Gun Violence and Doctors

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

Medical Marijuana

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

Medical Marijuana in Florida

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

Guns and Public Safety

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

Weapons in Doctors Offices

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

Medical Marijuana

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

Judge Strikes Down Drug Testing Law

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

Cheaper or Better Care

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

Medical Marijuana

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

Health Department Bars Insurance Aids

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

Does Fear Drive Defensive Medicine?

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

Medicare Myth

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

Prescription Drug Monitoring Program Under Attack

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

PDMP on Life Support

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

Healthcare Law Implementation Delayed

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

Florida Gun Laws and the Absence of Common Sense

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

Big Profits (Again) For Florida's HMOs

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

Healthcare in Florida

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

Insurance Rate Increases

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

Stop Medicare Fraud

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