August 15, 2016 Recent News





The US is getting more like the UK with rationing of care.  However, it is not the feds that are doing it.  It is the private insurers.  The pharmacy benefit managers continue to look at the bottom line and restrict drugs that are expensive.  Express Scripts will exclude 85 meds to save $1.8 billion.  CVS is eliminating 35 meds including Alcortin A External Gel which rose in price 2850% in the last three years.  If a drug is off formulary the patient will need to pay a high co-pay.  CVS is switching to biosimilars for the high cost drugs.

Medicare has penalized a huge number of hospitals for their readmission statistics.  They will withhold mover a half billion dollars from 2579 hospitals.  The penalties will rise by 20%. 

The administration that told you lie after lie is at it again.  This time they are trying to cool the information coming out of all areas that Ocare is not working.  They say the marketplace is adding healthier and lower risk consumers (patients).  They say medical costs in 2015 were unchanged as compared to 2014.  They also believe the huge increases in premiums for the upcoming year are a one year event.  They do not know if this is true as the insurers don't know.  See next two stories.

California Blue Shield must not have gotten the CMS memo of how good Ocare is.  They are closing down for one week in September to reduce payroll liabilities due to losses in Covered California.

Aetna must not want their merger too badly.  They are pulling out of Ocare in some areas due to increased costs.  This follows United pulling back as did Humana.  This is direct slap at Obama who touted Aetna after United pulled out.

Medicare states that physicians are billing Medicare patients for things that are supposed to be exempt.  They point to the Medi-Medi patients who should pay nothing but the insurance payments.  Some providers are billing for the co- payments even though the patient does not have to pay by law. 

Calpers has unilaterally paying contracted hospitals a maximum for certain surgeries.  They are calling it reference pricing.  If a patient wants to get the surgery done at a higher priced hospital they need to pay the difference themselves.  Therefore a patient would have to pay their usual cost sharing plus the difference.  The procedures were all elective.    

The VA is giving up on their EHR VistA.  They are now looking for a replacement to go forward.

Karen DeSalvo is leaving her position as the head of IT but will stay on as assistant secretary for health.          Top


In it must be a slow news day story, NBC investigated Lee County, Florida, pediatricians for dropping eight families due to bad social media postings.  The patients who wrote the reviews don't think it is right to be dropped but the physicians do not have to take patients who are not happy.  People should think before they publish on social media.

Aetna has begun notifying physicians regarding their prescribing habits in regard to opioids.  This is true for those prescribing in the top 1% in their specialty.  Oncologists were excluded from the notification.  They are saying to look at your own practice to see if you can improve.

Four independent orthopedic groups in North Carolina have merged into a supergroup.  This will mean 49 locations in 21 counties.  There will be 126 physicians and be one of the largest orthopedic groups in the country with a lot of bargaining power.  More groups are expected to join next year.

Apparently the people at the American College of Surgeons have too much time on their hands.  They have issued a guideline with no teeth regarding the proper use of operating room scrubs.  

MGMA has issued a report that shows the cost of IT for physicians has reached $32,00 per doctor.  

In the joke of the year, the feds are urging more physicians to get training to prescribe buprenophine based drugs to combat opiod addiction.  If they spend their own money to get the un-needed training they will still be limited to 30 patients at a time.  Whoopie!

Medicare is finding that as they cut back on physician funding physicians are finding new ways to make money.  They now do services in their offices to get around the Stark Law with a small number of physicians (10%) accounting for more than 50% of the rise in spending for each of the four highest news office tests.  These tests (1) do tear osmolarity to see if the eyes are too dry, (2) sweat tests to measure sweat response, (3) electronic brachytherapy the radiates skin cancer in place of surgery and (4) electroretinograpy to test retina function.  Brachytherapy is being reimbursed at about $11,000 per cancer versus $600 for surgical removal.  This include the payment to oncologic radiologists to operate the machines.  The payments are now being reduced to the $3500 range.

Medscape has an article stating that physicians will flee Medicare over the new MACRA payment rules.  For those small groups look for merging into large groups.  Even CMS believes there will be fallout from the new rules.  They predict that most physicians in groups below 25 will get significant penalties in 2019.  They also believe that 81% of physicians in groups over 100 will get bonuses.  Soloists are predicted to get a penalty rate of 87%.  Watch for these to leave.

As a corollary to the above, there was a story about primary physicians opting out of all insurance and doing medicine for a monthly or per visit fee called direct primary care. The physician can spend as much time as they want with the patient and not do the high volume now required by those that hire physicians.  The American Academy of Family Practice is now holding seminars in direct care.         Top


A woman was visiting Cancun, Mexico, and had an acute MI needing acute intervention followed by another blockage and a second surgery.  Neither surgery would be done unless the person paid $25,000 and an additional $30,000 upfront.  Both surgeries at the private hospital were successful but the hospital is demanding an additional $40,000 before she could be released.  If these funds were not paid she was threatened with arrest.  After intervention by her US Representative she was released from the hospital.  The hospital attorney said the Amerimed hospital will never refuse to release a nonpaying patient for financial reasons.   Hospital scams are well known in all parts of Mexico where tourists gather.  People also should realize that Medicare will not pay any money once a patient leaves the country.

Another CEO with a head in the sand.  DeSha McLeod, the CEO of the Community Hospice of Modesto (California) has lost five physicians including the past medical director.  They aired their grievances with the local newspaper as they got no where with McLeod.  The hospice offered new contracts to the physicians for less money.  The physicians wanted a seat on the board and more nurse education.  The board will do what all boards do when they are in disarray, hire a consultant.  The medical director came to the job and heard multiple complaints that she tried to pass on but was rebuffed by the CEO.  

East Tennessee University has got problems.  Their OB/Gyn residency is on probation due to poor training by the faculty.  They have been on probation for a year due to the problems with teaching and fear of retaliation.  After a year they are still on probation for the same reasons.  The OB department is not alone.  The departments of Family Medicine. Internal Medicine and Pulmonary Disease and Critical Care are on continued accreditation but with warning for the same concerns as the OB Department.

The NICU at Prince George Hospital in Cheverly, Maryland, has closed and the babies transferred after two died and it was discovered pseudomonas in several babies.

Kaiser continues to impress.  The San Francisco Business Times reports that in the first half of this year the organization increased operating revenue and enrollment.  They didn't do so well in investments, net income or total first half income.          Top


 DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.