{"id":4150,"date":"2015-06-28T19:25:20","date_gmt":"2015-06-28T23:25:20","guid":{"rendered":"http:\/\/www.khpi.org\/blog\/?p=4150"},"modified":"2017-02-13T14:10:16","modified_gmt":"2017-02-13T19:10:16","slug":"potpourri-of-health-policy-issues-in-june","status":"publish","type":"post","link":"http:\/\/www.khpi.org\/blog\/potpourri-of-health-policy-issues-in-june\/","title":{"rendered":"Potpourri of Health Policy Issues in June."},"content":{"rendered":"

My cup runneth over with potential issues to explore.<\/strong><\/h1>\n

June has been a busy month both locally and nationally insofar as things I like to write about. The shame-on-me is that I have not carved out enough time to do so!\u00a0 In part I am still picking up the pieces after my early spring travels. Exploring how to unpack and deal with the new Medicare prescription drug data base also took a lot of time.\u00a0 The truth is that I am a slow writer handicapped by a default and probably over-wordy professorial style.\u00a0 I haven\u2019t even been able to update the Institute\u2019s Facebook<\/a> and Twitter<\/a> pages!\u00a0 What follows is a list of things that occured during the month that I wanted to write about and hope to do so in more detail later.\u00a0 These are not necessarily in chronological order or of importance.<\/p>\n

The Supremes Rock & Rule!<\/b>
\nWe were presented with two back-to-back major decisions by the U.S. Supreme Court. The first, King v. Burwell<\/a>, allows federal subsidies of health insurance premiums for low income individuals and their families to continue even if their insurance was purchased in states that chose to allow the federal government to operate their health insurance exchanges.\u00a0 The lawsuit brought by Obama\/Obamacare-haters to limit premium support to insured individuals in states like Kentucky that chose to operate their own exchanges would have essentially gutted the Affordable Care Act (ACA) and tossed millions back into the uninsured category. For the time being, Obamacare stands intact for at least the next year and a half, despite promises by opponents to throw up additional challenges. All our legislators should be working together to deal with a major remaining deficiency of the ACA.\u00a0 The Act has been very successful in decreasing the number of uninsured people, but it makes little headway against the exploding costs of unnecessary, marginally effective, or for that matter even necessary medical care.\u00a0 Continuing to forbid the federal government to negotiate over the prices of drugs is a case in point. Subsidies were deemed necessary for a reason!<\/p>\n

Love Wins!<\/b> (The eponymous lawsuit and commitment both.)
\nThe second Supreme Court decision in Obergefell v. Hodges<\/a>, announced only last Friday, not only requires all states to recognize legal same-sex marriages performed in other states, but now requires all states to provide civil marriage licenses of their own to same-sex marriage applicants!\u00a0 The practical result of this decision is that in all state and federal law, the benefits and responsibilities of marriages are identical, regardless of the sex of the marriage partners. Arguments that marriages are essential to promote the breeding of human livestock, or are ordained and allowable only for people who believe in God were dismissed.<\/p>\n

True, true, and related.
\n<\/b>The two decisions mentioned above are not entirely independent of each other.\u00a0 It has recently been demonstrated that after\u00a0same-sex marriage became\u00a0legal in New York, that a substantial number of the partners and their children rose\u00a0from the ranks of the medically uninsured.\u00a0 This occurs chiefly because employers may no longer discriminate and must offer identical individual and family benefits to all their employees.\u00a0 It will be interesting to see how this plays out in Kentucky where in the past such differential treatment of employee families was a fact of life.\u00a0 Additionally for the healthcare industry, the oft-complained-of situation where a same-sex spouse is excluded from communication or denied other privileges enjoyed by a married partner of a patient should entirely disappear. Should examples of the disparities described above continue to occur, I hope someone will contact me.<\/p>\n

Sad commentary to the above<\/b>.<\/b>
\nThe prominent loss of respectful good will among elected officials of the two main political parties appears to have bled over to the Supreme Court. In my opinion, the language of the dissents in the cases above, especially that of Justice Scalia, moves from disagreement through snarky to frankly nasty. Parallel polarization is probably to be expected given the intensely political process used to nominate and approve the Court\u2019s justices.\u00a0 Public confidence in the decisions of the Court has become contaminated by our appetite for the blood sport of politics.<\/p>\n

Prescription drug abuse in Southern Indiana<\/b>.<\/b>
\nThe Courier-Journal reported arrests<\/a> of out-of-state unauthorized traveling salespeople of the restricted narcotic painkiller Opana\u2014 a drug of choice in the troubled communities<\/a> of Scott County and southern Indiana where illegal drug use, HIV, and hepatitis-C have become epidemic. Opana and Opana ER (Extended Release) are brand names of oxymorphone HCL. The arrest stimulated me to look in the Part-D Medicare prescription drug database to see where Opana was being prescribed locally to Medicare beneficiaries and perhaps through them to the profitable secondary market.<\/p>\n

The results were both of interest and potentially troubling. Of all the 72 cities and towns of Indiana in which Opana was prescribed in 2013, only in Fort Wayne and Indianapolis were more prescriptions written than in New Albany or Seymour which were numbers 3 and 4 in the list.\u00a0 Jeffersonville was number 8.\u00a0 It is clear that there are plenty of Opana ER pills available within the state. (Table of top 30 cities here.<\/a>)<\/p>\n

Some other stunning outliers are present.\u00a0 For example, among the 206 Indiana providers who prescribe Opana ER to more than 10 patients, the average number of prescriptions written per provider is 35 and the median is only 20.\u00a0 Striking then is the observation that 15 providers prescribed more than 100 times each\u2013 the highest being 265 prescriptions by a single provider.\u00a0 I continue to be perplexed by the overall observation that nurse practitioners and physician assistants as groups prescribe opioids so extensively. In Indiana, the category of provider that prescribes the most Opana ER is Nurse Practitioner. \u00a0(Table of prescriptions by provider type here<\/a>.) \u00a0Of course I do not at this time conclude that anything improper is going on, but I do think that some entity needs to take a look. “Pill mills” have been known to use the provider numbers of nurses in the past. \u00a0If requested, I will present the underlying data for your review and further analysis.<\/p>\n

Medicare Fraud and Medical Kickbacks.<\/b>
\nOn June 18 and with considerable fanfare, the FBI, other law enforcement officials, and Health and Human Services announced the largest ever coordinated crackdown against Medicare fraud and the the first major action focusing on Medicare Part-D drug fraud. It involves 243 people (of which 46 were licensed healthcare professionals) and $712 million. Andrew Wolfson of the CJ pointed out that 12 of those charged<\/a> with $8 million worth of fraud were in the Western Federal Court District of Kentucky including schemes involving opioid narcotics.<\/p>\n

In an apparently separate action, the New York Times (June 25) reported that a Connecticut nurse pleaded guilty to receiving $83,000 as a kickback<\/a> for promoting the use of Subsys, a brand name for the powerful opioid-analgesic fentanyl.\u00a0 This was not the first time that Insys Therapeutics has been looked at for improper marketing of its product and no doubt will be under the microscope in the future. The nurse may have come to the attention of law enforcement because she was found to a high prescriber of Subsys although this probably happened before the Part-D database was released to the public.<\/p>\n

I looked at the current database reflecting prescriptions to Medicare patients in 2013. The nurse in question was only ranked #10 in the list of 69 providers nationally who prescribed Subsys to more than 10 patients.\u00a0 She wrote 69 prescriptions for 20 patients for a total of $239,224. Of the 9 providers prescribing Subsys more often, two were physician assistants. Our Connecticut nurse was a piker however compared to the top physician who wrote 1161 prescriptions for 258 patients for a total of $6,443,778 worth of drug.\u00a0 Notice the large amount of money in play for brand names of this drug, and Subsys is only the third most expensive per presctiption in the list of 10 different fentanyl preparations!\u00a0 I am relatively gratified to note that only a single Kentucky provider prescribed Subsys and only 17 times to more than 10 individual patients at that.\u00a0 There were none in Indiana!<\/p>\n

I predict that the publication of payment amounts to hospitals and other providers for services to Medicare patients is going to identify large numbers of other fraudulent activities and will provide the impetus for earth-shaking changes in the way healthcare is financed and indeed how healthcare itself is delivered. While there are better medical reasons to move to a single payer or similar model, having a comprehensive payment database will help weed out fraud, misuse, and waste in our extraordinarily expensive system.\u00a0 I invite my readers to look through the tables I present in these pages or the main CMS files themselves to help our system evolve for the better.\u00a0 In particular, and in the spirit of a non-judgmental examination of the payment numbers, I invite anyone to point out examples of how this important information can identify best practices.\u00a0 Otherwise CMS has done little more than provide a tool for law enforcement.<\/p>\n

UofL Board of Trustees.<\/b>
\nThe Board met earlier in the month.\u00a0 There were none of the blowups that characterized May\u2019s meeting.\u00a0 The bulk of the meeting was filled with tours, in which I participated, of several UofL and KentuckyOne Health facilities.\u00a0 At the limited formal business meetings, the main and final action-item was the official raising of student tuition for 2015-16.\u00a0 The Trustees were addressed by Catholic Health Initiatives CEO, Kevin E. Lofton.\u00a0 In his refreshingly candid presentation, Mr. Lofton confirmed some of the difficulties attendant to the working integration of the two partner institutions about which I and others have been writing.\u00a0 Of note, included in future plans include\u00a0a new “east-end ambulatory center with potential small inpatient program.” \u00a0It appeared to me that an important goal of the day\u2019s sessions was to attempt to convince the Trustees of the importance of maintaining the UofL\/KentuckyOne Health partnership.\u00a0 Conversely, in my opinion, several presenters went out of their way to assign blame for University problems to Norton Healthcare. I hope to say more about this carefully orchestrated day\u2019s activities and Mr. Lofton\u2019s presentation later.<\/p>\n

New UofL Trustees appointed.
\n<\/b>As I write this, the Governor\u2019s office has announced two new UofL Board appointments and the reappointment of a third. How these appointments effect the direction of Board action remains to be seen.\u00a0 No doubt the Governor has taken current events into consideration in making his choices.<\/p>\n

State Auditor to examine UofL Foundation and board governance.<\/b>
\nBased on requests from \u201cdozens of business and community leaders\u201d and at least one UofL Trustee, the office of state Auditor Adam Edelen will examine elements of governance related to the University of Louisville and at least one of its associated foundations, the UofL Foundation. In my opinion, such an outside examination that is truly independent is long overdue.\u00a0 The University has brought this upon itself with its secrecy and arrogant posture of non-accountability. I need to gather more facts, but it appears that this will be a management audit, and not the follow-the-money audit that I think is absolutely necessary to restore the public\u2019s confidence that has been unnecessarily squandered by this state educational institution.<\/p>\n

Is the QCCT fund defunct, or just been diverted to other uses?<\/b>
\nIn reviewing Mayor Greg Fisher\u2019s proposed Louisville Metro Budget for 2015-2016, I noticed that the amount of the city contribution for the Quality Charity Care Trust was zeroed out.<\/a> The QCCT has provided a dependable amount of state and city funding\u2013matched by Medicaid\u2013 to University Hospital in exchange for a promise to provide medical care to all indigent Jefferson County patients and a limited number of out-of-county patients. It was anticipated that with the passage of the ACA, that the number of uninsured patients would decrease and indeed that has happened. I have been informed that University Hospital is having a record low number of uninsured patients and a corresponding large increase in revenues.\u00a0 Nonetheless, a prior agreement had stipulated that at least some contribution to the QCCT by the city would occur in this last year of the state\u2019s budget biennium.<\/p>\n

I have argued that the QCCT model of public funding for indigent and financially needy patients had outlived its time<\/a>, and indeed is contrary to the interest of both the public and individual patients alike. Wondering what was going on, I called the Mayor\u2019s office where a spokesperson offered that no funding was necessary this year because University Hospital had not even used its allotment from last year, but that the Trust itself was being kept open at the request of the University so that existing funds could be expended. I have no idea what the state<\/a> is going to do.<\/p>\n

Because I think the matter of how we as a public finance and provide medical care to the most vulnerable among is important and tells a lot about us as a community, I have begun to look into the matter in more detail. I have concluded so far that the whole story is yet to be told! Indeed, the records of the Trust that used to be kept on the UofL website have not been updated in over a year\u2013 this despite a scolding by the state auditor in 2012<\/a>. In response to initial requests to the QCCT corporation, I received a copy of most recent contract<\/a> dated November, 2014.\u00a0 There have been some significant changes since the last contract in November 2012<\/a> including a promise by the city to contribute $3 million for FY 2015-16. Perhaps most interesting are clauses specifying that the University of Louisville itself will for the first time make a contribution of $5 million to the fund for FY 2014-15 and up to $5 million for FY 2015-16.\u00a0 I must assume that the University Contribution will be put up for a Federal Medicaid match as an Internal Governmental Transfer as has been the practice of the city and state in the past.\u00a0 Additionally, beginning with the contract of 2012, the new faculty private practice building is designated as an eligible recipient of QCCT money for hospital services with implications for enhanced Medicare payments.<\/p>\n

Of note, the current signatories to the QCCT contract are still the Commonwealth, the City, the University of Louisville, and University Medical Center, Inc.\u2013 the legacy manager of the hospital that now is said to manage women\u2019s and obstetric services within the University Hospital building.\u00a0 It is curious that KentuckyOne Health, the manager of the University of Louisville Hospital and provider of the vast bulk of indigent care at University Hospital, is not a signatory to the QCCT and thus makes no promise to provide all necessary indigent care.\u00a0 I don\u2019t understand what is going on, but the current QCCT contract only adds to the mockery of the supposed clinical separation of KentuckyOne and the Center for Women and Infants. They are separate clinical entities by faith alone.<\/p>\n

I am still gathering information, but I have to ask is what is going on here?\u00a0 Whether or not matching federal dollars are involved, how is the already transferred money and future contributions being spent?\u00a0 Is the money being used for indigent patient care that we are told is no longer needed? Is even more money being bled off the hospital for commercial research or in pursuit of the stated UofL goal of harvesting more healthcare money for general University purposes. Given the inclusion of the new faculty practice building as an entity eligible to receive QCCT finding, are QCCT funds being used to bail out faculty private practices still reeling from having to pay reparations for University misuse of Passport Medicaid Managed Care money? Surely the public is entitled to know. In any event it is already clear that the QCCT contract is already null and void <\/a>on the face of it.\u00a0 I will post relevant documents as I receive them. [All previous contracts<\/a> available here.] Further information as I learn it.<\/p>\n

Concern over ethics of KentuckyOne marketing of its Cyberknife<\/b>.
\nAndrew Wolfson reported (June 17) that the Ethics Committee of University of Louisville Hospital wrote to its KentuckyOne administration expressing its concern that a large banner on the walkway across Jackson St. exhorting patients to \u201cFight Cancer with 5 or Fewer Treatments\u201d was misleading and requested that it be removed.\u00a0 Reporter Wolfson collected statements<\/a> from respected outside experts in both medical ethics and radiation therapy that agreed with the Committee.\u00a0 The Hospital declined to remove the promotion.<\/p>\n

This is in my opinion an exceedingly important matter.\u00a0 It was the Hospital Ethics Committee and not the University Research Committee that stood up to KentuckyOne when the hospital requested that existing standard language in patient informed-consent forms<\/a> for clinical research that mentioned contraception and termination of pregnancy be removed. For that and other reasons I have great respect for the hospital Ethics Committee. I was troubled too when I saw the Cyberknife advertisement.<\/p>\n

There are many facets of this story that deserve public airing and discussion.\u00a0 Where is the line past which medical marketing should not cross?\u00a0 In matters of public\/private partnerships such as the Cyberknife, what degree of even potential conflict of interest should be disclosed publicly?\u00a0 To my knowledge, and despite my attempts to find out, the initial and current investors in the Cyberknife have not been fully disclosed. In my opinion, especially given the discrepancy between declarations by the the hospital and clinical department offering the Cyberknife service, and the comments of credible outside observers, KentuckyOne must fully disclose the ownership history of this complicated financial entity in order to rapidly dispel accumulating clouds of concern. Surely both the public and potential patients must not be allowed to wonder even for a moment or in error that clinical recommendations are being colored by pressures from\u00a0outside investors.<\/p>\n

Also in order is comparative information about the composition, practices, and independence of our local hospitals\u2019 ethics committees. What should such committees consider?\u00a0 Are they or should they be limited in any way about what medical issues they may consider?\u00a0 Who do they report to?\u00a0 What entity has final say or veto over their decisions?\u00a0 What part of the committee\u2019s work, if any, should be influenced by specific religious doctrine?\u00a0 Given that all our local hospitals are part of hospital systems, what is or should be the role or permissible influence of corporate management on individual hospitals? \u00a0 I plan to elaborate on the known history of the Cyberknife at UofL and the important issues raised in a future article.<\/p>\n

Not short.<\/strong>
\nWell, I hit 3000 words again, but at least the individual topics addressed were several. Let me know which you think among these I should address in greater detail sooner, or for that matter, what have I left out.\u00a0 Help me correct any errors.<\/p>\n

Peter Hasselbacher, MD
\nPresident, KHPI
\nEmeritus Professor of Medicine, UofL
\nJune 28, 2015<\/p>\n

Share this:<\/h3>