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Liquid Gold: Pain Doctors Soak Up Profits By Screening Urine For Drugs

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https://khn.org/news/liquid-gold-pain-doctors-soak-up-profits-by-screening-urine-for-drugs/

The cups of urine travel by express mail to the Comprehensive Pain Specialists lab in an industrial park in Brentwood, Tenn., not far from Nashville. Most days bring more than 700 of the little sealed cups from clinics across 10 states, wrapped in red-tagged waste bags. The network treats about 48,000 people each month, and many will be tested for drugs.

Gloved lab techs keep busy inside the cavernous facility, piping smaller urine samples into tubes. First there are tests to detect opiates that patients have been prescribed by CPS doctors. A second set identifies a wide range of drugs, both legal and illegal, in the urine. The doctors’ orders are displayed on computer screens and tracked by electronic medical records. Test results go back to the clinics in four to five days. The urine ends up stored for a month inside a massive walk-in refrigerator.

The high-tech testing lab’s raw material has become liquid gold for the doctors who own Comprehensive Pain Specialists. This testing process, driven by the nation’s epidemic of painkiller addiction, generates profits across the doctor-owned network of 54 clinics, the largest pain-treatment practice in the Southeast. Medicare paid the company at least $11 million for urine and related tests in 2014, when five of its professionals stood among the nation’s top billers. One nurse practitioner at the company’s clinic in Cleveland, Tenn., single-handedly generated $1.1 million in Medicare billings for urine tests that year, according to Medicare records.

Dr. Peter Kroll, one of the founders of CPS and its medical director, billed Medicare $1.8 million for these drug tests in 2015. He said the costly tests are medically justified to monitor patients on pain pills against risks of addiction or even selling of pills on the black market. “I have to know the medicine is safe and you’re taking it,” Kroll, 46, said in an interview. Kroll said that several states in which CPS is active have high rates of opioid use, which requires more urine testing.

Kaiser Health News, with assistance from researchers at the Mayo Clinic, analyzed available billing data from Medicare and private insurance billing nationwide, and found that spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year — more than the entire budget of the Environmental Protection Agency. The federal government paid providers more to conduct urine drug tests in 2014 than it spent on the four most recommended cancer screenings combined.

Yet there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

Urine testing has become particularly lucrative for doctors who operate their own labs. In 2014 and 2015, Medicare paid $1 million or more for drug-related tests billed by health professionals at more than 50 pain management practices across the U.S. At a dozen practices, Medicare billings were twice that high.

Thirty-one pain practitioners received 80 percent or more of their Medicare income just from urine testing, which a federal official called a “red flag” that may signal overuse and could lead to a federal investigation.

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

Blue Cross Blue Shield insurers are still doing well

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https://www.axios.com/the-blue-cross-blue-shield-insurers-are-still-doing-well-2507217868.html

 

 Blue Cross Blue Shield health insurance companies have more than quintupled their net profits in the first half of this year compared with the same six months of 2016, according to an analysis of financial records by Fitch Ratings.

The bottom line: We reported over the summer that the Blues, which have the most exposure to the Affordable Care Act marketplaces, are making a lot of money despite the Trump administration’s threats and actions against the ACA. Why are profits still growing for the Blues? They raised premiums a lot, people are not going to the doctor or hospital as much, and the federal government modified some enrollment policies to the benefit of insurers.

The details: Fitch analyzed the first-half financial documents of 34 Blue Cross Blue Shield companies, including the publicly traded Anthem as well as other large Blues brands such as Health Care Service Corp. and Blue Shield of California. Almost every company improved its finances year over year, leading to the following aggregate financial data for the first six months of 2017:

  • $135 billion of revenue (up 7%)
  • $7.7 billion underwriting profit, or the amount of money made after subtracting medical costs from premiums paid (up 194%)
  • $6.5 billion net profit (up 441%)
  • 85.9% medical loss ratio, which reflects how much of the premium dollar is spent on medical care (down 0.8 percentage points)

What was true previously is still true now: Most health insurers are not currently losing their shirts on the ACA’s individual marketplaces, although next year could be different depending on what happens to the law’s cost-sharing subsidies. While the higher premium rates have not harmed people who get federal subsidies, they have caused more financial pain for middle-class people who have to pay the full cost of their health insurance.

Looking ahead: Congress delayed the ACA’s health insurer tax throughout 2017 — another reason why companies have done so much better this year. Insurers have conducted a lobbying blitz to get Congress to repeal or delay that fee again, and legislation that would delay the tax for another two years could be folded into a year-end package.

Injecting Arthritic Knees Carries Sepsis Risk

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https://www.medpagetoday.com/rheumatology/arthritis/69066?xid=nl_mpt_DHE_2017-11-07&eun=g885344d0r&pos=17&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202017-11-07&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days

Image result for knee injections

 

Study identified four risk factors for sepsis after injections for knee pain.

As knee osteoarthritis becomes increasingly prevalent in the aging population, more patients are turning to their physicians for intra-articular injections. But a Chinese retrospective case-control study in Seminars in Arthritis & Rheumatism has underscored several associated risk factors for deep knee infection and chronic low-grade infection, and points to the need for more thorough pre-injection evaluation of patients and stricter training for doctors administering injections.

Foremost among infection risk factors was injection performed by family physicians, which had an odds ratio (OR) of 5.23 (95% CI 2.0-13.67). In addition, a body mass index of ≥ 25 had an OR for infection of 2.3 (95% CI1.1-4.7), and rheumatoid arthritis an OR of 2.61 (95% CI 1.20-5.68). Injection with corticosteroids versus hyaluronic acid had an OR of 3.21 (95% CI 1.63-6.21).

“We underline the importance of the accurate evaluation of clinical history and comorbidities for every IA injection, particularly for patients with obesity and RA and those receiving corticosteroid injections,” wrote Jiying Chen, MD, of People’s Liberation Army General Hospital, Beijing, and colleagues. “Strict training on septic technique is necessary before doctors should perform invasive knee treatments.”

The authors note that post-injection side effects are generally uncommon and mild — approximately 2%-1% per injection — with most complications being injection-site inflammatory reactions such as pain, swelling, and skin or fat atrophy. But though uncommon, deep knee infection can have serious, sometimes life-threatening, consequences, especially with injections on the rise. Chen and associates refer to an epidemiological analysis reporting that in U.S. patients with knee osteoarthritis, over a 5-year period 43.5% of those who eventually underwent total knee arthroplasty were prescribed preoperative intra-articular steroid injections.

The Beijing investigators identified 50 cases of injection-induced knee infection patients undergoing surgery from 2010-2016 and matched them with 250 non-infected controls. The mean age of patients overall was about 67 years and about 65% were female.

There were 21 cases of septic arthritis and 29 cases of chronic low-grade infection, with the former cases showing significantly higher metrics in fever, localized warmth, swelling, resting pain, night pain, limited motion, serum white blood cell counts and C-reactive protein levels.

Patients who developed infection had a slightly higher mean BMI of 26.2 versus 25.2 for controls.

Of those experiencing infection, 60% underwent injection with corticosteroids versus 34.8% of controls, while just 40% had injections of hyaluronic acid versus 65.2% of controls.

In 82% of deep knee infection cases, injection was administered by a general practitioner compared with 43.6% for controls. Just 12% and 6% received injections from an orthopedic surgeon or a rheumatologist, respectively, compared with 28.8% and 27.6%,respectively, for controls.

“This finding suggests that doctors should receive strict training and pass a formal practice exam before they perform invasive knee treatments, such as intra-articular injections,” the authors write.

Bacterial culture determined that Staphylococcus aureus was the by far the most common microorganism in septic arthritis (47.6%), while low-virulence coagulase-negative (CNN) Staphylococcus was most commonly implicated in chronic low-grade infection (31%), followed by Propionibacterium acnes at 24.1%. Other organisms involved in septic arthritis cases were CNN, Streptococcus, Enterococcus, and gram-negative bacilli, all at 9.5%.

“These results completely jibe with what we see in our practice,” Bharat Kumar, MD, of the University of Iowa in Iowa City. “They show that injection technique is extremely important, and part of that is training and part of it is practice.”

Kumar advised physicians to observe strict asepsis measures and evaluate patients carefully before giving injections. “Joint infections don’t happen in a vacuum. There are tissue factors in bone to consider, and you have to look carefully at people who have rheumatoid arthritis, are immunosuppressed, or are sick or weak, as they are at increased risk for infection.”

MedPage Today reported a recent study that suggested corticosteroid injections may also hasten cartilage breakdown.

Among the study limitations reported by Chen et al were its small size, single-center location, and retrospective nature, which introduced the possibility of recall bias. In addition, since some patients injected at the study site may have been followed up at an external referral institution, the investigators were not able to identify all cases of post-injection deep knee infection.

 

Are Payers the Leading Cause of Death in the United States?

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https://www.medpagetoday.com/blogs/revolutionandrevelation/68935?utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%202017-11-07&utm_term=Daily%20Headlines%20-%20Active%20User%20-%20180%20days

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Milton Packer wonders if people suffer and die because it is cost effective.

As everyone knows, we are in the midst of a horrific opioid addiction epidemic. Physicians are prescribing opiates for pain relief, and patients are becoming addicted to them. One-fifth of patients who receive an initial 10-day prescription for opioids will still be using opiates a year later. That is simply extraordinary.

Physicians are prescribing opiate formulations that are highly addictive. But they do not need to do that.

There are several newer formulations that relieve pain and are far less addictive than older agents. But they are prescribed uncommonly. Why is that?

It is not because physicians are uninformed.

It is because payers will not pay for the alternatives. The less-addictive opiates are more expensive, so payers have declined to support them. Patients get addicted because paying for highly addictive opiates saves the payers money.

The New York Times also noted that the treatment of opiate addiction is expensive. It is far cheaper for payers if physicians continue to prescribe opiates than if physicians enrolled a person into a drug addiction program.

What does that look like? Patients get more prescriptions for opiates instead of getting the help they need.

The Payers Are in Charge

If you are looking for someone to blame for the opioid epidemic, you can certainly blame physicians. You can blame pharmaceutical companies. But while you are at it, don’t forget to include payers.

This conclusion should not be surprising. We live in a world where payers — not physicians — determine what drugs and treatments patients receive.

If patients have a life-threatening condition, it is not unusual for a payer to demand that a physician first prescribe a cheaper and less effective alternative. Physicians know that the drugs they are allowed to use may not work very well, but frequently, payers demand that they be tried first anyway.

What happens if the patient doesn’t respond to the cheap drug?

Often, the physician continues to prescribe it, because — to gain access to the more effective drug — physicians need to go through a painful process of preauthorization. For many practitioners, it isn’t worth it.

Don’t patients eventually get the drugs that they need?

No. All too often, physicians stop trying. Or patients get frustrated and give up. Often, payers says “No!” no matter how many times they are asked. And if the drug is for a life-threatening illness and enough time passes by, then the patient may no longer be alive to demand that they get the right drug.

So we spend more for healthcare than any other country in the world, but Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician’s knowledge or judgment. They are being driven by what payers are willing to pay for.

How many people are affected by all of this?

Everyone.

That includes me and my family. That includes everyone that I know.

Medicine has made incredible progress in the last 20-30 years. But you are not likely to benefit from it.

Do you want to blame the high cost of drugs? You can do that, but if you do, you will be missing the point. We should expect better drugs to be more expensive than less effective ones. But we do not expect to have a company decide that we will get the inferior drug simply because they want to make a profit.

Are payers the leading cause of death in the United States? If you think this is a crazy question, please think again.

GOP unlikely to repeal ObamaCare mandate in tax measure

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GOP unlikely to repeal ObamaCare mandate in tax measure

Image result for aca individual mandate

The House is unlikely to repeal the mandate to buy insurance under ObamaCare as part of its tax-reform bill, GOP sources say, though the issue could return down the road.

President Trump and conservative lawmakers are pushing for the individual mandate to be repealed in the bill, but House Ways and Means Committee Chairman Kevin Brady (R-Texas) has expressed worry that the controversial measure would jeopardize the broader tax-reform bill, given the Senate’s failure on health care earlier this year.

“It hasn’t ever been in the [House] bill,” said one Republican on the Ways and Means Committee who has been taking part in the negotiations. “I expect that it will be added somewhere down the sausage-making venture.”

“I agree there is a chance, but I think if it gets included, it would be on the Senate side,” added a second Ways and Means Republican.

Senate GOP leaders said they plan to roll out their own tax bill on Thursday. Sen. Tom Cotton (Ark.) has been the leading GOP senator pushing to include repeal of the mandate in the tax bill.

House leaders emerging from a meeting Monday evening said no final decision has been made on the individual mandate issue, and Brady and Speaker Paul Ryan (R-Wis.) both said in interviews in recent days that they have not ruled out the idea.

“We have an active conversation with our members on a whole host of ideas on things to add to this bill and that’s one of the things being discussed,” Ryan said during an appearance on “Fox News Sunday.”

But Brady expressed concerns about including the mandate’s repeal at an event last week.

“There are pros and cons to this,” Brady said at an event Friday hosted by Politico. “Importing health care into a tax-reform debate has consequences.”

If Congress doesn’t act, Trump has vowed that he will. The president is reportedly considering taking executive action on the insurance mandate if Congress leaves it out of the tax-reform bill.

A lobbyist told The Hill the administration is working on guidance, which might not be in the form of an executive order, that would expand what are known as “hardship exemptions” that allow people to be exempted from the mandate’s requirement to have health insurance or pay a fine.

Brady said Monday that repeal of certain ObamaCare taxes would not be included in tax reform. Instead, he said he is working with Democrats on temporary relief from measures like the medical device tax and health insurance tax.

“We are working on common-sense temporary and targeted relief from many of these taxes to be acted on in the House before the end of the year,” Brady said.

Repealing the mandate could destabilize health insurance markets, experts warn, by removing an incentive for healthy people to enroll. The Congressional Budget Office has previously estimated that repealing the mandate would increase premiums by 20 percent.

Trump has been pushing to repeal the mandate in the tax-reform bill. Brady said last week that Trump had asked for it twice on the phone and once in person. Trump also told a meeting of Republican lawmakers at the White House last week that he wanted to repeal the mandate in tax reform and floated adding it in the Senate, attendees said.

Two conservative leaders, House Freedom Caucus Chairman Mark Meadows (R-N.C.) and Republican Study Committee Chairman Mark Walker (R-N.C.), have been pushing leadership to repeal the mandate in the tax bill. Walker has been slightly more aggressive, calling it a “good move.”

“When given the opportunity to actually address even part of an ObamaCare repeal with a simple majority, our leadership consistently finds excuses to justify their failure,” said a conservative House lawmaker who favors adding repeal to the bill.

“The individual mandate will be repealed by the president while Congress makes excuses.”

A number of lawmakers — both on and off the Ways and Means panel — are predicting the tax legislation Brady unveiled last week would attract the 218 GOP votes needed for passage.

While a handful of vocal New York and New Jersey Republicans are objecting to a provision of the bill that scraps or limits state and local tax deductions, most moderate Republicans have signaled they will go along with the legislation rather than derail one of the GOP’s top campaign promises of the 2016 elections.

So there is a reluctance among GOP vote-counters to add the insurance provision and upset that fragile balance.

“I believe it’s going to be a very strong vote based on my interactions with members and their passion to reform the tax code,” Rep. Jason Smith (R-Mo.), who serves on both the Ways and Means Committee and Ryan’s leadership team, said of the current version of the bill.

Transparency – All Cards Face-Up

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Transparency – All Cards Face-Up

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Creating and leading high-performing teams in any setting requires a high-trust environment.  A critical component in creating and keeping that trust is complete transparency across the team.  Having seen the empowering effect of this simple notion, I regularly reminded my direct-reports that the expectation was, “All cards are face-up on the table for the full team, in every decision and on every topic.”

I first learned the value of this kind of full transparency during my years working in the Mission Control Room while operating Space Shuttles and the International Space Station.  Everyone on the team reviewed every report, procedure, and mission-related communication of any kind between Mission Control and the astronauts.

That thorough transparency was never about micro-management.  It was in recognition that:

  • Every area of responsibility on the team affects the overall risk to the mission (e.g. if any single critical system fails, the entire spacecraft, and all the astronauts, are in jeopardy).
  • Any part of the team can and will make a mistake.
  • If not caught and corrected, combinations of seemingly small mistakes, or even some single mistakes, could lead to a failed mission or worse.
  • Conversely, there is so much talent in every part of the team, that as a team we can catch each other’s mistakes, offer suggestions from different perspectives, and come up with better overall solutions to problems.

Everyone on the team knew that it was team success that mattered, not simply individual performance.  “Showing our work” to our peers was not a threat to our individual authority.  It was an easy method to get more eyes on every problem and engage broader and deeper expertise to ensure nothing slipped past us.  Rather than slowing down decision-making, for decades these teams have routinely discussed and resolved exceptionally complex issues and have been able to take critical actions in minutes to protect a spacecraft hurtling through space.

The same risks often apply in management, where mistakes in one part of a company can have ripple effects that cause problems for other areas.  If poorly managed or left unsolved, those problems can cost the company money, erode product quality, bankrupt the company, and in some industries, injure employees and worse.

Just as we discovered in Mission Control, transparency is the simplest way to engage all members of the management team, and with them, the expertise and perspective of the organizations they led for the enterprise.  And just like in Mission Control, that greater engagement brings with it better informed, highly-reliable decision-making.

As an executive managing a $650 million/year enterprise, my direct-reports would often quote me before telling me and their peers some “ugly truth” or something they didn’t think I’d want to hear, “Just remember, you always say, all cards on the table…”

Every time they used that quote, it made me smile and think, “Now we’re talking!  Now we’re getting to it.”  More times than not, what followed was news about a project that was over budget or behind schedule, an unresolved engineering hurdle with an upcoming mission, or some mistake we had made in an earlier decision that was now putting us at risk.  Most importantly, it gave the full senior management team and the team’s they led an opportunity to help us find the best solution.  In the end, this is never about highlighting some part of the team’s mistakes, it is to ensure the team catches any weakness in our on-going performance.

Of course, transparency does not just protect the boss from the team’s mistakes.  It also allows the team to catch and correct the boss’s mistakes, as well as to offer innovations the boss may not see, which I was reminded of as the boss many times.

For example, during a tour in a development lab, I was shown a demonstration version for a new space station simulator based in a desktop personal computer.  Seeing a cost saving potential, I suggested several copies be made immediately available for testing by a number of our divisions.  Eyes widened around the room, including by several senior managers, but the team saluted and went to work.

After months of mixed reviews, the division responsible for managing and developing our training systems reported, “Look, Paul, this isn’t going to work.  We never thought it would, but you told our people to do it, so we did.  We can keep throwing money and manpower at it, but the answer won’t change for a long time.  However, we can accomplish what you’re after through some other work we’ve been doing, and we’re ready to show that to you and the management team any time.”

What followed became a project that moved our space station training software from $2 million sets of equipment that filled a room, to a single rack of servers costing $50,000 and contributed to total fixed cost reductions of more than 50 percent.

Lesson learned:  Share those great ideas with the full management team before giving direction.  Rely on the same transparency to spark discussions that can lead to better ideas and innovations that deliver.

This kind of transparency can become a habit and part of your culture.  It isn’t just for the bad news, but also for routine requests for better ideas, assurance that we’re not missing something, sharing resources to the areas that can make the next big gain… it makes us stronger and more successful as an enterprise.

Yes, the truth will set you free, and transparency is the way to find it and set the entire team free.