The AOA is MIA as Insurers Marginalize Osteopathic Medicine

For more than a decade insurers have been implementing discriminatory policies that result in the automatic downcoding of claims filed by osteopathic physicians.

An official journal of the American Osteopathic Association recently published on this topic, but the osteopathic physicians on the front lines are asking the AOA to explain why it has been largely silent to this point and not taken meaningful action to stand up for the best interests of its members.

Here is a letter to the AOA Richard Koss, D.O. shared with IP4PI:

I hope you find the article in the recent DO magazine, dated November, 14, 2018, regarding the major insurers pushing back on the use of the modifier 25 as disturbing and discriminatory as I do.

What is the AAO’s policy, and plan to keep OMM specialists from being marginalized and discriminated out of existence? What is the economics committee doing to prevent this from happening? This has been going on for so long now (about 18 years) that there should be regular updates in all AAO communications about the membership’s ability to earn a living at their chosen profession. Where are these updates?

Yes I know that the AAO is under the AOA, but the AOA has no interest in protecting its members who practice OMM.

If you can’t get paid for your services than you do not exist. As OMM is being wiped off the payment rolls, the upcoming students and residents will have no way to pay back their loans, or make a living. So the existence of the AAO is also at stake here.

The beginnings of this trend started back in the 1950’s when the AOA leadership fought and pushed for full practice rights. That is to prescribe drugs and surgery. To do so they had to put OMM in the closet and denigrate it as a pseudoscience. This began the official death of Dr. Still’s Osteopathy. Now there are no Osteopathic hospitals, and all postgraduate programs are ACGME. Dr. Still is not even mentioned in the Academy Programs.

The AOA has known about the billing problems for 20 plus years and continues to be reactionary bending to the dictates of the AMA, and Federal Government, Insurance company mandates without any fight. This I can speak from personal experience. The modifier 25 issue has been going on for at least 18 years. Most recent in 2010 in Vancouver, Washington and Portland, Oregon. Then came the CMS illegal denial of the modifier 25 in the northeast in the last 2 years. Now this article in the DO……

I asked Mr. Goldman the head of the AOA PAC when he asked of PAC donations: “What is AOA policy and plan to support legislators and programs who support OMM?” His answer: “There is none.” The AOA has no plans or policies to keep OMM in its future business model (especially the “Branding advertisement”). Therefore it is up to the AAO to fight for our right to practice.

Please submit this communication to the board of trustees, governors, and I hope you publish this as an OP ED piece or letter to the editor of the AAO newsletters. To continue to be silent in this matter will condone the AOA’s current path.

Osteopathically,

Richard W. Koss, D.O., C-SPOMM, C-ACOFP

P.S. I hope I am not the only one who finds this disturbing. Is this even addressed in the “Five Year Plans” of the AAO? Because if it is not then we really are in trouble.

P.P.S. Of course the AOA is asleep at the wheel and has not done anything to help their members ability to make a living in their chosen profession. The AAO, our OMM specialty organization, also does not want to get involved. I pointed this out to both organizations on several occasions over the years and never gotten acknowledgement or communication on these issue, only “Crickets”. Thus I expect the same response to this letter.

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Shenanigans, Larceny, And Fraud Define The Corporate Practice of Medicine

Bob Campbell, MD, co-founder of Physicians Against Drug Shortages writes in:

I have been gathering a lot of information for a “Corporate Practice of Medicine” project. Not sure what will come of it if anything but some of the shenanigans are very harmful at times. At other times just simple larceny.

The federal court in Philadelphia has issued a new decision in Aetna v. Mednax/Pediatrix Medical Group, 2018 WL 5264310 (E.D. Pa. 2018) involving fraud allegations asserted by Aetna against Mednax, a pediatric private equity firm.

The federal court held that Aetna’s allegations regarding Mednax’ alleged fraud upcoding scheme could proceed in litigation. Aetna alleged that Mednax routinely listed CPT codes that exaggerated the care needed and performed by designating infants as being sicker than they truly were so that it appeared as if the infants required more intensive treatment than was truly the case. This process allowed Mednax to submit inflated bills to Aetna so that Aetna would reimburse Mednax for more money than was justified.

Aetna also alleged the upcoding scheme permeated Mednax’ operations. Mednax trained and required physicians to engage in upcoding and encouraged physicians to perform unnecessary services to support higher billing rates. Mednax also sometimes inflated the codes itself above the level indicated by the physicians before submitting the claim forms. Aetna obtained evidence from former employees of Mednax that were aware of the upcoding scheme.

The court ultimately held that the specific types of upcoding that allegedly occurred, such as listing an infant as requiring critical care rather than general hospital care, sufficiently established the legal basis for fraud.

The federal court also allowed the litigation against the private equity firm controlling pediatric/neonatal intensive care physicians to proceed far beyond the 2-year statute of limitations based upon the “continuing fraud violation doctrine.”

I just wanted to keep you apprised of additional developments in the fraud realm in the context of private equity firms and some of the concerns raised about driving profits improperly. This is literally in your backyard, but also involves an alleged nationwide scheme.

Medicare for All Will Sabotage Your Healthcare and Your Freedom

Politicians promise to lower costs and assure quality medical care, but voters need to beware.

Here are some common misconceptions about Medicare for All:

Myth: Medicare for All would get rid of profiteering insurance companies and thereby save billions.

FACT: The “insurance” monoliths would still be there to manage the system. Look at the profits of Medicare Advantage plans and Medicaid managed-care contractors. Their business plan is to deny care.

Myth: Quality would be assured by government.

FACT: “Quality” would be defined by government, based on compliance with population-based guidelines, not what is best for individual patients.

Myth: Government would “negotiate” lower prices.

FACT: Government would impose price controls. Cuts of 40 percent to providers have been proposed. Overhead is at least 50 percent of a physician’s revenue, and if a practice can’t cover its costs, it closes.

Myth: The system would be like in Western Europe: free, but with great care available when you need it.

FACT: Private insurance is available and widely used in Europe. It would be outlawed in Medicare for All. Cost-saving methods in Europe include Britain’s Liverpool Care Pathway—dehydrating troublesome patients to death, and expanding euthanasia in Belgium, the Netherlands, and Switzerland.

Myth: Corporations and the “rich” would pay for it with “modest” tax hikes.

FACT: Costs of greater than $40 trillion cannot be paid by any available or proposed source of revenue. And of course business costs are paid by the consumer, or the business disappears.

Myth: Care would be “equal” and “fair.

FACT: It is obviously not possible to reduce spending and give more care to the disadvantaged without cutting off care to some who now receive it (such as the elderly).           “

Obama promised—falsely—that if you liked your health plan or your doctor you could keep your doctor or your health plan. With Medicare for All, your insurance plan would be outlawed, and ‘your doctor’ would be the assigned plan ‘provider,’ who may have minimal training or experience. The candidates supporting Medicare for All are preparing to sabotage the voluntary American system of medical care and replace it with a system that will resemble Venezuela, not Denmark.

Looking for more information?

Click and Comment to End Killer GPO/PBM Kickbacks

Co-Founder of Physicians Against Drug Shortages, Bob Campbell, writes:

Go to this site and click on the right button “Comment Now”
https://www.regulations.gov/comment?D=HHSIG-2018-0002-0001

There are already a bunch of comments from PADS members and you are able to read them first for inspiration. Those representing organizations should also submit a comment on behalf of their organization’s membership.

I wrote the passage below and then added an attachment GPO/PBM Facts which is added here as an attachment. There are some great WSJ comments below too which may be an inspiration. I hope this makes it easy. Say who you are why you care and then cut and paste to your heart’s delight. Also you can just compose from the heart.

During our October 22 White House meeting I hope to have a “large number” of comments to get rid of the Middlemen Kickbacks. I will personally deliver a “click count” to the White House so lets aim to impress.

Best
Bob Campbell

Suggestions for Comments:

In my 29 year career in medicine I have witnessed the emergence of middlemen GPO/PBM Kickbacks. What began as a nuisance has become the largest cost driver in healthcare. HHS should formally recommend repeal of the GPO/PBM Safe Harbor. It is a policy that is long overdue. Independent analyses demonstrate 35%-47% of the consumer cost of drugs is used to fund kickbacks. These GPO and PBM contracts are highly guarded and kept secret for a reason. Repeal the Safe Harbor. Reduce costs and end deadly drug shortages.

Repeal the Group Purchasing Organization (GPO) Kickback Safe Harbor {42 CFR § 1001.952(j)} and make the American healthcare system great again.

The GPO/PBM Middleman is the cartel responsible for spiraling healthcare costs, They are responsible for the unprecedented drug price spikes and dangerous, even fatal shortages that began in 2006. The GPO executives and there enablers are growing immeasurably rich in the process. Meanwhile the American people are facing escalating hospital costs. Americans can no longer afford health insurance or medications.
HHS OIG, the Department of Justice, and the Federal Trade Commission are failing to intervene to restore a competitive healthcare supply chain. Congress has failed to confront the powerful businessmen who have criminalized the healthcare supply chain.
Eliminating kickbacks in the healthcare supply chain will save $30b-$90B per year based upon empiric published analyses.

What can saving these billions of dollars do?

Restore the drug marketplace so that inexpensive and available generic medications are once again available to patients.

Rejuvenate the moribund generic drug manufacturing industry in the United States with the creation of hundreds of new plants and tens of thousands of new high paying jobs for American workers.

Allow savings to the Medicare and Medicaid programs totaling $11.1B-$33.3B that would occur immediately with no reduction in health care delivery.

Restore competition in the purchasing of all healthcare supplies. Kickbacks create high prices and low supply. Competition creates low prices and abundant supply. Competition lowers prices and improves quality. Cartels inflate prices and diminish quality.

End dangerous drug shortages that sometimes hurt and sometimes kill patients
Ending the healthcare supply chain kickbacks are a required component of any remedy for the rising cost of healthcare. It is also a necessary step if we are to continue to improve the quality of healthcare in any and all healthcare delivery institutions across the country. The intersection of law, economics, and medicine is where the next chapter in improving patient safety and extending high quality health care to all citizens begins.

The anticompetitive healthcare supply chain should be replaced by one that omits the market allocation fees and vendor access kickbacks. It is a necessary and inevitable event. There is no pathway to affordable high quality healthcare until Medicine’s Mobster Middlemen are vanquished.

Letters to WSJ:

Drug Rebates Help Many, but Not Patients

Pharmacy-benefit managers that are middlemen to middlemen, two orders of magnitude between the consumer and producer.

Joseph Antos and James C. Capretta write in support of pharmacy-benefit managers (PBM) that are middlemen to middlemen, two orders of magnitude between the consumer and producer, with market discipline totally absent (“Drug Rebates Aren’t ‘Kickbacks’” (op-ed, Sept. 17). Certainly, in today’s electronic age pharmaceutical manufacturers could have websites for consumers to purchase their products after an electronic prescription is received. Alternatively, for a known additional amount, a pharmacist could advise and dispense. Americans with health accounts could pay directly for most drugs, especially generics. Insurance could supplement the individual’s payment to purchase the newer, more expensive items. Reforms of the drug-approval process to lower costs would be beneficial.

Kenneth A. Fisher, M.D.
Kalamazoo, Mich.

The entire PBM industry is all about kickbacks and market manipulation. The more rent takers, the more forced manipulation of consumers and the less transparency there are, the less free any market can be. Oligopsony is the antithesis of a free market and directly leads to increased consumer prices. The safe harbor allowing kickbacks and market manipulation for PBMs needs to be rescinded.

Howard C. Mandel, M.D., FACOG
Los Angeles

Rebates create an environment where higher-list-price drugs are favored, providing zero incentive for pharma companies to introduce lower-priced medicines in competitive therapeutic classes. Over the last five years, according to the Department of Health and Human Services, pharmaceutical spending has increased by 38% while the average individual health-insurance premium has increased by 107%. During the same period, rebates, discounts and fees paid by the biopharmaceutical industry to insurers and PBMs have risen from $74 billion to $153 billion—an increase of 107%. Rebates, discounts and fees haven’t slowed precipitous premium increases.

Because PBMs retain a portion of negotiated rebates and other price concessions as compensation for their services, list prices are rising rapidly even as net prices have held steady. Unsurprisingly, manufacturers are willing to raise prices and transfer the greatest list-price-based rebate value to middlemen to secure preferred formulary position at the expense of real free-market competition, while also limiting the therapeutic options of physicians and patients.

Most rebates are generated from the medicines needed by the sickest patients, including those with cancer, autoimmune disorders and HIV. These patients pay 10 times more out of pocket than healthy patients and are forced to try cheaper or more rebate-rich drugs before getting medicines that work best. Faced with higher out-of-pocket costs and barriers to access, people are more likely to stop their treatment, getting sicker and more expensive to treat.

Rebates targeting the most vulnerable Americans aren’t just kickbacks, they are discriminatory and deadly measures as well.

Peter J. Pitts, Robert Goldberg
Center for Medicine in the Public Interest
New York

Legalized kickbacks for an industry that is controlling the prescription market? This has turned the pharmaceutical market into a pay-to-play operation as manufacturers can pay an increasing kickback for a coveted place on the formulary. Euphemistically calling them rebates is simply a way to keep the money flow of health care hidden from the unsuspecting public.

Marion Mass, M.D.
Perkasie, Pa.

Can Organized Medicine Say Goodbye to Bias?

As physicians are saying goodbye to organized medicine maybe organized medicine should realize it is time to say goodbye to bias.

In a recent email “Update” the NJ Association of Osteopathic Physicians and Surgeons trumpeted a headline copied directly from the Governor’s press release:

Governor Murphy Announces Impact of New Jersey’s Actions to Stabilize Health Insurance Market

Can’t we at least report the news without bias and have the debate and discussion in our newsletter rather than a rosy review a Partisan headline?

The recitation of the Governor’s talking points continued:

The reduction in health insurance rates is the direct result of New Jersey’s first-in-the-nation action to continue an individual mandate, after the elimination of the mandate by the Trump Administration at the federal level, and to implement a reinsurance program beginning in 2019. The two laws, signed by Governor Murphy in May, were cited by the Center for American Progress in its listing of New Jersey as the national leader among states for having taken action to protect consumers from federal sabotage of the Affordable Care Act.

Why isn’t the headline, “Governor Murphy forces mandatory tax payer bailout of insurance companies per ACA.” ACA 2010 forces taxpayers to bailout insurance companies and their cronies under penalty of law and IRS.
We can objectively and comparatively report on what health insurance cost in 2009 when basic and essential (B&E) coverage by Horizon was inexpensive before it was canceled due to ACA. For many New Jerseyans, their premiums, deductibles and out-of-pocket costs doubled due to ACA since 2010.

Can’t we at least Report the news without bias and have the debate and discussion in our NJAOPS newsletter rather than a rosy review a partisan headline directly from Trenton?

We do credit NJAOPS for excising this sentence from its version of the Governor’s missive:

“Our work is based on the core belief that health care is a right – not a privilege,” said Governor Phil Murphy. “

 

We also credit NJAOPS with responding positively to this inquiry that they will try to improve their reporting in the future

However, IP4PI will take this opportunity to educate NJ Governor Murphy:

You are either FOR Killer GPO PBM Kickbacks or Against Them

Bob Campbell, MD, co-founder of Physicians Against Drug Shortages writes:

Want to introduce an element of competition into healthcare? Ending the GPO/PBM kickbacks is the best place to start. Low hanging fruit and no room for compromise. You are either FOR sole source pay to play inflationary kickbacks or against.

So far since Trumps rumored new introduction of barriers to the kickbacks have been “rumored” to be “possibly written for possible introduction “ as new HHS rules Sen Warren and Hatch and Congressman Walden have emerged to keep the kickbacks in place and unfettered by HHS. They have not seen the rumored rules but if the rules might interfere with the essential kickbacks then the rules must never be enforced. Not good for America. Senators Toomey and Casey of Pennsylvania are both long time defenders of pay to play kickbacks. Pennsylvania Senate campaigns are very expensive and the PBM GPO cartels are very generous to supporters. Remember Trump can only erect barriers to access to the safe harbor. Congress made kickbacks and racketeering legal for GPOs and PBMs with the safe harbor law. Only Congress can make pay to play payola illegal again. That is an enduring solution. Trump cannot do that. Congress can.

A bill that is written, reviewed polished, and ready to go for any courageous Member of Congress. One version for the House and one for the Senate. President Trump says not one person in Congress is capable enough to take action on this matter. Is anyone willing to take him up on his challenge? All we need is a Healthcare Hero.  How about 100 new generic medication manufacturing plants with 200 jobs at each plant all in the state that leads the way. High paying clean manufacturing jobs that will stay busy throughout economic boom and bust cycles. Hundreds more just like it across the country, but the state of the Member of Congress who will introduce the bill gets first dibs.

A capital investment frenzy occurs if this bill passes. We need chemotherapy, saline, potassium chloride, potassium phosphate calcium carbonate, calcium chloride, sodium bicarbonate, epinephrine,ephedrine, norepinephrine, dopamine dobutamine, glucose, nitroglycerin, cardiac surgical drugs, antibiotics, obstetric medications, pediatric seizure medications and hundreds more.

I need drugs to paralyze people and unparalyze them. I need drugs to increase blood pressure and increase heart rates when they are too low. I need drugs to decrease blood pressure that is too high and slow down heart rates that are too high. Right now using smoke and mirrors. We should postpone all cardiac surgery until the Unsafe Safe Harbor is repealed. Right now we have Fake Anesthesia.

Trust me that is way more dangerous than Fake News. No more Fake Solutions from politicians for explosive healthcare costs and drug shortages. Exclusive Pay to Play Market Allocation Contracts is all that is keeping American companies from lowering costs for drugs and ending drug shortages. All contracts are written by an unnecessary extra layer of Middlemen inserted into the healthcare supply chain with a uniquely powerful ability to demand kickbacks from manufacturers to permit them to make lifesaving medications and medical devices for Americans who need healthcare. Drug Shortages never had to happen and can be ended. Healthcare Kickbacks never had to happen and can be ended.

Aug. 30: Town Hall – Why Is Healthcare so Expensive?

The Healthcare Costs NJ 2018 Townhall with take place on Thursday, August 30th from 6:30pm ET to 8:30pm. It will be held at the Rastelli Market Fresh at Hill Creek Farms located  at 1631 State Hwy 45-S in beautiful Mullica Hill, NJ.

Contact: Craig M. Wax DO, office 856-478-4780 IP4PI@comcast.net

Why is Health Care so expensive?  This question is on nearly every American’s mind.  85% of Americans are more concerned about health care costs than other major expenses, and for good reason:  The average family of 4 will spend $28k on health care this year, $1200 more than last year. And even more concerning is that 44% of Americans skip care because of costs.

The Aug 30 event, featuring a word-class panel of experts on the drivers of medical costs, will explore and provide true solutions to this crucial problem, for both patients and policy makers. The townhall is held in conjunction with Practicing Physicians of America at PracticingPhysician.organd Independent Physicians for Patient Independence at IP4PI.wordpress.com. It is a free event and open to the public.

Speaker Bios:

David Hyman, MD, JD is an adjunct scholar at the Cato Institute and a Professor of Law at Georgetown University. A doctor as well as a lawyer, Hyman served as the Ross and Helen Workman Chair in Law and Professor of Medicine at the University of Illinois, where he directed the Epstein Program in Health Law and Policy. He focuses his research on the regulation and financing of health care and has taught insurance, medical malpractice, law and economics, professional responsibility and tax policy in addition to civil procedure. Hyman served as special counsel on the Federal Trade Commission, where he organized and led hearings on health care and competition – leading to the first joint report issued by the Federal Trade Commission and Department of Justice, “Improving Health Care: A Dose of Competition.” Earlier in his career, he was an associate at Mayer, Brown & Platt in Chicago, practicing tax litigation and health care law. He has been a visiting law professor at the University of Texas and George Washington University, a law professor at the University of Maryland and a lecturer at the University of Chicago. Hyman earned his BA, JD and MD degrees from the University of Chicago. Dr. Hyman recently published a book called Overcharged: Why Americans Pay Too Much For Healthcare. https://www.cato.org/overcharged

Kimberly Legg Corba,  DO is a family physician in private practice in Allentown, PA.  She is a 1993 graduate of the Philadelphia College of Osteopathic Medicine.

She has owned and operated her independent, solo practice since 2003 and transitioned the office to the model of Direct Primary Care in January of 2016.

Dr. Corba has been a speaker for Docs 4 Patient Care Foundation, the Free Market Medical Association, and will be speaking at the 75th Annual meeting of AAPS.

She testified about DPC in December 2017 for the PA Senate Banking and Insurance Committee in support of S. 926 and authored an policy for in-office medication dispensing for PA practices supported and approved by PA Med Society.  On a federal level, Dr. Corba has lobbied several times in Washington DC with the other national leaders for health care reform and most recently met with HHS, White House Administration, The Department of Treasury in support of Direct Primary Care and was present for the May 2018 rose garden speech concerning prescription costs by President Trump and Secretary Azar.   She is a founding member of the Direct Primary Care Alliance and the original founder of the Mid-Atlantic Direct Primary Care Alliance.  Dr. Corba has also authored and published The Manual of Policies and Procedures for Direct Primary Care which helps DPC practices maintain compliance.

Craig M. Wax, DO, is a family physician that practices family medicine and health through prevention in private practice in Mullica Hill, NJ. He is a tireless advocate for the patient-physician relationship and free-market health care. He has a bachelors degree in Food Science Research from Rutgers University in NJ, and a Doctorate in Osteopathic Medicine from the New York College of Osteopathic Medicine in 1994. Dr. Wax serves on the U. S. congressional subcommittee National Physicians Council for Health Care Policy at NPCHCP.org. He is the Vice President for health policy at Practicing Physicians of America at PracticingPhysician.org. Dr. Wax served on Medical Economics journal editorial board and frequently published articles on topics of free market medicine. He is the health talk show host and executive producer for “Your Health Matters ,” on Rowan Radio 89.7 WGLS – FM at RowanRadio.com since 2002. Dr. Wax was honored by the Society of Professional Journalists of Philadelphia with an SPJ award for his ability to make complicated matters simple to understand. He blogs at Independent Physicians for Patient Independence at IP4PI.wordpress.com. Dr Wax began HealthIsNumberOne.com, a free public information source on health in 1999.