Cheaper or Better Care

I hope that you are all doing well and have " survived " Thanksgiving. Well, I have another turkey for your to digest. According to the attached article published in HEALTH AFFAIRS (November 2013 vol. 32 no. 11 1977-1984) titled "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics" in which the authors claim that the elimination of restrictions on NPs’ scope of practice could have a large impact on the cost savings that can be achieved by retail clinics. Using multistate insurance claims data from 2004–07, a period in which many retail clinics opened, the authors analyzed whether the cost per episode associated with the use of retail clinics was lower in states where NPs are allowed to practice independently and to prescribe independently. They also examined whether retail clinic use and scope of practice were associated with emergency department visits and hospitalizations. The authors found that visits to retail clinics were associated with lower costs per episode, compared to episodes of care that did not begin with a retail clinic visit, and the costs were even lower when NPs practiced independently. We have to be prepared to counter these arguments by pinpointing the interface of quality and costs of care and that family physicians have the experience to achieve BOTH. Focusing on costs alone may have a detrimental effect on the quality of care rendered. Yours Bernd Happy Chanukkah to those who celebrate the Jewish holiday.

Medical Marijuana

In today's Miami Herald Paula Dockery argues in favor of legalizing marijuana for medical purposes stating that " legislative leaders refuse to consider the use of medical marijuana despite the growing body of medical evidence as to its beneficial use." She further emphasizes that medical marijuana has many uses and clinical indications and that legalization would provide access to treatment for those suffering from debilitating diseases. But her arguments are based on inflated claims and not facts. Yes, one can find clinical trials using cannabinoid extracts to treat pain and spasticity in multiple sclerosis and to improve nausea in patients undergoing radiation treatment BUT these trials are limited and rely on standardized dosages of cannabinoid extracts which the inhaled delivery of marijuana often cannot provide! There is no growing body of medical evidence as to medical marijuana beneficial effects and I favor clinical research initiatives to further investigate these claims. Meanwhile, the supporters of medical marijuana are deluding the public with premature and even false medical claims. I can only speculate that the prospects of huge profits from the sale of medical marijuana drive these initiatives. But in the end who will pay for the treatment of those who need help to treat their marijuana addiction? Are we again privatizing profits and leaving the cleanup of the mess for the taxpayer to pay for?

Health Department Bars Insurance Aids

The Miami Herald reported on September 11th 2013 that Florida government officials created another hurdle to the new health insurance marketplace, which opens in Florida on Oct. 1. Citing "privacy concerns" health department officials explicitly prohibit outreach workers known as navigators to assist and support eligible Floridians to sign up for health insurance. The order from Deputy Health Secretary C. Meade Grigg went out late Monday to the 60 local health department directors across the state emphasizing that the outreach workers intend to collect consumer information that will be gathered for use in a federal database which is, according to the underlying "thought process" of the health department officials, inherently unsafe. Health and Human Services Department spokesman Fabien Levy called the Florida directive “another blatant and shameful attempt to intimidate groups who will be working to inform Americans about their new health insurance options and help them enroll in coverage, just like Medicare counselors have been doing for years.” In a Miami Herald editorial titled " Rubbing salt into the wound" the authors characterized the state officials action as "outrageous and spiteful" and emphasized that this " will not prevent those who need help with healthcare insurance from getting it, but it will make it harder for them to do so. It represents a unilateral and shameful denial of service by the state to its own citizens." Furthermore, the editorial pointed out that "it strains credulity to believe that privacy is a practical concern. In the first place, virtually all Americans — anyone who contributes to Social Security, pays taxes to the IRS, is a veteran of the armed forces or otherwise has any contact with the federal government — is already in a federal database of one sort or another without privacy becoming a serious concern." Florida state officials also seem to ignore that U.S. Health and Human Services officials have stated unequivocally that “consumers will never be asked to provide their personal health information to the (insurance) Marketplace, whether through a Navigator or not.” This shameful action taken by the Florida government is intended to sacrifice the health and well being ( maybe even lives) of almost 4 million uninsured Floridians on the altar of ideological purity. If health department officials still have a conscience then they should resign in protest. Otherwise, they are nothing but spineless bureaucrats working for a government which ignores the needs and rights of its own citizen. Shame on you!! Yours Bernd

Does Fear Drive Defensive Medicine?

A recent study published in the journal Health Affairs revealed that whether a physician practices defensive medicine may depend more on a doctor’s fear of being sued than the level of noneconomic damages caps and insurance premiums in that physician’s state. The research was conducted by the Center for Studying Health System Change, a policy research organization, examined responses from 3,469 physicians to questions about how concerned they were about medical liability lawsuits in the center’s 2008 Health Tracking Physician Survey. Then they compared the physicians’ concerns with actual Medicare claims for more than 1.9 million patients who came to their offices with headaches, chest pain or lower back pain from 2007 to 2009. Physicians who reported a high level of malpractice concern were most likely to engage in practices that would be considered defensive when diagnosing patients who visited their offices with new complaints of chest pain, headache, or lower back pain. Of the conditions studied, chest pain was the most common (n = 12,161), followed by lower back pain (n = 10,109) and headache (n = 6809). For patients with headache, the likelihood that a medium-concern physician would order advanced imaging was 8.5% compared with 6.4% for a low-concern physician (P ≤ .05). Similarly, the likelihood a high-concern physician would order advanced imaging was 11.5% (P ≤ .05 compared with physicians at both the low- and medium-concern levels). Similarly, if the patient had low back pain, the likelihood was 22.4% that a physician with a medium degree of concern would order conventional imaging compared with 17.6% for low-concern physicians (P ≤ .05) and 29.0% for high-concern physicians (P ≤ .05 when compared with physicians with low or medium levels of concern). High-concern physicians were also significantly more likely than low-concern physicians to order advanced imaging (6.1% vs 4.1%; P ≤ .05; no significant difference was seen for physicians with a medium degree of concern). However, there was a 1.6% likelihood that medium-concern physicians would order a trip to the ED compared with 1.0% for low-concern physicians (P ≤ 05) and 1.4% for high-concern physicians (difference not significant). The authors suggested that reducing defensive medicine may require approaches focused on physicians’ perceptions of legal risk and the underlying factors driving those perceptions. In my opinion we also should provide physicians the tools to provide defensible medicine by utilizing patient encounter documentation templates, evidence based treatment approaches and patient-centered outcome guidelines. All of these components are part of the Affordable Care Act and should be translated into practice sooner than later. Yours Bernd

Medicare Myth

"The reports of my death are greatly exaggerated." Mark Twain Critics of the Medicare program often allege that the restrictive Medicare regulations and bare-bone reimbursements are causing a rising number of doctors to refuse to serve Medicare patients.According to a recent editorial in the NYT "In the critics’ most dire scenarios, baby boomers nearing retirement age could find that their current doctors are no longer willing to treat them under Medicare and that other doctors are turning them down as well." But is this true? A recent analysis by experts at the Department of Health and Human Services finally debunked this myth! The analysts looked at seven years of federal survey data and found that doctors are not fleeing Medicare in droves; in fact, the percentage of doctors accepting new Medicare patients actually rose to 90.7 percent in 2012 from 87.9 percent in 2005. They are not shunning Medicare patients for better-paying private patients, either; the percentage of doctors accepting new Medicare patients in recent years was slightly higher than the percentage accepting new privately insured patients. Still, a small number of doctors have dropped out of the Medicare program. Roughly 9,500 practicing doctors have currently opted out of Medicare, according to the Centers for Medicare and Medicaid Services but the number of doctors opting out is tiny compared with the number of doctors, 735,000, who remain in Medicare. These findings should encourage us to work even closer with Medicare, to participate in quality improvements and pay-for-performance initiatives to reduce healthcare costs and to maintain this valuable program which provides essential healthcare for 16% of US citizens. Yours Bernd

Prescription Drug Monitoring Program Under Attack

The Florida Prescription Drug Monitoring Program is under attack. Launched in 2011 to track controlled substance prescribing, the database was designed to shut down pill mills and stop doctor shopping. According to Attorney General Pam Bondi the database is an important tool against drug abuse and that prescription drug-related deaths have declined for the first time in nearly a decade. But according to a law suit filed in Volusia county the Florida's prescription drug monitoring database program violates the state's constitution, invades the privacy of residents and subjects them to unreasonable searches. The constitutional challenge is part of a growing legal battle over how the State Attorney's Office for the 7th Judicial Circuit wound up with the prescription records for an estimated 3,300 residents and why that information was provided to five of six defense attorneys representing defendants related to a prescription fraud investigation. The American Civil Liberties Union said this week it could file federal complaints with the Department of Justice and the Department of Health and Human Services related to the disclosure of the prescription information. As a physician, supporter and PDMP user I submitted a letter to the editor to the Miami Herald which was published on 07/15/2013 pointing out that it was the illegal use of data obtained by an attorney which triggered this debate and that the PDMP does NOT violate patient privacy. I wholeheartedly agree with State Attorney Pam Bondi that "there are strong safeguards in place to protect people's prescription drug information within the Prescription Drug Monitoring Program by limiting access to that information, and those safeguards have not been compromised." These facts should be taken into consideration before attempting to dismantling the PDMP which is an essential tool to safe lives and protect the public from prescription opioid abuse and diversion. Yours Bernd

PDMP on Life Support

Attached a link to an article published in today’s Miami Herald titled “Statewide pain-clinic database may be abolished” focusing on efforts to shut down the Prescription Drug Monitoring Program (PDMP)in Florida. On Monday, the Florida Department of Health will hold a workshop in Tallahassee to discuss further limiting access to records of who writes and fills prescriptions for the most addictive drugs. The meeting comes in response to allegations last month that medical data for 3,300 Floridians had been “leaked.” The American Civil Liberties Union of Florida demanded a federal investigation, and critics pointed to the incident as evidence that the system was fundamentally flawed and had allowed an inevitable breach of privacy. It also proved a rare point of agreement between the ACLU and conservative lawmakers who have opposed the database for years, even as Florida gained a reputation as ground zero of a deadly prescription drug abuse epidemic. “I think this leak by the PDMP proves it is a risk for patients,” said state Rep. Rob Schenck, R-Spring Hill. “We should do away with the whole database.” But the leak is not due to a design flaw of the PDMP but the inappropriate use and misuse of data downloaded from the database. In this case a DEA agent queried the program for names of the doctors’ patients and got about 3,300 in return. That request led to six arrests, seven people whose identities had been stolen and 63 fake names used to get fraudulent prescriptions. The names of all those patients, including those not under investigation, were provided on computer discs to prosecutors and to the defense attorneys of those charged. They included clear warnings that the records were confidential. But one of those defense attorneys recognized a name on the disc — fellow lawyer Michael Lambert — and gave him a copy of all the names, despite the confidentiality warning. Lambert filed a lawsuit, alleging that law enforcement should never have received information about innocent patients. He demanded an injunction and asked the court to determine if the program is “an unconstitutional infringement upon the fundamental rights of the plaintiff and other Florida citizens.” In a subsequent complaint to the U.S. Department of Health and Human Services, the ACLU of Florida echoed Lambert’s objections. But no one asked an obvious question: was the “leak” made by the agent who included the names on the disc, or by the attorney who gave the disc to Lambert? As a result of this data leak Florida legislators and the ACLU are calling for the dismantling of the PDMP. Would Florida lawmakers also call for the dismantling of the electronic banking system because bank employees have access to financial data and some may even abuse this privilege? Lets not forget that the program is already on life support receiving a measly $500,000 annual funding out of a $74 billion budget, which was only granted in the final night of the 2013 session. In my professional experience the PDMP provides for accountability and transparency in the prescribing process for controlled substances. In my medical practice I identified at least a dozen patients who received controlled substances from several physicians and NONE of those colleagues were aware of it. Several of those prescriptions, if not identified, could have triggered accidental overdose and death. Instead of dismantling the system we should expand the program, fund an awareness campaign to educate physicians on how to use the program and to increase security measures to ascertain patient privacy. Now is not the time for rash decisions but rational thought and measured decision making. Lets not throw out the baby with the bath water. The PDMP save lives! Yours Bernd

Healthcare Law Implementation Delayed

In a stunning move the Obama administration announced today to delay, until 2015, the healthcare law's mandate that larger employers provide coverage for their employees or pay penalties. But by delaying the mandate for businesses and it reporting requirements, the government will be unable to confirm before 2015 whether employers are offering insurance to their employees. Therefore, for officials running the exchanges it will be almost impossible to know in advance who is entitled to subsidies if employers do not report information on the coverage they provide to workers. In my opinion this move is a mistake and a major setback in our efforts to provide insurance for the millions of uninsured Americans and to offer physicians the opportunity to get reimbursed for the medical services they already provide for many of those who can't pay. Yours Bernd

Florida Gun Laws and the Absence of Common Sense

Gov. Rick Scott signed a gun control bill Friday to close a loophole in firearm sales to some mentally ill people. According to the press release "Mental health and second amendment advocates worked together to produce this bill that does not affect persons voluntarily seeking mental health exams or treatments but rather closes a loophole in current law that could potentially put firearms in the hands of dangerous, mentally ill individuals who are a threat to themselves or others as determined by a court." The bill addresses a gap in Florida law that has allowed people who voluntarily commit themselves to a mental institution to buy a gun once they are released. The new law requires that before agreeing to voluntary treatment under the state’s Baker Act, individuals receive written notice that if treated, they may be prohibited from buying a gun or “applying for or retaining a concealed weapons or firearms license” while they’re deemed a danger to themselves or others. Their names are then added to a national data base that informs retailers of people prohibited from buying a gun. People who are involuntarily committed are already added to that list. A judge and a physician have to concur that an individual is no longer a danger to themselves or others to have their name taken off the national database. Scott said that since 2002, "just under 100,000 individuals have been disqualified from purchasing a firearm based on court adjudications of mentally defective or mental commitments." I applaud the Governor to his sudden realization and insight that " common sense parameters balance the rights of individuals to purchase firearms with society's reasonable expectation of public safety." I hope that he will apply the same parameters to allow physicians asking their patients if they store their guns safely to avoid an accidental shooting death within the confines of their home and family. Meanwhile, he continues to litigate in federal court seeking to prevent physicians asking their patients these common sense question. Yours Bernd

Big Profits (Again) For Florida's HMOs

According to an article published in the South Florida Business Journal titled "Commercial HMOs report healthy profit margins" , the commercial business lines of Florida HMOs had a combined profit margin of 4.1 percent in 2012, down from 4.2 percent in 2011. That was still the second-highest profit margin of the past five years. Some health plans were more profitable than others with United Healthcare leading the way at 10.8 percent. Let's not forget that despite these gains the real money in HMOs isn't on the commercial side, but in Medicare Advantage plans.In this market Florida's Medicare HMOs had a combined profit margin of 8 percent in 2012, up from 7.4 percent in 2011. This SHOULD trigger a debate in Congress over whether Medicare HMOs are overpaid and WHY physicians are receiving a shrinking share of this profit pie. What do you think? Yours Bernd

Healthcare in Florida

In healthcare there seem to exist two parallel universes:the one for normal earthlings crushed by 30% health insurance premium increases and the one for our politicians who pay peanuts for their own insurance. For example, Florida House members will pay just $8.34 a month for state-subsidized health care next year, or $30 a month to cover their entire family. That’s one-sixth of what state senators and most state employees will pay, and one-tenth of the cost to the average private-sector worker, according to the Kaiser Family Foundation. It’s also less than the $25 a month House Republicans wanted to charge poor Floridians for basic coverage such as a limited number of doctor visits or preventive care. Unless we enjoy living in a parallel universe we should NOT let them get away with it!!! Yours Bernd

Insurance Rate Increases

Blue Cross and Blue Shield of Florida (aka Florida Blue) has obtained the approval for a rate increase for several of their individual health insurance policies including BlueOptions-PPO-Individual-16842FL007, MyBasic NetworkBlue-PPO-Individual-16842FL008, BlueChoice-PPO-Individual-16842FL009, BlueSelect-EPO-Individual-16842FL012 and MyBasic BlueSelect-EPO-Individual-16842FL013. According to their web site the average increase will be 15.32% effective July 1st, 2013 and will affect 264,850 people. As a Florida Blue customer my rate increased almost 30% ! The reasons driving the dramatic premium increase include a 189.37% increase in costs for inpatient care compared to a 111.07% increase in outpatient care. It's of interest to note that the current Medical Cost Adjustment - the difference between what the insurer thought it was going to pay for medical services and what it actually paid during the current year - DECREASED by 466.64%! For the final rate determination the Florida Insurance Code requires that all individual and small group carriers obtain approval of their premium rates from the Office of Insurance Regulation (OIR). In addition, the Patient Protection and Affordable Care Act, otherwise known as Health Care Reform, requires that all weighted average rate increases in the individual and small group markets that exceed a stipulated threshold (currently 10%), must be assessed to determine if they are "reasonable". For individual and small group carriers issuing coverage in the state of Florida, the federal enforcement agency for the Patient Protection and Affordable Care Act, Health and Human Services (HHS), has delegated the authority to determine if rate increases are reasonable to the OIR. According to the OIR all Florida Blue's rate increases for individual and small group products either do not exceed the threshold, or have been determined to be "reasonable." Anyone who has received his/her new premium notice might have to get used to the new definition for "reasonable" rate increase. Its probably listed in the alternative Wikipedia published by the healthcare industrial complex which pays our politicians and corrupts our public life. Yours Bernd

Stop Medicare Fraud

I applaud the efforts of the Miami Herald Editorial Board to refocus our collective attention on the out-of-control Medicare fraud in South Florida. Several former and current leaders of organized medicine in Florida have attempted to address and resolve this problem only to find themselves rebuffed by a wall of silence, feigned commitment to seek solutions, or refusal to accept responsibility. During my tenure as President of the Dade County Medical Association I traveled to Jacksonville to meet with the leadership of First Coast Service Option, advertised as " one of the nation’s largest Medicare administrators for more than 45 years, and is the current Medicare Administrative Contractor (MAC) for Jurisdiction 9 (J9), which includes Puerto Rico, the U.S. Virgin Islands and Florida." Once I "dared" to raise the issue of accountability and transparency for the (in)action in regards to Medicare fraud and contacted Senator Nelson, I was reminded that my public position could be interpreted as defaming their business and might trigger legal action. Needless to say that I had to back off. Why does nobody hold Medicare contractors such as FCSO accountable for their inability to stop blatant Medicare fraud? Why do honest providers toil under intense scrutiny, whereas others gain outsize profit with brazen abuse? Until we are addressing those issues nothing will change. Yours Bernd

Hospital Hiring on Hold

Attached an article titled " Rare drop in healthcare hiring brings Miami-Dade its slowest job growth in three years" which highlights the dependence of the healthcare industry on (ir)rational political decisions made in Tallahassee and Washington. Small business owners like me and hospital executives have to pay attention to the grinding stalemate resulting from the ideological rigidity of our Florida legislature. The refusal to reach ANY decision regarding the Medicaid expansion and acceptance of federal money borders not only on legislative malpractice but essentially forces healthcare business leaders to put hiring decisions on hold. Hospitals, which are the largest employers in South Florida, expected that with the Medicaid expansion the numbers of uninsured would drop, thereby decreasing the costly treatment of uninsured in emergency room. But by providing health insurance for more people through Medicaid and other programs, including the requirement that everyone obtain health insurance, there should be less need for federal government payments under the “Disproportionate Share Hospital” (DSH) program. DSH payments are made to hospitals that serve a high number of patients without health insurance as well as a high number of Medicaid patients. Starting in 2014, the government will reduce total DSH allotments by $0.5 billion, and that reduction will increase to $4 billion per year by 2020. But without Medicaid expansion and facing diminishing DHS payments hospitals have no other choice but to defer scheduled workforce expansion. Small business owners like me also expected to see increased Medicaid payments for primary care physicians and an expansion of their insured patient base. Now, I will wait and see and I definitely won't hire new staff. Meanwhile, in Tallahassee, our legislators appear to live in splendid isolation from the real world. They seem to be more concerned about ideological correctness than solving problems that affect all of us. Yours Bernd

Medicare Fraud

Attached a link to an interesting article published in today's Miami Herald titled " Miami actor, cable station founder arrested in Medicare fraud takedown" highlighting the audacious Medicare fraud activities in South Florida. As a Medicare provider I still don't get it how Medicare works.Whereas I am being scrutinized to justify each and every meagerly claim, asked to submit medical records and evidence for care rendered, the fraudsters are getting away with millions. Why did Medicare(i.e. First Coast) pay millions of dollars without questioning the sudden spike of claims? How is that possible? Who is accountable for these transactions? Shouldn't financial institutions notify the authorities when suddenly millions of dollars appear on newly opened business accounts? How many doctors were paid to refer patients? Who credentialed those fraudulent providers? After so many years of continuous and outrageous Medicare fraud we still haven't learned how to fight these fraudsters. I witness this ongoing fraud with clenched fists in my pocket and growing anger and frustration in my belly. Yours Bernd

The Gun Lobby Target Doctors

The gun lobby paranoia seems to have infected all branches of our government, but even I am surprised how far politicians are willing to go to please their NRA sponsors. In today's Miami Herald an article titled " Medical liability bill gets snagged by gun concerns" highlights such an example. According to the article a Senate priority bill to limit the liability of Florida doctors ran into trouble in the House on Monday when opponents suggested that it could be used by insurance companies who represent the doctors to create a private registry of gun owners. The bill, HB 827, would deal with what are known as “ex parte communications” in malpractice cases and would allow lawyers for doctors hit with a malpractice claim to interview any other doctor about a patient’s health record in private. Rep. James Grant, R-Tampa, believes that the provision could open the door to lawyers asking doctors about the gun-toting habits of their patients and, over time, use that information to build a database of gun owners who could be charged higher insurance rates. Grant filed an amendment to the bill Monday that would prohibit doctors from revealing any information about a patient’s gun ownership, as well as any history of child abuse, sexual abuse, substance abuse, mental health and reproductive history unless the patient’s lawyer is present. Just to make sure that we understand this mind-boggling political acrobatic: Rep Grant BELIEVES that insurance companies will mine these records to essentially eliminate potential risky clients, especially gun owners, who then would be charged higher insurance rates. Therefore, according to his amendment, doctors would be prohibited from collecting and revealing such information, unless the patient's lawyer is present. Sounds reasonable? Well, probably in the mind of those who believe that the government is trying to disarm Americans by buying ammunition in large amounts, or those who believe in black helicopters following their every move etc. What is more troubling that those "freedom fighters" are willing to gag doctors and force them to sanitize their medical records in order to please their NRA masters. Why do we vote for these NRA stooges? What happened to our individual freedom from interference in our lives and professions? Its time to expose these so-called politicians as willing executioners of the NRA. Yours Bernd

Health Data Leaks

Attached an article published in the recent edition of the South Florida Business Journal titled " Breached: Health data security has sprung an expensive leak" highlighting the connection between the increasing identity theft and tax fraud in South Florida with the "leaky security" at healthcare facilities. Identify thieves and tax fraudsters are often purchasing patient data from employees in the healthcare services sector which are then being misused for fraudulent tax filings costing the federal government $5 Billion last year. As physicians we have to be part of the prevention and cure of this problem. Therefore, I do not collect social security numbers anymore in my office and safe all sensitive patient data on a secured server. Once I enroll a new patient into my practice my EHR creates an internal ID for identification purposes eliminating the need for recording the social security number. Unfortunately, Medicare is still imprinting the identification cards with the recipient social security number. This should be replaced with a tracking number which then has to be verified through a secured server accessible only by registered providers of healthcare services. This of course will not eliminate the human factor and the susceptibility for financial bribes and other incentives. But we must start today to stop identity theft. Breached: Health data security has sprung an expensive leak Brian Bandell Senior Reporter- South Florida Business Journal South Florida’s identity theft and tax fraud epidemic is often tied to leaky security at medical providers that fail to safeguard patient records. Fraudulent tax filings cost the federal government $5 billion last year, and South Florida is epicenter for this scam, said Wifredo A. Ferrer, U.S. attorney for the Southern District of Florida. Criminals could not file fraudulent returns without easy access to victims’ personal information. The identity thieves, often former street criminals, are willing to pay hundreds of dollars for each Social Security number, he said. The masterminds have “filing parties” where they teach others to do fraudulent returns in exchange for a cut, Ferrer said. “Hundreds of thousands of people go to hospitals and, if you have someone inside willing to sell your information for a couple hundred dollars, that will happen.” In the past few years, employees of Jackson Healthcare System, Memorial Healthcare System, Mount Sinai Medical Center, Boca Raton Regional Hospital and the Palm Beach County Health Department have been charged with stealing patient data to aid fraud schemes. Many other defendants worked for smaller local medical offices. In other cases, health care providers had data stolen or hacked by outsiders, Ferrer said. While his office is working hard to find criminals by tracking the IP addresses used to file bogus returns and the flow of stolen tax dollars, Ferrer is urging hospitals and doctor offices to secure the information. The U.S. Department of Health and Human Services requires health care providers and insurers to report data breaches affecting more than 500 patients and post it on the HHS website. Since this began in 2009, there have been 17 data breaches affecting 1.44 million people at health organizations serving South Florida. The largest breach was at Miami-based AvMed Health Plans, with 1.22 million records leaked from stolen laptops, which led to a lawsuit from its members. Still a problem 17 years after HIPAA Medical records were supposed to be safeguarded by the Health Insurance Portability and Accountability Act (HIPAA), which passed in 1996, but apparently, many providers still haven’t plugged the leaks. “This will keep happening because many health care companies don’t have good internal controls, don’t have physical controls to prevent them from walking out with records and don’t have proper security awareness and training for employees,” said Silka Gonzalez, president of Miami-based Enterprise Risk Management, which helps companies with data security. Banks take a more aggressive approach to data security because regulators have been tough on them, but the health care industry hasn’t been under as much pressure, Gonzalez said. They’re more interested in investing in patient care than data security. “If some hospitals are far from having the best security possible, forget about small practices,” Gonzalez said. “They won’t have any security in many cases.” The government is trying to show that HIPAA compliance is serious, but so few doctors have been fined over the years that the chances of getting penalized are pretty slim, said Luis Salazar, a partner with Miami-based Salazar Jackson, which has a data privacy law practice. Salazar said he was a victim of tax fraud, but he was able to sort it out fairly quickly and file his tax return. “Most people realize they are victims in the first three or four months, but 20 or 25 percent don’t catch onto it for three or four years,” Salazar said. The Social Security number should only be available during billing and intake, but Salazar has seen hospitals that have multiple terminals with patient information available to all employees. In response to the data theft by its former employee, Boca Raton Regional Hospital enhanced its security to block out full Social Security numbers from patient records, conduct random workspace audits of records security and additional employee training on HIPAA, spokesman Thomas Chakurda said. Electronic records make theft easier The push to use electronic medical records had the unintended consequence of making data theft more efficient, said Alan Brill, senior managing director for New York-based Kroll Advisory Solutions. “If you want to steal 5,000 sets of identity, it might take days to copy it from physical files, and someone might notice,” Brill said. “Now it’s on a computer and it may be no more difficult than putting in a USB key or staying late and printing things.” Brill worked a case where a hospital technician replaced a backup DVD with a blank DVD, copied the entire set of patient records and made counterfeit credit cards. Two Palm Beach County Health Department employees were arrested in February for stealing more than 2,800 patient records for a tax fraud scheme. PBCHD spokesman Tim O’Connor said the employees, who worked in the medical records department, targeted patients born between 1991 and 1996 because they could claim the youngsters were dependent on their parents and claim a big refund. The health department has since put safeguards in place – such as replacing Social Security numbers with independent patient numbers, O’Connor said. Only financial counselors will have access to Social Security numbers, he added. Miami attorney Mark A. Dresnick, who represents health care providers in HIPAA cases, said he would not give providers his Social Security number unless there is a valid reason because he doesn’t want it stolen. “My suspicion is that a lot of the tax fraud is coming from doctor offices due to theft of Social Security numbers by receptionists and clerical staff,” Dresnick said. HHS has become tougher with penalties and has targeted smaller providers, Dresnick said. In Massachusetts, an ear and eye clinic was fined $1.5 million after a data breach. Dresnick said regulators would be less forgiving of medical offices that ignore HIPAA training for employees and don’t take sufficient steps to secure data. HIPAA expands beyond health providers A new rule expanded HIPAA compliance for patient record security to companies that provide services to the industry. Jorge Rey, associate principal and director of information security and compliance at accounting firm Kaufman, Rossin & Co., said this includes consultants, medical records storage companies, law firms, collection agencies. If there is a data breach or lax security, they could face monetary penalties, he added. Brill added: “You’re not a security company, yet you have the responsibility for doing the right thing.”

The New Prescription Abuse Epidemic

Attached you find a link to an important article published in today's New York Times titled "A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise" highlighting the staggering increase in ADHD diagnosis and related stimulant prescription use. Nearly one in five high school age boys in the United States and 11 percent of school-age children over all have received a medical diagnosis of attention deficit hyperactivity disorder, according to new data from the federal Centers for Disease Control and Prevention. The figures showed that an estimated 6.4 million children ages 4 through 17 had received an A.D.H.D. diagnosis at some point in their lives, a 16 percent increase since 2007 and a 53 percent rise in the past decade. About two-thirds of those with a current diagnosis receive prescriptions for stimulants like Ritalin or Adderall, which can drastically improve the lives of those with A.D.H.D. but can also lead to addiction, anxiety and occasionally psychosis. About one in 10 high-school boys currently takes A.D.H.D. medication, the data showed. Sales of stimulants to treat A.D.H.D. have more than doubled to $9 billion in 2012 from $4 billion in 2007, according to the health care information company IMS Health.Even more teenagers are likely to be prescribed medication in the near future because the American Psychiatric Association plans to change the definition of A.D.H.D. to allow more people to receive the diagnosis and treatment. The question remains: are millions of children receiving medication merely to calm behavior or to do better in school? We also should be aware that those medications are often NOT taken as prescribed, shared with or sold to classmates, contributing to diversion long tolerated in college settings and also gaining traction in high-achieving high schools. The C.D.C. director, Dr. Thomas R. Frieden, likened the rising rates of stimulant prescriptions among children to the overuse of pain medications and antibiotics in adults.“We need to ensure balance,” Dr. Frieden said. “The right medications for A.D.H.D., given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate.” “There’s no way that one in five high-school boys has A.D.H.D.,” said James Swanson, a professor of psychiatry at Florida International University and one of the primary A.D.H.D. researchers in the last 20 years. “If we start treating children who do not have the disorder with stimulants, a certain percentage are going to have problems that are predictable — some of them are going to end up with abuse and dependence. And with all those pills around, how much of that actually goes to friends? Some studies have said it’s about 30 percent.” As physcians we should stop giving in to parents and patients pressures to prescribe these stimulants indiscriminately. We must refocus our efforts on proper and evidence based ADHD diagnosis, demand special training of stimulant prescribers and tracking of stimulant prescriptions. Otherwise, we will force the federal government to step in with tighter regulations.

Medicaid Robber Barons

The Governors support for Medicaid expansion in Florida is a positive development but no done deal. The Florida House and Senate will have to reconcile their different political and ideological views regarding this issue. Meanwhile, Florida also won its request from the federal government for a waiver granting a statewide expansion of the Medicaid Managed Care Program. That means that Medicaid recipients will be coerced to join managed care companies which will receive state and federal funding to run the Medicaid program. Unfortunately, this is not only bad news for Floridians who will now routinely experience service denials and rationing of care but even worse news for participating doctors and other healthcare providers. Already primary care physicians receive reimbursements as low as $15 per patient to care for complicated chronic diseases and are being forced to manage those patients 24/7. These sweat shop conditions are being condoned by Florida Legislators who only consider the bottom-line: cheaper is better. Who is implementing and monitoring the necessary accountability and transparency measures to curtail managed care abuses? In the end we will create a new robber baron class: managed care company executive who are being showered with billions of federal dollars. Physicians and patients will be the recipients of trickle down healthcare economics. Who cares?

Medicaid expansion

According to a recent FAFP (Florida Academy of Family Physicians) communication AHCA has informed the FAFP that the logistics for increasing Medicaid rates to Medicare levels will most likely not be completed until sometime in April, yet confirmed that retroactive payments will be made to make up the increases due for services billed between January 1 and implementation. One of several complicating factors is deciding how payments will be made to the managed care companies and then passed through to the physicians. That's an important issue because I just received a contract asking me to join the Preferred Medical Plan as a provider offering $15 reimbursement per Medicaid patient! I guess the private insurance companies will benefit greatly from the Medicaid expansion and the "increased" reimbursement for physician will follow the trickle down economics model. So who will gain from the federal subsidies? The private corporations and NOT the patients nor the physicians. Again, privatizing the profits and socializing the risk! Nothing changes!! Yours Bernd

Gun Violence Prevention

Attached a link to an interesting article titled "Gun violence research, policies need physician voice" in which the author highlights five strategies outlined by Frattaroli and UC Davis physician Garen Wintemute emphasizing the physician's role in gun violence prevention. " The doctor is a clinician, in which he or she can ensure mental health treatment is available to prevent suicide gun deaths and support policies limiting gun purchases to at-risk individuals. The doctor also plays a role in managing fear; as a researcher, helping ensure money is appropriated for violence prevention research; and as a policy advocate, where physicians can be heard together to influence Congress in new policies. Lastly, the physician plays a role as a leader." We should use these arguments when responding to those who question that physicians can play any role in gun violence prevention. Its our social responsibility to contribute our time and efforts to protect our communities from senseless gun violence and to promote gun safety initiatives. Yours Bernd

The Anti-Aging Myth

Attached a link to an interesting article published in today's Miami Herald highlighting the proliferation of so-called anti-aging clinics in South Florida whose unscrupulous operators are peddling steroids and growth hormones. I also recommend reading the excellent commentary by Fred Grimm. I hope that my fellow colleagues will join me in the effort to curtail the (ab)use of steroids and growth hormone products which can have serious and detrimental health effects. We should point out those so-called "doctors" who are profiting from promoting the use of steroids for muscle-building and human growth hormone (hGH). We should make it clear to those "doctors" that federal law prohibits the use of such substances except for rare circumstances such as growth retardation. Instead, those "doctors" are promoting the use of human growth hormone therapy to treat patients suffering from low energy, increased fat or a slowing sex drive. Now is time to act and to speak up. Yours Bernd

Gun Safety

Attached a link to an article titled " The Pediatricians vs. the NRA" published on slate.com. We need to continue pushing for the implementation of common-sense gun safety measures and doctors play an important role to communicate this issue with their patients. Yours Bernd VISIT MY NEW WEB SITE AT www.bwollschlaeger.com

Lawmakers,Drugs,Money and the Taxpayer

Attached an article titled "Fiscal Footnote: Big Senate Gift to Drug Maker" reporting that key Senate lawmakers inserted a paragraph into Section 632 of the “fiscal cliff” bill which essentially delays a set of Medicare price restraints on a class of drugs that includes Sensipar, a lucrative Amgen pill used by kidney dialysis patients. The provision gives Amgen an additional two years to sell Sensipar without government controls which is projected to cost Medicare, or better the tax payer, up to $500 million over that period. Amgen, which has a small army of 74 lobbyists in the capital, was the only company to argue aggressively for the delay. Amgen’s success also shows that even a significant federal criminal investigation may pose little threat to a company’s influence on Capitol Hill. On Dec. 19, as Congressional negotiations over the fiscal bill reached a frenzy, Amgen pleaded guilty to marketing one of its anti-anemia drugs, Aranesp, illegally. It agreed to pay criminal and civil penalties totaling $762 million, a record settlement for a biotechnology company, according to the Justice Department. Amgen’s employees and political action committee have distributed nearly $5 million in contributions to political candidates and committees since 2007, including $67,750 to Mr. Baucus, the Finance Committee chairman, and $59,000 to Mr. Hatch, the committee’s ranking Republican. They gave an additional $73,000 to Mr. Mitch McConnell, some of it at a fund-raising event for him that it helped sponsor in December while the debate over the fiscal legislation was under way. More than $141,000 has also gone from Amgen employees to President Obama’s campaigns.In some cases, the company’s former employees have found important posts inside the Capitol. They include Dan Todd, one of Mr. Hatch’s top Finance Committee staff members on health and Medicare policy, who worked as a health policy analyst for Amgen’s government affairs office from 2005 to 2009. Mr. Todd, who joined Mr. Hatch’s staff in 2011, was directly involved in negotiating the dialysis components of the fiscal bill, and he met with “all the stakeholders." This is a sweet deal for Amgen because Congress in 2008 required Medicare to pay a single, bundled rate for a dialysis treatment and related medications starting in 2011. But lawmakers carved out a two-year delay in the inclusion of certain oral drugs, Sensipar among them, in the new bundled payment system. That meant demand for Sensipar would not decline and Amgen would maintain control over pricing and make MORE money. With that two-year exclusion set to expire in 2014, Amgen’s lobbyists successfully pushed for another two-year delay. Many lobbyists and Congressional aides said they first learned of the language when the final bill was posted publicly, only hours before being approved. It called for cutting $4.9 billion over 10 years by lowering Medicare payments for dialysis, but left hundreds of millions on the table by extending the oral drug delay. What is the moral of this story? Companies make big bucks, lawmakers line their pockets and we the people pay the bill. But the story gets even better: the Internal Revenue Service regards some of Amgen's penalties as a cost incurred in the course of doing business. Result: It's fully tax-deductible! So the taxpayer will subsidize them for the money they're ponying up to pay the fines. Are we really want to take this any longer? Yours Bernd

Penny Wise and Pound Foolish

Attached a link to an interesting article titled "Florida’s Medicaid fraud fighting cuts cost state millions in matching money, report says" highlighting the fact that Florida missed out on millions in federal funds by cutting the budget for its Medicaid fraud unit and prosecution referrals and arrest warrants are down. Twenty-three positions in the fraud unit have gone unfilled because of budget shortfalls, according to a report issued by the Florida Attorney General’s Office and the Agency for Health Care Administration.The report said because of “critical” shortfalls, “the Medicaid Fraud Control Unit’s general revenue budget reduction was approximately $631,290, which resulted in an additional loss of $1.89 million in federal funds to the State of Florida.” The federal government provides $12.5 million of the Medicaid fraud unit’s $16.7 million budget, but the money is partly tied to matching state funds, which were $4.2 million for the year ended June 30. Not mentioned in the release, but available in a 62-page report from the two agencies, is documentation of budget cuts and a decline in some measures of anti-fraud efforts: —A 9 percent decline in cases opened, 324, compared to the previous year. —A 15 percent decline in referrals for prosecution to 52. —A 22 percent decline in recoveries from Medicaid Program Integrity audits to $62.2 million. —A 23 percent decline in warrants for arrest to 69. In my opinion the (in)action taken by the State of Florida regarding the Medicaid fraud unit funding is either an indicator of administrative malpractice, or reveals plain simple stupidity. Who will be hold accountable for the loss of $1.89 million in federal funds to the State of Florida? Yours Bernd

Guns,NRA and the Affordable Care Act

The tragedy of the horrific shooting in Newtown Connecticut gradually faded from the daily news. Sadly, this shooting will be followed by another one and we will continue to seek answers to why it happened and what we could have done to prevent another massacre. In my opinion we have to recognize that the National Rifle Association (NRA) tentacles of influence have penetrated all aspects of our lives. An article published in the Washington Post highlighted that the National Rifle Association successfully lobbied for the national health care law signed by President Obama in 2010 to include provisions restricting the ability of doctors and health plans to collect patient information about gun ownership.The language, pushed by the National Rifle Association in the final weeks of the 2010 debate over health care was discovered only in recent weeks by some lawmakers and medical groups and is drawing fierce criticism. The provision says that “wellness and prevention” portions of the health-care law “may not require the disclosure or collection of any information” relating to the “presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property.” Further, the measure says the law cannot be used to “maintain records of individual ownership or possession of a firearm or ammunition.” It adds that the price of health coverage may not be affected by the ownership, possession or use of guns. The deal to add gun language to the health-care bill was struck so quietly that several top officials in the Obama administration and in Congress had no idea the passages had been added until approached by The Washington Post last week. Its important to understand that this questionable legislative compromise erected an almost insurmountable barrier to the type of research required to address gun safety and gun control issues vital for addressing the issues involved in the post-Newtown policy debate. Again, the NRA has skillfully implemented a gag rule into the health care law preventing physicians to contribute to the data collection of ANY gun related issue. As parents, responsible citizens and physicians we need to continue and intensify our struggle against the metastasizing influence of the NRA in our government and lives. Yours Bernd ADDENDUM: Attached the original wording contained in Sec. 1001\2717 PHSA t: PROTECTION OF SECOND AMENDMENT GUN RIGHTS.- "(1) WELLNESS AND PREVENTION PROGRAMS.-A wellness and health promotion activity implemented under subsection (a)(l)(D) may not require the disclosure or collection of any information relating to- "(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or "(B) the lawful use, possession, or storage of a firearm or ammunition by an individual. "(2) LIMITATION ON DATA COLLECTION.-None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to- "(A) the lawful ownership or possession of a firearm or ammunition; "(B) the lawful use of a firearm or ammunition; or "(C) the lawful storage of a firearm or ammunition. "(3) LIMITATION ON DATABASES OR DATA BANKS.-None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition. "(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE.-A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon- "(A) the lawful ownership or possession of a firearm or ammunition; or "(B) the lawful use or storage of a firearm or ammunition. '(5) LIMITATION ON DATA COLLECTION REQUIREMENTS FOR INDIVIDUALs.-No individual shall he required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to- "(A) the lawful ownership or possession of a firearm or ammunition; or "(B) the lawful use, possession, or storage of a firearm or ammunition.