Seven Words You Can Never Say at HHS

The recent announcement of the seven words you can never say at Health & Human Services (HHS) reminded me of the late George Carlin’s routine, “Seven Words You Can Never Say on Television” (1). Policy analysts at the Centers for Disease Control (CDC) in Atlanta were told of the list of forbidden words at a meeting last Thursday, December 14, with senior CDC officials who oversee the budget, according to an analyst who took part in the 90-minute briefing (2). The forbidden words are "vulnerable," "entitlement," "diversity," "transgender," "fetus," "evidence-based" and "science-based." In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said. In other cases, no replacement words were immediately offered.

This is the latest attempt by government departments to distort fact. As an example, The New York Department of Education tried a similar tactic in 2012 (3). Among the words were dinosaur, birthday, and Halloween. Some of the reasons given were that dinosaurs suggest evolution which creationists might not like; Halloween was targeted because it suggests paganism; and birthday because it isn’t celebrated by Jehovah’s Witnesses; The Bush administration waged a similar war on climate change (4). That war has been extended by the Trump Administration as part of their war on any science that the Trump administration does not like (5). Science that does not fit Trump’s agenda or ideology is insulted or called “fake news”. Climate change is fact and not a hoax dreamed up the Chinese as Trump has claimed (6).

Mr. Carlin is not alive to make fun of the latest war on free speech but perhaps others will take up Carlin’s calling. Seven words they might suggest be banned include stupid, moron, fool, clown, weird, dumb and incompetent-all frequently used by President Trump on Twitter (7). The CDC is a scientific organization. Appointing unqualified politicians to head scientific organizations to carry out a political agenda is like mixing oil and water. No matter how times you say it, the water will not float on top of the oil. Science relies on a precise vocabulary and is not Republican or Democrat, conservative or liberal, or right or left. In my view, those that banned these words made an indirect attack on fact and should be “ashamed” (7).

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Carlin G. 7 words you can never say on television. Available at: https://www.youtube.com/watch?v=kyBH5oNQOS0 (accessed 12/18/17).
2. Sun LH, Eilperin J. Words banned at multiple HHS agencies include ‘diversity’ and ‘vulnerable’. Washington Post. December 16, 2017. Available at: https://www.washingtonpost.com/national/health-science/words-banned-at-multiple-hhs-agencies-include-diversity-and-vulnerable/2017/12/16/9fa09250-e29d-11e7-8679-a9728984779c_story.html?utm_term=.c983e2f2af81 (accessed 12/18/17).
3. CBS News New York. War on words: NYC dept. of education wants 50 ‘forbidden’ words banned from standardized tests. March 26, 2012. Available at: http://newyork.cbslocal.com/2012/03/26/war-on-words-nyc-dept-of-education-wants-50-forbidden-words-removed-from-standardized-tests/ (accessed 12/18/17).
4. Union of Concerned Scientists. Scientific integrity in policy making. September, 2005. Available at: https://www.ucsusa.org/our-work/center-science-and-democracy/promoting-scientific-integrity/reports-scientific-integrity.html#.Wjf0TFWnGUk (accessed 12/18/17).
5. Editorial Board. President Trump’s war on science. New York Times. September 9, 2017. Available at: https://www.nytimes.com/2017/09/09/opinion/sunday/trump-epa-pruitt-science.html (12/18/17).
6. Marcin T. What has Trump said about global warming? Eight quotes on climate change as he announces Paris agreement decision. Newsweek. June 1, 2017. Available at: http://www.newsweek.com/what-has-trump-said-about-global-warming-quotes-climate-change-paris-agreement-618898 (accessed 12/18/17).
7. Lee JC, Quealy K. The 394 people, places and things Donald Trump has insulted on twitter: a complete list. New York Times. November 17, 2017. Available at: https://www.nytimes.com/interactive/2016/01/28/upshot/donald-trump-twitter-insults.html (accessed 12/18/17).

Cite as: Robbins RA. Seven words you can never say at HHS. Southwest J Pulm Crit Care. 2017;15(6):294-5. doi: https://doi.org/10.13175/swjpcc154-17 PDF 

EMR Fines Test Trump Administration’s Opposition to Bureaucracy

Earlier this week the Health and Human Services Office of Inspector General (OIG) released an audit report on $6.1 billion paid to 250,000 clinicians in the incentive program for meaningful use of electronic medical records (EMRs) (1). A random sample of 100 clinicians who had received at least one incentive payment revealed that 14 of them who had had not met all meaningful use requirements as they had attested (Table 1) (1,2).

Table 1. Meaningful use deficiencies identified in 14 of 100 clinicians.

• Six clinicians couldn't provide a mandatory analysis of security risks;
• Four clinicians couldn't prove that they had generated at least one list of patients-another requirement -who had the same condition;
• Three clinicians could not provide patient encounter data to document that they had met various meaningful use measures;
• One clinician had 90-days' worth of patient encounter data when a year's worth was needed;
• One clinician did not use certified EHR technology as much as required.

The OIG recommended that the Center for Medicare and Medicaid Services recover the $291,222 paid to the clinicians in the sample group and extrapolated the recovery to $729 million from the remaining clinicians based on this random sample. This is about 13% of the incentives paid to clinicians for the CMS EMR program. The decision to carry out the recommendation will ultimately fall to a US Department of Health and Human Services (HHS) secretary, Tom Price MD, who has opposed government programs that created regulatory hassles for physicians.

"We would protest if they went through with this," said Robert Tennant, director of health information technology policy at the Medical Group Management Association (MGMA). "Going after folks who tried to meet arbitrary government requirements, who made a good faith effort, isn't fair” (2). Tennant said that this complexity, made worse by evolving requirements, helps explain the deficiencies listed in the OIG audit. "I'm not surprised some providers found it daunting to keep up with the changes," he said. The requirement for a security risk analysis is a problem, Tennant noted, because CMS hasn't given clinicians sufficient guidance on how to meet the requirements. "This is a real stumbling block for smaller practices," he said. "They're not security experts, they're clinicians" (2). American College of Physicians Vice President of Governmental Affairs and Medical Practice Shari Erickson said that clinicians who originally attested to meaningful use lacked clear, specific guidance on what documentation they needed for each requirement (2).

CMS incentivized using EMRs because many clinicians were reluctant to initiate EMRs in their practices because of cost and efficiency considerations. Average costs to initiate an EMR were $163r,765 for a single practitioner and $233,298 for a practice with five physicians (3). Reimbursement under the EMR program was about $65,000 per provider (4). Furthermore, there was an 8% decrease in productivity after EMR initiation (3). In other words, if physicians wanted to see Medicare/Medicaid patients they were asked to use EMRs that cost them money and made them work harder.

The violations identified in the OIG audit seem fairly minor and are the type of trivial violations that the lawyers and bureaucrats seem to delight in identifying and excessively penalizing clinicians. In contrast, large health care organizations seem to go unpunished for more egregious violations. Witness the lack of action against Banner Healthcare for compromising 3.7 million medical records in 2016 (5). The average cost of data breach has been estimated at $398 per compromised record (2). Extrapolating, Banner should be fined nearly $1.5 billion.

Medicine is likely the most regulated industry in the US. Several of my colleagues have complained that the regulation seems more directed at them and not at the hospitals and insurance companies that seem to create most of the increase in cost and the violations. Some of the more paranoid clinicians viewed the EMR as nothing more than a tactic to gain further control of their practice and viewed Hillary Clinton as someone who would continue the onslaught on clinicians. These fines for EMR noncompliance are the first true test for the Trump administration in the area of healthcare regulation. Many of my colleagues are watching Trump and Price to see if their opposition to bureaucracy was merely lip service or has some backbone. 

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Levinson DR. Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements. Department of Health and Human Services. Office of the Inspector General. June 2017. Available at: https://oig.hhs.gov/oas/reports/region5/51400047.pdf (accessed 6/15/17).
2. Lowes R. Proposal to take back EHR bonuses galls med societies. Medscape. June 13, 2017. Available at: http://www.medscape.com/viewarticle/881563?nlid=115819_4502&src=wnl_dne_170615_mscpedit&uac=9273DT&impID=1368453&faf=1 (accessed 6/15/17). 6
3. Fleming NS, Aponte P, Ballard DJ, Becker E, Collinsworth A, Culler S, Kudyakov R, McCorkle R, Chang D. Exploring financial and non-financial costs and benefits of health information technology: the impact of an ambulatory electronic health record on financial and workflow in primary care practices and costs of implementation. The Agency for Healthcare Research and Quality (AHRQ). 2011. Available at: https://healthit.ahrq.gov/sites/default/files/docs/publication/R03HS018220-01Flemingfinalreport2011.pdf (accessed 6/15/17).
4. Hayes TO. Are electronic medical records worth the costs of implementation?American Action Forum. August 6, 2015. Available at: https://www.americanactionforum.org/research/are-electronic-medical-records-worth-the-costs-of-implementation/ (accessed 6/15/17).
5. Robbins RA. Banner hacked-3.7 million at risk. Southwest J Pulm Crit Care. 2016;13(2):80-1. [CrossRef]

Cite as: Robbins RA. EMR fines test Trump administration's opposition to bureaucracy. Southwest J Pulm Crit Care. 2017;14(6):312-4. doi: https://doi.org/10.13175/swjpcc079-17 PDF