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.    

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.