AOA’s Problematic Response to President Trump’s Executive Order

Friend of IP4PI, Richard Koss, D.O., writes in:

Below is the response from the AOA regarding the recent presidential executive order regarding Medicare.

Well they do make some accurate points towards the end of the letter there are many problems and issues that need to be brought out.

First. The federal government like most of America do not know what a DO or osteopathy is. Since this is a presidential executive order, does the President of the United States even know what osteopathy is? I doubt it! therefore the bureaucrats in Washington DC will not pay attention to this letter.

Second. The AOA does not speak for the 145,000 DO’s in this country. They can only speak for their membership which at this point is below 30% of all DO’s. since the AOA has not brought this information out to the membership and asked for support they cannot speak for any DO at this point. Likewise only 15% of MDs belong to the AMA. And again the AMA cannot speak for the vast majority of physicians in this country. Yet they do.

Third. Where in this response letter does the AOA expound on the difference between allopathic and osteopathic physician’s? And show our superiority in quality, cost containment etc. based on OSTEOPATHIC PRINCIPLES! Where does the AOA champion the use of osteopathic manipulative medicine in the care for seniors.

Interstate licensure Compact…NO!

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Osteopathic Medicine in Crisis: Fighting for the Existence and Future of Osteopathy

Friend of IP4PI, Richard Koss, D.O., writes:

The current issue with Resolution 17 points to a larger issue facing the American Osteopathic Association (AOA) and osteopathic physicians.

I was about to send the American Academy of Osteopathy (AAO) a four-page letter outlining the dilemma of the future of osteopathy. However in this current crisis I will try to simplify and outline the issues and hope that the leadership will take an aggressive, proactive role in fighting for the existence and future of osteopathy. I am pleading to the AAO leadership to keep their membership fully informed and transparent as to the issues we currently face! This will not be solved from a top down decision/solution. The solutions will be like the very beginning is of our profession. It will come from the people, and membership who will force the change at the political top.

I hope the AAO leadership can see the larger implications of Resolution 17 and what it means to the future of osteopathy.

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Update: AAFP Should Stand Up for Patient Access to Independent DPC and Withdraw Support for HR 3708

Update: Here is Mr. Shawn Martin’s reply. He granted permission for IP4PI to share it with the understanding that it should not be considered an official statement from the AAFP.

On Oct 25, 2019, at 7:17 AM, Shawn Martin wrote:

Craig-

Thank you for your email. I hope you are doing well. Your email outlines several areas of concern that we share and have been communicating to the various bill sponsors and Committees. We are working to make changes to the bill and I am confident that we will be able to do so.

AAFP policy only speaks to the allowable use of HSA funds for the periodic payment for primary care DPC practice. The bill language meets this objective. We are, however, very concerned with the exclusionary definition of services, specifically pharmaceuticals. Family physicians are not homogenous and the inclusion of a standardized definition and payment rate for “primary care” is concerning. We also are concerned that the allowable periodic payment amount is established irrespective of the patient and their health condition(s).

The other concern we are advancing is the simple fact that the language would apply the permissible use of the HSA to the periodic payment and not the patient themselves. This is nuanced, but basically the permissible amount should apply only to the patient/HSA holder and should have no impact on the practice or the practice’s financial operations.

There are other structural issues, but these are the big items we are working on.

Have a nice weekend – SM

Update 2: From: Shawn Martin, Date: October 25, 2019 at 2:06:39 PM EDT

October 25, 2019 at 2:06:39 PM EDT

I think the challenge in the next few weeks is this – is there a pathway to codify the permissible use of HSA funds for the explicit purpose of periodic membership payments and, if yes, what is the scope of services for such a permissible payment.

The relationship between not permissible (current) and permissible at $x (as proposed in legislation) is not the point in my mind.  The point is providing clarity in statute that an individual may use their HSA funds for a defined purpose – in this case periodic payments to a DPC practice.  Any limitation on the amount of a permissible expenditure is secondary to the permissibility question more generally.  There are defined limits on tax advantage accounts broadly – FSA, CTC, mortgage deduction, SALT, etc.

Its an interesting policy question that I have been kicking around since the ACA.  The HRA is cleaner because it is a defined contribution.  Anyway – look forward to the call with you and others.


10/24/2019 letter from IP4PI founder Craig M. Wax, DO to AAFP Senior Vice President for Advocacy, Practice Advancement and Policy, Shawn Martin:

Dear Shawn

Long time no see, or hear for that matter. I hope you and your family are well and that you landed safely at another entity. I’m writing to express concern about HR 3708 in the House and AAFP support of it. AAFP has been supportive of DPC in recent past and that support is much appreciated, but this bill, as written, would do more harm than good.

Enacting an aggregate cap on patient use of HSA funds for access to value-based care would be a bad precedent and the proposed prohibition on the ability of physicians to include medications in a DPC agreement is contrary to the best interests of patients.

In addition, all specialties, not just primary care, should be permitted to arrange innovative direct payment arrangements with the patient, eliminating the middleman and optimizing care with reduced cost.  HR 3708 appears to preclude the ability of a patient with diabetes from using HSA funds to pay for a monthly arrangement with an endocrinologist, for instance.

The bill also seems to risk the potential for States and others to misclassify DPC as an insurance plan by not properly and clearly defining DPC as medical care.

In its current form, this bill is unacceptable and I am disappointed that AAFP is supporting it. The previous Primary Care Enhancement Act from 2017 (HR 365) was an excellent template, while HR 3708 is flawed.

Please let me know what can be done to revoke AAFP support for this harmful legislation, and work for better options to support DPC and empower both physician and patient independence.

Best wishes for good health,
Craig M. Wax, DO
Family Physician
Independent physicians for patient independence
National Physicians Council on Healthcare Policy member
Host of Your Health Matters
Rowan Radio 89.7 WGLS FM
Twitter @drcraigwax 


Help Stop Blatant attempt to Blur Lines Between Physician and Non Physician

Amy Townsend, MD of Physicians for Patient Protection writes in:

Certified Registered Nurse Anesthetists (CRNAs) are working to get the Idaho Board of Nursing (BON) to officially change their name from nurse anesthetist to NURSE ANESTHESIOLOGISTS.  

This is a blatant attempt to blur lines between physician and non physician and to deceive the public.  The American Association of Nurse Anesthetists (AANA) plans to do this in every single state.  

It is important that we all stand up to these assaults on our colleagues in every specialty.  

Please help by spreading this information and signing this letter (after modifying it to your satisfaction).

Transparency in healthcare is critical.  And this name change is the exact opposite of what healthcare needs.  

Link to Letter: https://asahq.quorum.us/campaign/22999/

Do Not Gloss Over the Devastating Impacts of Policies that Declare Mid-Levels are Equivalent to Physicians

Friend of IP4PI Amy Townsend, MD writes in:

Please do not gloss over the potentially devastating impacts that Section 5 of President Trump’s Executive Order on Medicare will have on our healthcare system.  

I am a board member for Physicians for Patient Protection, a grassroots physician group that promotes physician led care.  We have been actively fighting scope of practice invasion in nearly every state for the last 3 years.  NPs and PAs can be a valuable part of a physician led team but they are not equivalent to physicians in education, training, or ability.  The government permitting them to independently practice medicine through legislation and not education will devastate healthcare.  Here are a few of my concerns:

1.  Patient safety, patient safety, patient safety!!!!

As NPs try to increase their numbers, they have sacrificed the quality of NP education.  They have created degree mills that are churning out 27,000 NPs per year.  Many schools have 100% acceptance and didactics that are 100% online and can be completed in as little as 18 months.  This is followed by a mere 500 hours of shadowing as their “clinical experience”.  Compare this to 16,000 clinical hours for a family medicine physician.  We are seeing and hearing devastating stories of misdiagnosis and mismanagement of these poorly trained practitioners daily.

2.  Medical expertise will be gradually diluted down.  

Why will our best and brightest students even try to conquer to academic rigors and expense of medical school when you can take a cheaper, less time consuming course to practicing medicine independently and have the same reimbursement (due to pay parity proposed here).  As a Family Medicine physician that has been practicing almost 15 years, I value every second of my training.  It is needed for me to be an expert at my craft.  

3.  NPs and to a lesser extent PAs, in general are corporate YES men.  

They have not been taught in their training to take ownership of patients as physicians do.  They do not take the same oath to protect patients at all costs.  If they are declared physician equals and can replace physicians, we will lose all negotiating power with corporate entities, government, and insurance companies.  If physicians stand up for patients, they will simply be replaced by a more agreeable, complacent NP.  
There are probably a million additional reasons.  But it is late and I’m sure you all are tired of reading my rant.  But I am begging you all to please give this issue it’s due respect.  The president has it WRONG on this issue.  We can not continue to have this conversations in the dark corners because we are afraid of liking like we are being mean to nurses.  Our profession, our fellow physicians, and our patients need us to speak up.  

Thank you all for your wonderful advocacy.  I believe it is people like us that can and will fix our broken system. 


Amy Townsend, MD, Family Medicine/Hospital Medicine

Cost transparency in BILLING!

By Paul Kempen, MD, PhD

Price transparency is a fallacy regarding posting of lists of costs when insurance is involved. Perhaps transparency in BILLING is more reasonable to create individual outrage regarding outrageous bills. Please consider the following:

Cost transparency in BILLING!

I want to hear if anyone sees the following proposal as useful in separating physicians out from the “cost of care”. The issue of transparency is nebulous “going into” getting care for a number of reasons. Patients are often ill, in urgent need, in a “closed market” and poorly educated.  Perhaps it  would be useful to push for legislation creating transparency of ALL BILLS, especially those produced by insurance companies which serve to foster that impression that insurance somehow actually pays for care.  Insurance controls payments through ”negotiated prices”, limitation of care delivery and other aspects. I question if it would it be useful to have laws which Demand EVERY “This is NOT a bill” produced by corporate entities include the following data:

HOSPITAL AND INSURANCE STATEMENTS

1) Itemized price charged (i.e. charge-master and/or “full billed price”)

2) Amount ACTUALLY PAID by insurance independent of  patient portion separated from negotiated deductions

3) What Medicare would have paid for every BILLED service in A) HOSPITAL and B) regional Doctor’s office

4) All facility fees separated from total cost as a separate component

Imagine if everyone SEES the “facility fee” and recognizes that doctor offices are CHEAPER!!

If everyone sees the hyperinflated insurance/hospital costs over physician offices

If everyone sees that the PATIENT is paying for care via the deductible and sees just how LITTLE insurance companies are paying from the large premium and this is NOT hidden in the “negotiated deductions” which gives an appearance of “saving money” for patients.

Anyone producing a bill MUST have access to such data and making everyone aware of these realities would create pressure on OVERCHARGES

Debunking Myths that NPs Increase Rural Access and Lower Costs

The “increased rural access” and “lower cost” rhetoric used to support nurse practitioner autonomy is a complete fallacy and there is zero data to support these claims.  

1.  The market factors that make it difficult for physicians to practice in rural, underserved areas is not any different for NPs than it is for physicians.  NPs are not independently more altruistic than physicians.  Poor payer mix and the expense of excessive regulatory burdens will make it difficult for anyone to keep their doors open in these areas.  

2.  Look at the states that have allowed NP independent practice for decades, like Arizona.  NPs are practicing in the exact same places as physicians.  They do not go to rural areas.  There are maps available from AMA that show this quite clearly.  

3.  There are multiple studies that show NPs make more referrals to specialists, order more inappropriate radiology studies, and perform more skin biopsies than physicians.  This all INCREASES cost to the healthcare system.  In practice, I see NPs ordering tons of worthless tests in order to try to bridge the gaps in their knowledge.  They order tests and then have no idea what to do with them which leads to more tests and more referrals.  At a time when we are focused on decreasing unneeded healthcare waste, how does it make sense to use these undertrained non physicians.  

4.  If they are arguing for pay parity, how exactly do they decrease healthcare costs?

Data references demonstrating NPs increase cost and lower quality:

NPs order more biopsies: https://doc-10-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/f3drubbtuuasggve85q8h4dmet2ru2n5/1570492800000/11904212300552749650/00862855625573411785/1Oa8BCwnGYyN8Qwxg4bk6NYPdEeaQETHw?e=download&nonce=5nnu0081r77o6&user=00862855625573411785&hash=rldhsra0pp9qca2lt28lrf0ccab5h8f2

NPs order more imaging: 
https://doc-04-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/8gvilblg17297cb1rr7h0rg62tem57o5/1570492800000/11904212300552749650/00862855625573411785/1khlK1Uaw9ZKBES85GxnAICJW9_QUS4qi?e=download

NPs make more referrals to specialists: https://doc-0c-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/pd0vv46pqfms4l8gfhefl9rtbjsjbnl9/1570492800000/11904212300552749650/00862855625573411785/1BYA0yZwLoHB0ozC8vOL6NVrHnDYj18MI?e=download

Prescribe more antibiotics =more antibiotic resistance: 
https://doc-00-58-docs.googleusercontent.com/docs/securesc/500pimnenqerpcb3jog4vu5k5j56276k/v0hj5lspvacc5qch9p312rn4hruf6b9u/1570492800000/11904212300552749650/00862855625573411785/1ifSQYhGKCQAzwqNWefUS5x7PA2G8HC5C?e=download

More general resources  https://drive.google.com/drive/mobile/folders/1FF7sTKg4XZa_L5mXpW2puGjlMU3BuwcO/1IwfXD0e5Lxk9BuJoPtD2egwQySsozxdS/1z-L86XfVOzW6KPFpolF13ltCEWrI3Vv5/1S3iJlDPUcGBiLZmVgK7CYolis8eiv41i?sort=13&direction=a