COVID is the Only Disease

Exhaustion. Anxiety. Insomnia. GERD/Reflux. Hair loss. Vaccines. To Mask or Not to Mask. To stay home vs. Run Wild. Beaucoup de face/ear/eyelid rashes--I will digress here--papules, pustules, chalazion, atopic dermatitis, angular cheilitis, impetigo, etc. The past 18 months have been like being on the amusement park ride without a restraint and flying upside down at any given and unknown moment. 

There will be oceans of words written about the experiment that we've been thrust into without our consent. I will only add my 0.02 cents here, as a practicing middle aged dermatologist. I am a digital immigrant. I still like to pick up the phone and talk to friends. More on this later....

The panic of dying from/with COVID is still present in a small minority of the my patients, and these are comprised mostly of elderly and immunosuppressed. I can't say I blame them. Their systems are vulnerable to the bacteria in their own colons and throat. Modern advanced procedures have them given them new years of life, with a tiny thread of mortality tugging at them that transforms into a ships' anchor rope tugging the off the cliff. A wild new virus will take them out, or at least give them major medical setbacks that may not be survivable. 

It's a still a virus that I don't understand. It's entirely unpredictable who will get severe symptoms and ICU/death, vs. a mild case of the sniffles. How can you "have it" and not even know it? How can you not have it and still die from it? Who has delta? who has mu? False positives? False negatives? Mild prior infection? Severe prior infection? Incomplete vaccine course? I can't do it anymore. I'm out of gas. I can't suppose anything. I don't know the truth. The data is soooo bad. The lies and manipulations are enormous. First we're told the hospitals are bursting with COVID. Then a few months later, ooops, about 30% of + patients in the hospital are asymptomatic carriers who only got tested upon admission--a rite of passage now--and got labeled as a COVID patient even if they were admitted for a broken hip. Then we can celebrate summer! No wait, even if you are vaccinated you must still wear a mask!!! Stay home NOW DAMMIT AND DO NOT EMERGE UNTIL YOU GET A VACCINE TO PROTECT THE OTHERS WHO ARE VACCINATED!!  

Is the White Rabbit in charge? Alice in Wonderland here is completely appalled and confused by the double, no, triplespeak. 

Bounties work. Call it a 'vid patient and the hospital gets a bonus. Hospitals have lost A LOT of money. Insurances are tightening the screws. Nurses and ancillary personal find that if they're exhausted and abused, they can quit and sign on with "traveling" agencies who provide staff for shortages and make double the money. Is there something like this for dermatology?

I read that in in New Zealand, you must not talk to your neighbor. The threat of catching it from a chat across the bushes in the yard is enormous and deadly! Stay in your room and play on your phone! Zoom your job, coworkers, friends!!

Many of my patients over the past 18 months have declined considerably in functional status, health, mental state. Dementia has increased. The once spry octogenarian who went to aqua aerobics twice a week now shuffles along with a walker and has long lank grey hair, afraid to go to a salon for a haircut. No more aqua aerobics because 'vid. No more hair salon visits. No more family or friends...they can kill you by breathing on you. 

As I type this stream of conscious flow of vignettes from my recent past, I feel incredibly sad. I'm crying. This is wrong. This is extreme. This is an experiment. 

I want everything and I want it NOW

The immediacy of our tech-bombed culture--you can text your gift certificate to your friend, you can schedule your manicure, automobile service, etc within seconds with an immediate gratification, an immediate "dzing" popping out of your little smartphone. But you can't get your colonoscopy tomorrow. And you certainly cannot demand that I drop other patients' appointments to accomodate your perceived emergency, which consists of skin tags or "a rash" present for 2 years, but THIS MORNING you got agitated about it and you want it erased. 

THE BODY DOES NOT GET YOUR TEXT MESSAGE. YOU CAN'T PING IT INTO SUBMISSION. 


Baby boomers...the generation we all love to hate. Gen-X physician here. I evaluate and treat baby boomers on a daily basis (there's just so many of them!) I will generalize and state that as a group, they're predictably the most narcissistic and consistently in-denial patients I see. When they need surgery, "what do you mean I need surgery? What do you mean my knees are shredded/I have skin cancer/arrythmias/I have to not bear weight for 2 weeks...yadda yadda yadda. The "greatest generation" tended to accept when they got old and frail and slid into senescence with benign acceptance. Boomers demand everything be done, immediately, and it cannot interfere with the upcoming cruise they booked, and they refuse to pay for it. They want Medicare to pay for face lifts. "it's important for my mental health to have a good looking face when I look in the mirror". Yes that may be true, but it isn't the financial responsibility of the American taxpayer. Go talk to your congressional reps...and they're smoking pot or getting their cannabis and pizza "just like I did in college in 1970" to care for their arthritic joints while they await the replacement. Paid for by you and me. Because they bungee jumped onto some rocks. Did they ruin the globe? maybe. "I'm a baby boomer but I don't want to be lumped in with these sociopathic morons"...the camel fails to see its own hump.

Noncompliance is bad for you and bad for the Doctor

It's always a challenge to discern why non-compliance occurs. One would think, you made the appointment, you showed up wanting/needing a doctors' help, you took advice, maybe had the test..then nada! I never see some of these patients again. Maybe they moved away. Maybe they got scared by the treatment, or by the fact they actually need to change a behavior in order to overcome illness. Maybe you, as the treating physician, just rubbed them the wrong way.

Communication gaps and expectation gaps are the two factors contributing to noncompliance. I see this popping up over and over. The patient didn't understand, or didn't WANT to understand, the illness or the treatment. Patients seek to apply their mental framework to their condition. "Doc, I know you say the biopsy showed it's a skin cancer, but I know I got bitten by a bug and I want to know how to avoid it".  They want to put things into their schema. They understand bugs...skin cancer is too abstract and scary. It's a struggle to try to get people to see that their own wishes are irrelevant in the aging process or the illness process. Dealing with an elderly population they bring their set-in-stone ways, in addition to their other concomitant medical issues which may make treatments more difficult or prolonged recoveries.

My most recent struggle is a patient I have seen a few times over a 2 year period. He's an octogenarian snowbird, which means he's physically present in my town for 6 months out of the year. He's loaded with skin cancers of the face, being of Scottish ancestry and a lover of golf in subtropical climes. He has numerous scars from skin cancer surgeries over decades of treatment. When he is in town, his life is consumed by golf games, bridge games, going out to lunch, board meetings with his condo association, and Caribbean cruises. It must be a nice life. But these lesions pop up on his nose and face and bleed incessantly and he comes to me for help. He is pleasant, nods his head, I prescribe treatments, I perform biopsies, he leaves my office in agreement, but then he cancels the follow up surgical appointment. The first time it happened I gave him the benefit of the doubt, called him, asked him to reschedule. He comes back 4 months later,  the skin cancer site has healed over and I can't find it, but lo and behold, there's a new one bleeding on his cheek. Out of side out of mind for this patient. If it bleeds it gets his attention. He is seemingly delusional and will not, despite my efforts, see that he has recurrent skin cancers. We've had conversations at every visit about his skin cancer propensity and condition and what to do to get it under control. But then he leaves for Ohio for 6 months; he's gone and it's beyond my efforts.  The most recent visit was a repeat of last years' pattern of behavior and diagnosis, so I advised the patient I cannot be his doctor under the parameters he has unfairly placed on me. Your skin cancer cannot be resolved in 1 visit. It can't be addressed when your priority is your golf game. You have to stay put for a suture removal. You have to pick one place to get care and stick to it. I will no longer be the one. I will no longer waste my time and block other patients' accessibility because we're holding an appointment for you.

I feel sorry that somehow I cannot pierce his delusion and I cannot treat him within the part-time residency /paradigm he has chosen in my sunshine state. Medicine and the human body is not a part time endeavor. It is full time and takes up your full attention and care. I wish there was a screening set of questions I could administer to gauge how motivated a patient is before they're scheduled for an appointment. This is unrealistic but I too can dream.

JCAHO and the Opioid Crisis

I remember in the 1990's when JCAHO and the NEW hospital administrators--oftentimes nurses fired from clinical duties and this was their new gig to avoid unions penalizing the HR hospital division--scolding physicians for withholding pain meds, patients were groaning in pain, you evil inhumane monsters!

GIVE THE PATIENT NON ADDICTING PERCOCET AND YOU'LL KEEP YOUR JOB!!!

https://www.beckershospitalreview.com/opioids/7-things-to-know-about-the-history-of-the-joint-commission-pain-standards.html

20 years later we're in a big fat mess. Not created by any one player, but I would wager the regulatory push to count pain as the "sixth vital sign" along with rewards for prescribing--the latter no longer exists--now as penance they count the free pens a pharmaceutical co. may give out and post this online in compliance with "the Sunshine act" (because sunshine is the best disinfectant!). Too late, the cat is out of the bag. The addicted patients go to the local Kwik Stop convenience and with some hand and eye gestures a drug dealer can appear and proffers heroin from Mexico, for cheap. I see these transactions when I go to to get gas. The a"authorities" know but what is the use? Arrest, bail, back on the street in 10 days.

No one solution will correct this complicated monster. But it will have to start with enforcement of law. If lowly me can identify the drug pushers when I stop for 5 minutes to get gas for my car, so can "the authorities". Get serious about inspecting every single thing that crosses the border--animal, vegetable or mineral. And yes, stop counting pain as a vital sign. Distractions, breathing, ice, Tylenol...that's what my Mom did when I was a kid and I hurt myself. We're going to have to start saying NO to pills and NO to JCAHO and NO to patients that whine. And also NO to that truck coming from Guerrero, Mexico.

The 90 day Update

I wrote about this last year. The government mandate that states all physicians' demographic information must be updated every 90 days, even if no changes have occurred.
Now they send smooth and yet slightly threatening emails. Every time the 90 days have elapsed, when I log into the portal a big red box on the top of screen appears. Not enough. Email reminders now clog my inbox like hair on the shower drain. Harass harass harass.

Here's the screenshot:

Updating your profile early helps you avoid distractions Hello,  To ensure accuracy for patients, state and federal laws require health plans to check the information in their provider directories every 90 days. That means lots of phone calls, emails, faxes, and letters asking you to update and verify the information your payers have on file…every quarter. There’s an easy way to cut down on the noise. Use Availity to verify your profile, and we’ll send that information to all participating payers. You can even download your verified profile, then print or email it to your other payers when they call. It only takes about 15 minutes to get through the process, because we pre-populate the forms with the information payers already have about your business and physicians. So when something changes, it takes just a few clicks to make sure your payers are updated. Remember that it’s important to verify and update your profile each quarter, even if nothing has changed. So log in to the Availity Provider Portal now to verify and update your profile—we’ll update your payers, and you’ll have your day back. Just another example of the thousand paper cuts that results in the doctor becoming paralyzed.

the electronic medical records movement must END

Corroborating what practicing physicians have claimed, a recent study published in the Annals of Internal Medicine found that during office hours physicians spent nearly 50 percent of their time on electronic health record (EHR) tasks and desk work.

Researchers concluded that for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day. Outside of office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work.

The time and motion study, led Christine Sinsky, M.D. and her colleagues from the American Medical Association, was funded by the AMA.

The study was based on observations of 57 physicians who work in ambulatory care in four specialties—family medicine, internal medicine, cardiology and orthopedics, in four states, Illinois, New Hampshire, Virginia and Washington. Researchers observed how much time physicians spent on four specific tasks, direct clinical face time, EHR and desk work, administrative tasks and other tasks and self-reported after-hours work.

Researchers observed that during the office day, physicians spent 27 percent of their total time on direct clinical face time with patients and 49.2 percent of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9 percent of the time on direct clinical face time and 37 percent on EHR and desk work. In addition, about one-third of the physicians also completed after-hours diaries and they reported one to two hours of after-hours work each night, devoted mostly to EHR tasks.

In an accompanying editorial published in the Annals of Internal Medicine, Susan Hingle, M.D., from SIU School of Medicine, wrote, “Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records, in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives.”

I'm a Luddite. I do not use emr/ehr and I've got all of my medical records on paper. During Hurricane Irma when my office had no electricity and no internet for 8 days, it would have completely impossible to access patient records if I had been using one. My paper charts by a window letting in natural light worked. I was able to see a few patients in those conditions and I was able to diagnose, write notes, and write prescriptions, all on paper. 

Another patient came to me just last week asking I had received results from her internist. I had not. The patient was seen by her internist for a routine check up and a skin lesion was noted on her leg, which the internist took a culture of said lesion and put the patient on an oral antibiotic. The patient asked the internist to fax those details and results/records to me. The internist, whom I have had interactions with in the past and uses Mod Med, told the patient that due to his being so behind on his electronic notes he wouldn't guarantee that he would be able to get those records to me by fax. That had occurred 10 days prior to my visit with this patient. 

On the day I saw the patient, I had no information about the relevant and important medical encounter because the doctor was too behind on the electronic tasks placed in front of him. 

EMR’s hurt patients and physicians, after all, the Health Information Technology (HIT) company which sold us our EMR system, an expensive EMR used by 35% of the US dermatologists, had assured us that their software and hardware would make our practice more efficient, productive, safer, improve our outcomes and speed compliance with new Federal Regulations to avoid a host of looming Federal penalties and enhance value based care (outcomes/costs). The company only rents access to its software to physicians from the highest reimbursed medical specialties. Their advertisements and marketing state that their EMR is, "Transforming how healthcare information is created, consumed & utilized to increase efficiency & improve outcomes".

THESE ARE PITHY MORSELS FROM----

Michael Sherling, MD, MBA

CHIEF MEDICAL AND STRATEGY OFFICER

Dr. Michael Sherling is the co-founder and Chief Medical and Strategy Officer of Modernizing Medicine. In 2014 Michael, along with Dan Cane, received the U.S. Chamber of Commerce’s Leadership in Healthcare Award.

Michael is responsible for the strategy and medical innovation within Modernizing Medicine’s suite of products and services for dermatology, gastroenterology, ophthalmology, orthopedics, plastic surgery, otolaryngology and urology specialties. With Dan Cane, he has developed novel software solutions for EHR, MIPS and ICD-10 automation.

Under his leadership, Modernizing Medicine has established a user base of over 10,000 providers and raised over $318 million in capital.

Michael is a dynamic speaker and has had the honor of speaking at the 2017 Association of Dermatology Administrators & Managers (ADAM) Annual Meeting, the 2016 Dermatology Entrepreneurship Conference and 2015 Health 2.0 Conference’s “Tools to Fix the Clinical User Experience.”

Michael has been a practicing dermatologist since 2006 and currently practices in a comprehensive skin care dermatology group in Palm Beach County, Florida. Michael also serves on the Advisory Board for the Florida Atlantic University Charles E. Schmidt College of Medicine. Michael is board certified by the American Board of Dermatology. Prior to relocating to Florida, he was the Associate Director of Laser Medicine and Skin Health at Brigham and Women’s Hospital in Boston and served as the Associate Residency Program Director for Harvard Medical School’s Department of Dermatology. He has several publications in peer-reviewed medical literature.

Michael obtained his BS in Biology at Brown University with honors in 1996, his MD from Yale School of Medicine with honors in 2002 and his MBA from Yale School of Management in 2002. He received his clinical training at Harvard Medical School, where he served as chief resident in dermatology

ANOTHER PHYSICIAN STORY: the EHR links to Amazon and sends emails to the patient on the OTC recommended by the physician!!!

" The liability for interfering with optimal outcomes with EHR company linked OTC product purchases is borne solely by the physician, and the revenue for sales of Amazon's OTC products shared solely by the EMR company and Amazon. 

Whose data is it anyhow, the patient's? the doctors'? the government or the EHR companies? Our EHR Company claims all the chart data is theirs."

Oh oh, no straight answers. Nobody knows!!

THERE IS HOPE!

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.
11
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.

PLEASE PASS THIS BILL TO STOP MOC IN FLORIDA!!

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.

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--

http://www.news-press.com/story/news/local/2016/12/16/specialists-in-urology-practice-closing-southwest-florida/95536280/


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.

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. 

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 DrScore.com, 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.

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!!!

MLN Connects® Provider eNews for June 30, 2016 

View this edition as a PDF 

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

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. 

Let's analyze the analysis of the analysis and ask for more money

Dr. Makary, a surgical oncologist, has published an article in the British Medical Journal where the sensationalized clickbait headline is "Medical Errors account for the third leading cause of deaths in the US". There it is, making the rounds on NPR, nightly news talk shows, etc. Patients and politicians are freaking out on those crazy doctors killing us. Read the actual article here.

Just step back for a moment. This man is a researcher whose niche is analyzing medical errors. He's a surgeon specializing in cancer. He wrote the book on implementing checklists in the operating room, like pilots have pre-flight, where the surgical team takes stock of where they are, who they are working on, and why. This is now why whenever you enter the health realm, you're asked 50 times by 50 personnel who you are and why you're there, and patients harrumph back and give bad reviews on HealthGrades on how they were continually asked who they were.

Dr. Makary notably ends his paper bemoaning that there aren't ways to measure medical errors because WE DON"T HAVE THE ICD-10 CODE FOR IT. That's right, we need ANOTHER code for this and every hospital, death certificate, etc has to have a space where the code for what the medical error was that caused the patient death.  He tugs at heartstrings, citing I assume from his world, a case of a young woman who was a transplant recipient (soooo, wouldn't she be dead already if not for the transplant?) whose death eventually came from an error in the judgement of a procedure she received when readmitted to the hospital because she fell ill again.

THEN he bemoans the lack of funding for medical errors, his niche area, and hence his dearth of grant money.

OK. Dr. Surgical Oncologist, why aren't you writing about surgical oncology? Not operating anymore, because no patients. So he sat around chewing the fat with a friend, and in the dicussion they figured the way out for them was to analyze the analysis of the analysis (spearheaded by the oft quoted Institute of Medicine 1999 Medical Errors paper) and in so doing, extrapolated their findings to the whole population of hospitalized/sick patients.

I've had enough of being demonized and it being assumed that doctors are making so many errors all the time that it's a wonder anybody is alive.

No question that medical errors happen. No question that there's been a slew of soul searching and action from all of these papers, editorials, CME, safety committees--"pause and stop and think and remember where you are".  Use your checklist.

All in the 7 minutes the doctor is allotted to attend to Mrs. Smith.  Do it fast AND to perfection, every minute, every day. We are already doing it as fast and as perfect as we can. We have to comply with MACRA, MIPS, MU, EHR mandates, 5-figure malpractice insurance premiums, our corporate bosses telling us speed it up or we're fired, denial of payment for actually rendering a service to the patient, calling them back, imploring them to take their meds, listening and comforting when they're in pain and infected and not doing too well. Overdose.Retire. Walk away. Suicide. We can't do it anymore.

How about the EHR errors? How about the government errors? How about the pharmacy errors? They all get lumped and dumped into medical errors. See what they did here. Medical is the root cause of all evil, and lets' get them out of the way.

I'm not sure who is actually going to be left to do the transplant. I hope when my time comes for real serious medical care, there's someone left who can fix my troubles, not MACRA, MIPS, MU, checklist charlie.

The Power Went Out

I decided years ago I wouldn't adopt an EHR. Yes, I use paper charts, with my own hand drawings for the purposes of illustrating TO MYSELF AND THE PATIENT where the suspicious lesions are geographically on their bodies. The lack, of and often nonsensical, governmental communications regarding HIPAA policy on storing, managing and receiving sensitive patient data electronically stopped me. I also practice on an island. Some may think it's paradise. But paradise doesn't come with buried electrical cables, and every tiny windstorm, thunderstorm, or power surge causes our power to go out, and it's always at 10am, in the heat of clinic. I cannot function without electricity, so I close for the day. I can still think, and write by a window for light, just like in the time of Adams. But I can't click away. God bless my colleagues who try. This is why they're quitting and leaving a shrinking pool of doctors or clinics who can accept new patients. The lack of control and endless frustrations with simple infrastructure is driving physicians out of the field entirely.

But I digress.

I searched a bit online, just for fun, about the whole flurry of excitement circa 2008 on EHR. It seems everyone was pushing for EHR implementation, and right quick, with no thought or consideration. Epic is the largest and the most profitable software vendor, contracted to Kaiser Permanente, Mayo Clinic, and lots of other illustrious medical centers. It's got to be good, right? With the imprimatur of world class institutions as clients, and a little old fashioned bribery, it took off.

Here's some interesting reading about the history/origins of Epic--click here.

Here's Michelle Malkin's (love her) pitbull terrier assessment from 2013: click here.

It gets better--she researched that Epic has the lock on EHR for the Dept. of Defense and the Pentagon. The health records of the military. The cake was big, and everyone had a slice at the party: click here.

These weak systems are being hacked for ransom by cybercriminals. A hospital in LA got hacked and held ransom for 17K in Bitcoins--smart financial move with the weak dollar. AND THE HOSPITAL PAID IT AND GOT THEIR RECORDS BACK. We are not privy to the information on where are the hackers, who are the hackers, are they in Ukraine? Panama? Peoria? This info isn't for the plebs. Nothing to see here, keep moving.

Who hasn't gotten a letter that their health information was hacked? I got one from the center where I got X-rays,  and my patients regularly get them from other doctors and hospitals and they ask me about it. I tell them that since I don't use EHR's, there is 100% chance that my records won't be hacked. I tell them we're all pawns in the machine. They get unhappy when I say this, like the kid yelling in the playground that there's no Santa Claus. Sorry folks, reality is where I live, wake up and smell it.

Now I see commercials from IBM touting Watson and the supercomputer that beat Jeopardy! It will one day be our collective physician. Look, physicians use it to supercompute through patient data! And the data show the patient had his seatbelt on and the shingles/pneumovax/flu shot!!

Can Watson evaluate the fingernails of a patient with factitial dermatitis, just like Sherlock's sidekick used to do --NO (literary fiction folks, Sherlock Holmes was not real--this is for the Millenials, the group we love to hate). Can Watson smell the alcohol on the breath of the limping white haired man with a total body skin rash for years? No.

Don't tell me it will take my place.

Care, But No Care

It never ceases to amaze me how much "care, but no care" I see from patients who come in with horrific skin conditions. They've been to 3-7 "doctors"--in reality, 3-7 nursing assistants or nurse practitioners supposedly working under the wing of a physician--this is never the case. They're confused and can't tell me what they have been told, diagnosed with, much less prescribed. They certainly got asked about their flu shot, seat belt, sunscreen usage, etc. heck a skin cancer screening was done!-- but the core issue they came in to get treatment for fell by the wayside. They have very extensive and severe dermatological conditions which require deep and thorough evaluations and work-ups. I request medical records. Sometimes I get them. More often I don't, and I have to start from scratch. It's easy to "start" because literally, nothing has been done. Patients look at me with eyes wide as saucers when I tell them I'm going to need to take a skin biopsy. I think they imagine a sledgehammer or cleaver behind the closet door to take the skin biopsy, and they're beyond shocked at how simple and quick it is for a SKILLED physician to do. No infections or extraneous bleeding all over the floor. Dermatologists do it clean. Would you ask the plumber to fix the oven? No.

I tell them this will be a process and that together, we will find a way to treat their skin problem. They tell me they were told "to put Vaseline on it".
EYEROLL.

Why is this happening? How did this happen?

My assessment: it's not heath care, or medical care, any longer. It's patch and turf, get the data into the EHR, collect the bonus. Punch the clock. Kick the can down the street. I'm tired and I want to go home.

This is deeply concerning and destructive. Doctors are quitting medicine altogether in droves. With no representation and no power "at the stakeholders' table", it has been widely documented that doctors nearing retirement have accelerated the process, and increasingly doctors in their prime are quitting medicine altogether. The AMA has long stopped representing physicians. It is a bewildered anachronism with a core mission to "improve the health of the Nation"--a big mission, nothing about protecting the doctor. I know of many who have quit lucrative medical careers and started yoga studios, vegan food services, medi-spas, health coach. Doctors are smart self-starters. They get tortured with EMR's, ICD 10, ACO (administrative) nurses with clipboards tallying the counts on the PQRS measure, and endless documentation bullshit. For doctors, money isn't the issue. It's about ownership of your skills and TIME. So they quit medicine forever. The tunnel narrowed and for these doctors, it was time to jump ship for sheer survival.

The latest most dangerous game: please the patient above all else so they give the clinic/hospital/staff 5 stars on Healthgrades or Yelp surveys. This includes the handing out of narcotics, to keep the masses comfortably numb and more apt to give a favorable online review. This is happening.

This isn't flying a plane. This isn't assembly of Toyota cars. This isn't an ATM transaction (although many would beg to differ). This is down and dirty, elbows-up-to-the-guts REAL LIFE. We witness birth and death. Pain, infections, cancers. Broken bones and broken hearts. Every human ailment, whether physical, mental, genetic, environmental. Populations don't get sick. Individuals get sick, and us humans are as infinitely different and crafted as nothing else in our world. We have free will. We can choose to take the pill, or not. To smoke, or not. And so doctors or clinics cannot be held accountable when the smoker gets readmitted for pneumonia while smoking 2 packs per day. Are clinic staff to go home with the patient,  following them around and being like a prison warden, cutting off the cigarette supply? Only 25% of ACO's have turned a bonus. That means 75% haven't earned a penny in "incentives for coordinating and streamlining duplicative care and producing efficient quality care". I suspect what's actually happening is a lot of hand waving and boxes being clicked, but no substantive results on anything. Florida Medical Association put together a concise article with startling statistics.

http://flmedical.uberflip.com/h/i/233300395-florida-medical-association-magazine-spring-2016

This is a giant waste. The maw of this monster must be stabbed, like St George slew the dragon. Doctors must regain the courage to say NO. I will not click the box. I will not see 78 patients in 6 hours. I will not work for free. Weekends belong to me now. I will not do a preauthorization, iPledge, online data entry, "in between patients". We must start saying no and we must start pushing back. Many already have. I'm just afraid that when it comes time for ME to have medical care, I will be turfed to the system that punches the card, in and out.

Thank you Government. Thank You Corporate. You've made lovely bedfellows. It's time to burn the bed.

Government largesse: the shell game

The current (version 174.5) acting head of CMS, Andy Slavitt, was a former CEO of Ingenix, a division of UHC. They were indicted in New York for operating manipulated databases with fraudulent reimbursement schemes pertaining to repricing out of network claims. (Complicated, I know, just stay with me here for a minute).
This same Mr. Slavitt now heads the government agency responsible for Obamacare, Medicare, and Medicaid. Not sure how that job interview went, but here we are. After much spouting about the wonders of Health Tech, Health It, EHR, Meaningful Use, etc. a stunning about face came about last week. Meaningful Use has been a pure torture device for doctors and clinics, the EHRs are so cumbersome and difficult to access. I personally tried to access my own patient portal when seeing doctors and they're buggy, circa 1991 FORTRAN in look and feel. The website for any consumer goods merchant is far more interesting, easy to access and interactive. I wouldn't dare ask an octogenarian patient to go log on or do whatever it takes to qualify. It's just not right, and for what purpose? Where is this all data going? what is the bribery or kick back for? Perhaps to close the loop on Epic-->money to congress-->law enacted in their favor-->crumb thrown at doctor for shelling out $100K on EHR.

Read about it --

In light of comments last week from Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt on Meaningful Use as a component of the Medicare and CHIP Reauthorization Act  of  2015 (MACRA) and the Merit-Based Incentive Payment System (MIPS), Mr. Slavitt and Karen DeSalvo, MD—National Coordinator for Health IT—prepared a January 19th blog post that included the guiding principles of how the Meaningful Use Program will fit in with MACRA implementation.  

Mr. Slavitt and Dr. DeSalvo’s blog identified the following principles for the future of Meaningful Use, health IT, and physician value-based payment

1. Rewarding providers for the outcomes technology helps them achieve with their patients.
2. Allowing providers the flexibility to customize health IT to their individual practice needs. Technology must be user-centered and support physicians.
3. Leveling the technology playing field to promote innovation, including for start-ups and new entrants, by unlocking electronic health information through open APIs – technology tools that underpin many consumer applications. This way, new apps, analytic tools and plug-ins can be easily connected to so that data can be securely accessed and directed where and when it is needed in order to support patient care.
4. Prioritizing interoperability by implementing federally recognized, national interoperability standards and focusing on real-world uses of technology, like ensuring continuity of care during referrals or finding ways for patients to engage in their own care. They stated they will not tolerate business models that prevent or inhibit the data from flowing around the needs of the patient.

Mr. Slavitt and Dr. DeSalvo’s blog also emphasized several important points for the physician and hospital communities, including how current law requires that HHS continue to measure the meaningful use of Office of the National Coordinator (ONC) Certified Health IT under the existing set of standards. Although MACRA does provide an opportunity to adjust payment incentives associated with electronic health records (EHR) incentives in concert with the principles that they outlined, it does not eliminate the EHR Incentive Program, nor will it instantly eliminate all the tensions of the current system. CMS and ONC vowed to continue to listen and learn and make improvements to these programs based on what is happening in the field.

In addition, MACRA only addresses Medicare physician and clinician payment adjustments. The EHR Incentive Programs for Medicaid and Medicare hospitals have a different set of statutory requirements and are not directly impacted by MACRA. Mr. Slavitt and Dr. DeSalvo will continue to explore ways to align the principles they outlined for physicians with hospitals as well as the Medicaid program.

Moreover, their goal in communicating these principles at this point is to give all stakeholders time to plan for what’s next and to continue to give CMS and ONC input. They encourage the entire community to review the MACRA regulations this year; in the meantime, existing regulations—including meaningful use Stage 3—are still in effect.

The blog also discussed how Congress, in December 2015, provided HHS new authority to streamline the process for granting hardship exceptions under the Meaningful Use Program. This new paradigm will allow groups of health care providers to apply for a hardship exception instead of each doctor applying individually, which should make the process much simpler for physicians and their practice managers in the future. Mr. Slavitt and Dr. DeSalvo promised to release guidance on this new process soon. 

Lots of words, little tangible information. 

Never Mind the Bullous

Heard from a colleague across the country about an elderly patient with blisters covering her feet and unable to walk, unable to function. Many visits to doctors, ER's and no continuous care, no management. Finally went to a cash only practice where the doctor listened, examined, treated. This no longer happens at practices that serve everybody at all times. Unable to even get a follow up appointment! I'll bet that patient was asked many times by "staff" at the other ER's and derm practices whether she had her flu shot or wore her seatbelt, like good comrades they had they her fill out the customer care survey. Never mind the pemphigoid. ****** the Sex Pistols "Never Mind the Bullocks"!!!!!!******

This patient was seen once by an actual physician---all other visits were conducted by assistants and "providers" who can't possibly know how to diagnose such a thing; they patched her up with maybe a top. steroid and Cephalexin and turned her out. She got worse and developed complications. It's sad, and not uncommon. 

I've seen very similar things here, once for example, where a man was told he had condyloma on his penis, and for several visits at other practices the ARNP/PA performed cryo on it; the scab and ulcer never resolved so 2 months later he came to me, where I spotted grouped vesicles below the scab. Herpes simplex. He never saw a physician all the times he had been to other offices, and he had an HMO plan I do not participate with. He was very angry at the others, as he should have been. Another elderly woman with Medicare was given top. steroids FOR YEARS to apply to the scaly patch on her cheek. I biopsied it on the first day and it was SCC, she needed extensive Mohs and reconstruction. I accepted her Medicare too. But at the other places she rarely, if ever, saw a doctor. 

The system is set up for volume, graft, lying, and nonsensical care. Government mandates, insurance companies covered items, non-covered items, all changing on a monthly basis; Obamacare, Medicare HMO's, etc have destroyed medical care in the US. Our voices have been drowned out because we are in the trenches doing what we do best. We rely on our organizations, not entirely, but still, to communicate to the power elite what is happening in real time and what to do about it. They have all colluded in creating a monster, with flow charts, EMR, nonsense and irrelevant "quality care" mandates, and penalties. The AMA and AAD sells lots of books and CD's on how comply with the mandates. They rolled over and surrendered. So I have ended my membership with them. 

Another dermatologist friend was freaking out when her boss was making them do PQRS at the end of 2015. She spent hours on the phone calling up her patients and asking if they had their flu shot. Not to then admonish them nor administer it, simply a box had to be checked in the software and she felt she could only do this truthfully by calling them at home, and asking them. Think about that. A board certified dermatologist who can cure complex skin CANCERS and disease and diagnose from the doorway, was reduced to this. What a waste!!

The pie of decent doctors taking Medicare will disappear, and the only pie left will be the churning, take a number, inferior clinics--staffed by who knows who-- that will accept Medicare but not cure disease. Hence the two tier system we are talking about, it's here. We are in it.  

 

All I can do is periodically email congressman and women, I even called the White House one particularly maddening day and I screamed at the operator--and I tell my patients openly and honestly what's going on. They don't get it. They have very busy complicated lives, they just want "to go to the doctor and get this taken care of". They have no clue that it's not about them anymore.