Why Medicaid Makes It Impossible To Practice Medicine

Attached a link to an article of interest titled " End of Medicaid parity will be costly to PCPs Medicaid reimbursement could drop 50% in many states." For me this development was predicable and I have to make a rational business decision if I can afford to take on new, or even service established Medicaid patients. Most of my Medicaid patient were transferred to me by United Healthcare and I am often faced with ZERO medical history and a patient demanding (rightfully) maximum quality care. Many of my Medicaid patients suffer from multiple chronic conditions, are poorly educated, have low levels of health literacy and are in need for coordinated care often contained in several medical records spread across a plethora of past and current specialty services providers who, despite all of my attempts, often do not exchange or transfer medical records. I reached a point of emotional and professional frustration and really do not know how it can be expected from me or my staff to work under those condition and to get paid now less than ever before! But to top it off Medicaid just informed me that they stopped all payments because letters sent to my business address were returned. When I inquired I noticed that they sent letters to an old practice address I vacated in 1997. Now I have to prove that I REALLY moved 17 years ago and that I really practice medicine at my current address. I am sorry but I can't take it anymore and have to limit, reduce or stop the care for Medicaid patients. This is a painful but necessary decision. Nevertheless, I wish all of you a healthy and prosperous New Year. Yours Bernd

Overdose Deaths Declined

Attached a link to an article titled " Prescription Overdose Deaths in Florida Plunge After Tougher Measures, Report Says" reporting that the death rate from prescription drug overdoses in Florida fell by 23 percent from 2010 to 2012, according to a report by the Centers for Disease Control and Prevention. The Morbidity and Mortality Weekly Report states that during 2003–2009, the number of deaths caused by drug overdose in Florida increased 61.0%, from 1,804 to 2,905, with especially large increases in deaths caused by the opioid pain reliever oxycodone and the benzodiazepine alprazolam. In response, Florida implemented various laws and enforcement actions as part of a comprehensive effort to reverse the trend. This report describes changes in overdose deaths for prescription and illicit drugs and changes in the prescribing of drugs frequently associated with these deaths in Florida after these policy changes. During 2010–2012, the number of drug overdose deaths decreased 16.7%, from 3,201 to 2,666, and the deaths per 100,000 persons decreased 17.7%, from 17.0 to 14.0. Death rates for prescription drugs overall decreased 23.2%, from 14.5 to 11.1 per 100,000 persons. The decline in the overdose deaths from oxycodone (52.1%) exceeded the decline for other opioid pain relievers, and the decline in deaths for alprazolam (35.6%) exceeded the decline for other benzodiazepines. Similar declines occurred in prescribing rates for these drugs during this period. The report also emphasizes that " the temporal association between the legislative and enforcement actions and the substantial declines in prescribing and overdose deaths, especially for drugs favored by pain clinics, suggests that the initiatives in Florida reduced prescription drug overdose fatalities." This should serve as evidence that a well designed and executed public policy can improve public health and safe lives. Therefore, we must push for increased funding for such measures including the Prescription Drug Monitoring Program (PDMP) which is a valuable and essential tool in protecting patients from accidental overdose. Happy 4th of July.

Gun Violence and Doctors

Dear Daniel: An article titled "Guns are a health issue-doctors shouldn't be muzzled" published in todays's Miami Herald highlights the the fact that, despite our politicians denial, guns are a health issue. Together with my colleagues Drs. Judith Schaechter and Tommy Schechtman we continue to raise awareness about the growing epidemic of gun related injuries and deaths among children and young adolescents. In 2010, 15,576 children and teenagers were injured by firearms — three times more than the number of U.S. soldiers injured in the war in Afghanistan. According to the New England Journal of Medicine, nationally, guns still kill twice as many children and young people than cancer, five times as many than heart disease and 15 times more than infection. Worst of all the unquestionable epidemic of firearm injuries morphed into an endemic , a self-sustaining illness maintained in the population without the need for external inputs. This has been described in an article by Katherine Kaufer Christoffel titled " Firearm Injuries: Epidemic Then, Endemic Now." Despite these indisputable, disturbing and troubling facts our politicians, Democrats and Republicans alike, refuse to accept this reality ! They care more about NRA rankings than our precious children injured and killed by firearms. The recent decision by President Obama to put the surgeon general nominee on hold because he dares to support gun control epitomized the reality detachment of our political cast, or maybe the dominating control of the NRA. W will continue our fight to defend our children's health and lives regardless of the outcome of the 11th Circuit Court of Appeals decision and need your support. Yours Bernd

Medical Marijuana

Medical marijuana is now going mainstream and that's to a large extent due to the efforts of physicians and journalists such as Sanjay Gupta. Gupta is the creator of a CNN program titled "Weed" which is being screened on CNN. Having watched this emotionally charged program I can only come to the conclusion that the world, according to Gupta, can be divided into "good" marijuana social entrepreneurs and "bad" cold-hearted doctors and scientists. Those doctors and scientists come across as cerebral and unemotional whereas the poor patients and their advocates are featured as the vanguards of medicine and science. In Sanjay Guptas's world individual case reports supersede any clinical study and the subjective improvement of individuals is served as clinical evidence. Yes, it is true that case reports, defined as the scientific documentation of a single clinical observation, have a time-honored and rich tradition in medicine and scientific publication. Yes, case reports and series have a high sensitivity for detecting novelty and therefore remain one of the cornerstones of medical progress BUT there findings have to be validated by rigorous randomized clinical trials!! This applies to marijuana, too. Systematic review and meta-analysis of double-blind randomized controlled trials that compare cannabis preparation to placebo are often not as convincing as the case reports of marijuana use may suggest. For example, a systematic review and meta-analysis of double-blind randomized controlled trials that compared any cannabis preparation to placebo among subjects with chronic pain revealed that cannabis treatment is moderately efficacious for treatment of chronic pain, but beneficial effects may be partially (or completely) offset by potentially serious harms. More evidence from larger, well-designed trials is needed to clarify the true balance of benefits to harms. These forms of critical differentiation are missing in Dr. Gupta's reporting. Meanwhile Dr. Guptas proudly declared that he wants to "double down" on his reporting and we will have to endure more of his unscientific rants. But don't worry! CNN will win big in the primetime viewership rating scale and can thereby charge higher advertising rates on Gupta's programs. What can we learn? Marijuana is big business for all involved, except for us doctors who have to clean up the mess and get paid pittance from the health insurance companies for our efforts. Yours Bernd

Medical Marijuana in Florida

The proponents of medical marijuana are gaining political strength and support and have almost unlimited financial support to promote their issues. Therefore, its important to keep abreast of the latest developments and news: In today's Miami Herald an article titled "Medical marijuana poised for ad-war win" reports that a January 2013 poll found medical-marijuana support at 70 percent. A Kitchens Group survey in July found 71 percent approval. Public Policy Polling surveys in October and this January, respectively, found 62 percent and 65 percent support. And Quinnipiac University’s poll in November found the highest support for the concept, 82 percent. Florida attitudes have been changing along with the nation’s. In November, a Quinnipiac University survey found that 48 percent of registered voters favored legalization for adults and 46 percent were opposed. The Republican state Senate district poll, conducted last month by the Tarrance Group, found that 47 percent of likely voters favored outright legalization and 48 percent opposed legalization. And voters strongly backed lighter prison sentences for nonviolent drug offenders. A major difference between the two polls: The Tarrance poll was in selected Republican-held state Senate districts where voters are more conservative; the Quinnipiac survey was a statewide survey that polled all types of voters.The Senate poll indicated that support for Charlotte’s Web stood at 79 percent in favor, 18 percent opposed — mirroring support for the broader medical-marijuana effort. Compared with a similar GOP Senate poll in April, support shifted a net 24 percentage points in favor of Charlotte’s Web. Voters by 65-28 percent favored reducing prison sentences for nonviolent drug offenders and, by 78-15 percent, they supported prison-diversion programs for those convicted of nonviolent crimes. BUT its also important to understand that the argument that medical marijuana leads to complete legalization can be a potent tool to defeat the proposed amendment. In my opinion it crucial to point out that the proponents of medical marijuana are painting a very rosy picture of marijuana's alleged medical benefits claiming treatment success for diabetes,multiple sclerosis, cancer and glaucoma. District 25 Florida House Representative Charles David "Dave" Hood, Jr., a Republican, even suggest that the federal government knew about its benefits since 1975 but continued to ban the medical application of marijuana! This is a blatantly false and misleading statement based on conspiracy theories. As medical professionals we should emphasize that there are VERY limited known medical applications and that clinical trials are necessary to verify and substantiate those claims. Furthermore, we should inform the public that we do have FDA approved cannabinoids available in the US for > 20 years! Dronabinol (Marinol) FDA approved in United States as Schedule I drug for appetite stimulation (1992) and for nausea (1985); moved to Schedule III effective July 2, 1999. Nabilone (Cesamet) Originally approved by the FDA for use in the US in 1985, but removed from the market until re-approved by the FDA on May 15, 2006 and made available in US pharmacies on Aug. 17, 2006. Other products could follow IF clinical efficacy, indications and safety can be established and verified. In my opinion the Florida House and Senate engages in legislative malpractice by approving a form of medical marijuana for the treatment of epilepsy WITHOUT clinical trials and the absence of any research that is needed to protect patients from potential adverse effects and harm. If physicians would engage in such behavior we would be sued by the very law firm which supports the legislation of medical marijuana. As a result of this legislation licensed marijuana dispensaries, often owned and operated by non-medical "social entrepreneurs", would engage in the practice of medicine without a license by dispensing a medical marijuana strain to a group of highly vulnerable children suffering from intractable seizures. Who will be responsible for long-term follow up of potential adverse effects??? Who will be hold liable for potential harm? Legislation by emotion is plain and simple insane!! We must engage in the battle and focus on the fact that if medical marijuana is approved then the camel is getting his nose under the tent and legalization will eventually follow soon. Furthermore, we must make it loud and clear that medical marijuana will seep into the adolescent population and will cause grave long-term harm. Lets not give up the fight!! Yours Bernd

Guns and Public Safety

Now, not only doctors but also insurance companies are prohibited from asking question about gun ownership. Instead of focusing on reducing insurance premiums our representatives in Tallahassee are pleasing their NRA supporters and are obsessively defending alleged Second Amendment violations. For starters: SB 424 would allow state regulators to fine or impose penalties on auto or property insurance companies that "refuse to issue, renew, or cancel a policy" because the policyholder owns a gun. It also prohibits the insurance company from disclosing to third party if the policyholder has a gun. HB 255 is going further by allowing policy holders to sue if an insurer takes such action. On the Florida Senate Senate Banking and Insurance Committee as well as on the Florida House Insurance and Banking subcommittee only ONE Senator and ONE House committee member voted against it! Soon insurance companies have to remove firearm questions from their screening application. Policy holders can now stock their household with assault weapons and thousands of rounds of ammunition to prepare for WW III, or to shoot rowdy neighbors. But wait, it gets better. Soon you can have your own gun range in your backyard. What could possibly go wrong with that! This is insane!!! Yours Bernd

Weapons in Doctors Offices

Attached a link to an article titled " Two dead, third person in hospital after shooting in suburban West Palm" reporting a fatal shooting which took place in the waiting room of a doctors office in West Palm Beach. The shooting occurred during what has been a particularly violent week in Palm Beach County. It was the county’s fifth homicide since Monday and the sixth overall in 2014. It was also the second time this week that local authorities have investigated a murder-suicide, and the third time in seven days that gunmen shot at other people, then killed themselves. As a physician and owner of a busy family medicine clinic I have encountered several patients who carried concealed weapons (handguns, knives) in my office which I discovered during a routine physical exam. I am a gun owner and concealed weapon permit holder myself, but I consider carrying a weapon in a doctors office as inappropriate and potentially dangerous. The fact remains that most healthcare professionals are unarmed and feel intimidated by a patient carrying a loaded weapon. According to Florida firearms regulations a carry license is valid everywhere other than in a few specially-defined areas which include airports, schools, universities, courthouses, establishments licensed to dispense alcoholic beverages for consumption on the premises,career centers, any meeting of the governing body of a county, public school district, municipality, or special district and any meeting of the Legislature or a committee thereof Why should doctors office not be included in the long list of specially-defined prohibited areas"? Why should legislators enjoy the freedom of not being killed by gunfire but doctors should continue working under the threat of guns? Why do neither representatives of organized medicine nor legislators have the intestinal fortitude to stand up and denounce the NRA which blocks all reasonable gun safety measures? Meanwhile, I informed my patients that I do not permit the carrying of any kind of weapons in my office and do not care if my decision backfires. Yours Bernd

Medical Marijuana

Attached a link to an article titled "Florida lawmaker agrees to work to legalize medical marijuana high in cannabidiol" published in yesterday's Tampa Bay Times reporting that Florida legislators agreed to file a bill to legalize the medical use of marijuana that has a high content of the chemical compound cannabidiol to "treat" severe epileptic seizures in children. The families pleaded with lawmakers to legalize strains of marijuana such as "Charlotte's Web" saying it is their last, best hope of relieving the uncontrollable seizures in their medically fragile children. The strain is high in cannabidiol or CBD, the ingredient that controls seizures, but is low in tetrahydrocannabinol, THC, the compound that creates a high. Their emotional pleas convinced the chairman of the legislative committee of the Florida House to support such a bill. Naturally, any opponent of such a move will be considered a heartless and uncaring individual. Most probably, the medical ethics of of physicians opposing such a decision will be questioned, too. But lets consider the facts: Charlotte's Web is a strain of medical marijuana developed in Colorado by the Stanley brothers and featured in the 2013 CNN documentary "Weed", hosted by Sanjay Gupta. It is named after Charlotte Figi, who experienced an immediate and remarkable reduction of her epileptic seizures after her first dose of medical marijuana at five years of age. The sudden publicity of this specific strain of medical marijuana is based on anecdotal evidence only but is now being used to justify the use of medical marijuana in general. Well meaning proponents of clinical research point out that such clinical research is blocked by strict Federal laws. Therefore, they call for reclassification of marijuana to facilitate the kind of rigorous evaluation that’s needed to determine the appropriate, physician-supervised doses and uses of medical marijuana. But before we join the chorus singing the praise of medical marijuana we should step back and analyze the facts. I recommend reading an article published in the Epilepsy Curr. 2013 Mar-Apr; 13(2): 81–82 titled " Slim Evidence for Cannabinoids for Epilepsy" which concluded that no reliable conclusions can be drawn at present regarding the efficacy of cannabinoids as a treatment for epilepsy. The dose of 200 to 300 mg daily of cannabidiol was safely administered to small numbers of patients, for generally short periods of time, and so the safety of long term cannabidiol treatment cannot be reliably assessed. The authors base their assessment of the efficacy of marijuana, or one of marijuana's constituents in the treatment of people with epilepsy on an exhaustive search of the Cochrane Epilepsy Group Specialized Register (May 15, 2012), the Cochrane Central Register of Controlled Trials (CENTRAL issue 4 of 12, and the Cochrane Library 2012),MEDLINE (PubMed, searched on May 15, 2012), ISI Web of Knowledge. This Cochrane review searched for direct evidence that cannabinoids can prevent human seizures in studies using the only acceptable standard, the randomized controlled trial. The researchers identified four studies, with a total of 48 patients randomized to placebo or to 200–300 mg of cannabidiol per day. This particular cannabinoid has few psychotropic effects and is not a controlled substance. Overall, these studies demonstrate the short-term tolerability of this treatment, with the only noted adverse effect being drowsiness in one study. Except for one study that reported two of four treated patients becoming seizure free for 3 months, the studies either reported no benefit, or the effect was not clearly stated. Methods of randomization or determining outcome were inadequate or not clearly detailed.Marijuana itself has major shortcomings as an epilepsy treatment. Its psychotropic action can only be regarded as an adverse effect. It is a biological product containing multiple compounds with unclear, possible, anti- or pro-convulsant effects, delivered in varying amounts from dose to dose. Long-term safety has not been adequately investigated. The authors correctly stated that new treatments for epilepsy are sorely needed. Cannabidiol or other individual cannabinoids with minimal adverse effects could be extracted and given in precise doses in rigorously designed, blinded, randomized clinical trials to test efficacy and safety. In my opinion this is the only reasonable route for development of new antiepileptic drugs. Legislative efforts, as well intended they may be, cannot substitute for the gold standards of scientific evidence. Unfortunately, nobody seems to have the fortitude to stand up and to defend those principles in public. I am afraid that medical science will have to succumb to populism and the efforts to create quick fixes and miracle cures. But at what price? Looking forward to your comments. Yours Bernd

Judge Strikes Down Drug Testing Law

The U.S. District Court handed Gov. Rick Scott a defeat on Dec. 31 when it struck down a law requiring drug screening of welfare recipients unconstitutional.The Miami Herald reported in a article titled "Scott vows to fight drug-test ruling" that federal judge Mary Scriven granted summary judgment on behalf of Luis Lebron, who at the outset of the 2011 case was a 35-year-old Navy veteran, college student and single father from Orlando. Lebron refused to submit to a drug test arguing that requiring him to pay for and submit to one is unreasonable when there is no reason to believe he uses drugs. Lebron was represented by the American Civil Liberties Union of Florida The judge rules that the mandatory urine drug test violate the Fourth Amendment's protection against unreasonable searches.In her ruling judge Scriven relied heavily on the 11th Circuit of Appeals opinion which cited previous U.S. Supreme Court rulings that restricted mandatory urine drug tests by government agencies to employees working at dangerous jobs or in jobs where school children were involved. Scott signed a law in 2011 to drug test recipients of Temporary Assistance to Needy Families. But the court issued a preliminary injunction a few months later. While the law was in effect from July through October 2011, about 2.6 percent -- or 108 of 4,046 people -- tested positive for drugs, the most common being marijuana. In my opinion an appeal will be an exercise in futility and a waste of precious tax payers money.