Free Choice of Physicians & Fee for Service Medicine Ending?

The Medicare Payment Advisory Commission is a panel of financial, economic and health policy advisors created by Congress to advise CMS (Center for Medicare Services) and Congress how to pay physicians, health care providers and facilities for services rendered. According to an online article on MedPage they are close to eliminating fee for service payments for health care. CMS has encouraged alternative delivery methods for years. For the most part this has resulted in hospital and health care systems buying up and employing doctors, mid-level providers being substituted for more highly trained doctors and these alternative systems covering care only with their panel of providers and diagnostic and treatment centers.

However, publicized figures have shown these Medicare alternative products actually cost more per patient per year than traditional Medicare. This particular article claimed a 1-2% savings.

We all see the ads for Medicare Advantage plans which, in addition to no co-pay and no deductible, provide for dental care, vision care, eye care and exercise and gym memberships. Apparently 50% of the Medicare population is now enrolled in such a program.

As a 69 year old individual paying into the Medicare system for the last 55 years I see the benefits and cost savings for seniors when they are healthy. What happens however, when you become ill? Clearly the Centers of Excellence for many of the ailments seniors contract are geographically and contractually outside the narrow networks and panels these private insurance companies run and the Accountable Care Organization run plans provide.

If I do not have coverage for the Mayo Clinic or MD Anderson Cancer Center or the Cleveland Clinic or Dana Farber Cancer Center or Johns Hopkins Medical Center then have I wasted 55 years of payments? Do I really want a nurse practitioner in south Florida directing my care off a protocol list of contracted providers or do I want a clinician who sees a dozen cases of this disease per week calling the shots?

I prefer the latter but may not have a choice but to pay out of pocket if MEDPACs recommendations are accepted by CMS and Congress and become law.

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Joint Commission Inspection and Data Entry Duty for the Doctors

I received an email from our hospital Accreditation Coordinator/Quality Coordinator in a manner that wasn’t clear if it was directed to me personally or if it was sent to the entire medical staff.  It said that she was reviewing the Joint Commission Accreditation of Hospitals recent survey which found that the charts did a poor job of reflecting the patient’s “Code Status”.  The institution only received a 40% rating.

Some patients were listed as “Do Not Resuscitate” (DNR) but did not have the yellow State of Florida DNR Form on the chart.  Some charts had the DNR form but the physician, in a progress note, had incorrectly indicated that if the patient’s heart stopped beating, or they stopped breathing, that the patient was in fact a “Full Code.”   Of the 25 charts reviewed only ten were in full compliance.

For some reason I took this email very personally.  In my practice I take the time to discuss end of life issues with all my patients who are at an age, or have issues, that make one believe they may face a catastrophic cardio- respiratory arrest in the future.  When I have the discussion with the patient and family, I present them with a large yellow State of Florida DNR form. The large top half and small detachable bottom half are identical. The patient is supposed to fill both out, with the physician signing both.  We photo copy the form and scan it into the patient chart while listing DNR Status on the electronic health record face sheet for all to see.  The patient is supposed to place the large yellow upper half on their refrigerator while carrying the smaller wallet sized version in their wallet or purse.

Most of my patients get to the hospital through the emergency department by self-referral. Sometimes they call us first but most times they call 911 or go themselves.  Most situations involve unexpected falls and trauma or pain from a chronic source.

When I am called by the ER staff the patient has been registered in, insurance has been checked, medications have been reviewed, as have allergies to medication, and the patient has been evaluated by nurses and physicians.  The patient’s record is a mix of paper documents and electronic health records.  The hospital recently instituted a new electronic health record system with inadequate staff training and support (in my opinion) with decisions for financial reasons.  The result is that most clinicians are constantly searching for information and not quite sure where all of it is.  There is still a loose leaf binder type shell for some daily paper information such as the EKG rhythm strips created on the telemetry monitors.  Where a State of Florida DNR form is kept is anyone’s guess.  I took the electronic health record training course on line and the two in person events. At no time did they discuss entering a code status or show us how to enter this data.

It seems to me that the question of a patients “Code status” is something that should be asked at registration in the ER and at elective pre admission. All patients should be considered a full and complete code unless they say otherwise and can produce the documentation needed. If they are not carrying the documents with them then the document should be re-executed and signed at the registration desk by the patient or their legal health care surrogate. When their physician shows up to admit them the document should be on the chart, filled out for us to see.  I can access my office patient files at the emergency department from my iPad but, due to lack of interoperability between electronic health records in the office and in the hospital, I have no way to print out the document from my office electronic health record while I am at the hospital.

If end of life issues have not been discussed with the patient prior to hospitalization, I have no problem beginning the conversation when the medical condition they are there with has been addressed and stabilized.

It turns out that the email was addressed to the entire medical staff and not directed at me alone.  None of the 25 charts reviewed by JCAHO were mine.  If administration wishes to fix the problem it needs to make sure its employed clerical staff are trained to ask the right questions and list the answers where the doctors and nurses can easily see them and interpret them and act on them if necessary. Don’t ask caregivers to be data entry clerks for JCAHO or anyone else.

Leave us free to provide health care.

Tdap Booster Vaccinations

Several years ago an epidemic of whooping cough (pertussis) was ongoing in affluent areas of California and Arizona. Epidemiologists from the Center for Disease Control (CDC) and National Institute of Health (NIH) descended on those areas to determine the cause of the life threatening illness to very young children.

Much to their surprise, grandparents were inadvertently transmitting it to their new and not completely vaccinated grandchildren. As youngsters, these grandparents took the suggested DPT series of shots believing they were resistant to diphtheria, pertussis and tetanus for life.

Like most things, as we get older, the immune system just doesn’t work as well. The immunity to pertussis waned and adults were catching the adult version of whooping cough in the form of an upper respiratory tract infection with bronchitis. The adult version resembled a run of the mill viral upper respiratory tract infection with a prolonged barking cough. This was just the type of infection which infectious disease experts were suggesting we do not treat with antibiotics and instead let our immune systems fight off independently. Unknown to us was the fact that even after we stopped coughing, if this was in fact adult whooping cough, we could transmit the pertussis bacteria for well over a year after we stopped coughing.

The solution to the problem was to give these adults a booster shot against pertussis when they received their tetanus shot booster. It is recommended that we get a tetanus booster every seven to ten years.

Tdap, produced by Sanofli Pasteur, was the solution and an international campaign of vaccination was begun. The campaign was successful but what do you do seven to ten years later when the next tetanus shot is due? In a study sponsored by the manufacturer, adults 18- 64, were given a second dosage 8-10 years after the first Tdap shot and tolerated it very well. Blood levels for immunogenicity taken 28 days later showed the benefit of the second shot.

The data has been submitted to the CDC and its vaccination Prevention Advisory Panel for consideration for a change in the recommendations on vaccinating adults.

Marijuana, Pain Relief and the Facts

On a daily basis patients of mine come in for office visits complaining of wear and tear injuries, as well as aches and pains, and their methods of dealing with chronic pain. As we all know, aging is a part of the normal life process.

For instance, as we approach 70 years old we typically lose three quarters of our functioning kidney cells (nephrons) but do well with our limited reserve as long as we do not constantly call on that reserve. When we take nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen to relieve pain we are challenging that reserve leading seniors to look for alternatives. Opioids, even when appropriate, have become taboo so alternatives are being searched for.

Medical marijuana has become a very hot topic recently.  It is being heavily marketed as a pain relief alternative in several forms.  However, what little legitimate research has been conducted indicates it is not very good at relieving non cancer related chronic pain.

Not a day goes by when several patients reveal they are using cannabis products obtained out of state for pain relief with no consideration of how it interacts with the medications they are already taking. Recently, strong public relations campaigns for legalizing medical marijuana have led to its legalization in different forms, in various states, even if it doesn’t work. A select group of investors have positioned themselves to make vast sums of money from a product with little documented upside and potentially unknown downsides.

At the same time that medical marijuana enters mainstream medicine there is a similar legislative and marketing push to legalize marijuana for recreational use. Once again, a well-financed lobby of investors is trying to sell the concept of marijuana being less troublesome than legalized tobacco or alcohol. In the last few weeks there have been several articles appearing in reputable medical journals and periodicals such as the Wall Street Journal, New York Times and New Yorker magazine all examining the known results of liberalizing marijuana use in three states.

First of all, today’s marijuana is far stronger and potent than the “love generation’s” weed of the 1960’s with a higher percentage of the hallucinogen THC. To that point, states that have legalized marijuana have seen a tripling of visits to the emergency department for psychotic behavior. Also, violent crime and murders have tripled in many jurisdictions. A growing body of evidence indicates auto accidents have increased as a direct result of marijuana’s use.

Medically speaking, there is little research evaluating marijuana as a drug. Many questions remain.  What is the minimal dosage to create an effect? What is the dosage that can cause medical illness? How does the mechanism of delivery affect the final effects such as smoking versus vaping versus eating the product? Beyond the stoners’ credo of “start low and go slow” there is little data to evaluate the product as a pharmaceutical drug and or how it can interact with other drugs prescribed for you.

I am far from an anti-marijuana critic. I’d just like to know what I’d be getting in to before I consider hallucinating. It seems to me that before we liberalize marijuana use, the product needs to be put through the type of research and scrutiny the old Food and Drug Administration (FDA) put a product through before it was approved for public use.

The Florida Legislature and Florida Medical Association Making Docs the Fall Guys

I wrote and mailed my annual $250 check to the Newborn Injury Compensation Act (NICA) fund today. In 1982-83, when there was a medical malpractice crisis and no physician could get insurance to practice, the Florida Medical Association (FMA) cut a deal with the trial lawyers and our elected officials to form NICA. Every physician, regardless of specialty, is required to pay $250 annually into this fund to cover the cost of injuries to newborns. Obstetricians pay $5,000 annually.

In exchange for making the social problems of the state the responsibility of Florida physicians alone, the legislature passed some changes to the medical malpractice laws which encouraged insurers to return to and start writing policies in Florida. Isn’t it time for the State of Florida and its citizens to assume their responsibility for providing reproductive education and prenatal opportunities to women of child bearing age nearly 40 years later? Why does it remain my responsibility as a physician to continue to fund this entity? The FMA thinks it is still a good deal and will not discuss lobbying for a change.

Recently I attended one of many continuing education courses mandated by the elected officials in Tallahassee. It was on prevention of medical errors. It’s the same course I took two years ago and two years before that. Most of the errors are surgical and do not apply to me. The others are communication issues.

I have proposed over and over to my hospital’s chief medical officer and medical staff that we form a medical staff communication committee to facilitate doctor to doctor, and doctor to staff, communication to improve patient safety and care. Time after time they turn a deaf ear to the suggestion yet they host the medical error meeting yearly.

They also host the Domestic Violence lecture yearly. It too is mandatory for license renewal in Florida. The same message is delivered every year. “If the assault is made with a knife or gun call the police because they can do something. If a weapon is not involved your only option is to recommend counseling and safe shelters.” The Legislature has done nothing to toughen domestic abuse laws but they make us sit through the lecture every two years.

I have the same message for the legislature, the FMA and the Florida Board of Medicine, “You can kiss my grits!”

Wasting Taxpayers Money, Medicare Advantage and the RAC’s

My wife and I try to catch up on TV shows on Thursday evenings. We sit down with a cup of decaffeinated coffee on the couch together petting our dogs and watching mindless entertainment after a day at work. Now that the election is over, almost every commercial in my South Florida market is an advertisement for a Medicare Advantage Health Plan. We are nearing the completion of the “open enrollment” period between October 15 – December 7 when senior citizens can change their Medicare Part D Prescription Plan to one that covers their formulary of medicines and they can choose to leave the Medicare system and join a private health plan for a capitated Medicare Advantage Plan. These plans were initiated by the Center for Medicare Services (CMS) as a way to save money on the health care of seniors. The theory was that if they offered a product with a fixed monthly and yearly cost budgeting would be simpler and at least they would know what they are paying.

These programs are run by private insurance companies such as Humana, Blue Cross Blue Shield, and Aetna. Over the years, research has shown that they now cost the Medicare system more money per year, per patient, than the traditional Medicare system. The private insurers are probably making a great profit on this program because the money and energy spent on advertising to attract patients is relentless. I have been receiving multiple daily promotional letters in the mail for weeks now. Full page ads are run daily in major newspapers and magazines. Prime time television is filled with expensive ads with noteworthy spokespersons like basketball hall of famer Ervin “Magic” Johnson in addition to actors, actresses and former elected officials.

The insurers make their money by rationing and denying care provided by doctors and hospitals which agree to see patients in volume for a discounted fee. Patients have no deductibles; have no out-of-pocket expenses for physician care or generic pharmaceutical products if they stay in network. If they happen to get sick out of the service area, coverage is spotty and varies by program with the advice truly being “buyer beware.”

It seems to me that if these programs are actually more expensive per patient than traditional Medicare then why is CMS continuing them and allowing the millions of dollars spent on advertising to attract patients to continue? The information they need to choose a plan is available on the easy to use http://www.Medicare.gov website at no cost.

I open some non-critical advertisement mail as well. One letter from the Center for Medicare Services addressed to me personally as a patient, not as a physician, was extremely interesting. In December 2014 I was involved in a serious auto accident with my vehicle totally damaged due to the negligence of another driver. I was taken by ambulance to the local emergency room, examined, treated and released. At the time I was 64 years old and several months short of being eligible for Medicare. My auto insurance paid my medical bills. My private insurer Blue Cross Blue Shield was not billed.

The letter from CMS was a form letter saying that a claim from December 2014 had been investigated by them and although no payment was made on this claim, which was paid by Traveler’s Insurance (my auto insurer), they were now referring it to the Recovery and Audit Division for further investigation. The threatening nature of the letter suggested that if I was compensated by Medicare for this claim I would be required to pay back the money with interest and penalties. Considering I was not yet on Medicare, and considering the charges were billed by the local hospital health system, I am not quite sure why the letter was generated and forwarded to me?

Once again a government agency is spending taxpayer money on a frivolous item. How many more of these letters go out yearly at our expense?

The second letter I opened was from Social Security. It said that since I was still working and generating income, my wife and I would be required to each pay an additional fee per month for our Medicare health insurance and for our Medicare Part D prescription drug plan. This is in addition to the tax on my salary that goes directly to Medicare. I have been paying this tax on each paycheck since I started working at age 14 (I am now approaching 69). I read this letter just after hearing one of our elected officials to the Senate refer to Medicare as an “entitlement program.”

My Medicare bills now approach what private insurers charge patients for health insurance. I paid into this system for 51 years before I became eligible to use it. I hardly think the Medicare system is an entitlement.

Patient Safety and the Joint Commission

Two of my local hospitals just invested $3 – $4 million dollars in preparation for an inspection of the facilities by the Joint Commission on Accreditation of Hospitals (JCAHO). The cost of the inspection runs in the $10 million dollar range after the preparation costs. The inspection is a high stress situation for the administration because if you fail, or lose your accreditation, the private insurers will void their contract with you and you won’t get paid for the work done.

Medicare through the Center for Medicare Services (CMS) is preferential to JCAHO so much so that they perform 80% of the inspections of hospitals in America. When JCAHO was initially formed it was in response to poor care in small private hospitals in non-urban nonacademic centers. They cleaned that up.

The current version uses up a great deal of money, creating a legion of hospital administrators running around with clipboards and computer tablets without making any meaningful dent in mistakes and outcome results. In a recent study published in the British Medical Journal the outcomes and re-admissions rate for the same problem within 30 days of discharge were compared at hospitals which rely on state surveys of quality and safety as opposed to the JCAHO ten million dollar survey. They found that there was no statistically significant difference.

In a related report hosted by the journal Health Affairs, a review of the 1999 report of the National Academies of Sciences, Engineering and Medicine entitled, “To Err is Human, Building a Safer Health System” was discussed. That controversial report claimed that 44,000 to 98,000 deaths per year occur due to medical errors. They discussed the work of Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. Her research looked at safety at 535 hospitals in four large states between 2005 and 2016. She called the results disappointing noting improvement based on suggestions in the 1999 report in only 21% of the hospitals surveyed and worsening in 7%. Most of her work involved the staffing and role of nurses which is critical to the quality of the care an institution provides.

Staffing or the ratio of patients cared for per nurse per shift is a critical component of safe patient care. Once a nurse on a non-critical care unit is asked to care for more than four patients the time spent at the bedside nursing diminishes. You cannot recognize problems, complications or changes in your patient’s condition if you are not spending time with them.

It seems to me as a clinician caring for patients in the outpatient and inpatient setting for 40 years that the more time nurses get to spend with patients the better the patients do. Maybe it’s time for government to separate the insurer’s ability to pay hospitals and JCAHO accreditation. Maybe the millions of dollars spent per inspection would be better spent on hiring more nurses per shift plus giving them the clerical and technical support they need to spend more time and care for their patients?