A Sick System

Attached an editorial from today's Miami Herald titled " A Sick Situation" highlighting how broken our Medicaid system really is. Profits before Patients, that's the new mantra. Big insurance companies receive approximately $248 per member per month and physicians, who carry the burden of the care for the very sick and needy, get paid a pittance. Anyone wonders why physicians are dropping their Medicaid provider status? Why do we have to accept this nightmare of a so-called healthcare system for the poor? Yours Bernd A Sick System: Florida’s impoverished children need legislative champions on both sides of the aisle — again. Last week, a federal judge blasted the state of Florida for shortchanging poor and disabled children and the pediatricians who care for them by setting the state’s Medicaid budget at an abysmally and artificially low level for at least 10 years. As a result of the state’s dereliction, many pediatricians across the state dropped out of the program, meaning thousands of children are denied lower-cost preventive medical and dental care. That means that, too often, they have to get more-expensive emergency care when a preventable illness worsened. And that means that, in addition to state leaders turning their backs on sick children, they have shortchanged taxpaying Floridians, too. U.S. Judge Adalberto Jordan last week found that the state’s stinginess forced Medicaid providers for poor children to be paid far below what private insurers would pay. In addition, it was below what doctors in the Medicare program, which serves the elderly, were paid. And, he said, it was illegal, a violation of federal laws Stuart Singer, the Fort Lauderdale attorney who for a decade has been battling on behalf children receiving care through Medicaid, told the Editorial Board that Judge Jordan will set a hearing to start the process of determining “injunctive relief.” The lawsuit goes back a decade, spanning the administrations of Govs. Jeb Bush, Charlie Crist and, now, Rick Scott. This record of failure should end on the newly re-elected governor’s watch. The less the state spends on Medicaid for children’s care, the fewer matching funds it gets from the federal government. That makes no economic sense whatsoever. The state has argued that the violations cited are a thing of the past, and that it is providing cost-effective care through the Statewide Medicaid Managed Care program. The judge’s findings, however, tell a different story. According to Herald investigative reporter Carol Marbin Miller’s article, Judge Jordan found that: ▪ Almost 80 percent of children enrolled in the Medicaid program “are getting no dental services at all.” ▪ Because physicians’ payments are so low, one-third of the state’s children on Medicaid are without preventive medical care, whether they are paying fee-for-service or under managed care. ▪ A high percentage of infants have not had “a single well-child visit in the first 18 months of their lives.” ▪ Florida health regulators sometimes switched needy children from one Medicaid provider to another “without their parents’ knowledge or consent.” ▪ Thousands of children are kicked out of the Medicaid program each year, sometimes because of nothing more than bureaucratic error. Judge Jordan would do well to render a judgment that the state must end these practices and make Medicaid the reimbursement rate commensurate to that for Medicare. Last year, Sens. Eleanor Sobel, D-Hollywood, and Denise Grimsley, R-Sebring, teamed up to muscle through improvements in how the Department of Children & Families monitors abused and neglected kids in its care. Sick kids will need similar advocates in the upcoming legislative session. With a hefty budget surplus, the estimated $200 million needed surely can be found. There is no excuse for undercutting children’s health. Pay now, or pay later. Read more here: http://www.miamiherald.com/opinion/editorials/article5466552.html#storylink=cpy

Why Medicaid Makes It Impossible To Practice Medicine

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

Overdose Deaths Declined

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

Gun Violence and Doctors

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

Medical Marijuana

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

Medical Marijuana in Florida

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

Guns and Public Safety

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