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.

Federal Health Insurance

Attached a link to an article titled " Most Governors Refuse to Set Up Health Exchanges" reporting that as of Friday, December 14th, more than half the states (including Florida) had rejected the Obama administrations pleas to set up their own health insurance exchanges. The exchanges are online market places where people can shop for private health insurance and obtain federal subsidies to help defray the cost. The Congressional Budget Office has estimated that in 2014 about 25 million people will eventually receive coverage through the exchanges. A total of 32 states that haven't agreed to set up their own insurance exchange could present the biggest challenge to fulfilling the law's requirement. In all, around 197 million people live in states that have chosen not to run their own exchanges. Of those people, about 18.3 million are uninsured and have incomes that could qualify them for subsidies if they bought policies through the exchanges.Federal officials and federal contractors will set up and run the exchange in any state that is unable or unwilling to do so. In my opinion the states refusal to set up their own exchanges will preclude those states to address specific insurance and demographic issues. A federal "off-the shelf" solution may not be sufficient to meet those specific requirements. The losers will be those uninsured who are forced to buy what the federal market place can offer. On the other hand, as a single payer advocate I also foresee that a consolidated federal market place may offer a first step for a national health insurance. So may be I should send a thank you note to Governor Scott. Yours Bernd

Medicaid and Primary Care

Attached a link to an article written by John Dorschner titled "Florida will pay Medicaid docs at new Obamacare rate" highlighting that Governor Scott's administration finally relented and, starting Jan. 1, Florida will begin paying Medicaid primary care doctors at new, higher rates required by the federal Affordable Care Act, a state spokeswoman said. The law requires that for the next two years Medicaid must pay primary care doctors at higher rates. According to a study by the Kaiser Family Foundation, Florida primary care doctors in 2008 were paid 55 percent of Medicare rates, meaning a $50 payment would be increased to $90 under the new system. That's indeed good news for all of us, primary care doctors and patients alike. In my case I re-enrolled as a Medicaid provider because more and more of my patients qualified for Medicaid and wanted to continue their care with me. Now, I can afford treating them without loosing money. A great victory for common sense!! But we also have to start demonstrating that this investment into preventive care and chronic disease management will save precious healthcare dollars by decreasing hospital admissions and emergency room utilization rates. That requires the implementation of new care delivery systems such as Patient Centered Medical Homes. I am confident that we can achieve these goals. Happy Thanksgiving Yours Bernd

Governor Scott and Common Sense: A Contradiction?

Attached a link to an article titled "Rick Scott Signals Willingness To Negotiate On Health Care Law" reporting that Florida Governor Rick Scott, one of the most outspoken critics of President Obama's health care law, signaled Tuesday that he may be ready to drop his longstanding opposition to the Patient Protection and Affordable Care Act. In an interview with the Associated Press, the Republican said that he is willing to negotiate with the federal government on implementing the new program. "The election is over and President Obama won," Scott said. "I'm responsible for the families of Florida. … If I can get to yes, I want to get to yes." "I don't think anyone involved in trying to improve health care should say 'no, no, no,'" Scott continued. "Let's have a conversation." Sounds good BUT talk is cheap. Governor Scott can show his change of heart by informing the U.S. Department of Health and Human Services by the deadline tomorrow whether he will set up a Florida health insurance exchange, partner with the federal government, or leave the task to U.S. authorities. The clock is ticking Governor!!

Tallahassee is not Teheran

Tallahassee is not Teheran: We need a real Governor and not a spiritual (mis)leader Attached a link to John Dorschner's excellent front page article in today's Miami Herald titled “Gov. Rick Scott may shift stance on health reform law” reporting that Florida Governor Rick Scott may be open to discuss the (partial) implementation of the Patient Protection and Affordable Care Act (PPACA). The article correctly points out three important milestones which need to be achieved in order to move ahead with the healthcare law implementation: 1) The statutory deadline for submitting Florida’s blueprint for a new health insurance exchange is November 16. Unfortunately, the stubborn refusal of our political leaders in Tallahassee to even consider the creation of a healthcare exchange will force the federal government to step in to set up such an exchange. 2) According to the final PPACA rule Medicaid payments to primary care physicians will be increased to reach Medicare levels. The final rule requires state governments to take further action prior to 2013 to implement this provision. States, including Florida, will receive an estimated $11 billion in new funds over 2013 and 2014 to bolster their Medicaid primary care delivery systems. More than six in 10 (64 percent) family physicians accept new Medicaid patients, and these beneficiaries comprise 15 percent of the average family physician’s patient panel. Governor Scott has refused to accept additional Medicaid funding to increase the pay for primary care physicians. As a result of the increasingly inadequate Medicaid payments nearly two in 10 family physicians have stopped accepting new Medicaid patients. 3) On Jan. 1, 2014, a major expansion of people covered by Medicaid will go into effect. If Governor Scott decides not to expand Medicaid coverage, Florida will lose $27.9 billion in federal funds over 10 years. That breaks down to a $4.5 billion loss for Miami-Dade during that time, and a $2.3 billion loss for Broward. Under the law, Washington will pay all Medicaid expansion costs for the first three years, but then the states would have to pay up to 10 percent of the costs in following years which will amount to approximately $1.7 billion over 10 years in Florida. The expansion could provide coverage to an additional million-plus Floridians. Florida's political leadership has so far stubbornly refused to participate in or prepare for ANY of the above mentioned changes. Subsequently, billions of federal funds will be appropriated to those states who do participate. Our political leaders should be aware about the adverse consequences of their stubborn refusal to implement this federal law. Florida having the third-highest rate of uninsured residents in the country stands to benefit more than most states from the Medicaid expansion intended to increase preventive care and to reduce unnecessary emergency room visits. Health experts warn that not expanding Medicaid could cost Floridians, because many of the state's 3.8 million uninsured residents will continue to receive care they can't pay for in hospital ERs. Those costs ultimately are passed down in the form of higher insurance premiums for everyone else and will further strain the existing Medicaid budget. Often hospitals end up absorbing large amounts of uncompensated, or "charity" care, which experts say affects Floridians in several ways. To recoup those costs, hospitals either reduce services or charge higher rates to insurance companies, or both. Those costs are often passed down to businesses as a “hidden tax” adding to the insurance costs for their employees. Furthermore, health providers have long complained that Medicaid reimbursements are so low they don't cover the costs of care. And because of low reimbursements, fewer physicians in the state actually accept new Medicaid patients. The increase in Medicaid reimbursement by almost 7 % for primary care physicians will allow family doctors, pediatricians and internists to accept new Medicaid patients and to offer urgently needed preventive medical care. I am convinced that Governor Scott knows all of the above mentioned facts but he still refuses to act. In my opinion this represents an egregious case of political malpractice ! Why is this being overlooked? Maybe, Republican leaders consider Tallahassee as their spiritual Mecca and are sacrificing the health of our citizens on the altar of ideological correctness and purity. But Tallahassee is not Teheran and we definitely do not need a supreme leader to decide our personal fate. Governor Scott should recognize that he is not the Governor of the Republicans of Florida but the Governor of the State of Florida. If he is incapable or unwilling to fulfill his constitutional obligation to implement a federal law then he should step down! Its time to man up Governor or to hit the road! Bernd Wollschlaeger,MD,FAAFP,FASAM

GOP Lawmakers call for suspension of meaningful use incentives

Its obvious that even the pending presidential election does not prevent the outbreak of a silly season on capitol hill. The letter sent by House Republican leaders to HHS Secretary Kathleen Sebelius is such an example filled with inconsistencies, falsehoods and fear mongering. The authors "believe that the Stage 2 rules are...weaker than the proposed Stage 1 regulations released in 2009. The result will be a less efficient system that squanders taxpayer dollars and does little, if anything, to improve outcomes for Medicare." They specifically point out that the Stage 2 regulation lower the threshold of compliance compared to Stage 1 meaningful use. The authors specifically criticize the fact that Stage 2 regulation "fail to achieve comprehensive interoperability in a timely manner" and claim that Stage 2 rules "eliminate the requirement to exchange information with other providers." They further claim that the alleged absence of interoperability standards represents a waste of $10 billion already spent for this program. To top it off they quote a New York times article claiming that EHR technology contribute to higher Medicare spending because EHRs " making it easier to bill for services, whether or not they [ hospitals and physicians] provide additional care." Based on the above arguments the Republican leaders call for a suspension of the incentive payments, significantly increase requirements for meaningful users, take steps to "eliminate the subsidization of business practices that block the exchange of information between providers." Now lets separate facts from fiction and ideology from reality. The Republican leaders and their staff seem to have omitted the fact that physician organizations asked CMS to lower the threshold of compliance and ease the requirements to achieve Stage 2 MU standards. In a letter sent to CMS by the American College of Surgeons,dated July 9th 2012, which was signed and endorsed by 24 medical specialty organization the authors emphasize that the Stage 2 rules may be too ambitious for small practices and " the significant initial price of implementation remains the greatest barrier to its adoption among small practices. For small practices, the high cost of EHR adoption is not offset by existing financial incentives. To the contrary, practitioners face uncertainty regarding the value they will receive. This is because the initial financial benefits of adoption, if they even exist, are difficult to quantify." Based on this request any further tightening of the compliance requirements will jeopardize the EHR implementation and a delay, or suspension, in incentive payments will make it nearly impossible for small practices to even comply with the Meaningful Use requirements. Until now more than seventy percent of hospitals have registered for the EHR incentive payments, and 55% have received their first-year payments. Healthcare organizations have made plans and are looking for that money to be paid to further invest in EHR technology and provider training. Nearly 294,300 physicians and other “eligible professionals” have enrolled for EHR incentive payments under the Medicare, Medicare Advantage and Medicaid programs and not quite 140,500 have been paid, according to the CMS. These funds represent a significant stimulus and provide desperately needed cash flow for financially strapped medical practices. Any suspension of those funds will especially penalize small business owners who will be forced to lay off staff and curtail purchasing. Is this what we need in our struggling economy? I am concerned that the Republican lawmakers, or their staff, have either not read, or misunderstood, the Stage 2 meaningful use objectives. Those clearly state that the test of “exchange of key clinical information” core objective from Stage 1 is eliminated in favor of a more robust “transitions of care” core objective in Stage 2; and the “Provide patients with an electronic copy of their health information” objective is also eliminated because it was replaced by the “electronic/online access” core objective. The final rule adds “outpatient lab reporting” to the menu for hospitals and “recording clinical notes” as a menu objective for both EPs and hospitals. There will be 20 measures for EPs (17 core and 3 of 6 menu) and 19 measures for eligible hospitals and CAHs (16 core and 3 of 6 menu). The final rule reduces some thresholds for achieving certain measures and modifies criteria for exclusions to respond to difficulties commenters identified in implementing certain objectives in certain situations. For example, for some objectives CMS has added exclusions based on broadband availability that allow providers in rural or underserved areas to achieve meaningful use with fewer hurdles. Initially, CMS also proposed two ambitious measures for the "Electronic Exchange of Summary of Care Documents " objective in Stage 2. The first measure required that a provider send a summary of care record for more than 65 percent of transitions of care and referrals. In the final rule CMS is reducing the first measure to a lower threshold of 50 percent. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals, and that the summary of care be electronically sent to a provider with no organizational or vendor affiliation. The intent of this second measure was to foster electronic exchange outside established vendor and organization networks. CMS is finalizing the 10 percent threshold for electronic transmittal, but eliminating the organizational and vendor limitations. Instead, CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR. Yes, interoperability is important and we should not relent our focus on this essential issue. But Stage 2 builds on the current phase and starts to emphasize data sharing. The main focus areas is the new requirements and enhanced standards for exchanging information. These rules are a true game changer in advancing interoperability between providers and patients. The goal of these rules is to improve patient outcomes by providing right information at the point of care. Highlights of improved/changed interoperability rules include: Provide summary of care document for transitions of care and referrals Provide online access to health information to patients with more than 5% of patients actually accessing the information Transmit structured electronic lab/image results to ambulatory providers Use secure messaging with patients A major one - use of data portability standards. Standards for coding structured data that is sent in the summary of care documents or other documents. Not only these standards will reduce errors but also will accelerate the use of analytics and secondary uses of the data. Transmission of information to cancer registries. Claiming that EHR technology contribute to higher Medicare spending because it easier to bill for services, whether or not they [ hospitals and physicians] provide additional care, is an insult to all decent physicians and other healthcare providers who, until now, had to accept dwindling insurance payments and intrusive insurance audits. EHR technology provides better documentation and coding tools which guarantees that a physician is being paid for what he does and not for what the insurance company decides he is worth receiving. EHR technology empowers physicians to be paid fairly and not arbitrarily. Its obvious whose side those Republican are representing. Its also obvious that insurance company lobbyist have contributed to the content of this letter and are now trying to scuttle any gains physicians made in achieving fair reimbursement. This letter should be rejected as an example of cheap propaganda and physicians bashing. Yours Bernd

Medicaid in Florida

I just returned from Germany where I attended a conference in Berlin. Read the attached excellent article by John Dorschner online in my hotel room and, what a coincidence, that same weekend an article in a German magazine highlighted healthcare cost control measures within the German universal healthcare system. In my opinion the Medicaid reform measures are doomed to fail as long as physician practices are incapable to measure the quality, outcome and costs of care rendered. The fee-for service model rewards volume above value of care and the participating physicians have no other choice but to apply this doomed treatment paradigm to keep their practices afloat. In a recent New England Journal of Medicine article the authors called for reengineering prevention into the U.S. System to accelerate the transition from Sick Care to Health Care. The Patient Centered Medical Home (PCMH) represents the foundation of such a new approach to health care including reconnecting medicine to public health services and integrating prevention into the management and delivery of care. Furthermore, the utilization of information technology tools within a PCMH allows for the value stream mapping for healthcare delivery to determine if what we spent for healthcare translates into cost-efficient, high quality and patient centered care. Eliminating administrative waste, i.e. insurance companies, is part of the value stream mapping process and must be addressed to transform our highly inefficient sick care system into a patient centered health care model. Bernd

Attached a link to a provocative editorial titled "Simple Treatments, Ignored" focusing on the poor outcome of hypertension treatment. The editorial reflects on the findings of a recent federal health analysis which found that nearly one-third of all American adults have high blood pressure and more than half of them don’t have it under control. The new analysis, issued last Tuesday by the Centers for Disease Control and Prevention, found that 67 million Americans had high blood pressure and that 31 million of them were being treated with medicines that reduced their blood pressure to a safe level. The remaining 36 million fell into three groups: people who were not aware of their hypertension, people who were aware but were not taking medication, and those who were aware and were treated with medication but still had hypertension.There are many missed opportunities for people with high blood pressure to gain control. Doctors, nurses and others in health care systems should identify and treat high blood pressure at every visit. The editorial not only points out that this is an abysmal record for a medical condition that is easy to detect and treat but also features solutions. Kaiser Permanente says that in Northern California it increased the percentage of patients whose hypertension was under control from 44 percent in 2001 to 87 percent in 2010. Over approximately the same period, stroke mortality declined by 42 percent, heart attacks by 24 percent and the most serious type of heart attack by 62 percent. The organization created a hypertension registry to track patients and the care they were getting; eased the burden on doctors by using pharmacists to initiate drug therapy and medical assistants to monitor patients’ progress; made it easy for patients to get free blood pressure checks; and showed doctors how their record on controlling blood pressure compared with others in the system. In my opinion our healthcare system is dysfunctional and deeply flawed. The system is still characterized by the separation of functions and tasks delivered by a plethora of healthcare providers who collect mountains of paper, or now Terabyte of data, but fail to share such data efficiently to coordinate care. We must break down these walls of isolation and collaborate in teams. Patient Centered Medical Homes can provide solutions to this problem but we need to accelerate its implementation and deploy community-based healthcare teams comprised of doctors, nurses, social workers, pharmacists, community activists etc. We have to break down the barriers built by professional organizations which protect the interest of its members, but lost their focus on public health. Such a local, regional and national strategy can control healthcare costs, improve quality of care and decrease debilitating morbidity related to chronic diseases. What are we waiting for? Yours Bernd

The Role of Safety Net Providers

Attached a link to an article published in the recent edition of Health Affairs titled " Safety-Net Providers In Some US Communities Have Increasingly Embraced Coordinated Care Models." The findings of this study were also the focus of an article by John Dorschner published in the Miami Herald titled " Jackson Memorial Hospital too weak, county too divided to provide good safety net, study says." Here are some background information, facts and study findings excerpted from the article: FACTS: Safety-net providers play a crucial role in providing health services to uninsured and low-income people. Although the Affordable Care Act is expected to expand coverage to more than thirty million uninsured people, it is generally recognized that the safety net will still be needed to provide services to an estimated twenty million people who will remain uninsured. In addition, in all likelihood, many existing Medicaid and newly insured patients will continue to use safety-net providers rather than private mainstream providers because the safety net can better meet low-income people’s specialized needs related to language, culture, and transportation PROBLEM: Delivery of health services through the safety net historically has been fragmented. Usually hospitals, community health centers, and private physicians providing charity care have operated independently of each other, with little or no coordination of the care of a patient. Such fragmentation can result in severe gaps in the availability of services, reduce quality, lead to redundant use, and increase the costs to providers who typically operate with limited resources and thin margins. SOLUTIONS: During the past decade, however, a variety of community efforts to better coordinate care for the uninsured that reduce the use of emergency departments and increase the use of primary care providers have been documented. Most community initiatives focus on providers’ efforts to better manage care for their uninsured patients; stretch limited public and private funds; and address serious gaps in services, particularly the lack of access to specialty care. Often these programs improve access to care for the uninsured at a much lower cost than either private insurance or local Medicaid programs. STUDY DESIGN: The Community Tracking Study, conducted by the Center for Studying Health System Change, consists of in-depth tracking of health system changes in twelve randomly selected metropolitan areas from 1996 to 2010. Representative of US metropolitan areas, the communities are Boston, Massachusetts; Miami, Florida; Orange County, California; northern New Jersey; Cleveland, Ohio; Indianapolis, Indiana; Phoenix, Arizona; Seattle, Washington; Lansing, Michigan; Syracuse, New York; Greenville/Spartanburg, South Carolina; and Little Rock, Arkansas. The article describes safety-net coordination efforts in twelve randomly selected communities and illustrates how these efforts evolved during the past decade. In particular, we focus on initiatives that attempted to coordinate care across multiple providers and were often communitywide in scope. These initiatives were better able to manage the care of uninsured patients than a more fragmented system of care (for example, the initiatives used more outpatient primary care to reduce inpatient and emergency department use). Some evidence obtained from the twelve communities indicates that initiatives to coordinate care across providers reduce high levels of emergency department use and reduce the cost of providing care to the uninsured, but barriers to coordination remain. SELECTED KEY ASPECTS & FINDINGS OF THE STUDY : Nine of the twelve communities studied had some type of organized safety-net program in 2010, compared to only three communities in 2000 Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. Five of the six programs explicitly require patients to have a medical home that they use for all primary care needs. A primary care physician practice that serves as a medical home is generally responsible for authorizing referrals for specialty care. Generally, a single primary care physician serves as the medical home for program participants. An exception is HealthNet in Boston, which is organized around the fifteen participating federally qualified health centers that serve as medical homes for the patients who are referred to Boston Medical Center (the safety-net hospital that administers HealthNet) for specialty and inpatient care. Centralized referral networks are the most common type of community initiative and have grown most quickly during the past decade. They focus primarily on providing a centralized location where patients can receive referrals to physicians and schedule appointments with private practice physicians (mostly specialists) who agree to treat uninsured patients for free or at reduced costs. A few of the (MEDICAL HOME) programs use provider incentives, such as capitation or enhanced fees, to encourage appropriate utilization of services for patients. For instance, the Medical Services Initiative in Orange County offers financial incentives for physicians to join the network. The program also includes extra payments for medical homes to provide at least one visit for each patient per year (two for people with chronic conditions), pay-for-performance incentives for medical homes to improve utilization of preventive services, and incentives for providers to reduce emergency department utilization. Health Advantage in Indianapolis pays capitated rates to primary care physicians to motivate physicians to encourage appropriate use of services and build relationships with their patients. It is unknown, however, whether these incentives are inadvertently discouraging the use of appropriate or necessary services. Formal evaluations of the six coordinated care programs have not been conducted or are not publicly available. One reason may be a lack of staff availability or other resources. However, available data show that Health Advantage in Indianapolis has been successful in decreasing inpatient use and emergency department use. In the first eighteen months after the program began, inpatient days for uninsured people decreased by 50 percent, and emergency department use decreased by 30 percent. In addition, in collaboration with researchers from the University of California, Los Angeles, the Medical Services Initiative in Orange County found that the ER Connect program reduced emergency department visits and increased the number of visits to primary care providers.Recent research on similar programs not included in the Community Tracking Study found that their patient costs were 25–50 percent lower than for patients enrolled in local Medicaid programs or through private insurance. What are the challenges and problems safety-net providers face? Many of the programs lack the capacity to serve all of the eligible uninsured. Providers’ practices are often full, and they have limited availability to see new patients, especially uninsured patients for whom they provide care for free or for reduced fees. Publicly subsidized programs are vulnerable to cuts in funding, especially given the strained local and state budgets of recent years. A major concern is the potential loss of funding for programs that have relied on Medicaid’s disproportionate-share hospital payments, extra payments to hospitals that serve a large number of Medicaid and uninsured patients, which are to be reduced under the Affordable Care Act. Health insurance coverage expansions in the Affordable Care Act may create the perception that the uninsured problem has been solved and these safety-net programs are no longer needed, potentially bringing an end to such efforts. Despite efforts at greater community collaboration, fragmentation and competition among safety-net providers remains. Competition among safety-net providers for Medicaid patients can inhibit closer cooperation. Most safety-net hospitals and federally qualified health centers depend on Medicaid patients for their financial viability both because reimbursements are based on the cost of care (and therefore are considerably higher than reimbursement rates to private physicians) and because grant revenue often doesn’t cover the full cost of care to the uninsured. Community health centers may be reluctant to participate in collaborative arrangements if they think that such cooperation could result in a loss of Medicaid patients. For example, interview respondents from Miami noted that some federally qualified health centers in the community were concerned that efforts by Jackson Health System (the main public hospital) to convert some of its primary care clinics to federally qualified health centers would increase competition for Medicaid patients, given the higher Medicaid rate that the hospital-based clinics receive. Safety-net hospitals are often the natural leaders for community integration efforts given their size and broad service area, not all safety-net hospitals are willing or able to assume that role. For example, Jackson Health System is the primary safety-net hospital for Miami-Dade County but generally does not provide a leadership role in coordinating care and services with other safety-net providers in the community. Part of this reflects Jackson’s financial troubles at the time of the site visit (Jackson lost about $240 million in 2009 and $100 million in 2010), which forced it to cut back on some services. But it also reflects the fragmented nature of Miami’s safety net, which respondents characterize as having more competition than coordination and collaboration among providers to provide care to low-income Medicaid and uninsured patients. Outlook & Opportunities: Safety-net providers—including health centers and hospitals—can form accountable care organizations to participate in Medicare’s Shared Savings Program, in which networks of providers that jointly take responsibility for the cost and quality of care provided to their patients can share in Medicare savings. New demonstration projects to test new payment and care delivery models have a potential impact on safety-net coordination.15 For instance, the bundled payment model involves a single payment to multiple providers for an episode of care, which motivates providers to coordinate and deliver care more efficiently. Safety-net coordination initiatives are also well poised to facilitate the insurance coverage expansions and health insurance exchanges created in the Affordable Care Act because of their established centralized enrollment systems that screen for eligibility for other public insurance. A MUST read article! Yours Bernd

Medicaid Expansion in the News

I case you missed those articles. Carol Gentry's great article titled Medicaid expansion could save over 5,000 lives was published in yesterdays Miami Herald " Other Views" section. In the article she referred to a recent New England Journal article titled Mortality and Access to Care among Adults after State Medicaid Expansions which concludes that State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health. Carol Gentry correctly argues that " If Medicaid expansion prevents 2,840 deaths/year for every 500,000, then Florida’s looking at 2,840 times 2, or about 5,680 a year. These are early deaths that are preventable. So when the debate begins about Medicaid expansion, remind those who control the state that they aren’t just talking about money. They’re talking about lives." She provided a factual contrast to Rick Scott's position whose "arguments" can be boiled down to a simple dogma: We need to help people get the skills and education they need to get a job, and help the private sector succeed so they have jobs to offer. Then you’ll have fewer people dependent on government programs because they’ll be pulling themselves out of poverty and financial distress. There is ONLY one problem! Even higher education and more skills won't get you better paid jobs anymore and no more unions are available to fight for workers rights, benefits and fair pay! Therefore, people need to work in two or three jobs to make ends meet which almost always is not enough to pay for expensive health insurance premiums. Rick Scott's line of argument reminds me of the statements made by communist party officials I encountered many years ago when I spent some time in communist East Germany and had to endure the ideological communism babble. Its almost the same tune: we need more .... ism to make people happy. Well, extreme right and left do meet each other at the fringes of extreme "thinking." But as of today at least I know that our rights come from nature and God, not from government. Guess, I have to do a bit more praying to get access to those rights fast because my health insurance premiums keep on rising. Yours Bernd