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 -- as matters stand now MOC proponents are treating physician colleagues as cannon fodder to be milked in support of narrow self-serving financial and power-driven interests.

"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. 

"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). 

UPDATE: The run for Diane Barnes' show, My Stroke of Luck,  has been extended: same place, same time, shows will resume 1/4 to 2/3 Thurs 8 PM, Sat 5 PM and Sun 1/21 and 1/28 at 2 PM. Don't miss it especially if you're involved in neuroscience either as a clinician or researcher. 

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.

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) 

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

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") 

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 

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.

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.

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














t

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. 

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) 

UTILIZATION REVIEW HYPOCRISY REVISITED -- One Doctor's Answer to Arbitrary Utilization Review Denials

UTILIZATION REVIEW HYPOCRISY IN VELVET GLOVES, originally published in this blog, 03-18-2014, has met its match in the psych practice of Richard Dorsey, MD. With Doctor Dorsey's permission, we publish his method of dealing with Utilization Review minions.

Doctor Dorsey uses an 866 number going to a 24/7 answering service. This number is used for all UR doctor calls as listed on his RFAs. What this method means is that every UR call gets a live answer, no voicemails. All of his UR calls will be logged in as to date and time. This method allows Dorsey to claim accurately that UR personnel who say they couldn't reach his office are likely lying.

Should odd-hour calls come in, said calls are noticed to Dr. Dorsey by e-mail and are then answered during normal business hours. Dorsey keeps a log for dates and times of the UR doctor calls he actually returns. Dorsey says he'll do two such calls per case. For UR calls that come in during regular business hours, Dorsey's answering service e-mails notification of same upon receipt. Far from creating hostility, this method allows Dorsey to develop his own rapport with the UR doctors such that his rate of  "cases approved" has reached a high level. 

For more about Dorsey's technique, go to dorseypsych.com 

References

Utilization Review: Hypocrisy in Velvet Gloves, politicsofhealthcare.com (The Weinmann Report), 3/18/14, & workcompcentral, 3/26/14

Out-of-State v. In-State Utilization Review, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 01/10/13

Malpractice by Utilization Review? politicsofhealthcare.com (The Weinmann Report), 12/13/14 and workcompcentral, 12/19/14

Malpractice Reform Reaches California Supreme court, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 4 Jan 2017

SB 863 Benefits Employers, Harms Injured Workers, politicsofhealthcare.com (The Weinmann Report) & workcompcentral, 7/26/16

Getting to Yes with UR and IMR, Dr. Steven Feinberg, workcompcentral, 02/07/17 (more on this topic in subsequent issues)

WHEN PATIENT CARE INTERFERES WITH REQUIRED DATA INPUT, IT'S THE PATIENT WHO LOSES

First, a word of congratulations to the CEO of the American Academy of Neurology whose reportable compensation from the organization (W-2/1099-MISC) in 2014 was listed as $596,190 and whose estimated amount of other compensation from the organization and related organizations was reported at $35,338 (total of $631,5280).

In 2015 the respective amounts in these two categories grew to $657,503 and $36,142, respectively, an overall increase of  $61, 313 in reportable compensation and an overall increase in both categories of $62,117 (for 2015 the total was $693,645).

Next,  look at the American College of Cardiology (ACC) where the Chairman/president's reportable compensation from the organization was $258,551 and whose "other compensation" was listed as $70,000 (total = $328,551).

Why is ACC financially outstripped by AAN when it reports about 49,000 members to AAN's 30,000?

Neither organization has committed to full scale opposition to MOC or EHR with its attendant penalties for non-compliance. 

AAN, meanwhile, in its December 2016 issue of AAN News, proudly announced that "AAN Lobbying Helps Ease Impact of MACRA Changes on Neurologists" -- a "new program involves a two-track system for Medicare reimbursement"-- actually, what members really want is a Zero Track System -- THAT is what AAN and ACC should be using its net assets to acccomplish.

Both organizations in the opinion of this writer are applying their assets to greasing through MOC, EHR, and similar programs desired by government and/or insurance companies. Both organizations give pricey seminars, continuing educational course, and examinations to members. The need for enhanced organizational income is real.

Dues alone will not pay for the high level of staff and CEO remuneration that have now replaced clinical devotion as the hallmark of the medical profession. This writer's opinion is that the boards and their financial allies can derive mutual income benefit if they can dominate CME (Continuing Medical Education) by making their courses and programs mandatory.  

The net result is less time spent with patients, more time spent doing computer input for EHR to avoid financial penalties for non-compliance, and time actually taken away from true Continuing Medical Education (CME) which produces real benefits for patient and physician alike. 

Patients may not see these issues straight away: what they see are doctors whose focus is on a near-by computer screen during what they thought was going to be a personal medical visit. 

References

AAN News (American Academy of Neurology), V. 30, # 12, December 2016

ACC website (American College of Cardiology, Official site, www.acc.org)

"Maintenance of Certifcation (MOC): a rising business opportunity," 15 May 2015, The Weinmann Report (www.politicsofhealthcare.com) 

IRS Form 990 for 2014; 2015, AAN, and 2015, ACC

"Medical Staff Votes Against Mandatory MOC (Maintenance of Certification Requirements)," 16 January 2016, The Weinmann Report (www.politicsofhealthcare.com) 

"Medical staff votes against Mandatory MOC, Workcompcentral. 22 Jan 2016

MALPRACTICE REFORM MAKES IT TO CALIFORNIA SUPREME COURT

The late and illustrious David J. DePaolo was on target in "Out of State UR" published on 4 January 2013 when he wondered why it should make any difference whether or not Utilization Review (UR) physicians were in-state residents or not. He summarized my own argument at the time by quoting the following: "Because reviewing doctors out of state can't be controlled by California licensing authorities, insurance companies are then free to 'scour the country' for doctors who are willing to to give favorable reviews to insurers." My conclusion at the time, and still is my conclusion, is that "in-state licensure should be required, not in-state residency."

The entire issue has now hit the proverbial fan. UR is now before the California Supreme Court. Fourteen and counting organizations have asked to file amicus curiae briefs. All of of them focus on a combination of clinical matters and legal issues over which looms the spectre of money.

The case at issue is  King v. CompPartners. In January of 2016 the 4th District Court of Appeal issued a ruling that UR physicians have an obligation to apply ordinary care and diligence in their provision of medical opinions with reference to the reasonableness of treatment for injured workers. The clinical issue had to do with the sudden discontinuation of klonopin without having taken due regard of risks, namely, that abrupt discontinuation of this medication is associated with epileptic seizures. This unfortunate situation befell Kirk King when the UR physician reviewing his treatment recommendation in turn advised discontinuation of the medication. The clinical argument is that the UR physician assumed responsibility for the patient when he made a recommendation that directly contradicted the treating doctor's treatment plan and thereby harmed the patient.

One of the organizations filing an amicus curiae brief is the California Applicants' Attorneys Association (CAAA). Their argument is that King is simply asserting his "common-law right to bring a lawsuit against someone ... who may have caused injury." In this writer's opinion, that is precisely what the UR physician did when the insurance company adopted his fallacious opinion and discontinued an indicated and necessary medication.

Not surprisingly, organizations that provide UR physicians are up to their necks in legal riposte. Coventry and Examworks provide UR physicians. These two organizations, among others, argue that UR doctors play only limited roles and as such should not be exposed to malpractice liability. They have the effrontery to argue that UR doctors do not interview or examine the patients so shouldn't be held to the same clinical standard as treating physicians.

They don't remind us about the corporate interests that supported SB 863 which established the misguided public policy allowing legal largesse to UR physicians and their Independent Medical Review (IMR) counterparts -- UR and IMR physicians are not required by law to be licensed in California although both are allowed under SB 863 to provide treatment directives such as the one that discontinued Kirk King's medication and brought the current case to the California Supreme Court.

There is history on this matter that turns out to  have been prescient, maybe even predictive:

In "Malpractice by Utilization Review?" (The Weinmann Report, www.politicsofhealthcare.com, 13 December 2014), this author described a case wherein lyrica was improperly suspended from an injured worker who had had a three-level cervical fusion (the medication was eventually restored by a California licensed physician). This case and the King case have in common that the UR physicians asserted clinical opinions that harmed the lives of patients dependent upon them for good faith judgments. I understand this argument to be the crux of the case being brought by Attorneys Law, Falcioni, and Lockwood on behalf of King.

In "Utilization Review Hypocrisy in Velvet Gloves" (workcompcentral.com, 26 March 2014), we pointed out more reason why the defective UR program should be replaced.

Finally, we mention again that former Medical Board of California (MBC) president Dr. Frantozzi long ago submitted opinion that UR is an aspect of medical practice and that UR physicians should be licensed in California. The underlying fault is inherent in SB 863 which provides the legal basis that allowed for the wrongful discontinuation of lyrica in the case of the patient with the the three-level cervical fusion and klonopin in the case of Kirk King.  

King's case should be sustained by the California Supreme Court. SB 863 should be repealed. The two situations are analogous: without SB 863 the cavalier determinations by  the UR doctors vis-a-vis one patient's lyrica and another patient's klonopin would not have taken place. 

References

"Supreme Court Gets Additional Amicus Briefs for UR Doctor Malpractice Dispute," workcompcentral, 2016-12-29;

"Supreme Court Gets Amicus Briefs in UR Doctor Malpractice Dispute," workcompcentral, 2016-12-16;

"Malpractice by Utilization Review?" The Weinmann Report, www.politicsofhealthcare.com, 2014-12-13

"Utilization Review Hypocrisy in Velvet Gloves," workcompcentral, 2014-03-26;

"Medical Board Asserts Jurisdiction over Utilization Review," workcompcentral, 2013-06-12;

"Out-of-State v. In-State Utilization Review," workcompcentral, 2013-01-10.