It seems that this may become a reality if state medical associations and the American Academy of Family Physicians do not become more aggressive in protecting primary care physicians from being overrun by nurse practitioners. Already, 21 states have granted full practice authority to nurse practitioners. Full practice authority does away with the requirement that a nurse practitioner have an “attestation agreement” with a physician in order to practice. Full practice authority allows a nurse practitioner to practice on his or her own.
In May, the State of Maryland was the 21st state to grant full practice authority. In March, Nebraska was the 20th state. Florida is currently taking steps to do the same. The latest attempt, in Florida’s recent Special Session, was Bill 27A.
In Florida, the argument used to justify full practice authority for nurse practitioners is that Florida has a primary care physician shortage because “1.6 million Floridians” have obtained healthcare coverage through Obamacare. The fact that “1.6 million Floridians” have obtained healthcare coverage through Obamacare does not mean that there are not enough primary care physicians in Florida to care for them. What percentage of the “1.6 million” had coverage prior to signing up for Obamacare? That figure is never quoted in the justification argument. Those arguing for full authority for nurse practitioners want you to believe that all of the “1.6 million” never had healthcare coverage before. That cannot be the truth.
If you are a primary care physician and have treated Medicaid patients it is no surprise that the U. S. Government Accountability Office [GAO] recently reported that 5 percent of Medicaid enrollees accounted for nearly half of the program’s spending each year from 2009 to 2011. The GAO reported that one percent of Medicaid recipients “accounted for about a quarter of spending.”
With Medicaid making up the largest component of most state budgets, it seems that the one percent that makes up this 25 percent should be a priority in controlling healthcare costs. But, it does not seem to be a priority. It may be time to change this. If Government cannot address it, then it should be time to give private enterprise a crack at it.
Private enterprise should be able to develop a national healthcare model that would be able to manage the one percent and control the costs of this population. I am sure there are healthcare entities that, if given the freedom they would need from unneeded regulations, would accept the challenge.
On April 15th, the Medicare Sustainable Growth Rate [SGR] was repealed by Congress. Afterward, there was much celebration by the AMA and other medical societies. But, it may be a little premature to celebrate based upon the language of the Bill that was used to repeal the SGR.
The SGR was a method used by the Centers for Medicare and Medicaid Services (CMS) to control spending by Medicare on physician services. It was enacted in 1997. It was designed to ensure that the yearly increase in the expense per Medicare beneficiary did not exceed the growth in the GDP. Unfortunately, the SGR was unworkable and every year since Congress had to suspend its implementation with legislation called the “Doc Fix.”
The language in the Bill repealing the SGR mandated a new Medicare means of reimbursing physicians. It is called the Merit-based Incentive Payment System [MIPS]. It expands Obamacare’s “pay for performance” strategies in which reimbursement is based on provider performance against a variety of metrics. It consolidates the Physician Quality Reporting System, the Value Based Modifier and Electronic Health Records System [EHR] Meaningful Use into it. The penalties associated with these consolidated systems will remain in effect. Physicians will be evaluated and given a score based upon on quality, risk-adjusted resource use, EHR meaningful use and clinical practice improvement.
Clinical practice improvement areas that will be evaluated by CMS must include:
1. “expanded practice access such as same day appointment …”
2. “population management, such as monitoring health conditions of individuals to provide timely health care interventions …”
3. “care coordination, such as timely communications of test results, timely exchange of clinical information … and use of remote monitoring or telehealth …”
4. “beneficiary engagement, such as the establishment of care plans for individuals with complex care needs … and using shared decision making mechanisms …”
5. “patient safety and practice assessment, such as through use of clinical or surgical checklists and practice assessments relating to certification …” and
6. “participation in alternative payment models …” such as shared savings programs and other models under Federal law.
The secretary of HHS can expand on these.
MIPS incentives will range from a maximum 4% bonus or penalty in 2019 to a 9% bonus or penalty in 2022. The penalty levels seem significant to me.
To meet the demands of MIPS, physicians will have to expand their IT use well beyond the current usage level of their electronic health records systems. This will require increased expenditures and increased disruptions to their practices.
The repeal legislation is pushing telehealth and remote monitoring as a way to increase physicians scoring under MIPS. I find this problematic. I have a difficult time seeing how physicians will continue to increase, or even maintain, quality of care without touching the patient. The liability issue of treating a patient without touching the patient is also self-evident.
The repeal legislation, 158 pages, covers a wide range. 158 pages of verbiage was not needed to repeal the SGR. One or two pages would have sufficed. How or if it can be effectively and fairly implemented is a question that remains. So, now is not the time to celebrate. Now is the time to remain anxious.
In April of 2010, the United States Library of Congress entered into an agreement with Twitter that allows the U. S. Library of Congress to archive all Tweets from 2006 to the present. The Library of Congress intends to make the Tweets available to researchers and policy makers.
Twitter’s Terms of Service do not mention that the Library of Congress is archiving all Tweets for posterity. I am unsure of how many individuals are aware of this. Would they continue using Twitter if they were? Twitter’s Terms of Service states: “This license is you authorizing us to make your Tweets available to the rest of the world and to let others do the same.”
I think it would be appropriate for Twitter to mention that all Tweets are to be perpetually archived in the Library Of Congress. There is a difference between making a Tweet available to the world for a finite time period and the archiving of a Tweet for perpetuity. Also, does a citizen of another country want his or her Tweets to be archived in the United States Library of Congress?
This seems like an intrusive cyber-activity. Normally, when considering this degree of cyber intrusion the National Security Agency comes to mind. But, here it is the United States Library of Congress. That is remarkable.
The other issue is the money being spent on this. Doesn’t the Country have other priorities that are more valid and urgent?
As a provider of services to Medicare patients, you normally submit a claim for payment of service to a Medicare Administrative Contractor [MAC] and expect to be paid within a reasonable timeframe. You are a business and have expenses that need to be paid in order for you to remain open. Any disruption in the flow of claim payments to you can result in severe hardship to you and your practice.
If the MAC denies your claim or claims, you can request a redetermination of the denial of payment. The MAC has 60 days to make a decision on the redetermination.
If the MAC continues to refuse to pay the claim or claims, you can then appeal the refusal to a Qualified Independent Contractor [QIC] and request a reconsideration of the MAC’s decision. The QIC has to complete its review within 60 days.
If your claim continues to be denied, you can request a hearing before an Administrative Law Judge [ALJ]. The Social Security Act requires that the ALJ “render a decision … not later than the end of the 90-day period beginning on the date a request for hearing has been timely filed.”
The process, from redetermination through the ALJ hearing and decision, should easily take less than 9 months. This is a long time to determine if a provider is being unduly deprived of funds. Actually, it is too long when one considers its impact on a practice’s cashflow.
On December 24, 2013, the Chief ALJ notified Medicare provider appellants that as of July 15, 2013, she had “temporarily suspended the assignment of most new requests” for ALJ hearings. She anticipated this would result in about a 2.5 year delay before a request for hearing could be heard. This delay was announced despite statutory and regulatory mandates to the contrary. The Obama administration has arbitrarily decided that it can delay a hearing that relates to provider claim payments for 2.5 years. The Obama administration justifies its actions by saying that its ALJs are overworked because their caseloads have increased significantly.
You have to ask yourself why has the number of appeals increased? The reason is simple: the number of provider claims denied or challenged has increased. CMS knew this would happen but did not prepare for it. CMS had contracted with private Recovery Audit Contractors [RAC] to audit provider claims. RACs are paid by contingency fee. They receive a cut of payments they recover. So, it makes sense that challenges of payments would increase. Common sense would have directed that the Obama administration prepare itself for this eventuality. It did not. And now, providers must endure significant delays in resolving payment challenges.
The Obama administration and Congress, both aware of the negative impact this has upon providers, have not come up with a solution. As of December 2014, attempts to make the Courts force the administration to adhere to statutory and regulatory mandates has fallen upon deaf judicial ears. No one in Government seems to be interested in the provider’s well being.
When will providers come to the realization that it is Government that needs them, not the other way around. The Government cannot provide healthcare to the Nation without providers. It seems that it may be time for providers to consider organizing into a more tightly knit group. Nothing else seems to be working.
You have to ask yourself why the Democrats would change the entire United States healthcare system for just 5 % of the electorate? Doesn’t make sense does it?
Fact: Senator Chuck Schumer, a key democratic senatorial leader, made the following public statements recently to the National Press Club:
Only about 5 % of the electorate benefits from Obamacare.
Only a third of the uninsured are even registered to vote.
The Democratic controlled Senate and Democratic controlled House of Representatives ignored the need of United States middle class citizens for better wages and jobs in order to pass Obamacare.
Senator Schumer actively supported the passage of Obamacare, voted for its approval and aggressively fought any attempts to correct the shortcomings of Obamacare.
Now, Senator Schumer admits that Obamacare has not benefitted the Democratic Party. He doesn’t seem interested in the damage Obamacare has done to the practice of medicine and the welfare of American middle class citizens. He is only concerned about the damage Obamacare has and will do to the Democratic Party.
The Democrats controlled the House and Senate when they wrote and passed Obamacare. The Democrats did not seek any input from Republicans when crafting Obamacare. So, why should the American Public have any faith in a political party which:
Ignored the obvious economic pain and need of American middle class citizens for more and better jobs in favor of passing the mandate called Obamacare,
Changed the entire United States healthcare system in order to benefit 5 % of the electorate,
In order to push through their leader’s agenda at the expense of 95 % of the electorate.
A lack of common sense and a lack of compassion for the middle class deluded Democrats into the belief that ignoring the interests of 95 % of the electorate in order to ram through the ideology of their leader would not ultimately backfire. The American Public is too smart to allow the Democrats to get away with that. Now, Senator Schumer acknowledges that “[t]o aim a huge change in mandate [Obamacare] at such a small percentage of the electorate made no political sense.”
American citizens cannot rely on a Political Party that admits it sacrificed the welfare of 95 % of the electorate in order to pass a healthcare entitlement that only benefits 5 % of the electorate. That is not a political party that is interested in the well-being of all American citizens.
In October of 2013 at the University of Pennsylvania, Dr. Jonathan Gruber who has been identified as one of the architects of Obamacare, made the following statement:
“Lack of transparency is a huge political advantage. And basically, you know, call it the stupidity of the American voter or whatever, but basically that was really critical to getting the thing [Obamacare] to pass.”
Transparency means clarity. It means that information needed by voters to make a sound decision on an issue is fully known. It means that those presenting the issue tell the American public the truth. Without transparency and truth, the American voter cannot make a sound decision.
Transparency can prevent corruption. The lack of transparency propagates corruption by those who manipulate the truth. The lack of transparency is the lack of truth.
Professor Gruber’s statement, one of many similar statements, indicates that a conscious decision was made to not be transparent when presenting the facts of Obamacare to the American voter. In order to insure the passage of Obamacare, a conscious decision, on the part of the Obama administration, was made to not tell the truth to the American voter. Professor Gruber admits this was necessary to insure that the bill would be passed.
Professor Gruber indicates that “the stupidity of the American voter” was the reason the Obama administration was able to dupe the American public with a lack of transparency concerning Obamacare.
The American public is not stupid. They have the ability to make sound decisions when they are presented with truthful facts concerning an issue. No one can make a sound decision when they are only presented with untruths and obfuscations.
Only elitists would consider the American voter “stupid.” Only elitists would abandon the common good and the rights of the American voter in order to proceed with their own agenda.
The Common Good
The common good insures that the social systems and institutions, which we depend upon, must operate in a manner that benefits all people. An example of a particular common good is a just and fair government that does not deceive its citizens. The common good does not just happen. It must be attained through cooperative effort.
The common good is served when a government does not deceive its citizens in order to promote its leader’s own agenda. Demanding that others bear the burden for this deceit does not serve the common good of either the government or its citizens.
A right is a justified claim on others. The justification of a claim is dependent on some standard acknowledged and accepted not just by the claimant, but also society in general.
U. S. citizens have a right to expect that their elected officials, and staff, shall function in a manner that will allow citizens to accurately understand the impact of legislative changes. The social costs of abandoning this right will result in damage to the institutions and individuals honored with preserving this right.
When will the American voter demand that this administration cease untruths and obfuscation. The ultimate betrayal of a government is to knowingly deceive its citizens.
With the recent lapses, intentional and non-intentional, in self-monitoring by Ebola exposed healthcare workers it has become apparent that certain questions must be answered.
Question 1: Is a 21-day self-monitoring quarantine adequate to determine Ebola exposure and infection?
Question 2: Can a negative blood test for Ebola be definitive before symptoms have developed?
Question 3: Can a mandatory quarantine be imposed upon an individual exposed to Ebola?
Fact: CDC Ebola interim guidance states:
“Ebola virus is detected in blood only after the onset of symptoms, usually fever. It may take up to 3 days after symptoms appear for the virus to reach detectable levels. Virus is generally detectable by real-time RT-PCR from 3-10 days after symptoms appear.” http://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf
Fact: Jacobson v. Massachusetts, a 1905 U. S. Supreme Court decision will support the right to quarantine an individual when there is a public need for quarantine.
Fact: Treatment of a quarantined individual has to be reasonable and decent. It cannot be punitive.
Fact: An individual must be given the right to protest an imposed quarantine.
Fact: Ebola is an infectious agent that has a known high lethality.
Quarantine is a time-tested response to slowing the spread of infectious disease. Voluntary compliance with an imposed quarantine is an important part of infectious disease control. A self-monitoring quarantine may be appropriate for individuals that have discipline and empathy toward their community. But, if the individual does not consider the impact of noncompliance on the community then a mandatory state imposed quarantine is justified.
“The liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good.” Jacobson v. Massachusetts, 197 U.S. 11, 11 (1905).
“It might be that an acknowledged power of a local community to protect itself against an epidemic threatening the safety of all, might be exercised in particular circumstances and in reference to particular persons in such an arbitrary, unreasonable manner, or might go so far beyond what was reasonably required for the safety of the public, as to authorize or compel the courts to interfere for the protection of such persons.” Jacobson v. Massachusetts at 27.
Healthcare workers should be cognizant of the impact their behavior has on the community and act in the best interest of the community. If they elect to self-monitor they should confine themselves for the duration of the quarantine. They should not potentially expose others to disease, even if they are not infectious, until the quarantine period is over. Currently, it seems that healthcare workers feel that they should not be subject to the rules of quarantine. This attitude does not reinforce confidence in the profession. It also creates a standard for the rest of the community to not be compliant if they are quarantined.
There are a certain percentage of individuals that will not show Ebola symptoms until after the standard 21-day incubation period. Both the CDC and the WHO understand this. Therefore, the incubation period and quarantine period will have to be increased in order to insure the safety of the community.
Ebola can be diagnosed by blood test only after the individual has developed symptoms. So, if an infected individual is tested before he or she develops symptoms, the blood test may come back as a false negative. Therefore, a negative blood test should not be used as a definitive test if there are no symptoms being demonstrated.
If you are an exposed healthcare worker feeling good, do not assume that you will not develop symptoms until at least 42 days out.
If you are a healthcare worker, recently exposed to Ebola, you have an obligation to adhere to any quarantine either imposed by the state or self imposed. You must consider the impact that noncompliance will have on others. Noncompliance will erode trust in the healthcare profession and may unnecessarily expose others to disease. That is morally and ethically wrong.
Any “fundamental” liberty interest you think you may have that justifies your noncompliance does not exist. Your liberty will be balanced against the state’s interest in protecting its citizens. The Court will usually side with the state.
The CDC has been aware of the lethality of Ebola for decades.
I have been listening to the Obama administration’s public health officials continually state that there is no need to terminate incoming travel into the U. S. from the West Africa Ebola hot zones. These public health officials justify their inaction with statements that limiting travel from countries in the hot zone will damage the West African nations’ economies, or make it difficult to get supplies and healthcare personnel into these countries, or make other nations less likely to announce, in the future, that they may have similar disease scenarios. These are baseless reasons for not enforcing a travel ban into the U. S. They defy common sense. They abandon the duty of the Obama administration’s public health officials to protect the American people from a deadly disease.
The correct public health action would have been to ban travel from West Africa until the Ebola crisis could be contained and managed. That would have eliminated the present situation of Ebola becoming a viable entity in the U. S.
Common sense dictated a ban.
The Obama administration should rethink its Ebola policy and initiate a travel ban immediately.