Practice Fusion Admits to Opioid Kickback Scheme

Practice Fusion, a San Francisco-based health information technology developer, will pay $145 million to resolve criminal and civil investigations relating to its electronic health records (EHR) software (1). The Department of Justice announced on January 27th that the company admitted it solicited and received kickbacks from a major opioid company in exchange for utilizing its software to influence physicians prescribing opioid pain medications. The pharmaceutical company is widely speculated to be Purdue Pharma which faces U.S. Justice Department probes and sprawling litigation over allegations it played a central role in the deadly opioid crisis (2).

The DOJ said Practice Fusion extracted kickbacks from pharmaceutical companies in exchange for implementing a clinical decision support (CDS) system in its electronic health records (EHR) software designed to increase prescriptions for their drug products. In exchange for “sponsorship” payments from pharmaceutical companies, Practice Fusion allowed the companies to craft CDS alerts to increase sales of the companies’ products, resulting in alerts that did not always reflect accepted medical standards. In their criminal probe of opioid makers, federal prosecutors have indicted pharmaceutical company executives, physicians and pharmacists. This is the first criminal action against an EHR vendor and no indictments of any Practice Fusion executives were made.

Founded in 2005, Practice Fusion offers an EHR tailored for smaller, independent physician practices. It supports practices that comprise 112,000 health care workers who see 5 million patient visits per month. Practice Fusion had expected to go public at a valuation of about $1.5 billion, but was instead acquired in 2018 by Chicago-based Allscripts for $100 million in cash.

Our practice at Arizona Chest and Sleep Medicine uses Practice Fusion in its outpatient clinics. None of us were aware of receiving any alerts advising prescribing opioids.

References

1. Johnson T. S.F.-based Practice Fusion Inc. admits to opioid kickback scheme. San Francisco Business Times. January 28, 2020. Available at: https://www.bizjournals.com/sanfrancisco/news/2020/01/28/s-f-based-practice-fusion-inc-admits-to-opioid.html (accessed 2/3/20).
2. Spector M, Hals T. OxyContin maker Purdue is 'Pharma Co X' in U.S. opioid kickback probe – sources. Reuters. January 28, 2020. Available at: https://www.reuters.com/article/us-purdue-pharma-investigation-opioids-e/exclusive-oxycontin-maker-purdue-is-pharma-co-x-in-us-opioid-kickback-probe-sources-idUSKBN1ZR2RY (accessed 2/3/20).

Cite as: Robbins RA. Practice Fusion admits to opioid kickback scheme. Southwest J Pulm Crit Care. 2020;20(2):63. doi: https://doi.org/10.13175/swjpcc010-20 PDF

Arizona Medical Schools Offer Free Tuition for Primary Care Commitment

The University of Arizona (UA) Colleges of Medicine in Tucson and Phoenix will offer free tuition starting in the spring semester for qualifying medical students agreeing to practice primary care (1). To be considered for free tuition, applicants must be an Arizona resident and current full-time medical student. A minimum commitment of 2 years practicing in an underserved Arizona community must be started within 6 years of graduation from medical school and completed within 10 years of graduation.

The money will come from part of the $8 million annual funding approved by the Arizona Legislature in May. According to the press release, nearly 100 students or about 10% of the student body could get free tuition at the two medical schools. Currently, tuition is $31,652/year in Tucson and $33,402 in Phoenix.

Arizona currently meets only 40% of its primary care physician (PCP) need, according to the Health Resources and Services Administration. Arizona ranks 42nd among states for total active PCPs at 77.9 per 100,000 (the US average is 91.7) according to the university's physician workforce report published in October.

In addition to enlarging the primary care workforce, the waived tuition is meant to reduce financial barriers to even applying to medical school with the looming promise of student debt. Nearly half of medical school graduates owe more than $200,000 in medical school loans, according to the latest Medscape Residents Salary and Debt Report.

UA joins a growing list of medical schools offering free tuition including New York University, the University of Houston, Kaiser Permanente, and Weill Cornell. None of the others require practicing primary care as a requirement for receiving the free tuition.

Reference

1. Marcia Frellick M. U of Arizona offers free med school tuition for primary care. Medscape. December 6, 2019. Available at: https://www.medscape.com/viewarticle/922275?nlid=132930_5461&src=wnl_dne_191209_mscpedit&uac=9273DT&impID=2196790&faf=1 (accessed 12/9/19).

Cite as: Robbins RA. Arizona medical schools offer free tuition for primary care commitment. Southwest J Pulm Crit Care. 2019;19(6):163. doi: https://doi.org/10.13175/swjpcc071-19 PDF 

Determining if Drug Price Increases are Justified

Drug prices continue to increase but the reasons for the increases are often nebulous. The Institute for Clinical and Economic Review (ICER) evaluated the pricing in partnerships with SSR Health Inc, a research firm, calculated the increases excluding discounts and after-market rebates (1). It was the first such annual report by the Boston-based research group, which assesses the cost-effectiveness of drugs.

A list of 78 drugs with price hikes at more than twice the rate of medical inflation was developed. From this list 9 drugs were selected for detailed review because they had the largest increase in drug spending due to a net price change. ICER reviewed these 9 drugs to determine if the price increases were supported by new clinical evidence based on new indications or data suggesting superiority over other drugs. Of these 9 drugs, ICER concluded 7 did not have justification for the price increases.

Advair, Glaxo’s beta agonist/steroid combination was the only bronchodilator on the list but was not selected for detailed review. Rituxan, a drug which can be used to treat granulomatosis with polyangiitis (GPA, formerly known as Wegener's Granulomatosis) and microscopic polyangiitis (MPA) was one of the drugs selected for review and ICER concluded the price increase was not justified.

ICER acknowledged it was difficult to determine the actual increase in spending on the drugs, but said it was confident that the seven drugs cost increase were more than other drugs (2). "If manufacturers weren't raising prices if they haven't shown a new important benefit, I think that would help," ICER Chief Medical Officer David Rind said. He added that he hoped pricing drugs based on new benefits could help slow cost hikes.

Not surprisingly pharmaceutical companies with drugs on the list were critical of the report. Gilead, Lilly, Pfizer and Roche were all critical of the report or defended their drug pricing policies (2). Both California and Vermont now have laws tracking substantial drug price increases, requiring drug manufacturers to submit information that might justify increases above a certain threshold (1). ICER hopes their report is a first step in providing the public and policymakers with information they can use to advance the public debate on drug price increases.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Institute for Clinical and Economic Review. Unsupported price increase report: 2019 assessment. October 8, 2019. Available at: https://bit.ly/31XIdyk (accessed 10/11/19).
2. Humer C. Humira, Rituxan top list of U.S. drugs with biggest price increases: report. Reuters Health News. October 9, 2019. Available at: https://www.reuters.com/article/us-usa-healthcare-drugpricing/humira-rituxan-top-list-of-u-s-drugs-with-biggest-price-increases-report-idUSKBN1WN1BE (accessed 10/11/19).

Cite as: Robbins RA. Determining if drug price incrases are justified. Southwest J Pulm Crit Care. 2019;19(4):123-4. doi: https://doi.org/10.13175/swjpcc064-19 PDF 

Court Overturns CMS' Site-Neutral Payment Policy

On Tuesday of this week (9/17/19) a federal district court judge ruled in favor of an American Hospital Association (AHA) and Association of American Medical Colleges (AAMC) complaint that the Centers for Medicare & Medicaid Services (CMS) had overstepped its bounds by implementing site-neutral payments in January. US District Judge Rosemary M. Collyer said in her decision, "The Court finds that CMS exceeded its statutory authority when it cut the payment rate for clinic services at off-campus provider-based clinics" (1).

Under its site-neutral policy, CMS had begun paying the outpatient provider-based departments of hospitals the same for visits that it paid to independent physician practices. Previously, the hospital providers had been paid significantly more for these services than to community practices and the change in CMS policy was expected to level the playing field between independent offices and hospital-employed practices. In addition, it lowered the incentive of healthcare systems to acquire more physicians and their practices, according to some health policy experts.

The difference in costs is substantial with hospitals charging 2-6 times more than an independent physician office (2). The site-neutral payments were expected to cost hospitals $760 million in 2020, according to the suit.

The Medicare Payment Advisory Commission had advised Congress that hospitals were buying physician offices and converting them to off-campus provider-based departments partly because payments were higher than independent physician offices. In the Bipartisan Budget Act of 2015, Congress allowed hospitals to bill CMS at the higher outpatient department rate if they existed prior to Nov. 2, 2015. The law permitted CMS to change the payment system for newly established hospital-based outpatient departments. However, one expert told Medscape Medical News last year that this provision of the budget act hadn't had much impact, because many hospitals just added newly recruited physicians to the PBDs that had been grandfathered in (1).

Asked to comment on the court ruling, a CMS spokesperson told Medscape Medical News, "We are aware of the decision and are determining next steps" (1).  The AHA and the AAMC were jubilant. In a joint statement, they said, "We are pleased with the District Court's decision that the Department of Health and Human Services exceeded its statutory authority when it reduced payments for hospital outpatient services provided in grandfathered, off-campus, provider-based departments. The ruling, which will allow hospitals to maintain access to important services for patients and communities, affirmed that the cuts directly undercut the clear intent of Congress to protect hospital outpatient departments because of the many real and crucial differences between them and other sites of care."

John Cullen, MD, president of the American Academy of Family Physicians, said in a statement that the AAFP is disappointed with the court ruling. "The decision preserves a system that both costs patients more in out-of-pocket expenses and limits their choice of physicians by paying hospital outpatient departments more for the same services provided by community-based physicians." he said. He added, these payment disparities across sites of service "force many community clinics to close their doors or sell their practices to hospitals. The small private practices, which provide high-quality care at a lower cost, are most at risk as a result of this decision." Robert Doherty, senior vice president, governmental affairs and public policy, for the American College of Physicians, tweeted, "This is very bad news for all the patients harmed by hospitals adding 'facility fees' for visits to doctors in practices they acquired."

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Terry K. Court overturns CMS' site-neutral payment policy; doc groups upset. Medscape Medical News. September 19, 2019. Available at: https://www.medscape.com/viewarticle/918744?nlid=131645_5401&src=wnl_dne_190920_mscpedit&uac=9273DT&impID=2101100&faf=1#vp_2 (accessed 9/19/19).
2. Carey MJ. Facility fees: the farce everyone pays for. Medical Economics. August 16, 2018. Available at: https://www.medicaleconomics.com/blog/facility-fees-farce-everyone-pays (accessed 9/19/19).

Cite as: Robbins RA. Court overturns CMS' site-neutral payment policy. Southwest J Pulm Crit Care. 2019;19(3):101-2. doi: https://doi.org/10.13175/swjpcc060-19 PDF 

Pulmonary Disease Linked to Vaping

As of August 21, 153 cases of severe respiratory disease associated with vaping had been reported to the CDC mostly in adolescents and teens (1). Cases have been reported in 16 states including California and New Mexico. No specific cause has been identified although the available evidence does not suggest and infectious source. Many of the cases appear similar with tetrahydrocannabinol (THC) containing products often mixed with the vaping solution (2). Patients’ respiratory symptoms at presentation included cough, shortness of breath and fatigue that worsened over several days or weeks before hospital admission. Some patients also reported fever, chest pain, weight loss, nausea or diarrhea.  Chest radiographs have been reported to show bilateral opacities and CT chest scans have demonstrated diffuse ground-opacities, often with sub-pleural sparing. In some cases, patients experienced respiratory failure requiring mechanical ventilation but subsequently improved with treatment with corticosteroids.

The Arizona Department of Health issued a warning to the public yesterday. If a case is suspected, the Arizona Poison and Drug Information System should be contacted at 800-222-1222.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. CDC. CDC, FDA, states continue to investigate severe pulmonary disease among people who use e-cigarettes. August 21, 2019. Available at: https://www.cdc.gov/media/releases/2019/s0821-cdc-fda-states-e-cigarettes.html (accessed 8/22/19).
2. CDC. CDC urges clinicians to report possible cases of unexplained vaping-associated pulmonary illness to their state/local health department. August 14, 2019. Available at: https://emergency.cdc.gov/newsletters/coca/081619.htm (accessed 8/22/19).

Cite as: Robbins RA. Pulmonary disease linked to vaping. Southwest J Pulm Crit Care. 2019;19(2):84. doi: https://doi.org/10.13175/swjpcc057-19 PDF