Trying to Destroy Healthcare the Ostrich Way

Copyright: <a href='https://www.123rf.com/profile_andreykuzmin'>andreykuzmin / 123RF Stock Photo</a>Ostriches reportedly stick their heads in a hole if they see something they fear. If they can’t see it, then it must have gone away. President Trump, with most republicans lawmakers going along, is trying that same tactic on the public. Despite 7 years of promises, and multiple attempts, Republicans have been unsuccessful overturning the Affordable Care Act, otherwise know as ObamaCare. So Trump has been doing everything he can to destroy it, with the hopes that it will wither and die, then he can blame Democrats on it’s demise, claiming it was bad legislation. This despite not having a good alternative.

One of the efforts have been to keep people from signing up for coverage for next year. The Trump administration has cut the advertising budget by 90%, shortened the enrollment window, and will close the site on some Sundays for, “maintenance.” They figure that if people can’t see it, they will think it must not be there.

Well sign up just started. If you don’t otherwise have coverage, such as through work, sign up right away, while you still can.  You must sign up by 12/15/17. Don’t wait until the last minute as you might not be able to get on the site. Don’t be scared off by reports of premiums going up. Although true, subsidies also go up per the law, and it costs nothing to find out what it would cost for coverage. Go to healthcare.gov.

Gluteus Maximus

I ordered atorvastatin (generic Lipitor) for one of my patients with high cholesterol and Medicare Part D coverage. It was denied. We then appealed it (prior authorization). A fax from Maximus Federal Services said their decision was, “UNFAVORABLE.” They said the patient had not tried and failed one of the preferred generic statins (lovastatin or simvastatin). They did note that we could appeal to an Administrative Law Judge.

In fact the person had tried simvastatin, which I had noted on the prior authorization. However the cost savings is minor. According to Goodrx, a 90 day supply of atorvastatin is as low as $19.25 around where I work.  For the equivalent dose of simvastatin it’s $10.06.

Yes, it’s almost half the price, but it’s still a pretty small amount, especially in my patient who had already had a heart attack, and the difference will only get smaller as Lipitor has not been generic for all that long. Contrast that with the staff time wasted dealing with this on both ends. Dealing with this is a pain in the Gluteus Maximus!

Medicare Audits – Or How I Spent Part of Labor Day Weekend

Copyright 2105 Daniel Ginsberg PhotographySome weekends I go to my office to try and catch up on paperwork. This Labor Day weekend I had to ‘labor’ away part of it to satisfy a Medicare requirement.

I received a fax from a medical supplier saying that Medicare had sent them an, “additional documentation request” for diabetic supplies for a patient of mine from June 2013. I didn’t see her on the date of service they listed, nor even see that I prescribed any diabetic testing supplies then, though it’s possible I filed out a faxed form and it wasn’t saved to her chart.

They requested that I include copies of the patient’s blood glucose testing logs. I do not routinely scan those into the chart, so I don’t know how that’s supposed to happen.

They also say to verify that the records contain the following other items, though it could be considered fraud to go back and add them now:

  • Patient’s Diagnosis and Prognosis
  • Patient’s Testing Frequency
  • Condition and Treatment History
  • Quantity and Day Supply Prescribed
  • Physical Limitations Due to Condition
  • A1c Lab Report
  • Insulin/Non-insulin
  • Insulin Injections/Pump
  • Medication lists

In addition, they want all documentation from 6 months before the service date up to the present day, and they want it, “ASAP.” That’s 2 years and 9 months of documentation, all for a few diabetic test strips I prescribed (which I don’t make any money from, for the record)!

What’s more, it says that we are not allowed to charge the supplier or the beneficiary (the patient) for providing this information.

That’s your government, hard at putting us primary care doctors to work.

Medicare Payment Formula Finally Changed – Win or Loss?

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Congress passed a  law in 1977 linking Medicare payments for physician services to growth in the economy.  Because it failed to take into account inflation and other factors, Congress has had to act 17 times to prevents cuts to physician pay under the sustainable growth rate (SGR) formula. This year physicians were set to get a 21% pay cut this year. This created a lot of stress and uncertainty for physicians, and caused some physicians to stop accepting Medicare patients.

The Senate recently voted to repeal this formula, 92 to 8. The bill was already approved by the House, and now President Obama has signed the bill.

That sounds like a great triumph for physicians. Although this may prompt some to pull out their imaginary violins in mock sympathy, I’m not so sure it will turn out to be such a great deal for physicians, which actually only consumes 12% of the Medicare budget.

The bill freezes the current rates, then increases them 0.5% a year from 2016 to 2019. For 2020 through 2025 there is no increase, and from 2026 onwards it increases by 0.75% per year. That is far below the current rate of inflation, and there is no provision if inflation gets worse than the currently low rate. That effectively means a real loss every year into the indefinite future.

There is a provision to transition payments to reward physicians for quality, rather than quantity. That is good in theory, but we’ll have to see how that works out in practice. Quality healthcare is very difficult to measure, and there is a risk that quality will be defined based on what’s easy to measure, and that will lead to physicians and other healthcare providers to concentrate on what they are rewarded to do, and not what may be in patients’ best interest. I hope I’m wrong.

Patient Satisfaction / Physician Dissatisfaction

Have you received a survey after you visit your doctor? You may be surprised to learn that how you rate them may affect their pay, their mental health, and even possibly your health.

Surveys, as administered by Press Ganey, and the CG-CAHPS,  are questions regarding various aspects of the care patient’s receive. Although that may seem reasonable, besides potentially incentivizing bad medicine, it’s exaggerated because they only count “top box” scores. That means on a scale of 1 to 5, only the 5 scores count, so that getting a 4 is no different than getting a 1, and if the score is 0 to 10, then only a 9 or 10 count. The scores only count if you answer “Always,” except for the question, “Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?.” In that case, only a 9 or 10 count.

I’m not sure how this rating system was developed, but I think it may have had roots in the hospitality business. A patient may stay with their doctor if they rate them as being good, as opposed to excellent, but if someone better comes along, they may change. So if if you want high customer loyalty, you want to aim for excellence. Thus from the point of view of the physician, or rather the point of view of the administrator who pays the physician, one should strive for the top box scores.

In practice it’s not so simple. Take the question, “In the last 12 months, when you phoned this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?” The only one that counts is the answer “Always.” So imagine you call 5 minutes before close to ask if you need to get lab work done before your appointment next week. Chances are for such a non-urgent question, it won’t even get to the doctor to answer before the next day, assuming you didn’t call on a Friday, and the doctor is in the office that day. You be perfectly satisfied to get a call back the next day, but if you answered the question honestly, you’d mark “Usually,” which when scored, would be the same as if you marked “Never.”

Although customer satisfaction is important in the medical field, it’s not the only thing that counts. I’ve had patients leave my practice solely because I told them things they didn’t want to hear, such as they needed to stop smoking, cut back on alcohol, exercise more, and lose weight.  I try to do it compassionately and offer them help, but it doesn’t necessarily make patients want to give you a good score.

What’s makes the system worse, is that when comparing scores, it’s graded on a curve. By definition, no matter how good doctors are, there will always be some that are on the high end of the curve, and some on the low end. This in turn is used to save money by paying the people lower on the curve less.

Sochi TimesLook at the charts above. The one on the left represents 47 individuals who were rated on something, showing their percentile rank, ranging from zero to the 100th percentile. Clearly there is a wide range in how well they did.

What about the chart on the right? Those are the same individuals showing the time in seconds they spent completing the task. There is less than a one second difference between the top 12 people. There is less than a two second difference between the person at the 49th percentile, and the one at the 85th percentile. So it should be easy to move up the percentile ranking, shouldn’t it?

What do these graphs represent? The results of the 2014 Olympics Alpine Skiing Downhill Men’s Final in Sochi.

What’s the point? Percentile rankings are not a good measure of excellence when the differences are small. In the Olympics we care who is number one, but patients want excellent care, and don’t distinguish between different doctors or institutions if they need a magnifying glass to see the difference. We all have room to improve, but it’s demoralizing to be told one is in the 20th percentile. I’d much rather be told I was only 6 seconds behind the winner.

How to Get Rich – A Guide for Pharmaceutical Companies

The Changling Ming Dynasty Tomb of the Yongle Emperor
The Changling Ming Dynasty Tomb of the Yongle Emperor – copyright 2012 Daniel Ginsberg Photography

Thanks to Congress, Medicare is not allowed to negotiate for the cost of medications. The bill was shepherded through by congressman Tauzin, the chairman of the House Energy and Commerce Committee that regulates the industry, who subsequently stepped down then took a job as the President and CEO of the Pharmaceutical Research and Manufacturers of America. This is a lobbyist group for pharmaceutical companies.

Here’s a suggestion to pharmaceutical companies; the next time you come out with a new first in class medication, for which there are no other medications that can be substituted, price it at 10 billion dollars a month. After the first prescription gets filled, it may move Congress to act, but by then you will be set and it won’t matter if you don’t sell another pill.

Up in Arms, Up in Smoke

20090715_japan_0671If you apply for health insurance, you may find you have to pay higher rates if you’re a smoker. Now federal regulators are trying to decide if insurers who participate in the Affordable Care Act (aka ObamaCare) exchanges can add a surcharge for those using e-cigarettes or vaporizers.  They already can for cigarettes in most states.

Some argue against this, in the name of harm reduction, the idea that if people are going to smoke, it’s better to smoke something safer. For example, Reynolds American Inc spokesman David Howard, said, “We don’t believe policies should be implemented that might deter current smokers from considering switching to smoke-free alternative products like e-cigarettes.”

Numerous studies have, shown, however,that the best way to get people to cut back on smoking, is to make it more expensive. E-cigarettes and vaporizers are cheaper than cigarettes, so paying more for insurance for all forms will encourage more people to stop smoking. No one is suggesting that those smoking alternative forms of tobacco be charged more than those who smoke cigarettes, so even if insurers charge extra for those who use e-cigarettes or vaporizers, they will not pay more than if they stuck with cigarettes, so really it won’t deter smokers from switching. People switch because it costs less, it’s more socially acceptable, or they perceive it to be safer.

In that last regard, vapor may be safer than cigarettes, but we really don’t know. Recent studies show they can definitely have known carcinogens, such as formaldehyde. Would you really want to inhale a chemical used to embalm corpses? I tell my patients that if they use e-cigarettes to help them quit smoking, which may or may not help, then I’m alright with that, but the goal should be to stop using tobacco products, and not just switch from one habit to another.

 

Cataracts and Hip Fractures

A recent study showed that cataract surgery helps prevent hip fractures. It looked at a sample of Medicare patients with cataracts who did or did not have cataract surgery.  Those who had cataract surgery had a 16% less change of subsequent hip fractures than those who did not have the surgery, though the absolute difference between the groups was small, because hip fractures were not that common in either group.

The design of this study was not optimal. It would have been better to randomly assign patients to get cataract surgery or not, to eliminate possible biases, but such a study is not practical.

We treat osteoporosis with medications such as Fosamax (alendronate) and vitamin D, but that just decreases the risk of a fracture. It’s still important to prevent the fall. There are various things that can help, including physical therapy to improve gait (walking), good lighting, good shoes, lack of loose rugs, canes, and more. Add to the list cataract surgery for those affected. Not only will such patients improve their vision, but they may save themselves from a hip fracture that at best will lay them up for a while, and at worst kill them from complications of pneumonia or a deep venous thrombosis (DVT or blood clot) and pulmonary embolism (blood clot to the lungs).

Testing Tribulations

When I was an internal medicine resident, one of my staff attending’s, Dr. Charles Reasner, used to ask, “What is the indication for ordering a TSH?” This is a test of thyroid function (thyroid stimulating hormone), and he was asking what reasons should one order the test. His answer was to order it if you think about it. An overactive (hyperthyroidism) or under-active  (hypothyroidism) thyroid can cause many different kinds of symptoms, treatment is relatively easy, and the test is inexpensive. Thus he said if it occurred to you to order the test, then you should do so.

Unfortunately the Centers for Medicare & Medicaid Services (CMS)does not allow us to order tests based on intuition, even though numerous studies have shown that people often make their best decisions based on reasons they can’t explain. When a quarterback such as Peyton Manning throws a football to a receiver, he first has to make the decision what to do very quickly, while a 300 pound lineman is bearing down on him. Based on prior experience he can quickly survey the field and make a decision where to throw the ball before he could make a decision based on a logical analysis. He might not be able to explain exactly why he did something, but his skill and training contributed to making the right decision seemingly without thinking.

When physicians order a test, we have to associate a diagnosis. Presumably the main purpose is to prevent wasting money for ordering tests. Although there is no benefit in ordering a PSA test for a diagnosis of glaucoma, for example, this only catches errors in the test ordered or diagnoses associated, which probably doesn’t happen often. It’s a real problem though for ordering a vitamin D level.

Medicare no longer covers a screening test for vitamin D, even though perhaps 85% of patients in the United States are deficient, treatment is cheap, and it probably saves money in the long run. Once a patient is diagnosed with osteoporosis then a level is covered, but that’s too late. Plus in men a screening bone density test is not covered, so it’s a Catch-22 situation.

At least if not that expensive, physicians should be able to order labs because they think of them. Insurance companies and the government should trust our intuition.

Penny Wise, Pound Foolish

A patient of mine has been on cyclobenzaprine, a muscle relaxer, intermittently for over a year. Now her insurance, a Humana, Medicare plan, said they will no longer cover it. I pointed out to them that the medication is generic and at Costco one could purchase 100 pills for $9.93 without insurance. That would be enough to last her over 3 months. The Costco price for tizanidine they suggested I switch her to costs even more. They told me to check their website for what they cover, which I did. It said cyclobenzaprine is covered, though on some of their plans it requires prior authorization, which is what I tried to obtain. Besides the risk of switching a medication to something new, Humana wasted the time of my nurse and I for what would be a minuscule, if any savings. They would not budge other than saying she had to first try and fail tizanidine.

I understand the need to control costs, but forcing doctors to change from one cheap medication to another cheap one is not the way to do it. It doesn’t save significant amount of money, and it frustrates their customers (the patients) and their physicians.

Insurance companies such as Humana place no value on physicians time. I hope other physicians join me contesting such things from time to time. Don’t just accept the first no. Make them deal with extra phone calls and faxes when they are unreasonable. If enough of us protested, I think we could force them to change their ways. Occupy Medical Insurance Companies Movement, anyone?