Doddering Doctors: Hospitals Take a Stab at Weeding Them Out

https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/78554?xid=nl_popmed_2019-03-14&eun=g885344d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=PopMed_031419&utm_content=B&utm_term=NL_Gen_Int_PopMedicine_Active

Image result for PAPA, the University of California, San Diego's PACE Aging Physician Assessment program

Screening programs take shape in San Diego as nationwide trend gains steam.

Interventional cardiologist Jerrold Glassman, MD, spent the first week of March schussing down Park City’s powdery slopes. He even braved black diamond runs, belying the fact that this July, he’ll be 69 years old.

“A 60-year-old today is not the 60-year-old of three decades ago,” he said proudly. “Skiing is my passion and I’m going back up tomorrow.”

He and his ski buddies, older physicians like himself, dodge moguls some 30 days a year. A new app tracks his stats, like altitude, speed and distance, and said he did 25 downhill miles that day.

Glassman has no plans to retire from the cath lab — or from skiing — anytime soon. But in coming weeks, medical executive committees for his 3,000-physician Scripps Health system in San Diego are expected to require screening for all physicians age 70 and older for cognitive impairment, among other things. It’s to be a condition for recredentialing every two years.

Doctors up for review will sit in a room alone, with no pencil or mobile aid, while they answer dozens of questions in the MicroCog, a computer-based test also used by the Air Force. The test scores thinking skills, such as the ability to solve simple math problems, count backwards from 100, or find similarities among shapes or pictures.

Following the computer test comes history, physical, and mental health screens that review issues like substance use and tests for hearing and vision. They fill out a form that asks about sleep patterns, continuing medical education, patient load, and typical hours at work. The entire process takes about three or four hours.

The policy is a major change for the system, acknowledged James LaBelle, MD, chief medical officer for Scripps Health. “About 150 physicians 70 or older are due to be recredentialed in 2019 and all would be subject to the policy,” he said. LaBelle did not respond when asked whether the two-year recredentialing cycle would subject a similar number to mandatory screening in 2020 — which would bring the total to about 10% of Scripps’ medical staff.

An undisclosed number of allied health professionals such as dentists and optometrists who seek status as a Scripps staff member are also covered by the policy, LaBelle said.

For most hospitals around the country, “this is pretty new. I do think Scripps is leading in trying to understand how to manage the aging physician,” he said, adding, “I hope it’s going to be easier than I think it’s going to be.”

Failing the MicroCog won’t automatically end a physician’s credentialing at Scripps. But it will flag him or her for further evaluation, perhaps prompting recommendations for more rigorous fitness-for-duty review lasting several days. Physicians who perform poorly there would see their ability to practice limited or revoked.

Come to PAPA

For Scripps and many other organizations, the plan is for screening to be done by PAPA, the University of California, San Diego’s PACE Aging Physician Assessment program — said to be the largest to provide this service in the nation. (PACE is an acronym for Physician Assessment and Clinical Education.) Many other organizations perform various screenings in house, with or without cognitive computer tests, or are working on plans to contract with four other service providers.

Surgeons and interventionalists like Glassman will likely also undergo PAPA’s 15-minute dexterity screen — in which they must correctly place shaped pegs into grooves in a board.

Although leadership’s commitment to a uniform policy is set at Scripps, some details are still being worked out, like how the system’s peer review committees will repurpose those long-time senior physicians who fail the tests but can still provide value to the workforce. LaBelle suggested the exact process Scripps will adopt “is a moving target” that may change, but added, “I have no doubt we’re going to learn a lot over the next few years around how to do this right.”

PACE is a multiple-day testing program which began 22 years ago to assess doctors referred by the Medical Board of California after negligence or behavioral issues threatened their license. Of the 1,000 physicians referred to PACE, an undisclosed number had age-related cognitive impairment that resulted in colleagues’ concerns, but the physicians continued to practice because the complicated peer review process takes a long time, and doctors don’t want to report on each other.

“In all honesty, when we started PAPA, it was because we saw so many wonderful careers that ended in disgrace and tragedy,” said PACE/PAPA director David Bazzo, MD. “Time and time again, the message we heard was ‘Gosh, I wish I had known, or I wish I had stopped or retired one case sooner,’ maybe because of a cognitive issue or dexterity issue. The regret is there.”

Absent screening, procedures for dealing with accusations of physician impairment, can take years. For example, a California medical board filing indicated that concerns about one gastroenterologist with a tremor were expressed internally in 2015, including that he “had forgotten that he was on call … exhibited occasional forgetfulness and confusion and had shown up on at least two occasions at the wrong surgery center.” The medical board didn’t receive a complaint until January 2017, however, and another 15 months elapsed before his license was revoked.

So it’s understandable that proactive screening is gaining traction. “I know it provokes a lot of anxiety, but in the end, it’s really around assessing how much deeper a doctor needs to be looked into, or doesn’t need to be looked into,” LaBelle said. It’s not a slam dunk that they would be sent packing — unless they refuse the tests, LaBelle said. “That’s a hard stop.”

Growth mode

With five PAPA contracts with healthcare organizations or medical groups now active and three more pending, Bazzo sees the demand for late career physician screening as a service line in growth mode. He gives talks about the process to hospitals and medical groups around the country, and estimates 10% of health systems now have some form of screening triggered only by a birthday, even if limited to certain departments. “It’s on the national radar,” he said.

Outside San Diego, other hospitals and health systems have also begun screening their senior clinicians, with or without the MicroCog. Among them are Stanford Hospital, Clinics in Palo Alto, and Eisenhower Medical Center in Rancho Mirage, California; Driscoll Children’s Hospital in Corpus Christi, Texas; and the University of Virginia Health System in Charlottesville. Many others have policies they declined to discuss with MedPage Today.

An American Medical Association report discussed at the November interim meeting noted that 300,752 physicians were 65 years or older in 2017, up from 241,641 in 2013, and 120,000 were “actively engaged in patient care,” up from 97,000. The literature is clear, an AMA report said, that cognitive and physical skills generally decline with age, and physicians are not excepted.

That report urged delegates to adopt principles to guide screening senior physicians for competency. “It is critical that physicians take the lead in developing standards … to head off a call for nationally implemented mandatory retirement ages or imposition of guidelines by others that are not evidenced based,” it said. The suggested guidelines failed to win approval but are being rewritten.

Clearly the issue is a touchy one at many organizations around the country, especially those with many clinicians who’ve long served as their hospitals’ elder statespeople and may serve on influential committees.

Asked if UCSD’s hospitals and clinics screened their senior physicians, a communications director replied, “UC San Diego Health is in discussion on a potential policy, however, it hasn’t established one because the science on the topic is unsettled.”

That prompted a strongly worded retort from William Perry, PhD, vice chair of the UCSD department of psychiatry and a PACE program psychologist.

Robust data

The data is fairly robust in two domains,” regarding the impact of age on physician care, Perry told MedPage Today, emphasizing that the communications director’s message was patently incorrect. “Abilities decline after a certain age and, as one gets older, adverse outcomes increase,” he said, citing unpublished data from PACE and other studies. “There’s no denying it; as we get older a lot of our functions decline.”

Perry said that these days, he’s receiving calls every week from around the country wanting him to give talks. “Organizations in North Carolina and New Jersey are putting together policies. It’s not a question of if, it’s a question of when this will become standard,” he said.

“I’m struck by how much science has demonstrated a connection between aging and impaired physician practice,” said Richard Barton, an attorney who represents physicians, medical groups, and hospitals and helped author a paper on the topic in 2015 for a Sacramento-based physician wellness group. In San Diego alone, Barton knows of three organizations, including Rady Children’s Hospital and UCSD Medical Center, who are also working on late career screening policies due to concern that some older physicians are at higher risk for causing patients harm.

Glassman, who has practiced at 655-bed Scripps Mercy Hospital since 1979 and was chief of staff for four years, said most older Scripps physicians favor the idea. “It’s kind of mom and apple pie. How can you say a physician who is not competent should be allowed to practice?” The big question is, after a clinician fails, which follow-up tests correctly determine whether an experienced physician can still practice?

One of Glassman’s fellow skiers, Jeff Sandler, MD, a Scripps endocrinologist, will be 72 this June and supports the idea of screening doctors his age. “If you think you shouldn’t be screened, maybe you shouldn’t be practicing,” he said. “It sounds discriminatory, but we have to protect the public from bad actors.”

But the issue remains controversial because screening based solely on age smacks of illegal discrimination and the age cutoffs are inherently arbitrary.

 

Segment 7 – Healthcare Power, Politics & Philosophy

Segment 7 – Healthcare Power, Politics & Philosophy

 

This segment reviews preconditions for having a focused discussion of healthcare reform necessitated by powerful vested interests, and it discusses how to overcome political polarization.

In the first six Segments, we have reviewed the relentless growth of healthcare spending. And how rising costs are literally built into the system as it is now. This review should give us some ideas on how to fix the system.

But before we talk about how to fix the healthcare system, we must first tackle some landmines that lurk beneath the surface. The landmines are power, politics and philosophy. They are the subject of the next 2 Segments.

In this Segment, we will discuss both preconditions necessary for a calm, focused discussion of healthcare reform as well as what I call “loaded” political words. Then in the following Segment we will look at traditional American values and principles that can be brought to bear on resolving the core philosophical dilemma that has kept us from fixing US healthcare all these years.

Let’s start with preconditions. The idea here is that healthcare now comprises 1/6 of the entire US economy. So, there are powerful interests, lots of money, and fierce political convictions that could derail any discussion before it even gets started.

So, I suggest setting preconditions to be agreed on beforehand. Only then can we calmly get into the meat of the discussion. Here are the preconditions.

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First, for purposes of discussion, let’s agree to keep dollar spending at the 2017 level – no winners, no losers, everything the same.

Second, let’s keep power the same. Keep the AMA, the hospital association, the VA, Health & Human Services, etc. No power struggles.

Third, strive to keep partisan politics out of the discussion. Make it a joint problem-solving project. Give credit where it’s due: to politicians or policy writers who contribute constructively. The motto is: “U.S. spells us.” Healthcare employs 1/6 of us and touches all of us.

Fourth, here’s where I will insert a viewpoint from my 40 years experience as a doctor: Human beings all get the same illnesses, all suffer, all are interconnected mind/body/spirits. I – like all doctors — have taken care of rich and poor, all races and nationalities, religious and non-religious, social outcasts and VIPs, saints and sinners. In a hospital bed or in the doctor’s office, we’re all the same. We should remember, “We’re all in this together”

Lastly, since healthcare is “too big to fail,” whatever is done should be done deliberately, slowly, with monitoring along the way and mid-course corrections when needed. If we accept these preconditions, we can have a Win-Win Discussion.

This kind of discussion should look at Facts, Goals, Values and lastly Methods, the actual Fix.

We have already discussed the Facts. The key facts are:

– the US health system has grown to 3.2 trillion dollars, representing 1/6 of the entire economy

– Cost growth is built into the system, has always outpaced inflation, and has resisted attempts to restrain the growth

– Healthcare spending is draining vitality from the economy, government and individual household budgets

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Here are the key Goals:

– We must stop excess healthcare growth beyond the natural increase expected from population increase, aging, and innovation.

– To do so will require fundamental reform of the system, not just tinkering with public finance and private insurance

– Since healthcare is “too big to fail”, a key goal is Avoid short-term disruption, again proceed slowly.

Slide13

The last things to discuss before we get to specific Methods – what I am calling the Fix of healthcare – are Politics and Values.

We all know that our country is polarized to an unhealthy extent. This has contributed to political paralysis – not getting anything done. I’m not a political scientist and cannot tackle the whole subject of healthcare politics.

But I do want to look at what I call “loaded words” that creep into our debates on healthcare. These words lock us into a closed, rigid mindset and can shut down discussion.

Let’s look at a few “loaded words” and suggest more neutral words to help keep the discussion open-minded.

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First is “socialized medicine.” This terminology stirs up the negative connotations of the so-called “Prussian menace” after World War I and “Red scare” after World War II. A more neutral term would be “publicly financed medicine.” The truth of the matter is that currently almost 50% of healthcare is already publicly financed through Medicare, Medicaid and other government programs. The issues behind the loaded words, which do need thoughtful discussion, are accountability; and also advantages and disadvantages of uniformity and nationwide scale, instead of the current fragmented system.

The next loaded terms are “free market” and “competition.” The connotations are freedom from government interference, freedom from politics, consumer freedom, and efficiency. The grain of truth behind the terms is that the law of supply and demand does drive down prices to a balance point in pure markets. The reality, however, is that healthcare is not a pure market, as we saw in Segment 5. Also, markets sometimes leave aside consumers who are poor or powerless, which includes many of the sick. A more neutral term is commercial market.

Next is “rationing.” The connotation is forcibly withholding something from an individual. A more neutral term is “limit-setting” or “prioritizing.” We will talk more about this in the next Segment, and about the need for patients’ to consent to limits on their health service or health insurance. The reality is that we already have de facto rationing by zip code, income level, government budgeting, and hospital technology policies. Prioritizing is not bad – it’s necessary.

Slide18

Another loaded word is “choice.” The connotation is that the government will interfere in choice of doctor or into the doctor-patient relationship itself. This was one of the scare tactics used by the insurance association in 1993 to bring down the President Clinton’s health reform plan. But the reality is that insurance network plans restrict patient choice of doctor more than government rules do. In addition, doctor inclusion in Medicaid – and other insurance plans, for that matter — is often a matter of the pay scales set by Medicaid or insurance companies, not the choices made by patients.

And the last loaded term I’ll mention is “big government.” The connotation goes back to President Reagan saying, “Government is not the solution to the problem; government is the problem.” We always hear about the Army’s 100-dollar toilet seats (in 1986 dollars) and the disastrous roll-out of the Obamacare website.

Slide19

And the truth is that government is big and can be just as flawed as any big institution. However, national government, unlike private companies, is legally transparent and accountable. Also, Government can fulfill some functions more effectively and efficiently than some private sector piecemeal approaches. Here are examples: FAA, FDA, FCC. Currently the military enjoys a high regard. Some examples of public-private partnerships are the moon shot, internet and healthcare research. Medicare has an enviable customer satisfaction rating of 77%.

The reality is that we are now a nation (and world) of big institutions – for-profit, non-profit, government, academic. All have institutional governance and administrative challenges, which are studied by the disciplines of public administration and business administration. Public administration and business administration tell us how best to run big institutions so as to fulfill their mission and to remain accountable and transparent. More neutral terms instead of “big government” are: public sector programs or taxpayer-funded program.

So we have some better neutral terminology to use for discussing healthcare to avoid inflammatory polemical words.

In the next Segment we will look at American values at stake in health care. We will also look at what philosophers say is a fair way to run US healthcare.

I’ll see you then.

 

 

Segment 3 – Healthcare Reform Successes & Failures

Segment 3 – Healthcare Reform Successes & Failures

Slide15

In Segment 2, we looked at the history of medical care in the U.S. until 1965, the year Congress enacted Medicare and Medicaid.

In Segment 3 we will look at reform movements, starting with Medicare and Medicaid. We will look at why later reforms failed and where that leaves us now.

By the early 1960s, nearly all employees were covered by Blue Cross/Blue Shield.

But problems emerged. First, low-wage workers were often not covered by their small businesses, and elderly retirees were not covered. Costs were going up because pre-paid insurance increased patient demand for services. Harry Truman had proposed national health insurance after he surprisingly was re-elected in 1948. But the AMA launched a multi-million-dollar publicity campaign to deride the plan as “Communism” and “socialized medicine.” Truman’s public insurance plan failed.

The next attempt at reform was successful – the 1965 passage of Medicare and Medicaid. Lyndon Johnson succeeded because coverage targeted the uninsured poor-and- elderly, leaving the rest of the private for-profit health system unaffected.

Senator Teddy Kennedy tried in 1971 to extend Johnson’s success to build a single-payer system, and won support from President Nixon. But this plan was derailed by the Watergate scandal.

The next attempt came from Bill and Hillary Clinton. After Clinton took office in 1992, Hillary and expert panels devised a plan for universal coverage including essential benefits and pre-existing conditions with mandated employer insurance and expanded Medicaid. This plan failed because the insurance industry launched a stinging publicity campaign featuring a down-home couple named “Harry and Louise.” Americans also balked at the tax increases needed to fund it.

The Clinton’s failure made it necessary to find another solution to rising costs. Managed care, which had first appeared in 1973, became that solution. And it did work, slowing growth to under 6%. But around the year 2000 came a backlash over mammograms and so-called “drive-by” deliveries, which undermined the ability of managed care to control costs.

What do we make of this history? Here are the main take-aways that help us understand our present health system. First, there has always been a tension between the profit motive in the free marketplace and a health promotion motive. Second, Americans have given special treatments to the health industry in return for medical advances. And third, powerful vested interests (doctors, hospitals, insurance, drug companies) have often used polemics and ideological arguments to defend their favored status, not necessarily actual health outcome data.

Slide09

So, this leaves the US with the largest, most expensive healthcare system in the world. In 2011 shown here it took in payments of 2.7 trillion dollars, mostly private insurance, Medicare, Medicaid and out-of-pocket. The figure for 2015 was 3.2 trillion dollars, representing 1/6 of the entire economy of the entire Gross Domestic Product. Government’s share of payments was almost 50% in 2016.

Slide10

This graph shows the dollars spent in 2011 – mostly on hospitals, doctors, drugs, long-term care. Remember that 25% of this pie graph actually goes to administrative costs, not medical services.

Slide11

In defense of U.S. healthcare, in 2012 then-House-Speaker John Boehner and then Senate Minority Leader Mitch McConnell famously said, “the U.S. has the finest health care system in the world,” and further that “wealthy foreigners flock to the U.S. because of its cutting edge facilities.”

2017-10-13-boehner-mcconnell.png

However, the World Health Organization rates the U.S. 15th in performance (life expectancy and delays in care), and only 37th in overall attainment (including financial and service fairness).

In 2015 the Kaiser Foundation compared the US with 10 other developed countries. Here are their results showing areas in which US is better, equal or lacking.

Here are the Commonwealth Fund’s 20-11 rankings – US is in the middle of the pack for most areas but dead last on several others and overall rank.

Slide14Source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

What about “foreigners flocking-for-care”? This pertains to highly specialized treatments available only in certain centers such as Mayo, Cleveland Clinic or Hopkins. Some centers in Florida and Texas do market to wealthy foreigners, who pay the full charge in cash, not discounted insurance rates like the rest or us. Boehner and McConnell pointed to Canadians coming to Michigan hospitals, but the Commonwealth study found that Canada is worst in timeliness and 10th worst overall, just ahead of the US in 11th place, so not surprising.

The further truth is that, according to Centers for Disease Control, 3/4 million Americans go abroad each year for medical treatments, such as for holistic care or dental care, but mostly seeking lower cost.

In the next Segment we will talk about cost, namely how the rising cost of healthcare is affecting our economy, our politics, our society – and some say our very existence.

I’ll see you then.

 

 

 

Segment 2 – Brief History of U.S. Healthcare

Segment 2 – Brief History of U.S. Healthcare

Slide04

In Segment 2, I will answer the question, How Did We Get Here? I’ll give a whirlwind tour of the history of medical care in the U.S., and I’ll also look at the birth of health insurance.

Let’s start with looking at healthcare in the Colonial period. The most famous doctor at the time was Benjamin Rush. He – like most reputable professionals of the day – got his medical training in Europe, in his case Edinburgh, Scotland, the leading medical center of the time. Rush was a signer of the Declaration of Independence and served in the Revolutionary Army. He became the “father of American psychiatry” because of his interest in mental illness as a disease, not demon possession.

Rush and other orthodox practitioners in the early Republic –trained in the scientific European tradition– faced competition from a panoply of practitioners in an unlicensed, unregulated “free market.” They peddled nostrums like snake oil and procedures such as blood-letting. Doctors of all types trained like apprentices. The sick were cared for in their homes, with the poor going to almshouses and mentally ill to asylums. Port cities did have public pesthouses for quarantines.

By mid-19th century, orthodox doctors began trying to solidify their place in the market. They did this through training at medical schools, beginning with Harvard, Dartmouth, College of Philadelphia (which eventually became the University of Pennsylvania) and King’s College (which eventually became Columbia). But by 1850 there were now 42 medical schools that often were little more than diploma mills. The course consisted of only two semesters of 3 months each. The medical school needed only 4 faculty, 1 classroom, 1 dissection lab and a charter to grant degrees. These schools were highly profitable.

In 1847, the AMA (American Medical Association) was founded by the orthodox physicians.

Meanwhile, the era of scientific medicine was blossoming in Austria, Britain, Germany and France. Here are some milestones – anesthesia, microbiology study of invisible germs, antiseptic surgery technique and x-rays.

In America, by the turn of the century, doctors and the AMA sought to further shore up their legitimacy by reforming medical education. States began requiring more formal education as a condition for licensure. The Association of Medical Colleges was founded in 1876. In 1893, Dr. William Welch brought to Johns Hopkins University the German model of education based on 3 or 4 years of training in clinical sciences. Industrialist and philanthropist Andrew Carnegie hired Abraham Flexner in 1910 to draw up a blueprint for medical school reform. Flexner is widely credited with ushering in the era of modern medicine in this country.

In the early 20th century, doctors enjoyed prestige and independence. Courts rules against corporations practicing medicine, ensuring the pre-eminence of private practice. Doctors joined together in hospitals to take care of growing populations in big cities, and to exploit emerging surgical and diagnostic technologies.

This brings us to health insurance. Surgery (which made great advances during the Civil War and World War I) and hospitals were becoming expensive. So in 1929, Baylor College started the first pre-paid hospital insurance. Baylor’s 1,200 teachers each paid 50 cents per month to cover up to 21 days of hospitalization. Surgeons and hospitals quickly embraced this arrangement, and the Baylor plan became the Blue Cross plan in Minnesota in 1933 and Texas in 1934. By 1950, just 15 years later, Blue Cross covered 57% of the population.

Here’s how it happened. After World War I, the war-torn countries of Europe, like Germany, were in turmoil. Social insurance, including healthcare, helped reestablish some social stability there. But in this country, politicians opposed Teddy Roosevelt’s plan to set up national health insurance for factory workers, calling public insurance a “Prussian menace”. Labor unions saw public health insurance as an encroachment on their special role to ensure worker benefits. The AMA also opposed public health insurance as a potential “interference with the practice of medicine.

Then during World War II, wages were frozen, but companies were allowed to give health insurance benefits instead. This sewed the seeds of the employer-based health insurance system. In 1948 the Supreme Court decided that unions could use health benefits in collective bargaining agreements. Then in 1954 Congress made employer-paid health premiums non-taxable. By the mid-1960s employer-paid health insurance was nearly universal.

Let’s summarize the history of medicine from Rush to Medicare. In the Colonial period and early Republic there was intense competition among doctors of all stripes, those that tried to understand the scientific basis of disease and those who peddled remedies on a trial-and-error basis (referred to as “empirical”), relying mostly on their placebo effect. We still see vestiges of this early competition today in the rivalry between MDs, DOs, chiropractors and podiatrists. During the industrial period, little by little science-based orthodox physicians in the European tradition prevailed over their rivals introducing advances in surgery, diagnosis and infection control. They shored up their gains with institutions such as the AMA, hospitals, and eventually insurance.

In the next Segment, we will look at reform movements, starting with Medicare and Medicaid in the 1960s. We will also look at why later reforms failed and where that leaves us now.

I’ll see you then.

 

 

 

 

The impossibility of bipartisan health-care compromise

https://theweek.com/articles/811962/impossibility-bipartisan-healthcare-compromise

People yelling at each other.

If there’s one thing political centrists claim to value, it’s compromise. It’s “the way Washington is supposed to work,” writes Third Way’s Bill Schneider. “Centrists, or moderates, are really people who are willing to compromise,” The Moderate Voice‘s Robert Levine tells Vice.

What does this mean when it comes to health care and the developing lefty push for Medicare-for-all? The fresh new centrist health-care organization, the Partnership for America’s Health Care Future (PAHCF), says it is a “diverse, patient-focused coalition committed to pragmatic solutions to strengthen our nation’s health-care system.” In keeping with the moderate #brand, PAHCF may not support Medicare-for-all. But perhaps they might support a quarter-measure compromise, like allowing people under 65 to buy into Medicare?

Haha, of course not. Their offer is this: nothing.

Valuing compromise in itself in politics is actually a rather strange notion. It would make a lot more sense to determine the optimal policy structure through some kind of moral reasoning, and then work to obtain an outcome as close as possible to that. Compromise is necessary because of the anachronistic (and visibly malfunctioning) American constitutional system, but it is only good insofar as it avoids a breakdown of democratic functioning that would be even worse.

However, “moderation” is routinely not even that, but instead a cynical veneer over raw privilege and self-interest. The American health-care system, as I have written on many occasions, is a titanic maelstrom of waste, fraud, and outright predation — ripping off the American people to the tune of $1 trillion annually.

And so, Adam Cancryn reports on the centrist Democrats plotting with Big Medical to strangle the Medicare-for-all effort:

Deep-pocketed hospital, insurance, and other lobbies are plotting to crush progressives’ hopes of expanding the government’s role in health care once they take control of the House. The private-sector interests, backed in some cases by key Obama administration and Hillary Clinton campaign alumni, are now focused on beating back another prospective health-care overhaul, including plans that would allow people under 65 to buy into Medicare. 

Behind the preposterously named “PAHCF” stands a huge complex of institutions that benefit from the wretched status quo. This includes the PhRMA drug lobby (Americans spend twice what comparable countries do on drugs, almost entirely because of price-gouging), the Federation of American Hospitals (Americans overpay on almost every medical procedure by roughly 2- to 10-fold), the American Medical Association (U.S. doctors, especially specialists, make far more than in comparable nations), America’s Health Insurance Plans, and BlueCross BlueShield (the cost of average employer-provided insurance for a family of four has increased by almost $5,000 since 2014, to $28,166).

The human carnage inflicted by this bloody quagmire of corruption and waste is nigh unimaginable. Perhaps 30,000 people die annually from lack of insurance, and 250,000 annually from medical error. America is a country where insurance can cost $24,000 before it covers anything, where doctors can conspire to attend each other’s surgeries so they can send pointless six-figure balance bills, where hospitals can charge the uninsured 10 times the actual cost of care, where gangster drug companies can buy up old patents and jack up the price by 57,500 percent, and on and on.

One might think this is all a bit risky. Wouldn’t it be more prudent to accept some sensible reforms, so these institutions don’t get completely driven out of business?

But wealthy elites almost never behave this way. John Kenneth Galbraith, explaining the French Revolution, once outlined one of the firmer rules of history: “People of privilege almost always prefer to risk total destruction rather than surrender any part of their privileges.” One reason is “the invariable feeling that privilege, however egregious, is a basic right. The sensitivity of the poor to injustice is a small thing as compared with that of the rich.”

And so we see with the Big Medical lobby. The vast ziggurat of corpses piled up every year from horrific health-care dysfunction is just a minor side issue compared to the similar-sized piles of profits these companies accumulate — which they will fight like crazed badgers to preserve.

As Paul Waldman points out, this means a big resistance to the prospect of doing anything at all, let alone Medicare-for-all. However, the political implication is clear. If compromise is impossible, then liberals and leftists who want to improve the quality and justice of American health care should write off the corrupt pseudo-centrists, and go for broke. Democrats should write a health-care reform bill so aggressive that it drastically weakens the profitability of Big Medical, and drives many of them out of business entirely. If you cannot join them, beat them.

 

 

 

 

Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks

The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.

The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.

With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.

From hundreds of letters sent to the government by health care executives and lobbyists in the last few weeks, some themes emerge: Federal laws prevent insurers from rewarding Medicare patients who lose weight or take medicines as prescribed. And they create legal risks for any arrangement in which a hospital pays a bonus to doctors for cutting costs or achieving clinical goals.

The existing rules are aimed at preventing improper influence over choices of doctors, hospitals and prescription drugs for Medicare and Medicaid beneficiaries. The two programs cover more than 100 million Americans and account for more than one-third of all health spending, so even small changes in law enforcement priorities can have big implications.

Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.

“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.

Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.

These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.

Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.

The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.

The Trump administration is calling its effort a “regulatory sprint to coordinated care.”CreditSarah Silbiger/The New York Times.

Health care providers can be fined if they offer financial incentives to Medicare or Medicaid patients to use their services or products. Drug companies have been found to violate the law when they give kickbacks to pharmacies in return for recommending their drugs to patients. Hospitals can also be fined if they make payments to a doctor “as an inducement to reduce or limit services” provided to a Medicare or Medicaid beneficiary.

Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”

Almost every week the Justice Department files another case against health care providers. Many of the cases were brought to the government’s attention by people who say they saw the bad behavior while working in the industry.

“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

But the laws are complex, and the stakes are high. A health care provider who violates the anti-kickback or self-referral law may face business-crippling fines under the False Claims Act and can be excluded from Medicare and Medicaid, a penalty tantamount to a professional death sentence for some providers.

Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community.

Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.

AstraZeneca, the drug company, said that older Americans with drug coverage under Part D of Medicare “often face prohibitively high cost-sharing amounts for their medicines,” but that drug manufacturers cannot help them pay these costs. For this reason, it said, the government should provide legal protection for arrangements that link the cost of a drug to its value for patients.

Even as health care providers complain about the broad reach of the anti-kickback statute, the Justice Department is aggressively pursuing violations.

A Texas hospital administrator was convicted in October for his role in submitting false claims to Medicare for the treatment of people with severe mental illness. Evidence at the trial showed that he and others had paid kickbacks to “patient recruiters” who sent Medicare patients to the hospital.

The owner of a Florida pharmacy pleaded guilty last month for his role in a scheme to pay kickbacks to Medicare beneficiaries in exchange for their promise to fill prescriptions at his pharmacy.

The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million.

The line between patient assistance and marketing tactics is sometimes vague.

This month, the inspector general of the Department of Health and Human Services refused to approve a proposal by a drug company to give hospitals free vials of an expensive drug to treat a disorder that causes seizures in young children. The inspector general said this arrangement could encourage doctors to continue prescribing the drug for patients outside the hospital, driving up costs for consumers, Medicare, Medicaid and commercial insurance.

 

 

 

Bundled Payment Program Does Not Drive Hospitals to Increase Volume

https://www.commonwealthfund.org/publications/journal-article/2018/sep/bundled-payment-program-does-not-drive-hospitals-increase?omnicid=EALERT1467649&mid=henrykotula@yahoo.com

Lower extremity joint replacement

The Issue

In 2013, the Centers for Medicare and Medicaid Services (CMS) introduced a voluntary program for hospitals called Bundled Payments for Care Improvement (BPCI). Under this alternative payment model, CMS makes a single, preset payment for an episode, or “bundle,” of care, which may include a hospitalization, postacute care, and other services. Evaluations of the program for lower extremity joint replacement surgery (e.g., a hip or knee replacement) have found that it reduced spending. But experts wonder if bundled payments could encourage hospitals to perform more surgeries than they would otherwise or to cherry-pick lower-risk patients. Commonwealth Fund–supported researchers explore these issues of volume and case mix in the Journal of the American Medical Association.The authors used Medicare claims data from before and after the launch of BPCI, comparing markets that did and did not participate in the program.

What the Study Found

3.8%

increase in mean quarterly market volume in non-BPCI markets after the program was launched

4.4%

increase in mean quarterly market volume in BPCI markets after the program was launched

  • Participation in the BPCI program was not significantly associated with an overall change in the volume of surgeries performed.
  • The mean quarterly market volume in non-BPCI markets increased 3.8 percent after the program was launched. For BPCI markets, the increase was 4.4 percent.
  • The analysis found only one change in case mix: patients who had previously used skilled nursing facilities were slightly less likely to undergo a lower extremity joint replacement surgery at a hospital participating in BPCI.

The Big Picture

Results from this study alleviate concerns that hospitals’ participation in voluntary bundles may increase the overall number of joint replacement surgeries paid for by Medicare. In particular, the savings per episode observed in prior BPCI evaluations are not diminished or eliminated by an increase in procedure volume. The findings do raise concerns: if patients with prior use of skilled nursing facilities are less likely to undergo procedures at BPCI-participating hospitals, perhaps it is because hospitals avoid them based on perceived risk. On the other hand, the authors note, these decisions could have been based on clinically appropriate factors, like risk of complications.

The Bottom Line

Hospital participation in a bundled care program did not change overall volume, thereby alleviating the risk of eliminating savings related to the program. In addition, participation was generally not associated with changes in case mix.