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 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.