Monday, June 18, 2018

27 Pediatricians on the Chopping Block.

In the fiscal fight over health care costs, pediatricians are on the chopping block. In hospitals and clinics across the country, pediatricians are being laid off in droves, leaving the clinical burden to mid-level providers, family physicians, and emergency room doctors. These decisions are being made by suits over scrubs, and they are putting patients at risk.

Recently, three pediatric facilities closed in Dallas when MD Medical Group acquired Children's Health Medical Center and consolidated pediatric operations, terminating twenty-seven pediatricians. In April, Maryland's MedStar Health announced the immediate closure of inpatient pediatrics and the pediatric emergency department at Franklin Square Medical Center. Last October, Boone Hospital Center in Missouri announced it was closing its pediatrics unit. Last September, Pottstown Memorial Medical Center closed its inpatient pediatric unit. And last summer, Mount Sinai hospital in Chicago ended its pediatric services.

“Pediatric hospital care is less available than it used to be..." said senior author Dr. Michael McManus, a pediatrician and professor at Harvard Medical School. "Hospitals are paring back on certain lines of business, and pediatrics is one I think they look at very closely..." said Allan Baumgarten, an independent health care financial analyst.

What's driving this phenomenon? It's largely an attempt for providers to maintain -- or in some cases, maximize -- profitability on a growing share of Medicaid patients. There have been more than 22 million new Medicaid enrollees since the beginning of 2010, when the Affordable Care Act, which greatly expanded the program, was passed. One in two births in the country is now paid for by Medicaid. Yet Medicaid's reimbursement rate is only about half that of privately-insured patients. As a result, hospital executives are looking to cut labor costs, which make up about 60 percent of hospitals' operating costs. 

Faced with these dynamics, many providers, including the prestigious Mayo Clinic, have selectively restricted or refused to treat Medicaid patients. Roughly half of doctors are unwilling to treat new Medicaid patients because they are not profitable. But this approach does little more than foist Medicaid patients onto already overburdened emergency rooms.

Laying off pediatricians in favor of NPs and emergency room physicians is an attempt to monetize these patients. But this is also problematic.

Most importantly, it puts patients at risk of substandard care. NPs require four years of college and a thousand hours of clinical experience -- significantly less than the eight years of college, three years of residency, and 20,000 clinical hours needed by physicians. While NPs can do a wonderful job caring for many problems, they receive far less rigorous training than even medical students, who would never be allowed to treat any patients unsupervised. Worryingly, there are also signs that NP training is becoming watered down by assembly line programs.   

Of course emergency room and family practice doctors will pick up the slack to some degree. But they also don't have the same familiarity or training necessary to meet the unique needs of children, whose physiology, treatment, and responses are often different. In our decades of clinical practice, adult physicians universally recognize the need for pediatric patients to receive care from the doctors who are specially trained to treat them.

Consider an example, which is representative of many other similar experiences throughout our careers. Dr. Al-Agba was able to catch the subtle signs of an unusual condition in an ill toddler during flu season. She was able to determine that the patient had ingested multiple small magnets, which were then attracted to each other and connected inside her intestines, which could have been fatal. She was immediately operated on and recovered uneventfully. 

Missing subtle signs in pediatric patients can lead to deadly consequences. Such cases demonstrate that all children, regardless of income, deserve access to adequate pediatric care.

Is there a solution to this problem short of comprehensive health care reform? Potentially. Instead of looking to pediatricians and other specialty physicians to cut labor costs, providers should look to cut administrative jobs, which have expanded to the point where there are now ten times as many administrators as physicians. Many of these bureaucratic positions offer little-to-no value to the patient or the doctor. In fact, they often impede physician productivity, reducing profitability. 

But for now, pediatricians must speak for children's right to access the physicians specially trained to care for them. Because it is increasingly clear that health care executives will not.

Niran Al-Agba is a pediatrician in solo practice and a board member of Practicing Physicians of America. Marion Mass is a pediatrician and co-founder of Practicing Physicians of America. 

This piece was originally published in the Hill.

Monday, May 28, 2018

Double Standards for Trojans and USC School of Medicine


University of Southern California (USC) appears to look the other way when male physicians harass or assault women.  In reality, sexual violence spares no occupation, including medicine, but the way an organization responds to crime against women indicates a certain level of integrity.  The World Health Organization estimates sexual violence affects one-third of all women worldwide. In a nation where women make up 50% or more of each incoming medical school class, only sixteen percent of medical school deans are female, making gender imbalance in leadership positions nearly impossible to overcome. 

For the second time in less than a year, USC President C.L. Max Nikias is grappling with sexual misconduct allegations against a physician faculty member.  Complaints go back to the early 1990s from staff and patients about inappropriate comments and aggressive pelvic exams done by Dr. George Tyndall, the only full-time gynecologist for the past three decades at the campus clinic.  USC ignored complaints until a nurse contacted the campus rape crisis center. 

Dr. Tyndall was initially suspended pending inquiry and forced to resign shortly thereafter.  More than 100 complaints have been received and five women are suing USC.  Astonishingly, the founded complaints against Dr. Tyndall were never turned over to authorities or reported to the Medical Board of California.  USC defended this decision, asserting there was no legal obligation to report misconduct. USC has a moral and ethical duty to protect students, staff, and faculty, yet failed on both counts.

USC is no stranger to scandal.  In 2007, Dr.  Carmen Puliafito, MD, a Harvard Medical School graduate, was chosen as Dean at the USC School of Medicine.  His background held clues he would be trouble. Just prior to arrival at USC, Puliafito settled a lawsuit for throwing a “tantrum” and committing assault and battery against an optometrist named Marc Brockman at the University of Miami.  During the trial, Miami University disclosed they had previously investigated sexual harassment complaints against Puliafito too. 

Puliafito was a strategic fundraiser, bringing in over $1 billion in donations for the Trojans; however, he kept company with criminals and documented his illicit drug use on video.  His nightlife came to screeching halt when a 21-year-old female companion overdosed in a Pasadena hotel room and an ambulance transported her to the hospital. Police confiscated more than 1 gram of methamphetamine from the hotel room, but inexplicably, no police report was filed until three months later identifying Puliafito as a witness to the overdose.

An anonymous witness phoned the office of the USC President Nikias and reported Puliafito’s activities.   Ten days later, Puliafito resigned, however President Nikias never filed a complaint with the California Medical Board or the authorities.  When the LA Times discovered Puliafito was still practicing as part of the USC faculty, President Nikias issued a ‘mea culpa’ admitting “they could have done better.”  Unfortunately, his next choice was anything but better. 

Dr. Rohit Varma succeeded Puliafito as Dean at the School of Medicine but resigned amid scandal after less than a year.  He had settled a sexual harassment claim in 2003 and was disciplined by USC.  Varma – then a 40-year-old junior professor – attended a conference with a young international student he was supervising.  He allegedly told his student that the grant they were travelling on only supported staying in a single shared room. When the student protested, Varma took her phone and threatened to have her visa revoked. USC reached a $135,000 settlement with the woman, of which Varma paid $11,000.  He was ordered to complete sexual harassment counseling and denied a promotion, yet one year later, earned full professorship, as if nothing ever happened.

Is USC defending “bad boys” with little regard for women? Or is there something else going on?  One might argue that threatening your subordinate with visa revocation is borderline sociopathic.  Are they being protected because they are physicians or simply because they are men?   

The only way to answer this question is to look at what happens when a female physician and male physician have a hostile interaction.  One evening, Dr. Meena Zareh, a cardiology resident at USC, reported being summoned to a windowless call room by Dr. Guillermo Cortes, her direct supervisor, to discuss a patient. When she attempted to leave, Dr. Cortes allegedly overpowered her, blocked the door, and assaulted her.  Dr. Zareh shared the incident with a co-worker afterward but did not report it to law enforcement or the residency program for fear of reprisal until three months later.  Dr. Cortes denied allegations and was placed on administrative leave pending investigation.

Dr. Cortes was allowed to return to work but was barred from unsupervised contact with Dr. Zareh.  Reprisals toward Dr. Zareh began almost immediately, a signal of mounting institutional pressure to sweep her allegations under the rug.  One male supervisor suggested she take a leave of absence, while others recommended deferring fellowship training or changing residency programs.  Dr. Zareh is suing USC and LA County for mishandling her report of sexual assault, a mistake in which USC seems to be accumulating expertise.   If the pattern holds, Dr. Cortes will get a promotion, a raise, and may become a future Dean at the Keck School of Medicine.

While double standards remain alive and well in academia, there are rays of hope.  Dr. Laura Mosqueda, a geriatric physician, is one of those.  She is the first woman chosen to lead the Keck School of Medicine since it was established in 1885.  It is about time.  In the race to become a top-tier program, I have no doubt Dr. Mosqueda will achieve a great deal more than her predecessors.  After all, how could she do any worse? 

Wednesday, May 9, 2018

MedStar Franklin Square Hospital: The Case Against Global Capitation

Baltimore County, Maryland is one hour north of Washington DC, where politicians appear impotent to contain runaway healthcare expenditures.  In January 2014, the Centers for Medicare and Medicaid Services (CMS) in partnership with the state of Maryland, piloted an “All Payer Model,” where every insurer, including Medicare and Medicaid, paid a fixed annual amount irrespective of inpatient or outpatient hospital utilization.  Maryland agreed to transition hospitals from fee-for-service arrangements to this global capitation model over five years. 

Capitation, in general, reimburses a fixed amount per patient, unrelated to service volume.  This sets an artificial fiscal ceiling and disincentivizes hospitals, physicians, and other healthcare personnel to provide healthcare. The philosophy is if hospitals or physicians reduce their output and save money, the unused funds can be kept by the organization. The basic premise of capitation pays hospitals, physicians, and others to AVOID providing care, an unfortunate consequence. 

Maryland is experimenting with global capitation, which allots a fixed sum to an institution from each payer, making revenue predictable, while at the same time, encouraging stewardship by the hospital to allocate funds wisely.  When expenses are lower than the prearranged sum, that hospital retains the leftover funds as additional profit.  To ensure care is not withheld to increase revenue, quality measures are assessed and shared publicly.  A 2015 report in the New England Journal of Medicine showed expenditure reductions of 0.64% and inpatient admissions decreased by 5%.   However, with unproven payment arrangements, unintended consequences always occur. 

The unforeseen casualty in this story is the pediatric department at MedStar Franklin Square Hospital.  On April 3rd, 2018, MedStar abruptly announced all pediatric inpatient care and emergency services were closing, effective April 6th, and all pediatric staff, including eight physicians, were terminated.  Sadly, Baltimore County is home to some of the nations’ most vulnerable families, struggling with high rates of drug addiction, domestic violence, and poverty.  The hospital catchment area serves children attending thirty-seven schools, half of whom are covered by Medicaid. In 2017, Franklin Square pediatric ER evaluated 17,000 children and over 800 were admitted as inpatients.

For hospitals in global capitation arrangements, higher profit margins materialize in those service lines with low utilization.  Commercially insured patients bear responsibility for out-of-pocket costs, co-pays, cost shares, and deductibles; therefore, they tend to be low utilizers. It is well accepted that costs generated by Medicaid patients are considerably higher than commercially insured patients.  Following Oregon Medicaid expansion, emergency department (ED) visits increased by 40% and follow up studies determined this upsurge did not dissipate over time.  MedStar Franklin Square has finite monetary resources; the pediatric service line is a “loss leader” when half of the pediatric patients have Medicaid coverage.

In the corporatized medicine world, improving profit margins is essential to justify inflated executive salaries, such as those of CEOs Kenneth Samet and Samuel Moskowitz, who in 2015, grossed nearly $5 million and $1 million, respectively. MedStar Franklin Square, a nonprofit hospital, was granted tax-exempt status in exchange for providing services to local communities, such as charity care and medical outreach.  However, global capitation payment arrangements slim the profit margin substantially, requiring maximum efficiency to optimize revenue. 

When hospitals make short-sighted decisions, the public should know the increased risk they will face.  Pediatricians are specially trained to provide care to children, their expertise lowers mortality rates for patients under the age of 18.  The death of 12-year old Rory Staunton is a cautionary reminder of consequences when subtle signs of disease in children are overlooked by non-pediatric experts.  Medical records released by his parents, showed he had signs of impending sepsis, including fever, elevated heart rate and respiratory rate, and a blood pressure of 103/50, far below normal in an adolescent who is 69 inches tall and 169 pounds. 

The U.S. Department of Health and Human Services (HHS) is condoning hospital systems to sacrifice the lives of children to reduce healthcare costs through global capitation.  MedStar Franklin Health likely prefers treating commercially insured patients over those on Medicaid.  They are not alone.  One year ago, Mayo CEO Dr. Noseworthy encouraged prioritizing commercially insured patients over those on Medicaid to preserve financial strength of the institution.  Small and large communities throughout the nation have lost critical access, including Albert Lea, Minnesota, Kitsap County, Washington,  and Louisville, Kentucky, yet politicians are too distracted by legislative gridlock to see what is happening in their own backyard.  Bob Dylan said it best, “How many deaths will it take ‘till he knows that too many people have died?”  The answer is not to hinder access or discourage utilization; the answer, my friend, is to incentivize hospitals to protect the lives of our most vulnerable citizens. 

Tuesday, April 24, 2018

The Tapeworms are Hungry for Direct Primary Care

When Amazon, Berkshire Hathaway, and JP Morgan (AmBerGan) announced their healthcare partnership, Berkshire CEO Warren Buffett declared “the ballooning costs of healthcare act as a hungry tapeworm on the American economy."  He is right.  Our broken system is infested with tapeworms. Tapeworms are parasites; they exploit their hosts, drain resources, and suck the life out of their prey.  Unfortunately, Buffett failed to call attention to the tapeworms specifically --they are insurers, hospital conglomerates, pharmaceutical companies, and pharmacy benefit managers.  

As healthcare costs continue to skyrocket, Americans increasingly find themselves struggling to make ends meet.  Direct Primary Care (DPC) is a “tapeworm-free” medical concept whereby: 1) a periodic fee is charged for comprehensive primary care services, (2) the arrangement is free from billing through third parties, and (3) if additional fees are charged, those are less than the monthly fee.  Depending on age, fees range between $60-150 per month. Patients gain direct access to their physician coupled with unprecedented levels of affordability. 

DPC physicians provide protracted office visits, after-hours appointments for emergencies, and occasionally, even home visits.  DPC practices can dispense chronic medications at wholesale prices, perform basic procedures in-office, and when outside testing is necessary, these physicians can negotiate discounted “cash” prices on behalf of their patients.  This model goes a long way toward restoring the sacred relationship between a patient and their physician.  It is no wonder patients are leaving the health care system in droves.

The last obstacle facing expansion of the DPC practice model is their misclassification as an “insurance” product rather than a “healthcare” entity.  Legislation, known as the Primary Care Enhancement Act, already exists to repair this mistake and has 29 cosponsors.  H.R. 365/ S.R.1358 would allow for two things:  1.  Taxpayers participating in a DPC arrangement may qualify for an HSA plan and 2. HSA funds could be used for monthly fees for a DPC arrangement.  According to the Moran Company, this legislation is nearly “deficit neutral.” 

Why has this legislation floundered? Because corporate interests, like those of the Amazon group and CVS-Aetna, have left Congress a little dazed and confused.  Enter Capitated Primary Care (CPC) from stage left, an entirely different medical practice model, where a pre-negotiated rate is paid monthly by a third party for unlimited primary care services.  This model welcomes the third-party back with open arms.

To make things more confusing, the Centers for Medicare and Medicaid Services (CMS) jumped on the DPC bandwagon by introducing a “Direct Primary Care Prototype,” is anything but direct primary care.  The CMS concept requires physician enrollment in Medicare and submission of patient data to receive capitated payments of $90-120 per month.  This innovative model is certainly intriguing, but is another example of capitation, not DPC.  Data on capitated payment for healthcare services is equivocal at best, an indication that cost containment is difficult to achieve with third party involvement.   

Following CMS footsteps, the Amazon group hired Martin Levine, MD, a geriatrician formerly of Iora Health, a Boston-based CPC entity focused on providing comprehensive services for the over-65 crowd, indicating they may be intrigued by the CPC model as well. Corporate entities should not lose sight of the fact that Qliance and Turntable Health went bankrupt last year after offering team-based CPC services to the masses. 

Tapeworms represent third parties who have ingratiated themselves into the patient-physician relationship in the interest of the almighty dollar.  As the distance has grown between patients and physicians, costs have spiraled out of control.  By inviting extra layers of bureaucracy, CMS and other corporations are essentially slapping lipstick on the tapeworm and trying to make CPC look as attractive as Direct Primary Care, but that is an illusion.  Cost-containment can only be achieved by bringing the patient and physician in closer proximity and eliminating the tapeworm infestation currently sucking the life out of the healthcare system.



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

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

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.