University of Kentucky Dental Professor Forced Off Faculty for Criticizing Gov. Bevin’s Medicaid Cuts Gets $620,000 in Court Settlement.

Yes.  But, behind them I suspect is the Emperor.
                                            Paul Atreides, in “Dune.”

More than a year ago I wrote about the capture of the academic process by the Kentucky Governor’s Office where some unnamed individual with clout became “pissed-off” when Dental Professor Dr. Raynor Mullins exercised both his faculty and first-amendment rights to suggest that cutting back on dental and vision services to Medicaid beneficiaries was a bad idea. Everyone involved seemed to know who in Frankfort held the power to intimidate the leadership of our “Flagship University,” but the Governor’s office denied any involvement in the matter.  (We have encountered that scenario before, right here in River City!)  The University rolled over and dismissed Dr. Mullins.

In response, and to both hold the University accountable and presumably to shine a bright light on what actually appended, Dr. Mullins filed a lawsuit against the persons of the Vice President for Administrative and External Affairs and the Dean of the University of Kentucky College of Dentistry.  In my earlier commentary, I opined that perhaps under oath that the truthfulness of the allegations would come out– or not!  It is not clear to me that any such disclosure happened.  As I understand it, before the case was to go to a jury trial, a settlement was reached without any admission of guilt.  I do not know how much pre-trial discovery was done. Today’s reports in the Lexington Herald and Courier-Journal do not refer to any information from depositions taken under oath.  Often such settlements include clauses of confidentiality that hide embarrassing findings from public view. Is it conceivable that court records might be sealed?  Is it possible that we may never know to whom the UK officials caved?

What is just as disturbing as not ever knowing the identity of the bully is the claim that communication within the University and with the Governor’s office in this matter was conducted using personal e-mails.  The use of personal electronic devises and emails to skirt open-meeting and open-record laws is an emerging threat to the ability of the public to hold its government accountable.

The University of Kentucky does not come off looking good in this matter.  It seemingly admits no guilt at all, but some UK entity now has a 6-figure settlement to pay with legal fees to boot. Dr. Mullins is taken back in to the faculty. Transparency disappears. No one is held accountable. Dr. Mullins may not have achieved all his goals, but in my view, he stood up to the state agency that is the University of Kentucky and won!

Peter Hasselbacher, MD
Emeritus Professor of Medicine,
University of Louisville
Dec 10, 2018

[If anyone has public court documents or other information that might shed light on this sad affair– or for that matter correct any misunderstanding of mine– I hope they will communicate with me confidentially or with the email link found in the side-bar of this website.]

Another St. Joseph- London Cardiologist Is Sentenced to Prison.

Could this have been averted early on before this unfortunate result?

Last week, following his conviction last April for medical billing-fraud related to medically unnecessary placement of cardiac pacemakers, Dr. Anis Chalhoub was sentenced to 42 months in prison; required to pay $257,515 restitution to Medicare, Medicaid, and private insurers; and fined an additional $50,000.  Dr. Chaloub’s attorneys had requested a shorter time in prison and perhaps it is possible they will appeal the sentence.

According to the press release from the U.S. Attorney’s Office, an additional term in the sentence was that following release from prison he will remain on probation for a three-year period during which the “court has prohibited him from practicing cardiology during that time.”  I am puzzled about whether a federal court has superior jurisdiction over Kentucky’s Medical Licensure Board for such a restriction on licensure.  If I were the Kentucky Board, I would be embarrassed or angry, or both.  Out of curiosity, I looked today at the Kentucky Board’s website which informs me and potential patients that Dr. Chalhoub still has an active Kentucky medical license with “no actions” or restrictions mentioned. (I confirmed this with a call to the Board.)  Although several physician-referral & rating websites have him affiliated with hospitals in Lousiville and Indiana, I do not know if he is still practicing medicine. Continue reading “Another St. Joseph- London Cardiologist Is Sentenced to Prison.”

Can Jewish Hospital in Louisville be Saved? Perhaps Not.

If not, what then?

Surely the end-game of the years-long efforts of Catholic Health Initiatives and KentuckyOne Health to sell some or all of their hospitals in Louisville must be coming to a climax. Transferring management of University of Louisville Hospital to KentuckyOne– a move that turned out badly for both institutions– was always as much or more about saving Jewish than ULH.  Many outside entities came to kick the tires of what KentuckyOne wanted to sell but walked off the lot.  The last acknowledged potential buyer whose keys KentuckyOne was holding was the tag-team of the private equity firm Blue Mountain and its spinoff for-profit hospital management company, Integrity Healthcare– now majority-owned by for-profit Nantworks Companies and Nantworks owner Dr. Patrick Soon-Shiong.  Sound complicated?  It is!  Casting a very dark curtain over this potential transaction in Louisville is last week’s announcement that Blue Mountain & Co.’s first and only attempt to take over a failing non-profit Catholic hospital chain in California has failed– the hospital system has filed for bankruptcy. These six Verity Hospitals (formerly the Daughters of Charity) might be bought by their communities, taken over by others, liquidated for their assets, or otherwise close.  I cannot avoid concluding that the same result would occur in Louisville and for much the same reasons.

CHI has played this one very close to its corporate chest. Fanned by anxiety about the future, rumors have been flying in increasingly disparate and desperate directions ranging from “Blue Mountain” has taken a second look and will sign on soon; or Blue Mountain has walked away for good; or that Nantworks and Dr. Soon-Shiong will move forward with the deal without Blue Mountain; or that CHI will give Jewish to the University for a song; and even that one or both of the sister Jewish & Sts. Mary Hospitals will soon shut its doors.  None of the potential players is in a strong place right now as I will outline below.  The one thing I am sure of is that the ground under the downtown hospital complex is going to quake hard, and that secondary seismic activity will be felt out in the county and beyond.  The Louisville Community is going to have to make some public health decisions that are both difficult and expensive. Continue reading “Can Jewish Hospital in Louisville be Saved? Perhaps Not.”

Honoring Sen. John McCain’s Service by Making CRS Reports Used by Lawmakers Available to the Public

Much will be written following the death of Sen. John S. McCain, the vast bulk of it of with sincere admiration for his personal courage and service to his country. I am among those admirers. His life was undeniably colorful– he was very much human. Equally undeniable was the magnitude of his service to his nation. He knew where his duty lay, and he gave palpably more than any critic to honor that obligation. He knew the difference between patriotism and nationalism or partisanism. Compared to his legislative peers, it is fair to say that few or none have displayed greater loyalty to the common good of our nation as opposed to any political party. In any world– but certainly in today’s political climate– he was a lion among sheep.

What Are CRS Reports?
I interacted with his Senate office one time in 1998 during my Congressional Fellowship and service to the Senate Finance Committee. Senator McCain filed a typically bi-partisan bill that would make most of the reports and issue-briefs prepared by the Congressional Research Service (CRS) available to the public. At the time, I had never heard of these.  CRS reports are among those prepared by the Library of Congress, often in response to requests by federal legislators for background information about current or potential legislation. I had hundreds of these available to me at my networked desk in a Senate office building. The resources of the Library are stunning. The academician in me recognized these reports and issue briefs as extraordinarily useful. They are well researched, and clearly written in language that can be understood by non-technical people. Best of all, these reports are as balanced and nonpartisan as anything can possibly be on Capitol Hill.  (The worst service a legislative aid can give their member is not to include all sides of an argument in their briefing.)  I downloaded and read as many reports related to healthcare matters as I could find, constantly regretting that I had not had them available earlier as I began a second career in health policy research. Continue reading “Honoring Sen. John McCain’s Service by Making CRS Reports Used by Lawmakers Available to the Public”

Second Cardiologist Found Guilty in Federal Court for Performing Unnecessary Cardiac Procedures at St. Joseph London Hospital.

Dr. Anis G. Chalhoub, formerly a cardiologist at KentuckyOne Health’s St. Joseph London Hospital, was indicted in Federal Court in June, 2016 for allegedly performing unnecessary cardiac procedures.  A jury trial concluded last Wednesday with a finding of guilty on all 12 counts.  (United States District Court, Eastern District of Kentucky, London. Criminal Case No. 16-cr-23).  I do not yet have many court documents, but one of the counts must have been related to the civil lawsuit in Laurel County against St. Joseph and Catholic Health Initiatives which awarded a record $21.2 million to a Corbin man for unneeded surgical heart procedures at the London Hospital. (That case is still being appealed.)  Dr. Chalhoub currently holds a valid medical license in Kentucky and practices in Louisville and Southern Indiana.

[Addendum April 17, 2018:  The Department of Justice released today a notice of the conviction with some additional details. The story was also reported this morning in the Lexington Herald.  This latter notice reported that Dr. Chalhoub was convicted on a single count rather than the 12 counts noticed to to me. I will correct this article when I can reference the original court documents.] Continue reading “Second Cardiologist Found Guilty in Federal Court for Performing Unnecessary Cardiac Procedures at St. Joseph London Hospital.”

Hundreds of Louisville Students and Their Supporters March For Their Lives– and Ours.

It was a dark and stormy afternoon last Saturday when as many as a thousand or more Louisville students, their families, and supporters marched a cold wet mile up Main Street to Louisville Metro Hall where a spirited rally was held. One could only be impressed with the student’s passion and justifiable anger. (I was taken back 50 years to the protests of my generation against the Viet Nam War.) The students had a right to be angry.  In addition to the apparently unstoppable drumbeat of shootings here and elsewhere, the day before the march a student brought a loaded gun into Louisville’s Valley High School, and a credible threat announcement was made against Manual High.  This is not somebody else’s problem.  We own it too!

Similar protests took place all around the country. In Washington, DC, the turnout was impressive, and may have been the highest for a one-day protest ever. Despite the passion and powerful rational rhetoric of the students, pundits are generally pessimistic that little more than cosmetic changes will result in the near future– if not the foreseeable one. I suspect however, that weaknesses in the defenses of the NRA/Industrial complex and their legislative partners are forming. Some in the Republican party and other NRA enablers of any party must be at least a little nervous.  The students know that they will soon be able to vote, and I suspect they will not have forgotten the promises they are making today.  If you were one of their parents, why would you not support them?

I believe if this generation of students can keep it up, that change is possible.  It is already starting to happen!  The spending bill signed by President Trump a few days ago reversed the previously unexplainable prohibition of federally sponsored research into gun violence.  Now that such violence is a formally recognized issue of public health, I have a legitimate justification to write about it in these pages!

North Oldham High School’s Zoe Kuhn was the principal student speaker at the Metro Hall rally. She delivered a powerful, articulate address in which she expressed her recurring fear, and that of her peers, that the prospect that gun violence might occur at any time in her school. There was, however, no trace of fear or lack of courage in her delivery!  I was immensely impressed and proud of her.  Her admission of fear did not ring as contrived to me, but her vulnerability did not inhibit the handful of pro-gun individuals in the crowd from attempting to shout her down in a derogatory manner.  Their camo-uniformed presence was the sole face of resistance to rational gun policy visible that day.  I suggest to other opponents of rational gun control that they not allow these counter-protestors to speak for them on this matter. Your silence can suggest that you are happy for them to do your work for you.  [I am not aware that any Republican official spoke that day, but I had to leave before the end of the rally because I was shaking too hard from hypothermia!  My endurance and commitment paled before that of the students.]

I confess to feeling a twinge of sadness from one statement in Ms. Kuhn’s speech when she told opponents of reform that it was not a goal of the students “to take your guns away.”  She is not alone in accepting this narrowing of possible outcomes before the debate has truly begun.  A principal goal of a think tank, lobby, or advocacy group is to establish what issues are on the table and to define the vocabulary of any political debate.  To be able to do so is to win.  This has been a great success of the NRA. Taking the possibility of decreasing the number of guns in our country off the table is premature, indeed an abdication.

In my opinion, and as is becoming even more clear to me as I pay attention to the daily reports of gun violence, that the suggested reforms already on the table will not have a significant impact.  Of course the mentally ill should not be able to buy guns, but neither should they be able to own the guns they may already have.  Indeed, how do we decide if someone is mentally ill?  I lived in mental hospitals for 13 years and assert from experience that there is no bright line between normal and mentally ill.  There are not enough mental health workers in the world to do all the checking necessary– even if we had accepted criteria to turn someone down.  There are not enough FBI agents or similar investigators in the country to do all the background checks necessary expose past criminality or violence, let alone a reliable, accessible registry for them to use.  An individual defined as sane or reliable at the time of purchase may not remain so in the future. Having teachers carry guns makes no more sense than having flight attendants do so. Shooting galleries in planes or schools make for collateral damage.  Even if schools become armed citadels, airport-grade security procedures will still be necessary.   If visitors with guns are not permitted in the Senate or House chambers, why should concealed or any other carry be permitted in a public place anywhere?  [What is good for the goose…?]  How long a waiting period is necessary before buying a gun legally?  Is there a shred of evidence that any waiting period will make a dent in gun violence?  There are just too many guns lying around for the mentally ill, the criminal, or the angry to pick up and use. I remain to be convinced that anything other than decreasing the number of handguns and weapons of war in private hands will diminish gun violence in any meaningful way.

I walked away from Saturday’s rally feeling that a glimmer of hope had been lit. However, my uptick in enthusiasm was dashed when upon turning the corner at 4th Street on my way back to my car, the visible glimmer on the ground turned out to be a spent 45-caliber bullet cartridge lying in the street. Thus the pendulum lurches back and forth.  Change will be neither easy or quick, but the experience of other countries tells us we can do better.  We need to start somewhere and its painful to imagine things could get worse.

Peter Hasselbacher, MD
March 27, 2018

 

 

 

 

How To Save Big Money on Prescription Drugs.

If I were King of Medicare.

I am still learning how best to extract useful information from the public-use Medicare Part-D Drug Utilization and Cost files. I view these as experiments of nature worth mining for what they can tell us about the clinical and business aspects of healthcare.  The last few articles I have written focused on the utilization and cost of Insulin, highlighting the seemingly unjustified increases in this life-saving drug for diabetics.  In this tweak, I learn how to combine data from drugs in the same therapeutic category including all the brand and generic versions of individual drugs within categories. I am still wrestling with technical issues related to presenting multiple groups in a single TreeMap visualization, but as an example, I will show that in 2015 three groups of drugs– insulin, opioids, and drugs used to treat Hepatitis-C–  cost the Medicare program 17.6% of the total cost of all Part-D drugs but comprised only 7.2% of all prescriptions.  These drugs were expensive for different reasons that I will illustrate.

I particularly like the TreeMap data-visualization format because it allows hundreds if not thousands of drugs to be compared at the same time and facilitates identification of unexpected or unjustified outliers much easier.  Since Medicare is now standardizing the formats of these drug files, changes in utilization and cost can be tracked over several years.  I believe that placing such analyses into the service of policy makers and payers can allow savings of billions of dollars without compromise of care. Continue reading “How To Save Big Money on Prescription Drugs.”

Our Unregulated Militia Is Killing Our Children.

Special interest  or public health issue?
I cannot conceive that any health professional would consider the incidence of death and injury from firearms as other than a public health issue. Surely the absolute numbers of people killed or injured (in excess of 100,000 per year); whether self-induced or by others; by accident or on purpose places the matter squarely before us on a regular basis no matter where we live. This uninterrupted endemic parade of victims is punctuated by epidemic outbreaks in crowded places like schools or workplaces.  There are carriers of this disease in all 50 states. No cure has emerged for this essentially American pandemic. The most recent outbreak which stimulated me to write this article occurred last month in Florida at the Marjory Stoneman Douglas High School in Parkland where 17 students were killed by another student, and 17 others wounded by an AR-15 military machine gun– a.k.a. assault rifle. The damage caused by this gun unnerves even hardened professionals.

Unlike most other epidemics of disease, reliable information about how to prevent non-military people from death-by-bullet is scarce because of a bizarre broad governmental prohibition to even study the matter. The self-censorship is deafening in a recent 476-page report from the U.S. Department of Health and Human Services.  It is titled, “Health, United States, 2016” but the words “gun” or “firearm” are not to be found in it. Disturbingly, it remains unclear that any meaningful national attempts to control this epidemic will be made or even that individual states will be permitted to do so.   Undeterred, advocacy groups are increasingly demanding that immediate and definitive action be taken to protect themselves and the rest of us.

Our young adults step forward.
Last Monday evening, I unexpectedly met a group of students from St. Francis High School here in Louisville who had come out for a program of Kentucky to the World to hear Nobel Laureate and scientist Phillip Sharp talk about the value of education for individuals and our communities. In chatting with the students, I learned that they were planning to participate in the National School Walkout to protest against gun violence and to demand gun control. I was touched by their commitment, and as a father of former students of St. Francis how could I not stand with them? Continue reading “Our Unregulated Militia Is Killing Our Children.”

Updated Look at the Rapidly Rising Cost of Insulin in Medicare Part-D Program.

The cost of Insulin to the Medicare program is frankly staggering. In brief summary, insulin is not only one of the most important drugs for beneficiaries, but also, in aggregate, one of the most expensive set of drugs used by Medicare patients.

I want to use this post to explore enhancements to Medicare’s Part-D drug utilization-and-cost files using Insulin as an example.  I have previously dissected the public use files released by the Centers for Medicare and Medicaid Services (CMS) to explore a number of health policy issues.  These included utilization and cost of medical services by hospitals and other providers; quality and safety issues related to hospitals; the overall monstrous rises in prices of generic and other drugs; and prescribing patterns of opioids by individual practitioners. Other analyses examined insulin utilization and cost for Medicare and Medicaid beneficiaries. The rapid (and large) increases in the price of insulin are exemplars of the gut-punch impact of drug prices on individuals and our healthcare system.  Drug companies have diabetics and their public and private payers over a barrel.  Large numbers of patients with diabetes need the drug to keep them healthy if not alive.  In mid-2016, CMS updated and standardized their Medicare Part-D databases making them comparable for the three initial calendar years of 2013 through 2015.  I took this opportunity to take another look at Insulin.   Although only some 70% of all Medicare beneficiaries are enrolled in Part-D Drug benefit programs, I suggest that prescribing patterns to these Medicare beneficiaries are not very different than those for non-Medicare adult patients and can be generalized.  To make the initial data available to some new colleagues and simply just to get a start somewhere, I placed my first peeks into the enhanced Medicare databases on my Tableau Public Site in three sets of interactive tables and visualizations individually for 20132014, and 2015. Continue reading “Updated Look at the Rapidly Rising Cost of Insulin in Medicare Part-D Program.”

More Expensive Medical Services or Products Does Not Equate To Better.

I have been writing articles for this health policy blog since 2009– almost all of the 390 posts since 2011. Of them, the one most frequently accessed by the public is a 2012 article titled “Horse Liniment for Your Arthritis and Healthcare Reform.”  I encourage you to read it also, because it provides my background for this article, and explains why I write a lot about how pharmaceutical companies – with the active consent of our elected government officials – are gouging the public. The earlier article caught my attention because of a tiny advertisement in the Courier-Journal notifying me that an “arthritis pain mystery” had been solved and that the secret was horse liniment. In my studied professional opinion, the claims were vastly overblown and that in any event, the “secret” was not a secret at all. The ingredients in the horse liniment were available in a variety of over-the-counter joint-rub-ons at a fraction of the cost of the “miracle” liniment offered for sale. I lament the fact that the public at large could be motivated to part with their money in such a way, but alas, physicians are equally as vulnerable to bamboozlement by the traditional pharmaceutical industry– think OxyContin. Sadly, the marketing approaches I wrote about in 2012 are still alive and well. Such advertisements in the Courier-Journal are now bigger and more numerous than ever.  A recent such sparked today’s article. Continue reading “More Expensive Medical Services or Products Does Not Equate To Better.”