Congress Can End Corrupt PBM Kickbacks as A Step to True Healthcare Reform

It’s past time for Congress to undo the damage it created back in the 80’s when it exempted hospital group purchasing organizations from anti-kickback rules intended to curb Medicare fraud and abuse. Hospitals claimed this exemption would lower their costs but in reality it created a loophole that ended up increasing costs for patients and lowering quality.  TownHall.com recently published an expose of the scam: “The Multi-Billion Dollar Solution: Repeal Safe Harbor”:

History is rife with examples of government applying band-aid on top of band-aid to fix problems that arise from earlier legislative failures. The problem is, each fix tends to create a new problem or even exacerbate existing problems.

It’s time to rip this particular band-aid right off.

The roots of this particular saga can be traced back to the passage of Medicare and Medicaid.  With patients no longer in charge of the health care dollar — and a third party managing most of of bills — schemes were hatched to bilk Uncle Sam and taxpayers for  medical costs that were either unneeded or not-provided at all.  Congress passed a number of rules to stop kickbacks that helped facilitate fraud and abuse.  Usually the fix came with unintended consequences precipitating even more rules and regulations.

Ending the GPO kickback scheme is a great start. But lasting and meaningful change will also require a hard look at the underlying disease behind higher costs and lower quality. To quote The CATO Institute,”As for socialist economics, it has always resulted in shortages, inefficiency, poverty, and desperation.”

The simple truth is this: Government intervention disrupts the free market forces that weed out bad actors while rewarding entrepreneurs who give customers the best products at the lowest possible cost.

Making high-quality care available to the greatest number of patients requires putting this truth into practice. There are thousands of middlemen who make literal fortunes from the broken status quo and will fight to keep this from happening.

The good news is that they are outnumbered by the hundreds of millions of patients who will benefit from a return to sound free market principles. Making sure Americans understand this truth is a challenging task, but one at which we must succeed.

Advertisements

More Fed carrots? Or just a different stick? #MACRA #MIPS

Secretary Azar says HHS may cease reporting requirements for MIPS “value-based” care. Perhaps you’re beginning to think that they are finally hearing us, right?

However reading further, things get murky fast:

Instead of requiring physicians who participate in MIPS to submit patient data, the proposal suggests having the government use claims data and patient surveys to grade doctors in the program. “We would be able to independently look at data ourselves to decide their compliance with the quality programs rather than their having to even report anything,” Azar said at Thursday’s hearing.

Here’s what some physicians are saying about this “new direction” from HHS:

  • I’m not going to celebrate just yet. Think of how often HHS/CMS have replaced a bad idea they had, with an even worse idea. If they begin using patient surveys (Press Gainey, etc.) to determine whether or not physicians are given a bonus or penalty, I think that could actually make this awful MIPS experiment even worse.
  • We must be careful what we ask for- and we must control the conversation. There is no reason the government needs to be involved at all – that’s the beautiful thing about the free market – the patient receiving the service determines the value – but the patient must have an  appreciable fiduciary responsibility and they vote with their wallet – good restaurants are busy – bad restaurants are closed – really quite simple.
  • MACRA/MIPS  is fatally flawed.  Patients are individuals and cannot be reduced to an algorithm.
  • There is nothing salvageable or workable in the MIPS system. There is no way on paper and with claims that physician skill, judgement or even outcomes can be legitimately assessed. Further, major institutions are rethinking patient evaluations of physicians, realizing that it is a one way system-i.e. there is no way to evaluate the validity of the patient evaluation and no way for the physician to respond.
    In my opinion our best/only meaningful way of reform is to condemn the entire MACRA/MIPS construct as wasteful and invalid without adding anything to patient care. In fact a point can be made that it detracts from actual care.
  • We should have a say in the type of patient survey they set up. And this should decide only incentives not penalties. The only difference between this and MIPS is that with MIPS we can lose money after spending it on data collection, whereas here we avoid double jeopardy because they do their own data collection and we don’t have to attest to anything. Overall I think what they have suggested is better than MIPS.
  • I just had a very cranky daughter complain about the resident who called her sister rather than her when her mother took a turn for the worst. She would give that resident a failing grade. So much subjectivity makes those evaluation meaningless. Also, when grading a physician on outcomes, which physician can take credit for which specific outcome? Many physicians are often involved. This evaluation scheme is totally unworkable.

I think you’ll agree there is more than a bit of skepticism that CMS is going to meaningfully change things for the better. Tell us what you think!

It is not only Aetna, but every major health insurer.

To: Mr. David Jones
Insurance Commissioner of California

Dear Mr. Jones:
I and many of my physician colleagues were gratified to learn in the news this week that you are opening an investigation into Aetna’s ‘prior auth’ practices. I share this little story from today, just so you know it is not only Aetna, but every major health insurer. This is a major reason why our country’s health care is the most expensive, and among the least productive in the developed world (the reverse of just a few years ago), and why U.S. life expectancy has now declined for the second year in a row. I have cc some great physician leaders that I have worked with in California.
Thanks,

Michael Strickland, MD
letmydoctorpractice.org

This is how tests were ordered 10 yrs ago:

Dr to staff: Get a Cat scan (CTPA) of the chest scheduled asap on this patient with recurrent chest pain (who called me last night with worsening pain), now coughing up small amounts of blood (which could become large amounts, at any time, until we know what is causing it), with abnormal fluid collection (pleural effusion).
Minutes later:
Staff: CT scheduled for 9 a.m. tomorrow.
Dr : Great. Next patient..

In 2018:

Tues afternoon:
Dr. to staff (above)
Wed. a.m., I haven’t heard when scheduled. Ask staff. “Hasn’t been scheduled yet. Anthem says it will take a couple of days for them to decide if this test is necessary.” (Note that if the patient gets CT done today and we find a problem, we still have time to do something about it. If Anthem approves it for Friday at 4 pm, there will likely be nothing we can do until Monday..assuming it has not become an emergency, during the delay.)
I call Anthem at 888-224-4902. Get transfer to “provider svcs” 800-345-4344. Get told I need to hang up and call ‘peer to peer line’ at 866-876-3184.

When I call, get voice mail that says “leave your information, and someone will get back to you WITHIN 30 DAYS” !!!!! (I left some information alright).

Call 1st no. back, tell them I want this test approved NOW, or get a Dr. or RN on the phone with me now, or I will send the patient to the ER, and Anthem can pay $5000 to get this done. (Then I remember, the patient has a $12,000 deductible. So, why is Anthem even involved?? “Oh, we still have to approve.”) An RN comes on the line. After a few moments, she says, “Well, a ‘case’ hasn’t been started yet. Your staff will need to call 800-554-0580.” I thank her for her help, tell her this is why I practice direct patient care and do not accept insurance, and ask if she’s seen the news this week that the state of California is investigating Anthem (oops, Aetna. Same thing) over its prior authorization practices.

Give staff above no. She calls and gets CT scan “approved”.

I spent 25 min total on phone w Anthem, plus 15 min w patient and staff, plus documenting (in case of bad outcome, d/t delay), i.e. about one hour of my (doctor’s) time, and staff tells me she spent about an hour on this as well, so 2 hours of the clinic’s time to get “approval” for a test that any 4th year med student would immediately know needs done, and needs done now. And 2 hours we did not do anything remotely resembling anything productive to patient care.

If you wonder why you can’t get into your doctor for days or weeks, and why it costs a fortune, look no further. This happens all day, every day, in every doctor’s office across America.

Next patient…never mind, I’m going to take an aspirin and lie down for a few minutes.

“Continuing Board Certification” sounds swell but harms patients.

Dr. Walter Wood writes:

I board certified prior to 1991 and have “lifetime” certification equivalent to an academic degree. I can attest that my younger colleagues and their patients are being harmed by costly and time consuming “requirements” to participate in “re-certification” and “maintenance” of certification, soon to be renamed “Continuing Board Certification,” which is not needed and not only does not help patients but harms them. Patients in need are harmed when a doctor is not taking care of patients because the doctor is busy preparing for or repeatedly jumping through hoops such as what lawyers experience once in a lifetime with their bar exam. I was somewhat stunned that an anti-trust judge thought it was necessary to demonstrate “harm to consumers” as a result of the egregious behavior of the ABMS and its colluding member boards. That judge needs to be asked whether s/he repeats the bar exam every ten years.

Walter Wood, MD, FAAD

P.S. I have posted these comments at certificationharm.org.

Pioneers and Powerhouses of DPC launch new organization

The Direct Primary Care Alliance launched on January 1, 2018 as a physician-led organization exclusively focused on growing the Direct Primary Care (DPC) movement. The Alliance was born from a grassroots network of practicing DPC physicians looking to provide a unified voice and resources for fellow DPC physicians. The motivations for launching the Alliance can be found in remarks from our inaugural president, W. Ryan Neuhofel, DO, MPH:

We now realize the transformative potential of the DPC model and are at the advent of moving beyond novelty.  But, many hurdles exist for us to achieve that vision. The challenges ahead of us are immense. Yet I can think of no better group of people to overcome these odds.


Trump Executive Order Births Sweeping New Rules Allowing Association Health Plans

From our friends at D4PC:

The Trump administration, encouraged by Senator Rand Paul, circumvented Congress with Executive Order 13813 to create rules through the Department of Labor that allow approximately 44 million Americans to create and/or join Association Health Plans (AHP).

These AHP are exempt from many of the ObamaCare mandates that have been cost drivers for the insurance policies offered to self-employed and small businesses that often doubled rates.

“The proposed rule is designed to make it easier for groups of individuals and small businesses to band together and buy the kind of insurance that large companies offer their workers. That kind of insurance is regulated under federal labor law and isn’t subject to all the requirements and consumer protections that apply to individual and small business insurance under ObamaCare.” -NYtimes.com

The sweeping new rules have been published for public comment for 60 days before they are implemented with the force of law.

Click here to read more.

Not news to physicians, but the media is finally seeing through EHR smokescreen

Others’ eyes are finally opening to what physicians have been seeing for years: EHR billing and compliance IT only adds to healthcare costs not quality, economy or patient satisfaction.

In 2016 Forbes reported that “U.S physician costs to keep up [with HIT] have reached more than $32,000 per doctor annually.”

https://www.forbes.com/sites/brucejapsen/2016/08/10/health-it-costs-surpass-32k-per-doctor-annually/amp/

IP4PI founder, Craig M. Wax, D.O., has been writing and speaking on this for the better part of this decade.  Here are just a few of his talks about EHR’s attack on patient care:

EHR privacy and security: mission impossible (patient town hall version 2012)

EHR privacy and security: mission impossible (physician version 2012)

EHR the Trojan horse (2014)

EHR remote control (2014)