MOC Feeds Big Data, Means Big Dollars, and Patients Suffer

It’s all tied together… Because pushing MOC on us is how they’re able to collect data… And the PBM’s, a.k.a. Optum, CVS, express scripts are big data collectors. So are the GPO…Granddaddy GPO Premire is the MOC data collector. 

Another facet: Pharmacist prescribing….The big box pharmacies are totally behind the dumbing down of who can prescribe.  Physicians have become an un-necessary tool.  The big boxers need an army of new pawns…. 

If you dig around CVS’s website you’ll discover they are offering scholarships for employees to go to pharmacy school.

Meanwhile, Walmart trains low level admin for $1 a day. (Warning- have nitro handy before you read this next link:) https://www.fiercehealthcare.com/finance/a-focus-primary-care-clinics-walmart-offering-its-employees-healthcare-workforce-education 

Walmart, the WORLD’s LARGEST company by revenue is about to subsidize the EXPANSION of a dumbed-down administrative state (is that even possible?) and add to optometry and pharmacy tech degrees.  

CVS now taking over PBM role for Walmart https://cvshealth.com/newsroom/press-releases/cvs-health-and-walmart-announce-new-pbm-pharmacy-network-agreement

And on top of it all, CVS and it’s vertical mergers are a wealth (literally) of conflicts of interests that perpetuate all of the above and more: https://thehill.com/opinion/healthcare/421697-put-the-brakes-on-the-cvs-and-aetna-merger-to-sustain-competition-and

Another everyday PBM failure; patient forced to be without meds

A physician-friend of IP4PI reports:

Our senior age patient with a Medicare Part D plan from @ExpressScripts mailed in a controlled substance prescription to the Express Scripts Mail Order Pharmacy on 01/13/20.

Two weeks later? The patient has not received the medicine and is unable to transfer the script to a different pharmacy. The patient called Express Scripts and logged onto their website to find that the plan received the Rx on 01/20/20.

We called Express Scripts. After being on hold for 15 min, Barbara R, said she was on the commercial side and couldn’t help with Medicare claims and put us back on hold. Then, we talked to Jerry C., a supervisor who informed us, in a condescending manner, that Express Scripts recorded that they received the Rx (erroneously) on January 26 it wouldn’t be ready for shipment for another week after today (01/27/20).

Yet another #PBM failure.

I had to give the patient another controlled script he could fill at local pharmacy. PBM added cost to all parties in terms of time and money, and another Rx for a controlled substance for the government to complain about.

HR 3708: Is Pre-Deductible Coverage of Direct Primary Care a Feature or a Bug of The Primary Care Enhancement Act?

Aren’t HSAs intended to empower patient choice? Enabling plans and employers to influence the patient’s selection of primary care physician seems antithetical to this purpose.


DPC practices are rightly concerned about the numerous limitations HR 3708 would impose on their innovative model.  Yet, the limitations on HSA-eligible DPC arrangements are needed “to keep the cost score estimate of the legislation down,” the flawed argument goes.

But the tax impact occurs when dollars are put into an HSA and not when they are spent, so why so much fuss? Yes, the bill would cause more people to become eligible to fund their HSAs tax-free. That would indeed be a source of lost tax revenue. However, wouldn’t the cost in lost tax revenue be about the same irrespective of how a DPC arrangement is designed, assuming patients are funding their HSA up to the modest limits allowed per year anyhow?

Continue reading

ACTION ALERT: STOP Legislators from Delaying Patient Access to Physicians and Facilities of Their Choice

NO To New Jersey Assembly Bill A5369 & S3816!

Following the example of Congress, the NJ Legislature has introduced a “Patient Protection Act” (A5369 / S3816) that is anything but protective of patient rights.

According to NJ Spotlight, “the proposal has drawn criticism from patient advocates and other healthcare experts who suggest that, in an effort to protect the business interests of Garden State hospitals, it could put patients in danger.”

What does this bill do? It erects a number of bureaucratic requirements that physicians would be required to fulfill before referring a patient to an out-of-state colleague or facility for needed medical care.

Here’s how Joe Nessa, Esq. explains it:

If passed, this legislation could have a devastating effect on patient care. Currently, physicians in New Jersey are free to refer their patients to world-renowned hospitals in Philadelphia, New York City, and across the nation for treatment. New rules imposed by the bill would require physicians to inform patients of the availability of in-state facilities even if they think their patient can receive better care elsewhere, notify the patient’s insurance company of the out-of-state transfer, and report the transfer or referral to the Department of Health. This addition of paperwork and red-tape will force physicians to make the easier, time-friendly decision of keeping their patients in-state, regardless of their thoughts on quality of care. Additionally, as if the above requirements aren’t enough, physicians would also be required to send quarterly reports of each out-of-state referral to their licensing board, accompanied by an explanation of the clinical necessity.

Earlier this summer, this bad legislation was being fast-tracked through the legislative process, and was quickly passed by the Assembly and a Senate Committee. It “has yet to be approved by the [full] Senate,” reports the Fall 2019 Edition of MDAdvisor. However, “[t]he sponsors are continuing to work on this legislation….”

Your help is needed to help STOP A5369 & S3816!  Here’s what you can do:

Call your NJ State Senator and Assembly Members. Tell them you are depending on them to stand up for patient rights and vote NO on A5369 and S3816. Patient care should not be put at risk to benefit the bottom line of special interests.

You can find their phone contact information here:
https://www.njleg.state.nj.us/members/abcroster.asp

If you don’t know who represents you, the legislature has tools to help you find out here:
https://www.njleg.state.nj.us/members/legsearch.asp

Medical facilities in NY and PA have put together a tool for sending e-mail messages to legislators which you might also consider using:
https://actnow.io/Y1rtnGO

Thank you for speaking out! Your voice makes a difference.

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/

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