Clear Stream

Clear Stream

Monday, February 13, 2017


THANK YOU AND GODSPEED!!!!!! The bill in the FL House is HB 723 and the Senate Bill number is pending. Fl Rep. Dr. Julio Gonzalez and Sen. Jeff Brandes. are co sponsoring. Here is the bill's text, simple and direct:

HB 723 2017 CODING:
 Page 1 of 3 F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
1 A bill to be entitled
2 An act relating to maintenance of certification;
3 creating ss. 458.3113 and 459.0056, F.S.; providing
4 definitions; providing legislative intent; prohibiting
5 the Boards of Medicine and Osteopathic Medicine,
6 respectively, and the Department of Health, health
7 care facilities, and insurers from requiring certain
8 certifications as conditions of licensure,
9 reimbursement, employment, or admitting privileges;
10 providing construction; providing an effective date.
12 Be It Enacted by the Legislature of the State of Florida:
13 14 Section 1. Section 458.3113, Florida Statutes, is created
15 to read: 16 458.3113 Conditions of licensure, reimbursement,
17 employment, or admitting privileges.—
18 (1) For purposes of this section, the term:
19 (a) "Maintenance of certification" means a periodic
20 testing regimen, proprietary self-assessment requirement, peer
21 evaluation, or other requirement imposed by a recognizing agency
22 approved by the board pursuant to rule 64B8-11.001, Florida
23 Administrative Code.
24 (b) "Recertification" means a subsequent recognition or
25 certification of educational or scholarly achievement beyond
26 initial board certification in a subspecialty by a recognizing
27 agency approved by the board pursuant to rule 64B8-11.001,
28 Florida Administrative Code.
29 (2) It is the intent of the Legislature to further improve
30 the efficiency of the health care market and eliminate
31 unnecessary administrative and regulatory requirements.
32 (3) Notwithstanding any other provision of law, the board,
33 the department, a health care facility licensed under chapter
34 395, or an insurer as defined in s. 624.03 may not require
35 maintenance of certification or recertification as a condition
36 of licensure, reimbursement, employment, or admitting privileges
37 for a physician who practices medicine and has achieved initial
38 board certification in a subspecialty pursuant to this chapter.
39 (4) This section may not be construed to prohibit the
40 board from requiring continuing medical education pursuant to
41 rule 64B8-13.001, Florida Administrative Code.
42 Section 2. Section 459.0056, Florida Statutes, is created
43 to read:
44 459.0056 Conditions of licensure, reimbursement,
45 employment, or admitting privileges.—
46 (1) For purposes of this section, the term:
47 (a) "Maintenance of certification" means a periodic
48 testing regimen, proprietary self-assessment requirement, peer
49 evaluation, or other requirement imposed by a recognizing agency
50 approved by the board pursuant to rule 64B15-14.001
51 Administrative Code.
52 (b) "Recertification" means a subsequent recognition or
53 certification of educational or scholarly achievement beyond
54 initial board certification in a subspecialty by a recognizing
55 agency approved by the board pursuant to rule 64B15-14.001,
56 Florida Administrative Code.
57 (2) It is the intent of the Legislature to further improve
58 the efficiency of the health care market and eliminate
59 unnecessary administrative and regulatory requirements.
60 (3) Notwithstanding any other provision of law, the board,
61 the department, a health care facility licensed under chapter
62 395, or an insurer as defined in s. 624.03 may not require
63 maintenance of certification or recertification as a condition
64 of licensure, reimbursement, employment, or admitting privileges
65 for an osteopathic physician who practices medicine and has
66 achieved initial board certification in a subspecialty pursuant
67 to this chapter.
68 (4) This section may not be construed to prohibit the
69 board from requiring continuing medical education pursuant to
70 rule 64B15-13.001, Florida Administrative Code.
71 Section 3. This act shall take effect July 1, 2017.

The MOC control bill would do the following:
1.       Prohibit MOC for Florida Medical License
2.       Prohibit mandatory MOC participation for membership on hospital medical staff.
3.       Prohibit mandatory MOC participation as condition to be included in Insurance physician panel.


Wednesday, January 4, 2017

Electronic-Everything Will Kill Us

Logged into a payer-sponsored web portal for eligibility and claims yesterday. Big red statement at the top "It's time to update/verify your credentials for Florida Blue". This painful process, even if no practice demographic data has changed, must be repeated every 90 days, they claim due to a mandate from CMS. I didn't bother to look up the actual CMS mandate, why fight every single battle that presents itself? And believe me, there is a potential fight every second of every day in medicine. I presume this is to fight fraud, to verify info, to avoid a cataclysm. The insurance company can point to this and say, "see, we have a system to keep our providers accurately enrolled and processed" but every 90 days seems like overkill. It can certainly be every 180 days, with the caveat that any changes you must log into the portal to report the changes in your demographics--you moved, you got a new last name, a new phone number, etc.... no more inaccurate networks of yesteryear, now we're into the overkill of verifying your existence every 90 days.

What if you're dead? Who logs in then? Just a question.....

After logging in, I then have to log into the verification center using different "provider identification" numbers. Then I get error messages--oops, try again later. So I try again later and after 7 times I'm able to get into my screen for my practice. Then I labor through every sub section that has to be re-verified, clarified, and updated, even though in 90 days I didn't get a new phone, didn't have my license up for a new renewal, didn't change a single thing. I get to the end, then I have to upload government issue photo ID to show that I'm me ( my drivers license). Then I can print and submit this monstrosity after reading a tiny print waiver/disclosure, like the one you get but cannot read every time your iPhone IOS updates. So I click yes and then again, "oops, we are having difficulties, try again later". NOOOOOOOOOOO.

By now 3 hours have elapsed and I'm doing this in between patients, phone calls, and the every day running of a practice. I'm in the red-zone--furious, angry, and frustrated. I call them and try to get a human to see what the trouble is. On hold for 45 mins through different menu punching options. Then I get a person and explain the predicament and nightmare. She blithely tells me, "you're fine, doctor, we got your submission, we've had many phone calls and many problems with the system today". So why didn't you update your website to say so? Why force the issue and have people plodding through it like wet cement? Too bad. We don't care. We don't have the staff. No apologies, no explanations. Shut up doctor, you did it and can move on.

Every 90 days this kafka-esque must be repeated.

Government mandates have paralyzed all of medicine into this horrible nightmare, and I pray every day for the demise of the dysfunctional mess.

Tuesday, December 20, 2016

Adventures in Medical Business

More turmoil, more bad news. I heard from an elderly patient --who had stage IV bladder cancer and seemingly has a permanent foley catheter--that his urologists were all "leaving town". He told me there was an article in the local newspaper last week stating that that Specialists in Urology --a big beautiful practice with a big, beautiful, glossy-white art-deco building, and 7 urologists--is scheduled to close in March 2017. I was alarmed and spurred to do some quick online searches about this.

Here is the local article--

Apparently, the Specialists in Urology group was bought by 21st Century Oncology, and this company was over extended debt-wise and rapidly going broke, failing to make a scheduled loan payment last month. The electronic health records were hacked, and there was a whistleblower act that resulted in heavy fines to Medicare. Bottom line, I smell bad management and bad planning resulting from greed. I think perhaps they were all too quick to jump into things they didn't fully understand, nor fully implement. I'm shocked and saddened to see so much effort and investment go to waste, but most importantly these abandoned patients are left without continuing urologic care. These are mostly prostate cancer and bladder cancer patients, not easy for another doctor to enter the picture without serious hiccups. I'm very disappointed in the government push for EHR and consolidation to help populations and make disease management more efficient--blah blah blah. The reality is that these government led mandates don't thrive well in the deep trench of medicine, much less in a subspecialty like urologic cancers. When the infrastructure and government mandates strangulate innovation and growth and encourage willy-nilly consolidation, it will inevitably end in divorces and unhappy doctors and patients. I don't know what will become of either but I hope they all find a way out of the mess. Like my patient said, "all my doctors left town". He has found a urologist in a town 50 miles with whom he will continue his care.

Upon leaving, he told me he was grateful that after 15 years of being his dermatologist, I'm still here. I told him, so am I.

Wednesday, December 14, 2016

Doctors under Attack

We're attacking everybody, lets also attack the doctor!

I've been accepting Medicare assignment for 17 years. Many patients in my practice have Medicare far longer than they have ever had any other third party payor. These are advanced octogenarians and folks into their 90’s. The biggest cause for attrition? They simply pass away from old age. 

Retirement plans (from their workplace) have been shifting retirement benefits from providing supplemental policies to Medicare to now they transfer all health insurance to a private payor which requires new contracts and affiliation and rate schedules to be signed. 

These are not bad companies, but they do have bad practices, with mergers and unclear guidelines for claim filing; call centers in India and Philippines;  I cannot speak to a rational human to get answers. 

I have no choice but to stop accepting assignment altogether on those plans. 

This leads to unpleasantness. Patients angry and bullying, dictating to staff what they will and won’t do. Telling my office “you don’t know what you’re doing”. They do not want to hear the bad news, and I'm not the only one. My local hospital has big signs allover waiting areas "WE NO LONGER ACCEPT XYZ PLAN", etc.

Patients feel entitled and invested in the third party payor process, yet they do realize they do not control the relationship with their doctor any longer. The third party payor dictates who the patient will see, and these requirements have exploded over the past 5 years. The infamous "if you like your doctor you can keep your doctor" a shameless political slogan has now turned into ugly reality--if you like your doctor, you cannot keep her. In fact, it's a guarantee that you'll be switching doctors. The industry, from my micro vantage point, is in constant churn. 

These private plans demand claim filing electronically thru their proxy website, signing of contracts and accepting treatment and payment protocols, thus stripping the doctor of the right to be a doctor. Stripping the patient of choice. 

Why don’t you just go to Aetna then when you have a bleeding tumor, let them attend to it.

This is the broken system with the only accessible professional, the doctor, left holding the bag to deliver the bad news. 

We are all human beings and deserve dignity in this mess that was thrown into our laps. As I read a quote by Boy George, "we're all just clinging onto a rock, some have a better grip than others". I am not offended nor upset if patients need to change doctors. Just as I am a doctor and may need to switch patients! It's a two way street of consternation. 

Monday, August 15, 2016

Maintenance of Certification©, Management of Coercion (MOC© squared)

In 1998, when I finished my residency in Dermatology, a necessary rite of passage was to acquire board certification. It meant that you were a fully trained and most decorated and venerated specialist in a medical field. It was a huge achievement. The test was administered nationally one weekend in the Chicago-O'Hare suburb of Schaumburg. We all had to fly there and stay for a long weekend to complete the 2 day exam. It was a high stakes and high pressure situation, like high school SAT's on steroids but this time, you're paying $2000 out of pocket just to take the test, and the trip isn't fun at all. Flying from California there was the jet lag, anxiety, and potential delays. Time off from work had already happened in spades with special intense weekend courses to buff up on the questions and answers. Slides were projected on a screen for what it seemed like hours, and you had to diagnose the disease and fill in the little round circle with your No. 2 pencil. Each person had a microscope and you were given pathology slides and in a timed fashion, view the slide, provide the diagnosis. It was a sizable investment and one had to ensure that the test would be passed. I passed, heaved a sigh of relief, and moved on with my life.

There were murmurings at the time that board certification was a time-limited certificate that would expire in 10 years, and to renew it one would have to take this test again. We were told that it would be an open book, at home exam, much less time intensive and much less expensive. The particulars had only been recently fleshed out, as the ABMS had issued a decree that all persons certified after 1990 would have time-delimited certification. By an accident of birth, my friends and I were sucked into the turbine of Maintenance of Certification©.

Well now here is the grand conclusion from this erratically administered certification process. Maintenance of Certification, the product sold by the American Board of Medical Specialties (ABMS) and for me in particular, American Board of Dermatology (ABD) is directly tied to the new MACRA Medicare pay schedule. So these private entities lobbied to have participation (and thereby purchase) of their product as a requirement for the acceptance of full Medicare payment. If you don't buy into this product line, you will be assessed a regulatory penalty. By the federal government.

My quick economic analysis suggests that money out, money in-- it will cancel each other out, and so the one thing you are losing is TIME. You will be spending hours completing hundreds of hours of advanced courses and quality improvement practice modules, performing patient safety courses, administering patient or peer surveys (now optional but who knows what will happen in the future), paying $150 annually in a non-negotiable fee which is a "pay to play" fee just to keep your board certificate registered. This can't be minimized. The time you could spend with your family, or planting a garden, or learning a new surgical skill, or learning a new language, forget it--you must spend this time in chains. I see this as a deliberate ploy to keep physicians so busy and so tied up in knots that they don't see the little man behind the curtain pulling the levers.

I naively completed some requirements in 2008-2013 because the draconian requirements at the time stipulated that these had to be completed once in each 5 year period. But like most regulations, they changed the rules mid-stream, and so whatever had been completed by 2014 would now be applied to the 10 year recertification cycle, and additional continuing medical education programs would now be added (which are conveniently sold to us by the American Academy of Dermatology). It was at this point that I started asking questions, mostly of myself. Do I really need this? Do I want to do this? Is this what my life will be forever, taking tests, preparing for them, running around doing all of this extra work, only to have it cease for a year and then start up again?

I said no more.

I reached the boiling point when the ABD stated we had to administer surveys to something like 90 patients (or 15 peers) in order to maintain board certification. So strangers would hold the bag of control over my certificate, my livelihood. To add to this, at the time there were 2 options to conduct these surveys. You couldn't do it yourself. You had a cost-free option administered by the ABD itself, a lengthy and cumbersome process by which you had to personally contact the people you trusted to take a survey on your character, then ask for their email address and phone number, then pray that they get it (check your spam folder!) then pray that they complete it in a nice fashion, then you're done. The other option was to purchase the survey services of, a company founded by a fellow dermatologist Dr. Steven Feldman. Hmmm, how did he get this contract and the siphoning of dermatologists flocking to his site, where $795 would get you the full service package? This was never answered in my letter to the ABD. I am a diplomate of this organization and no response was deemed necessary. Shut up and pay your fee and keep your head down.

The answer came last year, where suddenly links to Dr. Feldman's website and services were taken off the ABD requirement list, and the ABD themselves pulled back and called the surveys entirely optional. Hmmmmmm again.

The trust has been irretrievably broken. I decided to immediately end my relationship with this monopoly. I figured I'd just wing it. If insurance companies would require me to purchase a product to continue on their networks, I'd resign. I'd notify my patients as to why. As it is, I've been a good girl and was kicked off the United Health Care Medicare Advantage network for unknown reasons, but later they admitted it because I wasn't a cost effective doctor. Never mind that I'm in southwest Florida where skin cancer is an epidemic, and the right thing to do is biopsy and/or excise the lesions. "No, that makes us pay out too much".  HELLO SKIN CANCER? ARE YOU GOING TO TAKE THE MEDICAL LIABILITY OF LETTING IT GO? I thought not. I wouldn't sign on to their EHR system nor their preauthorization system. In short, I wouldn't sign on to be their vassal. And I'm board certified and have jumped through every hoop, but it doesn't matter, "we can't control you and we're removing you from our network, and we can do this because it's stipulated on p. 15 line 35 of your contract". OK, good bye and good riddance!

There was no other alternative at the time, but since then Dr. Paul Tierstein, a cardiologist at Scripps Clinic San Diego, was angry enough to found an alternative board certifying body, the National Board of Physicians and Surgeons. Finally a sane alternative. Register for a flat fee, provide proof of previous board certification, continuing education credits, and state licensure in good standing, and you're set. This is how it should be. This is what I'm deciding on. I have the blessing of my staff, manager, patients...that's all I need.

Thursday, June 30, 2016

Dreaming of Freedom

It's a day early, but it's basically 4th of July weekend. I don't know if kids learn what the 4th of July means anymore, but to me it was huge, the birth of the nation, freedom, no more tyranny from the English king. I still see it like that. A nation's birthday, a national holiday that is imprinted in all Americans' hearts. Who can forget the Cool Whip and berry pies, the lemonade, the grills firing up. The older I get, the more nostalgic I become thinking of the picnics, summer parades, fireworks-- I especially remember the HUGE national party in 1976. I was 8 years old and we lived in an apartment complex on the New Jersey side of the Hudson River, and from our balcony I remember seeing the masted ships and colonial-era reproductions sailing down the river. I remember the fireworks at night. I remember president Carter speaking, and I remember mostly the pervasive sense of hope. We were touching the past but also touching the future, with hope and excitement for the our country, the greatest nation--"200 years old and she's just a baby" went the jingle on the radio. I remember the hot sun and how freeing it felt to run through sprinklers, and that our playground had all the mommies gather on benches to chit chat while watching us kids play. No fears nor smartphones. No posing for selfies nor tattoos. I'm an old fart now and I'm going to kvetch. There were social rules and we (mostly) followed them. We wanted to be great and strong and free. As an 8 year old I was immune to whatever national problems were simmering. Backbiting and stabbing were certainly going on but my childish view didn't include that. Fresh from Watergate, Vietnam, assassinations and civil unrest, it seems like in 1976 we took a collective sigh and let it all out. 

That was 40 years ago. Today I feel something very different. 

I hear daily lamentations from my patients. They're fearful, unsure, angry. They've been lied to. I'm often the bearer of bad news and in general they're kind about it and don't lash out at me personally. I'm not talking about the medical bad news. It's financial bad news. Every medical person/clinic/establishment has to analyze, digest and deliver t to the patient what the insurance plan covers, or not. What the annual deductible is, and how much of it they've used up or how much they owe. What the preauthorization yielded, or what the denial was about. The rules change mid game, or to use a football analogy, the rules change in mid air from the time the quarterback makes a pass to the time the ball lands---in the mid-air trajectory, the rules of game changed. 

How the hell can we work in a situation where the rules are changing, unknowable, so fluid that we never know what's actually in force much less what's going to happen?

Hence the anxiety. I try very hard to find outlets for my own anxiety, but believe me it's there. So many of my patients are taking prescribed daily benzodiazepines because they're not sleeping, they're not eating, they're truly at the end of their rope. Unemployment, illness, the inability to meet medical costs and bills despite the promises, despite the "Affordable" being right there in the title of the law. I see desperate eyes every day. 

Nobody has a crystal ball. The unknown is always there, just ahead, that's the blessing and the curse. Would it be any better to know what exactly is coming down the path? No. But the hourly bad news and the harsh reality of a stagnant economy, of lack of opportunities, and of wounded Iraq war veterans coming home to commit suicide has stained my community. I feel that America is at a breaking point, people are more nervous, anxious, and fearful than I've ever experienced. 

I pray that this long weekend we can all take a collective sigh, and in a small way shift our thoughts to the patriots who founded our nation. They were anxious, unsure, putting everything on the line--their lives and livelihoods, their families. All for the dream of freedom. We must still hold on to that dream. We are free. We must embrace that feeling and apply it, defend it daily when it's under assault, call on the little dictators in our lives and tell them they're causing individuals--and the nation-- harm. 

Below is an example of the Medicare e-newsletter, today's edition. It's rife with warnings, alphabet soup programs and rules that I have no clue about. To fully comply with this would take days to decipher what each program refers to and how to implement the rules. In this spirit, I would say, reclaim our freedom from the impostors in government. We cannot live life in a Kafkaesque tunnel with no way out. Whatever you may think of whatever political party, they have all lost touch with the people of the nation and have trampled on them with unabated tyranny. We must remember that we are the ones who consented to be tyrannized. And we are the ones who must put a stop to it.

"Be bold, and great forces will come to your aid"--Goethe

May you all have a blessed and healthy 
4th of July!!!

In this Edition:
News & Announcements
  • ESRD and DMEPOS: Proposed Updates to CY 2017 Policies and Payment Rates
  • Home Health Agencies: Proposed Payment Changes for CY 2017
  • July 2016 DMEPOS Fee Schedules Available
  • Moratoria Provider Services and Utilization Data Tool
  • EHR Incentive Program: Hardship Exception Applications Due by July 1
  • CMS to Release a CBR on Physician Assistant Use of Modifier 25 in July
  • Updated Inpatient and Outpatient Data Available
Claims, Pricers & Codes
  • 2017 ICD-10-CM and ICD-10-PCS Files Available
Upcoming Events
  • Clinical Diagnostic Laboratory Test Payment System Final Rule Call — July 6
  • DMEPOS Competitive Bidding Program Round 2 Recompete Webinars — July 7 and 12
  • Quality Measures and the IMPACT Act Call — July 7
  • SNF Quality Reporting Program Call — July 12
  • Comparative Billing Report on Diabetic Testing Supplies Webinar — July 27
Medicare Learning Network® Publications & Multimedia
  • Medicare Coverage of Diagnostic Testing for Zika Virus MLN Matters® Article — New
  • Recovering Overpayments from Providers Who Share TINs MLN Matters Article — New
  • Implementation of Section 2 of the PAMPA MLN Matters Article — New
  • Physician Compare Call: Audio Recording and Transcript — New
  • SBIRT Services Fact Sheet — Reminder
  • Remittance Advice Resources and FAQs Fact Sheet — Reminder

Thursday, June 9, 2016

Alphabet Soup from our Masters

The Medicare bureaucracy has exploded into a Medusa-like spherical blob that consumes everything in its wake. I receive daily emails from my states' Medicare contractor. Each state is a part of a sector geographically where a middle layer of bureaucracy interprets and implements the morass of rules coming out of Washington' Center for Medicare and Medicaid Service (CMS). I found this out when I signed up to participate in Medicare 16 years ago. Florida has since become a part of the sector that oversee Puerto Rico and the US Virgin Islands. Yes, if you have Medicare and you live on those islands, you're set. I have no clue how much this extra layer of bureaucracy costs the taxpayer. It's there because Washington is such an extreme behemoth it can't delegate the tasks to an office for each state. No, each state must have its own middleman as it were. I doubt the government could even provide a balance sheet of what these "Medicare Administrative Contractors" cost.

For entertainment purposes, here is a sample of one of the latest emails. Mind you, I've signed up to receive filtered and relevant content, such as that for Medicare Part B Outpatient directives. No matter, I need to wade through it all.

In this Edition:
News & Announcements
  • Medicare Makes Enhancements to the Shared Savings Program to Strengthen Incentives for Quality Care
  • TEP on Refinement of NQF #0678: Nominations due June 10
  • New PEPPER for Short-term Acute Care Hospitals and June 21 Webinar
  • 2016 PQRS GPRO Registration Open through June 30
  • Long-Term Care Facilities: Mandatory Submission of Staffing Data via PBJ Begins July 1
  • Antipsychotic Drug use in Nursing Homes: Trend Update
  • Home Health Quality of Patient Care Star Ratings TEP Summary Available
Claims, Pricers, and Codes
  • 2017 ICD-10-PCS Updates Available
Upcoming Events
  • Physician Compare Initiative Call — June 16
  • IRF Tier Comorbidity Updates: Soliciting Stakeholder Input Call — June 16
  • Quality Measures and the IMPACT Act Call — July 7
Medicare Learning Network® Publications & Multimedia
  • Updated Information on the IVIG Demonstration MLN Matters® Article — New
  • June 2016 Catalog Available
  • Medicaid Program Integrity: What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs? Fact Sheet — Revised
  • Vaccine and Vaccine Administration Payments under Medicare Part D Fact Sheet — Revised
  • Reading the Institutional Remittance Advice Booklet — Reminder
  • Medicare Enrollment Guidelines for Ordering/Referring Providers Fact Sheet — Reminder

It would take days to decipher what this means. And this is just one days' email. Every day I get an email with identical content and appearance. 
When the governed are placed in a situation where the rules are so numerous, so arbitrary, and continually changing, a certain helplessness sets in. It isn't within the scope of daily practice for a physician to comprehend, let alone implement, this barrage of alphabet soup being thrown our way. 

This is one example of the enormity of government regulation on the practice of medicine. Hence the anger and frustration of the American physician.