New Center for Physician Rights

Cases of unfair physician treatment by regulatory boards and hospitals have been well publicized. However, little action to insure oversight of physician regulatory bodies has been done. Physicians who believe they have been subjected to unfair discipline now have a place to turn for information, advice, and support. The new center called The Center for Physician Rights (CPR) was founded by Kernan Manion, MD. According to their website the Center will offer:

1. Free confidential case review;
2. Case consultation and coaching;
3. Serve as a central authoritative informational and consultative resource;
4. Pursue organizational and legislative change.

CPR will develop an informational website and produce a monthly e-newsletter / blog updating subscribers of relevant developments. They hope to serve as the definitive “go to” knowledge resource by establishing a centralized reference library with essential resources based on their extensive research and cumulatively accruing knowledge of judicial decisions, case trends and operant medical licensing boards.

Manion’s own career-ending experience with the North Carolina Medical Board (NCMB) was well publicized (1). His case dates back to September 2009, when he worked as a civilian psychiatrist under contract with the Deployment Health Center at Naval Hospital Camp Lejeune, in Jacksonville, North Carolina. After he raised concerns with the US Navy and a personnel contractor about what he believed was dangerously deficient care of active duty service members who had posttraumatic stress disorder, he was dismissed. Later an anonymous source raised concerns about his mental health, which resulted in an investigation by the North Carolina Medical Board. Although an independent, comprehensive psychological evaluation determined he had no mental disorder or other psychological impairment, an assessment by the Board concluded otherwise, and he was forced to deactivate his medical license. In 2016, he launched a lawsuit against the NCMB, which was ultimately unsuccessful on appeal because it exceeded the time limit for filing a petition. Manion blamed the NCMB for using stall tactics to delay the legal process.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Anderson P.  One-Man Fight: MD Takes on State Medical Board, PHP. Medscape. November 8, 2016. Available at: https://www.medscape.com/viewarticle/871569 (accessed 11/13/18).

Cite as: Robbins RA. New center for physician rights. Southwest J Pulm Crit Care. 2018;17(5):137. doi: https://doi.org/10.13175/swjpcc116-18 PDF 

CMS Decreases Clinic Visit Payments to Hospital-Employed Physicians and Expands Decreases in Drug Payments 340B Cuts

The Centers for Medicare and Medicaid Services (CMS) has reimbursed hospital-employed physicians more than self-employed physicians. However, CMS is moving forward with plans to expand its site-neutral payment policy to clinic visits, a move that could save the agency hundreds of millions of dollars (1).

Clinic visits are the most common service billed to CMS. CMS estimates that it is now paying about $75 to $85 more on average for the same service in hospital outpatient settings compared to physician offices. Beneficiaries are responsible for 20% of that increased cost. The payment change is projected to save Medicare $610 million and patients about $150 million. Higher CMS payments to hospital-employed physicians have also been have associated with higher commercial prices and spending for outpatient care which could save CMS even more money (2).

However, CMS abandoned its 2016 plan to expand a site-neutral rule. That regulation would have paid hospital off-campus facilities less than hospital-based outpatient departments if they started billing Medicare after Nov. 2, 2015. Following pushback from the American Hospital Association and others, the agency said it decided to not finalize that provision.

CMS’ 340B Drug Discount Program requires drug manufacturers to provide outpatient drugs to eligible hospital-based departments at significantly reduced prices. CMS will expand last year's cuts to 340B discounts given to outpatient facilities. Last year, the agency cut 340B drug payments by $1.6 billion, or 22.5% less than the average sales price. CMS is expanding the 340B cut to off-campus provider-based departments to prevent hospitals from moving their drug administration services for 340B-acquired drugs to an off-campus facility to receive a higher payment.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Dickson V. CMS slashes clinic visit payments, expands 340B cuts. Modern Healthcare. November 2, 2018. Available at: https://www.modernhealthcare.com/article/20181102/NEWS/181109978 (accessed 11/2/18).
2. Neprash HT, Chernew ME, Hicks AL, Gibson T, McWilliams JM. Association of financial integration between physicians and hospitals with commercial health care prices. JAMA Intern Med. 2015 Dec;175(12):1932-9. [CrossRef] [PubMed]

Cite as: Robbins RA. CMS decreases clinic visit payments to hospital-employed physicians and expands decreases in drug payments 340b cuts. Southwest J Pulm Crit Care. 2018;17(5):136. doi: https://doi.org/10.13175/swjpcc115-18 PDF 

Big Pharma Gives Millions to Congress

Pharmaceutical companies contribute millions of dollars to U.S. senators and representatives as part of a multipronged effort to influence health care lawmaking and spending priorities. Kaiser Health News (KHN) recently developed a database of contributions by pharmaceutical manufacturers to members of Congress for the past 10 years (1). This was done by examining campaign finance reports from the Federal Election Commission to track donations from political action committees (PACs). The amounts are totaled quarterly and the exact amounts but can change as amendments and refunds are reported. Occasionally, refunds are reported in a different cycle from the original contribution, resulting in a negative total for the cycle. The database can be used to look up any individual candidate or pharmaceutical company and will be updated periodically according to KHN. Contributions to members of Congress from the Southwest states of Arizona, California, Colorado, Hawaii, Nevada and New Mexico are summarized in Appendix 1.

The drug industry ranks among lawmakers' most generous patrons. In the past decade, Congress has received $79 million from 68 pharma political action committees, or PACs, run by employees of companies that make drugs. The amount has steadily increased each year from $11.8 million in 2008 to $15.8 million last year. Since the beginning of last year, 34 lawmakers have each received more than $100,000 from pharmaceutical companies. In the Southwest one of those – Rep. Kevin McCarthy of California, the House Republican majority leader, received more than $200,000 so far this election cycle (2017 and 2018 to date) and has received more than $1,000,000 over the past 10 years (Appendix 1).

While PAC contributions to candidates are limited, a larger donation frequently accompanies individual contributions from the company's executives and other employees. According to Medpage Today, it also sends a clear message to the recipient, one they may remember when lobbyists come calling: “There's more where that came from” (2).

The KHN analysis shows that pharmaceutical companies give generously to a wide swath of lawmakers. Since the beginning of 2017, drug makers contributed to 217 Republicans and 187 Democrats, giving only slightly more on average to Republicans, who currently control both chambers of Congress (2). This was also the case for Democrats during the 2010 election cycle, when they controlled Congress.

Money also tends to flow to congressional committees with jurisdiction over pharmaceutical issues that can affect things like drug pricing and FDA approval. in early 2017, For Example, Rep. Greg Walden from Oregon has watched his coffers swell since he became chairman of the powerful House Committee on Energy and Commerce (1). Walden has received over $278,000 this election cycle. The six members of the committee from Southwest states (Reps. Walters, Eshoo, DeGette, Matsui, McNerney, and Peters) have also received $415,500 to date.

Nearly 50 drug makers made contributions with the amount roughly following the size of the company. Genentech, Pfizer, Amgen, Bristol-Myers Squibb and Eli Lilly were the top 5 over the past 10 years. The PAC for Purdue Pharma, the embattled opioid manufacturer, gave to only a handful of members this cycle. However, it focused much of its giving on lawmakers from North Carolina, its headquarters for manufacturing and technical operations. Insys, the opioid manufacturer from Chandler, Arizona, was not listed as making any contributions.

Campaign contributions tell only part of the story. Drugmakers also spend millions of dollars lobbying members of Congress. So far over $430 million has been spent this election cycle by pharmaceutical companies lobbying Congress (3). Another source is indirect lobbying through to patient advocacy groups, which provide patients to testify on Capitol Hill and organize social media campaigns on drug makers' behalf. A previous investigation by Kaiser Health News, "Pre$cription for Power," examined charitable giving by top drugmakers and found that 14 of them donated a combined $116 million to patient advocacy groups in 2015 alone (4).

Previous studies have suggested that political contributions may influence voting behavior. These sizable contributions may help explain, at least in part, why drug prices in the US are the highest in the world and why Congressional legislation regulating these prices has been so difficult to pass.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Lucas E, Lupkin S.   Pharma cash to Congress. Kaiser Health News. October 16, 2018. Available at: https://khn.org/news/campaign/ (accessed 10/23/18).
2. Huetteman E, Lupkin S. Drugmakers funnel millions to lawmakers. Medpage Today. October 16, 2018. Available at: https://www.medpagetoday.com/washington-watch/electioncoverage/75737?xid=nl_mpt_investigative2018-10-23&eun=g687171d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=InvestigateMD_102318&utm_term=InvestigativeMD (accessed 10/23/18).
3. Pharmaceuticals/health products. OpenSecrets.org. August 28, 2018. Available at: https://www.opensecrets.org/lobby/indusclient.php?id=h04 (accessed 10/23/18).
4. Kopp E, Lucas E, Lupkin S. Pre$cription for power. Kaiser Health News. 2018. Available at: https://khn.org/patient-advocacy/#+initialWidth=1170&childId=patient_advocacy&parentTitle=Pre%24cription%20For%20Power%3A%20KHN%20Patient%20Advocacy%20DatabaseKaiser%20Health%20News&parentUrl=https%3A%2F%2Fkhn.org%2Fpatient-advocacy%2F (accessed 10/23/18).

Cite as: Robbins RA. Big pharma gives millions to Congress. Southwest J Pulm Crit Care. 2018;17(4):117-8. doi: https://doi.org/10.13175/swjpcc113-18 PDF 

Gilbert Hospital and Florence Hospital at Anthem Closed

Gilbert Hospital and Florence Hospital at Anthem, two medical centers owned by parent company New Vision Health LLC, will close according to the Arizona Republic (1). Gilbert Hospital's emergency room will stay open until 1 p.m. Saturday and the Florence ER will close 8 a.m. Monday. Anyone receiving care was to be transferred or discharged, according to company spokesman Alex Stevenson.

The two hospitals and the parent company have been plagued with financial troubles. Creditors filed for involuntary Chapter 11 bankruptcy protection this spring, the second time they had faced bankruptcy in four years. A Maricopa County Superior Court judge on June 7 appointed a receiver, who concluded that the financial problems "were simply too significant to overcome." Bankruptcy court documents show the two medical centers owe creditors at least $13.1 million in unpaid loans. Both hospitals were operating under terminated leases because they could not pay rent, according to court records.

Gilbert Hospital was recently penalized by Medicare because of high rates of patient injuries, according to Kaiser Health News (2). Gilbert Hospital lost 1 percent of its Medicare funding this fiscal year. New Vision Health is also the owner of Peoria Regional Medical Center which filed for Chapter 11 bankruptcy protection in federal court in October 2017.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Altavena L. Bankruptcy forces abrupt closure of Gilbert Hospital, Florence Hospital at Anthem. Arizona Republic. June 15, 2018. Available at: https://www.azcentral.com/story/news/local/gilbert/2018/06/15/bankruptcy-gilbert-hospital-florence-hospital-anthem-close/705452002/ (accessed 5/16/18)
2. Rau J. Medicare penalizes group of 751 hospitals for patient injuries. Kaiser Health News. December 12, 2017. Available at: https://khn.org/news/medicare-penalizes-group-of-751-hospitals-for-patient-injuries/ (accessed 6/16/18)

Cite as: Robbins RA. Gilbert Hospital and Florence Hospital at Anthem closed. Southwest J Pulm Crit Care. 2018;16(6):340. doi: https://doi.org/10.13175/swjpcc080-18 PDF 

Editor's Note: Gilbert Hospital was located at 5656 S. Power in Gilbert and should not be confused with Mercy Gilbert Medical Center which is located 3555 S. Val Vista Drive also in Gilbert.

CMS’ Star Ratings Miscalculated

Modern Healthcare is reporting that the Centers for Medicare and Medicaid Services (CMS) has miscalculated hospitals star ratings since they were first released in 2016 (1). Officials at Rush University Medical Center in Chicago exclusively disclosed their analysis and correspondence to Modern Healthcare. The investigators found that instead of evenly weighting the eight measures in the safety of care group, the CMS' star ratings formula relied heavily on one measure— The Patient Safety and Adverse Events Composite, known as PSI 90 —for the first four releases of the ratings and then complication rates from hip and knee replacements for the latest release. The single measure accounted for about 98% of a hospital's performance in the safety group, according to Rush's analysis. The safety group can also greatly influence a hospital's overall star rating, the analysis concluded. Rush's findings likely prompted the CMS to announce this week that it would postpone the July release of its star ratings (1).

The statistical model the CMS uses likely caused the miscalculation. The model, called latent variable modeling, uses scores for seven groups of measures to calculate the star ratings:

1. Mortality
2. Safety of Care
3. Readmission
4. Patient Experience
5. Effectiveness of Care
6. Timeliness of Care
7. Efficient Use of Medical Imaging

The three outcome groups—mortality, safety and readmissions—are each weighted the most at 22% each. Measures within each group are supposed to be evenly weighted to calculate the hospital's performance in that area. Rush's analysis found that the weight given to the PSI-90 measure was much greater than the seven other measures in the safety group. Specifically, PSI-90 was weighted 1,010 times stronger than the catheter-associated urinary tract infections measure, 81 times stronger than the C. difficile infection rates measure, 51 times stronger than the central line-associated bloodstream infection rates measure and 20 times stronger than either the surgical site infection rate measure.

Latent variable modeling changes the weighting and is inappropriate for measuring clinical outcomes, said David Levine, senior vice president of advanced analytics and informatics at Vizient (1). "Given the disproportionate weighting of the safety scores over time, they did not represent a composite measure," said Dr. Omar Lateef, an author of the analysis and Rush's senior vice president and chief medical officer (1). Lateef said he and his colleagues at Rush were alarmed by a rating drop from 5 to 3 stars because they have improved performance on five of the eight safety measures since the December release. " Lateef added that although CMS was initially dismissive of Rush’s concerns that CMS has come around since presented with Rush’s analysis.

CMS announced earlier this week that it was delaying release of the star ratings "to address stakeholders concerns." No date has been set for when the new ratings will be released.

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Maria Castellucci M. CMS star rating system has been wrong for two years, health system finds. Modern Healthcare. June 15, 2018. Available at: http://www.modernhealthcare.com/article/20180615/TRANSFORMATION01/180619933?utm_source=modernhealthcare&utm_medium=email&utm_content=20180615-TRANSFORMATION01-180619933&utm_campaign=am (accessed 6/15/18).

Cite as: Robbins RA. CMS' star ratings miscalculated. Southwest J Pulm Crit Care. 2018;16(6):338-9. doi: https://doi.org/10.13175/swjpcc078-18 PDF