Monday, June 26, 2017

OPIOID DENIALS AND OBSTRUCTION OF ALTERNATIVE TREATMENTS


"Doctor's Duty to Ease Pain at Issue in Calif. Lawsuit" was headline news for The Washington Post on 7 May 2001. The story was about how a patient died in pain at age 85 after his  doctor reportedly "discharged him from the hospital with what (his daughter) said was inadequate pain medication."  

Meanwhile, HEADACHE, Vol. 11, #2, summer 2000, in a series entitled "Controversies in Headache Medicine," published a column on "Long-Acting Opioids as Preventive Medicine for Severe Headaches." The report recognized the risks of opioid medication but opined nonetheless that "when they are not overused, the opioids are safe medication" and that "the doses must be kept low" since "occasionally, the body develops tolerance to the narcotic and the patient needs increasing doses to achieve the same result." The HEADACHE article discussed methods of management. 

Pain management physicians understand these complications while also facing the needs of patients who suffer from chronic pain. That is why physicians try alternative methods to achieve pain relief, for instance, physical therapy, aqua therapy, and other methods not dependent on medications (these alternative methods are felt to induce secretion of endogenous substances that enhance pain relief). The trouble is that injured workers offered treatment under these techniques are likely to have these recommendations denied or delayed by Utilization Review (UR) and Independent Medical Review (IMR). DWC is ultimately responsible for care to injured workers and for the frequent denials and inadequate authorizations of treatment by UR and IMR. These denials then help throw these patients into opioid regimens because alternative treatment has been denied. The usual ruse is to call these treatments "experimental" or "unproved." 

That's when the primary treating physicians (PTPs)  and their consultants inherit the blame. Now that the political winds are against opioid use and physicians try to avoid their use, the ultimate sufferer is the injured worker and chronic pain patient. There is no winner in this sad game. 

References

HEADACHE, V. 11, #2, Summer, 2000, by Lawrence Robbins, MD ("Long-acting opioids as preventive medicine for severe headaches") 

The Washington Post, May 7, 2001, by Susan Okie ("Doctor's duty to ease pain at issue in Calif. lawsuit")

Workcompcentral, 2016-07-26, by Robert Weinmann, MD ("SB 863 benefits employers, harms injured workers")

Workcompcentral, 2017-01-04, by Robert Weinmann, MD ("Malpractice reform reaches California Supreme Court") 

Saturday, May 20, 2017

Single Payer (Healthy California Act, SB 562, Lara & Atkins) wins Senate Health Committee support


SB 562 or Healthy California Act is better known as the Single Payer Act. Senator Ricardo Lara's position is that "healthcare is not a privilege, it's a human right."

1) SB 562 promises to cover all Californians for "all medical care, including inpatient, outpatient, emergency care, dental, vision, mental health, and nursing home care;

2) Co-pays and deductibles will be eliminated;

3) Californians will choose their doctors from "a full list of health care providers, not a narrow network chosen by insurance companies" (now we'll just have to worry about who makes up these lists of providers -- physicians should now understand why MOC is such a hot potato);

4) Referrals will not be required for members to see "any eligible provider" (shades of 1998: the undersigned spoke on this topic at the White House when President Clinton signed off on allowing federal HMO members to go directly to specialists without having to see a primary care doctor first); 

5) Californians will be covered when they travel;

6) The bill will say that "physicians and nurses will make decisions about care, and have the ability to override computers or clinical practice guidelines in the best interest of the patient" (notice that this provision mentions "physicians and nurses" and avoids designating MDs and RNs); 

7) The bill says that "Healthy California will be governed by a nine-member, unpaid board appointed by the governor and legislature and a public advisory committee (italics added ) of doctors, nurses, other health care providers, and consumers" (in other words, kind of like the Independent Payment Advisory Board of Obamacare).

In fact, SB 562, specifies under Chapter 2, Governance, that one of the board members will be a "representative of a labor organization representing registered nurses." It is proper that Registered Nurses get this recognition.  

It would be a good idea to make sure that physicians and surgeons with MD degrees also get such recognition. Under SB 562 they do not -- in fact, they almost get ignored. SB 562 states that the governing board will include "at least one representative of the medical provider community." The "medical provider" community includes many kinds of providers of services, e.g, physical therapy, massage, non-RN nurses, nurse anesthetists, physician assistants, naturalists, chiropractors, acupuncturists, etc. 

An additional amendment this writer recommends is that SB 562 should require that "at least two California licensed representatives will be medical physicians/MDs, one surgeon and one internist or family physician."

As for the public advisory board, it will also be obliged to meet certain statuatory requirement, it would be required of the board "to seek all necessary waivers, approvals, and agreements to allow various existing federal health care payments to be paid to the Healthy California program which would then assume responsibility for all benefits and services previously paid for with those funds." 

In the words of too many pundits to count, SB 562 still needs work.

Reference

"SB 562," 17 April 2017, The Weinmann Report, www.politicsofhealthcare.com 

Monday, May 15, 2017

Senate Bill 790 (McGuire): Me too legislation on gifts and benefits


Once again we see a loose cannon approach to limiting gifts and benefits from manufacturers of prescribed products or distributors of medical devices to health care providers. Physicians are the main target of this legislation despite the authors' unctuous assertion that "the vast majority of medical professionals in California do their job well and put the needs of their patients first."

Nonetheless, Sen. McGuire finds that "current voluntary efforts are not enough to ... protect patients from overpriced prescriptions. SB 790 will restrict pharmaceutical gifts and help control drug costs."

On this basis Sen. McGuire seeks to regulate food and beverages served by pharmaceutical companies at meetings of medical professionals -- these meetings are usually dinnertime functions with educational presentations by prominent and respected physicians. It is correct that the participants dine at the expense of the sponsoring company. The pitch in favor of the bill is that "SB 790 gives California an opportunity to put patient care and drug affordability before corporate profits. The bill would significantly restrict the manufacturer (of a prescribed substance or device) from offering or giving gifts and incentives such as travel and lodging, consulting fees and expensive meals and alcohol to health care providers." Sounds good, doesn't it?

There are problems with this expansive bill. For instance, physicians know that the speakers at these commercial enterprises are actual clinicians with field experience, physicians whose lectures are known to be knowledgeable and reliable. Thanks to the pharmaceutical companies we don't have to buy risky tickets on airlines that routinely overbook. Education is brought to our doorsteps. These benefits would be thrown out with the dish water were SB 790 to become law. 

This bill will redistribute the wealth so that medical centers and health plans will still be allowed to put on seminars, dinner and wine included, in other words, will be allowed to advertise their own clinical services while foisting lower level and comparatively inexperienced faculty on attendees, e.g., it is not unusual for medical centers to put on these dinner meetings and draft junior faculty as speakers. The idea is to have attendees at such symposia use the sponsors' hospitals, clinics, and healthcare plans. THAT is not precluded by SB 790  which actually plays into their hands.

Actually, there is an approved exception: conferences or seminars accredited by the Accreditation Council for Continuing Medical Education (ACCME)  or comparable organizations would be allowed to offer these conferences provided the sponsor is not the manufacturer of prescribed products. In other words, courses given by the American Boards or their separate but contiguous professional associations or academies would be exempt (compare our previous items on Maintenance of Certification or MOC and rue the day you left the hen-house for protection by the fox). 

Finally, many of the physicians who attend dinner-meetings put on by pharmaceutical companies do not use or prescribe the products discussed: they come to hear experts discuss the mechanism of action of new medications and techniques and to enjoy the company of colleagues in an environment where there's no "911" calls. 

Where this battle needs to be fought is in the courts and in Congress which so far have allowed Medicare and other entities to avoid negotiating with suppliers for better prices. 

As written, SB 790 also shows flagrant ignorance on how drug profits are actually made, e.g,, Senator McGuire's press release from 4/25/17 says that the current "interaction with the pharmaceutical industry is associated with negative consequences that includes unnecessary drug prescriptions, drug cost increases borne by the patient and less availability of generic drugs (italics added)."

What the authors fail to mention is that the mark-up or profitability of generics is often more than trade name medications. That is because the so-called "filler molecules" entailed in their making are less regulated since they're not the active substance. In other words, generic drugs are not by definition  "bioequivalent" to their brand name counterparts but may be more profitable nonetheless. 

Our suggestion to McGuire and Monning: try again, without grandstanding.

Thursday, April 27, 2017

ARE THE STAKES AT MOC (MAINTENANCE OF CERTIFICATION) TOO HIGH TO GIVE UP?


Scandalous overreach by the proponents of Maintenance of Certification (MOC) invites investigation by the Federal Trade Commission (FTC) and by Internal Revenue Service (IRS). 

FTC should determine whether or not trade is being or is likely to be restricted by the tenets of MOC doctrine and its financial operatives. IRS, meanwhile, should examine whether or not the ABIM Foundation meets IRS 501(C)3 requirements. The question is whether or not there is reliable evidence that MOC revenue is being diverted into the pockets of selected individuals.

Many observers think that is the case and that the amount of money paid out in personal remunerations seems exorbitant. This finding forces the question, namely,  to what extent the ABIM Foundation is a charitable organization or a well heeled 501(c)3 enterprise. 

Here are some facts and figures:

The president & CEO of ABMS (American Board of Medical Specialties), according to IRS Form 990, received total compensation of $779,487 for tax year 2013;

The ABPN (American Board of Psychiatry and Neurology) CEO in 2012 received total compensation of $843,591 -- according to IRS Form 990 for that year;

The ABIM (American Board of Internal Medicine), schedule J, Form 990, for 2012, reports base compensation for the president-CEO as $628,952;  

Reported base compensation for Senior VP/COO, ABIM, was $464,747;

Base compensation for the Sr. VP/CIO, ABIM, was $382,092;

Base compensation for the Senior VP/COO,  ABIM, was $326,520;

Base compensation for Senior VP/CFO,  ABIM, was $452,630.

-- not too shabby especially when one keeps in mind that these figures do not include income from what IRS refers to as "related organizations". In order to see this additional money jockeying, just go to Schedule J, IRS Form 990, and look at lines i and ii -- add 'em up and weep. Not to worry. Increased fees down the road re MOC will take care of any shortfalls. 

Readers are invited to check out this data by looking up Form 990 information. We expect to add to this report from time to time so stay tuned.  These figures show why MOC will not be easily vanquished -- the stakes are too high.


Monday, April 17, 2017

SENATE BILL 562 (INTRODUCED BY LARA & ATKINS): A PR0P0SAL FOR SINGLE-PAYER THAT INCLUDES PROVISION FOR COLLECTIVE BARGAINING


Senate Bill 562 enjoys the nickname of The Healthy California Act because it is intended to offer comprehensive health-care coverage to all residents of California -- it would be innovative as a single-payer plan for Californians. All the same the California Medical Association (CMA) is opposed.

By contrast the Union of American Physicians and Dentists (UAPD) holds a more guarded position and currently is "watch" on this bill although it is widely thought that the majority of its physicians who are employed or salaried favor SB 562. 

The reasoning goes like this: California already has a state-wide program called Medi-Cal (the stateside version of Medicaid). This program is administered by DHCS (Department of Health Care Services) and is largely governed and funded by the federal program, Medicaid. SB 562 purportedly would expand this program to cover all residents of California. 

The chief argument in favor of SB 562 is that it would cut out the meddlesome middleman, namely, the insurance company. Supposedly so doing would reduce costs; however, there is nothing in the law that mandates passing on these costs reductions to the patient. More likely the savings in costs would find their way into the pockets of the corporate overseers in the form of increased corporate compensation. 

The argument stumbles on, akin to the United States Postal Service whose rates have gone up while its efficiency has not. What is more likely than not is that the single-payer system would simply declare certain expensive services out of bounds as was done in the summer of 2015 when cardiac pacemakers were put on a rationing status by requiring conditions beyond what most cardiologists would require, e.g., Big Gubbamint decided that Mobitz Type II syndrome did not require a pacemaker.

How about rationing? Under the Affordable Care Act (ACA), popularly known as Obamacare, Sections 3403 and 10320 are especially relevant -- these sections set up how a public policy committee will be set up within the ACA to keep costs down. 

The method used for Obamacare was to appoint a committee,  the Independent Payment Advisory Board (IPAB) whose job it would be to decide, once costs got too high, which services should  be curtailed. The IPAB as envisioned in the ACA will not report to Congress. The salary is expected to be about $165,000 each for 15 appointees (none will be elected). 

Trouble is that SB 562 envisions a similar mechanism, namely, "a public advisory committee to advise the board on all matters of policy for the program." The members of this committee would include 4 physicians (one must be a psychiatrist) appointed by the Governor, Senate Rules Committee, and two by the Assembly Speaker. It doesn't get more political than that, does it!?

Two appointees would be registered nurses appointed by the Senate Committee on Rules. One would be a dentist appointed by the Governor. One representative would be from the private hospital sector, also appointed by the Governor. Another appointee would be a representative of the public hospital system, appointed, wouldja' believe, by the Governor. Another would be a representative of an integrated health care delivery system, no surprise by now, also appointed by the Governor. There would also be other representatives appointed by the Governor, the Assembly Speaker, and the Senate Committee on Rules. 

So instead of a science-based advisory board, we'll be offered a "public advisory" board steeped in political intrigue. 

Under Chapter 2, Governance, we learn that there will be "Appointments to the board by the Governor, the Senate Committee on Rules, and the Speaker of the Assembly," to wit 

(A) "At least one representative of a labor organization representing registered nurses,"

(B) "At least one representative of the general public,"

(C) "At least one representative of a labor organization,' 

(D) "At least one representative of the medical provider community."

Does it escape anyone's notice that the first dictum above guarantees appointment of two RNs and that none of the provisions guarantees the appointment of an MD? The closest it comes to that is the statement about someone from "the medical provider community" but not necessarily an MD.

Notice also how the provisions outlined above tilt to labor, e.g., the two RNs are to be from "a labor organization representing registered nurses" AND "at least one representative of a labor organization" which makes at least three appointees from Big Labor. Not, come to think of it, that the insurance companies haven't earned this shift in appointee preference!

In referring to a piece done by the undersigned for the Indiana Daily Journal in 2009 it was mentioned that "the trap to avoid is restrictive utilization review such that we get Rationing Coupons as opposed to access to care." When this comment came to the attention of Stuart A. Bussey, MD, JD, UAPD president, he stated that "we will follow this bill 562 and suggest safeguards to avoid restrictive utilization."

Finally, that brings us to why unions might be interested in SB 562. On page two of the current draft still in committee, we read that "the bill would authorize health care providers, as defined, to collectively negotiate rates of payment for health services." 

We will no doubt continue this discussion as SB 562 walks, runs, or stumbles its way through the legislative process. 

References

"Single-payer health plan has its own disadvantages," Indiana Daily Journal, Franklin, Indiana, August 8-9, 2009

"Medicare versus the Independent Payment Advisory Board (IPAB)," The Weinmann Report, www.politicsofhealthcare.com, June 29, 2015














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Monday, March 27, 2017

HOW OBAMACARE'S SURVIVAL MAY ENHANCE UTILIZATION REVIEW DENIALS IN WORKERS COMPENSATION


Sections 10320 and 3403 of the Affordable Care Act (ACA) remain in force thanks to the calamitous Trump-Ryan campaign to repeal Obamacare in its entirety while omitting discussion whenever possible about aspects of the ACA where the Republicans would've been better off with debate and compromise. By not bringing the issue up independently, the Democrats joined hand-in-glove with their Republican opponents.

Sections 10320 and 3403 of the ACA enable a particularly harmful method of disallowing coverage of healthcare known as the Independent Payment Advisory Board (IPAB). The IPAB has often been linked to rationing of healthcare. Here's how it will work once it is installed as allowed by current ACA legislation.


The basic idea of the IPAB is to eliminate services from healthcare once it can be shown that such services are financial encumbrances to the program. In order to decide which diagnostic and treatment protocols qualify under this rubric, a special committee will be appointed. It will not be necessary to be a physician to get appointed, but it will be necessary to get a political appointment. The job is envisioned to pay about $165,000 per year. It will not be required for the committee to report to Congress which will happily divest itself of this controversial oversight. It is expected that the committee will be appointed in 2017 or 2018 or as soon as costs escalate beyond current levels.

An example is the restriction that Medicare recently imposed on cardiac pacemakers. The decision as to which patients should have pacemakers used to be up to one's cardiologist. No more. There is now an impediment, namely, Medicare itself. In the absence of specific findings mandated by administration authorities, pacemaker coverage can now be denied. Not the pacemaker itself, mind you, just its coverage under Medicare -- so, Dear Reader, if you are  among those whose concern about pacemakers is less than theoretical, here is the information you may need when the IPAB nixes your application: cardiac pacemakers cost about $6,000 on the open market. That does not include professional fees and other related costs.

This IPAB program has been called "rationing." It isn't rationing on a per se or individual basis. It is rationing across the board for entire classes of potential recipients. It's purpose is to stretch the ACA dollar since it is expected that the ACA's financial troubles will get worse sooner than expected given recent increases in policy costs and deductibles. This reasoning, cost reduction, is the same as California's approach to Utilization Review (UR) for Injured workers.


Injured workers on the wrong end of Utilization Review (UR) whose rejection of treatment is usually upheld by Independent Medical Review (IMR) will immediately recognize this technique as a denial of care mechanism. In a nutshell, Congress has now extended the ACA'S chief mechanism for "denial of care" and has managed to keep the public in the dark. No more! This writer urges all of us, injured worker or not, to make one's own legislator face this issue.


By way of recent history, the IPAB was initially aimed at Medicare's recipients -- it was called the IMAB (Independent Medicare Advisory Board) then. It got deleted from Medicare when thousands of Medicare recipients protested loudly enough for Congress to hear them.

My recommendation: whether or not one is an injured worker, but especially if one is an injured worker, the time to shout out for repeal of Sections 10320 and 3403 of the ACA has arrived.  This step can be taken without repeal of the entire ACA which would remain a separate issue. 



Tuesday, March 21, 2017

OBAMACARE, TRUMPCARE, OR RYANCARE?


"We own it," that's what Rick Santorum, former presidential candidate and senator said with reference to the on-going Republican  proposed healthcare bill to replace Obamacare.


By now we know what the successful aspects of Obamacare (the Affordable Care Act, ACA) are that reflect the lifeline of the ACA as it now stands. 


The successful parts of the ACA include keeping children insured until age 26 and disallowing the exclusion from healthcare plans of persons with pre-existing conditions. On the other side of the ledger, once President Obama dumped the Public Option from the ACA, the greedy doors of the insurance companies swung open to raises in premiums and deductibles. In turn, as the cost of the ACA goes up, attempts to control costs raise their ugly heads.



Chief among these ugly heads is the Independent Payment Advisory Board (IPAB) which effectively, once it becomes operative, will facilitate the rationing of health care. Review of recent healthcare history shows that there was a predecessor to the IPAB known as the IMAB (Independent Medicare Advisory Board) which was deleted from Medicare because of public opposition by Medicare recipients. Unfortunately, a revised version of the IMAB wormed its way into the ACA as the IPAB -- if the ACA is repealed the IPAB goes down with it, unless, unless it is brought back to life by as yet unknown devotees willing to throw grandma under the bus. 


The IPAB's lease on life comes from Sections 3403 and 10320 of the ACA (this writer has sought repeal of both sections for the past 7 years, see articles from The Hill newspaper, 9/16/09, and POLITICO, 12/10/10 and 12/17/10). Once the costs of the ACA reach critical levels, these ACA sections allow the appointment of political operatives whose job will be to regulate costs by deciding which procedures and treatment protocols are too expensive to maintain -- not quite the death panels touted by some ACA opponents but too close for comfort.


At this moment in Congress, the deep divide is how much of Obamacare to keep, if any. It appears that complete repeal without adequate replacement will disenfranchise millions. On the other hand, if Obamacare maintains its lease on life, millions risk losing access to care because they'll not be able to afford the ever rising premiums and deductibles. 


Santorum in Congressional hearings points out that either way the blame or credit will fall upon the Republicans. If the proposed health care law fails, the Republicans risk losing seats in the midterm elections (sad to say how much this aspect rules Congressional thinking). So at the moment here's the scoop: Trump does not want the currently proposed bill to be called Trumpcare since its passage could replace the disastrous aspects of Obamacare with new equally disastrous effects. That's why in the glorious halls of Washington, DC, the current Republican proposal is wryly called Ryancare. 


References


The Hill newspaper,  Washington, D.C.,  "What Obama should've said about health reform," 9/16/09


POLITICO, "How to Ration Care without Using the R Word," 12/14/10

POLITICO, "I Will Insure that No Government Bueaucrat Gets between You and the Care that You Need," 12/17/10 

The Weinmann Report, "Affordable Care Act and the IPAB," 03/28/12,  (www.politicsofhealthcare.com)