Wednesday, November 29, 2017

MOC's (Maintenance of Certification) update from the American Academy of Neurology (AAN) deserves review.

AAN President Ralph L. Sacco, MD, reported in his President's Column, December 2017, that "AAN is Working Hard to Modify ABPN Maintenance of Certification (MOC)" -- not, in my opinion, hard enough and not with the enthusiasm necessary to get the job done. Here's why:

1) In The Weinmann Report (www.politicsofhealthcare.com), Friday, April 17, 2015, it was disclosed that IRS Form 990 for 2012 had reported that Larry R. Faulkner, MD, president and CEO of ABPN (American Board of Psychiatry and Neurology) was paid $843,591 for base compensation, retirement, and non-taxable benefits.

2) If we now compare that with Schedule J (Form 990) for 2015, we see that Dr. Faulkner's total compensation reportedly was $936,000. Six other ABPN persons were also paid above $250,000 including three whose compensation was well above $300,000.

3) If we study the AAN Schedule J, Form 990, for 2015 we see Executive Director Rydell's total compensation listed as $765,415. Five other persons are listed between $312,000 and $397,000.

The point to shout from rooftops loud enough for IRS and FTC to hear is that these financial figures are what motivates and drives MOC --- there's no way this kind of money will come from ordinary rank and file dues alone.The MOC gimmick is needed to make this pot boil. ABMS boards, along with their collegial societies and academies, are generating more generous self-payments from tax-exempt structures than they would were they for-profit companies. IRS should have investigated long ago -- what has held them back?  

Sacco said in his editorial that AAN's goals are to develop strategies to further understanding of health care disparities among individuals suffering with neurological conditions, that AAN wants to identify an approach to reduce these disparities, and to develop methods to improve our awareness re bias in health care outcomes of the neurological patient. He did not disclose financial disparities such as MOC fees that enrich ABPN and its enablers. 

In his November 2017 editorial Sacco talked about the December 4th meeting wherein he said "the societies will host a summit with representatives from ABMS and specialty boards, the Accreditation Council for Graduate Medical Education, Federation of State Medical Boards, Council of Medical Specialty Societies, and American Medical Association ... AAN recognizes these hassles of recertification ...  " 

Sacco mentions how these hassles "can contribute to burnout... " and says that AAN wants "to help you prepare for MOC." Actually, it appears more likely than not that all of the post-graduate organizations that sponsor MOC are doing so for self-serving financial purposes -- never in the history of medicine have administrative fees generated as much income as now. MOC proponents cannot afford to water down the fees that rank-and-file physicians will pay. If they did that then the hefty remunerations listed above would be severely trimmed. 

Our conclusion: MOC is a financially slick and clever maneuver on the brink of implosion. It should be replaced with more friendly methods of continuing medical education




Thursday, November 9, 2017

"Trickle Down" economics


Questions have come our way about "trickle down" economics. i.e., will it work if companies invest, expand their businesses, and hire more workers. In theory, were it to follow this format, it would. The problem is that there is no way to enforce "trickle down," previously tried and sold to the public by at least one previous administration. Here's why: employers and owners are free to skim off the profit and invest it either in the USA or abroad. There is no requirement to expand the local factory, increase production, or allow increased profits to "trickle down" anywhere other than to  corporate owners personal use. In the debate and reconciliation process we await in Congress we'll listen carefully to whatever details about "trickle down" either side cares to reveal. We suggest that our readers e-mail or write their Members of Congress to ask how they expect to enforce "trickle down" to make sure that the concept isn't siphoned off and translated into personal emolument to feed CFCs  (corporate fat cats) at the top. 



Wednesday, November 8, 2017

"MY STROKE OF LUCK" by and starring DIANE BARNES, MD



Today's post is not a political piece: it is a theatre review of a remarkable one woman show. Here's the scoop: a few years ago, Diane Barnes, MD, San Rafael, California, was working comfortably as a radiologist until, suddenly and unpredictably, she suffered a brain hemorrhage from a ruptured aneurysm. Although she sustained considerable damage to speech, she eventually recovered without paralysis and regained linguistic competence. The show dramatizes her story and at the same time provides astonishing insight into neurological recovery, e.g., how at one time while fighting her way through dysphasic speech she'd find herself thinking she was speaking while instead she was uttering gibberish ("word salad," in technical neurological speak). She was able to return to radiology but in due course found she had thespian talent. The show depicts her transference to her new life. She'll appear through December 9, 2017, at The Marsh, 1062 Valencia Street, San Francisco (tickets are available via themarsh.org or 415-282-3055). 

Monday, September 11, 2017

More Unfinished Business: AB 1048 (Arambula):opioid prescribing


It's no secret that that the State of Opioids in California and elsewhere is a mess. In 1999 the Orgeon medical board sought to discipline a physician because it was claimed that he hadn't prescribed enough pain medicine. In 2001 the State of California made page one of The Washington Post when a patient's family sued because they said the doctor hadn't prescribed enough pain medicine. Now the shoe is on the other foot and doctors everywhere are beleagured for prescribing opioids to relieve pain. Comes now to the mini-partial rescue, Dr. Arambula, whose bill would allow pharmacists as of 07/01/18 to dispense Schedule II controlled substances as a partial refill if asked to do so by the patient or the prescriber. As of this writing the bill is on the Senate Floor where it is being sponsored by the CMA and guided by Alecia Sanchez from CMA's legislative office. This publication favors the bill -- a phone call or fax from you to your state senator advising an aye vote is our recommendation.

The matter will not be settled by this vote. It will continue to be an issue and will be the CME topic for the Union of American Physicians and Dentists at their meeting on October 28th (Marriott, Los Angeles airport). Contact UAPD for more information. 

Late Flash: AB 1048 cleared the state senate on 09/13/17, by 40 to zero. On 9/15/17 it was designated as "enrolled." 

Updating: AB 1048 is now on the Governor's desk according to the CMA Hot Lists dated 9/29/17 and 10/03/17 (that means the bill awaits the governor's signature). Phone calls, faxes, or e-mails intended to influence this legislation should go directly to the governor's office, 916-445-2841, 916-558-3160 (fax), or www.gov.ca.gov

Reference

"Opioid prescribing and panic," WORKCOMPCENTRAL, 08/15/17

See previous post this date (9-11-17) for current status of MOC and how ABMS boards profit from it (at members' expense, of course). 

UNFINISHED BUSINESS: first, the boards, MOC, and rapacious financial conduct


Under Unfinished business we wryly observe that MOC (Maintenance of Ceritification) remains viable and unwell. We now know without doubt that ABMS specialty board physicians and executives are profiting from MOC fees which, allegedly, are supposed to support the not-for-profit educational mission of our traditional (since 1922) specialty boards. In fact, reasonable argument can be made that the original not-for-profit motif of the boards has been converted into one of personal gain that belies the legal enablement of the boards under 501(c)3 rules and regulations. What is called for now is an investigation by the FTC (for possible restraint of trade) and by IRS (are the boards conducting themselves in conformity with the law governing 501(c)3 organizations)? 

Here's some grist from the mill, in this case, from the 990 Form filed by the American Board of Psychiatry and Neurology (ABPN) in 2015:

The MD president was allocated $613,314 as "reportable income from the organization (W-2/1099-MISC)." In addition his "estimated amount of other compensation from the organization and related organizations" was $322,686.

Four ABPN Directors are listed as having received "reportable compensation" ranging from $175,947 to $246,012. In addition, the same four got additional "compensation from the organization and related organizations" ranging from $73,914 to $83,546.

Two managerial remunerations were reported as $111,661 (with an additional $50,351 listed as "other compensation") and $106,552 (with an additional $37,608 listed as "other compensation").

The VP of Research came in for $286,384 plus $99,668 for "other compensation"). 

Other remunerations were equally fat.

Here's the point: if a 501(c)3 organization has high enough expenses including salaries it is obvious that it can't make a profit if all of the money it takes in gets distributed to private hands inside the organization in the form of expenses. In this way, a not-for-profit organization can make more money for its officers, directors, trusteee, and others than can a true for-profit business.

Is this the way we want our ABMS boards to function?

References

"Specialty Boards Profiting from Physician MOC Fees," MEDSCAPE, 08/01/2017

"Medical Staff Votes Against Mandatory MOC," WORKCOMPCENTRAL, 01/22/2016

Form 990 (2015), Part VII, Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees, page 8.








Sunday, August 13, 2017

OPIOID PRESCRIBING FOR PAIN IS INHIBITED FOR INJURED WORKERS


   The mechanism of opioid action
is through a receptor mechanism that we all have, namely, mu, delta, and kappa receptors. Human opioid receptors are endogenous (meaning that their mechanism comes from within the system and does not require an external source) and can be activated by endogenous peptides such as the enkephalins, dynorphins and endorphins. These substances are released by neurones and are made available for pain modification. Endogenous opioid peptides comprise a class called endorphins.  

  This class of neurochemical stimulation is available to injured persons and can be mobilized into action without prescribing the likes of vicodin, oxycodone, oxycontin, or similar controlled substances (or illegal non-controlled substances). This level of neurochemical stimulation can be triggered to release endogenous substances in the human body that relieve pain.  For instance, physical therapy, aquatic therapy, or massage can have this favorable effect. When this method doesn't work, analgesic medication including opioids may then  be prescribed.

  The trouble is that in the case of injured workers covered by workers comp, these alternative methods to opioid prescribing are often rejected by Utilization Review (UR). Then that rejection by UR gets rubber-stamped by anonymous Independent Medical Review (IMR) doctors whose prejudices cannot be addressed since their names are kept secret. When the PTP or Primary Treating Physician's attempt to prescribe an alternative to analgesic relief is denied authorization, the next step is pharmacological, usually NSAIDs (non-steroidal anti-inflammatories), then opioids if the NSAIDs fail. That's when the bureaucratic howling begins. What should happen instead is that the UR and IMR doctors who denied treatment by physical therapy or massage should be relieved from duty. 

"Turn the Tide," a publication of The Office of the Surgeon General, discloses resources for the proper prescribing of opioids for pain, chronic pain in particular. For instance, once opioids are prescribed, they should only be continued if "meaningful improvements in pain and function without significant risks or harm" can be documented. Interestingly, the brochure distributed by The Office of the Surgeon General, states in red capital letters, "Start Low and Go Slow."

In fact, in The Weinmann Report, 6/26/17, "Opioid Denials and Obstruction of Alternative Treatments," we discussed how The Washington Post in 2001 made a front-page headline about a doctor in California who was being sued for not prescribing enough pain medication. Two years earlier the Oregon Medical Board actually disciplined a physician for not prescribing enough medication to relieve pain. We also cited a peer-reviewed reference from HEADACHE that stated that opioids were useful in pain management but that that its use had to be slow, slow, slow -- this advice was 17 years ahead of "Turn the Tide" and 10 years before Paduda's original article. 

In a panic-ridden piece entitled "Narcotic use is rampant in workers compensation," we are told that "the problem is showing up in a doubling of emergency room admissions due to prescription drug abuse, driven primarily by oxycodone, methadone, and hydrocodone." This particular article makes no reference to the Utilization Review denials for physical therapy, massage, and alternative treatments that force patients into the pharmaceutical stream.

On the contrary, Dr. John Torres recommended massage therapy on MSNBC with moderator Craig Melvin on August 1st, 2017. It isn't clear whether or not Dr. Torres knew he was recommending a treatment often rejected by workers comp Utilization Review. Since we  had the privilege of evaluating just this kind of patient recently, we'll see what happens if and when the PTP asks for overturn of the denial of massage therapy.

Readers should not be surprised. Since the emphasis now placed on evidence-based-medicine, the reliance on the winds of fashion and bureaucracy has increased. Discipline for not providing enough pain medication has been supplanted by a new chorus chanting for discipline for doctors who provide too much.  

References

The Weinmann Report, 6/26/17, "Opioid denials and obstruction of alternative treatments"

"Controversies in headache medicine," summer, 2000, HEADACHE, V. 11, # 2, Lawrence Robbins, MD (opioids can be used:  "when they are not overused, the opioids are a safe medication")

"Doctor's  duty to ease pain at issue in Calif. lawsuit," Susan Okie, Washington Post, 05/07/2001

"Oregon Board disciplines doctor for not treating patient's pain,"  New York Times, 09/04/99

"Narcotic use is rampant in workers compensation," Joseph Paduda, October, 2010

"Prescribing Opioids for Chronic Pain," TURN THE TIDE, Office of the Surgeon General, CDC

Commentary by Dr. John Torres, 1 August 2017, MSNBC TV (recommends massage for pain relief) 







Friday, July 28, 2017

OBAMACARE REPEAL IS DEFEATED IN THE SENATE


Rife predictions of disaster are among us now that Obamacare (ACA) has been defeated in the Senate. Senator Ted Cruz may not be far from the mark when he says that annual increases of $7,000 per year in health insurance premiums should be anticipated since Obamacare was not repealed. On the other hand, the preservation of Obamacare means that coverage for pre-existing conditions will be continued. Medicaid funding (Medi-Cal in California) will be continued whereas under repeal of Obamacare Medicaid would likely be directed to the ashcan of political poverty. Keep in mind that federal legislators and their families have their own healthcare plan and are not dependent on Obamacare or even on any replacement that has been offered to date. That fact alone may explain why so many federal legislators know so little about the ins and outs of Obamacare or, for that matter, Any Care. A solution would be to dissolve the special health care coverage that federal legislators and Congressional staff get for themselves, including admission to military hospitals and clinics. Congress should  have the same healthcare insurance that the rest of us are obliged to get. THAT would perk up Congressional interest. 

Comes now HR 849, the Protecting Seniors Access to Medicare Act. 


HR 849 would repeal sections of the ACA that would implement the Independent Payment Advisory Board (IPAB). The IPAB has been called a "death panel." This columnist, while favoring repeal of the IPAB, doesn't call it that -- here's why: the actual intent of the IPAB is to reduce the costs of Medicare. It is not expected to do that by pulling the plug on individual patients. The expected protocol will be to see to it that in certain situations the plug is never inserted. This issue is already alive and unwell with reference to cardiac pacemakers which The Center for Medicare and Medicaid Services (CMS) has already determined as of 6 July 2015 will be restricted to patients with "non-reversible symptomatic bradycardia." This restriction ties the hands of cardiologists whose medical judgement is herewith cut to shreds. 


In layman's terms, that means that your cardiologist may think you should have a cardiac pacemaker because you have asymptomatic Mobitz Type II Heart Block. THAT is the type of medical decision that the IPAB will be enabled to prevent from implementation. The decision-makers will not be obliged to report to Congress even though the entire panel will be political appointees and even though there is no requirement by law that any of them be a physician. 

Reform of Obamacare is the way to go

It is probably correct Medicare costs are growing -- the constant stream of administrators and bureaucrats that clogs our healthcare systems is largely to blame. The first reform that we should make is repeal of the IPAB (the law as currently envisioned anticipates 15 appointees at $165,000 each). So  let's start the savings by not appointing an IPAB panel and then by repealing the ACA provisions that enable the IPAB. Previously, this writer has stated that the IPAB is "a form of rationing with a special dagger aimed at the hearts of the elderly." 

Implementation of the IPAB could conceivably extend a financial lifeline to the Medicare program while at the same time pulling life preservers away from patients. It has fiscal merit at the expense of the sick and injured whose healthcare needs would be subverted when the money originally intended for their care gets directed other than to patient care. 

Our recommendation is to repeal the IPAB to enable  physicians to provide treatment instead of the shackles favored by regulators who don't take care of patients. 

At this time, there are two ways to repeal the IPAB: my choice is to improve the ACA. The other choice is to pass H.R. 849

References

"Medicare versus the Independent Payment Advisory Board (IPAB), "The Weinmann Report, www.politicsofhealthcare.com, 6/29/15

"Affordable Care Act & the IPAB," The Weinmann Report, www.politicsofhealthcare.com, 3/8/12

POLITICO, "I will insure that no government bureaucrat gets between you and the care that you need," 12/17/10

POLITICO, "How to ration care without using the R word," 12/14//10

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