Tuesday, April 5, 2016

MOC (Maintenance of Certification) sneaks in little by little


We've just seen how MOC stealth worked in Kentucky where an attempt to require MOC for licensure may've been nicked in the bud. The  KY legislature passed a bill to prohibit the KY Board of Licensure from requiring MOC as a condition of licensure. The bill was delivered to the Governor on March 29 after a 90 to zero vote. This column will disclose if it was signed or not as soon as we get notification. The point is that in California some have said the situation isn't as dire because the thrust in California is to require MOC only for continuing certification as a specialist recognized by the ABMS (American Board of Medical Specialties) and by its contingent boards such as ABPN (American Board of Psychiatry and Neurology) which in 2012 compensated the CEO to the tune of $843,591 while the former president was paid $471,362 -- the ABMS boards are showing us how one can make more money from non-profits than from for-profit companies (this information  is available on each ABMS board's IRS 990 form, open to public scrutiny). 

In California, while the issue hasn't reached the level of requiring MOC for licensure, but only for specialty recertification, the situation now exists whereby non-MOC physicians may lose hospital privileges or suffer disqualification from insurance company panels. In San Jose the  medical staff at Regional Medical Center voted down any requirement for MOC -- their feeling was that the current requirement of 50 hours of CME (Continuing Medical Education) every two years was enough. In Michigan we've learned that BCBS now requires certification for payment as a specialist.  We've also learned that the Washington State Medical Association has come in as opposed to MOC (one of their bill's authors called me for a comment about CMA -- I referred him to a CMA person who is good at mumbling). 

If we look at the IRS form 990 for the ABIM (American Board of Internal Medicine) we find out that aside from the $628,952 paid to its physician-prexy another 14 persons were compensated from $197,239 to $464,747. These levels of compensation explain why heavy-duty MOC fees are needed -- that's the fuel required to pay for $55 million-a-year businesses such as ABIM.  

We don't hear much about this subject in our professional journals. One can guess with reasonable medical accuracy that most journal editors are comfortable and won't want to raise the hackles of the ABMS. There appears to be conflict between the well enfranchised and their less well endowed colleagues in fulltime practice that now is coming close to outright hostility. 

It appears that government and big business have made a joint discovery  --  control of medical practice is more lucrative than the actual practice of medicine.

Paul Teirstein, MD, put it this way in a letter to NEJM: "it's time for practicing physicians to take back the leadership of medicine."
In 1995, this writer wrote an editorial about "regaining control of medical practice." If that objective is looking increasingly like a pipedream, the losers will be our patients.

References

Weinmann, Robert L.,MD, CLINICAL EEG, V. 26, # 1, 1995

Teirstein, Paul, MD, NEJM, 8 January 2015


Friday, March 4, 2016

Trigeminal neuralgia -- one helluva headache! One helluva denial of care!



President Obama made this ringing declaration when he was promoting the Affordable Care Act:  "I will ensure that no government bureaucrat gets between you and the care that you need." 


Now comes Trigeminal Neuralgia,  known in medical neurological parlance as a particularly vicious type of headache, so severe  that some victims contemplate suicide. All the same there is a treatment for this disease that is remarkably successful in most cases. The usual treatment is with a medicine known as tegretol. Today's story is about a star-crossed patient who was unable to tolerate tegretol and what happened to her when Gubbamint Bureaucrats got their hands on her case.   

Initially, the patient was overjoyed. Her debilitating headaches evaporated under treatment with tegretol. Imagine, then, her consternation when she developed an allergic reaction to the medication. The allergic reaction included skin rash and an alarming development of abnormal hepatic function tests. There was no choice but to discontinue the tegretol. 

Doctor X replaced the tegretol with gabapentin which also worked. However, there were physiological non-allergenic side effects, e.g., dizziness, impaired balance, and sedation. So now the second successful medication had to be replaced. This step was taken with an extended release form of gabapentin known as Gralise. Medicare approved the use of Gralise but after a year another application to continue use of this medicine had to be submitted to the Center for Medicare and Medicaid. The Center for Medicare and Medicaid then rejected the proposed use of Gralise even though it had now been the patient's chief headache prevention medication for over one year. 

The reason was that FDA had approved Gralise for Herpetic Neuralgia only, not for Trigeminal Neuralgia. On this flimsy basis, Medicare in one fell swoop allowed the misery of intractable headache to invade this patient's life once again. Use of the medication for a different type of pain was called "off label" and subjected to unthinking automatic rejection. 

Doctor X appealed at the state level. In California the law allows continuation of care under such circumstances, e.g, AB 974 (Gallegos), a managed care reform bill that requires managed care plans to continuously provide prescription drugs. Unfortunately, this state legislation can be overruled by federal law that precludes "off label" prescribing. The next step was appeal to the Medicare Appeals and Grievance coordinator who pointed out that Medicare only allows medications to be covered on Part D when the FDA has approved the medication for that specific use -- in this case FDA had approved the medication for one form of neuralgia but not for another. Next, Doctor X sought a hearing before a judge in the Office of Medicare Hearings and Appeals. The case was made that FDA approved the medication for one form of neuralgia so it was reasonable in this case, especially since the medication had worked well for this patient for over one year, to allow renewal. 

Unfortunately, logic and science lost out to rule-making and semantics. The court ruled that the patient could not have the Gralise covered under Medicare. The judge's final letter of denial was issued on 2/18/16. The question arises as to what extent the federal system is responsible for denial of care when an adverse event occurs as a result of governmental ineptitude. 

In 1999 the Oregon Board of Medical Examiners disciplined a doctor for insufficiently treating pain. In discussing an analogous situation in California in 1979, Dr. Wm. Steinmith wrote that "a variety of official police bureaus -- under the rubric of protecting the public from professional abuse and abusers -- are rapidly destroying the professional foundations of humane and rational medical care." This author's opinion is that the Center for Medicare and Medicaid acted arbitrarily and wrongly in this case. 

Previously, The Weinmann Report, www.politicsofhealthcare.com, 3/18/14, and workcompcentral, 3/26/14, showed how an insurance company's Utilization Review company declined authorization of analgesic medication. 

This writer's finding is that the newest epidemic is the denial of medications by one or another form of Utilization Review at both state and federal levels. Physicians will take the blame while patients get the shaft. We need to hold the presidential podiatry to the fire on this issue lest all of us in due course get burned by the "government bureaucrats" from whom President Obama promised to protect us. 

References

"Utilization Review: Hypocrisy in Velvet Gloves," workcompcentral, 2014-03-26 and The Weinmann Report, www.politicsofhealthcare.com, 2014-03-18;

The Hill Newspaper, Washington, DC, 9/16/09, "What Obama should've said about health reform," by Robert L. Weinmann, MD;

Headache Quarterly, V. VII.  #4, 1996, "Predatory Policies in Health Care: Headache Patients as 'Marks,' " by Robert L. Weinmann, MD;

New York Times, National, 09/04/99, "Oregon Board Disciplines Doctor for Not Treating Patients' Pain;" 

San Francisco Medicine, "Professional Judgment," July 1979, by William Steinsmith, MD. 








Saturday, January 16, 2016

MEDICAL STAFF VOTES AGAINST MANDATORY MOC (MAINTENANCE OF CERTIFICATION REQUIREMENTS)



BOARD CERTIFICATION: SHOULD THE GENERAL PUBLIC HAVE AN INTEREST IN THIS ARCANE SUBJECT? IN THE OPINION OF THIS WRITER, THE ANSWER IS YES. The extravgant remuneration of American Board of Medical Specialty (ABMS) CEOs and presidents has been disclosed to be as high as $1.3 million at the American Board of Pediatrics (ABP), $681,000 at the American Board of Internal Medicine (ABIM), and over $800,000 at the American Board of Psychiatry and Neurology (ABPN). This level of remuneration requires high costs for Maintenance of Certification (MOC) and for study programs acceptable to each of the boards. These requirements in turn cut down on the amount of time practicing physicians can spend with patients and their own families. MOC requirements unnecessarily increase physicians' administrative costs, in turn helping to drive medical costs ever upwards. To date there is no evidence-based science showing that these requirements improve medical care. Here is how one medical staff recently dealt with this matter (the following is verbatim reproduction of the resolution passed by the hospital's medical  staff). 

ARGUMENTS AGAINST

THE BYLAW AMENDMENT REQUIRING BOARD CERTIFICATION 

Several concerns have been raised as to the way this amendment to the medical staff bylaws has been written

#1  Requirement for board certification is NOT the community standard.

#2  New physician members who subsequently allow their board certification to lapse or marginally fail to pass recertification will immediately lose their medical staff privileges.

#3  The logistics of maintaining continuous active certifications in multiple boards (as required by certain subspecialties) carries with it the very real risk of a possible time gap in active certification (with a resultant loss of privileges)

#4  Physicians at the mid-point of their careers, who are otherwise well qualified in their specialty and who have previously passed their boards (but did not recertify) would not be eligible to apply for medical staff privileges.

#5  Current physicians who fail to complete the re-application process or pay their medical staff dues in a timely fashion automatically lose their medical staff membership and are REQUIRED TO FILE A NEW APPLICATION.  These long-standing members may well be subject to the new requirements.

#6  It is not unthinkable that the new medical staff members (who are subject to these strict requirements) will quite reasonably feel that ALL medical staff members should be bound by the same mandate. These new members may ultimately be represented in such numbers that they tip the balance and there is a resulting Bylaw change to that effect. 

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Editor's comment:  Our recommendation is that physicians opposed to mandatory MOC adopt this amendment or one similar to it at their own hospitals. The physician who led this charge against mandatory MOC was James B. Weidner, MD, specialist in cardiovascular disease and internal medicine. The hospital is Regional Medical Center in San Jose, previously known as Alexian Brothers.

Meanwhile, at the Union of American Physicians and Dentists (UAPD) Triennial, the UAPD passed two resolves of interest concerning MOC. Resolution # 5 states that "Medical Staff Bylaws allow medical staff membership for physicians who meet the minimum state requirements for the position (board certificate or eligibility is not a hiring requirement)." Resolution # 10  states that "UAPD negotiate for reimbursement of the Maintenance of Certification/Fees Programs by the state in our contract." 
   

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References:

Change Board Recertification, http://www.changeboardrecert.com

Open Letter to the American Board of Pediatrics, http://rebel.md/open-letter-the-american-board-of-pediatrics/

"Maintenance of Certification (MOC) and the IRS: where money and power meet," 7/29/15

"Maintenance of Certification, a rising business opportunity," 5/15/2015

"When does a $681,000 salary require additional incentive compensation?,"  4/17/15

"Resolutions passed at the UAPD 2015 Triennial," December 8, 2015



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Wednesday, November 25, 2015

WHAT HAPPENS WHEN CLINICIANS DON'T TRUST REGULATORS?


USA Today published a piece on whether or not physicians should be forced to check a prescription database before writing opioid prescriptions. In Massachusetts Governor Charlie Baker proposed measures to obstruct physicians from prescribing these medications. Among the irresponsible provisions recommended for this purpose, one was to limit opioid prescriptions to 72 hours.  In all but the most emergent situations this rule would prevent patients from getting their prescriptions for more than three-days. 

Meanwhile, in California, Senator Lara submitted legislation, SB 482, that would require physicians to rely on a statewide data base known as CURES that does not yet exist before prescribing Schedule II or III medications. Failure to do so would make the physician subject to discipline by the state's medical board. This bill is currently on hold and awaits the 2016 legislative season that begins in January.  In the meantime, Gov. Brown signed off on AB 679 (Allen) which was chaptered on 11 October 2015 and extends the deadline for mandatory enrollment in the CURES system from 1/01/16 to 7/01/16. 

California also has Utilization Review (UR) obligations that primary treating physicians (PTPs) are obliged to accept. It works like this: physicians may prescribe diagnostic studies,  treatment programs, even medications, including non-opioid, or ask for consultations. Instead of complying with same, the patient is hung out to dry by the insurance company which says it is obliged to submit all such requests to UR before the prescription or treatment can be "authorized." Never mind that the doctors belong to MPNs or Medical Provider Networks and have already been approved by the insurance company. In many cases patients are kept in pain because the treatment they're seeking -- and that has been properly prescribed -- is being withheld by the insurance company.

There is an appeal process. If UR doesn't reverse its denial of care in timely fashion based upon an initial complaint by the treating doctor, the decision is passed over to an Independent Medical Review agency which may employ doctors who are out-of-state and whose names are concealed by the insurance companies from the patient and the actual treating doctor. Statistics show that the vast majority of cases denied by UR get denied again by IMR.

Under these circumstances, many physicians including the most prestigious simply refuse to accept industrial or workers comp cases -- injured workers who get injured on the job expect that they'll get authorized treatment from their industrial carriers. Strike one occurs when their access to treatment is delayed. Strike two occurs when UR denies care that had previously only been delayed. Strike three occurs when IMR goes along with UR and gangs up to deny care again. There's a 4th strike that occurs when the likes of Governor Baker, Governor Brown, and State Senator Lara help insurance companies and corporate interests shirk their obligations to provide timely medical and surgical care. 



Stanford Hospital and Clinics knows what to do. In a letter to a California physician, July 24, 2014, Stanford refused to provide neurosurgery consultation to an injured worker. The letter from Stanford gave the following reason: "We don't take WC cases."

Thursday, October 15, 2015

NO, THE GOVERNOR DID NOT AVOID A COLLISION IN HEALTH CARE POLICY


Governor Brown in his veto message of AB 1542 (Mathis & Cooley) said "this bill undermines the Division of Workers Compensation's authority ... when it determines eligible medical specialties ... that power resides with the physician's licensing board. If the Board of Psychology believes there is value in recognizing neuropsychology as a subspecialty, it should do so."

It turns out that the Governor knowingly acted on an incorrect opinion from the Department of Industrial Relations (DIR) and from Christine Baker in particular. It seemed lost on the Governor that AB 1542 was supported by the California Psychology Association and by the Board of Psychology. It was well known to Governor Brown, or should have been, that the Board of Psychology does not formally recognize or enfranchise subspecialties. However, the Board of Psychology does recognize the American Psychological Association (APA) of which it is a member. The subspecialty of clinical neuropsycholgy is in fact recognized by the the APA, a fact that the Governor, in his zeal to support Christine Baker, ignored. By his veto  Governor Brown evidently felt he was supporting "the Division of Workers Compensation's authority." Regrettably, the reverse is true now that NeuropsychologyQMEs have been relegated to the basement of medical and psychological evaluation and treatment for injured workers with traumatic brain injuries (TBIs). These injured workers will no longer have the direct access to NeuropsychQME evaluation as they have had for the last 22 years. Employers will find that assigning TBI patients to appropriate return-to-duty status has just been made more difficult. Trades where head injuries are more common, e.g., construction, working at heights, or around heavy equipment, have just been made more risk laden by Governor Brown's arbitrary veto. 

By contrast Governor Brown signed AB 2127 (Cooley) last year so that high school athletes who sustain TBIs can get direct access to health care providers. These health care providers are supposed to be trained to recognize and evaluate concussions and TBIs. It looks like Gov. Brown feels that injured workers do not need the same access to first level responders as do high school athletes who get hurt playing football, or soccer. 

We understand that the underpinnings of the Governor's veto was his desire to support DIR Christine Baker and the Division of Workers Comp as seen through her eyes. What's too bad is that in this effort the injured workers who do construction and other risky jobs have been short-changed, actually, to put it bluntly, they've been torpedoed. 

To correct this egregious mistake, it would help if the Board of Psychology changed its policy to provide formal recognition to NeuropsychQMEs and if Mathis, Cooley, and others would reintroduce a revised version of AB 1542 in 2016.




Tuesday, September 29, 2015

AB 1542 AND AB 2127 -- WILL THE GOVERNOR AVOID A COLLISION IN HEALTHCARE POLICY?


Governor Brown's healthcare policies are now colliding. In 2014 Governor Brown signed AB 2127 (Cooley) into law. As a result of this decision the California Education Code now requires that high school athletes who have sustained a cerebral concussion, even a mild one, must be evaluated by someone trained to make this evaluation before the athlete can return to play. The idea is to reduce the consequences of traumatic brain injury (TBI) which may follow a cerebral concussion or be delayed until a series of such concussions have occurred. The injured athlete is now required to get written clearance from a licensed health care provider trained in the management of concussions. This legislation is a step in the direction of protecting high school athletes.

Governor Brown now has a chance to sign legislation, AB 1542 (Mathis & Cooley),  that would similarly help injured workers. We have previously recommended that he sign this bill. Nonetheless, the bill remains subject to possible veto. Construction workers, roofers, persons who work at heights, are particularly prone to the type of injury that may cause cerebral concussion and lead to post-concussion syndrome secondary to TBI. California's injured workers deserve protection that is at least as cognizant of their well being as AB 2127 tries to be for high school athletes. That is in part why we ask again that Gov. Brown sign AB 1542, just as he signed AB 2127. In the case of the injured worker trained specialists in the form of NeuropsychQMEs are available and have been for 22 years. It makes no sense to cut this specialty out of the loop. They already are the "licensed health care provider" trained in the management of concussion that is required by law and by common sense. The injured worker who has sustained TBI should have this level of evaluation available.

AB 1542 also looks out for the employer because it provides a sound scientific basis whereby reassignment to modified work or to one's usual and customary job can be made with reasonable medical judgment. It is analogous to deciding whether or not injured athletes can return to play.
In the case of a TBI expertise is also needed for treatment decisions.

A veto of AB 1542 after having signed AB 2127 sends mixed messages on health care. Such a decision would relegate injured workers to a level of healthcare protection below that of injured high school athletes. We do not believe that Gov. Brown wants or needs such a healthcare policy collision.





Wednesday, September 2, 2015

AB 1542 (Mathis and Cooley): DRAMA IN THE CAPITOL


Now that AB 1542 (Mathis and Cooley) has passed the Senate, 39 to 0, having already passed the Assembly, 79 to 0, we have a unique situation wherein the Governor is being pressured by the Department of Industrial Relations (DIR)  to veto a bill that has unanimous bipartisan support. The reason given by DIR Director Christine Baker for public consumption is that "the California  Board of Psychology does not recognize neurospsychology as a subspecialty in psychology." 

On the other hand, the same California Board of Psychology accepts the American Psychological Association's (APA)  recognition of specialists in neuropsychology. In short, the APA recognizes neuropsychologists. Given these facts, it is difficult to fathom why DIR should object to AB 1542 unless there are other reasons we don't yet know about. What we are left with is that a specialty with national  recognition is being denied recognition in California. 

Medical specialists involved in the diagnosis and treatment of traumatic brain injury (TBI) also recognize the specialty role provided by the neuropsychology specialists, for instance, the American Academy of Neurology has published on this matter since 1966. 

In my personal letter to the Governor, I indicated that the DIR position, if the Governor bows to it, is likely to increase litigation since the current easy access to neuropsyche Qualified Medical Evaluations will be impeded. It will then be up to the applicants' lawyers to fight tooth-and-nail for neuropsyche evaluations for their TBI clients and for the defense lawyers to forestall successful litigation by the applicants' lawyers. Lawyers who fail to support their applicants' cases to the hilt may find themselves on the wrong side of a malpractice suit.

The same goes for the physicians who treat and evaluate injured workers. Failure to obtain neuropsyche assessment may be seen as a dereliction of duty by the physician, enough so that the physicians themselves become subject to potential liability or malpractice claims.

Disallowing recognition of neuropsychologists harms brain-injured workers and impairs the ability of the workers compensation system to take care of injured workers with TBI. Employers are also harmed when TBI patients are not properly assessed with reference to return to work status or feasibility for continued employment. 

AB 1542 preserves access of injured workers to neuropsychological expertise. I believe that should be enough reason for the Governor to sign AB 1542 into law.

References

"Reasons to Keep Neuropsychology as a Specialization in QMEs," Hannah Pence, MS, CRP, 09/01/2015;

"Three Comp Bills Left for Final Week of Session," workcompcentral, 09/04/2015;

"Does Somebody Want to Sabotage Neuropsychological Evaluations," workcompcentral, 5/20/2015;

"Neuropsychology Medical-Legal Evaluations (Neuropsyche QMEs): Does Somebody Want to Sabotage Neuropsychological Evaluations," The Weinmann Report, www.politicsofhealthcare.com, 4/25/2015;

"Is Mandatory Malpractice Ordered to Begin on Tuesday, 1 September 2015," The Weinmann Report, www.politicsofhealthcare.com, 8/27/2015;

"Neuropsychology -- The How and Why," James R. Cole, PhD, QME, California Society of Industrial Medicine and Surgery," 8/18/2015;

Analysis from Assembly Committee on Appropriations, 7/08/2015, Jimmy Gomez, Chair, prepared by Lisa Murawski.