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Wednesday, May 24, 2023

SHORTCUTS TO HELL. In the “Wild West” of Outpatient Vascular Care, Doctors Can Reap Huge Payments as Patients Risk Life and Limb

 

In the “Wild West” of Outpatient Vascular Care, Doctors Can Reap Huge Payments as Patients Risk Life and Limb

by Annie Waldman

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

Series: Arterial Motives





In the suburbs of Maryland, Dr. Jeffery Dormu’s presence is hard to miss. He’s a regular on the local TV station, which has featured him and his practice five times over the past five years. And he smiles down from an electronic billboard outside a three-story vascular center he calls The Watcher. “It has a biblical reference, which is to watch over the community,” he said at its 2018 opening. In response to the country’s “tragedy of cardiovascular disease,” the center trademarked the phrase “vascular devastation,” a slogan frequently invoked in its marketing, along with a claim to have “saved over 34,000 lives and limbs.”

Dormu and his group, the Minimally Invasive Vascular Center, have been a magnet for people with leg pain who worry they have peripheral artery disease, a condition that afflicts more than 6.5 million Americans and happens when fatty deposits narrow the arteries and block blood from flowing to the legs.

But Dormu’s portrayal of his practice as a heroic refuge hid a distressing statistic: The vascular surgeon was performing an invasive leg treatment more often than almost any other doctor in the country, even when his patients didn’t need it and even as evidence of harm mounted.

One man had to have his leg amputated after Dormu administered multiple invasive treatments for mild pain, according to legal filings. A 62-year-old grandmother bled out and died shortly after Dormu cut into her, according to another lawsuit.

Dormu’s go-to procedure, the atherectomy, involved shaving blockages with blade-topped catheters. Best practices recommend that doctors hold off on invasive procedures like these, which can lead to complications including limb loss, on patients in the earliest stages of disease; doctors should first see how the patients do with exercise and medication. Dormu defaulted to atherectomies almost immediately, patient legal and medical records show.

Four years ago, leading researchers warned the Centers for Medicare and Medicaid Services that some doctors were potentially abusing interventions. The researchers implored the government insurer to scrutinize its own data to identify overuse, noting that some of the doctors could present an “immediate threat to public safety.”

There is no public evidence that CMS meaningfully responded.

But a ProPublica analysis of CMS data suggests that if the agency had reviewed its own figures, it would have discovered that Dormu was part of a small pool of physicians performing a disproportionate number of treatments. From 2017 to 2021, the analysis shows, the top 5% of doctors conducting atherectomies — about 90 physicians overall — accounted for more than a third of all procedures and government payments, totaling nearly a billion dollars.

Near the top of the list sits Dormu, logging more atherectomies — and making more money from them — than almost every other doctor in America.

CMS paid Dormu more than $30 million in the past decade for vascular procedures he performed on hundreds of patients.

Dormu declined to be interviewed and did not respond to emailed questions.

But a chorus of experts told ProPublica that the federal government’s decision to provide unconditional payments for vascular procedures — and then not pay attention to what happened — is a prime example of what’s wrong with the American health care system.

“The government is really to blame for setting these tremendously high reimbursement values without looking into whether these procedures are helping people or are just worthless procedures or, in fact, are hurting people,” said Dr. Dipankar Mukherjee, a vascular surgeon and chief of vascular surgery at Inova Fairfax Hospital in Virginia.

CMS kicked off the problem 15 years ago when it tried to rein in the swelling hospital costs for vascular care. Over the past few decades, advances in technology allowed patients with serious circulation problems to avoid open surgery and instead undergo minimally invasive treatment with cutting-edge devices. As they flocked to hospitals for these procedures, patients with clogged leg arteries became even more expensive than patients with clogged heart arteries.

In 2008, recognizing that the procedures could be done safely and more efficiently outside hospitals, CMS officials turbocharged payments to doctors’ offices that deployed balloons and stents to widen arteries. And in 2011, they began to reimburse those offices for atherectomies.

Before the change, an office provider inserting a stent could make about $1,700 from Medicare; deploying a balloon could bring in roughly $3,800. By 2011, the payments rose to about $6,400 and $4,800 respectively. But nothing compared to the payout for atherectomies conducted in offices: about $13,500 per procedure, as opposed to roughly $11,450 in a hospital.

Instead of saving money, the government started a boom.

Atherectomies increased by 60% from 2011 to 2014; Medicare’s overall costs for peripheral vascular treatments climbed by nearly half a billion dollars, or 18%.

The government insurer didn’t change course in 2014, when research began to indicate that atherectomies may not be more effective than cheaper alternatives, or in 2019, when experts warned the procedure may be associated with a higher risk of complications.

From 2013 to 2021, the most recent year of Medicare data, the number of atherectomies has doubled and payments to doctors have nearly tripled, totaling about $503 million in 2021.

“There are definitely places where atherectomy is very helpful,” said Dr. Caitlin Hicks, an associate professor of surgery at Johns Hopkins University School of Medicine. “But it’s definitely being used inappropriately, and that’s when bad things happen.”

Experts fear patients are being caught up in a new era of profit-driven procedure mills, in which doctors can deploy any number of devices in the time it takes to drill a tooth and then bill for the price of a new car.

The generous reimbursements have created a conflict of interest for doctors running their own practices, who are supposed to make unbiased medical decisions while also being responsible for a lease, overhead and staff. And unlike hospitals, which have panels and administrators who spot adverse events and questionable billing, these offices don’t face such scrutiny.

CMS, experts say, should step up: It could reduce its reimbursements or even investigate doctors with outsized procedure patterns.

ProPublica reached out to CMS more than two weeks ago, listing the facts in this story, asking questions and requesting an interview. CMS did not make an official available to talk or provide any written answers.

“Vascular medicine now is the frontier of the Wild West,” said Dr. Marty Makary, a professor of surgery and health care quality researcher at Johns Hopkins University School of Medicine. “People are flying blind walking into the clinics of these doctors with egregious practice patterns, and we know that their pattern is indefensible.”

It was at the cusp of this lucrative new era in vascular medicine that Dormu, an ambitious young doctor from Washington, D.C., entered the scene.

After earning his medical degree at the New York Institute of Technology College of Osteopathic Medicine and completing an additional eight years of training in New York and New Jersey hospitals, including a residency in general surgery and two fellowships in cardiothoracic and vascular surgery, he received his license to practice medicine in Maryland in 2007. That year, he founded the Minimally Invasive Vascular Center.

“People in general are just afraid of surgery,” he later told a local TV journalist. “They can get by with minimally invasive surgery, a needle puncture without having to be cut, without having to worry about an amputation. They walk in and within hours they walk out, and pretty much healed.”

Dormu opened several vascular offices in the region. At one point, his group also partnered with the Washington, D.C., Department of Aging and Community Living, providing hundreds of free vascular screenings for elderly patients at senior centers and residences across the capital.

But according to public records and lawsuits, as his profile and his practice grew, so, too, did evidence of harm.

In March 2016, while he was performing an elective aorta repair at Providence Hospital, the patient began to hemorrhage, according to a District of Columbia Board of Medicine document on the incident. After trying to control the bleeding, Dormu transferred the patient to the intensive care unit for resuscitative efforts and then left the hospital for his private practice and other appointments.

He was gone for more than two hours, and in that time, hospital staff couldn’t reach him. The hospital patient died in the recovery room from hemorrhage and organ failure, the report said. Six years later, the District of Columbia Board of Medicine would reprimand him for the incident alongside a $5,000 fine, finding that he abandoned a patient in need of further emergency care, “knowing the high risk of mortality and without adequate communication to other hospital staff.”

The death of the patient did not interfere with his medical license or appear to slow his career.

Nine months later, a mechanic sought his care for mild leg pain. As the owner of his shop, Steve Rosenberg clocked long hours, six days a week, repairing anything with wheels or an engine. But as he reached his mid-50s, the long days of standing under vehicle lifts had begun to strain his legs.

His primary care doctor suggested that he see a vascular specialist and handed him a list of physicians to choose from. Dormu happened to have an office in the same plaza as Rosenberg’s auto shop, between a jujitsu studio and a dentist’s office.

He first visited Dormu’s practice that December.

Instead of starting with more conservative treatment, Dormu deployed a trifecta of interventions on both of Rosenberg’s legs within three months, widening his arteries with stents and balloons, and debulking his vessels with atherectomy devices, according to later legal filings.

Shortly after one of the procedures, Rosenberg’s left foot grew numb and was cool to the touch. He went to the emergency room, where doctors discovered that one of his stents had clogged, hindering his vessel from carrying blood.

Dormu called him back to his office, where he repeated the procedures: shaving the blockages, ballooning the artery walls, and installing another stent.

The next day, he repeated the procedures again, ballooning his vessels and installing yet another stent.

Dormu sent Rosenberg to Providence Hospital in Washington, D.C., for further treatment. Within a day, his left foot had grown cold, a sign that blood likely no longer flowed freely through his vessels.

According to the terms of a legal settlement in a malpractice suit against Dormu, Rosenberg cannot comment on his care. However, public documents filed in his case, including assessments from medical experts, illuminate the cascade of procedures and the outcome.

A vascular surgeon Dormu retained for his defense, Dr. Garry Ruben, said the interventions were warranted; he said Rosenberg had been prescribed an anti-platelet medication, which he did not consistently take. In legal filings, Dormu blamed Rosenberg’s injuries on his preexisting medical conditions and circumstances outside his control.

However, after reviewing medical records and diagnostic studies, Dr. Christopher Abularrage, an expert retained by Rosenberg and a professor at Johns Hopkins who specializes in vascular and endovascular surgery, found several “breaches of the standard of care.” He found that Dormu had failed to prescribe conservative therapy and lifestyle modifications first and “persisted with unindicated, endovascular interventions in the face of persistently poor outcomes and diminishing returns.”

In less than six months, Rosenberg had been transformed from a patient with mild leg pain to one with a high risk of limb loss, he concluded.

Rosenberg spent nearly a week at Providence Hospital, the life slowly draining from his leg, before he was transferred to Washington Hospital Center on April 8, 2017, according to records. By then, his left leg was gangrenous and had no pulse. All of the stents had become blocked.

Without better options, doctors amputated his leg.

Between 2013 and 2017, Dormu earned about $14.5 million from Medicare — more than 99% of other vascular surgeons across the country — for treating hundreds of patients a year, the vast majority of them in his clinics.

In 2018, he was able to afford an upgrade.

The Watcher was not like other surgical centers. At its entrance stood a juice bar that could serve organic cold-pressed drinks to patients. Crystal chandeliers adorned its hallways. Moist air was pumped through its vents. And more than a dozen original modern paintings lined its walls, making it feel like an art gallery. “We wanted it to give that shock and awe,” Dormu said in a video interview from the facility’s opening day.

His clinic provided a litany of medical services, including treatments for uterine fibroids, erectile dysfunction and varicose veins, and elective nonsurgical fat reduction.

The expansive facility boosted Dormu’s earnings. From 2018 through 2021, he earned nearly $18 million in Medicare payments for all of his clinic’s activities.

One procedure stood out from the rest: Nearly $12 million of that came from atherectomies, according to Medicare data.

He performed one on Alice Belton, a high school nursing teacher who sought help in 2018 for lower extremity pain, numbness, and tingling. Her artery blood flow was normal; even Dormu noted that she didn’t have severe leg pain, according to an ongoing lawsuit. And yet, he conducted multiple procedures over about a year, shaving plaque, ballooning her vessels, treating her veins and running invasive scans; the procedures were unnecessary, according to a medical expert retained in her case.

Belton says she has since developed permanent nerve damage in her leg, which has prevented her from working full-time. In legal filings, Dormu denied the allegations and claimed that the alleged injuries were caused by preexisting conditions.

“The experience with Dr. Dormu has shaken my confidence in health care practitioners and more importantly in myself,” she said. “I feel duped that this surgeon convinced me, a nurse, that my problems required such radical surgical interventions.”

And then there was John Malinich, who had no leg pain but wanted to get his circulation checked in 2019 after he saw Dormu’s billboard. At first, Malinich didn’t question Dormu’s treatments; the doctor’s confident demeanor and lavish facility impressed him and put him at ease.

“After surgery on both of my legs, they wanted me to go back and do it over again,” he said. “After that, I started getting suspicious.”

He said he got a second opinion from another vascular surgeon who informed him that the prior procedures, which involved balloons, an atherectomy and a stent, had been unnecessary. To ensure his stent doesn’t collapse or clog, doctors now have to annually monitor Malinich. He filed a lawsuit against Dormu, who has denied allegations of overtreatment. The case is ongoing.

“I trusted the guy,” Malinich said. “But it was just to make money.”

The next year, Heather Terry was looking forward to her mother’s return home after a six-month stint rehabilitating in a nursing home. For years, Heather had helped take care of 62-year-old Linda Terry, who had debilitating epilepsy. After a fall down a flight of stairs and subsequent back surgery, Terry was left paraplegic and unable to walk.

Just before she was supposed to be discharged from the nursing home in August 2020, the staff told Heather Terry that her mother had leg pain and ulcers on her heels that needed treatment. According to her family, Linda Terry had no prior circulation issues. The procedure was simple, the staff said, and would be conducted in a clinic just down the road.

On Aug. 13, Terry was transferred to Dormu’s center, where he started an atherectomy procedure, inserting the small tube capped with blades into her vessels to shave the plaque from her artery walls.

Less than 15 minutes into the treatment, her blood pressure began to drop.

With atherectomy, there’s always a risk that the device may dissect the vessel, which would require immediate care.

Dormu aborted the procedure and brought Terry into the recovery area. She was drowsy and her blood pressure continued to waver, signs that she may have been bleeding internally, according to her family’s attorney. Instead of being rushed to the emergency room, legal filings show, she was sent back to the nursing home, where she became unresponsive.

The nursing home called an ambulance, which ferried her to the emergency room at the University of Maryland Laurel Medical Center. Three hours later, she was pronounced dead, according to the lawsuit, a consequence of severe anemia due to internal blood loss.

For the aborted procedure, according to the family’s attorney, Dr. Zev Gershon, Dormu charged her insurance about $20,000.

Heather Terry believes that if Dormu had treated her mother with appropriate care and transferred her directly to the hospital, she might have survived. “It went from ‘She’s going to come home tomorrow’ to ‘She’s dead,’” said Terry, whose ongoing malpractice case against Dormu is set to go to trial this year.

In legal filings, Dormu denied any involvement in her mother’s death. He said in a deposition that he did not see evidence of bleeding and that Linda Terry’s anemia could have been due to a prior fall. He said he also gave a directive to send her to the hospital after the aborted procedure, despite EMS records obtained by the family’s attorney showing that Terry was sent back to the nursing home.

“I trusted doctors,” Heather Terry said, “but now I’m starting to think that maybe they shouldn’t be as fully trusted.”

By 2021, Dr. Kim Hodgson, a former president of the Society for Vascular Surgery, recognized that unfettered profiteering in his field was not just a threat to patients, it also stood to damage the credibility of his specialty. Notably, abuse in outpatient vascular facilities was the No. 1 complaint he had received from members. That August, the vascular surgeon stood before hundreds of doctors at the society’s annual conference and made a plea.

“Somebody has to address what should never have been allowed to get to this level of threat to us and our patients in the first place,” he said. “We can play whack-a-mole every time the bad actors surface until the cows come home, but that leaves a trail of harmed patients and wasted resources.”

In dozens of slides, he laid out evidence exposing the magnitude of the crisis: the Medicare incentive, the explosive growth of procedures in clinics and the potential for inappropriate treatment. Most critically, he warned about the risk of patient harm. In recent years, researchers have found that patients in the early stages of vascular disease had less than a 2% risk of amputation after five years. However, with aggressive interventions, that risk could surge up to 5% or even 10%.

“The problem is that these behaviors — unindicated early interventions and overuse of unproven technologies — still have costs and more often than not, those costs are borne by our patients,” he said. “We can and should do better, otherwise we are also enablers.”

The issue has magnified into a crisis that has splintered the specialties that conduct these procedures, which include interventional radiologists, cardiologists as well as vascular surgeons. Some physicians do not view overuse as an urgent problem and feel the recent academic attention unfairly stigmatizes private practice doctors.

“The majority of operators are doing the right thing,” said Dr. Jeffrey Carr, an interventional cardiologist and the founding president of the Outpatient Endovascular and Interventional Society, which represents physicians working in outpatient settings. “We need to call out the bad actors, but to cast a narrative that puts us all in the same arena is wrong.”

Other doctors recognize a need for considerable reforms.

CMS could reverse the change that kicked off the entire problem, some experts said, by reducing its outpatient reimbursement rates. “If you shut off the money, the whole thing will stop tomorrow,” Mukherjee, the Virginia vascular surgeon, said.

But such cuts might hurt doctors practicing responsibly and could even nudge the least scrupulous ones into higher gear to make up the financial difference. “You could incentivize people to do more procedures, and some of them may be inappropriate,” said Dr. Peter Lawrence, the former chief of vascular and endovascular surgery at the University of California, Los Angeles, who developed an outpatient center connected to the university.

More critical than payment cuts, Lawrence said, is greater oversight of office-based facilities. Many states don’t require doctors in those settings to have special vascular training or hospital privileges in case of complications, he said. “You could be a psychiatrist and do these procedures,” he said.

Many physicians also support improved data collection, particularly for newer technologies like atherectomy, to ensure that they’re not only safe but result in improved outcomes.

“Many of the vascular procedures that are done are relatively safe or can be done with good short-term results, but the failures are long term — it’s what happens in two to five years,” Lawrence said. “Unless you have a reimbursement system, which not only pays you for the initial procedure but whether or not it’s durable, you can have procedures done in our society that have great short-term results but have poor long-term results.”

CMS could require physicians to participate in patient registries, said Dr. William Schuyler Jones, an interventional cardiologist and associate professor of medicine at Duke University School of Medicine. “That type of required reporting would make our system better,” he said, “and would ultimately put the onus on all of us to do more appropriate care.”

For Dormu, patients were the ones to prompt accountability, airing their grievances to the Maryland Board of Physicians. Among them was a woman who sought his care for excessive leg itching and said he tried to pressure her into an invasive artery scan. When she sought a second opinion, the doctor concluded that her itching likely stemmed from a reaction to an insect bite.

The medical board examined the records of 11 of Dormu’s patients. Two peer reviewers, board certified in vascular surgery, independently concluded that Dormu had performed “medically unnecessary and invasive vascular procedures” and failed to meet appropriate standards of care for 10 of the 11 patients, “exposing them to potential risks such as bleeding, infection, blood vessel injuries which could acutely or chronically worsen the patient’s circulation, and limb loss.”

One patient who sought Dormu’s care to evaluate blockages in their legs could walk a mile before treatment, but after the procedures, they could not walk at all.

“There exists a substantial likelihood of risk of serious harm to the public health, safety, and welfare in Dr. Dormu’s continued practice,” the board’s executive director, Christine Farrelly, concluded.

Last October, the board found him in violation of state medical law, citing his overuse of procedures and his failure to uphold standards of care. It fined him $10,000, suspended him and put him under a two-year probation, during which he must be supervised and enroll in an ethics course.

Maryland Department of Health spokesperson Chase Cook said the agency’s Office of Health Care Quality, which is responsible for oversight of the state’s surgical centers and licensed Dormu’s current facility, was not aware of his sanctions nor the allegations of harm. The office “will follow-up in accordance with federal and state regulations,” Cook said.

Despite lacking an active license to practice medicine in Maryland, Dormu is still listed on his clinic’s website as the lead vascular surgeon, “currently available for office visits and in-patient consultations.”

When ProPublica called Dormu’s office to inquire whether he was still practicing, the receptionist said he was no longer seeing patients and that “Dr. Seibles” was providing all the same services. According to the Virginia Board of Medicine’s directory, Dr. Ayana Jonelle Seibles spends 20% of her time practicing at Dormu’s center in Maryland.

An emergency medicine physician who does not have specialty training in vascular surgery, Seibles appears to have a close relationship with Dormu; according to county property tax records, they have owned a home together since at least 2017. Seibles did not respond to ProPublica’s questions that were sent by email.

In a lawsuit deposition last month, Dormu said that he stopped doing surgery this year as a “personal choice.” When asked the name of his supervisor, he stated that he couldn’t recall it. He also couldn’t recall how many times he had been sued for malpractice, any of the details of the cases, nor the names of the attorneys representing him. He also couldn’t specify how many atherectomies he had performed, only estimating that he had done more than 100.

According to Medicare data, over the past decade, he has done at least 3,400.

For most of his life, Rosenberg trusted doctors; his own father was one. But the mechanic has lost faith in medicine. Memories of his 2017 amputation have been largely buried by the trauma, but he recalls lying in his hospital bed after the operation, the remnants of his left leg wrapped in a cloud of white bandages. “Life isn’t supposed to turn out like this,” he said.

He was discharged to his three-story colonial home, where two steps led to the front door and 13 steps gave way to the second floor; he could only ascend them by crawling backward. Eventually, he sold the house and his family moved into a flat, ranch-style home.

He tried to maintain his auto shop, relying on his wife and teenage stepson to help out. But with his limited mobility, first in a wheelchair and later maneuvering with his prosthetic and a cane, he could not repair cars like he used to and was forced to sell his business and retire.

Before, he could get dressed and out the door in less than 30 minutes; it now takes more than an hour. He used to prepare meals for his family, but after, his stepson had to learn how to cook. In the months following the surgery, he often fell asleep by 7:30 p.m., tired from carrying his body around all day. Discomfort would awaken him by 4 a.m.

Half of his days are now spent navigating the complex web of amputee providers, arguing with insurance agents, attending physical therapy and meeting with specialists to keep his vascular system in check.

Above all, managing the pain has remained a lingering burden. Even though he lost most of his left leg, its memory has been indelibly burned into his brain, haunting him like a phantom. Sometimes the bottom of his missing foot itches or a jolt surges down his absent calf.

“And there’s nothing anyone can do about it,” he said, “because it’s not there.”

In the end game, science and medicine are limited by 'clinical judgment'.  A very subjective term difficult to measure.  Primum non nocere .


Tuesday, May 16, 2023

Here's what for-profit health system CEOs, CFOs made in 2022


Everyone thinks physicians make so much money, but there are those who profit extravagantly in our health care system.

Here's what the CEOs and CFOs of major for-profit health systems made in 2022

It was a bad year for hospital C-suites.  They are blaming it on the pandemic. 

In 2022, the CEOs and chief financial officers of HCA Healthcare, Tenet Healthcare, Universal Health Services (UHS), and Community Health Systems (CHS) all received compensation packages anywhere from $1.6 million (CHS CFO Steve Filton) to over $9.7 million (Tenet Healthcare CEO Saum Sutaria, M.D.) lower than the year prior, according to annual proxy statements filed with the Securities and Exchange Commission.

Though each of their organizations turned a profit during 2022, yearlong volume interruptions and rising expenses meant that the companies’ financial results were a marked step back compared to 2021.

For the executives, that meant a slight dip in their stock awards and major cutbacks in nonequity incentive plan compensation, the latter of which are structured to only pay out should the company hit specific performance thresholds.

Still, CEOs of the four for-profit systems managed to bring home a collective $43.3 million across their reported total compensations, per the filings. This was down about a third from 2021’s $65.3 million of collective total compensation.



Source: Securities and Exchange Commission proxy filings


Read on for the full breakdown of how the CEOs and CFOs of HCA Healthcare, Tenet Healthcare, UHS, and CHS made their millions in 2022.

1. Samuel Hazen, HCA Healthcare CEO

2022 total compensation: $14,637,726

CEO to median worker pay ratio: 254:1

2. Saum Sutaria, M.D., Tenet Healthcare CEO

2022 total compensation: $11,047,128                                                                                                  CEO to median worker pay ratio: 189:1

3. Marc Miller, Universal Health Services CEO

2022 total compensation: $10,919,976
CEO to median worker pay ratio: 221:1


4. Tim Hingtgen, Community Health Systems CEO

2022 total compensation: $6,302,542

CEO to median worker pay ratio: 97:1


1. William Rutherford, HCA Healthcare CFO

2022 total compensation: $5,058,078


2. Kevin Hammons, Community Health Systems CFO

2022 total compensation: $4,191,086


Dan Cancelmi, Tenet Healthcare CFO

2022 total compensation: $3,608,084


Steve Filton, Universal Health Services CFO

2022 total compensation: $3,268,104

It should be noted that a portion of executive pay is connected to the economic performance of their hospital(s). and is represented by stock shares, and pension plans

The executive pay scale compared with other large enterprise corporations does not seem excessive.  However, in a world of healthcare disparity, the ratio of executive pay scales (CEO to MEDIAN WORKER ) ranges from 254:1 (HIGHEST) to  97.1 (LOWEST).

Healthcare incomes are in line with the huge disparity of income in our overall society where the middle class is fast disappearing. Some 'ordinary' hospital workers live at or near the poverty line.  Some fast food workers earn more than a nurse's aide. 

The bottom line for hospital employees in Califonia is the State mandated following,

In 2016, California passed a law to raise the minimum wage to $15.00 per hour statewide by 2022 for large businesses with 26 or more employees, and by 2023 for small businesses with 25 or fewer employees

The Healthcare Worker Minimum Wage Ordinance will become effective on September 26, 2022. The Ordinance creates a healthcare worker minimum wage of $25.00 per hour for covered employees.

California is offering a 1 billion dollar bonus for eligible health workers for workers impacted by the COVID pandemic 

How many of those workers receive stock shares, or retirement plans?

All in all it is a very sad state of affairs and nothing that any hospital chain should be proud.

Transparency makes little difference since these statistics are easily obtained.  Non-profit executives fare no differently from their counterparts in the for-profit sector.




Here's what for-profit health system CEOs, CFOs made in 2022

Thursday, May 11, 2023

EPA proposes bold new limits for tackling 'forever chemicals' in drinking water | Environmental Working Group



Water, water everywhere, and not a drop to drink!  

Imagine yourself lost on a life raft in the middle of the sea !  Your throat is parched, so badly you finally relent to drinking from the sea, knowing full well it will kill you. Yet you drink. Perhaps this tale is a foreboding of things to come.

Although the surface of the earth is seventy percent water,  how much is drinkable? Only about three percent of Earth's water is freshwater. Of that, only about 1.2 percent can be used as drinking water; the rest is locked up in glaciers, ice caps, and permafrost, or buried deep in the ground. Most of our drinking water comes from rivers and streams.

The Environmental Protection Agency unveiled unprecedented new limits on the toxic “forever chemicals” known as PFAS as a way to tackle drinking water contamination. The proposal targets six notorious PFAS – PFOA, PFOS, GenX, PFBS, PFNA, and PFHxS. 




One hundred years ago water was abundant, and great reservoirs were built and filled from the runoff of mountains, and glaciers.  Some were enormous holding tanks fashioned by dams built at a time when arid lands were sparsely populated. 

In many countries, we see remnants of civilizations gone, abandoned cities, dwellings built into cliffsides, and structures seen only with satellite mapping of roads, and buildings covered by earth and vegetation.

Did water shortages, pandemics, or earthquakes put a swift end or a slow end to those settlements?

Mass migrations are occurring as I write this blog, in Turkey, Sudan, and Northern Africa.  Political instability is fueled by a shortage of water and/or food.

Political instability is often the result of climate-induced disruptions to agricultural systems, but responses to disasters are crucial determinants of when and where conflict may occur. Historically famines have been aggravated by the failure of political elites to respond appropriately and by political economy doctrines that obscured their causes. Little evidence suggests that such events or conflicts over scarce water supplies turn to violence. 



Climate change will cause populations to migrate, although it is difficult to be precise about exactly how and where except in the case of low-lying coastal states that face entirely predictable inundation. International political instabilities and related failures to anticipate climate change curtail fossil fuel usage, and unilateral attempts to adapt to climate disruptions are the major issues facing the future of climate change governance in the Anthropocene.

Populations no longer trust the water coming from their faucets. Witness the increase in the use of bottled water. The search for safe, clean, and uncontaminated water has increased. 





EPA proposes bold new limits for tackling 'forever chemicals in drinking water | Environmental Working Group

Prescription For Parents: Vet Your Doctor

Coming from me, that is a statement to remember.  I always question my physician, I check credible sources in regard to credentials, and I ask other people about physicians I am going to see.
These recommendations not only apply to pediatrics but all medical specialties.

As Bob Dylan sang, "The Times They are a Changing" I update that to "The Times Have Changed"

Here is my checklist

1.  Disregard anything the medical board says about your doctor, except suspension, or cancellations. Make sure your physician has a valid medical license.  Although State Medical Boards are the ultimate judge of who can be licensed they are miles away from your doctor.  They only assess complaints from patients, or requests from authorized institutions, medical groups, hospitals, or specialty boards. Each time a physician applies for hospital staff membership their records from medical boards in the state in which the hospital exists to all other previous state licensures, medical specialty boards, personal and professional references, criminal records

2. Disregard hospital recommendations. Once the doctor is granted staff privileges, suspending or canceling privileges without a due diligence procedure is very difficult. Hospitals will refer physicians on their own staff. They will be the last to know about their physicians unless there has been a major medical or surgical incident.  Incidents are kept confidential and away from the media to avoid libel suits.

3. If possible vet your future doctors well before you need them. 

         I recommend these specialties

.        Primary Care (these can be Internal Medicine or Board Certified Family Practitioners
         Surgeons (including OB/GYN as they may be considered primary care physicians}, Pediatricians
         Ophthalmologists. Cardiologists

        You can also check your provider lists from your HMO, or Private Insurers. Medicare or Med-Cal             listings

        Check with your friends and coworkers. But be wary since their opinion may be clouded by a long wait or poor staff.  Most doctors don't tolerate poor staff

        An academic appointment is nice but not necessarily good. Some academics are good at teaching or research and may be outstanding technically, but fail at emotional intelligence. However, if you have an uncommon, potentially fatal,  or rare disease they are your best option for diagnosis and treatment. 

        There are also some world-class referral institutions such as Mayo Clinic, Cleveland Clinic,                     Ochsner  Clinic, and others in your region.

        Centers of Excellence are very questionable.  Almost every community hospital markets a "Center of Excellence". It is a marketing ploy by staff physicians to attract and compete with real  regional centers.

4. A combination of some or all of the above procedures will give you some advantage in selecting a competent and caring physician
        
        


Prescription For Parents: Vet Your Child’s Doctor

Recommendations for Evaluating Donor Eligibility Using Individual Risk-Based Questions to Reduce the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products | FDA

Historical perspective:

During the 1980s HIV presented a major public health problem.  There were no successful treatments for patients with HIV. It was determined that HIV was prevalent in the 'gay' population.  Their blood was 'tainted' with the Human Immunodeficiency Virus (HIV).  Blood banks were advised to not accept blood donations from anyone who was gay or had sexual encounters with those of the same sex, especially those who engaged in anal sex.


HIV and. AIDS attacks the CD4 white blood cells which form part of the protective immune system of the body.  When these cells are destroyed the immune system is no longer able to recognize and protect against bacterial fungal and protozoa infection. These resulting infections are what kill AIDs patients.

In the last five decades pharmacologic advances produced effective treatments for HIV. A fulminant case of AIDs does occur until well after a person is infected with HIV.  It lies dormant, gradually reducing the CD4 cell count until the immune system is overwhelmed by infectious agents.

The Clinical Guideline for Prevention and Treatment have eliminated AID and HIV as a fatal illness.

Blood Banks have used the above criteria for preventing blood donation by HIV/AIDS patients. 

Changes in FDA Guidance for Blood Donation by Gay Persons
 
US Food and Drug Administration on Thursday paved the way for more gay and bisexual men to donate blood by finalizing new risk-based rules for blood donation. Going forward, prospective donors will be asked the same set of questions regardless of their sex or sexual orientation.


The new criteria are risk-based questions, rather than discriminating against a group of people labeled as gay. This ruling comes as gay people are now in a protected class of people

The new questions are designed to reduce the risk of transmission of HIV, or human immunodeficiency virus, through blood donation. The FDA says it made the changes after reviewing data from other countries that have similar rates of HIV and have already implemented risk-based eligibility for blood donations, information on the accuracy of tests to detect HIV, surveillance information from a system that monitors infections passed by transfusions, and information on individual risk factors gleaned from a government-funded study.

Under the new rules, anyone reporting a new sexual partner, more than one sexual partner, or recent anal sex will be told to wait at least three months to donate blood. This reduces the likelihood that someone with a new or recent infection could donate during a window of time when their infection would not be picked up by lab tests.

Anyone taking medications to treat or prevent HIV, such as PrEP, would also be deferred from donation. The FDA says that while HIV is not transmitted during sex in people whose viral levels are undetectable, the same does not apply to blood donation. Blood is transfused directly into a vein, and involves a larger volume of fluid, making it inherently riskier than sexual contact.







Recommendations for Evaluating Donor Eligibility Using Individual Risk-Based Questions to Reduce the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products | FDA

Monday, May 8, 2023

DEA buys time on proposed telehealth rules for controlled drugs

This is. Big, Very Big



Fierce Telehealth reports. 

Facing major backlash to its proposed rules released in February, the Drug Enforcement Administration (DEA) is looking to buy some time to reconsider whether it should enforce stricter limits around the prescribing of controlled substances via telehealth. 

The Biden administration said at the time that the new rule seeks to provide safeguards to prevent online over-prescribing of controlled medications. Teleprescribing has been touted as a robust tool for bringing medications for opioid use disorder (MOUDs) to rural areas in the ongoing treatment of the opioid epidemic. 

The agency received a record 38,000 comments on its proposed telemedicine rules, according to a statement from the DEA Administrator 

Last week, the DEA filed a draft temporary rule with the Office of Management and Budget titled “Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications.”

Milgram said further details about the rule will become public after its full publication in the Federal Register.

The DEA issued proposed rules three months ago that would reinstate strict limitations on the virtual prescribing of controlled substances and roll back telehealth flexibilities extended during the COVID-19 pandemic. The proposed rules would once again require patients to be evaluated in person by a doctor to receive prescriptions for some controlled substances (PDF) including stimulants like Adderall and opioids

Provider groups, telehealth advocates, and patients submitted comments largely panning the proposal, arguing that it would create barriers to care. 

Under the proposed rule, Schedule 2 medications or narcotics would require (PDF) an in-person prescription. Schedule 3 or higher medications, including buprenorphine, can be prescribed for 30 days via telehealth but would require an in-person visit before a refill. Non-narcotic drugs like Ambien, Valium, Xanax, and ketamine also fall into this category. If a patient is referred to a provider, an in-person appointment is not required as long as one took place with the referring physician.

If a telemedicine relationship was established during the COVID-19 public health emergency, the DEA will extend the in-person exam waiver for an additional 180 days.

DEA buys time on proposed telehealth rules for controlled drugs

Saturday, May 6, 2023

Why It is Essential to Review your Electronic Health Record


How often do patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes do they report?

Findings  In this survey study of 136 815 patients, 29 656 provided a response, 1 in 5 patients who read a note reported finding a mistake and 40% perceived the mistake as serious. Among patient-reported very serious errors, the most common characterizations were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient, and sidedness.
In today's world, almost all doctors use electronic health records.  It is difficult to provide an accurate percentage of doctors who do not use an electronic health record (EHR) as it can vary depending on the country, healthcare system, and specialty of the doctor. However, in the United States, where EHR adoption is widely promoted and incentivized, a 2019 survey found that about 9% of physicians still used paper records exclusively, while 84% used EHRs. The remaining 7% used a combination of both. It's worth noting that the percentage of doctors using EHRs has likely increased since then. This figure was given by ChatGPT which is current only to Sept. 2023.

It is estimated 99% of doctors use an electronic health record system. 

Data systems, ie electronic records never forget. 

You must access your EHR via a portal. If you do not know what that is you can learn from ChatGPT or ask someone in your doctor's office or clinic how to go about that.  It is your legal right to be able to obtain your medical record (Federal Law).  

In the United States, there are federal laws that give patients the right to access their electronic health records (EHRs). The two main laws governing access to EHRs are the Health Insurance Portability and Accountability Act (HIPAA) and the 21st Century Cures Act.


The 21st Century Cures Act is a United States law enacted in December 2016 that aims to accelerate medical innovation, enhance research into diseases, and improve patient care. The law includes several provisions related to the development and approval of medical products, including drugs, devices, and biological products, as well as provisions related to mental health and substance abuse.

Some of the key provisions of the 21st Century Cures Act include:

Streamlining the clinical trial process to expedite the development and approval of new drugs and devices
- Promoting the use of real-world evidence in drug approvals
- Encouraging the development of precision medicine and the sharing of genetic and clinical data
- Investing in research on cancer and other diseases
- Providing funding to combat the opioid epidemic
- Improving mental health services and resources

Overall, the 21st Century Cures Act aims to promote innovation and collaboration among researchers, industry, and patient advocates to advance medical treatments and improve patient outcomes.
Under HIPAA, patients have the right to access their protected health information, which includes EHRs, held by covered entities such as healthcare providers, health plans, and healthcare clearinghouses. Covered entities must provide patients with their records within 30 days of the request, and they can charge a reasonable cost-based fee for copying and mailing the records.

The 21st Century Cures Act, which was signed into law in 2016, expands on the HIPAA requirement by mandating that healthcare providers and EHR vendors provide patients with access to their electronic health information in a structured, standardized format that can be easily shared with other healthcare providers and apps. This is known as the "open notes" provision, and it aims to empower patients to become more engaged in their care by giving them greater access and control over their health information.

Overall, these federal laws give patients a legal right to access and control their EHRs, which can help them make more informed decisions about their healthcare and improve the quality of care they receive.









Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes | Electronic Health Records | JAMA Network Open | JAMA Network

Thursday, May 4, 2023

End of the COVID-19 Public Health Emergency (PHE) Declaration - Public Health Communication Collaborative



The Federal Covid emergency declaration ends on May 11,2023.

What does this mean? COVID-19 is not over. Although the emergency declaration is ending considerable federal resources will remain in effect.

On May 11, 2023, the public health emergency (PHE) declaration will end. Among other policy implications, the end of the PHE will impact health policy measures associated with access to COVID-19 testing and treatment.

How will the end of the public health emergency affect community members?
When the public health emergency ends, COVID-19 vaccines will continue to be free for all, as long as the supply of federally purchased vaccines lasts. However, access to and cost of testing and treatment will vary on whether they have public, private, or no health insurance.

Does the end of the public health emergency mean COVID-19 is over?
No. COVID-19 cases are down sharply, but the end of the emergency declarations does not mean the virus is no longer a threat. The virus remains a leading cause of death in the United States, with about 250 daily deaths on average. Visit CDC’s website and your state and local health departments for information about local infection rates and recommended precautions.

CDC continues to advise that everyone stay up to date on COVID-19 vaccinations, use at-home tests if they’ve been exposed or have symptoms, stay home if they’re sick, and wear a high-quality mask when COVID-19 levels are high. These precautions are the best ways to protect yourself and your loved ones.

How will the end of the public health emergency affect community members?
When the public health emergency ends, COVID-19 vaccines will continue to be free for all, as long as the supply of federally purchased vaccines lasts. However, access to and cost of testing and treatment will vary on whether they have public, private, or no health insurance.

Vaccines

Vaccines will remain free for everyone when the public health emergency ends. As long as the supply of federally purchased vaccines lasts, COVID-19 vaccines will remain free.
Testing and Treatment

Coverage for COVID-19 testing and treatment will vary by insurance type.
For people with Medicaid coverage, COVID-19 testing, and treatment will remain covered at no cost through September 2024. For those without insurance, COVID-19 testing and treatment will no longer be covered, and the cost will be determined by individual providers. However, free tests and treatment may be available at local free clinics or community health centers.

State and County Public Health Advisories are available   HERE.  

Requirements for Masking, Indoor Activity, and Distancing will vary according to the incidence of COVID-19 from Low to Medium to High.  In addition, CALOSHA makes recommendations for masking in the workplace






Messaging: End of the COVID-19 Public Health Emergency (PHE) Declaration - Public Health Communication Collaborative

Public Health Turnover Threatens Community Health and Safety - de Beaumont Foundation

Public Health Turnover Threatens Community Health and Safety


According to a recent analysis of data from the Public Health Workforce Interests and Needs Survey (PH WINS)nearly half of state and local public health employees left their jobs between 2017 and 2021, exacerbating an existing workforce shortage and causing a critical lack of skills and experience that puts communities at risk. 

The study, published today in Health Affairs, compared intent to leave or retire in 2017 with actual separations through 2021 among state and local public health staff at agencies that participated in the PH WINS survey in both years. The study authors found that 46% of state and local employees left their organizations during that time – a number that rose to 74% among employees under age 35 and 77% among employees with less than five years. experience.

Public Health is one of those subjects which gain little attention in medical school. Med School students assign it a low priority, such as basket weaving in high school. It is a bit like being an anesthesiologist with long periods of inactivity, boredom, and occasional moments of sheer panic.

COVID-19 amply demonstrated how Public Health works, a slow recognition of an impending catastrophe and a slow ramp-up of an inadequate workforce. The workforce in good times is inadequate.  It is just not an exciting field of healthcare. In fact, the deficit is so bad that the National Guard is often 'called up" by Governors to serve. The private sector and large health institutions have the resources to address the huge increase of patients in emergency departments.

In such situations, testing and vaccination must be accomplished a remote mobile workforce is activated.

The added burden of personnel and medical devices (PPE), and pharmaceuticals (vaccines) requires emergency funding by state and federal governments.


During such events, other agencies and specialty officials are called in to supplement forward-facing personnel, such as the CDC, DEA, WHO, and the USPHS. Politicians usually become involved as well because it enables them a public forum for recognition. This is not always a good thing, since their announcement has political implications and divides the goals of science to gain political advantage.  This became apparent during the Covid Pandemic.

The future of Public Health lies in the balance.

Understanding the size and composition of the state and local governmental public health workforce in the United States is critical for promoting and protecting the health of the public. Using pandemic-era data from the Public Health Workforce Interests and Needs Survey fielded in 2017 and 2021, this study compared intent to leave or retire in 2017 with actual separations through 2021 among state and local public health agency staff. We also examined how employee age, region, and intent to leave correlated with separations and considered the effect on the workforce if trends were to continue. In our analytic sample, nearly half of all employees in state and local public health agencies left between 2017 and 2021, a proportion that rose to three-quarters for those ages thirty-five and younger or with shorter tenures. If separation trends continue, by 2025 this would represent more than 100,000 staff leaving their organizations, or as much as half of the governmental public health workforce in total. Given the likelihood of increasing outbreaks and future global pandemics, strategies to improve recruitment and retention must be prioritized.


Public Health Turnover Threatens Community Health and Safety - de Beaumont Foundation

Tuesday, May 2, 2023

Health Misinformation

With the abundance of health information available today, it can be hard to tell what is true or not. We all need access to trusted sources of information to stay safe and healthy.

Why health misinformation matters


We can all benefit from taking steps to improve the quality of the health information we consume. Limiting misinformation helps us make more educated decisions for ourselves, our loved ones, and our communities.

Health misinformation is a serious threat to public health. It can cause confusion, sow mistrust, harm people’s health, and undermine public health efforts.”
Dr. Vivek H. Murthy

Vivek Mirthy M.D.Surgeon General of the United StatesThe Rest of IT


Monday, May 1, 2023

Physician Unionizing How, Why, Who? SMHS residents and fellows vote to unionize – The GW Hatchet

Medical residents and fellows at the School of Medicine and Health Sciences voted overwhelmingly to unionize Thursday.

SMHS residents and fellows voted 253-16 Wednesday and Thursday join the Committee of Interns and Residents — a subsidiary unit of the Service Employees International Union. Maryssa Miller, a physician who helped organize the unionization effort, said the union will form a bargaining committee in the coming weeks representing residents’ departments like internal medicine, emergency medicine, and obstetrics and gynecology.



Every year some group of physicians organizes to form a union. Most often they are not successful. The reasons are many.



George Washington University School of Medicine and Health Sciences is no worse than any other academic center.

1. Trainees have a limited time span 1-3 years in a position where they are subject to abuse.
2. A moral and ethical imperative to care for a patient, no matter the circumstance in hospital.

Always a point of contention is the long hours and difficulties for physician trainees.

COVID-19 exacerbated the intense work and long hours for all caregivers, including physicians.

Physicians' Unions have rarely gained strength in the United States.  Perhaps the worst working conditions exist in academic settings.

Trainees are in a captive and at times abusive environment.  This has been a never-ending story. Forty years ago when I was a trainee it was even worse.  At times I would work 36-hour shifts.  Today in 2023 Academic residency programs are required to abide by rules regarding training hours, limiting the work week to no more than 80 hours.

Medical residents and fellows at the School of Medicine and Health Sciences voted overwhelmingly to unionize Thursday.

SMHS residents and fellows voted 253-16 Wednesday and Thursday to join the Committee of Interns and Residents — a subsidiary unit of the Service Employees International Union. Maryssa Miller, a physician who helped organize the unionization effort, said the union will form a bargaining committee in the coming weeks representing residents’ departments like internal medicine, emergency medicine, and obstetrics and gynecology.
A recent report from the American Council for Graduate Medical Education reveals that despite the rules many institutions are being cited for infractions. 

Some specialties were cited more often, Internal Medicine, Family Practice Transitional year (Internship). It is common practice for trainees in the initial year of training to be expected to carry a disproportionate workload.  The reasons are a subordinate position as related to superiors, and the necessity to acquiesce to unreasonable demands to ensure being advanced to the next level of training.

What is the ACGME 16-hour rule?

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) reduced the consecutive number of hours that post-graduate year-1 residents can work in a single shift, from 30 to 16. This rule was intended to improve patient safety by reducing residents' fatigue.

It has been over ten years since this guideline was recommended by the ACGME.  Ongoing examination reveals there has been considerable resistance to the ACGME guidelines. 

Why is this? 

The demands of clinical care are ongoing, 24/7/365/. It is a bit like 7-11.   The relative shortage of physicians creates an undeniable demand for those working in the system.  There is no reasonable solution for this confounding fact.  The result would be a lack of physicians for a considerable portion of patients in the hospital.  Can you imagine a patient needing emergency surgery at night and there would be no surgeon available?

Pros of Unionization

Unions provide an integrated and time-proven methodology of negotiations between employees and employers by an experienced third party

Cons

A Union introduces factors and dues whether you decided or not that prospective union members may not have factored into their voting.




SMHS residents and fellows vote to unionize – The GW Hatchet

Sunday, April 30, 2023

Where is the Pain ?

 

Why do we reduce humans who suffer from chronic pain to simple molecules and receptors? Pain psychologist Rachel Zoffness, P.h.D. returns to talk about fibromyalgia, stomach pain, anxiety, the role of trauma, and much more.

Dr. Rachel Zoffness is a Health and Pain Psychologist, international speaker, author, and thought-leader in pain medicine. She is an Assistant Clinical Professor at the UCSF School of Medicine, a Stanford lecturer, and a Mayday Fellow. Her podcast episodes on The New York Times Ezra Klein Show, Ologies (Dolorology), and The Jordan Harbinger Show are viral sensations with more than 6 million views and downloads.

Dr Zdogg, as he is known is Zubin Damania MD a graduate of UC San Francisco. His background is in intensive care and primary care.  ZdoggMD is well known on the YouTube circuit. 


Dr. Z's book, links to our prior interview, audio podcast, and full transcript:

The Pain Management Workbook: Powerful CBT and Mindfulness Skills to Take Control of Pain and Reclaim Your Life

Rachel Zoffness, P.h.D. examines the segments of the pain mechanism in this video.

Key Topics:

0:00 Intro
1:14 The bio-psycho-social nature of pain: phantom limb pain, the limbic system & emotion-pain connection, social contributors
9:00 The stigma of “psychological” pain and holistic approaches to managing it
16:15 The concept of “pain volume” and how emotional states affect it
18:56 Releasing negative emotion: the idea of “tea-kettling”
26:21 Fibromyalgia & trauma, pain amplification and “central sensitization”
33:14 The importance of desensitization practices for chronic pain
36:14 The benefits and risks of narcotics, the danger of removing them too fast
40:41 Sympathetic nervous system, the interaction of trauma and adverse childhood experiences (ACEs)
47:44 Placebo & the mind-body connection
53:34 Anxiety/Depression and Overmedicalization by Big Pharma
1:00:00 Non-pharmacologic treatments for pain, anxiety, and depression
1:04:06 The mind-gut connection: Irritable Bowel Syndrome, performance anxiety, and more
1:11:14 Emotional repression, fear of speaking and exposure therapy, PTSD
1:18:28 Imposter Syndrome and Dunning-Kruger effect, gender roles (vocal fry/uptalk)
1:25:00 The Problem of emotional repression, and Solutions
1:28:37 How biofeedback works

Why do people experience pain in a limb that is missing? (Phantom Limb Pain)

Pain causes angst, anxiety, and physiological effects.  What is the connection between the psycho-biological-emotional aspects of pain?


Wednesday, April 26, 2023

CMS cracks down on prior authorization requirements in MEDICARE ADVANTAGE plans


Tension has developed between CMS and their Medicare Advantage Plans.



Whose prior authorization is it anyway? MA plans are contracted to provide insurance benefits via a private contract. Strictly speaking, MA plans are not the same as fee-for-service Medicare. The goal was to reduce Medicare costs by contracting with groups and/or private insurers (ie, Humana. Aetna and smaller insurance entities (local). These MA plans are paid a contract amount for covering the same benefits as FFS Medicare.  In some cases, this is an FFS arrangement with the MA plan.

In order to contain costs prior authorizations are used to filter out unnecessary tests, or procedures.
In real life, this serves to deny coverage, and at the least increases costs for the providers. (more personnel to process prior authorizations.  In some cases, additional insurance billers are required for at least 1 FTE, or more in some cases for group practices. The cost has been absorbed by the provider.

Medicare Advantage (MA) plans will find it harder to require prior authorizations for their coverage under a new final rule from the Centers for Medicare and Medicaid Services (CMS).


CMS says the new rule, announced on April 5, is intended to address MA member complaints that the plan’s prior authorization requirements restrict their access to care. In response, the rule will:
limit the use of coordinated care MA plans’ prior authorization policies to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary,
prohibit coordinated care MA plans from requiring prior authorizations for an active course of treatment for at least 90 days when a patient switches MA plans, require all MA plans to establish utilization management committees to ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines, and require that prior authorization approvals remain valid “for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.”
“Together, these changes will help ensure enrollees have consistent access to medically- necessary care while also maintaining medical management tools that emphasize the important role MA plans play in coordinating medically-necessary care,” CMS said.

The rule comes in the wake of a 2022 report from the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services that found that some MA plans have been denying prior authorization requests even though the requests met Medicare coverage rules.

The OIG report also found that plans were denying payments to providers for some services that met both Medicare coverage and the MA plan’s own billing rules.

Physicians’ groups hailed the rule. “Family physicians know first hand how this will help ensure timely access to care while alleviating physicians’ administrative burdens and patients’ care delays,” American Academy of Family Physicians President Tochi Iroku-Malize, MD, FAAFP, said in a tweet.

 




CMS rule cracks down on prior authorization requirements in MA plans