Archive for the ‘Medicine’ Category

AAPS Sues the American Board of Medical Specialties for Restraining Trade through Its Burdensome Recertification Program

TUCSON, Ariz., April 24, 2013 /PRNewswire-USNewswire/ –The Association of American Physicians & Surgeons (AAPS) has filed suit today in federal court against the American Board of Medical Specialties (ABMS) for restraining trade and causing a reduction in access by patients to their physicians. The ABMS has entered into agreements with 24 other corporations to impose enormous “recertification” burdens on physicians, which are not justified by any significant improvements in patient care.

ABMS has a proprietary, trademarked program of recertification, called the “ABMS Maintenance of Certification®” or “ABMS MOC®,” which brings in many tens of millions of dollars in revenue to ABMS and the 24 allied corporations. Though ostensibly non-profit, these corporations then pay prodigious salaries to their executives, often in excess of $700,000 per year. But their recertification demands take physicians away from their patients, and result in hospitals denying access by patients to their physicians.

In a case cited in this lawsuit, a first-rate physician in New Jersey was excluded from the medical staff at a hospital in New Jersey simply because he had not paid for and spent time on recertification with one of these private corporations. He runs a charity clinic that has logged more than 30,000 visits, but now none of those patients can see him at the local hospital because of the money-making scheme of recertification.

There is a worsening doctor shortage in the United States, such that the average physician has the time to spend only 7 minutes with each patient. Roughly half the counties in our nation lack a single OB/GYN physician to care for women. There are long delays to see primary care physicians in Massachusetts, and about half of them are not even taking new patients.

Money-making schemes that reduce access by patients to patients, as “maintenance of certification” does, are against public policy and harmful to the timely delivery of medical care. AAPS’s lawsuit states, “There is no justification for requiring the purchase of Defendant’s product as a condition of practicing medicine or being on hospital medical staffs, yet ABMS has agreed with others to cause exclusion of physicians who do not purchase or comply with Defendant’s program.” AAPS adds that ABMS’s “program is a moneymaking, self-enrichment scheme that reduces the supply of hospital-based physicians and decreases the time physicians have available for patients, in violation of Section 1 of the Sherman Act.”

ABMS does the public an additional disservice by inviting patients to search on which physicians have “recertified” and which ones have not, despite the lack of evidence that there is any difference in malpractice rates between the two categories. ABMS should try to make money by helping patients, rather than disparaging the many thousands of good physicians who spend their time caring for patients rather than on ABMS’s self-serving recertification scheme.

A recent survey by AAPS showed that only 9.5% of 167 respondents thought that “maintenance of certification is good; we should support it.” In anearlier survey, only 22% of physicians who had been through the process said they would voluntarily do it again.

AAPS’s lawsuit, which was filed today in Trenton, New Jersey, seeks declaratory and injunctive relief to enjoin ABMS’s continuing violations of antitrust law and misrepresentations about the medical skills of physicians who decline to purchase and spend time on its program. AAPS also seeks a refund of fees paid by its members to ABMS and its 24 other corporations as a result of ABMS’s conduct.


AAPS Sues to End Recertification Program


For Episode 2, go to Cartoon Network

Sunday 10:30 PM on Cartoon Network Adult Swim


by Mike Hale

BY Rob Corddry’s own count, he did a hundred interviews when his Web series “Childrens Hospital” appeared in 2008 in which he said that it was “in no way a television idea,” and that a television version “will never happen.”

So, of course, it happened. “Childrens Hospital” begins its new life as a television series Sunday night, part of Cartoon Network’s Adult Swim programming, making Mr. Corddry either a liar or a very bad prognosticator. As he did postproduction work recently at a North Hollywood editing studio, he chose to plead ignorance when asked why his show, among hundreds of online series, should be one of the few to make the jump to the slightly bigger screen.

“We have a very good relationship with the people over at Warner Brothers,” he said, referring to the company that owns, where his show first lived, and is a corporate sibling of Adult Swim. “Beyond that I have no idea.”

He’s more definitive about the inspiration for “Childrens Hospital,” which was born out of the enforced idleness caused by the 2007-8 Writers Guild strike. (The strike was the seedbed for other high-profile Web projects like “Dr. Horrible’s Sing-Along Blog,” with Neil Patrick Harris, and the Lisa Kudrow show “Web Therapy,” which will be seen on Showtime later this year.)

“The idea was born of child abuse, essentially,” Mr. Corddry said. At a hospital with his daughter, who had injured her arm, he was taken by the comic possibilities of the terrifying scene: “scared parents, crying mothers, tiny bodies on tiny gurneys.”

A result was an unsparing parody and, in its twisted way, a celebration of mainstream hospital shows, packed into 10 episodes of about five minutes each. The primary target was “Grey’s Anatomy,” with nods to “ER” and “Scrubs” and a subtext of deep affection for “M*A*S*H.”

Doctors committed darkly humorous varieties of malpractice when they weren’t breaking up or making out, sometimes with their young patients. Mr. Corddry wore slasher-movie clown makeup as Dr. Blake Downs, who refused to operate, believing instead in the healing power of laughter.

Getting the online show made wasn’t necessarily a huge challenge. “Studios were green-lighting tons of Web shows and treating it as near-free development,” Mr. Corddry said. But what made “Childrens Hospital” stand out from the start was its cast, an unusually accomplished group in the anonymous and poorly paid world of Web series.

In addition to Mr. Corddry, with his “Daily Show” and film credentials, it included Megan Mullally (“Will and Grace”), Lake Bell (“Boston Legal”), Erinn Hayes (“Parenthood”), Ken Marino (“Reaper,” “Party Down”), Nick Offerman (“Parks and Recreation”), Ed Helms (“The Office”) and Jason Sudeikis (“Saturday Night Live,” “30 Rock”).

“I don’t know what to say,” Mr. Corddry said. “We got everybody we wanted. We went up to our friends and, uh …. ”

Jonathan Stern, an executive producer and writer on the show along with Mr. Corddry, leaped in. “It was faith in Rob and his abilities and what he’d bring to it,” he said. “And knowing that they’d have a good time on it with their friends, and knowing, what’s the worst that will happen? We’ll have two days of doing so-so material.”

After the Web series was posted, both Adult Swim and Comedy Central approached Warner Brothers with the idea of adapting it for television; Adult Swim won what Mr. Corddry called “a very low-stakes bidding war.” He, Mr. Stern and their fellow executive producer David Wain managed to keep most of the cast together for the television show (Ms. Bell, committed to the HBO series “How to Make It in America,” will appear in only four episodes) while adding new regulars like Malin Akerman, Henry Winkler and Kurtwood Smith.

The quality and familiarity of the ensemble is a large part of the answer to the earlier question Mr. Corddry left hanging, regarding why “Childrens Hospital” has been able to follow the path to television blazed by Web series like “quarterlife” and “Sanctuary.”

“Megan Mullally, herself, green-lights a show,” he acknowledged. “I think that’s our main strength.”

Ms. Mullally plays the Chief, an oversexed chief surgeon who flails about on crutches and is an obvious take-off on Dr. Kerry Weaver, the character Laura Innes played for 15 seasons on “E.R.” She said she called Ms. Innes, a fellow Northwestern alumna, before shooting the Web series: “I was like, mmm, just in case. Just in case. But she thought it was great.”

The actors and writers have more room to breathe now that “Childrens Hospital” is a television series, but not much. The episodes for Adult Swim are 15 minutes long (11 ½ minutes after commercials); they will be shown in a half-hour slot at 10:30 p.m. with another 15-minute show, “Delocated.” The original Web episodes have been combined, two at a time, into television episodes that will be shown beginning Sunday. The new episodes will begin on Aug. 22.

The difference between making 5-minute and 11.5-minute shows was substantial. “Essentially the Web series was a series of sketches,” Mr. Corddry said. “The TV series, there has to be some semblance of a story. Unfortunately, because I have no idea how to write that.”

Mr. Winkler and Mr. Smith help carry the expanded story lines, as a wacky administrator and a villain intent on suppressing a cure for cancer. Mr. Stern cautioned against putting too much stock in the plot, however.

“Eleven and a half minutes made us create the veneer of actual story lines and character growth without requiring that we be committed to that,” he said. “We hit all the beats as if the characters were developing and important things were happening and as if there were a beginning, middle and end to the story, but we don’t really have to get too emotionally invested in any of that.”

One change you might expect would be some toning down of the show’s humor, an alternately surreal and raunchy mélange of situations and jokes involving sex, body parts, sex, children, Sept. 11, Puerto Rican midgets and sex. But Mr. Corddry said that editing the original Web episodes for television had just meant bleeping “about a handful of words.”

“It’s sort of the same tone,” he added, speaking of the new episodes. “We get away with a lot on Adult Swim.”

That freedom is part of the attraction for the actors, who find time for “Childrens Hospital” between or during their better-paying gigs. “This show is like any other show we do except the words on the page were much wackier,” said Mr. Marino, who plays the yarmulke-wearing Dr. Glenn Richie and who has also directed an episode.

He was one of several cast members who had gathered at the studio to do audio looping, talk with me and trade jokes. Rob Huebel, who plays the spectacularly clueless Dr. Owen Maestro, had his own reason for sticking with the show: “It’s opened up a lot of doors for me sexually. I can literally have sex with anyone in this room. Anyone. If I wanted to.”

Mr. Corddry’s hopes were more prosaic, if equally unrealistic in the arena of Web series and 15-minute television shows. “I have no ambitions besides keep doing more seasons, as many as they give us,” he said. “And then eventually we’ll just sit back and make money. Right?”

photo by Phillip Toledano from the New Yorker

photo by Phillip Toledano from the New Yorker

from New York Times Editorial June 13, 2009

Doctors and the Cost of Care

Published: June 13, 2009

As the debate over health care reform unfolds, policy makers and the public need to focus more attention on doctors and the huge role they play in determining the cost of medical care — costs that are rising relentlessly.

Doctors largely decide what medical or surgical treatments are needed, whether it will be delivered in a hospital, what tests will be performed, and what drugs will be prescribed or medical devices implanted.

There is disturbing evidence that many do a lot more than is medically useful — and often reap financial benefits from over-treating their patients. No doubt a vast majority of doctors strive to do the best for their patients. But many are influenced by fee-for-service financial incentives and some are unabashed profiteers.

All Americans are affected. Those with insurance are struggling to pay ever higher premiums, as are their employers. If the government is going to help subsidize coverage for the millions of uninsured, it will need to find significant savings in Medicare spending, at least some of which should come from reducing over-treatment. In the long run, if doctors can’t be induced to rein themselves in, there is little hope of lasting reform….

A glaring example of profligate physician behavior was described by Atul Gawande in the June 1 issue of The New Yorker. (His article has become must reading at the White House.)

None of the usual rationalizations put forth by doctors held up. The population, though poor, is not sicker than average; the quality of care people get is not superior. Malpractice suits have practically disappeared due to a tough state malpractice law, leaving no rationale for defensive medicine. The reason for McAllen’s soaring costs, some doctors finally admitted, is over-treatment. Doctors perform extra tests, surgeries and other procedures to increase their incomes….

Dr. Gawande’s reporting tracks pioneering studies by researchers at Dartmouth into the reasons for large regional and institutional variations in Medicare costs. Why should medical care in Miami or McAllen be far more expensive than in San Francisco? Why should care provided at the U.C.L.A. medical center be far more costly than care at the renowned Mayo Clinic?

When President Obama speaks at the annual meeting of the American Medical Association on Monday he will need all of his persuasive powers to bring doctors into the campaign for health care reform. Doctors have been complicit in driving up health care costs. They need to become part of the solution.

The Cost Conundrum by Atul Gawande in the New Yorker

Top doctors

from the Washington Post:

Doctors Rated but Can’t Get a Second Opinion
Inaccurate Data About Physicians’ Performance Can Harm Reputations

By Ellen Nakashima
Washington Post Staff Writer
Wednesday, July 25, 2007

After 26 years of a successful medical practice, Alan Berkenwald took for granted that he had a good reputation. But last month he was told he didn’t measure up — by a new computerized rating system.

A patient said an insurance company had added $10 to the cost of seeing Berkenwald instead of other physicians in his western Massachusetts town because the system had demoted him to its Tier 2 for quality.

“Who did you kill?” the man asked sardonically, Berkenwald recalled.

In the quest to control spiraling costs, insurance companies and employers are looking more closely than ever at how physicians perform, using computers, mountains of health claims and billing data and sophisticated software. Such data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.

It also raises questions about the line between responsible oversight and outright meddling in the relationship between caregivers and their patients. And it shows how people such as Berkenwald are at risk of losing control of their reputations as corporations and other organizations mine electronic data to draw conclusions about them and post them online.

The trend is in its infancy, but such programs are already in more than 100 insurance industry markets or regions across the country, from entire states such as Massachusetts to metropolitan areas such as Los Angeles. Supporters say the programs have slowed the rate of growth of insurance premiums by 3 to 6 percent in their first year.

Arnold Milstein, chief physician for Mercer Health and Benefits, a health-care consulting firm based in New York, said that employers and insurers fully expect resistance but that the benefits are undeniable.

“In every industry, consumers have a thirst for performance information,” said Milstein, whose firm is analyzing data for the Massachusetts program that ranks physicians. “People don’t want to go to a movie or buy a book or buy a car or go to a restaurant without some ability to assess value for dollar. What’s taking place here is inevitable.”

Physicians who have been profiled, including those with top ratings, say that the data often contain errors and that doctors often lack the ability to correct them. The effort is more about cutting costs than raising quality, some say, adding that doctors could begin to “cherry pick” healthier patients whose problems are less costly to treat. Such systems fail to capture the intangibles of quality, such as a doctor who visits a dying patient at home, critics say.

The trend, which parallels a push by President Bush to promote consumer access to information about health-care quality and cost, has spurred a lawsuit in Seattle, a physician revolt in St. Louis and a demand by a state attorney general that one insurer halt its planned program.

Physician profiling relies on the growing practice of creating electronic medical records. Once kept only on paper, records about patients, doctors, hospitals, pharmacies and other caregivers are increasingly aggregated in giant digital storehouses. In Massachusetts, six health plans pooled their data after stripping away names, and the resulting 120 million claims are crunched by analysts to assess a doctor’s performance.

Doctors are rated on standards of quality of care and cost efficiency. An internist, for example, gets higher ratings on quality if he puts his heart attack patients on beta blockers, a medicine that reduces the workload on the heart, or if diabetic patients are tested for blood-sugar control.

Analysts assess cost efficiency by looking at factors such as how many and what types of exams were conducted. Was a breast mass biopsy done in a hospital with an overnight stay or in an out-patient clinic? Was a generic or brand-name pain medication prescribed?

Doctors are then rated against peers in the same community, by type of patient and illness, and against clinical performance guidelines created by specialists such as the American Heart Association.

The systems differ. A doctor who performs well might be awarded stars, a smiley face or a Tier 1 rating. An inferior doctor’s patients might receive higher co-payments, or the physician might be shut out of an insurer’s preferred network.

In the Washington metropolitan area, UnitedHealthcare has been gathering and evaluating data on physicians and in January rolled out a Web site that ranks physicians with zero, one or two stars. Officials at the District of Columbia Medical Society said they were told that the goal of the Premium Designation program was to encourage physicians to refer patients to two-star doctors and for patients to seek out two-star physicians.

“We were shocked that they would be profiling physicians for the past 18 months and not tell anyone,” said Peter Lavine, chairman of the board of the medical society, which met with UnitedHealthcare officials last fall.

Officials with UnitedHealthcare, the nation’s second-largest health insurer and a unit of UnitedHealth Group of Minnetonka, Minn., said the goal is merely to provide information to consumers and to help doctors improve their performance.

“Our focus is really on transparency,” said Lewis Sandy, UnitedHealth Group senior vice president for clinical advancement.

UnitedHealthcare announced it would delay launching its program in New York, New Jersey and Connecticut after doctors complained and after New York Attorney General Andrew Cuomo threatened legal action.

One doctor fighting ratings systems is Seattle internist Michael Schiesser, who said his rating plummeted from excellent to the 12th percentile within a few months. He said initially Regence BlueShield, an insurer in the Northwest, ranked him in its top 90th percentile of doctors and awarded him a $5,000 check.

Later, when Regence cut him from its network and patients had to pay out-of-pocket to see him or go elsewhere, he pressed to see his report. He said he discovered that he had been penalized because of errors in data-gathering.

“I couldn’t believe the extent to which they had botched the data,” he said.

He said Regence faulted him for failing to control diabetes in patients who did not have the disease. He said he was docked points for not performing a Pap smear on a woman who had a hysterectomy. He added that his colleague was faulted for not performing a mammogram on a woman who had undergone a double mastectomy.

Last fall, Schiesser joined five other doctors and the Washington State Medical Association in suing Regence BlueShield, claiming defamation and deceptive business practices after the health plan told participating members that they no longer had access to about 500 doctors because the doctors did not meet the insurer’s quality and efficiency standards.

Regence spokesman Charlie Fleet said that because of the lawsuit, the company could not comment on the data issue. He did say, however, that the data were “provided from the physicians themselves.”

In December, Regence abandoned its plan.

Doctors critical of ratings systems say they are held accountable for whether patients exercise, take their medications or follow their prescribed regimens.

Berkenwald, the Massachusetts internist, said he was pushed from Health New England’s top 10 percent of physicians into its second tier because several of his female patients did not get the mammograms or Pap smears he prescribed.

But Berkenwald received a top-tier rating by several other insurers participating in the state’s Clinical Performance Improvement Initiative because the health plans use different cut-points for determining who falls into which tier.

Disparate ratings can confuse patients and cause turbulence in group practices.

When Elizabeth Trobaugh of Amherst, Mass., had a tick bite last fall and her family doctor was not available, she saw her doctor’s partner, who had a lower rating. Trobaugh was upset when she was charged a $10 higher co-pay. “Why should I be penalized for going to this person’s partner?”

Despite its flaws, proponents say the systems encourage much-needed quality and cost control.

Dolores Mitchell, executive director of the Massachusetts Group Insurance Commission, which launched its physician-rating program four years ago, said she’s heard doctors’ complaints about errors. But at $1 billion in annual spending on health care, she said, improving performance and efficiency is crucial.

“The data may not be perfect,” she said. “But they’re better than any data that we’ve had before.”

Staff researcher Richard Drezen contributed to this report.

Are Doctors to Blame for US Health Care Costs?

NY Attorney General Objects to Insurer’s Ranking of Doctors by Cost and Quality

Insurers’ Lists on Doctors Under Fire

Plan Would Tie Copayments to Doctors’ Rankings

One wonders what they were thinking during the interview.

Interview with Harvard physician and New Yorker author Dr. Jerome Groopman, author of “How Doctors Think”

as heard on NPR Morning Edition, March 26, 2007
Health Care
Doctors Shoulder Mounting Insurance Burdens
by Joanne Silberner

“Somebody’s got to do it. Who else is going to advocate for these people? I’m stuck being a secretary more than a doctor sometimes.”
Dr. Rebecca Jaffe, Family Physician

Physician participation in managed care (health insurance, HMO and PPO) sharply increased between the late 1980s and the late 1990s. In that same time, the percentage of physician income from health insurance providers more than doubled.

· Behind Dr. Rebecca Jaffe’s desk hangs a large black-and-white framed photo.

“That’s me on my third birthday, sitting on my grandmother’s step,” Jaffe says, “with my junior doctor kit.”

When she was younger, Jaffe says, she wanted to grow up to be just like the doctor who took care of her family.

She didn’t know that her life would be very different from that of her family’s doctor. She is a family physician, practicing in Wilmington, Del. But she increasingly struggles to spend quality time with her patients as disputes with insurance companies demand more of her attention.

For the first time in nearly two decades, efforts to improve the health care system are back on the national agenda. But even since former President Bill Clinton tried to overhaul the system, practicing medicine has greatly changed.

As Jaffe sees it, “insurance hopes to keep people well until they’re 65 and on Medicare.” After that, she says, it becomes somebody else’s problem.

Because insurance companies watch costs aggressively, Jaffe says she has to fight to get her patients the care they need. On two occasions, insurers told her they would pay less for an immunization than it would cost her to buy the vaccine, let alone administer it.The insurance company told her to make up the cost by seeing more patients.

“I just felt that was so wrong,” Jaffe says. She believes that good medical care takes time.

for full article and podcast, go to NPR Morning Edition March 26, 2007

Disposable Doctors

Posted: January 18, 2007 by Doc in Endings, ER Docs, Medical, Medical career, Medicine

disposable-doctors.gifDisposable People
When I started practice a little more than a decade ago, I got on staff at our suburban community hospital. With my shiny new diploma fresh out of training, I was probably more than a little condescending, having been taught at the big city academic medical center (BCAMC) where I trained, that REAL cutting edge medicine could only be practiced at BCAMCs.

Fortunately, I was knocked off my ivory tower , brought down to earth, and saved on what would turn out to be many, many occasions, by my favorite ER docs. These guys had battle experience, having worked in big city hospital ERs, they knew the patients, they had smarts, and heaps of common sense. Aside from taking care of a never-ending stream of patients, they also had to constantly beg for admission beds, cajole cranky consultants to come in, and sweet-talk the lab or radiology to speed up that blood test or CT scan. When I got that 2AM call from a wheezy asthmatic, all I had to do was send them to the ER and I could rest easy that my patient would be well cared for until I got there. We were a team, and I never even thought what it would be like without them to rely upon.

So, I was stunned when I heard that these wonderful doctors, who had served our community well for more than 10 years were being fired! Why? you may ask, and I asked the same question. The reason given was that they had not done a residency in Emergency Medicine and did not have ABEM certification! Now, please note that the ER docs in question had done residencies in Internal Medicine and Surgery and had board certifications in these specialties and/or were certified by the ABPS, and more importantly, WERE EXCELLENT ER PHYSICIANS AND HAD DONE AN OUTSTANDING JOB FOR MORE THAN 10 YEARS! Why would the hospital be one day happy with their services, then next day suddenly dispose of them like used Kleenex? Well, apparently the hospital CEO decided (without consulting the medical staff) that he would like to “improve” the ER by contracting with an outside company that would bring in their own doctors, none of whom we knew or ever met, but were ER residency trained and ABEM certified, and they did not hire non-ER trained ER physicians, thus our old ER docs were OUT. It is heart breaking and shameful that after devoting a significant portion of their lives and careers to this hospital and community, our ER docs were dismissed, (as if talented experienced physicians are so easily replaceable), through no fault of their own.

Apparently, this episode is not so uncommon nowadays. Nassau University Hospital planned to fire all of its ER doctors in 2005 and only backed down under pressure from the union. ER doctors in New Mexico and New York have also gotten the same shoddy treatment. I don’t understand this mad rush to replace good ER doctors when there is a supposed shortage of ER physicians and a full 38% of ER physicians in this country are NOT ER residency trained and ABEM certified, approximately 13,000 physicians.
What I also find distressing is that no one is speaking up for my friends. Not the AMA, and ACEP, which is supposed to advocate for ALL ER doctors (not just the ER trained, ABEM certified) has been far from helpful, in spite of their policy which states:

“A qualified emergency physician is defined as one who possesses the training and experience in
emergency medicine sufficient to evaluate and initially manage and treat all patients who seek emergency care. ACEP believes that the ED medical director should be responsible for assessing and making recommendations to the hospital’s credentialing body related to the qualifications of emergency physicians with respect to the clinical privileges granted to them. Such qualifications may include

    -professional credentials such as board certification;
    -objective measurement of care provided;
    -prior training;
    -and evidence of continuing medical education.

Although board certification in emergency medicine is an excellent benchmark that should be considered when delineating clinical privileges,
no single criterion should provide the sole basis for decisions regarding an individual’s emergency medicine practice.
(Approved 1985; Revised 1991; Revised 1995; Reaffirmed 1999; Revised 2004)

Some organizations, such as the EMRA and the AAEM even actively campaign against their non-ER residency trained colleagues. Is this what we’ve come to? No wonder the malpractice lawyers and insurance companies have no problem picking us off. Instead of getting our act together and supporting one another, we are too busy stabbing each other in the back.

To the hospital staff’s credit, petitions were circulated, special meetings were held, and outraged letters to the administration and the press were written, there was much wailing and moaning, but to no avail. My friends are gone, and as one of the other doctors said, “The ER is a strange and cold place” without them. ER care since they left is more fragmented and confused, because the new guys are still on a learning curve and they don’t know the patients or the other docs.

All this has left those of us remaining disgusted and demoralized, but we will recover, and life will go on. Excuse me while I go throw up now.

“Qualifications” on Scalpel or Sword
“Rant” on Gruntdoc
Disposable Doctors 2: ER Docs Fight Back in NY
News from AAPS vs. NY-DOH