The Controlled Substance Witch Hunts in Florida

Florida State SealI care for a 65 year old woman suffering with sarcoidosis affecting her lungs, her skin, her bones, her nerves, her blood chemistries, her kidneys, her colon and her mind. She has gone from an active spouse, mother, grandmother, tearing up the dance floors with her husband, to a home recluse calling friends to drive her to medical and care appointments while ambulating with assistance of another strong individual supported by a 4 wheel walker with a seat. She describes her foot pain as feet burning on fire. An evaluation with the Cleveland Clinic and ultimate biopsies of her skin and nerves led to a diagnosis of severe small vessel polyneuropathy. An experimental course of an IV immunosuppressant provided short term relief and hope for relief of pain but those drugs effectiveness waned quickly. She has recurrent kidney stones from sarcoidosis effect on her calcium metabolism and is in chronic and recurring pain with frightening blood in her urine as small sharp kidney stones wind their way down her ureters towards her bladder. She has had colitis for twenty years now. Normal barium enemas and colonoscopies initially resulted in her being considered a neurotic quack. When the Mayo Clinic suggested a biopsy on the normal colon and the pathology revealed a new entity responsible for all her symptoms she was reclassified from a neurotic annoying wife of a professional to “an interesting and rare case” by many in the medical community. Throughout her trials and tribulations she has sought the care of board certified gastroenterologists, nephrologists, urologists, rheumatologists, psychiatrists, psychologists, ophthalmologists, dermatologists, general internists and a neurologist specializing in pain management.

The State of Florida suffered through an epidemic of illegal pill mills at the turn of the century. Criminals hired criminal physicians to prescribe narcotic pain pills for cash irrespective of a justifiable medical condition or medical exam. These prescribing practices were spurred on by a “blue ribbon “physician panel (financed by the same pharmaceutical firms who made the pain pills) suggesting doctors use more narcotics and less nonsteroidal anti-inflammatory medicines to control chronic pain. They additionally encouraged supplementing your income by dispensing pain pills in addition to prescribing medications. I never believed in that because there was too much opportunity and room for inappropriate prescribing.

Our unfortunate chronic patient had her pain controlled by a board certified neurologist who through trial and error found a formulary that the patient tolerated. During the months of experimentation the patient suffered through nausea, vomiting, constipation, diarrhea and dehydration. Trips to the ER for anti-nausea medications or IV hydration were frequent and common. When her neurologist found a mix that worked he stuck with it. That patient’s pain doctor moved out of the state of Florida 3 years ago because he was afraid that the implementation of the Florida pain law would limit his patients’ access to needed medications and make his prescribing subject to inappropriate review and scrutiny. He is currently working at a university medical center in North Carolina providing patient care and teaching medical students and doctors in training.

As the patient’s primary care physician I became the narcotic prescriber for the patient in her neurologist’s absence. The patient executed a pain contract with our office which she has followed religiously while she continued her care with her multiple specialty doctors. We tried several other neurologists and pain physicians but the high volume impersonal nature of medicine today left her unhappy and dissatisfied with the care and attention provided.

When the patient turned 65 years old and went on Medicare she purchased a Medicare Part D prescription drug plan which directed her to a large chain pharmacy. They told her they would not prescribe her narcotics because they did not want the liability and did not like the combination of medications ordered by her board certified pain specialist. That company had been fined for illegally selling pills without prescriptions to drug dealers out of their Samford, Florida distribution site. The alternative pharmacy, a popular supermarket chain was audited by state regulators this week. The auditors were upset with the pharmacy releasing a controlled substance in the quantity given especially along with her antianxiety and anti-migraine headache medicines on this patient’s medication list. They had no patient records or history to explain why she was receiving these scripts, but nonetheless so intimidated the pharmacy that they called the patient and told her they would no longer be able to sell her the prescribed pain medicines. The patient called my office in tears wondering where to obtain her medications and frightened about the prospects of abruptly stopping these medications. The pharmacy simply said the liability and fear of losing their license necessitated the change in policy.

I am a board certified physician in internal medicine, with extra study in Geriatrics who has practiced in this community for 36 years. I list on my medical license application every 2 years that I will prescribe pain medications for legitimate chronic conditions. I take my required continuing education courses especially in the areas of prescription pain medication to meet the state requirements. My patients who receive chronic pain medications must execute a pain medicine contract which outlines their responsibilities as well as mine. I do not take lightly the prescribing of a controlled substance, but recognize that sometimes there are medical conditions which leave you with no other options. I have been told that after the state regulators look at the pharmacies role in prescribing short term narcotics for long term use, they will be contacting the Florida Board of Medicine to review my prescribing of these medications for this patient. It is clearly an attempt to coerce and intimidate at the expense of a sick and vulnerable group of patients. I have probably prescribed fewer pain medications in my 35 year career than a pill mill prescribed in one day of business. The response to the Florida Board of Medicine will require hiring an attorney and involve time, research and aggravation. Our legislators, prosecutors and law enforcement officers should be able to differentiate between a functioning medical practice and an illegal pill dispensary. I am beginning to believe these same officials could not recognize the difference between a house of worship and a functioning brothel. Their inadequacies and inefficiencies threaten to prevent the citizens of Florida from receiving relief from pain even if they have a legitimate reason for receiving pain medication on a long term basis. Do the citizens of Florida want their doctors making these decisions or legislators and bureaucrats with no clinical patient care experience?

Weight Loss May Prevent Recurrent Atrial Fibrillation

Heart - CopyAtrial fibrillation is a chaotic heart rhythm seen generally in patients with an enlarged left atrium chamber of the heart and or disease of the heart valves. The heart beats irregularly in many cases decreasing the effective pumping ability of the heart muscle. Patients with atrial fibrillation tend to form blood clots in the left heart chambers which are at risk to break off and travel downstream especially to the brain causing embolic strokes. Newly diagnosed patients are placed on anticoagulant medications such as warfarin, dabigatrin, rivaroxaban, or apixaban to prevent these clots from forming in addition to medicines to slow down the heart rate and hopefully shift you back to your normal heart sinus rhythm in time. Other patients are forced to undergo electrical shock cardioversion to re-establish their normal sinus rhythm while others require ablation therapy to do the same. Once these procedures and chemical maneuvers have been successful, and many times they are not, patients are placed on medications to maintain the correct rhythm.

At a meeting of the American College of Cardiology, Rajeev K. Pathak, MBBS, of Australia’s Royal Adelaide Hospital, presented data showing patients who went on a diet and lost 10% of their body weight were six times more likely to be free from the arrhythmia without having to use antiarrythmic medication at five years (rate 46% versus 13% with less than a 3% weight loss.) The results were presented at the ACC meeting and published in the Journal of the American College of Cardiology.

The study looked at 355 patients who had atrial fibrillation and a body mass index of 27kg/m2 or greater. They were offered a low fat, low carbohydrate weight loss program plus an exercise program at a weight loss clinic. They determined freedom from recurrent atrial fibrillation by using a seven day Holter monitor recording. The evaluations showed that those patients who kept the weight off with less than a 2% fluctuation in weight were 85% more likely to not have recurrent atrial fibrillation or require medication use to control their rhythm.

Lifestyle modification in the form of weight loss is always preferable to the use of medication and procedures. Bernard Gersh, J. MBChB, DPhil, of the Mayo Clinic in Rochester, Minnesota was adamant in saying, “Bottom line is this is a very simple strategy for people with atrial fibrillation. They must lose weight.” He went on to say that weight loss should be considered and tried before a patient is sent for an ablation procedure.

It is important to note that this study is an observational study and did not actually prove that losing weight caused atrial fibrillation to disappear. A further study is underway to prove this point. The article additionally did not specify if the researchers discontinued anticoagulants in the weight loss group no longer exhibiting atrial fibrillation.

Brown Fat Injections Reverse Weight Gain in Obese Mice

Overweight, Belly, ManThere is hope for those of us battling weight gain and obesity. An article appeared this week in the journal Endocrinology discussing the research of Wanzhu Jin, PhD, of the Chinese Academy of Sciences involving weight loss and reversal of Type I diabetes. Researchers are well aware of the different types of lipid or fat in all mammals. Brown fat or brown adipose tissue has been felt to have protective effects against weight gain, lipid abnormalities and glucose metabolism problems.

Dr Jin, used mice that were genetically engineered to be overweight or fat. He injected them with a quantity of Brown Adipose Tissue (BAT) and these mice lost weight and improved their glucose metabolism into the non-diabetic range. The success in weight loss and sugar control was felt to be due to the BAT increasing the energy expenditure of the genetically altered mice. The sugar control occurred through similar mechanisms and was unrelated to the production of insulin or insulin metabolism. Dr Jin’s team of researchers felt that the transplanted brown adipose tissue activated and enhanced the BAT already present in these obese mice allowing it to produce the weight loss and improvement in glucose and lipid metabolism. Their research seemed to hint that brown adipose tissue actually acted as an endocrine gland like the pancreas or adrenal gland or thyroid gland, secreting substances that improved metabolism of obese mice.

Dr Jin’s work will provide an incentive for human researchers to look at brown adipose tissue and its modulation and enhancement as a way to control human obesity and diabetic epidemic in the future.

Physical Therapy as Effective as Surgery in Lumbar Spinal Stenosis

Physical TherapyAnthony Delitto, PT, PhD and colleagues at the University of Pittsburgh published an article in the April 7, 2015 Annals of Internal Medicine documenting that at the two year mark, physical therapy was as effective as surgical decompression in spinal stenosis of the lumbar spine. The study involved 169 patients diagnosed with spinal stenosis with imaging confirmation by either CT Scan or MRI. These patients all met the accepted criteria for surgical intervention, all had agreed to and signed consent for surgery and all had leg pain with walking (neurogenic claudication). None of the patients had previous back surgery.

After all had consented to surgery they were randomly assigned to a surgical group or a physical therapy group that had exercise sessions twice a week for 6 weeks. They were then followed for two years. The physical therapy exercises included general conditioning plus lumbar flexion exercises.

All the participants charted their course with a self- reported survey of physical function which consisted of scores from zero to 100 on topics such as pain, function and mental health. The patients were all reassessed at 10 weeks, 6 months, 12 months and 24 months.

There was no difference between the surgical group and the physical therapy groups in the category of physical function at any time during the follow-up. Despite this 47 of the 82 patients assigned to the physical therapy group crossed over and had surgery with nearly a third in the first ten weeks. Patients crossed over to surgery for both medical and financial reasons citing the high cost of copays for physical therapy. Jeffrey Katz, MD, director or the Orthopedic and Arthritis Center at the Brigham and Women’s Hospital in Boston felt that the paper “suggests that a strategy of starting with an active, standardized physical therapy regimen results in similar outcomes to immediate decompressive surgery over the first several years.”

This paper gives us excellent data on the belief that surgery of the back should be a last resort. Since it doesn’t follow the patients for more than two years it is hoped that continued follow-up over time will allow us to see the real life situation we see in our patients who live with this condition for decades not months.

Addendum: “Why You Can Not Find a Doctor to Accept Medicare”

Center for Medicare ServicesOn April 14, 2015 the Senate, having returned from a recess, voted to repeal the SGR initiative thus halting a proposed 21% minimum payment reduction to health care providers (physicians). Under the new legislation sent to President Obama for approval, doctors will receive between a 0.5% to 1% annual increase in reimbursement through 2019. The measure proposes alternative pay structures which are designed to reduce overall health care costs and rate of health care cost growth. They involve paying one large entity which would then dole out pre-negotiated payments to its members delivering the services.

The American Medical Association as well as specialty medical and health groups are hailing this as a major victory for doctors and patients. I see it a bit differently.

Since 1977 the Congress of the United States has held practitioners at loaded gun point always threatening to reduce physician reimbursement without reducing physician costs or bureaucratic burdens in the least. Generations of policy advisors and elected officials have created a level of mistrust and uncertainty between themselves and providers while always painting the health care delivery teams as greedy money craving individuals more interested in their personal gain than the health of their patients. The result is that for years doctors have left the Medicare system and or retired early.

The current annual increase of up to one percent is accompanied by additional bureaucratic requirements having little or nothing to do with the doctor patient relationship. One percent will not keep up with the cost of inflation or the additional costs involved to meet the bureaucratic new requirements of CMS and policy wonks.

To hail this as a victory is like trying to sell Custer’s last stand at the Little Big Horn as a victory for the US Cavalry. The net result will be the destruction of small private practices, the growth of concierge medicine and the growth of enormous conveyor built corporate medical groups where patients are a product not a human individual.

Electronic Health Record System Down – Observations

EHROn Monday March 30, 2015 our Greenway Prime Suite electronic health record had a system wide failure at the level of the Edgemed Computer service center in New York State. It meant that I was back to using pencil and paper to interview patients and record the answers and physical findings. With much trepidation I began seeing patients with two sheets of white blank paper on a clipboard and my trusty BIC pen. To my surprise the sessions went by with ease. I was able to make much better eye contact with my patients, listen a bit closer and jot down the pertinent positive and negatives of the session to later enter into the computer record. My office visits are scheduled for 45 minutes each for routine follow up sessions and you need every second to be comprehensive and thorough and to check all the boxes and requirements imposed by government bureaucrats to comply with Meaningful Use and PQRS and Core Measure requirements. I found that without the computer it took at least ten minutes less time to see a patient and the visit was far more personal than with the magic box working.

Computerization was forced on physicians by the ARRA 2008 Congressional Law proposed and encouraged by the Bush administration to stimulate the economy and orchestrated further by the Obama Administration. Government grants and funds were set aside to computerize medical records, make the records more transparent and have data freely transmittable and reviewable from one system to the next. ARRA 2008 created a high tech committee which was funded at an extraordinary high salary level and staffed with the CEO’s and chief executives of the major health software manufacturing firms. If this sounds like asking the foxes to guard the hen houses you are beginning to get the picture. Their greed and self-serving interests led to multiple companies, with multiple products for sale most not designed or reviewed by practicing clinicians. Initially they were unable to communicate with any other competing systems and for the most part they still cannot. Interestingly when the 2014 Congress failed to refund the grants to the high tech committee this past session the CEO’s who ran it all resigned leaving the program rudderless.

The doctors and hospitals were promised a carrot at the end of the stick if you followed the ever changing rules but there was a financial penalty and reduction in reimbursement if you did not comply. The financial reward at the end of the stick in no way compensated an office for the work and trouble involved and was nowhere near the level of rewards the CEO’s who staffed the high tech committee actually received.

The computer software was supposed to be transparent and talking to each other by 2015. If this happens by 2020 it will be a true miracle. Yes the computer software corrects for illegible handwriting but not much else. Its costly, time consuming, expensive to maintain and it’s still difficult with the generic templates being used to determine if the patient the note is talking about looks like Haystacks Calhoun or Twiggy.

The system glitch was over by 4:00 p.m. that day and it took me about 3 hours to enter the patient visits into the system. My wife wondered why my “staff” couldn’t enter the data, but the vendors have not trained them for that function. So on Tuesday March 31, it is back to touch typing and computerized records so that the next President of the United States at his State of the Union Address can brag about how computers have brought down the rate of growth of spending on health care.

Why You Can Not Find a Physician Who Accepts Medicare

CMSSGR (sustained growth rate) is a policy and law put in place by the U.S. Congress signed into law four Presidential administrations ago and kept in place year after year by our non-creative elected Federal officials. It was designed to keep the costs of health care growth down by reducing payments to providers if they exceeded the health spending budget for the previous fiscal year. The problem is that health care spending has climbed continuously and it has never stayed within the budgetary guidelines legislated by Congress.

After the first year of the law the General Accounting Office noted an 8% increase in health care spending above the budgeted amount. Congress was supposed to reduce health care payments to providers by 8% the next year, but the providers howled about an 8% reduction and the President and the Congress backed down. Instead of a reduction they gave providers a cost of living increase. The GAO showed that the increased spending was not due to physician pay increases or physician generated costs but due to increased usage and expense in areas outside provider control. Every subsequent year since the SGR became law, the Congress has backed down and granted a miniscule increase instead. The difference between what was budgeted and what was actually spent has accumulated from year to year and each subsequent Presidential administration and U.S. Congress has been reluctant to correct the SGR because the monetary difference would appear on their administration’s balance sheet and legacy. That continued until the Affordable Health Care Act (Obama Care) passed and signed into law before anyone who voted on it actually read it, made correcting the SGR part of the law.

On January 1, 2013 the SGR was due to be repealed by Congress and health care providers were due to receive an 18%- 45% reduction in fees for services. Congress kicked the can down the block until January 1, 2014 and again until December 31, 2014 when Obama Care made the reduction mandatory. The last Congress kicked the issue down the road until April 15, 2015. They were supposed to settle the issue before their spring recess but they adjourned for the spring recess with promises of passing new legislation upon their return on Monday April 13, 2015. That was yesterday when Conservative Republicans announced that after two weeks of consideration they had major problems with provisions of the legislation they had agreed to pass before their spring recess. Their delay will go beyond April 15th.

The Centers for Medicare Services or CMS decided simply to not process any bills or make any payments to health care providers until Congress makes up its mind. Since April 1st they have paid no one except themselves. If no legislation is agreed upon by midnight tonight, CMS will begin processing payments to providers retroactively to April 1, 2015 with a minimum 21% reduction in fees compared to the 2014 payment rates. Physicians are reacting just as expected. Many have decided to no longer see Medicare patients. Those that do see Medicare patients will require payment for services by cash or credit card at the time of service with payments up to 115% of the 2014 Medicare allowable rate for that service. Many will leave the Medicare system entirely.

Our office will continue to see Medicare patients at the current time under the existing payment systems and we will give this Congress an opportunity to fix the problem. When we refer you to specialty physicians we have no way of knowing who will be seeing Medicare patients and who will not. We suggest you ask that particular office before your planned visit so there are no surprises at the check in check out window.

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