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!”

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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?

Bureaucracy, High-tech and a Day Rounding at the Hospital

We have a new electronic medical health record system at our hospital. It was introduced with what I believe is a short and ineffective training program for physicians followed by a far too short on-location use of experts to help the doctors and nurses learn the new system. It is frankly a pain in the neck to access the computer from outside the hospital due to the multiple layers of security and passwords you must use. It is simpler and less complicated at the hospital but the request for frequent change of the password for security purposes makes remembering the password problematic for me especially when I am sitting in the ER at 2:00 a.m. sleep deprived and wanting to get home.

On an average day the computer adds a minimum of 10 minutes of work per patient seen. We have electronic health records to comply with the massive number of Federal mandates requiring it and; to avoid the financial penalties for not complying. The Feds offered each hospital an 11 million dollar incentive for putting in these systems which made their decision to computerize far simpler.

Recently, when I made rounds and attempted to access the computer, a brand new screen greeted me. On the left-hand side it instructed me to tap my ID badge against the screen for an automatic log in access. On the right-hand side was the traditional log in screen.

I must be fair and admit the hospital did notify staff to stop by the Medical Staff Office to be issued a new ID badge which would provide easy access to the system. Since that office opens at 8:00 a.m., and I am usually there earlier than that, I had not yet picked up my new badge. So I used the right-hand side of the screen and accessed it the traditional way typing in my User ID and current password. A swirling circle appeared and swirled for three minutes. Then another screen appeared for two minutes. By this time I was annoyed and frustrated.  A kind nurse noticed my frustration and told me that when you attempt to log into the new screen the first time, it takes about 10 minutes to be logged onto the system. I sat patiently until finally I was let in.

The delay in access pushed me back 10 minutes.  By the time I finished rounds it was 8:00 a.m. I stopped by the Medical Staff Office on the way to my office and asked for my new ID card. I also asked if I could keep my old ID card as well because over the last 40 years I had become attached to it. We needed that ID card to swipe our way into the parking lot, into the building and onto the elevators and certain hospital floors and units.

I was told I needed to keep my old ID card as my new card was to be used only for computer access. It would not get me into the parking lot or the building or special floors and units. They gave me a fancy new ID card holder that accommodates two ID cards.

That’s the high-tech world’s idea of efficiency and progress – I suppose!

Commercial Air Travel is Really Safe

For the last 25 years I have had the privilege of being a designated airman medical examiner by the Federal Aviation Administration. To earn that privilege, it required flying to FAA headquarters and taking a one week training course followed by refresher training material every three years.

The FAA grades medical examiners annually by our judgment and decision-making. The nature of the questions we are required to ask the pilot candidates, and the exam, have been dictated by the rigors of being a pilot and reflect the stresses unique to flying a plane safely. Many of them were created after a plane crash, fatality and the resulting National Transportation Safety Board (NTSB) investigation revealed a health reason involved in the crash.

I attended my refresher course in Washington, D.C. this past week over a three-day period. Physicians designated by the FAA fly to the event and stay at their own expense. By law, the FAA is not permitted to pay for food, coffee or any expenses. Over 50% of the attendee physicians are pilots who fly to the conference in their own private planes. There are about 2,800 physicians performing these exams around the world and, judging by the grey hairs, and canes in the crowd; they are getting significantly older reflecting the same process in the physician population in our country.

This was the first time I attended this meeting and I saw a significant number of women physicians in the audience which makes me believe there is diversity in the physician examining population as well. The speakers on medical topics are first rate. We heard from leading doctors at the best places, all leaders in aerospace medicine and research in cardiology, neurology, psychiatry, otolaryngology, ophthalmology, fatigue and sleep medicine. I learn a great deal of general medicine to bring back to my medical practice medicine at these sessions.

Performing FAA exams for pilots is not a particularly lucrative proposition. You see 3 classes of candidates including the commercial pilots for class 1 exams, navigators for class 2 exams and general aviation or civilian private pilots for class 3.

As our pilot population continues to age, domestic airlines are now retiring them at age 65. If perfectly healthy, a class 1 pilot starts getting EKGs annually at age 39 and they are then seen every six months at a minimum. The exam and paperwork takes 45 minutes at least and must be transmitted back to the FAA by computer. If you detect a problem either by your taking a history, or performing an exam, there is a further investment of time and research to provide the FAA safety experts with the medical records they need to determine if the pilot is healthy enough to safely fly a plane.

I would say the vast majority of examiners charge only $175 or less for these exams. Try getting that time, attention and value when you go to most physicians for an exam.

The reward for being a designated airman medical examiner is being part of a team that keeps the skies safe for the flying public. Seeing accident and mortality rates decrease year after year brings an extraordinary sense of satisfaction. I get to work with extraordinarily talented and dedicated employees of the FAA, from the staff at my Regional Flight Surgeons headquarters in Atlanta, and the professionals in Oklahoma City and D.C. who read, train and study so when I fly from place to place, I arrive there intact after an uneventful flight. There you have it. Commercial air travel is really safe.

Consumerism and Convenience Gone Wild in Health Care

I have received several phone calls in the last few weeks from young adults requesting information about their last vaccinations. They are travelling to areas of the world that suggest or require certain vaccines and do not remember if they had them or not. Others are applying for positions of employment which require travel and the employer’s human resources department needs the patient’s updated vaccination records.

When we tell them that we only have a record of the vaccinations we have given them in the office they act surprised. “You mean XXX hasn’t sent you a copy of my tetanus booster shot?” Others inquire if the travel health service they went to sends us a record of the vaccines they administered. The answer is “sometimes”.

The State of Florida instituted a website called Florida Shots for immunization records a few years back which is incomplete at best. At one time you received all your vaccinations and immunizations in the doctor’s office and a record was then maintained.

In the new world of consumer convenience first, pharmacies are paid by insurers for administering vaccines while the same shot given in your doctor’s office is not a covered service. In some cases, we have the childhood vaccination records from a pediatrician and a college health form updating us on meningitis and hepatitis A and B vaccines. Those adults out of college for more than seven years who do not have a copy of that form are just out of luck. This is a prime example of consumerism and convenience gone wild for no good reason

Another example is the creation of the BasicMed program allowing non-commercial pilots to obtain a medical certification to fly instead of going to a highly trained certified FAA Airmen Medical Examiner Physician (AME). If you have a driver’s license and pilot a plane for 6 or less passengers, which will not fly faster than 250 knots, or ascend above an altitude of 18,000 feet; you can go to any doctor with your driver’s license and be certified to fly.

Why would a pilot go to BasicMed rather than to a trained and certified and recertified physician in aerospace medicine? Probably because they are concerned that the trained physician will not pass them based on their health and the non-certified doctor will either go easier on them or just miss the problems that an AME might investigate.

 

This law was the result of lawsuits against the FAA by pilots not meeting the standards and resulted in Congress passing this private pilot friendly law. In recent years, expensive private flight schools have become the pathway for a student to eventually become a commercial airline pilot. They are replacing the previous pathway of hiring former military pilots who are more experienced, more disciplined and usually older and more mature than flight school candidates. This new breed of air transport pilot will now be sharing the skies with private civilian pilots receiving their medical clearance from less physicians with less aerospace medical knowledgeable. Is this not also convenience and consumerism gone wild?

Prostate Cancer, Digital Rectal Exams, PSA and Screening

The PSA blood test, to detect prostate cancer, clearly has saved lives according to numerous studies. The United States Preventive Task Force (USPTF) recognizes this but has decided that screening for prostate cancer is not a great idea in men aged 55-69. They point out the PSA can be elevated from an enlarged prostate, an inflamed or infected prostate, a recent orgasm while having sex and other causes.

Elevated PSAs led to trans-rectal ultrasound views of the prostate and biopsies of the prostate. These biopsies were uncomfortable, even painful, and often followed by inflammation and infection of the prostate. Many times the prostate biopsy was benign with no cancer detected. The USPTF felt the cost, worry, and potential side effects were a risk far outweighing the benefits of screening. They consequently came out against screening men in this age group.  Naturally this position produced a tidal wave of criticism from urologists and other.

So, the USPTF has produced new recommendations calling for patient education and making a shared decision whether or not to obtain a PSA measurement before you send it out. This is a bit confusing because we always discuss the pros and cons of a PSA before we draw it. Adult men are entitled to hear the pros and cons so they can make their own informed decision.

To complicate matters, a study out of McMaster University in Canada reveals physicians are poorly trained in performing a digital rectal exam. They cite the lack of experience coming out of school and going into training and cite numerous research studies showing a rectal exam is a low yield way to detect prostate cancer. They do not recommend performing digital rectal exams for prostate cancer screening.

This received much media hype and the blur between the efficiency of detecting prostate cancer via a rectal exam and the use of the rectal exam to detect rectal and colon disease has been lost. We perform digital rectal exams to detect prostate cancer and look at the perirectal area for disease. We test the strength and performance of the anal sphincter muscle. We feel for rectal polyps and growths and, in certain situations, test the stool for the presence of blood.

During my internal medicine training my teachers always required a digital rectal exam, stool blood test and slide of the stool as part of the exam. As trainees, we realized the invasiveness of the exam and did our best to be polite, gentle and caring. I always asked for permission first, and still do. How can you tell if something is abnormal if you haven’t performed normal exams?

Last but not least, Finesteride, a medicine used to shrink an enlarged prostate by inhibiting male hormones, has finally been shown to be protective against developing prostate cancer. A study published in the journal of the National Cancer Institute found that men taking it for 16 years had a 21 % lower incidence of prostate cancer.