Tuesday, April 17, 2018

The Health Care Policy Podcast with David Introcaso.





This week, I am sharing a podcast with David Introcaso.  He invited me on the show after reading a piece of mine written in support of the National Walkout on March 14, 2018.  We covered some great material about what I believe physicians should be doing about gun violence.  I do hope you enjoy listening.  

#enoughisenough #NeverAgain




http://www.thehealthcarepolicypodcast.com/2018/04/upcoming-podcast-pediatrician-dr-niran-al-agba-discusses-gun-violence-ie-her-experience-treating-col.html

Monday, April 16, 2018

How These Useless Doctors' Exams Are Raising Health Care Costs (via Fortune Magazine Online)




By Niran Al-Agba and Meg Edison April 9, 2018



Maintenance of Certification (MOC) tests for doctors like us might sound like a good idea at first glance. MOC requires us to take frequent modules and tests to remain certified and keep our jobs.

But the truth is that these tests provide no value to doctors or patients; in fact, they contribute to rising health care costs because they take doctors’ precious time away from treating patients.

Recognizing the MOC burden, nearly 20 states have introduced legislation to curb it, with Washington state passing a bill to forbid it as a condition of licensure in late March. The rest should follow suit.

MOC is a cash cow for the American Board of Medical Specialties (ABMS) and its 24 specialty boards, which administer the exams. According to its most recent tax filings, ABMS president Lois Margaret Nora made nearly $700,000 in compensation from the organization in 2016. Thirteen other executives made over $150,000 from the nonprofit in the same year. In total, ABMS spent over $10 million on compensation, more than half its annual revenues, which largely come from inflated testing fees. That’s good work if you can get it.



But can doctors like us ever be under-educated, given the complex and vital nature of our jobs? Of course not.

It’s true that doctors can never learn enough. That’s why we are the most trained professionals in existence, studying for more than 10 years before becoming certified. We then complete 50 hours of continuing medical education every year to maintain our state medical licenses and keep up to date with the latest developments in our fields.

MOC is different. It is credentialization, not education. The tests don’t mirror real-world scenarios. They provide no educational value. A 2002 meta-analysis of 33 studies found no association between MOC and positive clinical outcomes. Older doctors, grandfathered in and exempt from MOC, are no less qualified than recent grads are. And two 2014 studies comparing MOC-required and MOC-grandfathered doctors showed no performance differences.

Depending on specialty, doctors must complete monthly modules, yearly tests, and complete board recertification every 10 years. No wonder a 2016 Mayo Clinic survey found that 81% of doctors think MOC is a burden.

Each year, millions of physician hours are spent on MOC, time that could otherwise be devoted to patients. MOC requirements have brought doctors to the point where they now spend roughly two-thirds of their workday on paperwork. For physicians in rural practice, the nearest testing center can be hundreds of miles away, meaning a whole day of lost time treating patients.

Allowing doctors to be more productive by limiting MOC would also help alleviate the growing physician shortage, which the Association of American Medical Colleges predicts will grow to 95,000 by 2025. MOC requirements contribute to this doctor shortfall, with studies suggesting some doctors take early retirement to avoid them.

MOC is technically voluntary, but in practice it is not. Requirements for MOC have been included in physician licensing, hospital credentialing, and commercial insurance contracts. This means that doctors who don’t participate can lose their licenses, credentials, and insurance contracts.

State bills to reign in MOC generally prevent hospitals and insurers from requiring it as a condition of employment, payment, or license. In 2016, Oklahoma became the first state to succeed. Georgia, Maryland, Missouri, North Carolina, Tennessee, Texas, and as mentioned earlier, Washington state have followed suit.

The ABMS won’t give up its slush fund without a fight. It is engaging in a fearmongering campaign claiming doctors need MOC to be qualified. It has retained a high-priced Chicago PR firm, to whom it gave close to $450,000 in 2015.

State legislators looking for marginal—yet effective—reforms to improve patient access to physicians should join the growing number of states passing laws to eliminate MOC requirements as a condition of physician employment. The only losers from such legislation would be nonprofit administrators who are making millions off this scam.

Drs. Niran Al-Agba and Meg Edison are pediatricians in Washington state and Michigan, respectively, and are advisory board members at Practicing Physicians of America, a physician advocacy organization.
This article appeared in Fortune Online at http://fortune.com/2018/04/09/doctors-maintenance-certification-moc-health-care/

Wednesday, April 4, 2018

Firing Dr. Shulkin, One Really Good Decision





Dr. David Shulkin once gave me this advice, “stop whining and complaining and lead with solutions.”  To the many frustrated physicians in this country, this critique is a fair one.  I took his words to heart. 

Let me start by saying my husband served 20 years in the United States Army and is a proud Veteran.  I think our veterans deserve better than Dr. David Shulkin.  His ousting as VA Secretary by President Trump this past week is akin to “leading with solutions” from my perspective. 

Dr. Shulkin appears to have engaged in considerable double-speak throughout his 13-month tenure in Trump’s Cabinet.  In his New York Times op-ed, he wrote, “I will continue to speak out against those who seek to harm the V.A. by putting their personal agendas in front of the well-being of our veterans.” 

When it comes to personal agendas, there are few who are as laser focused as this man.  Initially endorsing campaign pledges by Trump committing to increased accountability at the VA, his European trip—for which taxpayers paid $122,334—involved more sightseeing and shopping with his wife than “official” government activities.  When the Washington Post first reported this story, Shulkin assured the public "nothing inappropriate” took place.

In February 2018, a report released by the Inspector General of Veterans Affairs contradicted his claims.  It found Shulkin and his staff committed ethics violations in planning and executing the 10-day international excursion, by altering emails and making false statements to justify the accompaniment of his wife on the taxpayer-funded trip. The VA paid over $4,300 in airfare for his wife alone.

The Inspector General’s report also found Dr. Shulkin had inappropriately accepted tickets to Wimbledon worth thousands and had directed an aide to act as a "personal travel concierge" for the trip.  In his op-ed piece, he feigns ignorance, “I am a physician, not a politician.”  Based on my personal experience, this is a classic tap dance move by the man who should be known as Dr. Wimbledon. 

Just over a year ago, I met Dr. Shulkin in his office while working in Washington DC on behalf of independent physicians.  A highly esteemed colleague of mine previously worked at the same hospital with Dr. Shulkin and scheduled a meeting to discuss healthcare reform.  My colleague asked for a “wing woman” and I happily tagged along.  Knowing their shared history, an exchange of pleasantries seemed far more likely than the haranguing with insults that ensued.  In my opinion, Dr. Shulkin was one of the most pompous men I have ever encountered. 

Suddenly, he was more politician than physician.  Dr. Shulkin said “physicians have no idea what they want” as if he was never one of our kind.  In the middle of his tirade, he took a breath.  Unable to hold back any longer, I jumped in head first.  Whether shocked by the exchange of reasonable ideas or simply surprised at a physician devoid of fear, my comments stopped him cold.  He replied, “huh, that might work.”  Brilliant, Sir Politician. 

As if on cue, his phone rang, and he let us know he and his buddy, President Trump, had important things to discuss.  “Now get out of my office and don’t come back.”  I wanted to respond, “if you were the last man on earth, holding the very last morsel of food, I would happily chew off my own arm before giving you the satisfaction of winning.”  Instead, I gritted my teeth, smiled, and choked out the word, “gladly.” Obviously, I will not have the opportunity to visit his office again. 

He closes his disingenuous opinion piece with “it should not be this hard to serve your country.”  Actually, Dr. Shulkin, it IS hard, very hard.  You are not a veteran yourself, so how could you have any idea what it is like on the battlefield?  While selling the notion you were fired for your stand against privatization, that is hardly what happened now is it?  You did not act with “the utmost integrity” in support of the 20 million U.S. Veterans.  You were charged with fixing a dysfunctional system built to serve a population who have devoted their lives to teamwork and sacrifice.  Our veterans deserve better than the healthcare currently being provided to them.  While some vilify President Trump for his decisions, let me assure you that firing Dr. Shulkin from a position he should not have held in the first place was great for America – and our veterans.    




Tuesday, March 27, 2018

Health Savings Accounts: Are Lawmakers Being Target-ed or Getting Amazon-ed?






Health Savings Accounts (HSAs) allow individuals to use pre-tax dollars to pay for high deductibles and other uncovered medical expenses.  Currently, individuals are ineligible for tax-advantaged HSA contributions if they have “other” coverage in addition to a High Deductible Health Plan (HDHP.)  Expanding HSAs to fund out-of-pocket expenses for routine healthcare places control directly in the hands of patients, a move that could bring down health expenditures.  Large corporations are wrestling for control to direct where patients spend their hard-earned money.

A group of lawmakers recently introduced the “bipartisan” Health Savings Account Improvement Act of 2018 (H.R. 5138). This bill allegedly “expands” HSA coverage to allow use at “retail-based” (think CVS/Target) or “employer-owned” clinics (think Amazon) without losing eligibility to make tax-advantaged contributions to their HSAs.  Increasing the flexibility of HSAs is a laudable goal yet, this legislation herds Americans like sheep into Minute Clinics for the benefit of corporate shareholders. 

This bill should not become law.  If HR 5138 passes, retail and employer-based clinics will become profit centers.   Alternative legislation, known as the Primary Care Enhancement Act (H.R. 365), amends the definition of “qualified medical expenses” to include fees paid to physicians as part of a “primary care service arrangement.”  This common-sense legislation flounders in Congress every year. 

A minute clinic seems convenient, but that is an illusion. In my experience, approximately one-third of patients are misdiagnosed at retail-based clinics, which drives up cost exponentially.  Many years ago, a little girl was seen twice at a “retail clinic” without improvement.  Presenting initially with abdominal pain, she was diagnosed with a urinary tract infection.  She returned the next day with a rash and was examined by a different “provider.”  He concluded her rash was caused by an allergy to an antibiotic.

On Monday morning, the mother brought her daughter in to my clinic.  She did not have hives.  She had petechiae --purplish spots that do not blanch-- covering the lower half of her body.  She had an uncommon pediatric condition known as Henoch-Schonlein purpura, an auto-immune condition, which causes complications when it goes unrecognized.  How many visits to the retail clinic would be necessary to get it right?  I do not want to know.

The lawmakers sponsoring this misguided legislation are Rep. Mike Kelly [R-PA-3], Rep. Brian K. Fitzpatrick [R-PA-8], Rep. Blumenauer [D-OR-3], Rep. Erik Paulsen [R-MN-3], Rep. Ron Kind [D-WI-3], and Rep Terri Sewell [D-AL-7].  Why are lawmakers giving “retail clinics” a leg up on the competition?  It appears they have been either Target-ed or Amazon-ed.

Representatives Kelly and Fitzpatrick appear to be afflicted with Amazon fever; two cities in their great state of Pennsylvania are currently under consideration as Amazon HeadQuarters 2.   Rep. Paulsen hails from Minnesota, where two of the nations’ leading retailers, Target and Best Buy, have their corporate headquarters.  The Target Corporation is the top contributor for his entire legislative career.  The Target Corporation also contributes heavily to Rep. Ron Kind from Wisconsin, another co-sponsor, hailing from the Midwest.

HSA expansion will be a bonanza for the banking, finance and credit industries, who hold and service HSA funds.  Rep. Terri Sewell from Alabama has close ties to these sectors, which make up some of her best contributors when separated by industry.  Rep. Blumenauer, from Oregon, is strongly supported by the Retail Industry Leaders Association (RILA,) a trade group for the world’s largest retailers and distribution centers [translation: Amazon].  In the financial sector, Berkshire Hathaway, a multinational holding company, is a top contributor to the Blumenauer re-election campaign. 

Our Government should be Of the people, By the people and For the people – not Of Target, By Amazon, and For Berkshire Hathaway.  Being seen by a midlevel provider at a big box retailer cannot save money.  Lawmakers sponsoring H.R 5138 are doing the nation a grave disservice by sponsoring this atrocious legislation.  The playing field should, at least, be level.  Health Savings Accounts (HSAs) must be expanded to allow patients to choose independent physicians, direct primary care practices, retail-based, or employer-based clinics.  Americans are quite capable of spending their healthcare dollars wisely.






Tuesday, March 13, 2018

National Walkout Day, March 14... These Boots are Made for Walking.






A National School Walkout Day is planned for March 14, 2018 at 10 a.m. and will last 17 minutes in honor of the 17 students and staff members killed at Marjory Stoneman Douglas High School in Parkland, Florida, on Valentine’s Day.  The heart of the nation has seemed to shift overnight regarding the debate on guns, but this change has been almost two decades in the making.  United and Delta Airlines pulled their support for the NRA, Dicks’ Sporting Goods will not sell assault-style weapons, and Walmart plans to raise the minimum age to purchase a gun to 21 years old. 

I am a pediatrician.  I have sat on the sidelines for far too long --  I watched from a front row seat as frightened, grieving children who survived the shooting at Columbine High School on April 20, 1999 struggled to put their lives back together.  My pediatric internship began June 23, 1999, at the Children’s Hospital in Denver, Colorado, approximately 20 miles north of Columbine High School.  Up until that time, a mass shooting inside the walls of a high school had been almost unimaginable.  Many students who had survived by hiding under a desk in the library that tragic day crossed my path over the next three years.  In reality, every student and teacher inside Columbine High School was irreparably damaged forever; they lost a huge part of themselves on that solemn, heartbreaking day. 

Why has so little changed in almost 20 years since Columbine? I don’t know.  Why has so little changed since the mass shooting at Sandy Hook where 20 children and 6 adults were gunned down in cold blood?  I cannot understand.  Why has the mass shooting in Parkland, Florida galvanized the nation?  Because now, it is our innocent children leading the fight for meaningful change. 

“Silence in the face of evil is itself evil.  Not to speak is to speak.  Not to act is to act.”  These are the immortal words of Dietrich Bonhoeffer, a German pastor and theologian, who was executed for his anti-Nazi beliefs in 1945.  Unspeakable damage is being done to our children and it is time we, as parents, teachers, administrators, and community members stand with them. 

Now is the time to speak and the time to act, before more children die.  At Columbine High School, it took only six minutes to kill 10 and wound 12.  At Sandy Hook Elementary, it took a mere five minutes to kill 26 and wound 2.  At Marjorie Stoneman Douglas High School, it took just 7 minutes to kill 17 and wound 14.  These statistics are sobering. 

As a pediatrician, I have spent over two decades acquiring knowledge on adolescent growth and development. Teenagers acquire higher-level thinking in the form of cognitive competence, which includes the ability to reason effectively, problem solve, reflect, think abstractly, and make plans for the future.  Linear, black-and-white develops into a broader understanding of the shades of gray.   These new capacities allow them to engage in mature decision-making with a depth they did not previously possess. 

Society is not giving them enough credit.  Teenagers are capable of a great deal more than we recognize.  This is the moment where we should stop talking, give these young people the floor, and listen to their words.  Their opinions matter.  Their continued growth and development matters.  Their mental health and safety matters.  Their contributions matter.  Their future should matter to all of us.  

While there are no easy solutions, I support the efforts of every student participating in National Walkout Day as they endeavor to bring much-needed attention to gun violence inside our schools.  Our children are actively engaging in a form of civil disobedience for likely the first time in their lives about a critical safety issue they face every day.  Young people are depending on the courage of the nation and our lawmakers to do what is right, which includes enacting bipartisan common-sense gun safety regulations that could literally save their lives.    Please join this generation of motivated students from Parkland, Columbine, Sandy Hook, and many other schools across the country to support their efforts, on March 14, National School Walkout Day.  While I may not agree with every idea or proposal of these young people, I respect them, I salute them and I validate their strong stand against what they see as injustice. 






Tuesday, March 6, 2018

The Peril of Online Physician Reviews



You may have heard that before you pick a doctor you are supposed to look them up online and see what other people have to say about them before you set up an appointment.
In the Age of Amazon this makes sense. Why wouldn’t you?
Allow me to give you a little insider information.  While they may well be a good idea in theory, Yelp.com and other online physician review sites have evolved in recent years to become the bane of my and fellow doctors existence. 
This past summer, Physicians Working Together, a non-partisan physician organization, started a petition on Change.org requesting Yelp remove online reviews of doctors.  To date, more than 30,000 physicians have signed it but I doubt Yelp will pay much attention.
Recently, the highest-level court in Germany ruled Jameda, an online physician rating site, must remove the name of a disgruntled physician.   A dermatologist from Cologne filed the case in the Federal Justice Court demanding Jameda remove her name due to the fact the anonymous nature of the rating site inspires the public to leave spiteful, vindictive comments.  Interestingly enough, in 2014, a gynecologist asked to be removed from Jameda, however the Court ruled the right of patients to be “well informed” about their doctor took precedence over freedoms of the physician.
What is the value of rating physicians online?  Are consumers becoming “well-informed?”
Patient advocates would argue rating sites for physicians improve transparency for consumers.   Physicians would counter with the argument that a medical clinic is not like a restaurant, hair salon, or shopping mall.  We engage in a highly personal way with the public that is quite different from sitting down for a meal.  The larger concern is whether or not Yelp.com patrons are actually “well-informed” by reading online physician reviews. 
After a little research, it appears the answer is no.  I used a local medical community as an example.  The reviews overall are not very good; on average the medical clinics are 3.0/5.0 stars.  Some reviews extol on physical appearance of the physician, be they female or male.  One reviewer discusses being offended by seeing a transgender physician, an element which has little to do with the provision of medical services.  At first glance, one might believe moving to Kitsap County, WA is akin to choosing between life and death.  Rest assured, most of the populace is alive and well. 
Online reviews are not a reflection of medical care quality.  Patients do not like receiving medical bills and do not like rude clinic staff.  They are unhappy if the physician disagrees with them, they abhor long wait times, and they detest prior authorizations, (news flash, so do physicians!) Yet these criticisms are not a reflection of the healthcare quality provided by the physician.  It is doubtful these grievances even have an impact on the mortality rate. 
According to “well informed” consumers, which qualities make a physician “good”?
Actually, the answer is amusing.  It is best if a physician is in fact, not a medical doctor at all.  It turns out EVERY naturopathic doctor, homeopathic doctor, chiropractor, and acupuncturist in my community is providing five-star-rated care.  One patron gave a few alternative practitioners only one star, but those reviews were more than nine years old; alternative medical practitioners were not as “well-accepted” by a “well-informed” public at that time.  As with other service businesses, the internet is unlikely to replace good, old fashioned “word-of-mouth” referrals. 
While internet ratings are not an accurate way to measure medical care quality, they are a way for angry individuals to air grievances, whether those are truth, lies, fiction, or somewhere in between.  For example, a one-star rating was left by a woman who did not like the way a staff member answered the phone at one clinic; she went on to give 5 one-star ratings to other physicians nearby at other clinics.  Interestingly enough, googling her name brings up a Yelp.com review describing her as having borderline personality disorder. 
What is the public being informed of exactly?  Not much.  Physicians may have difficulty responding to patient reviews without compromising protected health information, ultimately rendering them defenseless.  If the goal is to keep everyone accountable, where is the balance between physicians and consumers?  Should physicians have a database to rate patients?  Accountability is where the rubber meets the road and it cannot be found in online reviews of physicians.  Ironically, the lawyers in my community have very solid 5.0-star ratings, that is, unless they delivered a summons, then they were given a 1.0-star rating. 
Yelp and other physician rating sites should remove the physician reviews entirely because these entities are selling something they cannot deliver.  Until a physician wins a case against Yelp, Google, or another physician rating site, it seems wise to give every patient exactly what they ask for, never argue or tell them the truth, hire staff members who are like Mary Poppins and “practically perfect in every way”, and prioritize timely visits no matter if a patient is dying in the next room.   
Is it any wonder the U.S. mortality rate continues to fall?

Tuesday, February 27, 2018

Sandy Hook Promise: The "Human" Side of the Gun Debate






Last week, another school shooting took place in Parkland, Florida, and cut short the lives of 17 high-school students.  The epidemic of school violence is a public health issue and warrants development and implementation of evidence-based prevention strategies.  Each school shooting begins long before the fatal shots are fired; studies show most have been planned up to 6 months beforehand.  The answer to gun violence cannot be found in the halls of Congress; the responsibility to protect our children lies with every parent, teacher, politician, student, and community member in America.  It is time to direct our efforts toward preventing violence BEFORE it happens by recognizing the warning signs of a child at risk and intervening. We must change the conversation about gun violence to alter the course of the future for our children.

On December 14, 2012, 20 children and six adults were gunned down inside Sandy Hook elementary school in Newtown, Connecticut.  A core group of parents who lost children that tragic day saw past their grief and created Sandy Hook Promise (SHP), a non-partisan national nonprofit organization focused on preventing gun violence BEFORE it occurs. SHP has trained 2 million adults across 50 states.  Since inception, their programs have helped stop multiple school shootings and suicides, reduced bullying and victimization, and ensured hundreds of youth receive mental health and wellness assistance.

Their three-part program is extraordinarily simple and effective. 

1.      Know the Signs to identify when a child is feeling alienated and connect with them by “starting with hello” and “saying something” to a trusted adult.

2.      Educate parents, teachers, and community members using evidence-based violence prevention strategies. 

3.      Focus on the “human” side of gun violence and be “above the politics.” 

“Start with Hello” is a program which encourages social inclusion and community connection. Our children can be taught to recognize isolation, marginalization, and rejection in their peers.  Parents and teachers can create a more inclusive school culture by training children to reach out to those who seem lonely and support growth of their coping skills.  Adverse childhood experiences can devastate even the most resilient among us.  The value of connectedness between children cannot be overstated.

 “Say Something” is designed for middle and high school-aged children to better recognize the warning signs of escalating behavior on social media in particular.   When adolescents are struggling, they tend to confide in their peers, many of whom are not equipped to intervene.  The second part of this program teaches young people to notify a trusted adult with their concerns.  By looking out for one another, and taking all threats seriously, whether written, spoken, in photo or video form, our schools and communities will be made safer. 

Safety Assessment and Intervention (SAI) is a cornerstone of the Sandy Hook Promise program that was developed by Dr. Cornell at the University of Virginia and has been rigorously evaluated for more than a decade.  SAI trains multidisciplinary teams within schools and communities to identify, assess, and respond to threats of violence while paying special attention to address the underlying conflict which led to concerning behavior in the first place.  Scientific studies show SAI-trained teams are capable of evaluating threats, distinguishing when they are serious, and intervening to prevent violent acts.

Hilary Clinton once said, “there’s no such thing as other people’s children.”   Every child is mine.  Every child is yours.  Every child adds value to the world.  By preventing just one child from bringing a gun to school, we could transform the life of not only that child, but also every student in attendance that day, plus every teacher, administrator, parent, grandparent, and community member working to support vulnerable young people.  

Laws will not change the mindset of a school shooter; we can only make an impact by altering the outlook of the school shooter.  It is time for meaningful action where we can find consensus.  It is too late to go back and save the children who were already gunned down at their schools, however we should honor their lives by supporting programs like Knowing the Signs, focusing on the delivery of mental health services to children and adolescents, and protecting at-risk individuals from firearm access and ownership.  We must talk with each other and our children about gun violence before more children die.

You can learn more about the Sandy Hook promise at www.sandyhookpromise.org. Additionally, I urge Gov. Jay Inslee and Washington State Superintendent of Public Instruction Chris Reykdahl to review the Sandy Hook Promise program and consider sharing the materials with every school district in Washington State.