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. 

You better not be telling me what to do

Interesting and shameless recent patient interaction. He comes in once a year, maybe. The last visit was 18 months ago, because "I don't like paying the $35 copay".  This patient has a $0 cost (to him), Medicare Advantage plan with a company currently embroiled in a merger deal with another big five company.  I say, "well, I don't like working for free". He says his INSURANCE agent (who gets a commission for every policy sign-up) told him to "tell the doctor to send in the claim as a prevention visit and it would be covered 100%". I told him to go to his agent for his future medical care, and I was only half joking.

Where to begin?

Doctor comes from the latin word, docere, meaning "to teach". I teach prevention at every visit. As a dermatologist, it boils down to the basics that everyone hears all day--stay out of the sun, wear sunscreen, stay hydrated, moisturize. We're not talking about a 30 year old coming in for a check up and wants to know how to take care of herself. We're dealing with an 88 year old man with a history of dozens of basal cell skin cancers, squamous cell skin cancers, many Mohs surgeries, a chart rife with biopsy report after biopsy report.

I am an end of the line specialist for this patient, firmly in the realm of management and treatment for skin cancer. Referrals get made annually for him for Mohs surgery for those skin cancers that are too aggressive, irregular, located in tough spots such as the eyelids. Every visit for the past decade involves a diagnosis and a treatment. Preventative advice is freely given, and never followed. This is the same patient who told me 4 years ago he would sit in the Florida sun for 30 mins every day so he would get his vitaminD. This is on the same day I excise a basal cell skin cancer from his face. After telling myself to stay calm, I advise him that it's a bad idea to sit baking in the FL sun, with his Caucasian-white and terribly sun ravaged skin. Broken bones resulting from low levels of vitamin D can be prevented by taking a daily vitamin. There's no such remedy for skin cancer. The damage was done decades ago, when he was self professed sun worshipper, visiting FL from the northeast where he would come down and get sunburnt, then go home and show off his tan. ***eyeroll***

We are long past the point of submission of "prevention visits" for this patient. We are in the business of keeping him alive and well and not letting him succumb and suffer from readily treated skin cancers. We are also not in the business of following the exhortations from a salesman. Borderline fraudulent, the falsehood perpetrated by this agent feeds into the whole gestalt in our culture right now, "I need to get something for nothing". This isn't possible. If I don't collect the copay, I lose money, and on a grander scale, I may need to close my practice if I take a 15% fee cut across the board from all my patients with a copay. Then where would we be? No doctor, no help, increased morbidity and mortality in a community. All from an agent who thinks he can help us all "game the system" by getting something for nothing. I'm not going to justify my business costs, nor defend my ability to stay in business, by allowing a bottom feeding salesman piece of trash to tell a patient to tell me what to do, and how.

To add insult to the injury, medical records are often audited by this same company's "provider payment integrity department", and if the record doesn't fit congruently with the medical claim, recoupment of payment is initiated. No recourse, no contest. The money is garnished from future earnings or sent to a collections agency, and a blemish on your financial record forever. So you see, I'm on the hook after the payment is made to me, by the insurance company, for my integrity and honesty --or I sink like the Titanic.

This story hasn't ended. I am waiting for the call from his agent. I can't wait for it, actually, it's going to be soooo fun to deal with this one.

CEO Helmsley--go get your pity sandwich yourself

Steven Hemsley Total Compensation 2014:$66,125,208 (Source Star Tribune)
Steven Hemsley Total Compensation 2013:$14,856,321
Steven Hemsley Total Compensation 2012:$34,721,122
Steven Hemsley Total Compensation 2011:$48,800,000
Steven Hemsley Total Compensation 2010:$102,000,000 (Source Star Tribune)

http://www.startribune.com/unitedhealth-ceo-stephen-hems…/…/

Total compensation for 5 years: $266,502,529
---comprised of stock and cash, directly siphoned from govt/taxpayer funds for Obamacare, bundled contracts, and probably less so from individual premiums.

Total compensation for Winnipeg Regional Health Authority CEO (Canada) $120,000 a year. (Source-- Glassdoor)

I love capitalism, America, and success, but this is crony capitalism, pork, corruption, and everything soul and life-sucking about our times.

This is the same CEO bleating about how much money UHC lost through Obamacare exchanges, and kicked yours truly off the Medicare Advantage Network because Dermatology isn't a medically necessary, cost effective (for them) "controllable" specialty. Tell that to the skin cancer patients in FL--it's an epidemic here.

I don't need you, UHC, at all. In fact, I'm happier and more productive off your network than on it.

http://www.modernhealthcare.com/article/20151119/NEWS/151119858

Maintaining certification, maintaining a parasite

I was looking through the ABD website, and the "Resource list"  http://www.abderm.org/moc/moc_tools.pdf  they publish was amended on 10/15/15. 

Dr Score.com, the previous entity through which we were exhorted to get patient and peer surveys, (founded and run by Dr. Steven Feldman, Derm at Wake Forest) was notably absent. Instead, a new business, MedConcert® is what they now list as "approved", this whole section is now optional of course. I believe Dr Score was removed due to all of our protests as to the inappropriate, opaque, and crony relationship which may or may not exist between the Board and Dr. Feldman. 

Of course, this now opens another argument, how was MedConcert® chosen, and why. 

I believe that all dermatologists who were forced into buying the DrScore product need to be refunded that cost due to the inappropriate and racketeering nature of the exercise. I can dream, right?

Medconcert ®

				Medconcert ® MedConcert is the healthcare industry's first multi-tenant, cloud-based platform designed to connect and align all stakeholders in a meaningful way to cost-effectiv...
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Here's the new  link through MedConnect®, a "social platform blah blah blah", "data collection" and "stakeholders" in the same paragraph --guaranteed to give you a migraine!

I received a nice letter from the FL attorney General that it isn't in their jurisdiction to address federal issues, that this doesn't pertain to the state. They listed the FL Congressional Representatives to contact. So now we need to contact Congress, another migraine...but I will write a new letter to my Congressional rep --Curtis Clawson (R) and senator Bill Nelson (D) and Marco Rubio (R). It can't hurt. I urge you all to do the same in your districts/states. They want to tie MOC to Medicare payment, probably licensure in the future. There's information to show this is ginning up at the federal level. 

The ABMS was found to have donated and lobbied heavily for MOC to be inserted into the HR-2 bill last year. ABD, as a member of ABMS, is guilty as well. 

https://gallery.mailchimp.com/30a32513ae04f5445c95f3239/files/20130612_cl_energyandcommerce_sgr.pdf

Here's a sample letter from last years' MACRA push from DrWes' blog  Dr. Wes: Doctors: If You Hate MOC, Write To Your Senator Today

				Dr. Wes: Doctors: If You Hate MOC, Write To Your Senator... There is nothing that has unified U.S. physicians more than their distain for the American Board of Medical Specialties' (ABMS) unproven Maintenance of Certificatio...
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Dear Senator ________________,

As a practicing physician in the state of _______, I respectfully request that you vote “no” to the upcoming Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2) that amends title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate (SGR). 

One argument for this bill is that it would repeal the flawed SGR and combine quality reporting programs to reward clinicians for improved patient outcomes.  However, several physician reporting registries within the bill are under investigation for anti-trust violations, tax fraud, misappropriation of physician testing fees, and use of fees to influence legislation thereby violating IRS rules for non-profit tax exempt status.  I encourage you to take another look and choose to defeat this highly flawed bill that will have a pernicious effect on the credibility of the legislation, practicing physician retention and patient access to health care.

There are several problems with this bill:

1. The American Board of Internal Medicine (ABIM), an independent 501(c)(3) non-profit organization, operates a proprietary Maintenance of Certification™ (MOC) program on behalf of the American Board of Medical Specialties (ABMS), portions of which are used in the bill. An antitrust suit is pending in federal court against both organizations (Civil Action No: 3:13-cv-2609-PGS-LHG). Additionally, the legitimacy of the ABIM’s MOC program has been called into question because of improper tax filings, questionable accounting practices, and funneling $30.6 million in physician testing fees to a separate non-profit 501(c)(3) organization (the “ABIM Foundation”) operated by the same leadership.

2. Because many parts of the flawed MOC program are distributed throughout H.R. 2 as physician reporting measures, the credibility of this legislation will be called into question if the charges against the ABIM are substantiated.

 

3. In the same way that Democrats were held responsible for the shortcomings of the ACA in the last election, this Senate will be held responsible when physicians refuse to participate in corrupt value-based incentives that enrich constituents at the expense of actual patient care.

 

4. I strongly encourage you to vote “No” on H.R. 2 and instead ask the Justice Department to investigate the ABIM/ABMS Maintenance of Certification program’s legitimacy as a provider of a value-based registry to the US government as part of H.R. 2 given these recent revelations.

Sincerely,

(your name, address and contact info)

Reference: 

http://drwes.blogspot.com/2015/04/newsweek-takes-on-moc-certified-medical.html

I called both my senators last spring right before this vote, and it did nothing. Bill Nelson voted for it, Marco Rubio voted against it, as did Ted Cruz, Mike Lee, and 5 others. The AMA was all for it, and now they're crying. I'm done with electing others to fight--AAD Advocacy, where are you? Phoning it in. 

Our little grains of sand may help to fill the bucket. It's the only way.

Fighting Obamacare

Message body

I decided that I'm not going to preach to the choir. I'm going to write and exhort 
opposition, liberal, democrats who voted for Obamacare to wake up. 
Here is my letter to Sen. Schumer---

Dear Sen. Schumer,

I appreciate your response and your efforts on this subject. I want to reiterate that 
big thinking, "outside the box" is required to attempt to fix the monstrosity 
that is Obamacare. We must call upon courage and honesty to free the country 
from this madness that is engulfing it.

Billions of taxpayer funds have evaporated in the co-ops around the nation 
that have declared insolvency in the past year. 

ObamaCare’s Cascading Co-op Failures

				ObamaCare’s Cascading Co-op Failures In The Wall Street Journal, Rep. Adrian Smith writes about ObamaCare’s regional co-op flops and says more than 500,000 people have lost coverage as many plans c...
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Obamacare Co-Ops Are Failing at a Rate of 50 Percent. Here's Why.

				Obamacare Co-Ops Are Failing at a Rate of 50 Percent. He... Obamacare co-ops are falling like dominos.
				View on dailysignal.com	Preview by Yahoo

The swelling in the # of enrollees is due in large part to improved recruitment/ sign ups 
for Medicaid. This doesn't address the middle class, the young singletons, working 
and trying to pay college loans, who simply can't afford this, and neither can their 
unemployed parents. 

In the current healthcare exchange for 2016 for Florida, all the plans listed are HMO's 
---extremely restricted networks and higher and higher deductibles. The plans are very 
expensive--the true costs hidden from those who can snag a subsidy-- only to then 
have high deductibles whack the consumer at the time they are ill. The consumer 
doesn't know this until they use it. Then they use it and start to scream, probably at 
you most of all ("you" meaning the government!). 

The Healthcare system wasn't broken, the finest doctors, the most cutting edge 
procedures, chemotherapies, techniques for curing cancer, etc you name it ---and 
the United States is the envy of the world when in it comes to medical care. 

The HEALTH INSURANCE AND PAYMENT system was, and is still, actually quite worse. 
Choices have been eliminated, large insurance mergers threaten competition, and 
prices have skyrocketed, with the result that people are going WITHOUT insurance. I
n fact, the current administration in D.C. admits 9 million people have signed up on 
the exchanges. Weren't there 30 million uninsured people 5 years ago? 
Where are they now? 

I'll share with you that in my office I see the tragic results of postponed and delayed 
care because people cannot afford the deductible hit, up to $12,000 for a family, 
even if they have an HSA. I tell patients up front what their fees will be, in an effort 
to be transparent and help them in their budget decision making. It isn't enough, 
and my part stops there, and starts allover again at the Pharmacy. The prices of 
drugs have skyrocketed and the drug shortages continue to plague us--there's 
a shortage of normal saline, for example. 

Saline Solution Shortages Drove Non-Sterile Intravenous Fluid Debacle

				Saline Solution Shortages Drove Non-Sterile Intravenous ... The drug shortage issue has been the quiet snake in the grass of the health care industry. Even intravenous saline products have been in short supply. Non-sterile
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Why? Because government restrictions and controls drive prices up while 
producing scarcity. In every nation around the world where the government 
controls the healthcare sector, the quality of medicine, medical care, and the 
ability to prolong life has been attacked. We are on the same path in the USA. 

The patient must be free to pay for a plan that insures what they want insured. 
Just like your car. You're a man, and you don't want maternity and infertility insurance? 
You do want cancer and in patient hospitalization covered? OK, a la carte purchasing 
power must be allowed. If I go to a gym and I have shown that I am taking care of my 
health, shouldn't I be incentivized, just like Allstate incentivizes its good drivers? 
Why am I to pay for the uninsured in Bed 2C? Why do the healthy need to pay for the 
decisions of the unhealthy? Why are we individually paying for the health consequences 
of the smokers and drinkers? Tough questions which need to be asked, and debated, 
at the highest levels. 

Washington needs to repeal PPACA, COBRA and EMTALA, and deregulate the health 
care insurance marketplace. If I want to buy a plan from Kansas that insures 
non smoking women, why can't I buy that? 

Why must the government institute price controls to hospitals and pharmacies? 
Why can't doctors build hospitals, only corporate entities that care about the filling 
of beds...can a baker open a bakery? Yes. Doctors lack freedom to do the same 
in the United States. 

This needs to be discussed MUCH MORE THAN IT HAS BEEN. Mrs. Pelosi's statement 
that we have to pass it to find out what's in it, is an insult and a rebuke to hard working 
and liberty loving Americans in her nation. I am disgusted at the methods used to ram 
this bill through, but now we must face it and dismantle it before it dismantles us. 
This is very real, and much work needs to be done.