Tuesday, December 28, 2010

Pill Mills are Gearing up for Big Business

Thanks to the ideological rigidity of our legislature and almost monoptic "vision" of our Governor-Elect the Prescription Drug Monitoring Program is almost dead before even going online. The Office of Drug Control is being dissolved and all employees are gone by January 3rd!
In today's Miami Herald editorial the issues at hand are being pointed out as they are.
Dr. Viamonte Ross, one of the few agency heads asked to resign, has the final opportunity to declare a public health emergency thereby forcing the state to approve an existing PDMP vendor contract. Unfortuantely, the Attorney General (and the Board of Medicine) do not believe that the current status quo justifies such an emergency order. The rate of prescription drug overdose death increased to 7 Floridians a day. So whats the "magic" number 10,20, 100...?
I urge all of you to contact your legislator to support an immediate declaration of a public health emergency.

The Miami Herald
Posted on Tue, Dec. 28, 2010
Pill mills still going strong

When it comes to the unsavory and downright illegal, South Florida owns the market in healthcare scams. Miami-Dade County is the nation's epicenter of Medicare fraud. Broward County is the state's biggest black market in prescription pain killers like oxycodone. By now, many of the pill mills should have been shut down. They're not.

Thanks to lax state oversight, walk-in pain clinics have flourished in Florida in the last three years. A 2009 Miami Herald series highlighted the proliferation of these pill mills. Broward clinics alone sell more oxycodone than is sold in several states. Anyone can get hundreds of pain pills from these clinics. The powerful narcotics are then resold on the street.

The growth of pain clinics, often run by discredited doctors, is causing an epidemic of prescription overdose deaths, says Florida drug czar Bruce Grant. The rate of deaths is about seven per day -- a shocking number that's preventable.

By now, these clinics were supposed to be regulated under tough new rules. Instead, most reforms are in limbo thanks to a contract dispute and a blunder by the Legislature during its November special session.

In 2009, the Legislature passed a bill to create a statewide database of all prescription narcotics sold by doctors and pharmacists to prevent patients from ``doctor shopping'' -- going to multiple clinics and doctors for pills to later resell. Tougher rules governing doctors working in pain clinics and who could own them are also in the new law.

The due date for the database was Dec. 1. The deadline came and went, however, because a company bidding on the project has legally challenged the contract award. Mr. Grant has asked Florida's surgeon general, Dr. Ana M. Viamonte Ros, to approve the contract on an emergency basis to protect public health.

Dr. Viamonte Ros is one of the few agency heads told to resign by Gov.-elect Rick Scott. But she is on the job till Jan. 3. Given those seven daily drug overdoses, Dr. Viamonte Ros should set the database in motion.

The other big glitch in moving forward with the regulations happened because of GOP lawmakers' zeal to override outgoing Gov. Charlie Crist's vetoes. They revived an anti-regulation bill requiring any new rules that may cost businesses or the government more than $200,000 a year to be subjected to legislative review before implementation.

This has stalled many pill-mill regulations, which now must await lawmakers' scrutiny in 2011. In vetoing the bill in its first incarnation, Gov. Crist wisely warned that the law would have required almost every new rule -- which can number in the hundreds in one year alone -- to await mandated review before being applied. What a nightmare.

Despite the setbacks, the state health department commendably has enforced a few rules. In November, state officials began inspecting pain clinics for the first time. So far, 17 clinics have been shut down.

That's a start, but as of November, there were 142 registered clinics in Broward and 94 in Miami-Dade. So much more could be happening right now to prevent more unnecessary deaths.

© 2010 Miami Herald Media Company. All Rights Reserved.

Monday, December 27, 2010

No Money For Florida

Recommend reading an interesting article entitled “ Medicaid Bonuses to Reward States for Insuring More Children,” http://www.nytimes.com/2010/12/27/health/policy/27medicaid.html?partner=rss&emc=rss reporting that the Obama administration plans to announce Monday that it will make $206 million in bonus Medicaid payments to 15 states — with more than a fourth of the total going to Alabama — for signing up children who are eligible for public health insurance but had previously failed to enroll.
This program was created to address the following issues:

* To enroll an estimated 4.7 million children who would be eligible for subsidized coverage if their families could be found and alerted. Two of every three uninsured children are thought to meet the income criteria for government insurance programs.
* The stubbornness of the problem is one reason the government expects millions of people to remain uninsured even after 2014, when the new health care law requires most Americans to have coverage and vastly expands government programs to make it affordable.

Alabama will receive a $55 million bonus, more than twice as much as any other state, for having 133,000 more children on its Medicaid rolls than projected by a formulated base line. The 15 states that will receive bonuses reported a total of 874,347 children above the baseline, which factors in population growth and, to some degree, demand driven by the economy.

Alabama, for example, has adopted “express lane eligibility” so that Medicaid application processors can use income findings from other safety net programs to validate eligibility.

Because of the formula’s requirements, none of the money will go to California, Texas or Florida, which account for nearly 40 percent of all uninsured children. States like Florida make enrollment cumbersome and devote minimal resources to marketing. Many of my patients have never heard about the program and I try assisting them to navigate poorly designed web sites and to complete forms they do not understand (neither do I.)

Shouldn't it be the goal of our new governor-elect to increase the enrollment for children qualifying for this program? Unfortunately, those children may have to wait for a long time because ideological purity comes first!

Who will pay the price? All of us, because those children will grow into sick adults requiring more expensive care to “correct” mistakes that could have been prevented in childhood.

Rick Scott and The Department Of Health: The Saga Begins

Finally, the planned program of Governor-elect Rick Scott is taking shape. Among the items that will affect doctors the most is the proposal calling for merging the Department of Health and the Agency for Health Care Administration. It would close the tuberculosis hospital at Lantana, privatize the state's mental hospitals, include the possible sale of Jackson Memorial Hospital in Miami and ....?!
Rick Scott seems to operate (again) in a vacuum, surrounded by advisors, not understanding the ramifications of his decisions.
The Florida Department of Health was created in 1889 one year after a devastating yellow fever outbreak killed over 400 citizens in Jacksonville and about 40 percent of the population fled the city due to a yellow fever epidemic which sickened a third of those who stayed. Similar epidemics of cholera and yellow fever struck the state almost annually, one of which almost wiped out the population of St. Joseph in 1841. In most cases, limited medical care was available for the sick and weaker people died, but not before infecting many others. Many survivors were carriers, continuing to pass the diseases to others as a result of poor sanitary practices. As a result control of infectious diseases was the major reason for establishment of public health services and remains a major focus today with new infectious diseases emerging as a the results of global climate change. In addition, substance abuse, including the devastating impact or prescription narcotic abuse and diversion, challenges the public health system killing seven (7) Floridians every day!! During the 1996 legislative session, the beleaguered Florida Department of Health and Rehabilitative Services was reconstructed as two entities: the Department of Health and the Florida Department of Children and Families to respond to the unique needs of its respective constituencies. Currently the Florida Department of Health operates County Health Departments in all 67 of the State's Counties. The agency employs more than 17,000 persons. It has championed immunization campaigns, tobacco control, and statewide preparedness response efforts. The Department of Health is a cabinet level agency of the state government, headed by the State Surgeon General who reports directly to the Governor.
I agree with Tim Stapelton, Florida Medical Association Senior Vice-President, that " ..this is a public safety concern and the governor must have a medical doctor advising him of these issues rather than another governor bureaucrat."
I also agree with Mr. Stapelton that its very questionable merging the department that REGULATES DOCTORS with the agencies that REGULATE HOSPITALS. This almost enshrines a conflict within the walls of one mega-agency. What kind of efficiencies does the governor-elect expect? On what expertise and experience is he basing his decision? Is he aware that his decision will undermine our already fledgling public health system?
Now is the time to raise our voices of concern and to let the (almost) one-party legislature know that absolute rule must be challenged.



Sunday, December 26, 2010

End-of-Life Care and Medicare

The New York Times reported today http://www.nytimes.com/2010/12/26/us/politics/26death.html?_r=2&hp that as of January 1st 2011 under a new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.
This is indeed good news for all family physicians because finally they can paid for a service we all are supposed to offer anyway.
I wonder how soon we can receive more detailed information about the new billing codes and reimbursement.


Wednesday, December 22, 2010

Closing the Office of Drug Control is Bad For Business

Governor-Elect Rick Scott notified all four full-time employees working in the governor's Office of Drug Control that their services will no longer be needed after he takes office next month. The office will be dissolved and all its duties turned over to the departments of Health and Law Enforcement.
Rick Scott has pledged to cut waste in state government and the annual budget of about $551,300 for funding the operations of the Office of Drug Control is considered "waste" that needs to be eliminated too.
But lets analyze and examine the facts:

* The Office of Drug Control was created by then Governor Jeb Bush in 1999 and is authorized by state statutes.
* The Office collaborates with other agencies on the implementation of a three-pronged approach of Prevention, Treatment and Law Enforcement to eliminate the devastation of substance abuse rampant in Florida's diverse communities.
* The Office issued a series of excellent reports http://www.flgov.com/drugcontrol/odc_statsreports.php documenting the increasing problem of drug abuse in Florida.
* The Office was instrumental in getting legislation passed that is intended to help curb prescription drug abuse — one bill targeting pain management clinics, which are often disguises for "pill mills," and another that establishes a prescription drug monitoring program.
* The Office championed the creation of a Prescription Drug Monitoring Program, which almost reached the point of going on-line.
* Prohibited by law to use state funds to pay for the PDMP Director Bruce Grant and his superb staff successfully obtained the necessary funding through federal grants and other sources

The current political leadership in Tallahassee seems to be under the impression that we DO NOT have a significant drug problem in Florida.
Governor Scott's spokesman Brian Burgess was quoted in an article that "I don't think we're going to have cocaine bales stacking up on the docks of Miami if we close this office."
Obviously, he did not bother to check the facts:

· Years of lax state laws and a plethora of pain clinics have made Florida a destination for prescription drug traffickers, drug peddling doctors and abusers.

· The DEA, using its most recent data, says that 49 out of 50 of the top oxycodone prescribers are located in Florida.

· The number of deaths caused by at least one prescription drug increased more than 100 percent from 2003 to 2009.

· Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association, said a recent study showed that substance abuse has a $43 billion negative impact on the state economy due to loss of job productivity, and costs associated with hospital and emergency room visits and incarceration. Fontaine said about 65 percent of Florida inmates have substance abuse problems.

· A 2009 Florida Department of Law Enforcement study concluded seven people in Florida die every day- ALMOST 2500 FLORIDIANS A YEAR - due to prescription drug abuse.


Is cutting $500,000 of "wasteful" spending is worth more than all of the above listed adverse impacts of substance abuse and diversion?
Isn't it penny wise and pond foolish to close the Office of Drug Control? Shouldn't such decisions be based on recommendation made as the result of a careful review process involving experts?

I am certain that closing the Office of Drug Control will have a significant adverse impact on our efforts to combat and control substance abuse and diversion forcing the allocation of much higher funding of law enforcement to deal with the consequences of a failed policy.



Bernd Wollschlaeger,MD,FAAFP,FASAM
Family Physician& Addiction Specialist

Sunday, December 19, 2010

Medicaid Cuts

Pollice Verso: How State Legislators try to revive an ancient custom

A recent article in Wall Street Journal, Health Studies Cited for Transplant Cuts Put Under the Knife, http://online.wsj.com/article/SB10001424052748703395204576024213729831704.html, highlights the looming issue of cost control.
Faced with skyrocketing healthcare costs, states will be forced to make tough decision on care allocation and coverage.
Arizona already has taken drastic steps to drop Medicaid coverage for some organ transplants as the state tries to plug a $1 billion gap in its health-care budget for next year. The state agency that recommended that Arizona stop paying for transplants of lungs and, for certain patients, hearts and livers, has defended the move by citing studies and figures that it says demonstrate the ineffectiveness of the procedures. But the state agency has gone a step further by selecting studies that proves the point that certain transplants are ineffective. To make its case for cuts, the Arizona agency cited several sets of numbers. In dropping coverage of liver transplants for patients with hepatitis C, the state said liver recipients suffer recurrence of the disease at a rate of 100%. And the state argued that candidates for lung transplants would live just as long with other medical care, citing data from university studies. Several transplant experts, however, point to flaws in the data and the way the state's Medicaid agency, called the Health Care Cost Containment System, has used the figures. Arizona "used data that were outdated or data that made no sense, or they misinterpreted or misrepresented what experts said," says Michael Abecassis, director of Northwestern University's comprehensive transplant center and president of the surgeons group. For lungs, a crux of the state's position was a 1995 study of 49 patients at the University of Washington, 25 of whom received transplants; the rest were waiting at the time of the study. The study concluded that transplant recipients would live half a year longer than those who didn't get a new lung, but the difference wasn't statistically significant—in part because the sample size was so small. Also, researchers didn't wait to track patients' survival, instead extrapolating long-term mortality rates from deaths and sickness in the short run.
So, what’s the solution? States should not be permitted to arbitrarily decide what services can be covered under the states Medicaid program. Instead, they should follow evidence-based data and, most importantly, comparative effectiveness research data.
Otherwise, we will revert to the Pollice verso (thumbs turned) used in ancient Rome by the crowd to indicate if the defeated gladiator should be condemned to death. Soon we do not need gladiators to revive this custom. We just need legislators who will decide the fate of condemned Medicaid recipients.



Saturday, December 18, 2010

Healthcare Facts

An article (Read more: http://www.miamiherald.com/2010/12/17/v-print/1977925/politifactcoms-lie-of-year-government.html#ixzz18WWAFJAz ) published in today's edition of the Miami Herald entitled, PolitiFact Lie of the Year: 'Government takeover of health care', summarizes the falsehoods attributed to the overhaul of America's health insurance system.
PolitiFact editors and reporters have chosen ``government takeover of health care'' as the 2010 Lie of the Year. Uttered by dozens of politicians and leaders within organized medicine, it played an important role in shaping public opinion about the health care plan and was a significant factor in the Democrats' shellacking in the November elections. The Patient Protection and Affordable Care Act, also falsely called "Obama Care", was passed by Congress, and relies largely on the free market:

* Employers will continue to provide health insurance to the majority of Americans through private insurance companies

* Contrary to the claim, more people will get private health coverage. The law sets up ``exchanges'' where private insurers will compete to provide coverage to people who don't have it.

* The government will not seize control of hospitals or nationalize doctors.

* The law does not include the public option, a government-run insurance plan that would have competed with private insurers.

* The law gives tax credits to people who have difficulty affording insurance, so they can buy their coverage from private providers on the exchange. But here too, the approach relies on a free market with regulations, not socialized medicine.

PolitiFact reporters have studied the 906-page bill and interviewed independent health care experts. They concluded it is inaccurate to call the plan a government takeover because it relies largely on the existing system of health coverage provided by employers. It's true that the law does significantly increase government regulation of health insurers. But it is, at its heart, a system that relies on private companies and the free market.
I encourage you to respond accurately to your patient questions regarding this law and impact on their lives and our profession.
Lets remember that facts should rise above cheap talking points and ideological gibberish.


Saturday, December 11, 2010

AMA Efforts Pay Off

Attached you find a recent AMA press release highlighting the important accomplishment of our AMA and other physician groups including the American Academy of Family Physicians to STOP the looming 25% Medicare cut for ONE year . This will protect many physicians practices from financial distress and will maintain and preserve access of seniors to physicians and other healthcare professionals. Now is the time to rally behind our AMA and to join this great organization to continue working on a long-term solution of the flawed physician reimbursement formula.


AMA Outreach Recruiter

AMA: Congress Passes One-Year Delay Of Medicare Physician Cut

Bill Now Moves to President for Signature

For immediate release:
Dec. 9, 2010

Statement attributable to:
Cecil B. Wilson, MD
President, American Medical Association

“The AMA welcomes bipartisan House passage of legislation to stop the Medicare physician payment cut for one year. Stopping the steep 25 percent Medicare cut for one year was vital to preserve seniors’ access to physician care in 2011. Many physicians made clear that this year’s roller coaster ride, caused by five delays of this year’s cut, forced them to make difficult practice changes like limiting the number of Medicare patients they could treat.

“The AMA will be working closely with congressional leadership in the new year to develop a long-term solution to this perennial Medicare problem for seniors and their physicians. This one-year delay comes right as the oldest baby boomers reach age 65, adding urgency to the need for a long-term solution before this demographic tsunami swamps the Medicare program.

“Now that the legislation has passed both the U.S. Senate and House, the bill moves to the President to be signed into law. The AMA thanks bipartisan leaders in both the Senate and House and President Obama for their leadership on this issue to preserve seniors’ health care. The joint efforts of AARP, the military community, AMA and other physician groups helped make this one year delay a reality for patients and their physicians.”


Media contact:
Katherine Hatwell
American Medical Association
(202) 789-7419

Brenda Craine
Director, AMA Media Relations
(202) 789-7447

Follow AMA on Twitter and Facebook.

Wednesday, December 08, 2010

Florida Legislators and Pain Clinics

osted on Wed, Dec. 08, 2010; Miami Herald

State lawmakers must not give `pill mills' a pass

The Dec. 3 editorial, Tallahassee's pill mills, correctly points out how the Republican-dominated state Legislature voted to delay the implementation of tough new pain-clinic regulations.
Consequently, unscrupulous clinic operators and drug dealers in white coats, wrongly called ``doctors,'' can continue to churn out prescriptions for powerful painkillers.
Legislators seem more concerned with ideological correctness and purity than the sobering facts detailed in a report released in June by the Florida Department of Law Enforcement. It indicated that an average of seven Floridians a day die from prescription-drug overdose.

Our lawmakers seem to live in another universe than most of us. In their world, reality has to be adapted to fit political theory. In their world, government regulation can only do harm and never do good. In their world, pain clinics are successful businesses contributing to the overall economy, and more regulations will drive them away from our state.

Legislators forget that the regulations were carefully crafted by Democrats and Republicans to protect Floridians from these unscrupulous businesses.

Now, the proposed rules must be submitted to the Legislature by Feb. 4 to qualify for consideration. Those that don't make it would have to wait until the 2012 legislative session.

I am outraged by this political checkmate and concerned about its adverse impact on public health. This issue is too important to allow politicians to gamble away the lives of Florida residents. We need to return to pragmatism and sound reasoning to address and resolve the problem of prescription-drug abuse in the state. Ideological grandstanding will only worsen the situation. We do not have much time left -- and the clock is ticking.

Bernd Wollschlaeger,MD
North Miami Beach


Read more: http://www.miamiherald.com/2010/12/08/v-print/1963311/state-lawmakers-must-not-give.html#ixzz17a0ATueT

Saturday, December 04, 2010

Pain Clinic Regulations Stalled

Attached some troubling updates regarding the pain clinic regulation issues:

1. A letter to the editor published in the Sun-Sentinel http://articles.sun-sentinel.com/2010-12-03/news/fl-pain-clinics-letter-1203-20101203_1_pain-clinics-prescriptions-for-powerful-painkillers-prescription-drug
2. Article about persistent over dose deaths in Florida http://www.sun-sentinel.com/health/os-deaths-florida-report-20101202,0,1564941.story
3. Medical Board Yanks License of Pediatrician http://www.sun-sentinel.com/health/fl-doctor-discipline-20101203,0,5563711.story
* Several troubling statements taken from the article:
* "On a related matter, a medical board panel decided not to take emergency action to initiate a strict set of pain clinic rules that have been delayed by legislative action. Legislators last month passed a law saying rules with substantial impact on small business cannot take effect until lawmakers give approval. The medical board could have declared the pill mill problem to be an emergency and put the rules into effect, but the panel found no grounds to do so."
* What other grounds do we need to declare an emergency??


Tallahassee's Pill Mills

ttached a stinging editorial published in yesterday's Miami Herald and my response in the form of a letter to the editor.


The Miami Herald
Posted on Fri, Dec. 03, 2010
Tallahassee's pill mills

Lawmakers don't usually side with pill traffickers. But that's what the Florida Legislature unwittingly did during its brief, vengeance-fueled special session last month.

In the lust to override lame-duck Gov. Charlie Crist's vetoes on a handful of bills, the overwhelmingly Republican Legislature passed a law that requires legislative approval for any new government rules that cost more than $1 million over five years.

The law was touted as a measure to help stop the government from imposing excessive restrictions on business. All well and good. But it turns out the measure had a nasty side effect: It also halted the imposition of new regulations on the state's pill mills, which help feed an illegal pill pipeline.

How embarrassing. And predictable.

Lawmakers ignored warnings

Pill mills cause real suffering for addicts and their families, but lawmakers were more interested in the politics of punishing Gov. Crist for leaving the Republican Party than they were on studying what's good for the state and its residents. They ignored warning bells and rushed to pass a new law without understanding its implications.

Two years ago, lawmakers vowed to get serious about regulating pill mills -- after a Miami Herald series of articles spotlighted South Florida as the pill-mill capital of the United States. Doctors at these pain clinics, many in Broward County, served dual roles as pain and addiction specialists. The black market for painkillers in Florida flourished, spawning an epidemic of overdose deaths in Kentucky, Ohio, West Virginia, Tennessee and other states.

The new regulations, which were set to kick in Nov. 28, would have helped to curb some aspects of the abuse, specifying basic standards for pain clinics and surprise inspections each year, among other provisions.

Victims of the pain pill business counted the legislation a victory. And then lawmakers got the bright idea to override Gov. Crist's veto of the rule-making bill.

In his veto, Gov. Crist warned that nearly every rule would have to wait for the Legislature's approval under the new law, a mind-boggling thought given the number of rules that government can propagate. As of right now, there are roughly 600 proposed rules that have yet to take effect. No one knows how many of them now will require final legislative approval.

One, for sure: pill mill regulation.

Little opposition

There were a few voices of dissent amid the cry to override Gov. Crist's veto. Sen. Mike Fasano, R-New Port Richey, voted against the rule-making bill, saying it needed more study. Mr. Fasano was also the sponsor of the pill mill legislation.

Re-imposing the regulations may be delayed until the 2011 legislative session in the spring. The state Board of Medicine will discuss the regulations at its December meeting in Orlando.

For now, until lawmakers fix this unintended consequence of their own haste, the pill pushers win.

© 2010 Miami Herald Media Company. All Rights Reserved.

Read more: http://www.miamiherald.com/2010/12/03/v-print/1954918/tallahassees-pill-mills.html#ixzz176r4uQ3s

An editorial in today's Miami Herald entitled “Tallahassee's pill mills” correctly points out how the Republican dominated legislature voted to delay the implementation of tough new pain clinic regulations. Subsequently, the unscrupulous clinic operators and drug dealers in white coats, wrongly called “doctors,” can continue to churn out prescriptions for powerful painkiller. The legislators seem to be more concerned with ideological correctness and purity than the somber facts detailed in a recent report from the Florida Department of Law Enforcement released June 30th 2010 indicating that an average of seven Floridians per day die from prescription drug overdose! It appears that our legislators seem to live in another universe than most of us have to live in. In their world reality has to be adapted to fit political theory. In their world government regulation can only do harm and never do good. In their world pain clinics are successful businesses contributing to the overall economy and more regulations will drive them away from our state. They seem to forget that the regulations were carefully crafted by Democrats and Republicans to PROTECT our citizens from those unscrupulous businesses, which contribute to the DEATH of seven Floridians a day!! Now, the proposed rules must be submitted to the Legislature by Feb. 4 to qualify for consideration. Those that don't make it would have to wait until the 2012 legislative session. I am not only outraged by this political checkmate but also deeply concerned about its adverse impact on public health. This issue is too important to allow politicians to gamble away the lives of Florida’s citizen. We need to return to pragmatism and sound reasoning to address and resolve the problem of prescription drug abuse in Florida. Ideological grandstanding will only worsen the situation. We do not have much time left and the clock is ticking.

Bernd Wollschlaeger,MD,FAAFP,FASAM

Board certified Family Physicians & Addiction Specialist

16899 NE 15th Avenue, North Miami Beach,FL 33162 Phone: (305) 940-8717

E-mail: info@miamihealth.com

Member of the Prescription Drug Monitoring Implementation and Oversight Task Force