STAT: Tell NJ Governor to Rescind Order Blocking Patient Access to Hydroxychloroquine (609) 292-6000

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Call New Jersey’s governor Murphy (609) 292-6000 to rescind his rule restricting early treatment of COVID-19 coronavirus patients. His rule is dangerous and likely would make people sicker and worsen the death toll. Call him, email or web page contact him and demand he reverse his rule. Let doctors be doctors.

Email: constituent.relations@nj.gov

https://www.nj.gov/governor/contact/

Join the physicians who are speaking out! The below letter from physicians explains the urgency for this request.


Doctor’s Letter to Governor

Dear Governor Murphy,

Based on the current circumstances of an extremely contagious deadly COVID19 virus that is creating chaos in our state and the world, your order to restrict physicians from writing prescriptions to treat their patients with Hydroxychloroquine (HCQ), we believe, is contrary to the best practices of medical care. We, as perhaps you, believe in the sanctity of the patient-physician relationship in personalized individual management and care, and that it must lie in the knowledge and wisdom between those two entities and not artificially imposed by others.

Your administration’s order of restriction to use HCQ, prevents patients’ access to a potential life-saving medicine, especially when administered in the early phase of the disease. (1) Creating such a mandate may risk the lives of many New Jersey residents.

Timely access to these medications may mean the difference between life or death for patients facing the battle of their lives. We respectfully suggest that working with New Jersey’s robust pharmaceutical industry to increase the supply of these drugs, both for NJ and the rest of America would benefit the residents of New Jersey and across the country.

Early treatment is crucial for keeping patients out of the hospital and off ventilators. Delaying treatment results in the opposite, more sick patients ending up in overburdened facilities.
HCQ prevents the virus from gaining access to the human cell and in doing so it prevents the infection. Additionally, in those patients who already have infection in their system, HCQ prevents access to the cellular structure called Endoplasmic Reticulum where it replicates. Preventing such replication, reduces the viral load and hence allows the human immune system to fight off the infection. Without this drug, many valuable human lives will be cut short with such an order as proposed and promulgated by your administration. (2)

Other State Governors of Nevada and Michigan formulated similar mechanisms of restrictions to the use of Hydroxychloroquine but seeing the burgeoning loss of life quickly reversed course. If restriction is to prevent hoarding of the medication, then perhaps using the Texas model of limiting the drug dosing for 10 days (20 pills) might be more appropriate. It prevents harm to our vulnerable, sick and infirmed patients. (3)

HCQ has many decades of history as used in the care of patients with Malaria and Rheumatoid Arthritis. Knowing its very low toxicity and it poses very little if any threat to the patient, clinicians in New York, Kansas, elsewhere are reportedly preventing deaths and ARDS/ventilator dependent long ICU stays. Waiting for placebo-controlled trials is not a wartime battlefield strategy, given the urgency of treatment.

As physicians it is our duty to treat patients with the best available therapy and available evidence to circumvent disease at its earliest phase, so as to prevent the loss of life and any future morbidity. It is with that wisdom and acquired knowledge that we respectfully ask you to reconsider this restrictive mandate.

That these drugs are effective against COVID-19 has been proven in laboratory experiments. (4) And now evidence is mounting that these drugs are working to decrease viral load in patients. Decreased viral loads means patients not only avoid the hospital but are less infectious to others.(1) There is growing evidence that early administration even in mild cases of COVID-19 prevents progression to worse disease, likely attenuating the need for ventilators and ICU beds and improves symptoms. (5) This will decrease the burden on the healthcare system and upon the doctors and nurses that bear the ultimately responsibility of the patient’s care.

The information available from across the world suggests that the prudent course of action is not to put hurdles in the path of patient care by restricting most valuable medications that can protect a human life. In fact, India is officially recommending health care professionals and family members of sick patients prophylactically take HCQ. (6) The New York Times reports of a recent study: “Cough, fever and pneumonia went away faster, and the disease seemed less likely to turn severe in people who received hydroxychloroquine than in a comparison group not given the drug.” (7)

We respectfully ask that you review this decision, given the influence of such overwhelming evidence to the contrary. It is with great respect and urgency that we ask you to reconsider this decision that can potentially cause a significant loss of life in the state of New Jersey. Each patient care decision is unique to an individual and their own personal situation and value system. Patients and their physicians must carefully weigh the risks and benefits of every potential intervention. The confidential patient-physician relationship must be held sacrosanct for this purpose.

Best health,

Craig M. Wax DO, Family Medicine
Parvez Dara, MD, Hematology/Oncology
Jim Thomas, MD, Interventional Radiology
Theresa Thomas, MD
Joeseph J. Fallon, Jr., MD, Endocrinology
Carl J. Minniti Jr., MD Medical Oncology & Hematology
Charles Dietzek, DO Vascular Surgery
Indrani Sen Hightower, MD, Neurology
Alieta Eck, MD, Family Medicine
Kelly Victory, MD, Trauma and Emergency Medicine,
Disaster Preparedness and Response
Christine Saba, MD, Pediatrics
Kim Legg Corba, DO, Family Medicine
Marion Mass, MD, Pediatrics
Katerina Lindley, DO, Family Medicine
Theresa Thomas, MD, Internal Medicine
Thomas W Kendall, MD
Family Medicine
Robert Campbell MD
Anesthesiology
Pain Management
Jane Hughes, MD, Ophthalmology
Kris Held, MD, Ophthalmology
Michael J. A. Robb, M.D., Oto-Neurology
Joel L. Strom, D.D.S.,M.S., General Dentistry
Independent Physicians for Patient Independence

References:

  1. Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial
  2. COVID-19 Drug Therapy – Potential Options
  3. Gov. Whitner reverses course on coronavirus drugs
  4. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro
  5. Efficacy of hydroxychloroquine in patients with COVID-19
  6. Recommendation for empiric use of hydroxy-chloroquine for prophylaxis of SARS-CoV-2 infection
  7. Malaria Drug Helps Virus Patients Improve, in Small Study

https://www.senatenj.com/index.php/pennacchio/growing-number-of-doctors-agree-with-senator-pennacchio/47292

ALERT: Opportunity to Help ALL patients access Direct Care with latest Coronavirus aid bill

Update 3/22/2020: It appears that the flawed language has been removed from consideration! Now it is time to ask the Senate to ADD good language from S. 3112, the Personalized Care Act.

Please contact your Senators ASAP with the following request: Please include S. 3112, the Personalized Care Act in the upcoming bill to address the Coronavirus epidemic. Allow all patients to use Health Savings Accounts for direct care arrangements with their trusted doctors, without unnecessary red tape and limits on patients’ options.

Phone numbers for all Senators and the email addresses of their healthcare legislative staff can be found at: bit.ly/senfull2020

Empowering patients to access low cost, high quality medical care, from independent physicians is more urgent than ever!


Tell Congress to Remove Flawed Direct Primary Care Language from Emergency Legislation

Dear AAPS Members and Friends,

Earlier this week we alerted you to provisions in the House coronavirus relief bill that are harmful to small medical practices and all small businesses.  The bill was made slightly less bad before it ultimately passed and was signed by the President.

You can read more about the changes and impact for small businesses here:

https://www.shrm.org/resourcesandtools/legal-and-compliance/employment-law/pages/senate-to-vote-soon-on-coronavirus-paid-leave-mandate.aspx

Now the Senate is working on a third bill related to the ongoing situation with COVID-19. 

A 247-page draft of the bill is now online here:
https://www.republicanleader.senate.gov/imo/media/doc/CARES%20Act%20Final%20-%20Mar%202020.pdf

It has a number of health policy related items tucked into it, for instance a temporary suspension of Medicare sequestration payment reductions.  It also has provisions easing FDA regulations that may impede timely care, and requires that “each provider of a diagnostic test for COVID-19 shall make public the cash price for such test on a public internet website of such provider.”

One immediate concern about the latest bill is that it contains flawed language (Sec. 4403) intended to fix the incompatibility of Health Savings Accounts and Direct Primary Care caused by current IRS law and policy.

A solution for this problem is needed, but the Senate language mirrors problematic policies from past versions of related legislation.

For instance:

1. The bill caps patients’ “aggregate” direct primary care fees at $150/month. Most DPC fees are well under that amount but imposing price controls on care paid for from HSAs would be a dangerous precedent.  And the cap also limits the flexibility of physicians and patients to tailor agreements based on individual patient needs. 

2. The bill limits DPC agreements to “primary care practitioners as defined in section 1833(x)(2)(A) of the Social Security Act.” It also imposes other limits on the types of care that can be included in agreements. These limitations are unwise and also improperly limits the options of patients and physicians.

3. The bill adds DPC to the the section of IRS code that lists types of insurance eligible for payment from HSAs. Labeling DPC as a type of insurance, or type of coverage, is not the right way to correct the flaws in the IRS code and increases the risk of overregulation of innovative DPC practices.

Here’s what you can do:

1) Ask your Senators to remove Section 4403:

Please call your Senators ASAP and ask them to“Remove Sec. 4403 from the 3rd coronavirus bill and replace it with S. 3112, the Personalized Care Act.  Sec. 4403 overregulates innovative direct care arrangements that are increasing patient access to low cost, high quality medical care. This flawed language will do more harm than good. Congress instead should enact S. 3112 and allow all patients to use Health Savings Accounts for direct care arrangements without unnecessary limits on patients’ options.”  

You can find your Senators’ phone numbers at: 
https://www.senate.gov/general/contact_information/senators_cfm.cfm

Alternatively, you may phone the United States Capitol switchboard at (202) 224-3121. A switchboard operator will connect you directly with the Senate office you request.

2) Next call your House members and tell them the same thing!

Contact info at https://www.house.gov/representatives or Capitol switchboard at (202) 224-3121

3) Finally call President Trump to warn him about this bad provision and ask him to demand Congress remove it:

White House Phone #:  (202) 456-1111.

White House Contact Form: https://www.whitehouse.gov/contact/

Please share this alert and encourage others to call. Thank you!

Possible COVID-19 case: Why private independent physicians are a better patient care choice

On Saturday morning at about 10 AM on March 14, I saw a patient for and infectious illness. He was a 51-year-old, military veteran, with a history of hyperlipidemia, cervical DJD, depression and low testosterone. He works as a government entitlement interviewer at a State/county office. His job includes computer data entry while interviewing candidates of all backgrounds for Government benefit eligibility.

He related a two day history of flu like symptoms that included fever with maximum temperature of 102.9°F, muscle aches, fatigue, and dry cough. He denied any history of travel out of the country or exposure to others with that history.  His physical exam was consistent with viral syndrome and negative influenza A and B office testing.  Because of his symptoms, negative influenza testing, and potential workplace exposure history, I was concerned for the possibility of coronavirus Covid 19 Infection. Unfortunately, there were no testing materials for commercially available coronavirus tests. Current testing reports three days turnover time. 

After conversations earlier in the week with Quest and LabCorp, we are on the list to get testing materials next week.  I called the local hospital laboratory and they transferred me to the infectious disease nurse coordinator. She said she would try to get permission to collect a sample from the New Jersey health department and call us back. She called back half an hour later and said that she couldn’t contact anyone and therefore I could not take a sample. 

I was concerned that this might be either COVID19, a false negative influenza test or another infectious illness. My preference was to obtain a viral culture but there were none privately or publicly available, prior to initiation of treatment. As a private independent physician, I decided to treat for two scenarios with Tamiflu 75 twice a day times seven days for influenza and Hydroxychloroquine 200 mg twice a day for seven days as a possible treatment for COVID19. The patient was to self quarantine at home for seven days, stay out of work, and call us with updates. we told the patient to have his live-in girlfriend get in touch with her doctor immediately for potential evaluation and treatment, as she had similar symptoms.

At my direction, my office staff called the New Jersey health department. The number was consistently busy so we sent the patient home. The staff then tried the NJ coronavirus consumer hotline. The attendant said she couldn’t take any information but gave us another number for the NJ COVID19 hotline. 

Upon dialing the next number, we got a polite attendant who also couldn’t take information. I spoke directly with her and she gave me contact information for the County Health Department. I recognized those numbers for daily practice. I knew they would only be available Monday through Friday during business hours and not Saturday morning, which it was. I pressed for another number and was given what appeared to be a cell phone number. 

I called it and spoke with a county health department employee, finally. I discussed the case with her and she said she would call me back after she spoke with her supervisor. She then called back sometime later after the patient had gone and said that given the above case, the New Jersey state coronavirus criteria would not allow a sample to be taken, despite my concerns for moderate risk. 

The major ironies are that the governor, to this moment, despite urging in school closures, has not closed all New Jersey primary schools. Another major irony is that the New Jersey state health department was inaccessible when needed, but coincidentally sent an email with general governance later that afternoon, as opposed to weeks before. 

Fortunately, as a private independent family physician, I was not limited to a hospital system protocol, insurance protocol, or government protocol. I actually diagnosed and treated the patient, definitively and comprehensively, for major disease risk factors.  We will stay in touch with him via phone during the coming week while he is on himself quarantine and out of work. 

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

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 


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

75 Years After D-Day It’s Time to End a Failed WWII-Era Economics Experiment … and solve the surprise billing quagmire too

It’s a sign of the divisive times: even the American business community is throwing its own under the Congressional bus. In a letter to the Senate HELP committee, a broad coalition of employers, including the National Restaurant Association, Auto Care Association, and the National Association of Wholesaler-Distributors, is calling on Congress to impose price controls on others that they would not tolerate being placed on themselves.

Yes, even the “Small Business & Entrepreneurship Council,” is joining this coalition, whose arcane name is a throwback to 1970s era overregulation—ERIC, the ERISA Industry Committee—to ask for legislation that is anything but entrepreneurial.  

These businesses are part of the growing chorus asking Congress to “do something” to address “surprise” medical bills. But instead of focusing on the root causes of the problem, ERIC, and others are demanding heavy handed price controls that will harm the physicians who render life saving medical care — often small businesses themselves. 

And putting the squeeze on physicians with government set fees, that may not even cover costs bloated by complying with a sea of federal regulation, ultimately harms patients’ ability to obtain high-quality, timely care in situations where care is most needed.

Let’s take a closer look at the real cause of the problem, and solutions that will put patients in the driver’s seat instead of putting their access to care on the hot seat.

“Surprise, your insurance plan is not going to cover the care you received,” is another way to describe the situation. Of course, insurers want to limit their costs, as any business would, and those who provide care want to be paid well for their services. 

But how much should emergency medical care cost? In a functioning marketplace prices are determined through an immeasurable number of mutually beneficial transactions between customers and producers, not by federal fiat. 

But American medicine is anything put a healthy market. 

The fact that ERIC is demanding price controls points to a big reason this is the case. Employers are stuck between employees and their medical care thanks to the downstream consequences of wage controls in WWII that spawned tax-deductible employer-funded health benefits. D-Day was 75 years ago, and while Europe was freed, flawed government economic decisions from the War are still trapping Americans “in-network” with soaring medical prices, deductibles, and co-payments, not to mention premiums.

Because employers and other third parties are often in charge of paying the bill and negotiating costs, patients have lost their leverage and pricing becomes untethered from the marketplace mechanisms that, for instance, have put not just a chicken in every pot, but supercomputers in the pockets of virtually every American over age 13, and a car (or two) in nearly every garage.

It’s time to begin extracting the employer from the health care equation. ERIC and its members can be freed from the burden of overseeing and paying for their employees’ care. Employers don’t like shouldering this responsibility and employees shouldn’t want their employer interfering in the exam room or operating suite.  And, sorry Berniacs, Medicare for All is not the right way to go about winding down employer-based coverage.

One answer is to give patients better options to become independent of their employer for their care, like through expanding Health Savings Accounts with the flexibility to be used to buy catastrophic coverage or pay Direct Primary Care (DPC) arrangements.

Another more long term goal, but one in line with the American spirit of freedom and individualism is to end the $280 billion tax exclusion for employer-based insurance benefits altogether. Increase wages and salaries proportionately and cut taxes across the board. Employees can then decide for themselves how to spend their hard earned dollars, whether on insurance, directly on care, or however they choose.  

This would be a win-win-win, for employers, employees, and all patients. A re-energized marketplace will unleash more competition and more facilities and practices emulating the likes of the Surgery Center of Oklahoma (knee-replacements can be 50% less than through “coverage”) , Atlas MD (unlimited primary care for $50/month, $2 lab tests, and wholesale cost prescriptions), and Green Imaging (home of the $250 MRI) where direct-to-patient pricing, that eschews insurance contracts, is a fraction of what “in-network” options charge for the same care. And yes, competition even works to lower the cost of emergency care, as demonstrated by lower-cost transparent physician-run ER and urgent care options already popping up in Arizona, Oklahoma, Texas, and elsewhere across the U.S.

So instead of a surprise bill, patients will be pleasantly surprised at how affordable and accessible high-quality medical care is even for emergencies, when they, not their employer, insurance CEO, Member of Congress, or government bureaucrat are the customer.


Action Item: Visit https://action.stoppricefixing.org/ and learn how to make an immediate difference in the fight to stop flawed legislation.