Death by a thousand cuts

Payments to doctors are going down in 2016. No matter, it will be made up in volume and turfing to nurse practitioners. Medicare is tightening the noose on the seniors' "benefits", whether they know it or not. I'm sure the deductibles will rise for 2016, along with the monthly cost, because Obamacare has to be paid somehow, and moving the shells around may help disguise the fact that there's no more new money being produced...except for what they print.
Senior citizens believe that they can something for nothing when they sign on to a Medicare Advantage plan, they're lured by $0 up front costs and "free" dental exam, "silver sneakers" elder gym membership, or eyeglass benefit, but beware the fine print....the deductibles and copay kick in big time. Or better yet, they go to find a doctor, or they come into their established doctors' office, only to find that there are no doctors on the networks!!! Yes, if you like your doctor, you can keep your doctor!!!! But there's no more doctors!!!!!BWA HAHAHAHAHAHAHA!!!!!

Seriously I'm laughing so hard I want to cry.

We're in for some tough truths folks. Believing that "Yes we can" or "Change you can believe in"--beyond naive, these are lovely slogans with zero substance.  The "Yes We Can" is a literal translation  of the "Si se puede" of the United Farm Workers' slogan courtesy of Cesar Chavez. Going a little further back in little known  history (from the American viewpoint), we can review the "No pasaran" or "they won't pass/go through" of the Spanish communist party.

Folks, don't believe for one minute that these similarities are accidental. They are deliberately chosen from the vast library of failed socialist/Marxist slogans that won't die.

"Freedom" won't die either. And I mean freedom from government tyranny and oppression. I will pray, respect any flag, eat or put anything into my body that I choose, the origin of all social ills and problem lies in the State. We're not going to take it, anymore.

My letter to the American Board of Dermatology terminating MOC

Dear ABD, 

I am a practicing dermatologist. I am in private practice. MOC destroys my ability to serve my community. My geographical region was designated a Health Professional Shortage area 2001-2012. I am the only MD, board certified FEMALE dermatologist in my town. Prior to my opening my practice, an older DO dermatologist--who obtained his dermatology training by apprenticing to a dermatologist in Michigan in the 1960's and then had no formal residency training, no boards--was the only dermatologist here. Now, down the street from my office, a family practice MD calls himself a dermatologist because he also apprenticed with a dermatologist somewhere out of state, and in Florida it's perfectly legal to call yourself anything if you're a doctor. I am providing this background as a preamble to my thesis, that MOC takes away the best, brightest, and true dermatologists from serving their communities, while older grandfathered physicians, who didn't even complete a dermatology residency, don't face this burden, cost, and drain. They get away scot-free. I have been marginalized and disenfranchised by the entire MOC system. I question the validity of the process, the conflicts of interest inherent in the system, and the gross racketeering and quid pro quo--give us the money, we'll give you a certificate. 

I called your office in 2011-2012 to clarify the thicket of requirements and to ask how to navigate the flow chart online in your website. The lady who answered the phone, and I didn't take her name, was beyond arrogant and rude. The conversation went like this:

Me: "I'm calling to ask about this flow chart online, how do I fill this out, how do check the boxes and list what I've done?"

ABD staff: "Well Dr., I see you haven't paid your annual $150 fee for the past 4 years, you need to go online and do that"

ME: "Yes, I know you want your money first and foremost, but I have questions about this whole process"

ABD staff: laughs--"OK, you're right Dr., you just have to pay that and then you type in the boxes online what you've completed"

MOC is reverse ageist (you're in trouble if you're a younger physician born after 1967), racist (I recall in your tests, patients with skin of color frequently involve AIDS, Mexican immigrants with leprosy, while the white patients have the autoimmune/orphan conditions like granuloma annulare or lupus--stereotypes, anyone?), and sexist (you assume we're all MALE doctors with "staff" who will magically do the dirty work for us, with an army of women serving us like in 1955--wake up) . MOC feeds into the corporate welfare model of business practices that has emerged in the past decade in the US. I urge you to reflect and critically analyze what you are doing, to whom, and why. You have alienated scores of dermatologists with your greed and hubris. 

The AAD membership has responded to your edicts with a standing resolution that MOC, as it exists, must change drastically. I know from a personal connection the many dermatologists involved in leading the Dermatology anti-MOC petition through change.org. Not coincidentally, many of us are women with families, single mothers, with private practices, cancer survivors, with elderly dementia/ill parents, with giant and complicated lives that you in your compartmentalized life where women and subordinates serve you, have no clue about. 

In the interim, the MOC mandates have exploded into a shameless trap to rob ALL physicians of our time, energy and goodwill. I have tallied a partial list of the monetary cost (not including the CME along the way nor the TIME cost) to me participating in MOC since 2006 and here it is:

*2006 cost of exam:                                 $2200

*Annual AAD dues $750 x10=                $7500 ( to aid in streamlining the credits and purchase/complete modules to fulfill MOC requirements)

*CPAT/QI acne module thru AAD:             $249

*200 Self Assessment questions                  $410

(thru AAD, 2010-2012)

*Patient Safety                                              $30

Healthstream /NBSP 2010 course online

*Annual $150 paid to ABDerm from 2006-2012=$900

______________________________________________

TOTAL:                                    $11319.00

[*hours spent in personally contacting 15 peers/colleagues --to obtain at least 12 to account for electronic snafus through your Data Harbor free survey--asking them to fill out a survey for me for MOC: 8 --one whole day taken out of my workweek in the office, in which I employ 3 people, and I lost roughly $3500 in doing so and I was kept away from treating patients who were waiting for a month to be seen]

I have stopped paying your annual $150 fee when my deepest analytical reflections on this whole process led me to have my trust in you irretrievably broken. My belief that you are the ne plus ultra of dermatology has been destroyed for the following reasons I will list below.

1. The closest Pearson VUE center (and how did Pearson-VUE get this contract from all the Boards? just a question that will never be answered from ABMS) to my home is 70 miles away, in Port Charlotte, FL. Again, I am disenfranchised and penalized for choosing to live and practice in a growing but less populated and semi-rural area of the US. There shouldn't be any every-10-year exam--the initial exam for initial board certification is more than enough, and freely chosen CME annually for the practicing dermatologist is the best way to ensure clinical cognitive relevance. Many doctors are moving on, and alternate pathways for external certification have appeared on the scene--

https://nbpas.org/

I sense you felt some heat from the plebs outside the castle gates last year, which led to the following message from you on Nov 18, 2014:

[November 18, 2014

Dear Dr. 
ID# 

As you are aware, the American Board of Medical Specialties recently granted specialty boards the flexibility to make meaningful changes to Maintenance of Certification (MOC) that help streamline the process for practicing physicians. As a result, the American Board of Dermatology has made changes to simplify Component 4 of the MOC program. 
Beginning January 1, 2015, the six activities previously required during every 10-year MOC cycle for Component 4—two peer surveys, two patient surveys, and two quality improvement projects—are being reduced to just two. You’ll recall that moving forward, diplomates must complete either two quality improvement projects, or one quality improvement project and one survey, with one exercise completed in years 1-5 and the second in years 6-10. Changes to your MOC table are scheduled to occur in 2015 with the launch of our new website and database.
Since announcing this change for the coming year, we’ve been working to develop a set of policies that are equitable to all—regardless of where you may be in the MOC 10-year cycle—including those of you preparing to take the 2015 MOC exam. 
For those of you who have already completed one survey (peer or patient) and one QI project, or two QI projects, congratulations. For those of you who have completed three or more Component 4 requirements, well done. Regardless of where you are in the cycle, you have fulfilled all requirements for MOC’s Component 4 for this 10-year cycle. 
For those of you who have not yet completed one survey (peer or patient) and one QI project, or two QI projects, you now have more time to do so. Due to these changes, you now have until the end of year five to complete one exercise and the end of year 10 to complete your second. Diplomates planning to take the 2015 MOC exam, however, must complete at least one Component 4 exercise before December 31, 2014.
The Board recognizes the many demands on physicians’ time and is committed to refining the MOC program to ensure it fosters high-quality patient care while minimizing unnecessary or duplicative processes. We believe these changes allow more time for diplomates to focus on what’s most important—the health and safety of their patients.

If you have questions about the changes and how they may impact your MOC status, feel free to contact the ABD office at abderm@hfhs.org. ]

Without warning and without justification, and with a paternalistic "well done" thrown in, you unilaterally issued an edict changing the way MOC is structured. 

2. I wonder how is it that drscore.com, owned / founded by dermatologist Steven Feldman, MD, got his company to be linked as a fee-based survey resource for MOC. I wonder how is it that since I completed online surveys for dermatology MOC-fulfilling colleagues "peers" through drscore.com, I have been flooded with emails from EMR/EHR companies eager to sell me their products. I cannot conclusively prove it, but I am sure my email and data was sold as marketing/advertising data point from drscore.com, and any patient who completes a survey through them will be subject to the same treatment, being sold as a data point. I decided 3 years ago that I wouldn't subject my patients to this, consequences be damned. To do this would hurt my reputation in my community, and not to mention I wouldn't be able to live with my conscience. This is shameless, not to mention unethical and antithetical to my whole ethos of being as a physician, where I truly have internalized and believe in the hippocratic oath. This erosion of our ethics and belief structure is not tolerable and I will not participate with an organization that besmirches my trust, much less my patients' rights and privacy. I am sure it has all been done anonymously and in aggregate, but what is happening to the data from these surveys? Who stores it, who controls it, who has access to it, for ever ad finitum? All unanswered questions. In addition, the surveys asked me about the physicians' building access to parking and the "pleasingness of the office decor". How is this relevant to MOC? How can a physician in Manhattan, Miami or Atlanta offer parking where there is none? Are we held hostage to city planning now, are we to control it for the ABMS? How is this relevant to MOC? All unanswered questions. Here's Dr. Feldman's interview from Dermatology Times, where he shares his viewpoint on how important it is to appear empathic--not actually BE empathic:

TAKEAWAY: Using patient satisfaction surveys to influence patient adherence, part 2

				TAKEAWAY: Using patient satisfaction surveys to influenc...   Listen to the conversation on mechanisms to convey empathyThere are a number of factors that influence whether a patient will adhere to a treatment regimen. In pa...
				View on dermatologytimes.mo...	Preview by Yahoo

 

3. You have provided no data nor evidence for the dermatology MOC implementation in 2005, (except for some blatherings I recall at the time that the ABMS was making it so for all specialties under their wing) and no such evidence for your requirement shift in 2014. You bleat platitudes about how limited research has shown that MOC improves patient care--by what metric? By what criteria? Unknown and opaque. Oh really, well....let's analyze one such study from the ABMS website itself. 

http://www.medtees.com/blog/ArchIntMed2008.pdf

The data in this article was obtained by of Qualidigm of Middletown, CT, a data analytics firm that does the following according to its website:

Data Analysis

Collecting relevant data, turning that data into information, and that information into action, drives almost every Qualidigm initiative and contract.

Qualidigm analysts have the qualitative and quantitative knowledge, skills and experience to provide a wide range of services including but not limited to:

• the analysis of claims data from a single source or aggregating claims data from multiple sources;
• the collection, integration and analysis of claims data, administrative data and medical records data;
• the geographic analysis of various types of databases, e.g., claims, medical records;
• the collection and analysis of qualitative data;
• providing definition of, and advice on, sampling strategies and sample size requirements;
• the design and production of performance reports in tabular and graphic formats;
• performing advanced statistical analyses including hierarchical modeling, computer simulations, logistic and linear regression, and survival analysis; and,
• outcomes analysis.

Qualidigm analysis services are available to clients either as the sole purpose of a contract or as an integrated component of a contract.  For more information, please contact Ann Spenard, Vice President, Program Operations or (860) 613-4183.

Utilization Review

                    Qualidigm offers utilization review services for recipients under Medicaid for the State of Rhode Island, evaluating the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities under the provisions of the their State benefits.

                        In addition to performing utilization review for the Medicaid Program, Qualidigm also offers two unique services.  We provide nurse care managers who work in primary care physician practices to assist patients to better manage their chronic illnesses and conditions.  We also offer a Pre-admission Screening and Resident Review (PASRR) Level II evaluation for nursing home residents.

So it appears that Qualidigm's authors did this study to justify the ends and means of MOC, and it was manufactured to defensively posture not only for the money it creates for these boards, but for insurance company claim denials. Qualidigm makes its living by hiring itself out to agencies such as Medicaid and Medicare to conduct claims investigations for accuracy and appropriateness in "utilization review", i.e. fraud. 

The extreme conflict of interests in this article is massively disturbing. The ABIM paid for and funded this data analysis, led and run by doctor employees of the ABIM and doctors employed by Qualidigm, all authors of this study. It's as if Merck funded its own study on a new lipid lowering drug, using its own employees and the employees of a different firm that they hired to do the study, all being subjects,  and all authors who themselves took the drug and used themselves as test subjects presented the report in the best way to benefit themselves--showing how gee whiz, look at what a great thing we do. There is no randomized, double blind study, no prospective analysis, just the "quality measures" proscribed by Medicare on Medicare beneficiaries' claims data, which in 2002-2003 could be satisfied by a staff member checking off a box on a piece of paper. This doesn't take into account the competence and clinical hard work done by physicians who don't participate in Medicare, nor those who work in a health professional shortage area, or in the military/VA, nor those who may be employed by a health system/ HMO such as Kaiser. It favors and uniquely presents data on physicians who treated Medicare beneficiaries and used HgbAIC lab testing--not the result-- as one metric for quality care, using the reporting system from Medicare. 

In sum, your lofty educational goals and byzantine requirements are increasingly poorly thought out, poorly implemented, poorly accepted. It is all about the money with you. The public has no idea what board certification means. They are too broke, confused with Obamacare, scared and frazzled to care. Dermatologists are in such scarce supply that family practitioners can call themselves dermatologists and treat patients, running busy "dermatology" practices, all the while the REAL dermatologists are waist deep in this labyrinth of expensive and spurious processes known as MOC. I am very angry at what you've become, what my specialty has become, and how I've been rendered a serf that has to shut up or get out. Your most recent newsletter online for diplomates is from January 2013. You've clearly decided to sit back and collect the money. 

Quis custodiet ipsos custodes? I'm done with you. 

Sincerely, 

Dr. G

Every one is a corrupt SOB

https://www.healthcare-now.org/wp-content/uploads/2014/05/2013CEOPayChart1.jpg

http://www.unitedhealthgroup.com/Investors/~/media/2B5EEC6F00F446AC9051674E259BA80B.ashx


 Here's some acid producing stuff for 2014--

CEO of ExxonMobil: $40 million

CEO of United Health Care: $12million

CEO of Aetna: $8.2 million

The CEO of Apple: $9.2million

UHC, take this job and shove it

I have tendered my resignation from United Health Care networks. Too much bureaucratic BS. It's all in my letter.

Just take note of the most recent news release on their 4th quarter profit.

http://www.unitedhealthgroup.com/Investors/~/media/2B5EEC6F00F446AC9051674E259BA80B.ashx

To: United HealthCare, Corporate National and Local offices

Friday, February 20, 2015

To Whom It May Concern,

After years of providing dermatological care for patients who possess health insurance from United Healthcare, this letter serves as your notification that I am resigning from your “provider panel” for all the networks and products you offer. I will no longer serve as a physician providing care to patients under United Healthcare. As of today, I am severing our relationship without cause, with three months’ notice per customary protocol.

I will communicate this to my patients currently enrolled with United Health Care. However, 90 days from today, beginning on May 20, 2015 I must not be listed on your online provider search engine, website, nor portals;  nor listed as a provider in any print or electronic communication with patients nor the public at large after that date. 

My experience as a physician with you has been extremely frustrating in the past 18 months. As long as you collude with the federal government, you have no risk and considerable profit, and billions of dollars are being siphoned that should have gone directly to patient care. Your medical care ratio ending in 2014 is 79.8%, meaning that 79.8% of the income from premiums is devoted to payment for medical claims. Where does the other 21% go? Perhaps in efforts such as expanding Optum; paying dividends to your shareholders and bonuses to your CEO; lobbying the government for more bailouts; or hosting coffee talks and sending glossy brochures to enroll more Americans, ignorant of your mercenary and crony capitalism ways.  

I have witnessed the decline of the public perception and personal experience with the United Health Care company as a whole, where patients had reasonable cost coverages and the website was easy to navigate. The trend for the past several years has been of skyrocketing deductibles, copayments and prescription costs, a cumbersome website that doesn’t verify coverage in a reliable real time fashion-- then we’re left with unanswered questions in the medical office because a person cannot be reached on your byzantine phone system. Shame on you for denigrating physicians, dismissing us summarily, without an explanation from your Medicare Advantage networks, leaving thousands of patients in the lurch and without alternatives, more confused than ever about their insurance status. Your reasons were couched publicly and online as promoting quality initiatives, but they were clearly cost control measures where patients were sacrificed and they did not obtain medical care, thus saving you money and promoting profits. Not one person from your company explained or ensured a transition would happen. Patients still are confused about this, 18 months after my letter was received and 1 year after it took effect, and they have been lied to and manipulated as a statistic point in your pursuit of federal dollars. I see what you are, and I want no part of it. 

Costs have escalated while benefits, and reimbursement, have plummeted. In light of onerous deductibles, complicated online password-requiring preauthorizations and online/paperwork deluge for pathology or lab testing, I find I can no longer practice medicine while under your provider list. Instead I am a navigator of insurance/medical/pharmacy bureaucracies.This is not coherent with my professional mission nor values. Thus, I am tendering my resignation from all of your networks. 

Sincerely, 

Dr. G

Close the gap and some navel-gazing

There is a huge push for payment for quality, payment for outcomes. Neither of these are defined in any sort of consistent, concise fashion. Not for one single diagnosis across the board in medicine.
It fails to take into account that the patient is the one and only arbiter of what goes into the mouth, what smokes go into the lungs, etc. Physicians are no more responsible for the behavior of patients than the plumber is responsible for the behavior of your toilet or the auto mechanic for your car. Nobody is addressing the fact that we don't have cures or favorable outcomes for everything. People all will eventually die. Mortality is a metric that dares not be breathed into any discussion.

Health care in this country isn't really about prevention, we can try to prevent every bad thing but people will, and can get, randomly--or genetically determined--illnesses such as lupus or leukemia. We need to differentiate between sick care and health care. Doctors promote health by treating and sometimes even conquering illnesses. But we generally don't go out there and lay waste to every cigarette counter at a local supermarket or set fires to Dunkin Donuts. Do these items promote health? No. But it's a free country and I will not agree with your cigarette and donut, but I will defend your right to get it. I will not participate in any insurance plan that requires my clicking of a box on smoking cessation counseling or trans fat free dietary management.

Grow up People!!!!

Yesterday I lost my patience with patients.

On the whole, I see and deal with people of all walks of life, all ages, all ethnicities. They may be ill with infections or cancer, or they may be the worried well. It's all the same for doctors everywhere in clinical practice.

I have a snowbird patient I saw once 4 months ago. She was given a prescription for imiquimod by her dermatologist in a another state prior to my seeing her, and not to my knowledge. She's 89 years old, she proceeded to use this with wild abandon on her face last month. She got very irritated and rashy, bleeding and crusting, and so she called me for help. Fine, she's here temporarily and I can manage the necrosis caused by a drug I didn't prescribe, nor am I in agreement on its being used by a geriatric patient with a history of traumatic falls and who doesn't have a permanent address. But I digress. A patient is in distress, I know I can help. ****Polyanna music to cue here*****

I see the patient, examine the horrible facial crusts, take a culture, prescribe an oral antibiotic, a topical steroid for the itching, and lots of rest and gentle cold compresses with topical OTC antibiotic ointment. I advised her that the local pharmacy in my area would certainly have the prescriptions available. She told me she lived in the next town over and would use a national store's pharmacy, it shall remain nameless except it's a big box that offers $4 prescriptions for CERTAIN drugs.
She calls my office 4 hours later to chew me out that "the oral antibiotic costs $4 and is a reasonable price, but the cream is $90 and I won't get it". This is the 756th patient to do so this month.

This is where the doctor sees red.

I was on the phone, listening to her rail, and her complaining ad nauseam about the costs of drugs---then I lost it. I told her I had no more patience to deal with her complaints and that she had to figure it out herself.

PHEW.

I am pissed that I have to be the arbiter of sick care costs, prescriptions costs, and all the while be cheerful and compassionate and sympathetic. No more. I am done and I will not respond to queries about drug costs or preauthorizations. Go complain to the govt and see if they'll treat your cancer while you're at it, your infections, your neoplastic processes.....I'm DONE DONE DONE. I'm a doctor, not a financial analyst, data acquisition specialist nor pharmacy advocate. I'm sick of the lies, you were promised free or cheap drugs, you could keep your doctor, you could keep your plan, all LIES. I hate this!!!!

Corruption

I've been reading with dismay and exhilaration the research done by Dr. Wes, a cardiologist who took it upon himself to audit the American Board of Internal Medicine and the finances and Foundations it controls. It's truly unreal, they're racketeering off of internal medicine doctors, threatening them with crashed careers for lack of re-certification.

It's the stuff of nightmares. The ABIM had purchased a 3-bedroom luxury condo in the historic downtown of Philadelphia for "board members to use for meetings to save on hotel costs". They decided to sell this property and it's listed at $2.3 million. At a very generous $400 per night hotel room charge, for maybe 10 nights for 12 people, the cost is $48,000. Extremely high, but nowhere close to $2.3 million. Why the purchase?

Perhaps there was so much money lying around that they had to invest in real estate for tax purposes.

Think about. It was the money of hard working doctors financing the Marie Antoinettes of the ABIM. I would support the revolution to topple this monarchy. Check it out...


http://drwes.blogspot.com/2014/12/the-abim-foundation-choosing-wisely-and.html