When healthcare providers end up really being healthcare deniers

I got the email below on Jan 1, 2024.  This pt’s story is not a unique issue. Another example of bureaucrats and politicians attempting to “solve” our fabricated opioid crisis by creating a “one size fits all” on pain management.

After having this blog for 12-13 yrs, I have developed a fairly sizeable network of chronic pain pts, chronic pain advocates, and numerous healthcare practitioners.  I shared this woman’s email with a couple of select people that I believed might be able to STEP UP. And one did:

When a pt’s long term medical records mean nothing when seeing a new practitioner

When everything seemed to start to fall into place for this young lady. This young lady’s pharmacist and the mid-level practitioner who was forcing her to reduce her pain meds had to step in to make sure that things were not going to change the way that this mid-level practitioner wanted things to happen. Here is a video this young lady sent that she personally explains what has happened.

Hi Steve,

I have sent you my story before. I am a single disabled palliative care sick patient in Maine. In September of 2021, my doctor and I were targeted by the assistant attorney general, Michael Miller. We think it was for 2 reasons-he was very effective at getting patients disability, testings, procedures, equipment, etc and because I require a high dose of opiates to physically and mentally function. Dr. Lommler believes Michael Miller made a deal with the insurance companies and profited somehow for taking him out. Michael Miller used at least 2 agencies to target, harass, and destroy us. They suspended Dr. Lommler’s license for going over the 100 MME limit on my prescription. However, Maine has a palliative care exemption that allows people (like me) to have access to opiates for pain control and disease treatment options. It also allows us to go over the 100 MME limit. They refused to lift the suspension unless he transferred to a “board approved” facility. He chose to retire because he wanted to stay at his independent office with his 200 complicated and unique patients. They gave neither one of us any due-process! They used backdoor methods and I believe they were illegal! There was a covering LNP seeing me for a year. We tried to find a doctor everywhere in Maine to see me but because of the Opiate Task Force and doctors getting red-flagged for going over the 100 MME limit and being dragged in front of the board, no one would see me. I was forced to transition to the hospital where all of my specialists are. You see, Maine and New Hampshire were the 2 states prescribing the most Opiates so they created a New England Opiate Task Force and sent them to work with the Governor Mill’s administration to red-flag doctors prescribing over the 100 MME limit and drag them in front of the board of medicine! They have forced independent providers to either retire or transfer to a “board approved” facility. These “board approved” facilities all have anti-opiate one-size-fits-all policies. The hospital that I am at has an anti-opiate provider masquerading as a “pain specialist.” She believes Opiates are life threatening and dangerous to everyone. She is force tapering me off all my pain medication! I am complicated and unique-I have multiple health conditions. I had an original medical nightmare that left me with life altering physical deformities and severe debilitating pain. I have Crohn’s disease, vitamin and bone deficiencies, and neuropathy-all of these cause malabsorption so I have to take double doses of all of my medication! I cannot have the conventional pain management treatments because I am allergic to everything and sensitive to anything and I have a prosthetic heart valve. I have Scoliosis and severe Osteoporosis with dangerously low Scores. I am 46 in an 86 year old’s body.
They are stereotyping anyone on opiates as addicts and forcing them off pain medication. The only option they give you is Suboxone-I cannot take this because the side effects would be catastrophic to my body. I had nothing but recovery and progress with my 8 1/2 year stable pain regimen. I was able to semi function independently with a decent quality of life. Since this provider has been force tapering me, I can no longer function independently at all and I have zero quality of life! According to Maine’s own definition and standards, what this facility and provider are doing to me is disability abuse! I tried to contact patient services for an advocate but was told there wasn’t one. The woman I spoke with for 2 minutes, asked me what my concerns were. I explained to her what was happening to me. 2 days later I received a letter stating my concerns were forwarded to the Medical Director and Operations Manager and they agree with the provider force tapering me. They also said there was no medical justification for my pain medication. I filed a public accommodation discrimination complaint with the Maine’s Human Rights Commission but haven’t heard a word since intake months ago! The letter gave an 800 number to call if you disagreed with their decision. It was the board of licensure telling you to submit a complaint. I already filed a complaint with the board of medicine and nurses months ago. So, you have to go to the same people that are red-flagging and harassing doctors going over the 100 MME limit. I won’t hold my breath! These are the same people that asked Dr. Lommler how he didn’t know that I was taking half of my pain medication and selling the other half! Dr. Lommler provided them with 7 1/2 years worth of passed urine screens and passed frequent random pill counts! I wasn’t even allowed to attend or participate into the investigation into my opiate use-I could’ve answered that question myself-I have never misused my pain medication! In fact, I did everything that I was supposed to do! How in the world can I trust they will help me!
Since this provider has been forcing me off my pain medication, I have had sky high blood pressures-202/129, severe bloody noses, I have been discharged from aquatic therapy-which I needed to get into my Crow Walker boot, I am completely dependent on my sons, I have had to quit tutoring for supplemental income, I can no longer walk on my crutches so I am trapped in my wheelchair, and I cannot mentally or physically function! My counselor and former providers have tried talking with this provider but she refuses to listen because she knows best. I had to spend my Christmas in the ER and I am now watching my right leg and foot do exactly what my left leg and foot did in my original medical nightmare. When my body is in severe stress, my multiple conditions play off of one another and wreak havoc on my body. Last time, the severe stress was an allergic reaction to hardware (we didn’t know why at the time, it took years to figure it out). This time, it is force tapering my pain medication! This time, it’s the providers choice to force taper me because of her personal feelings about a medication! Medical providers are supposed to do what is in the best interest of the patient, not what is in the best interest of their personal feelings! I have cellulitis in my right leg and foot with ulcers everywhere! I maintain my left leg and foot with Cuban for compression. I tried to wrap my right leg and foot but it’s not used to being wrapped, and I get continuous Charley Horses. They are intolerable with all of my pain medication being taken away! I have severe PTSD and zero trust in doctors from my original medical nightmare! I never ever wanted to go back to that sick person trapped in a wheelchair, I thought I left it behind for ever! This time, I don’t have a heart valve to lose! I am petrified and profoundly devastated because I worked so hard for 8 1/2 years to recover and progress and now that has been destroyed! I see people helping doctors that have been arrested but what about people, like me, who have been targeted, harassed, discriminated against, and literally going through disability abuse-who tells our story and helps us?
My counselor gave me a brochure for adult protective services and she told me to call because what they are doing to me is discrimination and disability abuse. I called and the lady said there is no process for this situation. She told me that it does qualify but the only thing I can do is file a complaint with the board of medicine and nurses because they are the only entities that have authority and jurisdiction over medical providers. I told her that I already filed complaints but it will take months because they only meet one day a month! I told her my body won’t make it that long and I asked her, “what if I die in the meantime?” She said, “let’s hope it doesn’t come to that but good luck!” WHAT? It’s like a nightmare that I cannot wake up from! I have contacted every politician in Maine and asked for their help. Crickets…I requested assistance from Governor Mills but she doesn’t even think she has to answer to her constituents. I have reached out to every volunteer lawyer’s projects and disability rights groups but they all claim no to have the resources to help me. I have documented, taken pictures, recorded videos, screenshot messages from my portal between her and I, audio recorded my video appointments exposing her discrimination and disability abuse! I cannot find an attorney in Maine to help me. This provider only saw me one time in person! She never looked at any areas causing my pain, she’s not monitoring my vitals or everything that is happening to me, she doesn’t even have the correct MRI’s-she’s going by a 2008 one when I was a normal person and could walk on my own, and she’s retaliating against me for filing a complaint! I need help and I don’t know where or who to go to! I even have an appointment with cancer care, January 23rd. I have MGUS and the blood work markers and symptoms all point to it turning into Multiple Myeloma. I asked her to please pause the force taper until I can get into my appointment. She said, “Oxycodone will not cure Multiple Myeloma so the force taper will continue!” How cruel is that!
I was hoping that you may have some direction or advice to help me. If I knew how to file a civil lawsuit against the hospital and provider, I would do it myself. Since September of 2021, I have had to be my own advocate, case manager, and attorney!
I already missed about 6 years of my sons’ lives because of my original medical nightmare! I can do no physical activity without my pain medication! I really don’t think my body will make it through this force taper! Opiates are literally life saving for me! They knew that I wouldn’t be able to find another doctor to see me and Michael Miller and the board of medicine took 2 doctors from me! The provider force tapering me filed a complaint against the LNP that saw me for a year. In it, she said that she felt compelled because Kaye endangered my life by prescribing these life threatening and dangerous medications. She also accused me of bribing Kaye in her complaint. That is ludicrous-I have never bribed anyone! Kaye made it very clear in her response that no one forced or bribed her. She also made it clear that I was the only patient she ever prescribed narcotics for in her entire medical career! I have been accused of selling half of my pain medication and bribing doctors! I am a law abiding Mainer and American just trying to live my life!
Thank you for taking your time to read my email. You can reach me any time at xxx.xxx.xxxx

most societies/communities have 1 or more agitators, disruptors, false prophets, scammers, traitors, saboteurs and cult leaders

Some believe our country is on the verge of a Civil War, they may be right, but it won’t be a bilateral war like our last Civil War..  Our society has voluntarily divided itself in – for lack of a better description – TRIBES.

The chronic pain community is not all that different from our country of as a whole.

Recently a fellow chronic pain pt who had been advocating for end stage pediatric pts in a large hospital system that has a “no opiate” policy.  All of a sudden the advocated was told that he was no longer permitted to advocate for these end of life pediatric cancer pts.  I suppose that this major hospital system will return to treating these pediatric pts with NSAIDS and Acetaminophen and let them live the rest of their lives in a torturous level of pain.

There are rumors as to who said what and to whom… I am not going to elaborate. However, they know who they are and what was said to cause this to happen.  One can only imagine the deprived mental status of those who have been involved in this.

Some have told me that this tribe of malcontents have monetized chronic pain pts’- personal information  and several other covert processes. I started my blog in 2012 and have tried to motivate and educate chronic pain pts in some ways that they can navigate their way to getting their pain management back.  Some chronic painers have told me that I should charge for my advice.  My Pharmacy degree, license and career has provided for Barb and myself a comfortable retirement.

After this issue with these end of life pediatric pts,  Going forward… I am going to ASK of people that want my advice to make a contribution to one of the four national charities listed below, these are all about THE KIDS… and charities we support.  Maybe in some small way, my advice can help more than just one person/family. 

 

https://www.stjude.org/ St. Jude Children’s Research Hospital – deals with kids dealing with cancer and/or life threatening health issues

https://lovetotherescue.org/ Shriners Hospital – deals with kids, born with “broken bodies” and birth defects

https://rmhc-kentuckiana.org/ Ronald Mc Donald House – this is near us and just a few blocks from a very large regional pediatric hospital ,3 other major hospitals within blocks, one being a teaching hospital and having the only LEVEL ONE TRAUMA CENTERS for 100 miles and part of a medical university and  helps provide housing for families with kids in the hospital

https://t2t.org/ Tunnel to Towers Foundation – helps get handicapable housing for veterans, first responders with “broken bodies” , families with spouse/parent killed in the line of duty and Gold Star Families

 

 

United Health Care for ALL

Why Aren’t Pharmacies Filling My Patient’s Life-Saving Medication?

Abt 15 yrs ago, I was working only as a “temp/locum” Pharmacist as an independent contractor. I had signed up with several Pharmacist temp services and I was working in all kinds of community pharmacies from independent pharmacies to Big Box stores. The technician brought to me a refill for a Suboxone, which was a couple of days early, had refills, but the pt’s insurance was not going to approve paying for it a couple of days early.  The technician offered the pt the cash price for the 2-3 tablets that he needed and the cost was too much for him to afford. I walked out front to talk to him, and he was obviously very upset. He was concerned that not having those 2-3 doses, his attempt to get sober may be compromised.  I always try to be a problem solver. In talking to this young man, I mentioned that insurance companies will often pay for early refills for someone going on vacation. “Did I hear you say that you were going on vacation and that was the reason for this early refill?”.  It took the young man a couple of minutes to catch on what I was asking. I asked him if he would like to use the pharmacy’s phone to call his insurance company to see if they would provide an “early vacation refill authorization”?  He made the phone call to his insurance and they approved the early refill, we filled his Rx for the 30-day supply that he could afford and he went happily on his way. Was he able to successfully get sober and stay sober? I don’t know because I was at this Big Box pharmacy that one day and knew that my “just saying no” to his refill, may have caused him to break his path to sobriety.

Why Aren’t Pharmacies Filling My Patient’s Life-Saving Medication?

https://www.doximity.com/articles/116b245b-74d8-4068-8eb8-ebea2a24805a

I sat on the phone yesterday consoling a single mother going through heroin withdrawal. In between bouts of vomiting and dry heaving, she pleaded, “When will I be able to pick up the medication you ordered that stops all of this?” This mother had already overcome significant barriers Americans face when seeking addiction treatment, including stigma associated with treatment, affordability of treatment, and finding high quality, highly trained addiction specialists. I had prescribed an FDA-approved addiction treatment medication that reduced her chance of death from addiction by more than 50%. Seemed like it should be a happy ending. Instead, she found her local pharmacy refusing to fill the prescription.

That pharmacy’s response is just one example of a troubling, growing trend. Pharmacies across the country are refusing to fill the life-saving addiction treatment medication buprenorphine/naloxone. As a multi-state licensed addiction psychiatrist, I find myself in daily debates across the country with major retail pharmacy chains who refuse to fill this medication. The DEA and the federal Substance Abuse and Mental Health Services Administration (SAHMSA) have both issued recent policy statements urging health care practitioners and pharmacies alike to increase access to this medication with fully telehealth treatment of substance use disorders.

Why are so many pharmacies refusing to fill valid, legal, physician-issued prescriptions for the single most important and effective medication used to treat addiction? The answer, ironically, lies in recent well-meaning landmark court proceedings designed to decrease the opioid epidemic.

In late 2022, CVS, Walgreens, and Walmart were forced to pay an eye-popping $10.7 billion to settle allegations that the pharmacy chains failed to adequately oversee opioid painkiller prescriptions, thus contributing to America’s opioid addiction crisis. CVS alone agreed to pay nearly $5 billion in fines over 10 years, while Walgreens would pay $5.7 billion over 15 years. With this decision, the pharmacy chains also agreed to implement robust “controlled substance compliance programs” that required additional layers of opioid prescription reviews, mandatory state prescription pharmacy database checks, and new employee training programs on prescription monitoring oversight.

This well-meaning legislation was designed to rightfully reduce access to dangerous and addictive prescription opioid drugs like Oxycontin, Percocet, and Vicodin, among others — drugs which are gateways to opioid addiction and are often involved in opioid overdose deaths. Buprenorphine is also a controlled substance, although it contains a very low, weakened amount of a “partial” opioid to treat withdrawal and ultimately has a very different, safer chemical make up than traditional opioids. The chemical makeup is designed to prevent people from getting high on it. It also contains the opioid overdose agent Naloxone or “Narcan,” which further reduces abuse potential. These important differences make it a safe, effective, FDA-approved medication designed to treat addiction, not cause or worsen it. Despite all of these important differences, some pharmacies continue to lump it in with other opioid medications. Ironically, the very measures designed to curb addiction are now resulting in less access to our most important medications used to fight addiction.

I spend a significant portion of my days trying to convince pharmacists to fill these prescriptions. Pharmacists’ objections to refilling the meds include: “The patient lives too far away from your treatment facility,” “You did not see the patient in person,” or “There is no previous prescription for buprenorphine on file for this patient.” Pharmacists concerned with no previous prescription is puzzling. Luckily, due to increased addiction treatment access, many patients are starting to treat their opioid use disorder for the first time — and this is a good thing! It means we are broadening treatment access to more folks who need it most and saving more lives.

I’m successful in convincing the pharmacist to ultimately dispense the drug about half of the time. After an hour on the phone with the pharmacist, I addressed all of her questions and she dispensed the prescription to the single mother waiting outside in the grocery store parking lot. Many other times, my patients are forced to pharmacy hop until we find an understanding and well-informed pharmacist. It is tiring and exhausting.

What is the solution? We desperately need advocacy help from our high-profile medical stakeholders, as well as more pharmacist education and training on buprenorphine. It would be helpful if the DEA, the American Medical Society, and SAMHSA released specific policy statements encouraging all pharmacies to fill these prescriptions without geographic, mileage, or in-person requirements. If you are a pharmacist reading this article right now, please share it with as many of your colleagues as possible to spread the word: we need your help!

The best way to quickly curb the opioid epidemic is increased access to effective treatment. This is one of very few life-saving addiction treatments in our medicine arsenal. Its effects on mortality rates mean that your loved one suffering from opioid use disorder is more than twice as likely to survive with this medication. We need help reducing well-meaning but misinformed pharmacy red tape to its access. We owe this to the American public. We owe this to our friends, family members, and loved ones whose lives are jeopardized by addiction. We owe this to our children. We owe this to the more than 500,000 people we’ve lost in the U.S. in the past two decades due to overdose. Martin Luther King Jr. famously said, “The ultimate tragedy is not the oppression and cruelty by bad people but the silence over that by the good people.” Now more than ever, we need loud, passionate advocacy from you: our good people.

Dr. Lauren Grawert is a double board certified addiction psychiatrist. She received her medical degree from Medical University of South Carolina College of Medicine and has been in practice 15 years. She speaks multiple languages, including Spanish. She was Chief of Psychiatry at Kaiser Permanente of the Mid-Atlantic from 2018-2022. She is currently the Chief Medical Officer at Aware Recovery Care. She enjoys working with the media in her spare time to reduce stigma around mental illness and addiction. She has been interviewed by SAMHSA on Co-Occurring Disorders and most recently published articles in Capital Psychiatry and Northern Virginia Magazine.

Anti-abortion politicians are now trying to take away people’s power to get emergency care if they are facing severe complications during pregnancy

Has anyone ever reached out to ACLU about denial of care at the Emergency Dept concerning your pain? I got this from ACLU this AM.  Apparently, according to this ACLU email, only pregnant females who are denied care at a ED with long-standing protections to access necessary emergency care at hospitals are being discriminated against.

 

 

Pharmacy desert coming to a town near you?

If you are patronizing any pharmacy that has/will close, expect to start getting emails, letters, etc.. communication(s) from your insurance/PBM promoting moving your meds over to their mail-order pharmacy. They will tell you how convenient their mail-order service is – they won’t tell you that your medications will often be subjected to temperatures that are outside those required/recommended by the FDA, USP, and NF.  They won’t mention that trying to get a solution to any problem you might encounter, you will be interacting with a nameless, faceless person working in a pharmacy that could be 1000’s miles away. If you don’t get your meds on time, they will tell you that they will pay for you to get them filled at a “local pharmacy”, which there is none left in your town, and the closest is maybe 30-50 miles away.

Rite Aid to shutter 53 more stores across 9 states

https://drugstorenews.com/rite-aid-shutter-53-more-stores-across-9-states

Rite Aid is reportedly closing stores in California, New York, New Jersey, Maryland, Massachusetts, Michigan, Pennsylvania, Ohio and Virginia, per a report in The Hill.

Rite Aid will close 53 more store locations across nine states, adding to the approximately 200 it has closed since filing for Chapter 11 bankruptcy protection last year, per a report in The Hill.

After filing for bankruptcy protection in mid-October, Rite Aid announced the closures of more than 150 stores across 15 states. In late November, the retailer announced the closures of another 31 stores. More stores were closed at the beginning of this year.

[Read more: Rite Aid divesting majority of Health Dialog assets]

A full list of closures is outlined in court documents released this month.

California

  • 1208 West Redondo Beach Blvd., Gardena, California
  • 1700 W Whittier Boulevard, La Habra, California
  • 15924 Bellflower Boulevard, Bellflower, California
  • 16491 Lakeshore Drive, Lake Elsinore, California
  • 334 South Vermont Avenue, Los Angeles, California
  • 5610 Stockton Boulevard, Sacramento, California
  • 37950 47th St E, Palmdale, California
  • 7224 Broadway, Lemon Grove, California
  • 1030 South White Road, San Jose, California
  • 14727 Rinaldi Street, San Fernando, California
  • 7211 Elk Grove Boulevard, Elk Grove, California
  • 439 Santa Fe Drive, Encinitas, California
  • 1650 Decoto Road, Union City, California
  • 888 Lincoln Boulevard, Venice, California
  • 35946 Winchester Road, Winchester, California
  • 3941 Spring Road, Moorpark, California
  • 4037 Ball Road, Cypress, California
  • 2500 North 10th Avenue, Hanford, California

Maryland

  • 250 Englar Road, Ste 22, Westminster, Maryland

Massachusetts

  • 10 Stafford Road, Fall River, Massachusetts

Michigan

  • 42481 West 13 Mile Road, Novi, Michigan
  • 11743 15 Mile Road, Sterling Heights, Michigan

New Jersey

  • 235 N Maple Ave, Marlton, New Jersey
  • 7835 Maple Avenue, Pennsauken, New Jersey
  • 480 North Beverwyck Road, Lake Hiawatha, New Jersey

New York

  • 139 Ronkonkoma Avenue, Lake Ronkonkoma, New York
  • 283 West Jericho Turnpike, Huntington Station, New York
  • 47 Niagara Street, Tonawanda, New York
  • 2047 Sheridan Drive, Buffalo, New York
  • 1910 Hempstead Turnpike, East Meadow, New York
  • 960 Halsey Street, Brooklyn, New York
  • 459 South Transit Street, Lockport, New York
  • 3249 Sheridan Drive, Amherst, New York
  • 218-35 Hempstead Avenue, Queens Village, New York
  • 1825 Brentwood Road, Brentwood, New York
  • 95-14 63rd Drive, Rego Park, New York
  • 2271 Richmond Avenue, Staten Island, New York
  • 592 East 183rd Street, Bronx, New York

Ohio

  • 2840 Youngstown Road SE, Warren, Ohio
  • 501 East Emmitt Avenue, Waverly, Ohio

Pennsylvania

  • 6744-46 North Fifth Street, Philadelphia, Pennsylvania
  • 118 Eagleview Boulevard, Exton, Pennsylvania
  • 6731 Woodland Avenue, Philadelphia, Pennsylvania
  • 2131-59 North Broad Street, Philadelphia, Pennsylvania
  • 124 South Front Street, Steelton, Pennsylvania
  • 510 East Baltimore Pike, Media, Pennsylvania
  • 4551 Milford Road, East Stroudsburg, Pennsylvania
  • 1536 North Atherton Street, State College, Pennsylvania
  • 3807 Lincoln Highway, Downingtown, Pennsylvania
  • 1200 West Market Street, York, Pennsylvania
  • 6201 Germantown Avenue, Philadelphia, Pennsylvania
  • 120 South Mill Road, Kennett Square, Pennsylvania

Virginia

  • 1808 Salem Road, Virginia Beach, Virginia

A Rite Aid spokesperson provided Drug Store News with the following statement:

“Rite Aid regularly assesses its retail footprint to ensure we’re operating efficiently while meeting the needs of our customers, communities, associates and overall business. In connection with the court-supervised process, we notified the Court of certain underperforming stores we are closing to further reduce rent expense and strengthen overall financial performance. At this time, we have not made or confirmed any decisions on additional specific store closures as part of our financial restructuring process.”

The company added:

  • The decision to close a store is not one we take lightly. The Company, with the assistance of its advisors, carefully considers various factors in its decision-making, including business strategy, lease and rent considerations, local business conditions and viability, and store performance.
  • For our customers, we make every effort to ensure they have access to pharmacy-based health services, whether at another Rite Aid or other nearby pharmacy, and we work to seamlessly transfer their prescriptions to ensure there is no disruption of service.
  • For our associates, we strive to transfer them to other Rite Aid locations where possible. In fact, approximately 75% of our associates have accepted opportunities to transfer locations if their store has been or is part of the ongoing store closures.

CMS finalizes 2025 Medicare Advantage rule: 11 key updates

CMS finalizes 2025 Medicare Advantage rule: 11 key updates

https://www.beckerspayer.com/policy-updates/cms-finalizes-2025-medicare-advantage-rule-11-key-updates.html

CMS issued its final 2025 Medicare Advantage and Part D rule April 4, setting new standards around marketing, broker payments, and prior authorization.

Here are 11 things to know about CMS’ final rule: 

  1. CMS set a fixed amount that agents and brokers can be compensated by MA plans, regardless of the plan a beneficiary enrolls in. The agency increased the final fixed amount by $100, compared to the proposed $31.
  2. Personal beneficiary data collected by a third-party marketing organization for marketing or enrollment purposes may only be shared with another TPMO when prior written consent is given by the enrollee.
  3. Insurers are generally prohibited from paying TPMOs volume-based bonuses for steering a certain number of enrollees to health plans. 
  4. CMS is adding behavioral network adequacy evaluation standards to include providers specializing in mental health and addiction issues.
  5. Plans are required to issue a mid-year notice to enrollees, informing them of any supplemental benefits they have access to in their plan that they have not used.
  6. MA plans must analyze their utilization management policies and procedures from a health equity perspective, including having one member of the UM committee with expertise in health equity and an annual health equity analysis of prior authorization policies.
  7. There are new restrictions on the marketing of supplemental benefits for chronically ill enrollees, requiring plans to disclose that these benefits are only available to beneficiaries with certain diagnoses, not all Medicare beneficiaries. 
  8. Independent contractors will review untimely fast-track appeals of an MA plan’s decision to terminate services in a skilled nursing or outpatient rehab facility, and for home health services.
  9. The rule reduces the number of plans able to enroll beneficiaries dually eligible for Medicare and Medicaid outside of the open enrollment period. This will crack down on year-round aggressive marketing of D-SNP plans, CMS said. 
  10. MA plans will be limited in how much information they can request from CMS when appealing risk adjustment data validation audits.
  11. Part D sponsors will have more flexibility around formulary substitutions of biosimilars with interchangeable generic products.

Read the full rule here.

Hospitals Cash In on a Private Equity-Backed Trend: Concierge Physician Care

Hospitals Cash In on a Private Equity-Backed Trend: Concierge Physician Care

https://www.medpagetoday.com/hospitalbasedmedicine/generalhospitalpractice/109518

Pricey membership fees for easier access to doctors becoming more common

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up healthcare costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, PhD, a hospital finance expert at Johns Hopkins University in Baltimore. “They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, MD, MPH, of Dell Medical School at the University of Texas at Austin and a former commissioner of the Connecticut Department of Public Health. She noted that concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” Mullen said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, DO, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California (UC), Berkeley and the University of Pennsylvania in Philadelphia found no impact on mortality ratesWhat the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30-50% increase in total healthcare spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said study co-author Adam Leive, PhD, of UC Berkeley. Inova, a healthcare services company in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, MD, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly 3-hour drive from Tampa. Mount Sinai Health System in New York City runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized healthcare experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

The War on Drugs Is Also a War on Pain Patients

The War on Drugs Is Also a War on Pain Patients

https://www.cato.org/blog/war-drugs-also-war-pain-patients

In a March 22 opinion column in the New York Times entitled “The DEA Needs to Stay Out of Medicine,” Vanderbilt University Medical Center associate professor of anesthesiology and pain management Shravani Durbhakula, MD, documents powerfully how patients suffering from severe pain—many of them terminal cancer patients—have become collateral casualties in the government’s war on drugs.

Decrying the Drug Enforcement Administration’s progressive tightening of opioid manufacturing quotas, Dr. Durbhakula writes:

In theory, fewer opioids sold means fewer inappropriate scripts filled, which should curb the diversion of prescription opioids for illicit purposes and decrease overdose deaths — right?

I can tell you from the front lines that that’s not quite right. Prescription opioids once drove the opioid crisis. But in recent years opioid prescriptions have significantly fallen, while overdose deaths have been at a record high. America’s new wave of fatalities is largely a result of the illicit market, specifically illicit fentanyl. And as production cuts contribute to the reduction of the already strained supply of legal, regulated prescription opioids, drug shortages stand to affect the more than 50 million people suffering from chronic pain in more ways than at the pharmacy counter.

Dr. Durbhakula provides stories of patients having to travel long distances to see their doctors in person due to DEA requirements about opioid prescriptions. However, despite their efforts, they find that many of the pharmacies do not have the opioids they require because of quotas. She writes:

Health care professionals and pharmacies in this country are chained by the Drug Enforcement Administration. Our patients’ stress is the result not of an orchestrated set of practice guidelines or a comprehensive clinical policy but rather of one government agency’s crude, broad‐​stroke technique to mitigate a public health crisis through manufacturing limits — the gradual and repeated rationing of how much opioids can be produced by legitimate entities.

In the essay, Dr.Durbhakula does not question or challenge the false narrative that the overdose crisis originated with doctors “overprescribing” opioids to their pain patients.

Unfortunately, Dr. Durbhakula’s proposed policy recommendations would do little to advance patient and physician autonomy. She would merely transfer control over doctors treating pain from the cops to federal health bureaucracies and let those agencies set opioid production quotas. For instance, she claims, “It’s incumbent on us [doctors] to hand the reins of authority over to public health institutions better suited to the task.”

No. The “reins of authority” belong in the hands of patients and doctors.

Dr. Durbhakula suggests that “instead of defining medical aptness, the DEA should pass the baton to our nation’s public health agencies” and proposes that the Centers for Disease Control and Prevention and the Food and Drug Administration “collaborate” to “place controls on individual prescribing and respond to inappropriate prescribing.” She elides the fact that these public health agencies will “respond” to doctors or patients who don’t comply with their regulations by calling the cops.

To be sure, Dr. Durbhakula has good intentions. But replacing actual cops—the DEA—with federal health agencies that can order those cops to arrest non‐​compliant doctors and patients is like rearranging the deck chairs on the Titanic. True, her proposed new pain management overlords would have greater medical expertise, but they would still reign over doctors and patients and assault their autonomy. And, as we learned during the COVID-19 pandemic, they will not be immune to political pressures and groupthink.

While her policy prescriptions may be flawed, Dr. Durbhakula deserves praise for having the courage to point out that the war on drugs is also a war on pain patients. Alas, courageous doctors are in short supply these days. Most doctors keep their heads down and follow the cops’ instructions.

After I read her essay, I wrote the following (unpublished) letter to the editor of the New York Times:

Dear Editor—

Kudos to Dr. Durhakula for speaking out against the Drug Enforcement Administration’s intruding on doctors’ pain treatment (“The DEA Needs to Stay Out of Medicine,” March 22, 2024). As my colleague and I explained in our 2022 Cato Institute white paper, “Cops Practicing Medicine,” for more than 100 years, law enforcement has been increasingly surveilling and regulating pain management.

The DEA maintains a schedule of substances it controls, and it categorizes them based on what the agency determines to be their safety and addictive potential. The DEA even presumes to know how many and what kind of controlled substances—from stimulants like Adderall to narcotics like oxycodone—the entire US population will need in future years, setting quotas on how many each pharmaceutical manufacturer may annually produce.

The DEA restricts pain management based on the flawed assumption that what they consider to be “overtreatment” caused the overdose crisis. However, as my colleagues and I showed, there is no correlation between the opioid prescription rate and the rate of non‐​medical opioid use or opioid addiction. And, of course, as fear of DEA reprisal has caused the prescription rate to drop precipitously in the last dozen years, overdose deaths have soared as the black market provided non‐​medical users of “diverted” prescription pain pills first with more dangerous heroin and later with fentanyl.

Researchers at the University of Pittsburgh School of Public Health found that overdose fatalities have been rising exponentially since at least the late 1970s, with different drugs predominating during various periods. Complex sociocultural, psychosocial, and socioeconomic forces are at the root of the overdose crisis, requiring serious investigation. Yet policymakers have chosen the lazy answer by blaming the overdose crisis on doctors treating pain.

When cops practice medicine, overdoses increase, drug cartels get richer, and patients suffer.

Sincerely,

Jeffrey A. Singer, MD, FACS

Senior Fellow, Cato Institute

When cops practice medicine, overdoses increase, drug cartels get richer, and patients suffer.

Hospitals’ Medicare Advantage problem hits an inflection point

Be cautious in signing up for Medicare-c (Advantage) prgms,  These programs are provided by FOR PROFIT INSURANCE COMPANIES. An increasing number of large healthcare corporations are canceling their contracts with Medicare-C programs. Patients in these programs may find themselves having to change primary healthcare providers, hospitals, and other providers that they have a relationship with.

Hospitals’ Medicare Advantage problem hits an inflection point

https://www.beckershospitalreview.com/finance/hospitals-medicare-advantage-problem-hits-an-inflection-point.html

As Medicare Advantage enrollment climbs to nearly 34 million people and the federal government implements new insurance policies, the scene has been set for tensions between hospitals and payers to intensify.

“The relationship between hospitals and managed care is strained at best right now,” Chip Kahn, president and CEO of the Federation of American Hospitals, told Becker’s. “[Insurers] are finding every way to not pay for the care that Medicare beneficiaries should receive. I don’t know how the issue gets worse — we’re at a critical stage, and I think CMS is sending those signals.” 

On April 1, CMS finalized a slight decrease in MA benchmark payments for 2025. The agency has also enacted stricter prior authorization rules this year and cracked down on when MA plans must cover inpatient care.

The health insurance industry has said the new rates will “put even more pressure on the benefits and premiums” of MA beneficiaries, a warning that individual insurers echoed in recent months.

“Payers know that they’re going to have to cut supplemental benefits, and premiums may even have to go up, but I wouldn’t want to be the first one to do it,” Scott Ellsworth, founder and president at Ellsworth Consulting, told Becker’s.

Mr. Ellsworth is a former senior insurance executive, overseeing large divisions at Centene, Optum and a BCBS plan throughout his career.

“Seniors have seen their benefits get better every year, but now we’re at an inflection point and the free lunch is over,” he said. “There is going to be a sharing of the pain. Providers have disproportionately shared the pain and now you’re seeing many of them say ‘enough is enough, we’re out.'” 

In 2023, Becker’s reported on at least 15 hospitals and health systems nationwide that dropped some or all of their Medicare Advantage contracts. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.

“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s in September. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.” 

Scripps terminated MA contracts in January for its integrated medical groups, citing an annual loss of $75 million on its contracts with insurers.

In March, Bristol (Conn.) Health announced it was eliminating 60 positions, 21 of which are occupied and will result in layoffs. Its CEO laid blame on Medicare Advantage, saying, “All the nice-to-haves are being taken out by the lack of insurance payment and the lack of reimbursement.”  

In January, the Healthcare Financial Management Association released a survey of 135 health system CFOs, which found that 16% of systems are planning to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have not made a final decision. The report also found that 62% of CFOs believe collecting from MA is “significantly more difficult” than it was two years ago.

“Medicare Advantage net reimbursement right now is terrible for hospitals — our clients average about 85 cents on the dollar, and it’s only getting worse,” Mr. Ellsworth said. “MA is a race to the bottom and I would argue that we’ve hit that bottom. Payers are going to struggle with this too, but no one wants to be the first to blink.”

Medicare Advantage denials increased almost 56% for the average hospital from January 2022 to July 2023, according to data from a joint American Hospital Association and Syntellis report. The denials and inconsistent reimbursement led to a 28% drop in hospital cash reserves.

Both Mr. Ellsworth and Mr. Kahn noted that it isn’t feasible for most health systems to completely walk away from Medicare Advantage given that it now makes up more than half of the Medicare population. Instead, many hospitals are paring down contracts and looking for payer partners that align best with their financial objectives. Some systems are even exploring launching their own MA plan built in tandem with one insurer. Others have partnered with grocers or other health systems.

“We will ultimately pick a couple of partners going forward, and I think a lot of health systems are going to do this,” Will Bryant, CFO of Chapel Hill, N.C.-based UNC Health, told Becker’s in November. “They’re going to be the partners who act like partners and not who deny care in order to bolster their billions of dollars of quarterly earnings.”

Sachin Jain, MD, CEO of SCAN Group — one of the nation’s largest nonprofit Medicare Advantage companies — cautioned hospitals that dropping MA plans is a short-term trend that is “going to backfire in a big way for these large health systems.”

“You’re a nonprofit system saying you’re no longer going to accept the insurance that low-income people actually have,” he said. “We’ll see how that works out for you.” 

Dr. Jain said any public policy program is going to create unintended consequences, adding, “What I would say to anybody who’s critical about the program is that you’re right, but let’s fix that.”  

Former CMS Administrator, Don Berwick, MD, told Becker’s in February that the battle between hospitals and Medicare Advantage is a “manifestation of an underlying broken system in which everyone that gives care wants to give more, and everyone that pays for care wants to pay less.”

“To me, the untold story yet is about the physicians and nurses who don’t feel directly tied to ongoing Medicare Advantage trends, but they are certainly immersed in a changing financial landscape,” Dr. Berwick said. “As venture capital, private equity and ownership of healthcare by private interests increases, it changes their worlds, what it’s like to practice, their feelings about themselves, and the degrees of freedom they have to care for their patients. That chicken is going to come home to roost.”

Despite the tensions with hospitals, the MA program has bipartisan support in Congress and a 95% quality satisfaction rating among enrolled members in 2023. There are about 4,000 MA plans being offered this year nationwide, and MA members spend an average of $2,434 less on out-of-pocket costs and premiums per year compared to traditional Medicare enrollees.

“Medicare Advantage is very important, especially for low-income seniors,” Mr. Ellsworth said. “Hospitals need to acknowledge the reimbursement problem and proactively address their relationships [with payers] head-on.”

Dr Ruan and Dr Meredith Taking out the best of us to terrify the rest

All police states have a modus operandi by which they can be recognized. One of those is the absolute and unreasonable, almost random, destruction of people selected to be an “example” to terrify the population. The most educated physician in American history, Dr. Xiulu Ruan, is still languishing in prison because, while the DEA has no right to dictate the practice of medicine, they have the unconstrained power to destroy those who do not toe the party line. And if the government has its way… Dr. Meredith Norris is next.

PAYBACK: tracking the opioid settlement cash

Payback: Tracking the Opioid Settlement Cash

 

The Tobacco Money Settlement is running out soon. Just about EVERYONE has their HAND OUT for some of the Opioid Settlement Money. From bureaucraties that had employees who are/were dealing with addiction and wants to recoup the money paid out for treating those employees, to Grandparents raising their Grandkids because their parents OD’d and they want financial assistance in raising their Grandkids.  Doesn’t Social Security pay kids $$ when a parent dies?

Not to mention the bureaucracies that the bureaucrats are creating to manage the distribution of those funds.

The total money that is to be paid out over the next 18 yrs, is but a drop in the bucket as to what the Tobacco Settlement amounted to. What industry is next?

Maybe they will go after the Tobacco wholesalers & retailers that didn’t get “taken to the cleaners” with the original settlement? There is always the Liquor industry, but will they sue those states that only sell liquor thru state-owned stores?

I am sure that they will find some other industry that is selling some legal product that they can fabricate some harm to people or with the current “green mindset”, products that “they” believe is harming our environment.

Maybe these law firms and bureaucrats have created a qazi  Rube Goldberg machine https://en.wikipedia.org/wiki/Rube_Goldberg_machine or a qazi “ATM machine” that never runs out of money!

One thing that no one wants to talk about is all this money that is being paid out or has been paid out from the Tobacco Settlement, These tobacco companies are still around and the price of their products are substantially higher than they were back in 1999, way above what the CPI/COLA increases would suggest.

Same thing with all these Opioid fines and settlements that started in the early 2010 decade and now will continue into the 2040 decade. While the DOJ/DEA & state AG’s are attempting to reduce the number of controlled meds produced and sold.