimate than Alternative Link’s code development process. The AMA said that—rather than discuss Alternative Link’s intellectual property any further—the AMA would establish an Alternative Therapies Workgroup to evaluate the need for CPT codes for alternative medicine. The AMA reiterated this position in a subsequent letter and, in a subsequent email, cancelled the intellectual property meeting of May 1st.
• Alternative Link responded to the AMA by asking the AMA to 1) assess ABCcodes before taking any position on the code set’s merit or value relative to CPT codes; 2) clarify its position relative to several direct questions; and 3) raise the level of discussion to ensure public health, business and HIPAA-related needs would be met by the code set integration solution. We referred directly to the need to comply with the guidance provided by the NCVHS regarding an initial review of intellectual property and a subsequent discussion of code set integration processes.
• The AMA responded with an email that ignored Alternative Link’s direct questions, implied that Alternative Link was being uncooperative vis-à-vis the proposed workgroup, and noted that the AMA was moving forward with the Alternative Therapies Workgroup with or without Alternative Link’s involvement. In this communication, the AMA cancelled the code set integration planning meeting that had been scheduled for May 14th.
• Alternative Link responded by emphasizing Alternative Link’s desire to cooperate and reiterating the need to comply with NCVHS/CMS instructions and raise the level of discussion to address immediate public health and business needs, as well as congressional intent under HIPAA.

For further information, please contact:

Alternative Link, Inc.
6121 Indian School Road, NE, Suite 131
Albuquerque, New Mexico 87110 USA
Tel: 505-875-0001 Fax: 505-875-0002
Email: mail@alternativelink.com
Website: www.alternativelink.com

File CodeNCVHS oral testimony-2002.05.30-4.doc 06-14-02 17:25

Endnotes

(1) Alternative Link holds a patent on the use of 5-character codes with 2-character modifiers, legal information and relative value units to edit and scrub insurance claims for alternative medicine, nursing and other non-physician interventions.

(2) http://www.ama-assn.org/ama/pub/category/3779.html.

(3) http://www.ama-assn.org/ama/pub/category/1811.html

(4) http://www.ama-assn.org/ama/pub/category/1854.html

(5) http://www.ama-assn.org/ama/pub/category/1922.html

(6) http://www.ama-assn.org

(7) D. Ted Lewers, MD.

(8) Please refer to http://qualityforum.org.

(9) Journal American Medical Association, Vol 284, July 26, 2000.

(10) David Eisenberg and others (on file).

(11) .1(200,000)(8) + .1(200,000)(8)=360,000.

(12) .1(200,000)(8)=160,000.

(13) .1(200,000)=20,000. 20,000/365=54.8.

(14) This assumes the AMA is able to develop 1/8 of the ABCcodes per year and that 200,000 lives are lost per year due to hospital and physician errors, as well as known side effects of conventional treatments.

(15) .1(200,000)/365=54.8. 3100/54.8=56.6.

(16) Please refer to http://www.delmar.com/cam/ and http://www.rvsdata.com/ps2.html to learn more about ABCcodes and related resources.

(17) Journal American Medical Association, Vol 284, July 26, 2000.