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.   

Tuesday, February 20, 2018

CMS Quietly Launches an Offensive Against Direct Primary Care

CMS could be a wolf in sheep's clothing 

Our healthcare system is self-destructing, a fact made more obvious every single day.  A few years ago, a number of brave physicians who were fed up with administrative burden, burnout, and obstacles to providing care for patients started a movement –known as Direct Primary Care (DPC.)  This is an innovative practice model where the payment arrangement is directly between a patient and their physician, leaving third parties, such as insurance or government agencies, completely out of the equation. 

The rapidly growing number of DPC physicians have organized into a group called the DPC Coalition (DPCC); suddenly, the Centers for Medicare and Medicaid (CMS) is paying attention.  As of February 2018, there are 770 DPC practices across the United States with new clinics opening each week as brave physicians leave the “system” behind, never looking back. Breaking free from the chains of insurance and government, this group is restoring the practice of medicine to its core, a relationship between a physician and their patient.   

CMS understands there is a problem with the way Medicare services are being delivered to tax payers; it turns out their idyllic version of “high quality” care is not as affordable as they predicted.  All evidence indicates the DPC model is not only capable of generating significant cost reduction, but also saving the federal government billions if administered on a large-enough scale.  As fewer physicians accept Medicare and convert to DPC practices, CMS wants a piece of the pie. 

CMS has chosen to hold focus groups in four cities, two meetings occurred in Boston and Dallas this past week; two more will be held in Denver on February 19th and 20th, and in Seattle on February 21st and 22nd.  One day is for independent FFS physicians and the other is for DPC physicians.  Last week, questions for the groups were reportedly: “what do you think is wrong with Medicare,” “what needs to change,” and “what will make it better?”  I find this approach patronizing as the majority of DPC docs (and many FFS) have OPTED OUT of Medicare entirely.

Two physician organizations supporting the DPC model are the American Academy of Family Physicians (AAFP) and the Direct Primary Care Coalition (DPCC.)  Representatives from both organizations were secretly present at the “listening sessions” last week, however neither organization openly disclosed the CMS meeting to their general membership.  These organizations should work to preserve and protect physician autonomy rather than invite the government to the table and conceal that fact from their membership.  DPC physicians already opted out of government control.  Why on earth would DPCC and AAFP entertain inviting a third party back into the fold? While some members of AAFP or DPCC might be interested in a Medicare program that incorporates DPC, the vast majority of the small independents are vehemently opposed to this approach. 

Sun Tzu once said all war is based on deception.  Wise commanders take measures to force opponents to react only to the wrong circumstances. Diversionary attacks, feints, and decoys are effective tactics.  CMS has incorporated a new one, raising the false flag -- an ancient ploy where ships were permitted to fly the enemy flag, so long as they raised one with their true colors just prior to attacking their foe.

One year ago, CMS introduced their “value-based” care model at the listening session I attended.  Now, CMS insinuated themselves into the leadership at the AAFP and the DPCC before unveiling their Direct Primary Care Prototype pilot program.  DPC physicians are satisfied with their practice model, who asked for a pilot program?  CMS has realized they need one.  They have designed a prototype which requires that physicians re-enroll in Medicare (capture), accept pre-determined payments of $90-120/monthly based on patient age and complexity (control), and entails submission of patient data for payment (capitulation.)   What appears on the surface to be a DPC-friendly endeavor will destroy the system from the inside. 

The DPC movement offers the first successful and innovative alternative health care approach to emerge in years.  CMS is focusing on physician capture, control, and capitulation, yet should not underestimate the fortitude of independent physicians.  We are steadfast, experienced in trench warfare, and refuse to succumb to their demands.  We will continue to fight relentlessly against mounting administrative burdens which interfere with the provision of patient care.   CMS will raise the flag with their true colors before long.  If you own a DPC or micro-practice, do not be fooled by this wolf in sheep’s clothing.  Stand strong and remain resolute.  Government, insurers, and hospitals will try to silence us, but physicians are absolutely essential to the delivery of proper healthcare.  Make no mistake, CMS is the enemy of independent physicians everywhere and our best defense is to have a good offense – leading with transparency to our patients and the public. 

If you are a physician who has been invited to these clandestine CMS listening sessions, have information to share, or wish to anonymously assist Denver or Seattle physicians who have not been invited to attend, please reach out on Twitter to me @silverdalepeds, or contact @IndDrs (Association for Independent Doctors), @IP4PI (independent physicians for patient independence), or @PPA_USA (Practicing Physicians of America.) 

This post was authored in collaboration with independent physicians who wish to remain anonymous.  May the force be with you all in the challenging days ahead.

Tuesday, February 13, 2018

MD + DNP = Dr.² (Doctor Squared): The Alternative to MOC Burden

The 4th amendment of the U.S. Constitution shields an individual (or business) from unreasonable government intrusion. It is inferred this right extends to ALL people, regardless of profession.  Advanced nurse practitioners are independently practicing medicine in 23 states yet are not subject to onerous Maintenance of Certification (MOC) requirements-- physicians are not equally protected under the law.  Physicians must fight, as one group, against the burden of MOC.  We have two choices:  become a Doctor Squared (Dr. ²) or join an alternative certification organization such as the National Board of Physicians and Surgeons (NBPAS.)

A Doctor Squared (Dr. ²) denotes one who obtains both an MD and a DNP (Doctor of Nurse Practitioner) degree.  This allows independent practice and eliminates the power of MOC.  Reviewing a list of affordable DNP programs in the country shows a degree from the University of Massachusetts – Boston DNP program only costs $10,180.  Coursework is online, and will take only 3 years if attending part-time.  Renewal of an MD license in Washington State costs $697 biannually while DNP license costs $125, putting more money in my pocket.  Additionally, the continuing education requirement is different; advanced practice nurses must complete 15 hours annually while physicians need 50 hours annually even though both professions are independently practicing medicine.  According to Medscape, malpractice insurance rates are $12,000 yearly (2012) for a family physician, while a family nurse practitioner pays $1200, one-tenth as high.  Remember, the cost of MOC for internal medicine is $23,600 every 10 years. 

While the American Board of Medical Specialties (ABMS) argues MOC participation makes for better doctors, no credible proof supports this assertion; only initial board certification has been scientifically validated.  Seven states already eliminated MOC compliance to maintain licensure, physician hospital employment, or insurance contracting, however this same freedom must be extended to the other 43.

Until then, an alternative certification pathway through the National Board of Physicians and Surgeons exists.  In 2015, the Washington State Medical Association resolved to allow alternative certification, yet MOC remains a requirement for licensure, hospital employment, and insurance contracting.  Recently, HB 2257 was introduced, precluding MOC as a condition for state licensure, though overlooks the fact hospitals and insurance companies require physicians, but not nurse practitioners, to comply with MOC.

Why are hospitals and insurance companies enforcing MOC compliance?  Conflict of interest (COI) is defined as a person or organization experiencing multiple benefits, financial or otherwise, which can corrupt motivation or decision-making.  ABMS appears full of corruption.  If there is a risk one decision could be unduly influenced by a secondary interest, a COI is present.  Margaret O’Kane serves on the Board of Directors at ABMS, and her secondary interest is her role as Founder and President of the National Committee for Quality Assurance (NCQA), the organization certifying insurance companies.  She has each hand in a different MOC cookie jar. 

NCQA requires that insurers credential only physicians who comply with MOC programs.  It appears Ms. O’Kane is profiting from the NCQA requirement on one hand while forcing physicians to spend millions completing MOC on the other.  While the average internist earns $150,000 annually, Ms. O’Kane appears to be handsomely profiting from this “arrangement.”  Wikipedia defines collusion as “an agreement between two or more parties, sometimes illegal–but always secretive--to limit open competition by deceiving, misleading, or defrauding others” to gain leverage. It is an agreement between individuals or corporations to divide a market or limit choice and opportunity.  Through Ms. O’Kane, ABMS and NCQA have a connection while misrepresenting themselves as being independent. 

ABMS assumed physicians would never contest corruption, however numerous brave physicians are fighting:  Dr. Wes Fisher, Dr. Ron Benbassett, Dr. Meg Edison,  and Dr. Paul Tierstein, who created the National Board of Physicians and Surgeons, (NBPAS).  While NBPAS has made headway with hospitals, not one insurance company will credential physicians who refuse MOC.  Should insurance companies be in charge of our healthcare system?   

The Maintenance of Certification (MOC) program was initially voluntary; however when billions in potential revenue were realized, participation became mandatory.  My brave friend and colleague, Meg Edison, MD refused to re-certify for the third time, yet was forced to bend to the insurer demands.  We have two choices:  1) Become a Dr² –having all the knowledge and experience of a medical doctor without the regulatory capture or 2) Credential with NBPAS and leave ABMS and NCQA in the dust.  Regulations will not disappear until physicians realize there is no healthcare without our blood, sweat, and tears.  May we all find our way once more. 

If you are struggling under the weight of MOC requirements, please consider taking this survey developed by a Dr. Wes Fisher, who is leading a crusade against forced MOC compliance.  Choice.  Transparency.  Autonomy.  https://www.surveymonkey.com/r/PPA_MOCSurvey.

Saturday, February 3, 2018

National Women Physicians Day: We Stand on the Shoulders of Titans #NWPD

Februrary 3rd is officially recognized as National Women Physicians Day (NWPD), commemorating the birthday of Elizabeth Blackwell, the first woman in the U.S. to earn a Medical Degree.  Allegedly admitted to medical school as a practical joke, she completed her studies despite vocal critics who viewed her gender as inferior. From my perspective, this holiday honors many brave women who trailblazed the path toward gender equality – one we continue to negotiate today. 

A hugely instrumental figure in the movement was born and raised here in Kitsap County, Dr. Esther Clayson Pohl Lovejoy.  She was a pioneering medical doctor, a suffragist, a health policy advocate, and later, a congressional candidate.  Born in Seabeck, Washington Territory in 1869, she spent her formative years in Kitsap County, where she attended primary school, attaining high marks. 

She had a working-class upbringing, spending her youth employed at the Bay View Hotel, which her family operated.  As a result of her conscripted childhood, she vowed to find a career she loved which had a meaningful impact.  After her family moved to Portland, Esther met Dr. Callie Brown Charlton, who became both a friend and mentor.  Despite being widowed with a young daughter, Dr. Charlton made her way in medicine against social and financial obstacles.  When asked for career advice, Charlton told her medicine “was the best vocation possible for a woman.”  Dr. Charlton was right.

Medical education for women in the United States in the nineteenth and early twentieth centuries was shaped by region.  Attitudes in the West were more favorable to women doctors, affording some advantages. Esther Lovejoy began coursework at the University of Oregon Medical Department (UOMD) in the fall of 1890, earning tuition money by working as a department store clerk.  Despite earning a medical degree with honors, professors rejected her application for an internship, and male physicians refused to work with her.  Even with these impediments, she opened a medical practice in Portland with her husband, a surgeon. Her notoriety grew, and her practice flourished. 

Dr. Lovejoy was appointed as the Health Officer for Portland, and in that role, was a staunch public health advocate, believing healthy communities were the responsibility of citizens and their government.  At the same time educational and vocational opportunities expanded for women, the suffragist movement gained momentum.  Dr. Lovejoy thought voting rights for women were pivotal to keep homes and cities healthy.  She had a hand in women being granted the right to vote in Oregon, which was achieved in 1912.   She continued working with the National American Woman Suffrage Association (NAWSA) to pass the Nineteenth Amendment, a feat considered the single greatest achievement for women in the last century. 

Today, female physicians are standing on the shoulders of titans.  These women not only left the medical profession better than they found it, but also the nation.  In the mid-1890’s, women were only 7% of medical students across all institutions.  Today, one-third of all physicians and almost half of matriculating medical school students are female. Now it is our turn to collaborate, mentor, and inspire the next generation. 

National Women Physicians Day represents all that is possible for men, women, and children.   Despite facing ridicule for breaking down barriers, Drs. Blackwell, Lovejoy, and countless others refused to accept the status quo.  While occupational disparities remain more than a century later for women and minorities, it is through honoring the trailblazers who went before us that their mission endures.   Our culture needs to change so women feel valued and respected, comfortable and safe in the workplace, and are provided ample opportunities for leadership and growth.

Recently, a little boy and girl came into my office for check-ups.  The boy shared his dream of becoming a doctor.  His older sister incredulously said, “boys can’t be doctors, only girls are allowed to be doctors.”  Amused, I informed her the field of medicine welcomes all individuals regardless of gender, race, religion, ethnicity, or disability. We must only bring a heartfelt pledge to heal the sick and comfort the suffering with us to embark on a medical education.  There is no other endeavor in the world more rewarding than saving a life using your hands and your hard-earned knowledge.

On National Women Physicians Day, we should honor the courageous women who lighted the way and be mindful of the awesome responsibility of passing the torch to the next generation.   The onus is on the medical profession as a whole to foster an environment of encouragement, collaboration, and mutual respect.    Looking to the future, it is important to understand our past.  Thank you Dr. Blackwell, Dr. Lovejoy, and every medical doctor who continues fighting for equality.