Monthly Archives: February 2014

Veterans Administration (VA): overprescribing narcotics/little media coverage

Yesterday’s hearing on VA Accountability by the House Committee on Veterans’ Affairs Subcommittee on Health produced no major public pressure on the VA, as I commented in this blog yesterday.

The only major media entity to cover the hearing was ABC News Radio. That report is linked here:
http://abcnews.go.com/US/va-doctor-forced-limiting-opiate-prescriptions/story?id=22673803

It was written by The Center for Investigative Reporting reporter Aaron Glantz and ABC News Senior Producer Teri Whitcraft. They are the same two who wrote the report seen on ABC World News Tonight on February 25, 2014, as previously noted in this blog.

Props to these two reporters for doing some good follow up. What is heartening is that Subcommittee Chairman Dan Benishek was quoted in yesterday’s ABC News Radio report as being skeptical of VA’s explanation at the hearing that the problem of pain treatment and opiates is under control, saying, “ VA still has a lot of explaining to do on how this problem escalated in the first place and why it’s taken so long to do anything about it.”

But the VA also has a lot of explaining to do about a lot more:

1. Why aren’t the 2010 clinical practice guidelines for the use of opiates in pain control being followed?
2. What are you doing specifically to get VA physicians to follow your own practice guidelines?
3. Can’t you use your much heralded electronic record system to monitor whether or not practice guidelines for opiates are being followed? If not, why not?
4. What were your staff pharmacists doing while all these opiate prescriptions were being dispensed?
5. Why have you fired physicians who didn’t follow administrator’s orders to dispense opiates against their better medical judgment? What are you doing to investigate these physicians’ allegations?

I was heartened by one part of VA’s Under Secretary for Health Robert Petzel’s written statement which was posted on the Subcommittee’s website after the hearing. He said that “Whenever clinically feasible, the concomitant use of opioid and benzodiazepine medications should be avoided.” Now let’s see if he can get that rule to be followed by the VA medical, nursing, and pharmacy staffs. I guess that will be a function of what is meant by “clinically feasible.”

I was disappointed by how the major print and electronic media largely failed to report this story. The Wall Street Journal and the New York Times were silent. The Wall Street Journal today devoted page 1 space to a military story – the Marines allowing soldiers to roll up their sleeves and bare their forearms.

I guess that is a more important story than thousands of veterans being addicted to opiates through no fault of their own.

And the New York Times: What’s their excuse? It’s not news fit to print? Perhaps Seth Rogen and Ben Affleck testifying on Capitol Hill yesterday were a big distraction.

And what is Fox News’ excuse? They always appear to wrap themselves in the American flag and stand for veterans. I wish Fox would tell us why this story is not newsworthy.

But then so should CNN, NBC, and MSNBC. They have all been MIA.

Veterans Administration (VA): overprescribing narcotic painkillers/ Congressional oversight

Just listened to the 1 hour and 57 minute House Committee on Veterans Affairs Subcommittee on Health hearing today (2/26/14) where the VA was supposed to answer the very serious charges levied against the VA on October 10, 2013 by 2 widows, 2 surviving veterans, and 2 whistleblower physicians.

The VA officials got off easy today. No tough questions about opiate misadventures in the VA system. There was no testimony about how the VA got 27,000 veterans off opioids since October 2013. Do they want us to believe that acupuncture works for severe chronic pain syndromes? Zero testimony about why the VA has not been following their 2010 clinical guidelines for pain management and how they are getting their pharmacists to monitor narcotic dispensing for dangerous combinations of drugs like opioids and benzodiazepines e.g. generic valium. This hearing was a complete whitewash.

The VA apparently put out some sort of news release trumpeting their “Opiate Safety Initiative Program” which coincidently was launched in October, 2013, after the House Committee on Veterans’ Affairs hearing. The VA claims it has gotten 27,000 veterans off opioids since October 2013. How did they do that? Did they send them all to rehab? Did they cold turkey them?

One Facebook entry from a veteran in Kentucky posted yesterday reports that the VA just suddenly started reducing her Tramadol dosage without telling her why.
http://surfky.com/index.php/communities/123-general-news-for-all-sites/45271-veterans-affairs

She says she has spinal/cervical pain and a “bad case of leg neuropathy.” She said they told her to take Tylenol to “boost” the effect of reduced Tramadol. Good luck with that. What about specific drugs for neuropathic pain? Or the use of a TENS unit? Or use of a spinal cord stimulator?

Speaking of spinal cord stimulators, ABC TV finally got around to covering this story yesterday on World News Tonight with Diane Sawyer. http://abcnews.go.com/US/vas-lack-pain-treatment-options-led-opiate-addiction/story?id=22673643

ABC did the story with the Center for Investigative Reporting (CIR), specifically reporter Aaron Glantz. Glantz has done a good job reporting the opiate problem and I recommend you go to the CIR site and look for his stories on this subject. You can find an interactive map that shows the rate of opiate prescribing for various VA facilities around the country. Glantz was also the only national reporter who reported some of the testimony of the 2 whistleblower physicians who testified last October. And in December 2013, he followed up by reporting the findings of the VA Inspector General in its investigation of opiate prescribing problems at the San Francisco VA Medical Center.

ABC featured a real hero, Justin Minyard, whom I met at the October 10 hearing. Minyard is straight out of central casting. Tall, good looking, articulate, and he hurt his back digging survivors out of the rubble of the Pentagon after the 9/11 attack. He told a harrowing tale of being addicted to narcotic painkillers that began when he was on active duty and was continued by the VA. His most shocking (and funny at the same time because it was so typical of the VA and what someone has to do to fight their outrageous bureaucracy) story was how he had to go door to door at a VA facility to find a pain specialist when he couldn’t get a referral. He actually barged into a doctor’s private office and demanded he be considered for a spinal cord stimulator. He eventually got one and got off narcotics.

ABC reported the VA’s Opiate Safety Initiative matter –of- factly with no critical questions about how or if it’s working.

ABC never brought up the 2010 VA clinical practice guidelines and didn’t ask any VA official what they were doing to make sure that doctors and pharmacists were following those guidelines.

Their interview of a pretty boy VA MD picked for his Looks Good on TV appearance was tepid to say the least.

Meanwhile, back at the ranch, at today’s hearing, there was ZERO mention of the issues raised by the widows, Kim Green and Heather McDonald and the two veterans who so eloquently testified last October. And ABC didn’t follow up on those issues. Yes, they told Minyard’s story, but that should have been “old news.” Four months after the hearing, which only CBS covered, (that’s right not even flag- waving, lapel-wearing Fox covered the story) ABC did not ask tough questions to find out how such outrageous overprescribing even occurred in the first place with all the VA’s sophisticated computerized medical records and practice guidelines.

ABC did feature one whistleblower physician who talked about VA doctors prescribing escalating doses of narcotics to those already addicted. Again, there was no mention of the two whistleblower physicians who testified in October, Drs. Pamela Gray and Claudia Bahorik.

For all of you who have been hoodwinked by the likes of Rick Perry, and think that lawyers file nothing but frivolous lawsuits, you need to consider how you can get justice for veterans who are addicted to narcotics through no fault of their own and for those who die because of VA negligence.

Can these American heroes and their families get justice in the halls of Congress? Or do they have to go to court to get justice?

The best part of today’s hearing came when Subcommittee Chairman Dan Benishek, himself a general surgeon who worked 20 years at a VA hospital in Michigan and also in private practice, redressed the VA under Secretary for Health, Dr. Robert Petzel, who had testified that VA medicine is as efficient as private practice. Dr. Benishek called Petzel’s answer “completely ridiculous” and “a complete fabrication of what actually occurs at the VA.” True!

I wish the honorable Chairman had been as critical of the VA’s anemic responses to the critical issues of how to reduce VA opiate prescribing and ensure that the 2010 clinical practice guidelines are followed – before more veterans die.

Today the VA officials who appeared before Congress got a hall pass. They needed to be sent to detention.

Veterans Administration (VA): Prescribing Narcotic Pain Killers

Today’s News Tip:

Watch tomorrow’s hearing of the House Committee on Veterans’ Affairs Subcommittee on Health in Washington, D.C. It will be on a live feed.  You can access it through the Committee’s website:

http://veterans.house.gov/

The Hearing is entitled: VA Accountability: Assessing Actions Taken in Response to Subcommittee Oversight. It starts at 10 AM EST.

It will be interesting to see if the VA responds to shocking revelations about narcotic pain killer prescribing at VA hospitals and clinics brought out at a hearing of the Subcommittee on October 13, 2013. That hearing is archived on the Subcommittee website at: http://veterans.house.gov/hearing/between-peril-and-promise-facing-the-dangers-of-va%E2%80%99s-skyrocketing-use-of-prescription

That hearing took place while Congress was “shut down.” There was little national media coverage. CBS Evening News was there and did cover the testimony of 2 widows whose veteran husbands died while taking medications prescribed by the VA. I attended the hearing with my client Kim Green, one of the widows whose testimony you can read. Kim has filed a lawsuit against the VA alleging negligence in prescribing painkillers and other drugs, for her late husband, Ricky Green.

But the testimony of two whistleblower physicians was not covered by the national media. Those doctors, whose testimony you can read and hear, alleged that the VA had a policy of forcing doctors to write prescriptions for narcotic painkillers without proper evaluation and other less harmful treatments were tried for pain control. One doctor, Pamela Gray, was fired for what she said was her protest of the way she was forced against her better judgment to prescribe narcotics.

Two veterans who survived also gave compelling testimony and you can read their testimony at the Subcommittee’s website.

The Chairman of the Subcommittee gave the VA 30 days to respond to the charges levied by the 2 widows and 2 veterans. But so far the VA has not responded. A staffer for the Committee told me that the VA was later given more time to respond. Let’s see what the VA says tomorrow.

Congress may have been disagreeing about most issues but at the subcommittee hearing there was bipartisan agreement that the VA had a big problem.

I tried to write an op-ed about the testimony of the two whistleblower physicians for the Wall Street Journal and for the local paper here in San Antonio, the San Antonio Express-News, for Veterans Day. Both papers rejected my proposal. Or I should say the WSJ rejected my proposal. The Express News never responded to my query. But, that’s par for the course for our one newspaper town. The local TV station where I did news reports for several years, KENS-TV, also rejected my attempt to get them to tell this story. The story had been alluded to by CBS TV. KENS-TV a CBS affiliate, so you would think that CBS’ endorsement of the story would have been enough. And San Antonio does have a huge number of military retirees and a major VA hospital. But KENS-TV said they couldn’t do the story because they couldn’t find a local veteran to illustrate the problem.

Wouldn’t you think that just covering the compelling stories presented in Washington on October 10 would have been enough to bring some veterans forward to tell their stories locally?

And, no, I didn’t promote this story to get new clients for my law practice. It’s a national scandal and veterans need to be warned about how the VA in some cases is not following its own clinical practice guidelines for prescribing narcotic painkillers. A two and a half minute story on the CBS Evening News is not enough to get the word out.

I’ll write more about this subject in future blogs.

How to be a Physician Leader in the World of ObamaCare

 

The February 1, 2014 issue of Internal Medicine News (IMN)has some advice for primary care physicians on how to become a physician leader in the new Accountable Care Organizations (ACOs) being promoted by ObamaCare.

The advice is provided by North Carolina attorney Julian ‘Bo’ Bobbitt, Jr. who the article says has “many years of experience assisting physicians form integrated delivery systems.”   Mr. Bobbitt’s law firm, Smith Anderson in Raleigh, according to its website, defends doctors and hospitals in medical malpractice cases, defends companies in product liability cases, and has been involved in “forming ACOs across America.”

 Internal Medicine News is a “medical throwaway,” meaning it’s one of the countless publications that come to a doctor’s office free but supported by pharmaceutical industry advertising. Still, I’ve collected these throwaways for many years, fascinated by what ideas and news they promote and who they get to write their articles. IMN on its masthead claims it’s “The Leading Independent Newspaper for the Internist – Since 1968.” For sure, you won’t find these small newspapers on file at any medical libraries around the country. They’re not intellectual enough for places like Harvard or Yale.  But they fit my lowbrow interests just fine, because they are a window on what the big money that controls health care policy wants doctors to do.

You can find this article and read it for yourself at: http://www.internalmedicinenews.com/views/aco-insider/blogview/five-steps-to-becoming-a-primary-care-leader/fd24cbf535d336943c6c596c0bfc074f.html

Here’s the way I summarize the article’s advice to primary care doctors:

1. Keep your mouth shut

2. Do what the hospital administrator tells you to do.

3. Lead from behind.

Bobbitt warns that “There is no need to seize the podium and tell others what to do. That will backfire.”

What he means is that the hospital administrator – you know – the guy who wears the expensive suits, gets the 7 figure salary he doesn’t have to disclose, stacks the community board with fat cats who know nothing about medicine or health care and other political appointees who will do his bidding –will run the team, and if you as a primary care physician try to challenge what the administrator has decided is the right way to practice, you will soon find yourself facing a quality audit for poor patient care that will threaten your medical career, unless of course you belong to a big group that produces big income from the hospital. Voila. You are now a disruptive doctor.

The vision that Bobbitt wants primary care doctors to buy into is in reality whatever vision the hospital administrator has concocted or heard from his higher ups if it’s a big hospital corporation, who in turn have been informed by their bean counters how to maximize profit centers and minimize cost centers.

Sick patients are cost centers. Doctors who order expensive tests with in capitated or bundled (lump sum) payment schemes are cost centers. Doctors who order expensive tests in a fee for service payment scheme can be profit centers.

But most ACOs are trying to move toward bundled payments. For example, the hospital will get paid a lump sum for a heart attack. The hospital administrator will get to dole out the payments to all the care givers: so much for the hospital, so much for the primary care doctor, so much for each specialist needed, so much for rehabilitation team, etc. The team players who will stay on the team and not get cut will be the ones who cut enough corners, oops, those who are efficient enough to leave some profit for the administrator to keep on getting his big salary and keep on employing the whole pyramid of other sub-administrators in the bloated hospital bureaucracy – now called an efficient ACO.

The whole exercise of the ACO process is to kill fee- for- service medicine, pit primary care doctor against specialist, lower doctor reimbursement, and deliver as much of the payment for each episode of care – for everyone caring for the patient – into the hands of the administrator.  The father of HMOs, Paul Ellwood, once called HMOs “the revenge of the primary care doctor.” But HMOs didn’t catch on in the 1990s because the rationing of care got too dangerous and the public rebelled. Now, 20+ years later, lump sum payments are back.

It is highly unlikely that ACOs will restore for primary care doctors “the multispecialty collegiality from their days of medical training” that Bobbitt envisions. Doctors all think they need to be paid more. Specialists ‘know” they are smarter than primary care doctors. One of the lessons of the 1990s – when multispecialty medical groups took on the risk of insuring populations of patients – with disastrous financial consequences – was that primary care doctors fought with specialists about how to divide the pie of the bundled payment for patient care.  The same thing will happen with ACOs.

Bobbitt and political leaders in Washington just hope that doctors have been beaten up so much and have so much college and medical school debt that they will submit to any manner of insult and salary cutting to work for ACOs and hospitals. They are probably right. Just see the number of doctors bailing out and selling their practices to hospitals these days.

For patients, this is probably not a good as it seems. It raises the specter of whether your doctor is now more interested in saving dollars than saving your life. Death panels may not be in Washington. They may be as close as your local hospital’s ACO, where your primary care doctor is “leading from behind.”

 

 

Why Another Blog About Health Care Policy?

 This is the first post to my new Blog, The Disruptive Doctor. First, to answer two questions:

1.  Why another blog by another doctor? The world is full of thousands if not millions of blogs by doctors, nurses, health care administrators, former HMO executives and others talking about medicine, health care policy and current political events that affect the practice of medicine.  I agree there are a lot of postings, but think I can present a unique perspective from someone who isn’t beholden to employers or large corporate interests. There are no hidden agendas in this blog. I’m not fronting for some lobbying group or client or any other entity that is trying to sell you something. I’m willing to say things and post information that a lot of others don’t want to say or don’t want you to know. I hope to break some news here from time to time.  My news comes from the front lines of medicine. It’s the same sources of information that have produced so many national media stories over the years. I’m tired of pitching stories to the national and local media. Now I’ll do the stories here.  Earlier this week I told a national reporter who wanted my billing records from the Mayo Clinic that he could have them after I did the story. I’ve been pitching that story about the Mayo Clinic for several years and no one has been interested.  Sorry, that story gets done here first. Sour grapes and axes to grind: you’ll find them all here.

2.  Why call it the “disruptive doctor?” Who or what are you trying to disrupt?   Disruptive refers to two processes. The first is the concept of disruptive ideas. I will examine conventional wisdom in health care policy from news, government agencies and foundation/non-profit sources.  There are a lot of hidden agendas out there. Those promoting the idea that all physicians should be salaried point to the Mayo Clinic model. We’ll look at whether Mayo is really the best model of an efficient cost effective health care system, as the health care planners have touted it to be for many years? And the second idea embedded in the concept of “disruptive” has to do with the process whereby hospital administrators and their hired well -paid consultants label doctors “disruptive” if they don’t knuckle under to hospital policies and procedures, but more importantly to the hospitals’ current takeover of medical practices promoted by ObamaCare.  As a lawyer, I have represented doctors in peer review disputes with hospitals and others. Again, that statement is not a solicitation for business, but merely background about one way I have come to be informed about “disruptive” doctors. The other ways are by my serving in medical staff (unpaid, volunteer) positions in local hospitals and extensive reading about the subject. And, yes, I understand that doctors who throw charts and yell at nurses are disruptive. But, we’ll explore a lot more aspects of “disruption” than are regularly reported.

My news tip of the day: A family physician in Texas reported this week that she got her first check for services rendered under an ObamaCare Blue Cross Blue Shield policy. The reimbursement was 30% lower than what she gets for the same service from Medicaid!  

ObamaCare said Medicaid and Medicare should pay the same amount for the same services in some primary care specialties: http://www.hca.wa.gov/medicaid/Documents/aca_faq.pdf 

Problems with low payments to doctors were forecast last year. See: http://www.kaiserhealthnews.org/stories/2013/november/19/doctor-rates-marketplace-insurance-plans.aspx

But now,  ObamaCare policy payments in some cases may be much lower than forecast.

And see the above Kaiser Health News article about how one ivory tower professor feels about doctors getting paid less.   

The family doctor and colleagues report it’s very hard to identify ObamaCare Blue Cross ObamaCare policies when verifying policy coverage. Right now, they think those policies begin with “ZHN” or “ZGN.”  Apparently, there’s a reason the insurance companies want these policies to fly in a stealth mode.  For example, an ObamaCare Humana policy here in Texas is labeled “HMOx.”  

My sources tell me that doctors are just starting to figure out that ObamaCare is not going to be any financial bonanza, and that they better figure out pretty fast who in their practices has these low paying policies and plan accordingly.  

Stay tuned for more reporting about ObamaCare payments to doctors here in Texas and who can afford to see these patients.