Health Insurance

Attached a link http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.pdf to a very interesting federal study titled "The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008-2009" published by the Center for Financing, Access, and Cost Trends of the Agency for Healthcare Research and Quality. Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) for 2008 and 2009, this report provides detailed estimates of the persistence in the level of health care expenditures over time. Studies that examine the persistence of high levels of expenditures over time are essential to help discern the factors most likely to drive health care spending and the characteristics of the individuals who incur them. According to the study in 2008, 1 percent of the population accounted for 20.2 percent of total health care expenditures, and in 2009, the top 1 percent accounted for 21.8 percent of the total expenditures with an annual mean expenditure of $90,061. The lower 50 percent of the population ranked by their expenditures accounted for only 3.1 percent and 2.9 percent of the total for 2008 and 2009 respectively. Of those individuals ranked at the top 1 percent of the health care expenditure distribution in 2008, 20 percent maintained this ranking with respect to their 2009 health care expenditures In both 2008 and 2009, the top 5 percent of the population accounted for nearly 50 percent of health care expenditures. Individuals who were between the ages of 45 and 64 and the elderly (65 and older) were disproportionately represented among the population that remained in the top decile of spenders for both 2008 and 2009. While the elderly represented 13.2 percent of the overall population, they represented 42.9 percent of those individuals who remained in the top decile of spenders. Focusing on the under age 65 population, health insurance coverage status also distinguished individuals who remained in the top decile of spenders from their counterparts in the lower half of the distribution. Individuals who were uninsured for all of calendar year 2009 were disproportionately represented among the population that remained in the lower half of the distribution based on health care spending. While 15.5 percent of the overall population under age 65 was uninsured for all of 2009, the full-year uninsured comprised 25.9 percent of all individuals remaining in the bottom half of spenders (figure 6). Alternatively, only 3.6 percent of those under age 65 who remained in the top decile of spenders were uninsured. What can we learn from the data and how should the data influence public policy? We are spending a disproportionally high percentage of precious healthcare dollars on a very small percentage of sick people.Most of them suffer from preventable chronic diseases which we still cannot manage properly within our existing healthcare system. The overwhelming majority of those "high" spenders were insured and there annual mean expenditure of $90,061 are not covered by the healthcare premiums they pay. The overwhelming majority of healthy "low" spender are uninsured and therefore do not contribute with their health insurance premium payment to cover for their eventuality of their own care needs. Taking all of these facts into consideration we should support an individual mandate that requires health insurance coverage for each and every American to spread the insurance risk. Spreading the risk assures that as the number of people in a given group gets larger, a company or governmental agency can more easily spread the risk (that would be the risk of a payout) among the pool of participants. They can therefore better estimate the average cost (or payout) per person in the event that one or even several of the group are victims of a catastrophic event. In the absence of such a mandate insurance companies can simply not afford to continue paying 50% of health care expenditures on 5% of the population!!! Alternative proposals to create high-risk pools are doomed to fail because the risk to cover "sick" participants is so high that it results in unaffordable health insurance premiums by private insurance companies. If those companies choose to opt out of providing insurances for such a high-risk pool then the government remains the insurer of the last resort, i.e the tax payer. Yours Bernd

US Healthcare Costs

According to the latest edition of "Health at a Glance" http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en published by the Organization for Economic Co-operation and Development (OECD) The United States stands out as performing very well in the area of cancer care, achieving higher rates of screening and survival from different types of cancer than most other developed countries. The United States does not do well in preventing costly hospital admissions for chronic conditions, such as asthma or chronic obstructive pulmonary disease, which should normally be managed through proper primary care. Avoidable hospital admissions for asthma complications and chronic obstructive pulmonary disease (COPD) are much greater in the United States than the OECD average. For asthma admissions, the rate in the United States was 121 per 100 000 adults in 2009, more than two times greater than the OECD average of 52. For COPD, hospital admission in the United States was 230 per 100 000 adults, compared with an OECD average of 198. Regarding healthcare expenditures the United States spent 17.4% of GDP on health in 2009, much more than the OECD average of 9.6%. Spending per person is two-and-a-half times higher than the OECD average. Following the United States were the Netherlands, France and Germany, which allocated respectively 12.0%, 11.8% and 11.6% of their GDP to health. Is US health spending higher due to higher prices or higher service provision? (or both?) Facts: 1) US prices for a set of hospital services is over 60% higher than the average of 12 OECD countries, 2) US prices for certain procedures (including appendectomy,coronary angioplasty, coronary artery bypass graft, hip & knee replacement) are much higher than in other OECD countries, 3) Almost DOUBLE the spending on Insurance administration expressed in terms of purchasing power parity. Its also of interest to note that in most countries, health spending is largely financed out of taxes or social security contributions, with private insurance or ‘out-of-pocket’ payments playing a significant but secondary role. This is not the case in the United States which, together with Mexico and Chile, is the only OECD country where the government plays the smallest role in financing health spending. The public share of health expenditure in the United States was 47.7% in 2009, much lower than the OECD average of 71.7%. However, the level of health spending in the United States is so high that public (i.e. government) spending on health per capita is greater than in all other OECD countries, except Norway and the Netherlands. For this amount of public expenditure in the United States, government provided in 2009 insurance coverage only for the elderly and disabled people (through Medicare) and some of the poor (through Medicaid and the State Children’s Health Insurance Program, SCHIP), whereas in most other OECD countries this was enough for government to provide universal health insurance. Public spending on health in the United States has been growing more rapidly than private spending since 1990, largely due to expansions in coverage. Private insurance accounted for 33% of total health spending in the United States in 2009, by far the largest share among OECD countries. Beside the United States, Canada and France are the only two other OECD countries where private insurance represents more than 10% of total health spending. Conclusions: we are spending more for healthcare per person than in any other country in the world utilizing an inefficient private insurance model. But also public (i.e. government) spending on health per capita is greater than in all other OECD countries but fails to provide universal coverage. We must achieve a broad based consensus on how to efficiently allocate our healthcare resource to achieve high quality healthcare for all Americans. Tinkering on the edge will not provide us with a meaningful and sustainable solution. If we do not engage in such a dialogue now we will face rationing and further economic slowdown. Yours Bernd

Medical Errors Awaiting Prevention

Attached a link http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html to an interesting article titled "Report Finds Most Errors at Hospitals Go Unreported" pointing out that according to recent federal study hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized. According to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services, some of the most serious problems, including some that caused patients to die, were not reported.The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said. More often, Mr. Levinson said, the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported. In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or “suspected that the events were isolated incidents unlikely to recur.”The inspector general found that “hospitals made few changes to policies or practices” after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any “systemic quality problems.”Organizations that inspect and accredit hospitals generally “do not scrutinize” how hospitals keep track of medical errors and other adverse events, the study said. The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said. What are possible solutions? 1) Train staff to report medical errors and to automatically flag those patients within an electronic health record for IMMEDIATE quality assurance review 2) Utilize software which automatically triggers alerts for diagnoses and conditions including medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners. 3) Deploy medical error prevention teams within hospitals to educate staff and to assist in the implementation of lessons learned from a root-cause analysis into the clinical practice. I am confident that we can achieve our goals to reduce medical errors and to save lives. Yours Bernd

Medicaid Pilot Program in Florida

Letter to the Editor published in Miami Herald, December 23rd, 2011 Patients protected The Dec. 16 article State can expand Medicaid pilot program incorrectly stated that the federal government approved the expansion of the Medicaid pilot project. Actually, the extension of the five-county Medicaid pilot project was approved until 2014, but with significant improvements to the program. They include the denial of the medical-loss-ratio waiver requiring the participating private health plans to spend 85 percent of the funds on patient care and the denial of capping benefit levels for Medicaid beneficiaries, which prevents the termination of Medicaid services because recipients have already met their maximum. These requirements will protect patients from arbitrary insurance denials and will force private health insurance plans to manage the taxpayers’ dollars more efficiently and responsibly. We should continue to oppose any expansion of the pilot project unless the state of Florida can provide solid data that it improves access and enhances the quality of healthcare for all Medicaid enrollees. Bernd Wollschlaeger, MD,

ER, Dental Care and Medicaid

I recommend reading an article published in today's Sun Sentinel titled "More patients turning to ERs for dental care" summarizing the findings of a study by the Florida Oral Health Coalition which found that more than 115,000 people went to the hospital last year for dental care that could have been prevented or done at a much lower cost in a dentist's office. That's up 9 percent since 2008. More than 15,500 of them were children. ERs charged $88 million for that dental care last year — $30 million to Florida's state-federal Medicaid program , the study found. Hospitals not reimbursed for the care likely pass on the cost to other patients through higher charges. The reliance on ERs for tooth care was even heavier in South Florida, with the number of ER visits up 32 percent in Broward County since 2008. To tackle the problem, the group suggests expanding services that can be offered by dental hygienists, raising Medicaid payments to attract more dentists, having Medicaid cover adult dental care, and expanding county health department dental clinics. But the recommendations would require more tax money at a time when state officials are trying to shrink the Medicaid budget.

Florida Medicaid Pilot

On Thursday the federal officials agreed to extend Florida's five-county Medicaid managed-care experiment to 2014 but required the state to make significant improvements to the program. They include the denial of the medical-loss-ratio waiver requiring the participating private health plans to spend 85 percent of funds on patient care and the denial to cap benefit levels for Medicaid beneficiaries preventing the termination of Medicaid services because recipients had already met their $500,000 maximum for the year. These requirements will protect patients from arbitrary insurance service denials and will force private health insurance plans to manage taxpayers dollars efficiently and responsibly. Meanwhile, we should continue to oppose any expansion of the pilot project UNLESS the State of Florida can provide solid and indisputable data that the pilot project improves access and enhances the quality of care for all  Medicaid enrollees. So far I have not found any evidence to substantiate Governor Scott's claim that "we've seen higher quality in administration of care, produced cost savings and consumers in the pilot have found improved access for Medicaid recipients." Looking forward to your feedback. Yours Bernd For more information see: http://htpolitics.com/2011/12/15/feds-make-key-decisions-on-medicaid-and-health-insurance-for-floridians http://blogs.orlandosentinel.com/news_politics/2011/12/what-is-changing-in-florida-medicaid-maybe.html

The Sick Business of Medicine

Attached a link http://www.miamiherald.com/2011/11/12/2499995/finances-strain-the-marriage-between.html to an interesting article by John Dorschner published in the Miami Herald titled "Finances strain the marriage between Jackson and the University of Miami" which details the increasingly strained relationship between Jackson Memorial Hospital and the University of Miami. At the center of the dispute are insured patients seeking medical care at Jackson Memorial hospital. UM critics claim that UM physician direct these patients to the UM hospital across the street, and that Jackson Memorial hospital is left with treating the uninsured patients. Miami-Dade taxpayers pay Jackson Memorial $330 million a year to treat uninsured people who seek treatment in the county-owned Jackson system. As part of the system that has evolved over the years, Jackson also pays UM when its doctors treat the uninsured at Jackson. UM critics also claim that once an uninsured patient gets insurance UM doctors are shifting their care to the UM hospital, which then receives the Medicare reimbursement money. UM calls that patient choice. Jackson counters that its paying patients shouldn’t be siphoned off to UM facilities. What troubles me is that patients are being considered as milkable cash cows and once they are loosing their production value they are being pushed back into Jackson Memorial Hospital. Its a sick system which encourages overutilization of medical services and drives up healthcare costs even further. Yours Bernd

Health Care Cost Control

"Unfortunately, few people really understand how much we spend on health care,how much we need to spend to provide quality care, and the difference between the two." The New York Times published three articles by Ezekiel Jonathan Emanuel,MD PhD focusing on how to control the escalating health care costs in the United States. I highly recommend reading the articles published so far and have attached the links to each article below. The following bullet points represent an excerpt of the arguments made in his articles: How much do we spent on health care in the United States? In 2010, the United States spent $2.6 trillion on health care, over $8,000 per American.The United States spends on health care alone what the 65 million people of France spend on everything: education, defense, the environment, scientific research, vacations, food, housing, cars, clothes and health care. In other words, our health care spending is the fifth largest economy in the world. For more than 30 years, health care costs have been growing 2 percent faster than the overall economy. That means every year we spend ever more on health care and therefore have to spend less on other things — or borrow money to pay for the extra health care. If we continue at this rate of growth, health care will be roughly one-third of the entire economy by 2035 — one of every three dollars will go to health care — and nearly half by 2080. This level of spending on health care is high, but is it worth it? Does it make us healthier? The United States spends around 20-30 percent more per person than the next highest-spending countries, Switzerland and Norway BUT the United States is not getting 20 or 30 percent better health care or results than other countries! As a country we are actually doing worse than a number of countries, like France and Germany, that spend considerably less! How do we spent our health care dollars and how can we start saving? In health care, you have to be talking about tens of billions of dollars before you are talking about real money. A useful threshold for savings is 1 percent of costs, which comes to $26 billion a year. Anything less is simply not meaningful. Cutting health insurance companies profits? Last year, health insurance companies did rack up big profits, but it turns out that the combined profits of the country’s five largest for-profit health insurance companies — United, WellPoint, Aetna, Humana and Cigna — were $11.7 billion, only 0.5 percent of total health care spending. Even confiscating every penny of those profits would add up to less than half of the cost-saving threshold. Cutting drug companies profits? Between 2004 and 2009, generic drug use rose from 57 to nearly 75 percent of all prescriptions. Paradoxically, over those same years, the total amount Americans spent on drugs actually increased by 31 percent — the same rate as overall health care expenditures. Even the best estimates suggest that savings from expanding generics’ use even further are, according to the Department of Health and Human Services, “likely to be small relative to total spending on drugs.” Pharmaceutical costs account for roughly 10 percent of total health care spending, some $260 billion in 2010. Importing brand name drugs from abroad would cut about 2 percent from that — $5 billion per year. Another cost control disappointment. Malpractice reform is the solution? In 2009, the Congressional Budget Office did a comprehensive assessment of the potential cost savings from medical malpractice reforms. Its conclusions: A package that included a $250,000 cap on noneconomic damages, a $500,000 cap on punitive damages and a one-year statute of limitations for claims by adults would save about $11 billion a year — 40 percent from reduced malpractice premiums and the rest in the form of fewer defensive procedures like M.R.I.’s. Frankly, $11 billion is not insignificant BUT at less than half the $26 billion threshold, malpractice reform is certainly not a cost savings magic bullet either. Restrict health care spending on exorbitantly expensive patients? An unpublished analysis of nearly 20 million commercially insured patients(provided to the author of the article) showed that there were only 255 patients who consumed over $1 million in 2010. Together they spent 0.5 percent of all costs — a very large number for so few patients, but just half the 1 percent threshold for cost-saving that matters. And not all of those costs could be saved. Are administrative services one of the biggest money wasters in our health care system? Administration accounts for roughly 14 percent of what the United States spends on health care, or about $360 billion per year. About half of all administrative costs — $163 billion in 2009 — are borne by Medicare, Medicaid and insurance companies. The other half pays for the legions employed by doctors and hospitals to fill out billing forms, keep records, apply for credentials and perform the myriad other administrative functions associated with health care. The range of expert opinions on how much of this could be saved goes as high as $180 billion, or half of current expenditures. But a more conservative and reasonable estimate comes from David Cutler, an economist at Harvard, who calculates that for the whole system — for insurers as well as doctors and hospitals — electronic billing and credentialing could save $32 billion a year. And United Health comes to a similar estimate, with 20 percent of savings going to the government, 50 percent to physicians and hospitals and 30 percent to insurers. For health care cuts to matter, they have to be above 1 percent of total costs, or $26 billion a year, and this conservative estimate certainly meets that threshold!!! How do we get to these savings? First, electronic health records would eliminate the need to fill out the same forms over and over. An electronic credentialing system shared by all hospitals, insurance companies, Medicare, Medicaid, state licensing boards and other government agencies, like the Drug Enforcement Administration, could reduce much of the paperwork doctors are responsible for that patients never see. Requiring all parties to use electronic health records and an online system for physician credentialing would reduce frustration and save billions. But the real savings is in billing. There are at least six steps in the process: 1) determining a patient’s eligibility for services; 2) obtaining prior authorization for specialist visits, tests and treatments; 3) submitting claims by doctors and hospitals to insurers; 4) verifying whether a claim was received and where in the process it is; 5) adjudicating denials of claims; and 6) receiving payment. Substantial costs arise from the fact that doctors, hospitals and other care providers must bill multiple insurance companies. Instead of having a unified electronic billing system in which a patient could simply swipe an A.T.M.-like card for automatic verification of eligibility, claims processing and payment, we have a complicated system with lots of expensive manual data entry that produces costly mistakes. The Affordable Care Act requires the Department of Health and Human Services to develop operating standards for electronic eligibility determination and payment — steps one and six — in the next few years, but we need to go further. We need the standard operating rules to encompass authorizing tests and treatments, submitting claims, verifying where in the process a claim is and the real-time adjudication of denials. And we must accelerate the process, covering all steps by 2015. Finally, the government needs to require that all parties — doctors, hospitals, insurers, government agencies — use the electronic systems. This platform of electronic eligibility, claims and payment would — in addition to saving billions of dollars in paperwork — facilitate anti-fraud measures like those used by credit card companies. It would ease the administrative burden on doctors, letting them do the work that really matters — treating patients. Finally, it could improve care through built-in guidelines; if a doctor tried to schedule a stent implantation for a patient with stable heart disease, the system could tell him to try medication first; if he tried to order an M.R.I for a patient with normal back pain, it could tell him to prescribe physical therapy first. We have to realize that there are no " magic bullets" to solve our health care cost crisis.Any solutions offered so far to provide universal health care coverage will fail UNLESS they are being combined with meaningful and sustained cost control measures. This requires a total reform of our reimbursement system transforming it from a quantity to a quality focused service industry utilizing state-of-the-art information technology tools. Unless we are not willing to change, we are going to be forced to further ration medical services. What do we prefer? Yours Bernd Links: Spending More Doesn’t Make Us Healthier, http://opinionator.blogs.nytimes.com/2011/10/27/spending-more-doesnt-make-us-healthier/ Less Than $26 Billion? Don’t Bother., http://opinionator.blogs.nytimes.com/2011/11/03/less-than-26-billion-dont-bother/ Billions Wasted on Billing, http://opinionator.blogs.nytimes.com/2011/11/12/billions-wasted-on-billing/#more-112339

Personhood Amendment

On November 8th Mississippi voters will be asked to decide on a proposed amendment to the state constitution, which would define as a person “every human being from the moment of fertilization, cloning, or the functional equivalent thereof.” For most voters it sounds like a good idea and it will most probably pass. Therefore, several other states, including Florida http://personhoodfl.com/, are preparing similar constitutional amendments. Florida Senate Majority Leader and former US Senate Candidate Mike Haridopolos recently signed the FL Personhood Amendment!! The ambiguous language in the Florida and Mississippi 'personhood' amendment are intentionally not being represented properly by the proponents of this ballot initiative. A recent New York Times article http://www.nytimes.com/2011/10/31/opinion/mississippis-ambiguous-personhood-amendment.html correctly points out the following problems: "First, what does “fertilization” mean? As embryologists recognize, fertilization is a process, a continuum, rather than a fixed point. The term “fertilization” — which is sometimes considered synonymous with “conception” — could mean at least four different things: penetration of the egg by a sperm, assembly of the new embryonic genome, successful activation of that genome, and implantation of the embryo in the uterus. The first occurs immediately; the last occurs approximately two weeks after insemination (or, in the case of embryos created through in vitro fertilization that do not get implanted, never). Thus, on some reasonable readings of the amendment, certain forms of birth control, stem cell derivation and the destruction of embryos created through in vitro fertilization would seem impermissible, while on other equally reasonable readings they are not." Following the "logic" of the "personhood" advocates doctors can be charged with manslaughter or even murder by prescribing morning after pills, because it can irritate the lining of the uterus (endometrium) so as to inhibit implantation of a fertilized egg, i.e. "killing a person." A doctor could also be criminally charged by inserting an IUD because it adversely affects a new embryo as it enters the uterus, thus preventing it from implanting in the uterine lining . Again, according to the "personhood" advocates this constitutes the "killing of a person." Even though, abortions are still being protected by federal law women may still face criminal charges according to state law. Other unintended consequences include the question if the treatment of an ectopic or a molar pregnancy requires first a court order to overrule a "personhood" amendment in the respective state constitution. Needless to mention that any delay of these time-sensitive treatment decisions may harm the mother and even jeopardize the life and well-being of a women. I urge all of you to speak up against any such ballot initiatives, to protect the physician-patient relationship and to guard against further state intrusion into our lives. Yours Bernd

Drug Treatment Instead Of Prison

Attached a link http://www.sun-sentinel.com/news/opinion/editorials/fl-prison-bill-editorial-dl-20111030,0,3676874.story to an interesting editorial published in today's Sun Sentinel titled " State prisons need drug treatment alternative." The Sun Sentinel Editorial Board supports legislation — CS/HB 177 and SB 448 — which intends to establish a re-entry program for nonviolent offenders that offers intensive substance abuse treatment, adult education courses and vocational training as alternatives to long prison sentences. The idea is to reduce recidivism, which is essential if state officials want to get a handle on the costs of incarceration. The bills are sponsored by State Sen. Ellyn Bogdanoff, R-Fort Lauderdale, and State Rep. Ari Porth, D-Coral Springs. The two lawmakers are trying to pass needed, positive legislation to help the state of Florida reduce the costs of operating its prisons. In my opinion we should support this legislation and begin lobbying members of the Florida House and Senate. E-mail, twitter, mail or call your representative because " Unlike prison privatization and the more controversial ideas to cut state prison costs, the re-entry program is a simple solution that promises both savings and a much-needed reduction in the state's ongoing recidivism problem." Yours Bernd

Substance Abuse Counseling and Preventive Health Care

Attached a link http://www.ama-assn.org/amednews/2011/10/17/bica1017.htm to an interesting article titled "Counseling on alcohol helps patients and is billable" published in AMA News and posted on October 17th, 2011. Several highlights:

* Since early 2011, many commercially insured patients have been able to receive alcohol counseling paid at 100% with no co-pay or deductible, and the same is expected to be true for Medicare beneficiaries as of Jan. 1, 2012.
* Just asking about alcohol abuse will not necessarily lead to reimbursable payment, but treating those who screen positive most probably will. In addition to the usual fee-for-service, other incentives on the table should further make dealing with the issue more financially feasible for practices and make it more likely that patients will enter treatment.
* Tracking the percentage of adolescents and adults with new episodes of alcohol or other drug dependence who initiate treatment is on the list of eligible professional measure specifications from the Centers for Medicare & Medicaid Services.
* Information should be noted in the patient's chart, along with the time spent on this task. Counseling sessions longer than 15 minutes are billable, but shorter ones are not.
* On July 19, CMS issued a proposed decision memo stating that, as of Jan. 1, 2012, Medicare will cover annual alcohol misuse screening. (A final decision has not yet been made.) Under the proposal, Medicare would pay for four brief, face-to-face behavioral counseling interventions a year. The American Medical Association and other medical societies support his move.
* In addition, alcohol misuse screening and counseling is on the list of preventive services that non-grandfathered health plans must cover at 100% with no deductible or co-pay, according to the Patient Protection and Affordable Care Act. Grandfathered health insurance plans are those that have not changed since the health system reform law was enacted. Non-grandfathered ones are new policies issued after Sept. 23, 2010, and must cover a recommended list of preventive services with no cost-sharing with patients.
* When billing private insurers, the CPT codes are 99408 for an intervention lasting 15 to 30 minutes. An intervention longer than 30 minutes should be coded 99409. H0049 is the code for alcohol and drug screening of Medicaid beneficiaries. H0050 can be used for every 15 minutes of intervention. The services can be provided by a nurse practitioner or physician assistant as well as a physician.

Yours
Bernd

Drug Testing Halted

Attached a link http://www.miamiherald.com/2011/10/24/2470519/florida-welfare-drug-testing-halted.html to another article titled "Florida's welfare drug testing halted by federal judge" reporting that A federal judge in Orlando on Monday temporarily blocked Florida’s controversial law requiring welfare applicants be drug tested in order to receive benefits. Judge Mary Scriven issued a temporary injunction against the state, writing in a 37-page order that the law could violate the Constitution’s Fourth Amendment ban on illegal search and seizure.Gov. Rick Scott, who signed the measure into law on May 31, touted it as a way to ensure taxpayer money isn’t “wasted” on those who use drugs. “Hopefully more people will focus on not using illegal drugs,” he said then.
But, in her order, Scriven issued a scathing assessment of the state’s argument in favor of the drug tests, saying the state failed to prove “special needs” as to why it should conduct such searches without probable cause or reasonable suspicion, as the law requires. “If invoking an interest in preventing public funds from potentially being used to fund drug use were the only requirement to establish a special need,” Scriven wrote, “the state could impose drug testing as an eligibility requirement for every beneficiary of every government program. Such blanket intrusions cannot be countenanced under the Fourth Amendment.”
Fortunately, our legal system still provides protection against the growing government intrusion in our lives spearheaded by a conservative majority in our legislature. We need to continue to push back the growing number of bills threatening not only the practice of medicine but also the freedoms each and every citizen is entitled to.
Yours
Bernd

Florida Prescription Drug Monitoring Program

Attached a link http://www.usatoday.com/news/nation/story/2011-10-13/pill-mill-drug-trafficking/50896242/1?loc=interstitialskip to an interesting article in USA Today titled "States target prescriptions by 'pill mills'" highlighting the Florida painmill problem, the actions taken to combat this issue which include the Prescription Drug Monitoring Program ( PDMP) . We should be ware that the death rate from oxycodone in Florida increased 265% from 2003 to 2009, the CDC found. By 2009, the number of deaths involving prescription drugs was four times the deaths involving street drugs, the CDC said in a July report. Hopefully, the number will decrease but this requires our active participation and support INCLUDING our use of the just recently launched PDMP, or E-FORCSE.
I am using this program now for the last week and am pleased to report that it truly works! For example, I have implemented a protocol which requires that the prescription record of each and every patient who receives a controlled substances has to be crosschecked with the medication listed on E-FORCSE.
I have already discovered that several of my patients did not inform me that they visit different physicians to receive controlled substances. One patient who is currently being treated with Suboxone received prescriptions for a total of 360 Hydrocodone pills from another MD "specializing" in pain management. I called her and she was very surprised to find out that I knew what she was prescribed. She tried to convince me that she only fills these scripts for "psychological reasons" but is not taking but hoarding them at home. I asked her to come to my office for a follow-up visit including drug testing but she never showed up. I suspect that she may sell, or share this medications with others.
I urge you to obtain your username and password and to incorporate this valuable tool into your practice.
Yours
Bernd

The number of Uninsured continue to soar!

Attached you find a link http://www.miamiherald.com/2011/09/30/2432980/uninsured-situation-worsens-in.html to an excellent article article by John Dorschner published in today's Miami Herald titled " More in S.Florida going uninsured" focusing on the soaring numbers of uninsured even in middle-class suburbs." The facts are indeed stunning and sobering:

"The data shows that almost a third — 31.2 percent — of adults aged 18 to 64 in the Kendall area, a middle-class suburb, were uninsured in 2010, up from 19.6 percent in 2008.
Those grim numbers reflect South Florida’s recent economic struggles that have driven up unemployment and forced many small employers to drop insurance coverage, said Steven Ullmann, a health policy expert at the University of Miami. The figures are part of a larger trend of growing numbers of uninsured and shrinking alternatives for the poor throughout Miami-Dade and Broward counties."

"The Kendall uninsured numbers — 50 percent higher than national figure for the same 18-to-64 age group — are “a reflection of everything the economy has been through,” Ullmann said. “It’s becoming an issue nationwide, but it’s reflected even more so in our local economy.”

"The Census data, released last month, shows 31.8 percent of Miami-Dade’s residents of all ages were uninsured in 2010. In Broward, it was 24 percent. In Monroe County, 32 percent — compared with a national average of 16.3 percent."

"A stunning 57 percent of Hialeah residents in that age group were uninsured in 2010, up from 53 percent in 2008.
In the City of Miami, 50.4 percent of 18-to-64-year-olds were uninsured, compared to 45.8 percent in 2008. In Deerfield Beach, 48.5 percent were uninsured, compared to 33.6 percent in 2008. In Miami Gardens, it was 39.9 percent, compared to 35.2 percent in 2008, while Miami Beach registered very little change, with 35 percent, compared to 35.8 percent in 2008. Weston continues to be the place in South Florida with the lowest rate of uninsured residents in the 18-to-64 age group, with 17.9 percent, compared to 13.8 percent in 2008."

The poor are also getting squeezed, says Ullmann. Many of them can qualify for Medicaid, the state-federal program for the poor, but Ullmann notes that as the state’s budget shrinks, legislators have been trying to reduce the program by lowering payments and forcing patients into health maintenance organizations."

Unfortunately, these numbers are not going to change and may even worsen. Many of those who are lucky enough to find a job are NOT offered health insurance because health insurance premiums for employer-provided health insurance jumped 8-9 percent in 2011, passing $15000 for family coverage!
As a result more people seek health care in emergency rooms driving up the costs even further, because those with insurance are paying the share for those who don't, or cannot, pay. Meanwhile, politicians are still engaged in trench warfare to fight off "Obamacare."
We must face reality and find solutions to this problem. One of them would be a countywide effort to create a network of primary care clinics offering a Patient-Centered Medical Home (PCMH) coordinating medical care. Such a network could be financed by grants and federal subsidies. The costs of such care would be substantially lower compared to the emergency room services provided. For example, one of my asthma patients has utilized the emergency room 2-4 times per month for treatment and medication refills. He is now enrolled in a chronic disease management program and has used the ER only once in two years.
I hope that common sense will prevail. Otherwise, we are going to face a very bleak future.
Yours
Bernd

The Legality of Online Health Care Discounts

Attached you find a link http://www.baltimoresun.com/health/fl-hk-groupon-medical-20110925,0,6420216.story to an interesting article titled "Are Groupon discounts for medical treatments illegal?" highlighting an important issue: Those big discounts on health care treatments offered on websites like Groupon may be illegal, medical law experts say. Not for the patients but for the medical professionals giving them.
"The law is very strict. This seems like a problem," said Michael Segal, a South Florida health-care lawyer. "I would urge [practitioners] to be very careful. You don't want to find out there's a concern after you have done it."
A number of national and local medical associations, including the Palm Beach County Medical Society last month, have warned members because the issue is still in doubt. Florida regulators said they have not discussed it. Medicare has taken no position. Nor has the American Medical Association or other medical trade groups.

Yours
Bernd

Hospital Performance

Attached a link http://www.nytimes.com/2011/09/15/us/hospital-performance-improved-report-finds.html to an interesting article titled "Report Finds Improved Performance by Hospitals," reporting that in the latest advance for health care accountability, the country’s leading hospital accreditation board, the Joint Commission, released a list http://www.jointcommission.org/assets/1/18/Top_Performers_2010_list_9_13_11.pdf on Tuesday of 405 medical centers that have been the most diligent in following protocols to treat conditions like heart attack and pneumonia. Almost without exception, most highly regarded hospitals in the United States, from Johns Hopkins in Baltimore to the Mayo Clinic in Rochester, Minn., did not make the list!

"With evidence-based ratings gaining prevalence, and a strengthening link between quality and payment, the Joint Commission report raised questions about how consumers should best use the data newly available to them. Increasingly, one component of that inquiry may be whether hospital reputations are deserved or mythologized."

"As an example, none of the 17 medical centers listed by U.S. News & World Report on its “Best Hospitals Honor Roll” this year are on the Joint Commission’s list of 405 hospitals that received at least a 95 percent composite score for compliance with treatment standards. About one-third of a hospital’s score in the U.S. News methodology is based on its reputation as gauged by a survey of physicians...the Joint Commission list of top performers included a disproportionate share of small and rural hospitals, as well as 20 Veterans Affairs medical centers. About 14 percent of roughly 3,000 eligible hospitals made the cut."

"As it is, both private and government health insurers are beginning to tie hospital reimbursements to quality measures like infection rates and readmissions. Next year, compliance with procedural standards will become even more consequential, as the Joint Commission plans to withhold accreditation from any hospital that posts a composite score below 85 percent."

This report serves as a reminder that payers will use this data to strengthen the link between quality and payment.
Therefore, physicians should consider adjusting their treatment protocols and quality measurements accordingly.

Yours

Bernd

Wollschlaeger et al vs. Farmer et al

Court Grants Preliminary Injunction Against Physician Gag Law

Since Taking Effect, Unconstitutional Gag Law Had Chilled Speech by Florida Doctors

The Florida chapters of three national medical organizations, along with six physicians, applauded the decision of a federal district judge today to immediately block enforcement of the new state law that bars healthcare professionals from asking patients if they own guns and have them stored properly. These questions are a key element in the practice of preventive medicine.

The groups, along with individual doctors, had asked Judge Marcia Cooke of the U.S. District Court for the Southern District, Miami Division to issue a preliminary injunction because the new law has already curtailed the First Amendment rights of physicians across the state to speak with their patients about gun safety. A preliminary injunction is an order that prevents a party from pursuing a particular course of conduct until a case has been decided. To grant a preliminary injunction, the court must find that plaintiffs have a substantial likelihood of success on the merits of the case.

Lisa A. Cosgrove, M.D., FAAP, President of the Florida Chapter of the American Academy of Pediatrics (Florida Pediatric Society) said: “Pediatricians simply want to do what they do best: protect children. We hope that now we will be able to get back to working with parents to maintain their guns, pools and poisons to keep kids safe."

Dennis Mayeaux, MD, Chair, Board of Directors, Florida Academy of Family Physicians said: “The impact of this law has already caused serious rifts in physician-patient relationships. Casual conversations with patients often bring other medical issues to light, and erosion of these opportunities also erodes the quality of care. The preliminary injunction will now allow us to talk to our patients again about firearm safety.”

Stuart Himmelstein, M.D., American College of Physicians Governor for Florida, stated: "Reversing this law is essential in order to preserve the sanctity of the doctor -patient relationship by keeping the government out of the exam room. The preliminary injunction will preserve free speech between both doctors and patients as protected by the Constitution and which is necessary to obtain the highest of quality care that every citizen deserves."

Physicians and other healthcare professionals routinely provide their patients with information about a variety of health risks in the home and broader environment. Such preventive counseling has become a cornerstone in the practice of medicine and is recommended by numerous professional medical societies. In the course of practicing preventive medicine, healthcare professionals routinely ask and counsel patients about firearm safety.

The state chapters of the American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians collectively represent more than 11,000 healthcare professionals in Florida. On June 24, 2011, these organizations, along with six individual physicians, filed papers asking the court to enjoin the law because it substantially curtailed their First Amendment rights to exchange information with patients about gun safety.

The lawsuit challenging the Physician Gag law was originally filed on June 6, 2011, shortly after Governor Scott signed it into law. Prior to filing suit, the physician groups urged the Governor to veto the legislation since it infringes the First Amendment rights of healthcare professionals throughout Florida.

The organizations and individual physicians in the lawsuit are represented by Ropes & Gray (lead counsel), Astigarraga Davis (local counsel), and lawyers from the Brady Center to Prevent Gun Violence’s Legal Action Project.


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PDMP goes online!

Attached a link http://www.miamiherald.com/2011/09/01/2385732/fla-prescription-data-base-goes.html to an article from today's Miami Herald titled " Fla. prescription database goes into operation" highlighting the fact that as of September 1st Florida's prescription drug tracking system finally was up and running. That means that dispensers and pharmacies must upload their prescription data for Schedule II to IV to the database. Rebecca Poston, the system's program director in the Department of Health said that "Everything is working wonderful, I have not heard of any glitches related to the dispensers registering or uploading information in the system."
The Department of Health will not begin registering doctors and pharmacists until Oct 1, nor will they be able to get information out of the database until Oct. 17. In my opinion the registration and training process should start now and be phased in either by region, or other criteria to be determined by the Department to allow for a smooth transition and to motivate doctors to use the system. Its not too late to do that but leaving it until October 1st is cutting it too short.
Yours
Bernd

United Health On The Move

Attached a link http://online.wsj.com/article/SB10001424053111903895904576542553422509280.html to an article titled" UnitedHealth Buys California Group of 2,300 Doctors" reporting that United Healthcare will acquire the management arm of Monarch HealthCare, an Irvine, Calif., association that includes approximately 2,300 physicians in a range of specialties. This will establish United's Optum health-services unit as a formidable presence in California. Optum had previously taken over the management arms of two smaller southern California groups, AppleCare Medical Group and Memorial HealthCare Independent Practice Association.This serves as an example of how lines are blurring between insurance companies and health-care providers.
What can we do? Consider forming cohesive primary care and/or multi-specialty associations, utilizing EHR technology and based on the Patient-Centered-Medical-Home Model to compete in the rapidly changing healthcare marketplace.
We cannot ignore the writing on the wall. Change is inevitable!
Yours
Bernd

Pill Mills Under Pressure

Attached a link http://www.nytimes.com/2011/09/01/us/01drugs.html to today's New York Times front page article titled "Florida Shutting ‘Pill Mill’ Clinics."
The article highlights the accomplishments made despite the initial resistance by the current administration in Tallahassee.:

As of July, Florida doctors are barred, with a few exceptions, from dispensing narcotics and addictive medicines in their offices or clinics. As a result, doctors’ purchases of Oxycodone, which reached 32.2 million doses in the first six months of 2010, fell by 97 percent in the same period this year.
One indication that law enforcement officials are choking the supply of prescription drugs sold illegally in Florida is that the price of Oxycodone on the streets here has nearly doubled from last year, to $15 per pill from $8.
On Commercial Boulevard, a major street in Broward County, the number of pain clinics has fallen in the past year from 29 to one.
The fallout from the tougher laws may include an increase in pharmacy robberies, a problem that has been worse in Florida than any other state since 2007 (there were 65 armed robberies of pharmacies here last year).

As of today any health care practitioner who has dispensed a Schedule II-IV controlled substance, as defined in section 893.03, F.S. (i.e., OxyContin®, Percocet®, Vicodin®, Klonopin®, Xanax®, and Valium®), is required to report dispensing information to the Prescription Drug Monitoring Program’s database within seven (7) days after dispensing, in accordance with section 893.055, F.S. This includes pharmacies licensed under chapter 465, F.S., and dispensing health care practitioners licensed under chapter 458, 459, 461, 462, or 466, F.S
Now we must push to start educate physicians on how to use the PDMP and to encourage accessing the database to identify "doctors shoppers."
I am optimistic that we can achieve our goals.
Yours
Bernd