Changes in Florida’s Prescribing Medication Laws

In their ultimate wisdom, the Florida Legislature has decided that all medication prescribing shall be done electronically by computer beginning in January 2020.  As of November 1st, the Florida Medical Association has not informed its members of this but it was discussed briefly at a hospital staff meeting.

We were told that most pharmacies will no longer honor paper written prescriptions.  My office electronic health record system, which slows down seeing patients remarkably, has had electronic prescribing software which we have used for several years now.  The big change is that we will now be required to order controlled substances online electronically when in the past it was not permitted.

Since the opioid crisis struck Florida, physicians have been required to create an account with the State’s narcotics hotline named E-Forsce and check out the recipient prior to prescribing controlled substances for pain.  We then issued a written prescription.

It never made sense to me why if one is trying to track narcotic prescribing it wasn’t being done on computers from the beginning?  Nonetheless, this is a change which will require prescribers to download additional software and use two methods of identification as the legitimate prescriber before you can actually prescribe for your patients.

It will give you the freedom to prescribe from your phone or tablet when out of your office which is a convenience not available in the last few years. It will however mean more time in front of the computer screen, more user names and passwords to remember and less time actually listening, talking and communicating with patients.

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.

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!”

Dealing with Pain Physicians Should not be so Painful

The State of Florida is trying to eliminate medical practitioners and facilities which prescribe narcotics freely without doing the proper evaluations. These pill mills sell drugs for cash and the resulting overprescribing of oral narcotics has flooded the streets of Florida and nearby states with oral pills leading to increased opioid related deaths and trips to the emergency departments for drug overdoses. The frenzy has been fueled by “blue ribbon physician panels” discouraging the use of nonsteroidal anti-inflammatory drugs for pain in favor of narcotics. The Florida Legislature responded by passing draconian legislation that separated opioid pain prescribing into acute prescriptions which all physicians may prescribe and chronic prescribing. For chronic prescribing health care providers must take a course and check a special box on their licensing reapplication form every two years. Pharmacies are coming under scrutiny for providing refills of short acting narcotics for pain when they have been refilled well past the 8 week suggested limit on these medications, even if the prescription is appropriately written by a legitimate physician. The pressure on the pharmacies by the state and law enforcement has led to a policy of not stocking narcotics or filling narcotic prescriptions at many Florida pharmacies. Sick patients with well documented sources of pain and legal prescriptions search endlessly for a pharmacy to fill their pain medications.

The Florida pain law encouraged the growth of pain specialist doctors especially anesthesiologists, rheumatologists and psychiatrists. I treat an elderly population of chronically ill patients many with severe long term chronic back, hip and joint problems. They arrive at my practice with a history of long term use of nonsteroidal anti-inflammatory medications for pain relief and many are using opioid narcotics for years. When referred to many of the pain specialists they are integrated into a conveyor belt type operation using injections of medications into joints, physical therapy with very little attention paid to the patient’s medical history. Most of the pain doctors prefer using injection techniques rather than working with oral or injectable medications, physical therapy, counseling or any of the alternative therapies.. The patients receive their series usually of three shots into an area of the body and then are expected to be able to tolerate their pain. The problem is that during the series of injections and after the series of injections, if the pain relief has been incomplete or inadequate, there is little time set aside to discuss what to do when it really still hurts. The result is that the patients call a doctor who actually answers the phones and returns calls promptly even if that physician does not have a degree in pain management or a large volume practice injecting joints for pain relief. That doctor is left with the option of prescribing the very oral medications we are being advised not to use, or chasing down the pain doctor to discuss exactly how they wish to address the problem? Usually the pain doctors are very willing to take ownership of the situation and they make suggestions of oral medications for that particular instance. The problem then usually recurs before the next round of injections or shortly after. There are very few pain practices actually talking to patients, examining them and working with oral medications or transdermal medications to relieve pain. They just do not have the time to discuss the situation especially with the procedures being so much more profitable. It is much like the situation in psychiatry where so many of the practitioners see patients briefly to adjust or regulate medications but spend little time engaging in counseling or psychotherapy any more.

There are however, several local pain doctors, who have answered my calls for assistance regarding patients having multiple cognitive and behavioral problems due to chronic use of opioid medications for legitimate pain. They have spent time analyzing the situation and helped the patients successfully withdraw from ineffective treatment regimens and resume a productive life. These clinicians are few and overwhelmed with chronic pain patients. The solution to the problem is an updating or retraining of our health care provider population so that more practitioners are comfortable treating chronic pain. At the same time our elected officials and law enforcement need to establish a system which prevents prescribers of pain medications from profiting from the dispensing or distribution of these products. Until that occurs I will continue to get phone calls from patients saying, “I had my third shot three days ago and I am still in excruciating pain. I cannot reach my pain doctor but their PA says I cannot get another shot for another three months. What should I do about the terrible pain?”

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?

Dying Should Not Be So Brutal

End of LifeIn an Op-Ed article in the NY Times, Ira Byock, MD, correctly details how brutal dying from a terminal disease is in this country. He cites the tragic case of a friend who fails to respond to conventional therapy for oncologic disease at a well-known Center of Excellence and the suffering he is going through. With conventional therapy failing he is offered a chance to enter a clinical trial or experiment to save his life. The author recommends Hospice care instead but if the patient chooses Hospice care he will be forced to forsake entering the clinical trial and turn his care over to the Hospice team. The author believes this is wrong and the patient should be able to receive comfort care and palliative care while still treating his disease. He goes on to make a list of sane recommendations regarding the future training of doctors and nurses so that patients and their loved ones will have the opportunity to be better informed about end of life issues.

I became exposed to Hospice in the late 1970’s early 1980’s when the Hospice movement consisted of caring angels of mercy , who at no cost to the patient or family provided comfort measures to the patient and support and counseling to the family. Hospice of Boca Raton met in a store front on Spanish River Boulevard off Federal Highway. It was staffed by volunteers from local churches, off duty paramedics, nurses, and community volunteers. They needed a medical director so I was asked to participate as part of a rotating group of physicians who donated our time to this worthy cause. Volunteers took a training course and devoted countless hours to providing bedside care and comfort to the sick and dying.

As one of the volunteer medical directors I attended care team meetings, reviewed care plans and signed for the prescription medications and narcotics needed to care for our patients. My time commitment was very structured and limited compared to the long hours the volunteer staff invested in providing comfort measures. We were paid nothing, expected nothing and worked with the patient, their loved ones and their doctors tailoring a care plan that fit each individual’s needs. We did not make them stop their treatments. We did not make them transfer their care to Hospice and away from their long time care team. In those days patients actually had a personal physician who knew them for years.

We were thanked and loved for our limited time investment far in excess to our contribution especially compared to those wonderful volunteers who performed the daily bedside and household care. This all changed when insurance and Medicare agreed to finance Hospice. At first we all thought the extra funding would now make it possible to provide service to many more individuals and pay for badly needed supplies and medications.

The first thing that happened is that many of the volunteers were dismissed and replaced with full time help. That included the volunteer physician medical directors. Medicare wanted full time people. Hospice became a business run by profit making corporations, hiring per diem help to go into homes instead of full time well trained Hospice staff. To be a patient in Hospice you were asked to relinquish your current doctor and medical care and transfer your care completely to the paid full time Hospice teams. In many cases patients were taken off their routine medications and over-medicated with narcotics producing a legal “Kevorkian-like” result even if the conditions did not dictate this approach. It became a big business, not a center for comfort and caring.

Dr. Byock’s article in the NY Times should be required reading for all families and persons over age 50. His suggestions should be discussed in our places of worship, places of education and especially in our medical school and nursing school curriculums. Dying from a painful incurable disease in America should not be this hard and brutal.

Medical Costs Rise as Retirees Winter in Florida

Healthcare CostsIn the January 31, 2015 edition of the NY Times, Elisabeth Rosenthal writes about the high numbers of tests performed on seasonal visitors to the state of Florida in the winter (as if seasonal visitors to Florida requiring health care are a new phenomenon). She cites a NY Times analysis of Medicare data released for 2012 showing twice the number of nuclear stress tests, echocardiograms and vascular ultrasounds for Medicare beneficiaries in Florida than in Massachusetts. She blames it on Florida cardiologists purchasing medical testing equipment for their offices and doing a large volume of tests to recover much of the income lost to a drop in reimbursement rates by Medicare to doctors for actually seeing patients, examining them and providing care. The article then goes on to discuss the increased number of tests in Florida in the last two years of a patient’s life compared to other areas of the country. She does admit that senior citizen rich population centers in NY, California, Arizona, South Texas and South Nevada have similar data showing high rates of testing than the rest of the country, but this is passed off as an afterthought. There are then a slew of anecdotal stories about individuals advised to undergo a procedure or test who declined and recovered nicely without it being done.

I have a suggestion for the NY Times, New York magazine and all the online purveyors of pearls of wisdom on health care. Suggest that your readers vacationing in Florida for the winter find a primary care physician (PCP). Find one who is willing to review the patients’ medical records from their northern physician and share clinical decision making on important issues with the physician(s) who know them longest and best.

For many years these prestigious periodicals have been suggesting that the patients’ only see a specialist. If the patients do not self-refer themselves to a specialist, their children often self-refer them to a specialist. Most specialty physicians are ethical, moral practitioners not churning out tests for self-profit. You can avoid the ones over utilizing at your expense by finding a well-trained internist or family practitioner who has no x-ray suite in the office, no nuclear stress testing equipment, no echocardiogram machines and no extensive in house laboratory. You probably won’t find that type of doctor if your physician is an employee of a hospital based health care system or Accountable Care Organization where the facility fee and incentives to over utilize are very strong. You won’t find that if you use the Emergency Room or a walk in center as your primary care physician because the same incentives exist.

You can find this dying breed of physician (dying because Medicare reimbursement for their services and influential periodicals have driven them out of existence) by calling the local county medical society or the local hospital medical staff offices and asking for a board certified internist or family practitioner who is not employed by the hospital or one of its large health care systems.

Consider a concierge or direct pay practice as well. The customer services in those practices, and additional patient time the doctors have, allows them to get the full story and communicate with those doctors who know you best rather than just shuffle you off for tests.  After all, time is the essence of quality, especially when it comes to healthcare.