“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
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Pharmacist Steve steve@steveariens.com 502.938.2414
It’s time for payment reform and a lasting remote follow-up option
With nearly 1% of Americans undergoing cataract surgery each year, the procedure is the most common operation Medicare covers. For many older adults, it’s a small miracle: a 15-minute procedure and suddenly the world is in focus for the first time in years.
What comes next can be much less miraculous. Patients must arrange rides and caregivers for brief follow-up visits. As an ophthalmologist who cares for these patients, every week I see how, for those who can’t drive, who live alone, or who use walkers or oxygen, these “routine” checkups can be the hardest part of the whole experience.
Meanwhile, Medicare is steadily cutting what it pays for that very surgery — even as Washington can’t decide whether to keep the telehealth flexibilities that would make follow-up easier.
For 2025, the Centers for Medicare & Medicaid Services (CMS) again cut what it pays physicians, marking the fifth straight year of reductions. Since 2018, Medicare’s payment for a routine cataract operation has fallen by about one-fifth, and overall physician pay in Medicare has eroded by roughly one-third since 2001 after adjusting for inflation, making it harder for small community practices to stay open. Now CMS has finalized another double-digit cut for cataract surgery in 2026.
In other words, Medicare is squeezing the margins on a high-volume, sight-restoring surgery that millions of older adults rely on — especially in community and rural settings where cataract surgery is often the only eye care readily available.
During the pandemic, Congress and CMS let Medicare patients use telehealth from home — including audio-only options — with no rural restrictions. Those flexibilities have been extended several times, most recently in a shutdown-ending deal that now runs only through January 30, 2026. After that, unless Congress acts, Medicare’s coverage for non-mental-health telehealth will snap back to the pre-COVID rules that limit services to rural patients in medical facilities — not people recovering from surgery at home.
This is exactly backward for cataract care.
Randomized trials and systematic reviews in recent years have found that virtual or telephone follow-ups for uneventful cataract surgery can match in-person care for safety and patient satisfaction, as long as higher-risk patients are excluded and assuming that concerning symptoms trigger rapid in-person evaluation. Simple web-based vision checks, phone or video visits, and emerging tools like artificial intelligence (AI) phone systems that screen for red-flag symptoms have shown promise for routine cases.
These tools don’t replace in-person exams for people with other eye diseases, complicated surgery, or worrisome symptoms, but they can safely reduce unnecessary travel and free up clinic slots for patients with real red flags. Most surgeons still want at least one early, in-person exam for many patients; the real opportunity is to avoid dragging every low-risk patient back for multiple routine checks when their vision and symptoms are reassuring.
When you combine repeated pay cuts with rigid expectations that every post-op patient trudge back to the clinic, the result is consolidation of facilities, small practice closures, and poorer access, especially in rural and lower-income communities.
For an 82-year-old who no longer drives and lives on a fixed income, automatically requiring every routine follow-up to be in person after an uncomplicated cataract surgery is not “conservative” medicine. It’s avoidable hardship — on top of a system that’s already asking surgeons to do more with less year after year.
It doesn’t have to be this way. If Congress and CMS are serious about keeping cataract care accessible while holding the line on costs, they should pair payment reform with a deliberate shift toward remote follow-up for appropriate patients, rather than letting telehealth die by a thousand temporary extensions.
That would mean making home-based telehealth for postoperative visits a permanent Medicare benefit for procedures like cataract surgery; explicitly allowing early post-op checks to be done virtually under the 90-day global payment that already covers follow-up care — without extra fees — as long as safety standards are met; and funding pilot programs that use telemonitoring to triage which patients truly need to be seen in person.
Telehealth expansions should come with clear guardrails: limiting remote follow-up to low-risk cases, using structured symptom checklists, and maintaining a low threshold to convert virtual visits to in-person exams when something doesn’t look or feel right. At the same time, Congress should replace yearly “yo-yo” cuts with stable, inflation-linked updates to Medicare’s physician payment formula.
Done right, the result would be straightforward. If a surgery was routine and the patient is seeing well, they could complete part of their follow-up at home — on a smartphone, landline, or computer — with clear instructions about when to call or come in. If anything looks concerning, the system connects the patient to an in-person, human doctor quickly. For clinicians, it would mean a payment system that stops penalizing the very surgery that restores sight for millions and a telehealth policy that recognizes reality: much of postoperative cataract care is about screening for rare problems and answering questions, both of which can be supported by remote tools.
At the moment, Washington is sending mixed messages: one set of rules tells surgeons to absorb pay cuts; another tells them to keep seeing every patient in person, even when the evidence says they don’t always need to. Fixing that mismatch — by stabilizing payment and embracing telehealth for routine cataract follow-up — is a concrete way to protect both patients’ vision and the future stability of their care.
The impact of the PBM/Insurance industry is mentioned very little in the article and not until near the end of the article. Little/no mention of lower profit margins for that part of our drug distribution system that other countries do not have within their healthcare system.
Most Favored Nation’ Pricing May Cut Drug Costs. It May Also Cut Off Rural America
The system is far more complex than Trump’s proposal conveys
Americans pay too much for prescription drugs. On that point, there is almost universal agreement.
In 2019, the U.S. spent more than $1,000 per person on prescribed medicines — more than any other high-income nation. An Organization for Economic Cooperation and Development (OECD) analysis put U.S. per-capita retail pharmaceutical spending at more than twice the OECD average. The Kaiser Family Foundation has shown Americans often pay more for the same drugs that cost far less across Europe and other wealthy countries.
Prices must come down, but how we get there matters. A lot.
The Trump Administration’s Proposal
In November, the Trump administration resurrected a Most Favored Nation (MFN) reference pricing policy, which would tie drug prices paid in the U.S. to the lowest prices paid in other developed countries. The White House has sold the idea as a tough negotiation tactic for bloated drugmakers and a gift to patients at the pharmacy counter.
Tie U.S. prices to those in other countries, the logic goes, and Americans will finally stop being the world’s ATM for brand-name drugs.
The plan outlined in November is an agreement between the U.S. and two pharmaceutical manufacturers, Eli Lilly and Novo Nordisk, and it concerns only a handful of drugs. But these prescriptions — for weight-loss drugs — represent the highest annual expenditures in the U.S.
According to the White House, under the president’s plan, the prices of semaglutide (Ozempic and Wegovy) will fall from $1,000 and $1,350 per month, respectively, to $350, while the price of tirzepatide (Zepbound) and orforglipron (if approved) will fall from $1,086 per month to an average of $346.
Sounds great, right? Let’s go deeper.
MFN Pricing Will Destroy Healthcare in Rural America
Because MFN does not operate in a vacuum, the president’s plan is dangerous.
Indeed, the MFN plan will sit on top of a landscape where rural hospitals are closing, small pharmacies are fragile, Medicaid is under pressure, NIH budgets are being cut, tariff threats inject uncertainty into global supply chains, and FDA practices have become less predictable for innovators.
Layer MFN on top of that landscape, and you do not just squeeze drug company margins — you compress the ecosystem that gets life-saving drugs to people. And that ecosystem is weakest in the very communities that can least afford another hit.
Consider a hypothetical, but familiar, patient: a 63-year-old woman in a rural county who relies on an infused biologic for rheumatoid arthritis. Her local independent pharmacy closed last year. The nearest hospital with rheumatology and infusion services is 90 minutes away. She lives on a fixed income; her copay assistance and manufacturer bridge program are the only reasons her treatment is sustainable.
Now dial in MFN. It is not that, amid price compression, a company will sit in a boardroom and say, “Let’s cut off rural patients.” But every thin margin in the distribution chain will get thinner. Wholesalers will negotiate harder. Pharmacies will drop low-volume products. Assistance programs that do not directly show up in a stock price get trimmed. When an infusion suite decides which therapies to carry, the high-complexity drug used by a small panel of rural patients will not be at the top of the list.
Incremental decisions will slowly erode care in rural communities.
Urban centers will likely be more resilient in the short term. Greater provider density, stronger hospital networks, and the presence of academic medical centers and specialty pharmacies mean that large cities can better absorb some shocks. Patients in Boston or San Francisco may see lower prices and relatively stable access — at least initially.
But MFN cannot insulate those cities from broader consequences. If MFN, coupled with tariff threats and regulatory volatility, makes the U.S. a less predictable market for high-risk innovation, investment will slow. If price compression contributes to drug shortages — a problem that has already been worsening for generics and sterile injectables — those shortages will hit big cities and small towns alike. And while urban centers have more hospitals, they also have deeper structural disparities. Lower prices alone have never been enough to fix that.
MFN Threatens Innovation, Especially for Rare Diseases
Speaking of innovation: the U.S. accounts for a disproportionate share of global pharmaceutical revenue and, in turn, global research and development. RAND estimated that in 2022, the U.S. represented 62% of total drug sales across OECD countries, but only 24% of volume.
That gap is precisely what funds the high-risk, high-cost development of new therapies.
We are already seeing how aggressive price regulation can delay or dilute access to innovative drugs. Analyses of external reference pricing (ERP) in Europe showed that when countries peg prices to one another, manufacturers often delay launches or skip smaller markets entirely rather than lock in lower prices. One study found ERP was associated with a 73% reduction in the likelihood of launching a drug within 9 months of regulatory approval.
The problem is even more acute for orphan drugs. European Federation of Pharmaceutical Industries and Associations (EFPIA) data show that patients with rare diseases often face years-long delays after European Medicines Agency approval — or never see certain drugs launched at all — because price regulation and fragmented country-by-country negotiations make it unattractive to bring those therapies to smaller markets.
If we import the most aggressive pieces of that model without creating stronger safety nets, we risk importing the delays and access problems while retaining our underlying inequities.
It’s Time for Whole System Reform
Americans want lower drug prices. Kaiser polling consistently finds large majorities of both Republicans and Democrats support policies like allowing Medicare to negotiate prices.
But the price a patient pays at the register is more complex than a politician’s talking points portray. Prices are the reflection of a byzantine system of rebates, pharmacy benefit manager (PBM) negotiations, insurance design, and manufacturer assistance programs. When you crush prices at the top without redesigning the plumbing underneath, the system will not suddenly become fair. It will become brittle.
Manufacturer-funded assistance programs are a prime example. Companies spend billions each year subsidizing access for low-income and underinsured patients. If MFN cuts revenue sharply, these programs will get cut first. The Americans already skipping doses because of cost — nearly one in seven, in some surveys — will be the first to feel those cuts.
We absolutely should not accept a status quo, but if we want to fix drug pricing without sacrificing equity and innovation, we need a balanced approach. We need real oversight of PBMs, transparency in the rebate system, support for rural pharmacies and hospitals, sustained NIH funding, stable FDA leadership, and coverage expansions that ensure people are insured.
Otherwise, MFN will not stand for “Most Favored Nation.” It will mean “Most Forgotten Neighborhood.”
AARP for a long time, endorsed United Health Insurance products and have “branded” the United Health prgms as provided under AARP’s association.
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The company says it is protecting nursing home residents by curbing unnecessary hospital transfers. Whistleblowers allege cost-cutting tactics have endangered the elderly
hree nursing home residents died because employees of the American healthcare giant UnitedHealth Group helped delay or deny them critical hospital care, two pending lawsuits and a complaint to state authorities have alleged.
The three cases involve a UnitedHealth partnership initiative that places medical staff from the company’s direct care unit, Optum, inside nursing homes to care for residents insured by the company’s insurance arm.
UnitedHealth says one of the initiative’s goals is to protect patients by reducing unnecessary hospital admissions. Those are admissions the insurance giant would otherwise have to pay for.
In Georgia, the family of a woman named Cindy Deal filed a lawsuit alleging that the 58-year-old died because Optum and her nursing home failed to hospitalize her for hours after she started foaming at the mouth and appeared to be having a seizure.
In Ohio, the family of a retiree named Mary Grant filed a lawsuit claiming that the 70-year-old died after Optum and Grant’s nursing home failed to send her to the hospital, though she had suffered a traumatic head injury and began vomiting.
Mary Grant’s daughter browses photographs of her mother on her phone. Photograph: Maddie McGarvey
In New York, a physician’s assistant named Christopher Bieniek alleged in a complaint to state authorities that a 63-year-old nursing home resident died due to “gross negligence” by an Optum employee. The employee refused to hospitalize the man, despite his kidney failure, according to text messages Bieniek says he shared with state investigators.
Citing patient privacy rules and pending litigation, UnitedHealth’s public relations team did not directly respond to specific questions about the three cases, but said that many of the claims were unsubstantiated or based on incomplete or embellished information.
The company has previouslydenied the Grant and Deal families’ claims in court, and attorneys representing UnitedHealth disputed some of Bieniek’s claims.
“We remain confident in our transparency, our compliance and our steadfast commitment to patient-centered care,” the company said. “We will not legitimize a one-sided and misinformed narrative by further engaging with it. Our focus continues to be where it belongs: delivering high-quality care for our members and standing with the clinicians and care teams who devote themselves every day to improving patients’ lives.”
The three cases highlight the dual role that UnitedHealth has taken on for thousands of nursing home residents across the country: medical insurer and provider of direct care.
Like many American health insurers, UnitedHealth has expanded across the healthcare sector and no longer limits itself to simply paying or denying its members’ medical bills.
In nursing homes, for example, the conglomerate deploys its own army of nurse practitioners and physician assistants from its medical services arm, Optum, to care for seniors covered by its insurance arm, UnitedHealthcare. During the day, these medical professionals listen to heart sounds, decide on new diagnoses, and address dangerous complications for insured residents at their nursing homes. At night and on weekends, other Optum employees on hotlines weigh in on their care from afar.
Optum headquarters in Eden Prairie, Minnesota, USA. Photograph: JHVEPhoto/Alamy
UnitedHealth insures more than 55,000 long-term nursing home residents through what are known as institutional special needs plans (I-SNPs), which are funded through the federal government’s Medicare Advantage program. While other insurers also employ their own medical providers, UnitedHealth is by far the biggest player in the I-SNP market, covering almost as many residents as all of its rivals combined.
UnitedHealth says this hands-on nursing home model provides an “extra layer of caring support” that helps reduce unnecessary hospital trips for long-term residents at more than 1,900 nursing homes in 29 states across the US. “United works with the nursing facility, primary care physicians, and specialists to deliver appropriate care for members in the most appropriate setting,” the company said in an email, noting that a nonprofit called the National Committee for Quality Assurance recently awarded its care model a 98.75% score.
Hospitalizations, the company notes, can lead to serious issues for nursing home residents, such as delirium, falls and pressure injuries.
They can also lead to major expenses for the insurance giant, a financial arrangement that lawmakers and corporate whistleblowers have framed as a potential conflict of interest incentivizing the conglomerate to discourage necessary hospitalizations too.
Under Medicare Advantage, the government pays insurers like UnitedHealthcare a set amount of money based on the expected healthcare needs of each senior enrolled in their insurance plans for long-term nursing home residents. The less insurers spend on residents’ care, the more they have left over in taxpayer funds for potential profit.
In addition to the complaints from the families and the outside medical provider, UnitedHealth’s nursing home initiative has been the subject of at least four whistleblower complaints from former employees. The whistleblowers allege that employees from Optum, UnitedHealth’s direct care subsidiary, engaged in unethical tactics that sought to curb costly but critical hospital care, or violated federal rules meant to protect nursing home residents from predatory insurance sales tactics.
Two of the whistleblowers, both former Optum nurse practitioners, filed declarations with Congress, alleging that company managers improperly pressured them to reduce hospital transfers for nursing home seniors, and to get residents onto medical directives, such as “Do-Not-Resuscitate” orders, that could pre-empt costly emergency room care. The declarations also allege that supervisors pushed them to creatively code patient diagnoses to increase federal payments for the company.
UnitedHealth said it categorically rejected any suggestion that its employees engage in practices that endanger patient safety or violate ethical standards. It said that the suggestion that its employees prevented hospital transfers was false, and that its permission is not required for nursing home residents to go to the hospital.
The company added that “the insinuation that the desire to decrease unnecessary hospitalizations is motivated solely by financial considerations ignores well established evidence of the harm unnecessary hospitalizations can cause.”
Policy experts say reducing unnecessary hospitalizations is important to cutting wasteful expenditures and protecting frail nursing home residents, but caution that these efforts must allow medical providers to follow their genuine clinical judgments.
“You don’t want to then overcorrect and basically align the incentives so that people are never sent to the hospital when they really need to go to the hospital for appropriate care,” said Gretchen Jacobson, vice-president of Medicare policy at the Commonwealth Fund, a healthcare research nonprofit.
Medical researchers have found that a sizable portion of hospitalizations of nursing home residents may be unnecessary. A study published in July in the medical journal JAMDA, for example, found that one-third of hospital admissions among thousands of “severely impaired” nursing home residents appeared to be “potentially avoidable hospitalizations”.
But while there has been research on the benefits of avoiding unnecessary hospitalizations for nursing home residents, there has been less study on how such efforts may have “overcorrected” and “resulted in less access to care generally”, according to Jacobson.
“We need to take a fresh look to make sure that programs like this are balancing the incentives correctly, and we don’t know if that balance is right,” she said.
In June, UnitedHealth sued the Guardian alleging defamation for a previous story about UnitedHealth’s efforts to reduce hospitalizations among nursing home residents.
The lawsuit from the healthcare giant, which brought in more than $400bn in revenue last year, was the latest in a series of aggressive tactics aimed at quieting its critics, the New York Times reported.
In the wake of the suit, the Guardian stood by its story, and continued its reporting process, which identified the three allegations of wrongful deaths.
These allegations, as well as details from four whistleblower complaints about United Health’s I-SNP nursing home program, have never previously been made public by the press or government agencies.
“We are disappointed the Guardian has continued a pattern of biased and misleading reporting that does not reflect the value of the I-SNP clinical model or the benefits we provide to our members,” UnitedHealth said in a statement. “The inaccuracies have been so persistent and harmful we have pursued legal action – an extraordinary step we take to protect the integrity of our work, our care teams and the people we serve.”
After the Guardian published its first story on UnitedHealth’s nursing home initiative, Senators Ron Wyden and Elizabeth Warren held a briefing with UnitedHealth about its nursing home program and decided to launch an investigation seeking company documents.
“Nursing home residents and their families should not live in fear of a for-profit health care company withholding care when it is most critical,” the senators wrote in a letter to the company.
A whistleblower’s complaint
When Maxwell Ollivant first started working as a nurse practitioner for UnitedHealth’s nursing home program, he believed in his company’s care model.
Maxwell Ollivant. Photograph: George Joseph/The Guardian
As an employee of UnitedHealth’s direct care subsidiary, Optum, Ollivant’s job was to visit and check on dozens of seniors at three nursing homes in the suburbs of Tacoma, Washington. The goal: to identify medical complications early and address them, protecting residents from needless hospitalizations.
Ollivant was excited to work in geriatric care. When he was young, his grandfather had supported him after the shock of his parents’ divorce. Now he would be able to care for seniors like him.
Less than a year into the new job, however, the nurse practitioner, a committed Christian, started to have concerns that his company was going too far, inserting itself into nursing home emergencies and effectively delaying or discouraging necessary hospitalizations, according to the lawsuit and congressional declaration he later filed.
When Ollivant visited his assigned nursing homes, he saw images with large red STOP signs in his patients’ charts, according to the declaration Ollivant filed in May with Congress as well as the Securities and Exchange Commission, the Federal Trade Commission and the Washington state attorney general. The signs instructed nursing home staff to call UnitedHealth’s Optum unit first, rather than their independent primary care doctors, when a patient’s condition worsened, the declaration said.
If a nursing home did send a patient to the hospital without first contacting Optum and following various protocols, Ollivant and his colleagues “were instructed to chastise the nursing facility staff”, the declaration said.
Such scrutiny could even follow a hospitalization for an emergency situation, as one Optum email stemming from Ollivant’s litigation indicates.
In that case, nursing home staff sent a resident to the hospital because she was found drooling, unresponsive and with a “slant to the side”, the email said. Thesymptoms pointed to a possible stroke, an emergency that requires rapid treatment, and the woman was subsequently admitted to a hospital’s intensive care unit for “intrabrain bleeding”, a life-threatening type of stroke, according to the email.
But after the transfer, Ollivant’s manager emailed her team that the nursing home had sidestepped the company’s protocol, failing to take the time to first call a hotline operated by Optum’s off-site medical staffers.
“This is by pass,” the manager wrote, referring to Optum’s term for when nursing home staff skipped over its intermediary clinicians to hospitalize a resident. “Nursing did not call Optum on call.”
The manager then met with the nursing home’s director of nursing services and scheduled an in-service training to re-educate the facility’s nurses, the email shows.
UnitedHealth did not directly respond to questions about this email.
Four months later, Ollivant went to UnitedHealth’s HR team with concerns about his company’s response to another emergency, involving a patient of his, public records from the Washington state attorney general show.
One Sunday earlier in September, the 66-year-old nursing home resident had been found with potential stroke symptoms, but his transfer to a hospital was delayed after his nursing home contacted UnitedHealth’s on-call hotline, instead of an independent doctor, according to Ollivant’s lawsuit, which referred to the man by his initials, “M.T.”
For Ollivant, the incident showed the danger of Optum’s involvement in emergency cases, according to the congressional declaration he later filed.
In its defamation suit and in statements to the Guardian, UnitedHealth maintained that it repeatedly pushed for M.T.’s transfer and faulted its nursing home partner for failing to hospitalize the retiree earlier.
Days after Ollivant reported his concerns about M.T. to UnitedHealth’s HR department, the company began investigating the nurse practitioner himself, records released by the company to the Guardian show. It concluded that Ollivant had failed to properly care for M.T. during a second incident which the nurse practitioner had also complained about, according to the company records.
Ollivant submitted his resignation that February – just over three weeks after he filed his internal complaint.
The nurse practitioner later sued UnitedHealth, then voluntarily dismissed his suit after the US Department of Justice declined to intervene in the case. In early May, with the assistance of the legal advocacy organization Whistleblower Aid, Ollivant submitted his declaration to state and federal authorities expanding on his previous claims.
In a statement, UnitedHealth said that Ollivant was “not in a position to assess the effectiveness of our programs”, claiming he “lacks both the necessary data and the expertise”.
“Our position is supported by peer-reviewed studies and measurable outcomes,” the company said. “In contrast, the criticisms being raised are based on anecdotes.”
Between July 2024 and June 2025, long-term nursing home members covered by UnitedHealth experienced 38,000 transfers to the ER and 16,000 hospital admissions, the company said. Of those admissions, it said, nearly half were ordered by skilled nursing facilities or primary care physicians without Optum’s involvement.
UnitedHealth also said that the Department of Justice investigated the whistleblower claims, interviewing witnesses and obtaining thousands of documents that “demonstrated significant factual inaccuracies in the allegations”. UnitedHealth previously told the Guardian that the Department of Justice found the allegations to be “meritless” and “found no evidence of wrongdoing”.
UnitedHealth did not respond to requests from the Guardian that it provide evidence for this claim.
‘The goal is to treat in place’
Mary Grant, the nursing home resident in Ohio, never made it to the hospital.
Photographs of Mary Grant in a family album. Photograph: Maddie McGarvey/The Guardian
One evening two years ago, when a nurse at her facility in Cleveland found the 70-year-old low on oxygen and covered in pinkish chunks of vomit, she called the care hotline operated by UnitedHealth’s Optum subsidiary, instead of an independent doctor, according to nursing notes and an Optum audio recording released through litigation.
The day before, a nursing home employee had accidentally rammed a cart into Grant, knocking her out of her wheelchair, according to a lawsuit that her family filed in state court in Ohio and was later moved to federal court. Her head, protected only by strands of thin, gray hair, hit the concrete floor, leaving a bump on her forehead, patient records released through discovery and the lawsuit assert.
Now Grant was experiencing nausea and vomiting – signs of potential bleeding inside her head, according to a doctor who later filed an affidavit as part of the lawsuit. To assess whether Grant was bleeding internally and needed surgery, she needed to go to a hospital and get a CT or MRI scan, the suit claimed.
But the Optum hotline employee that the nursing home nurse called for instruction “did not order” Grant’s transfer to the hospital, according to the suit. After hearing about the fall and head bump from Grant’s daughter and Grant’s vomiting and low oxygen levels from the nurse, the Optum liaison determined that a transfer was not yet necessary, according to a UnitedHealth call log disclosed in response to the suit.
“The goal is to treat in place,” a log from the Optum employee noted later that evening, using language reflecting the company’s efforts to curb unnecessary hospital transfers. “But if condition worsens, send to Soft Point [sic] hospital.”
Yalonda Phillips looks at a photo from her wedding day with her mother, Mary Grant. Photograph: Maddie McGarvey
The Optum employee told the nursing home to continually check Grant’s vital signs, order a chest X-ray at her facility, and give her medicine and oxygen, company logs and audio recordings released through discovery in the suit show.
This plan of care that Optum coordinated with its nursing home partner failed to reckon with the possibility that Grant had suffered a traumatic head injury that was causing a growing pool of blood to compress the tissue in her brain, according to court filings by her family.
The next day, nursing home staff found the retiree dead in her room, according to nursing home notes released through litigation.
In August, attorneys Michael Hill and Matthew Mooney filed a lawsuit on behalf of Grant’s family alleging that the off-site nurse practitioner for UnitedHealth’s Optum unit was not acting “as an independent and objective medical professional” on the company’s hotline, but instead as “an insurance adjuster” so that the healthcare giant could “preemptively deny Mary Grant necessary medical care”.
In a court filing, UnitedHealth denied the Grant family’s allegations.
UnitedHealth’s public relations team did not directly respond to questions about the Grant case, but said in a statement: “Where litigation is ongoing, we are limited in what we can share, but we contest inaccuracies and will vigorously defend ourselves.”
Allegations of upcoding and changing medical orders to increase federal dollars
The other former Optum employee who filed a whistleblower declaration with Congress submitted it while still working at the company. Like Ollivant, the clinician – who has chosen to remain anonymous – said they were initially supportive of UnitedHealth’s nursing home initiative.
Once on the job, however, the nurse practitioner discovered that their team was under pressure to reduce hospitalizations while inserting questionable diagnosis codes into patients’ charts in order to increase federal payouts to UnitedHealth, according to the declaration provided to state and federal agencies.
“It felt so unprofessional and bizarre, based on other medical facilities I worked in, to have managers challenge well-established critical interventions in cut-and-dry cases,” the whistleblower wrote.
Bonuses went to nurse practitioners who rarely transferred residents to the hospital and who mined colleagues’ charts for lucrative diagnosis codes they could use to bill the federal government, the nurse practitioner wrote.
Staff went through training to learn how to deploy diagnosis codes for weak foot pulses and minor skin spotting, and would be re-educated by company coding specialists if their coding was deemed insufficient, the declaration alleges.
“These changes in codes did not change the treatment plan, but they did generate higher Medicare Advantage payments for UnitedHealthcare,” according to the declaration.
UnitedHealth did not directly respond to a question on the allegations about its employees coding patient diagnoses to increase federal dollars. But the company said in an email that the Centers for Medicare and Medicaid Services gave UnitedHealth’s nursing home plan a 4.5 star rating.
The declarations from the anonymous whistleblower and Ollivant also alleged that UnitedHealth’s Optum unit pushed to get nursing home residents to consider medical directives, such as “Do-Not- Resuscitate” and “Do-Not-Hospitalize” orders, which can limit access to life-saving interventions and pre-empt costly hospitalizations.
UnitedHealth pointed out that advanced care planning has a positive impact on the quality of residents’ end of life care and said that the company tracks residents’ care preferences “to align the care provided with the patient’s health and care goals”.
In the declaration, the anonymous whistleblower acknowledged that advanced care planning is “very necessary”. But Optum staff, the nurse practitioner wrote, sometimes convinced patients to agree to orders limiting their care through counseling that failed to make clear that some of their ailments may be reversible, and that patients with chronic conditions might still benefit from hospitalization for less serious complications.
“This resulted in what seemed to be a de-escalation of care,” the whistleblower wrote, for patients “who desired to live longer without extraordinary measures but still sought treatment for manageable conditions”, such as heart failure, urinary tract infection, or acute kidney injury.
In his declaration, Ollivant echoed these concerns, describing the conglomerate’s “push” for “Do-Not-Resuscitate” and “Do-Not-Hospitalize” orders as an “unconscionable measure” that sought to reduce UnitedHealth’s costs while increasing its profits.
UnitedHealth denies these claims.
The company said Optum clinicians are trained to have high quality conversations about advance care planning to allow members and families to make the most informed decisions possible. The company said that it has never encouraged or pushed a member to sign a “Do-Not-Hospitalize” or “Do-Not-Resuscitate” order.
“Our health care providers are ethically bound to respect patient autonomy and support informed decision-making,” UnitedHealth said in an email.
UnitedHealth’s June lawsuit criticized the Guardian’s previous reporting on allegations about its advanced care planning practices. Company whistleblowers, however, were not alone in questioning its discussions with patients and their families about such care directives.
More concerns about UnitedHealth’s end-of-life planning push
In August of 2023, Christopher Bieniek, a physician assistant working for an independent medical group in upstate New York, filed a complaint with state authorities alleging that “gross negligence and incompetence” by an Optum nurse practitioner working at a nursing home alongside him “resulted in the death” of a resident experiencing congestive heart failure and kidney failure.
According to the complaint, the 63-year-old resident was complaining of dizziness and had very low blood pressure. But when Bieniek pushed for the resident to go to the hospital citing his kidney failure, the Optum employee simply responded “no”, according to text messages Bienek says he showed to investigators from New York’s office of professions, the state’s licensing authority.
Screenshot of a text message that Christopher Bieniek said he showed to state authorities. Photograph: Christopher Bieniek
“No? He has symptomatic hypotension with end organ dysfunction,” Bieniek replied on the text chain, noting that the man needed rapid IV fluid injections which he could not receive at the nursing home. The 63-year-old’s medical orders form “says to send to hospital when medically necessary”, Bieniek pointed out.
Instead of helping to get the man to the hospital where he might have received costly but life-saving care, Bieniek alleged in his complaint, the Optum employee “talked the family into changing” his care goal to comfort care – an end-of-life approach – “despite the condition being readily treatable and probably reversible even at that late stage”.
The nursing home resident died soon thereafter, according to Bieniek’s complaint, which specifically pointed to UnitedHealth’s financial stake in his patient’s care.
“There is also significant conflict of interest at play as the patient in his decompensated state would have likely required hospitalization and higher cost of medical care which in working for the insurance company would conflict with their goals,” Bieniek wrote.
The Optum employee, Bieniek continued, had on more than one occasion “talked a family into changing goals of care to palliation when the patient has an easily treatable and reversible condition such as an acute infection”.
Bieniek said he was interviewed by state investigators, but never heard what happened to the case afterwards.
Rachel Connors, a spokesperson for the New York State Education Department, which oversees the office of professions, declined to comment on the case, citing confidentiality requirements.
The Optum employee did not respond to requests for comment.
In response to questions about Bieniek’s complaint, Jered Ede and Thomas Clare, attorneys representing UnitedHealth, said that the Optum employee had been nominated for an excellent service award by the nursing home that year. The attorneys also said the resident’s family had asked for palliative care and that the Optum employee “did nothing except ensure the patient was cared for in the way the family wanted”.
Dr Ferdinando Mirarchi, an expert on advance care directives, told the Guardian that he was invited by a nursing home in Erie county, Pennsylvania, to review the medical orders of residents living there, including some covered by UnitedHealth.
Between 2017 and 2018, Mirarchi interviewed over one hundred patients there, covered by multiple insurers, and found that some of their paperwork did not align with the care goals they described to him.
When residents covered by UnitedHealth plans told him that they wanted fewer future medical interventions, the doctor helped them to amend their care orders and got no pushback, he recalled. But Mirarchi said that when he did the opposite – changing residents’ medical orders because residents “wanted to go to the hospital” or “wanted to be resuscitated” – UnitedHealth’s Optum team “got annoyed” and sometimes complained to nursing home administrators or families that he was meddling.
Dr Ferdinando Mirarchi. Photograph: Daniel Lozada/Photo by Daniel Lozada for The Guardian
A few months into his review, Mirarchi said, tensions boiled over at a meeting in which he told Optum staffers that he didn’t want the company’s lower-level providers altering his orders after he had identified errors in patients’ files.
“I’m a physician. I got a hell of a lot more training and experience than those they have assigned to come in there and have conversations with patients,” Mirarchi, who has authored more than a dozen medical journal articles on advance care planning, told the Guardian. “And they’re trying to tell me I’m doing wrong.”
UnitedHealth said its training on discussing potential medical orders with patients comes from “gold-standard materials developed by the Harvard School of Public Health and Ariadne Labs, ensuring patients and families are supported through these decisions”.
In a letter, attorneys representing UnitedHealth noted that more than half of the patients whose medical orders Mirarchi helped to correct voluntarily chose to de-escalate their care. The attorneys also pointed out to a past statement from Mirarchi that discussions about people’s end-of-life wishes should not be a “one-and-done” practice.
Allegations about UnitedHealth sales practices
When Brook Gonite first started pitching UnitedHealth’s Medicare Advantage plans in nursing homes across Georgia, the salesman believed his team was in compliance with guidelines intended to protect vulnerable seniors, according to a federal whistleblower lawsuit he later filed.
Gonite, an employee of UnitedHealth’s Optum unit, would sit in the common rooms of nursing homes with his colleagues, wait to be approached by residents or their families, and offer them contact authorization forms to sign, the lawsuit claims.
But this approach, Gonite alleges in the suit, became impossible to maintain once a new manager took over his team and ratcheted up its monthly sales goals.
Brook Gonite. Photograph: A former colleague of Gonite’s
At one early meeting, the lawsuit claims, the manager told subordinates that he didn’t care how they made their Medicare Advantage enrollment numbers “as long as you make me look good”.
Gonite’s lawsuit alleges that his sales team violated multiple federal rules – cajoling nursing home staff to leak them seniors’ confidential medical records, cold-calling seniors without required contact authorization cards, and offering nursing home operators payments if they helped market the healthcare giant’s plans.
Nursing homes that contracted with UnitedHealth could earn monthly fees for every new member that joined UnitedHealth’s long-term nursing home plan, giving them part of the company’s Medicare Advantage revenues, according to Gonite’s suit. Nursing homes that helped the insurer reduce hospitalizations could get quarterly “premium dividend” bonuses, or other incentive payments that offered them a percentage of UnitedHealth’s savings on medical expenses, according to Gonite’s lawsuit, internal company documents and documents released through public records requests.
At one meeting with a nursing home near Georgia’s border with South Carolina, Gonite’s manager told the facility’s staff they needed to get 40% of the home’s residents onto UnitedHealth’s Medicare Advantage plan if they wanted to move forward with the contract, the suit alleges. (The manager declined an interview request and did not respond to detailed requests for comment for this story.)
Following the manager’s instructions, the nursing home’s director of clinical evaluations handed over lists with the names of all his residents – as well as their ages, Medicare ID numbers and other personal information – so that Gonite’s team could solicit seniors and their families, according to the lawsuit. At least 16 residents at the nursing home joined UnitedHealth’s Medicare Advantage plan, Gonite’s complaint alleges.
In court filings, UnitedHealth has characterized Gonite as a “disgruntled, terminated employee” and denied that any of the company’s payments to nursing homes amounted to illegal kickbacks.
In a statement, UnitedHealth denied that it imposed enrollment thresholds on nursing homes or offered financial incentives to nursing homes to enroll residents. Its payments, the company said, incentivize improvements in patient care quality and reimburse “member services”.
UnitedHealth claimed that Gonite was fired for his own unethical conduct, claiming the company caught him falsifying enrollment materials and fraudulently enrolling residents at several nursing homes into its Medicare Advantage plans. All of this, a company spokesperson said, “was done without the company’s knowledge and in violation of company policy”.
The UnitedHealth spokesperson said the company’s firing of Gonite was an example of its “decisive corrective action” when learning of “improper sales tactics”, and noted that the Department of Justice had declined to pursue Gonite’s allegations against the company.
UnitedHealth’s defamation lawsuit accuses the Guardian of irresponsibly relying on Gonite and other “facially unreliable sources”.
Tom Clarkson, Gonite’s attorney, declined to comment on UnitedHealth’s allegations against his client, but noted that the federal judge overseeing the lawsuit had allowed the case to proceed.
In April, federal judge Marc Treadwell ruled that Gonite’s complaint “plausibly alleges” that UnitedHealth violated HIPPA, the federal law that protects the confidentiality of patients’ medical information, as well as federal rules aimed at protecting vulnerable nursing home residents from aggressive sales tactics.
Alleged pressure to cut corners
In court documents, UnitedHealth’s attorneys reject Gonite’s allegations and refer to his boss as a “purportedly rogue sales director”.
But last year, Abbi Mathis, the other former Optum sales employee turned whistleblower, made similar allegations in a lawsuit filed in Iowa state court, claiming that her boss at Optum also used nursing home residents’ confidential medical records to solicit signups, and barged into one resident’s room without permission to try to sell them a Medicare Advantage plan.
In another instance, Mathis alleges in her complaint, her boss tried to approach a nursing home resident, who was unable to speak and simply bobbed his head and smiled in response to his entreaties.
Mathis believed the man had a traumatic brain injury and wasn’t capable of consenting to an enrollment with UnitedHealth, the suit claims. The suit alleges that when she objected to these tactics, her supervisor told her: “It’s not our job to decide whether someone is able to be self-responsible or not.”
Mathis left the job after filing a human resources complaint about her boss, according to her lawsuit against Optum. She settled the lawsuit this year, according to court documents and her attorney.
Asked for comment about the allegations, Mathis’s former boss said in a brief phone call that he did not “want to be involved”. He did not provide answers to specific questions the Guardian subsequently sent him about his former subordinate’s claims.
A UnitedHealth spokesperson said it trains its sales agents on ethical practices and that when it learns of improper sales tactics, it takes decisive corrective action, including terminating employees for violating company policy.
Attorneys representing UnitedHealth told the Guardian that Mathis’s claims “were never substantiated or corroborated”, but that the company terminated the supervisor “as soon as it corroborated other allegations that the supervisor may have violated marketing guidelines and company policy”.
Two wrongful death lawsuits
In 2022, the family of Cindy Deal, the Georgia nursing home resident, filed a suit alleging that UnitedHealth’s care subsidiary Optum and its nursing home partner failed to promptly hospitalize her after she suffered an apparent seizure and started foaming at the mouth one evening.
Though Deal was unresponsive, her nursing home nurse consulted with an Optum nurse practitioner, who directed her to give Deal medicine, instead of ordering her to transfer Deal to the hospital, according to an affidavit filed by a medical expert who reviewed health records from the incident on behalf of her family.
Deal continued to gasp and struggled to breathe and it took until 1.30am – nearly three hours after she was found foaming at the mouth – for the nursing home to receive an order to call 911, the affidavit alleges. According to an amended complaint filed by Deal’s family in November, the authorization for that ambulance call came from another Optum nurse practitioner starting her shift.
Five minutes later, EMS responders found Deal laying in bed unconscious with pale skin, large open pupils and discolored lips, the affidavit states. Deal was pronounced dead shortly after she arrived at the hospital at 2.07am, according to the affidavit.
Deal’s symptoms indicated she was “experiencing a potentially life ending medical emergency”, the expert, Dr Bruce Charash, wrote. “Based on a reasonable degree of medical certainty or probability,” he wrote, Deal died from cardiopulmonary arrest because the nurse and nurse practitioners involved in her care “failed to appreciate the significance associated with Cindy Deal’s declining health and promptly request medical transport to a hospital”.
Darren Penn, an attorney for Deal’s family, said he reviewed notes from an Optum nurse practitioner involved in the case, which were released through discovery in the lawsuit. In an interview with the Guardian citing the notes, Penn alleged that the Optum employee specifically told the nursing home hours before Deal’s death that it did not need to transfer her to the hospital.
Deal’s nursing home initially denied the family’s claims in court, then settled the case last year for an undisclosed amount.
Optum remains a defendant in the case. In court records, attorneys for Optum have denied the family’s allegations and asserted that its nurse practitioner “met or exceeded the applicable standards of care”. The attorneys did not respond to a request from the Guardian for comment.
The other wrongful death lawsuit against UnitedHealth was filed by Yalonda Phillips, the daughter of the Ohio nursing home resident, Mary Grant.
Yalonda Phillips outside of her home in Cleveland, Ohio, in September. Photograph: Maddie McGarvey
On the night of 18 August 2023, Phillips received a call from an off-site Optum employee about her mother vomiting, an escalation in symptoms after her fall from her wheelchair, which resulted in a bump on her head the day before.
Though the caller identified herself as an employee of Optum, UnitedHealth’s care subsidiary, Phillips said in an interview that she thought she was speaking to someone from the nursing home. She didn’t realize, she said, that she was speaking to a representative of a company tied to her mother’s insurer.
During the call, Phillips told the Optum employee that her mother had a bump on her forehead, which she described as “sensitive to the touch”, a company recording of their conversation released in discovery shows.
The Optum employee, a nurse practitioner who had not examined the 70-year-old in person, assured Phillips that it didn’t “seem as if” her mother was in “any acute distress”, citing a prior conversation with a nursing home supervisor, the recording continues. If Grant’s condition got worse they would send her to the hospital, the off-site clinician promised, according to the recording.
At about 10pm that evening, the Optum employee called a doctor and reported: “She has a knot on her forehead, but it doesn’t sound like a hematoma or anything.” The doctor then OK’d continuing to treat Grant at the facility after speaking to the Optum employee for less than two minutes, according to a recording of their conversation.
Because Grant was kept at the nursing home, the suit claims, the 70-year-old never received an MRI, which would have allowed surgeons to figure out whether she had internal head bleeding and proceed to surgery if warranted.
The Optum employee did not respond to questions for this story.
No autopsy was performed after Grant’s death, and in her death certificate the nursing home’s medical director later attributed her passing to various years-old conditions that did not refer to the head injury, according to the family’s lawsuit.
In an affidavit, Dr Timothy Klein, a medical expert hired by Grant’s family, said the knot on her forehead was likely a hematoma pointing to internal head trauma. Grant’s vomiting and nausea the next day were likely the symptoms of that traumatic head injury, caused by blood spurting out inside her head and pooling up outside her brain, according to the affidavit.
Lying in her bed alone in the final hours before her death, Grant likely experienced an “intense headache as pressure built up within her skull, compressing her brain”, the affidavit says. As the pressure inside her head eroded her body’s ability to function, Klein wrote, Grant’s lungs were also likely being filled with stomach fluids – a process that would have caused her “intense pain” as she was in essence “drowning in her own vomit”.
At 12.06pm on 19 August 2023, the day after Grant had begun vomiting, a nursing home nurse once again called the Optum hotline.
It looked like the senior had vomited again and now she was not breathing, the nurse reported on the recorded line. She could not get a pulse.
A remote Optum employee offered to call Grant’s daughter. The nurse agreed, saying, “I’m like a wreck right now.”
By the time Phillips rushed to the nursing home, it was too late, the recordings show. The daughter was not able to comfort her mother as she passed away.
“Working dx [diagnosis]: Cessation of life,” the Optum log from 12.09pm noted.
Eight minutes later Grant was officially pronounced dead, according to company records.
In court documents, Optum denied the Grant family’s allegations.
While this EO “reads” rather straight forward! BUT… the DOJ/DEA has done very little in a straight forward arena in applying the CSA against those in the controlled substance distribution system. There are FOUR FDA APPROVED Fentanyl analogs as safe for use in humans.
HOWEVER, if one of those four FDA approved Fentanyl analogs are in the possession of someone who they were not prescribed to, they become an ILLEGAL/ILLICIT CONTROLLED SUBSTANCE.
Could the DOJ/DEA twist their interpretations of this EO, that if they determined that one or more Rxs filled for Fentanyl was determined was not for a valid medical need and thus they end up selling a illicit Fentanyl product.
19 hours ago • Visible to anyone on or off LinkedIn
The White Housedesignates illicit fentanyl & its precursor chemicals as Weapons of Mass Destruction. “DEA will use every lawful tool to dismantle the networks that manufacture, move, & profit from this poison,” says DEA Administrator Cole.U.S. Department of Justice
DESIGNATING FENTANYL AS A WEAPON OF MASS DESTRUCTION
By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered:
Section 1. Purpose and Policy. Illicit fentanyl is closer to a chemical weapon than a narcotic. Two milligrams, an almost undetectable trace amount equivalent to 10 to 15 grains of table salt, constitutes a lethal dose. Hundreds of thousands of Americans have died from fentanyl overdoses.
The manufacture and distribution of fentanyl, primarily performed by organized criminal networks, threatens our national security and fuels lawlessness in our hemisphere and at our borders. The production and sale of fentanyl by Foreign Terrorist Organizations and cartels fund these entities’ operations — which include assassinations, terrorist acts, and insurgencies around the world — and allow these entities to erode our domestic security and the well-being of our Nation. The two cartels that are predominantly responsible for the distribution of fentanyl in the United States engage in armed conflict over territory and to protect their operations, resulting in large-scale violence and death that go beyond the immediate threat of fentanyl itself. Further, the potential for fentanyl to be weaponized for concentrated, large-scale terror attacks by organized adversaries is a serious threat to the United States.
As President of the United States, my highest duty is the defense of the country and its citizens. Accordingly, I hereby designate illicit fentanyland its core precursor chemicals as Weapons of Mass Destruction (WMD).
Sec. 2. Implementation. The heads of relevant executive departments and agencies (agencies) shall take appropriate action to implement this order and eliminate the threat of illicit fentanyl and its core precursor chemicals to the United States. This includes the following actions:
(a) the Attorney General shall immediately pursue investigations and prosecutions into fentanyl trafficking, including through criminal charges as appropriate, sentencing enhancements, and sentencing variances;
(b) the Secretary of State and the Secretary of the Treasury shall pursue appropriate actions against relevant assets and financial institutions in accordance with applicable law for those involved in or supporting the manufacture, distribution, and sale of illicit fentanyl and its core precursor chemicals;
(c) the Secretary of War and the Attorney General shall determine whether the threats posed by illicit fentanyl and its impact on the United States warrant the provision of resources from the Department of War to the Department of Justice to aid in the enforcement of title 18 of the United States Code, as consistent with 10 U.S.C. 282;
(d) the Secretary of War, in consultation with the Secretary of Homeland Security, shall update all directives regarding the Armed Forces’ response to chemical incidents in the homeland to include the threat of illicit fentanyl; and
(e) to ensure the United States uses the full array of appropriate counter-fentanyl tools, the Secretary of Homeland Security, as consistent with applicable law and in coordination with the heads of relevant agencies, as appropriate, shall identify threat networks related to fentanyl smuggling using WMD- and nonproliferation-related threat intelligence to support the full spectrum of counter-fentanyl operations.
Sec. 3. Definitions. (a) “Illicit fentanyl” means fentanyl that is manufactured, distributed, or dispensed, or possessed with intent to manufacture, distribute, or dispense in violation of section 401 and 406 of the Controlled Substances Act (21 U.S.C. 841, 846).
(b) “Core precursor chemicals” means the core chemicals that create illicit fentanyl and its analogues, such as Piperidone or other Piperidone-based substances.
Sec. 4. General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect:
(i) the authority granted by law to an executive department or agency, or the head thereof; or
(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.
(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.
(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.
(d) The costs for publication of this order shall be borne by the Department of Justice.
Case report of a male patient whose death was hastened by chronic pain.
Having been a physician for over 30 years, I have treated literally thousands of patients of all ages who have come from virtually all walks of life. As a solo private practitioner for over 25 years, specializing in rheumatology and pain management, I see first hand the impact chronic pain can have not only on the patients’ health but also on the quality of their lives, especially when it comes to interpersonal relationships and finances. Chronic pain can be a significant stressor per se and its sequelae can often include divorce, social isolation, and financial ruin.
At the twelfth annual American Academy of Pain Management meeting, I lectured on the topic of chronic pain shortening life. It was entitled, “Can Pain Kill?”¹ I emphasized that chronic pain is a significant source of stress and that stress can cause problems with a patient’s immune system which, in turn, may lead to increased risks of infection, cancer and other medical problems. Having been trained as an immunologist whose PhD thesis dealt with B-cell and T-cell cooperation, I naturally approached the subject of chronic pain from an immunological perspective. More recently, authors have described deliterious effects of chronic pain affecting other organ systems.²˒³ Moreover, abrupt discontinuation of opioid medication can result in potentially lethal cardiac problems such as a Takotsubo-like cardiomyopathy.⁴ This case report focuses on the untimely death of a relatively young adult due, in part, to chronic persistent pain. It was first described by me in 2005.⁵ Since that time, other such cases have come to the fore.
Case Report
A 39 year-old white male was referred to my office by his attorney for an evaluation of injuries he sustained while working on a barge. He was employed as a tankerman with an oil company and was dispatched to load a barge with gasoline. While doing so, a chicksan (an apparatus used to transfer fuel from storage tanks to barge) malfunctioned and struck the patient on the chest, left shoulder, abdomen, left leg/ankle, and right leg/ankle. He was driven into the mooring cell and became trapped. He had chemical/gasoline burns on his feet and suffered injuries from being crushed between the loading arm of the chicksan, barge, and the dock’s mooring wall. He was taken by ambulance to a hospital where he was admitted to the trauma service. On the way to the hospital he was noted to be hypotensive with a blood pressure of 90/P. He was given intravenous fluids which raised his blood pressure to 110/P. He was discharged from the hospital with a diagnosis of:
right bimalleolar ankle fracture,
left ankle sprain,
left dorsal foot abrasion,
hypertension,
diabetes.
He was treated with Warfarin Sodium (Coumadin®) for prophylaxis against thrombosis, 1800 calorie ADA diet, closed reduction and splinting of the right foot and ankle, and immediate release Oxycodone/Acetaminophen (Percocet®) for pain. He was seen by several consults and was transferred to a Rehab Hospital where he remained for 8 days. The patient told me that while he was in the hospital he rarely slept because he was in a lot of pain and often was up while the other patients were sleeping. He became quite anxious and was very upset at the fact that he could not work and was in a great deal of pain. He was discharged from the hospital on tapering doses of slow release Oxycodone (Oxycontin®), Gabapentin (Neurontin®) 300 mg bid for neuritic type pain, oral hypoglycemics for noninsulin dependent diabetes, Warfarin sodium, enalaprilat (Vasotec®) for hypertension and other medications. He developed acute cellulitis of the right foot and was readmitted to the hospital 13 days after initial discharge where he remained for 3 more days. He was treated with intravenous cephalo-sporin, intravenous Morphine Sulfate, oral Warfarin Sodium. He was discharged on oral cephalexin (Keflex®) and acetaminophen with codeine. The patient told me that this analgesic did not adequately take care of his pain. He was seen at an outpatient rehab facility for three months. Multiple physical therapy modalities were used. The patient told me that he could not tolerate some of the modalities because it caused increased pain while adequate analgesia was never attained. A Work Conditioning Evaluation/Plan of Care was written. In part it stated that the patient had made “…substantial improvement with work conditioning. However he remains limited in tolerance for ambulation distance due to pain and antalgic gait. The patient is also not safe on ladders and presents with only fair balance on level surfaces.”
Follow-up
He was seen in follow-up and reported that he had ongoing ankle pain after a bimalleolar ankle fracture and had become depressed. As late as 9 months after the accident the patient was noted to have severe right ankle pain but “no orthopedic pathology.” When he presented to my office he was being treated in a Pain Control Clinic where he had been initially seen approximately 10 months post accident. On presentation to my office, he was taking zonisamide (Zonegran®) 100 mg bid for neuritic pain, tramadol with acetaminophen (Ultracet®) for pain (this did not seem to help), Trazadone (Desyrel®) 150 mg at bedtime (this did not help him sleep very much), and rofecoxib (Vioxx®) 12.5 mg. This regimen did not seem to alleviate the pain very much. He was also taking sertraline (Zoloft®), venlafaxine (Effexor®), and Paroxetine (Paxil®)—all for depression. He was also taking medications for diabetes but he had also needed daily insulin injections. Even with the addition of insulin, his blood sugar was rarely controlled. The patient was quite miserable. His activities of daily living were severely affected. He could not work. He rarely left his home which he shared with his mother. His weight fluctuated. His appetite varied. He complained of headaches, fatigue, insomnia, loss of hair, blurry vision, dry mouth, abdominal pain and cramping, constipation alternating with diarrhea, muscle aches and cramps in various muscle groups and muscle weakness. His right leg tended to go out from under him at times. He described himself as being depressed and anxious. He had problems with memory and concentration. He was not sexually active and was quite worried about his condition. He did not seem to be getting any better. In fact, he seemed to be getting worse. Any prolonged sitting, standing, turning, twisting, bending, or lifting caused increased musculoskeletal pain, especially on the right side of his body, particularly his right leg but also his left shoulder area. His low back also gave him a great deal of discomfort. He could not sit for any prolonged period of time. He was very distracted because of pain. One of the most distressing symptoms was this patient’s insomnia. He simply was in too much pain to sleep through the night. When he awakened numerous times in the middle of the night—on the occasions when he did get to sleep—he often had trouble falling back asleep because he was worried and depressed. Consequently, he woke up tired in the morning. In fact, he woke up as tired as when he went to bed. He could not understand why he was not getting medication to help his pain. When he had been given Oxycontin®, the pain was relieved a great deal more, yet now he was only on Ultracet® and 12.5 mg Vioxx® for pain but these medications were not helping. He had been on them for about six months. Neither of these two latter medications was scheduled. He paranoically described himself as someone who was the victim of a conspiracy. He could not understand why he was not getting pain medication that worked.
On a scale of 0 to 10 on a visual analog scale he rated his pain at approximately 9 (10 being unbearable pain). He was fatigued at approximately 9 on a scale of 0 to 10 (10 being severe fatigue). He had much difficulty dressing himself including tying shoelaces and doing buttons and a great deal of difficulty getting in and out of bed. He was unable to walk outdoors on level ground on some days because of the pain and instability of his right leg. On good days, he did so with much difficulty using a cane in his right hand. On bad days, he had much difficulty washing and drying his entire body. He definitely had a great deal of difficulty bending down to pick up clothing from the floor. Getting in and out of a car was very difficult on bad days and somewhat difficult on good days. Weather changes and increased activity definitely caused increased musculoskeletal pain. He described himself as being lightheaded, dizzy, and sometimes losing his balance. I inquired as to whether he had ever been offered a Duragesic® patch (transdermal Fentanyl), a Lidoderm® patch (transdermal lidocaine), Kadian® or Avinza® (forms of long-acting oral morphine). The patient denied knowledge of these medications. He did not have a best time of day; he was always miserable and the pain was “always there.” He was being treated in a mental health setting for “Code 296.22.” The patient told me the code number. He stated that this represented anxiety and depression. The patient also told me he had nightmares. Everything was an effort and he was miserable every day. I asked him if he would be willing to come to see me for treatment. He told me that it was simply too much of an effort and it was hard for him to get a ride to go to the doctor for treatment. He seemed very despondent and depressed when he told me this.
Patient History and Examination
His past medical history was remarkable for having diabetes mellitus diagnosed 9 months prior to the accident. Routine blood tests that he took for employment had revealed this problem and had required hospitalization. Prior to his barge accident, the patient had numerous other medical problems including: a contusion of the right heel, chronic left shoulder pain due to having rotator cuff tendinitis documented on MRI scanning, a question of carpal tunnel syndrome, ulnar compression of the right wrist, and kidney stones treated with lithotripsy. Conspicuous in its absence was any mention of low back musculoskeletal problems prior to the accident.
On examination, this right-handed, white male was noted to be 6’ tall weighing 256 pounds. HEENT examination was remarkable for a flat affect, unkempt hair, and poor dentition. He had markedly decreased range of motion of the cervical spine. He lacked 10 degrees in flexion, lacked 4 degrees in extension, lacked 7 degrees in rotatory motion to the left and 8 degrees in lateral bending to the left compared to the right. There was no alopecia, malar rash, or oral ulcers. Cardiopulmonary exam was remarkable for wheezes and rhonchi. The patient told me that he was presently a smoker but he was not complaining of having a cold or any respiratory symptoms when I saw him. There were no rales or pleural friction rubs. S1 and S2 were heard well. There were no murmurs, thrills, rubs, gallops, or heaves appreciated. Abdominal examination was remarkable for a very large panniculus and lax abdominal musculature. He was globally deconditioned but what struck me was atrophy of the right leg. The patient had 18 of 18 fibromyalgia tender points with pain on palpation of the bilateral occipital, low cervical, trapezius, supraspinatus, second rib, lateral epicondylar, medial knee fat pad, gluteus medius, and greater femoral trochanteric bursal areas with normal controls. He had spasm, myofascial bands and trigger points in numerous muscles including the bilateral trapezius, bilateral levator scapulae, bilateral rhomboids, left quadratus lumborum, left iliocostalis, bilateral multifidus, bilateral gluteus medius, bilateral gluteus minimus areas. He had tautness of the erector spinae muscles of the thoracic and lumbar spine as well as splenious capitis and splenius cervicis regions bilaterally. The patient had a great deal of pain on palpation of the bilateral sacroiliac regions with the presence of bilateral episacroiliac lipomas. Tinel’s Sign was positive bilaterally. Adson’s maneuver was negative bilaterally. Deep tendon reflexes were two plus and equal bilaterally in both the upper and lower extremities as were distal pulses. However he had positive straight leg raising bilaterally at approximately 15 degrees. No vasculitic lesions were noted. There was markedly decreased range of motion of the left shoulder but also some decreased range of motion of the right. He could abduct the right shoulder 84 degrees and the left shoulder 62 degrees. External rotation, internal rotation and adduction were markedly limited on the left and mildly limited on the right. The right knee measured 39.8 cm. The left knee measured 40 cm. Measuring the thighs 10cm above the patella, on the right the thigh measured 50.7cm and the left measured 53cm. Going 15cm above the patella, on the right side the thigh measured 54cm, on the left side 58cm. Mid-calf circumference on the right was 37cm and on the left was 41 cm. The right ankle measured 28cm and the left ankle measured 26.4 cm. The right ankle and foot were very cold compared to the left. There was a dearth of hair growth on both feet, the right being worse than the left. Reactive hyperemia was noted on skin examination of the upper back. The patient had pain on patellar compression much more so on the right than on the left. Blood pressure was noted to be 154/94, pulse rate 86 and regular. The patient was cooperative but appeared somewhat tired and slow moving. The patient had a brownish/blackish scar on the lower outer right foot area below the lateral malleolus measuring 3/4 inches by 2 inches (the site of the chemical burn). There was a well healed scar which was faintly visible on the dorsal aspect of the left foot. The patient had some chronic venous stasis changes on the bilateral lower calves. No bony ankylosis was noted.
Patient Evaluation
This patient had numerous problems. The status of the right ankle—post a bimalleolar fracture—had evolved into reflex sympathetic dystrophy of the right lower leg (complex regional pain syndrome, type 1 or CRPS Type 1). Furthermore, he had chronic lumbar strain as a result of the accident and a chronic problem with the left shoulder which started off as a rotator cuff tendinitis diagnosed prior to the accident but made much worse by the accident. I was concerned that he may actually have had a contracture of the left shoulder joint in addition to a severe adhesive capsulitis of the left shoulder. While he did not fulfill American College of Rheumatology criteria for fibromyalgia6 he certainly had all 18 fibromyalgia tender points. This patient did have an element of diabetic polyneuropathy, but one does not get atrophy of one limb because of diabetic neuropathy. He had right leg atrophy on the basis of several problems including reflex sympathetic dystrophy, chronic lumbar strain/sprain, and myofascial pain syndrome (which is multi-regional in nature). He also had bilateral sacroiliac dysfunction, right worse than left. All of these were the result of the aforementioned accident.
“ It was quite clear to me that this patient’s pain was so severe that it was not being maintained adequately on the medications he was presently taking.“
I reviewed a report of a defense medical evaluation done by a medical doctor who, in my opinion, did not fully appreciate the severity of the patient’s conditions nor the effect it was having on his quality of life. I concluded that this patient was unemployable at his usual job as a tankerman. In fact, it was my professional opinion, to a reasonable degree of medical certainty, that he was totally unemployable for any job in any capacity. He was probably totally and permanently disabled as a result of the injury. Not only did this patient have CRPS Type 1 of the right foot/ankle, his entire right leg was atrophied, he had severe depression, insomnia, and cognitive problems. I attributed the cognitive problems to depression but also to chronic sleep deprivation. His memory and concentration problems were severe and likely due to depression, chronic pain, and insomnia. Therefore it was my professional opinion the patient was 100% totally and permanently disabled from any job or occupation for compensation as a result of the injuries he sustained in the barge accident. It was also my professional opinion that this patient’s injuries were permanent, that is, while symptoms could be helped and the patient’s quality of life could improve, he would require treatment for these injuries for the rest of his life. It was quite clear to me that this patient’s pain was so severe that it was not being maintained adequately on the medications he was presently taking. I suggested to him that he ask his family medical doctor to have him try a Duragesic® patch since I have had a great deal of success with this transdermal opioid delivery system in many of my patients. While I gave him information for this medication, I did not prescribe it for him since he was only seen in my office for an evaluation. I told the patient I would be happy to assume his pain management if he chose to come back and see me.
I wrote to the patient’s attorney that it was clear to me that this patient was in a great deal of pain and that, even worse, he was losing hope. He was not able to sleep. He was very depressed and he told me that he thought that his situation was not going to get any better no matter what he tried. I also noted in my letter to his attorney that he looked about 10 years older than his stated age and that I believed that he was truly suffering greatly and required aggressive pain treatment. While the patient had only been sent to me for an evaluation, I phoned the patient’s attorney who, upon hearing my suggestions, commented that he would be happy to arrange for the patient to come to my office for treatment and I certainly agreed accept him as a patient.
Within a week and much to my surprise, I got a phone call from the patient’s attorney informing me that the patient was found dead in bed. The patient was only 39 years of age. I naturally thought the worst and believed he may have taken his own life, but an autopsy revealed that he had died of “acute coronary thrombosis.” The report further stated that this “was a complication of arterial sclerotic and hypertensive cardiovascular disease.” The medical examiner further wrote that this patient “…most likely would have been able to control his diabetes and hypertension by working out as he used to do before he suffered his devastating injuries. The physical and emotional stress caused by the injuries he sustained…played a significant role in leading to his death…” Moreover, the medical examiner wrote: “His heart disease was significantly worsened by debilitating consequence of the work-related injuries he received.”
Discussion
This case serves as a reminder that chronic persistent pain, under-treated and uncontrolled, can result in tragedy. This patient was 37 years old prior to his accident. He was gainfully employed and enjoying a good quality of life. Chronic pain can be a tremendous stressor and can affect virtually every organ system of the body. Tennant reviewed the literature and concluded that “Persistent unremitting pain may adversely affect the body’s endocrine, cardiovascular, immune, neurologic and musculoskeletal systems, and require aggressive treatment of the pain as well as the resultant complications.”² Plotnikov et al,⁷ in a book published over a decade ago, made a particular point of showing that stress—regardless of the cause (naturally chronic pain can be one such stress)—can have an extremely deleterious affect on the immune system and even lead such patients to have higher risks of developing malignancies.
One common chronic painful condition, fibromyalgia syndrome (FS),⁸ for example, has been associated with adult growth hormone deficiency characterized by low levels of somatomedin-C or insulin dependent growth factor one (IGF-1) and altered reactivity of the hypothalamic-pituitary-adrenal axis,⁹˒¹⁰ as well as a poor overall quality of life.11 Low levels of IGF-1 have been associated with an increased risk of heart failure in some patients12 as well as other serious health problems likely to negatively affect longevity.¹³˒¹⁴˒¹⁵ Furthermore, FS patients may have a higher risk of developing other disorders ranging from osteoporosis¹⁶ to malignancies.¹⁷ This is not surprising since widespread body pain has been associated with an increased risk of cancer as well as reduced cancer survival.¹⁶ This particular patient suffered greatly. His chronic pain went undertreated and thus initiated a cascade of other problems which eventually led to his premature death at the age of thirty-nine. An argument might be made that the patient’s use of Vioxx® (rofecoxib) contributed to his demise since Vioxx® was voluntarily withdrawn by its manufacturer, Merck, in October, 2004 after it was learned that there was an increased relative risk for adverse cardiovascular events such as myocardial infarction. These adverse effects, however, were only confirmed to occur in patients who had been taking the medication for at least eighteen months. This was not the case with the patient who is the subject of this report. Review of medical records revealed that he was taking the lowest dose of Vioxx® (12.5 mg) for a maximum period of less than six months.
The ineffectiveness of codeine in treating this patient’s pain may have, in part, been due to its not being converted to morphine-like analogs which might have been effective. A small percentage of the population cannot make this conversion. However, even if the codeine preparation was adequately processed, pain relief would have been of only a short duration. Clearly this patient’s painful condition required an analgesic with a long half-life. Oxycontin® did seem to work the best of all the analgesics tried but it was discontinued. The medical records give no reason for this. However, prescribing long-acting opioids over an extended period of time does place the clinician in the unenviable position of being scrutinized by the medical board and/or regulatory agencies such as the Federal Drug Enforcement Administration (DEA). In my community, many physicians avoid prescribing controlled substances for just that reason. Furthermore, more is expected of clinicians in the area of risk management and prevention of diversion of controlled substances.¹⁹ This reluctance to prescribe opioids extends not only to the types of medications but the doses as well.
The fear of “over prescribing” opioids may deter physicians from providing enough medication to adequately control pain. This fear, while palpable in my community, is without foundation if the physician is prescribing opioids for a patient whose painful condition is well documented and the prescriber exercises due diligence in his care of the patient. In support of this assertion, I refer to a publication of the European Federation of Chapters of the IASP. In part, it states, “No upper limit of dose of pure opioid agonist can be established.”⁴ One must titrate for effect in order to optimize analgesic effect while minimizing side effects. The fear and embarassment at being manipulated and hoodwinked by drug-seeking addicts may also be a factor in the under-treatment of pain. However, this does not relieve the physician of his obligation to ease the suffering of his patient. According to the public policy statement of the American Society of Addiction Medicine, “Physicians who are practicing medicine in good faith and who use reasonable medical judgment regarding the prescribing of opioids for the treatment of pain should not be held responsible for the deceptive behavior of patients who successfully obtain opioids for non medical purposes.”²¹
Conclusion
Every prudent and caring physician has been in the precarious position of balancing patient care and risk prevention. The practitioner must keep in mind state and federal law while, at the same time, fulfill what he believes to be his duty to his patient. Adequate analgesia can usually be attained. While the clinician must be wary and take appropriate precautions, he/she must also not withhold opioids when a patient clearly needs them to control pain and regain sufficient functionality to regain control of his life.
Because chronic pain syndromes are quite common and these medical conditions can cause significant systemic stress and adversely affect the quality of life, the clinician should treat pain aggressively as early as possible. The longer one waits to adequately get chronic pain under control, the more likely the body will decompensate and cascade into other significant medical problems affecting the endocrine, cardiovascular, immune, neurologic and/or musculoskeletal systems. This case report is a reminder of what can happen if chronic pain is not treated successfully. Can pain kill? You be the judge.
In watching this video, pay attention to two very serious misstatements by Dr Singer.
1. He did not clarify that there is – according to Wikipedia.com – upwards of 200 different known Fentanyl analogs and only FOUR have went thru FDA clinical trials and approved for safe use in humans, and are available via a prescription only. There is no commercially available tab/cap dosage forms.
2. Dr Singer mentioned Fentanyl topical patches. In particular, the Fentanyl 25 mcg patch. Those patches release so many mcg/hr and the patches are suppose be worn for 72 hrs. So over 72 hrs, one of those patches will release 1.8 milligrams or 1,800 mcgs.
In the end, It only took us 12-14 yrs to figure out that Alcohol prohibition did not work, but the war on drugs has been going on since 1969-1970. 25 yrs, does that suggest that our federal bureaucrats are AT LEAST HALF AS SMART as those back in the day that repealed the Alcohol prohibition.
Below is the comments that I made. Please DO NOT COPY THEM and submit them as yours. If the DEA sees a lot of “identical submissions” will just dilute the impact of what was submitted.
What I did was ask perplexity.ai a half dozen questions. Asking it to refine/expound its previous answer. Ended up asking 5-6 additional questions on the subject matter.
Then I took all the answers and asked perplexity to created a concise synopsis of all the answers.
I figured the longer any submission the less that it is likely to be read.
I consider perplexity’s final summary is pretty damning to what the DEA/DOJ and many in our judicial system has – and is – doing to the chronic pain community.
But pretty much what has been done and what is going to be done could. Clearly outlined as a “culling of the herd” or a covert genocide, and there will be little/few stats on the deaths will be tracked or if tracked, never see the light of day.
Below is a link to another blog post that I made with some more information, and links to where you can read the proposal and a link to make your comments
