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Physician compensation continues to climb amid postpandemic change
In addition, gender-based pay disparity among primary care physicians shrank, and the number of physicians who declined to take new Medicare patients rose.
The annual report is based on a survey of more than 10,000 physicians in over 29 specialties who answered questions about their income, workload, challenges, and level of satisfaction.
Average compensation across specialties rose to $352,000 – up nearly 17% from the 2018 average of $299,000. Fallout from the COVID-19 public health emergency continued to affect both physician compensation and job satisfaction, including Medicare reimbursements and staffing shortages due to burnout or retirement.
“Many physicians reevaluated what drove them to be a physician,” says Marc Adam, a recruiter at MASC Medical, a Florida physician recruiting firm.
Adam cites telehealth as an example. “An overwhelming majority of physicians prefer telehealth because of the convenience, but some really did not want to do it long term. They miss the patient interaction.”
The report also revealed that the gender-based pay gap in primary physicians fell, with men earning 19% more – down from 25% more in recent years. Among specialists, the gender gap was 27% on average, down from 31% last year. One reason may be an increase in compensation transparency, which Mr. Adam says should be the norm.
Income increases will likely continue, owing in large part to the growing disparity between physician supply and demand.
The projected physician shortage is expected to grow to 124,000 by 2034, according to the American Association of Medical Colleges. Federal lawmakers are considering passing the Resident Physician Shortage Reduction Act of 2023, which would add 14,000 Medicare-funded residency positions to help alleviate shortages.
Patient needs, Medicare rules continue to shift
Specialties with the biggest increases in compensation include oncology, anesthesiology, gastroenterology, radiology, critical care, and urology. Many procedure-related specialties saw more volume post pandemic.
Some respondents identified Medicare cuts and low reimbursement rates as a factor in tamping down compensation hikes. The number of physicians who expect to continue to take new Medicare patients is 65%, down from 71% 5 years ago.
For example, Medicare reimbursements for telehealth are expected to scale down in May, when the COVID-19 Public Health Emergency, which expanded telehealth services for Medicare patients, winds down.
“Telehealth will still exist,” says Mr. Adam, “but certain requirements will shape it going forward.”
Medicare isn’t viewed negatively across the board, however. Florida is among the top-earning states for physicians – along with Indiana, Connecticut, and Missouri. One reason is Florida’s unique health care environment, explains Mr. Adam, whose Florida-based firm places physicians nationwide.
“Florida is very progressive in terms of health care. For one thing, we have a large aging population and a large Medicare population.” Several growing organizations that focus on quality-based care are based in Florida, including ChenMed and Cano Health. Add to that the fact that owners of Florida’s health care organizations don’t have to be physicians, he explains, and the stage is set for experimentation.
“Being able to segment tasks frees up physicians to be more focused on medicine and provide better care while other people focus on the business and innovation.”
If Florida’s high compensation ranking continues, it may help employers there fulfill a growing need. The state is among those expected to experience the largest physician shortages in 2030, along with California, Texas, Arizona, and Georgia.
Side gigs up, satisfaction (slightly) down
In general, physicians aren’t fazed by these challenges. Many reported taking side gigs, some for additional income. Even so, 73% say they would still choose medicine, and more than 90% of physicians in 10 specialties would choose their specialty again. Still, burnout and stressors have led some to stop practicing altogether.
More and more organizations are hiring “travel physicians,” Mr. Adam says, and more physicians are choosing to take contract work (“locum tenens”) and practice in many different regions. Contract physicians typically help meet patient demand or provide coverage during the hiring process as well as while staff are on vacation or maternity leave.
Says Mr. Adam, “There’s no security, but there’s higher income and more flexibility.”
According to CHG Healthcare, locum tenens staffing is rising – approximately 7% of U.S. physicians (around 50,000) filled assignments in 2022, up 88% from 2015. In 2022, 56% of locum tenens employers reported a reduction in staff burnout, up from 30% in 2020.
The report indicates that more than half of physicians are satisfied with their income, down slightly from 55% 5 years ago (prepandemic). Physicians in some of the lower-paying specialties are among those most satisfied with their income. It’s not very surprising to Mr. Adam: “Higher earners generally suffer the most from burnout.
“They’re overworked, they have the largest number of patients, and they’re performing in high-stress situations doing challenging procedures on a daily basis – and they probably have worse work-life balance.” These physicians know going in that they need to be paid more to deal with such burdens. “That’s the feedback I get when I speak to high earners,” says Mr. Adam.
“The experienced ones are very clear about their [compensation] expectations.”
A version of this article first appeared on Medscape.com.
In addition, gender-based pay disparity among primary care physicians shrank, and the number of physicians who declined to take new Medicare patients rose.
The annual report is based on a survey of more than 10,000 physicians in over 29 specialties who answered questions about their income, workload, challenges, and level of satisfaction.
Average compensation across specialties rose to $352,000 – up nearly 17% from the 2018 average of $299,000. Fallout from the COVID-19 public health emergency continued to affect both physician compensation and job satisfaction, including Medicare reimbursements and staffing shortages due to burnout or retirement.
“Many physicians reevaluated what drove them to be a physician,” says Marc Adam, a recruiter at MASC Medical, a Florida physician recruiting firm.
Adam cites telehealth as an example. “An overwhelming majority of physicians prefer telehealth because of the convenience, but some really did not want to do it long term. They miss the patient interaction.”
The report also revealed that the gender-based pay gap in primary physicians fell, with men earning 19% more – down from 25% more in recent years. Among specialists, the gender gap was 27% on average, down from 31% last year. One reason may be an increase in compensation transparency, which Mr. Adam says should be the norm.
Income increases will likely continue, owing in large part to the growing disparity between physician supply and demand.
The projected physician shortage is expected to grow to 124,000 by 2034, according to the American Association of Medical Colleges. Federal lawmakers are considering passing the Resident Physician Shortage Reduction Act of 2023, which would add 14,000 Medicare-funded residency positions to help alleviate shortages.
Patient needs, Medicare rules continue to shift
Specialties with the biggest increases in compensation include oncology, anesthesiology, gastroenterology, radiology, critical care, and urology. Many procedure-related specialties saw more volume post pandemic.
Some respondents identified Medicare cuts and low reimbursement rates as a factor in tamping down compensation hikes. The number of physicians who expect to continue to take new Medicare patients is 65%, down from 71% 5 years ago.
For example, Medicare reimbursements for telehealth are expected to scale down in May, when the COVID-19 Public Health Emergency, which expanded telehealth services for Medicare patients, winds down.
“Telehealth will still exist,” says Mr. Adam, “but certain requirements will shape it going forward.”
Medicare isn’t viewed negatively across the board, however. Florida is among the top-earning states for physicians – along with Indiana, Connecticut, and Missouri. One reason is Florida’s unique health care environment, explains Mr. Adam, whose Florida-based firm places physicians nationwide.
“Florida is very progressive in terms of health care. For one thing, we have a large aging population and a large Medicare population.” Several growing organizations that focus on quality-based care are based in Florida, including ChenMed and Cano Health. Add to that the fact that owners of Florida’s health care organizations don’t have to be physicians, he explains, and the stage is set for experimentation.
“Being able to segment tasks frees up physicians to be more focused on medicine and provide better care while other people focus on the business and innovation.”
If Florida’s high compensation ranking continues, it may help employers there fulfill a growing need. The state is among those expected to experience the largest physician shortages in 2030, along with California, Texas, Arizona, and Georgia.
Side gigs up, satisfaction (slightly) down
In general, physicians aren’t fazed by these challenges. Many reported taking side gigs, some for additional income. Even so, 73% say they would still choose medicine, and more than 90% of physicians in 10 specialties would choose their specialty again. Still, burnout and stressors have led some to stop practicing altogether.
More and more organizations are hiring “travel physicians,” Mr. Adam says, and more physicians are choosing to take contract work (“locum tenens”) and practice in many different regions. Contract physicians typically help meet patient demand or provide coverage during the hiring process as well as while staff are on vacation or maternity leave.
Says Mr. Adam, “There’s no security, but there’s higher income and more flexibility.”
According to CHG Healthcare, locum tenens staffing is rising – approximately 7% of U.S. physicians (around 50,000) filled assignments in 2022, up 88% from 2015. In 2022, 56% of locum tenens employers reported a reduction in staff burnout, up from 30% in 2020.
The report indicates that more than half of physicians are satisfied with their income, down slightly from 55% 5 years ago (prepandemic). Physicians in some of the lower-paying specialties are among those most satisfied with their income. It’s not very surprising to Mr. Adam: “Higher earners generally suffer the most from burnout.
“They’re overworked, they have the largest number of patients, and they’re performing in high-stress situations doing challenging procedures on a daily basis – and they probably have worse work-life balance.” These physicians know going in that they need to be paid more to deal with such burdens. “That’s the feedback I get when I speak to high earners,” says Mr. Adam.
“The experienced ones are very clear about their [compensation] expectations.”
A version of this article first appeared on Medscape.com.
In addition, gender-based pay disparity among primary care physicians shrank, and the number of physicians who declined to take new Medicare patients rose.
The annual report is based on a survey of more than 10,000 physicians in over 29 specialties who answered questions about their income, workload, challenges, and level of satisfaction.
Average compensation across specialties rose to $352,000 – up nearly 17% from the 2018 average of $299,000. Fallout from the COVID-19 public health emergency continued to affect both physician compensation and job satisfaction, including Medicare reimbursements and staffing shortages due to burnout or retirement.
“Many physicians reevaluated what drove them to be a physician,” says Marc Adam, a recruiter at MASC Medical, a Florida physician recruiting firm.
Adam cites telehealth as an example. “An overwhelming majority of physicians prefer telehealth because of the convenience, but some really did not want to do it long term. They miss the patient interaction.”
The report also revealed that the gender-based pay gap in primary physicians fell, with men earning 19% more – down from 25% more in recent years. Among specialists, the gender gap was 27% on average, down from 31% last year. One reason may be an increase in compensation transparency, which Mr. Adam says should be the norm.
Income increases will likely continue, owing in large part to the growing disparity between physician supply and demand.
The projected physician shortage is expected to grow to 124,000 by 2034, according to the American Association of Medical Colleges. Federal lawmakers are considering passing the Resident Physician Shortage Reduction Act of 2023, which would add 14,000 Medicare-funded residency positions to help alleviate shortages.
Patient needs, Medicare rules continue to shift
Specialties with the biggest increases in compensation include oncology, anesthesiology, gastroenterology, radiology, critical care, and urology. Many procedure-related specialties saw more volume post pandemic.
Some respondents identified Medicare cuts and low reimbursement rates as a factor in tamping down compensation hikes. The number of physicians who expect to continue to take new Medicare patients is 65%, down from 71% 5 years ago.
For example, Medicare reimbursements for telehealth are expected to scale down in May, when the COVID-19 Public Health Emergency, which expanded telehealth services for Medicare patients, winds down.
“Telehealth will still exist,” says Mr. Adam, “but certain requirements will shape it going forward.”
Medicare isn’t viewed negatively across the board, however. Florida is among the top-earning states for physicians – along with Indiana, Connecticut, and Missouri. One reason is Florida’s unique health care environment, explains Mr. Adam, whose Florida-based firm places physicians nationwide.
“Florida is very progressive in terms of health care. For one thing, we have a large aging population and a large Medicare population.” Several growing organizations that focus on quality-based care are based in Florida, including ChenMed and Cano Health. Add to that the fact that owners of Florida’s health care organizations don’t have to be physicians, he explains, and the stage is set for experimentation.
“Being able to segment tasks frees up physicians to be more focused on medicine and provide better care while other people focus on the business and innovation.”
If Florida’s high compensation ranking continues, it may help employers there fulfill a growing need. The state is among those expected to experience the largest physician shortages in 2030, along with California, Texas, Arizona, and Georgia.
Side gigs up, satisfaction (slightly) down
In general, physicians aren’t fazed by these challenges. Many reported taking side gigs, some for additional income. Even so, 73% say they would still choose medicine, and more than 90% of physicians in 10 specialties would choose their specialty again. Still, burnout and stressors have led some to stop practicing altogether.
More and more organizations are hiring “travel physicians,” Mr. Adam says, and more physicians are choosing to take contract work (“locum tenens”) and practice in many different regions. Contract physicians typically help meet patient demand or provide coverage during the hiring process as well as while staff are on vacation or maternity leave.
Says Mr. Adam, “There’s no security, but there’s higher income and more flexibility.”
According to CHG Healthcare, locum tenens staffing is rising – approximately 7% of U.S. physicians (around 50,000) filled assignments in 2022, up 88% from 2015. In 2022, 56% of locum tenens employers reported a reduction in staff burnout, up from 30% in 2020.
The report indicates that more than half of physicians are satisfied with their income, down slightly from 55% 5 years ago (prepandemic). Physicians in some of the lower-paying specialties are among those most satisfied with their income. It’s not very surprising to Mr. Adam: “Higher earners generally suffer the most from burnout.
“They’re overworked, they have the largest number of patients, and they’re performing in high-stress situations doing challenging procedures on a daily basis – and they probably have worse work-life balance.” These physicians know going in that they need to be paid more to deal with such burdens. “That’s the feedback I get when I speak to high earners,” says Mr. Adam.
“The experienced ones are very clear about their [compensation] expectations.”
A version of this article first appeared on Medscape.com.
Get action! – Teddy Roosevelt
“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!
No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.
Yes, for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”
Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.
Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”
Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.
Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.
Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!
No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.
Yes, for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”
Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.
Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”
Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.
Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.
Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!
No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.
Yes, for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”
Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.
Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”
Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.
Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.
Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].
Medicare expands CGM coverage to more with type 2 diabetes
Medicare is now covering continuous glucose monitoring (CGM) for all beneficiaries with diabetes who use insulin, as well as those with a “history of problematic hypoglycemia.”
The new policy decision, announced earlier this year by the Centers for Medicare and Medicaid Services, means that coverage is expanded to those who take even just a single dose of basal insulin daily or who don’t take insulin but who for other reasons experience “problematic” hypoglycemia, defined as a history of more than one level 2 event (glucose < 54 mg/dL) or at least one level 3 event (< 54 mg/dL requiring assistance).
Previously, coverage was limited to those taking frequent daily insulin doses.
The additional number of people covered, most with type 2 diabetes, is estimated to be at least 1.5 million. That number could more than double if private insurers follow suit, reported an industry analyst.
Chuck Henderson, chief executive officer of the American Diabetes Association, said in a statement: “We applaud CMS’ decision allowing for all insulin-dependent people as well as others who have a history of problematic hypoglycemia to have access to a continuous glucose monitor, a potentially life-saving tool for diabetes management.”
According to Dexcom, which manufacturers the G6 and the recently approved G7 CGMs, the decision was based in part on their MOBILE study. The trial demonstrated the benefit of CGM in people with type 2 diabetes who use only basal insulin or have a history of problematic hypoglycemic events.
On April 14, Abbott, which manufactures the Freestyle Libre 2 and the recently approved Libre 3, received clearance from the U.S. Food and Drug Administration for the Libre 3’s stand-alone reader device. Previously, the Libre 3 had been approved for use only with a smartphone app. The small handheld reader is considered durable medical equipment, making it eligible for Medicare coverage. Abbott is “working on having the FreeStyle Libre 3 system available to Medicare beneficiaries,” the company said in a statement.
A version of this article first appeared on Medscape.com.
Medicare is now covering continuous glucose monitoring (CGM) for all beneficiaries with diabetes who use insulin, as well as those with a “history of problematic hypoglycemia.”
The new policy decision, announced earlier this year by the Centers for Medicare and Medicaid Services, means that coverage is expanded to those who take even just a single dose of basal insulin daily or who don’t take insulin but who for other reasons experience “problematic” hypoglycemia, defined as a history of more than one level 2 event (glucose < 54 mg/dL) or at least one level 3 event (< 54 mg/dL requiring assistance).
Previously, coverage was limited to those taking frequent daily insulin doses.
The additional number of people covered, most with type 2 diabetes, is estimated to be at least 1.5 million. That number could more than double if private insurers follow suit, reported an industry analyst.
Chuck Henderson, chief executive officer of the American Diabetes Association, said in a statement: “We applaud CMS’ decision allowing for all insulin-dependent people as well as others who have a history of problematic hypoglycemia to have access to a continuous glucose monitor, a potentially life-saving tool for diabetes management.”
According to Dexcom, which manufacturers the G6 and the recently approved G7 CGMs, the decision was based in part on their MOBILE study. The trial demonstrated the benefit of CGM in people with type 2 diabetes who use only basal insulin or have a history of problematic hypoglycemic events.
On April 14, Abbott, which manufactures the Freestyle Libre 2 and the recently approved Libre 3, received clearance from the U.S. Food and Drug Administration for the Libre 3’s stand-alone reader device. Previously, the Libre 3 had been approved for use only with a smartphone app. The small handheld reader is considered durable medical equipment, making it eligible for Medicare coverage. Abbott is “working on having the FreeStyle Libre 3 system available to Medicare beneficiaries,” the company said in a statement.
A version of this article first appeared on Medscape.com.
Medicare is now covering continuous glucose monitoring (CGM) for all beneficiaries with diabetes who use insulin, as well as those with a “history of problematic hypoglycemia.”
The new policy decision, announced earlier this year by the Centers for Medicare and Medicaid Services, means that coverage is expanded to those who take even just a single dose of basal insulin daily or who don’t take insulin but who for other reasons experience “problematic” hypoglycemia, defined as a history of more than one level 2 event (glucose < 54 mg/dL) or at least one level 3 event (< 54 mg/dL requiring assistance).
Previously, coverage was limited to those taking frequent daily insulin doses.
The additional number of people covered, most with type 2 diabetes, is estimated to be at least 1.5 million. That number could more than double if private insurers follow suit, reported an industry analyst.
Chuck Henderson, chief executive officer of the American Diabetes Association, said in a statement: “We applaud CMS’ decision allowing for all insulin-dependent people as well as others who have a history of problematic hypoglycemia to have access to a continuous glucose monitor, a potentially life-saving tool for diabetes management.”
According to Dexcom, which manufacturers the G6 and the recently approved G7 CGMs, the decision was based in part on their MOBILE study. The trial demonstrated the benefit of CGM in people with type 2 diabetes who use only basal insulin or have a history of problematic hypoglycemic events.
On April 14, Abbott, which manufactures the Freestyle Libre 2 and the recently approved Libre 3, received clearance from the U.S. Food and Drug Administration for the Libre 3’s stand-alone reader device. Previously, the Libre 3 had been approved for use only with a smartphone app. The small handheld reader is considered durable medical equipment, making it eligible for Medicare coverage. Abbott is “working on having the FreeStyle Libre 3 system available to Medicare beneficiaries,” the company said in a statement.
A version of this article first appeared on Medscape.com.
ChatGPT as a tool in the ob.gyn. office
Artificial intelligence (AI) has recently gained significant public attention, primarily driven by the launch of a noteworthy program by OpenAI called Chat Generative Pre-trained Transformer (ChatGPT). This large language model is an AI system that enables users to interact with it using plain language. In just the first 2 months since its release, over 100 million subscribers have registered to use ChatGPT.
AI is now deeply integrated into our daily lives, pervading a wide array of smart devices such as phones, tablets, and numerous other gadgets that we rely on every day. These sophisticated technologies operate seamlessly in the background, often without us being consciously aware of their presence. Nevertheless, we greatly appreciate the way they enhance our lives by simplifying tasks and streamlining our routines.
A key factor contributing to ChatGPT’s popularity is its ability to accept input in the form of prompts in plain English. Our team published a comprehensive journal article showcasing examples of how this technology can be utilized by general ob.gyn. practitioners. ChatGPT has the potential to streamline work flow, generate letters to insurance companies, draft clinical plans, and assist with various other routine tasks in any ob.gyn. practice environment.
As with any new technology, it is essential for users to familiarize themselves with its capabilities and understand its limitations. A critical aspect to consider with the current version of ChatGPT is that it was developed using information primarily sourced from the Internet up until September 2021. This limitation is especially significant in the field of medicine, where practitioners consistently seek the most up-to-date and current information to inform their decisions.
However, it is expected that, in the near future, these programs will gain access to real-time information from a diverse range of sources, including but not limited to the Internet. This development will enhance the program’s utility and relevance in medical contexts.
Another limitation of ChatGPT is its propensity to “hallucinate.” Large language models are trained to respond to the best of their abilities, occasionally attempting to fill knowledge gaps with fabricated information. Being aware of these limitations enables users to recognize the program’s potential while also understanding the need for careful monitoring.
Our expertise and clinical knowledge are crucial in guiding and refining this technology, ensuring that it serves as a valuable tool in the ever-evolving landscape of medicine.
Another crucial factor to consider is that users must adhere to all guidelines and policies established within their work environment. This entails complying with HIPAA regulations and ensuring that any information generated by these programs is thoroughly examined before being integrated into practice work flows. As an increasing number of organizations develop specific guidelines for such technologies, the aim is to safeguard patients, users, and the organization itself. The individuals utilizing these technologies must exercise utmost caution and refrain from storing or sharing any sensitive or proprietary information.
The aim of this article is not to provide an exhaustive overview, but rather to offer a selection of examples and inspire readers to consider adopting these programs. By doing so, we hope to facilitate the exploration of innovative approaches that can improve the practice of ob.gyn.
The first example illustrates a common scenario that we frequently encounter – the situation in which an insurance company denies coverage for specific care or treatment for a patient. In fact, this was one of the first examples that was demonstrated by others on social media as a possible benefit for this technology. It effectively demonstrated the ability to save time and surmount the challenges of writer’s block that we occasionally encounter.
Prompt input:
“Write a letter to the insurance company who is denying cervical length surveillance for a patient with a short cervix and add references.”
ChatGPT response:
[Your Name]
[Your Address]
[City, State, Zip Code]
[Date]
[Insurance Company Name]
[Claims Department]
[Insurance Company Address]
[City, State, Zip Code]
Re: Request for Reconsideration – Cervical Length Surveillance
Policy Number: [Policy Number]
Insured: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Claim Number: [Claim Number]
Date of Service: [Date of Service]
Dear Claims Reviewer,
I am writing to request a reconsideration of the denial for cervical length surveillance for my patient, [Patient’s Name], who has been diagnosed with a short cervix. As a healthcare provider, I strongly believe that this is a medically necessary service for the patient in order to prevent preterm birth and its associated complications.
A short cervix is a well-established risk factor for preterm birth, and numerous studies have shown the efficacy of cervical length surveillance in the prevention and management of preterm birth. I kindly request that you reconsider the coverage for this essential service and refer to the following authoritative sources:
Berghella, V., & Saccone, G. (2019). Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews, 2019(7). doi:10.1002/14651858.CD004843.pub3
American College of Obstetricians and Gynecologists (2016). Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology, 128(4), e155-e164. doi:10.1097/AOG.0000000000001711
Society for Maternal-Fetal Medicine (SMFM), McIntosh, J., Feltovich, H., Berghella, V., & Manuck, T. (2016). The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. American Journal of Obstetrics & Gynecology, 215(3), B2-B7. doi:10.1016/j.ajog.2016.03.015
By denying coverage for cervical length surveillance, the insurance company is putting [Patient’s Name] at an increased risk for preterm birth and the numerous health complications that can accompany it, both for the mother and the infant. It is crucial to provide this service in order to improve health outcomes and reduce the risk of costly neonatal intensive care unit (NICU) admissions and long-term medical issues.
I kindly request that you review this case with the provided references and reconsider the coverage for cervical length surveillance for [Patient’s Name]. Thank you for your attention to this matter. Please feel free to contact me if you require any further information or clarification.
Sincerely,
[Your Name]
[Your Title]
[Your Phone Number]
[Your Email Address]
The document took less than 15 seconds to generate, it is well written and concise, and can also be utilized as a template for future use. But as mentioned above, it is important to confirm all the information within the document. For example, references 1 and 3 in the ChatGPT-generated letter above include document objective identifiers that do not correctly correspond to the reference.
Other uses that the reader might consider: patient education, helping to answer a patient question utilizing appropriate grade-level language, dietary plans for a patient - the potential list is endless. Another key aspect of utilizing these types of programs is understanding how to effectively ask a question. This involves providing ample detail about the inquiry you wish to have answered by the program. With some practice and review of guidance on how to do this from the Internet, one can become highly proficient at crafting questions and generating relevant responses. But as mentioned above, it is important to keep in mind that all information generated by this program needs to be vetted prior to utilization.
This groundbreaking technology is not only here to stay but will continue to become increasingly pervasive. It is already being integrated into conventional search engines such as Google and Bing. Microsoft has ambitious plans to incorporate this innovation into its entire suite of Office products. Just imagine working on a document and seeking assistance for editing or rephrasing, effortlessly searching your inbox for all emails containing a specific phrase or topic, or even crafting a PowerPoint presentation for a lecture while receiving help with both content and formatting. These scenarios offer just a glimpse of how AI programs can significantly assist and enhance our workflow.
I also anticipate that our patients will increasingly adopt this type of technology to generate customized lists of questions tailored to their specific medical conditions, which they can then ask their health care providers. Often, our patients express uncertainty about the appropriate questions to ask during a particular visit. Now envision a scenario in which they can effortlessly obtain a comprehensive list of relevant questions, specifically designed for their office consultation. This would empower them to engage more actively in their health care and enhance communication with their clinical team.
I highly recommend that readers explore and experiment with these programs. By doing so, we can provide valuable assistance and guidance not only within our specific medical specialties but also for our patients. In this way, we can effectively harness the power of technology to improve patient care and optimize our office work flow, ultimately benefiting both our patients and our practices.
Dr. Chavez is professor, department of obstetrics and gynecology, at NYU Long Island School of Medicine and director of maternal and fetal medicine at NYU Langone Hospital–Long Island, both in Mineola, N.Y. He has no disclosures.
Artificial intelligence (AI) has recently gained significant public attention, primarily driven by the launch of a noteworthy program by OpenAI called Chat Generative Pre-trained Transformer (ChatGPT). This large language model is an AI system that enables users to interact with it using plain language. In just the first 2 months since its release, over 100 million subscribers have registered to use ChatGPT.
AI is now deeply integrated into our daily lives, pervading a wide array of smart devices such as phones, tablets, and numerous other gadgets that we rely on every day. These sophisticated technologies operate seamlessly in the background, often without us being consciously aware of their presence. Nevertheless, we greatly appreciate the way they enhance our lives by simplifying tasks and streamlining our routines.
A key factor contributing to ChatGPT’s popularity is its ability to accept input in the form of prompts in plain English. Our team published a comprehensive journal article showcasing examples of how this technology can be utilized by general ob.gyn. practitioners. ChatGPT has the potential to streamline work flow, generate letters to insurance companies, draft clinical plans, and assist with various other routine tasks in any ob.gyn. practice environment.
As with any new technology, it is essential for users to familiarize themselves with its capabilities and understand its limitations. A critical aspect to consider with the current version of ChatGPT is that it was developed using information primarily sourced from the Internet up until September 2021. This limitation is especially significant in the field of medicine, where practitioners consistently seek the most up-to-date and current information to inform their decisions.
However, it is expected that, in the near future, these programs will gain access to real-time information from a diverse range of sources, including but not limited to the Internet. This development will enhance the program’s utility and relevance in medical contexts.
Another limitation of ChatGPT is its propensity to “hallucinate.” Large language models are trained to respond to the best of their abilities, occasionally attempting to fill knowledge gaps with fabricated information. Being aware of these limitations enables users to recognize the program’s potential while also understanding the need for careful monitoring.
Our expertise and clinical knowledge are crucial in guiding and refining this technology, ensuring that it serves as a valuable tool in the ever-evolving landscape of medicine.
Another crucial factor to consider is that users must adhere to all guidelines and policies established within their work environment. This entails complying with HIPAA regulations and ensuring that any information generated by these programs is thoroughly examined before being integrated into practice work flows. As an increasing number of organizations develop specific guidelines for such technologies, the aim is to safeguard patients, users, and the organization itself. The individuals utilizing these technologies must exercise utmost caution and refrain from storing or sharing any sensitive or proprietary information.
The aim of this article is not to provide an exhaustive overview, but rather to offer a selection of examples and inspire readers to consider adopting these programs. By doing so, we hope to facilitate the exploration of innovative approaches that can improve the practice of ob.gyn.
The first example illustrates a common scenario that we frequently encounter – the situation in which an insurance company denies coverage for specific care or treatment for a patient. In fact, this was one of the first examples that was demonstrated by others on social media as a possible benefit for this technology. It effectively demonstrated the ability to save time and surmount the challenges of writer’s block that we occasionally encounter.
Prompt input:
“Write a letter to the insurance company who is denying cervical length surveillance for a patient with a short cervix and add references.”
ChatGPT response:
[Your Name]
[Your Address]
[City, State, Zip Code]
[Date]
[Insurance Company Name]
[Claims Department]
[Insurance Company Address]
[City, State, Zip Code]
Re: Request for Reconsideration – Cervical Length Surveillance
Policy Number: [Policy Number]
Insured: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Claim Number: [Claim Number]
Date of Service: [Date of Service]
Dear Claims Reviewer,
I am writing to request a reconsideration of the denial for cervical length surveillance for my patient, [Patient’s Name], who has been diagnosed with a short cervix. As a healthcare provider, I strongly believe that this is a medically necessary service for the patient in order to prevent preterm birth and its associated complications.
A short cervix is a well-established risk factor for preterm birth, and numerous studies have shown the efficacy of cervical length surveillance in the prevention and management of preterm birth. I kindly request that you reconsider the coverage for this essential service and refer to the following authoritative sources:
Berghella, V., & Saccone, G. (2019). Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews, 2019(7). doi:10.1002/14651858.CD004843.pub3
American College of Obstetricians and Gynecologists (2016). Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology, 128(4), e155-e164. doi:10.1097/AOG.0000000000001711
Society for Maternal-Fetal Medicine (SMFM), McIntosh, J., Feltovich, H., Berghella, V., & Manuck, T. (2016). The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. American Journal of Obstetrics & Gynecology, 215(3), B2-B7. doi:10.1016/j.ajog.2016.03.015
By denying coverage for cervical length surveillance, the insurance company is putting [Patient’s Name] at an increased risk for preterm birth and the numerous health complications that can accompany it, both for the mother and the infant. It is crucial to provide this service in order to improve health outcomes and reduce the risk of costly neonatal intensive care unit (NICU) admissions and long-term medical issues.
I kindly request that you review this case with the provided references and reconsider the coverage for cervical length surveillance for [Patient’s Name]. Thank you for your attention to this matter. Please feel free to contact me if you require any further information or clarification.
Sincerely,
[Your Name]
[Your Title]
[Your Phone Number]
[Your Email Address]
The document took less than 15 seconds to generate, it is well written and concise, and can also be utilized as a template for future use. But as mentioned above, it is important to confirm all the information within the document. For example, references 1 and 3 in the ChatGPT-generated letter above include document objective identifiers that do not correctly correspond to the reference.
Other uses that the reader might consider: patient education, helping to answer a patient question utilizing appropriate grade-level language, dietary plans for a patient - the potential list is endless. Another key aspect of utilizing these types of programs is understanding how to effectively ask a question. This involves providing ample detail about the inquiry you wish to have answered by the program. With some practice and review of guidance on how to do this from the Internet, one can become highly proficient at crafting questions and generating relevant responses. But as mentioned above, it is important to keep in mind that all information generated by this program needs to be vetted prior to utilization.
This groundbreaking technology is not only here to stay but will continue to become increasingly pervasive. It is already being integrated into conventional search engines such as Google and Bing. Microsoft has ambitious plans to incorporate this innovation into its entire suite of Office products. Just imagine working on a document and seeking assistance for editing or rephrasing, effortlessly searching your inbox for all emails containing a specific phrase or topic, or even crafting a PowerPoint presentation for a lecture while receiving help with both content and formatting. These scenarios offer just a glimpse of how AI programs can significantly assist and enhance our workflow.
I also anticipate that our patients will increasingly adopt this type of technology to generate customized lists of questions tailored to their specific medical conditions, which they can then ask their health care providers. Often, our patients express uncertainty about the appropriate questions to ask during a particular visit. Now envision a scenario in which they can effortlessly obtain a comprehensive list of relevant questions, specifically designed for their office consultation. This would empower them to engage more actively in their health care and enhance communication with their clinical team.
I highly recommend that readers explore and experiment with these programs. By doing so, we can provide valuable assistance and guidance not only within our specific medical specialties but also for our patients. In this way, we can effectively harness the power of technology to improve patient care and optimize our office work flow, ultimately benefiting both our patients and our practices.
Dr. Chavez is professor, department of obstetrics and gynecology, at NYU Long Island School of Medicine and director of maternal and fetal medicine at NYU Langone Hospital–Long Island, both in Mineola, N.Y. He has no disclosures.
Artificial intelligence (AI) has recently gained significant public attention, primarily driven by the launch of a noteworthy program by OpenAI called Chat Generative Pre-trained Transformer (ChatGPT). This large language model is an AI system that enables users to interact with it using plain language. In just the first 2 months since its release, over 100 million subscribers have registered to use ChatGPT.
AI is now deeply integrated into our daily lives, pervading a wide array of smart devices such as phones, tablets, and numerous other gadgets that we rely on every day. These sophisticated technologies operate seamlessly in the background, often without us being consciously aware of their presence. Nevertheless, we greatly appreciate the way they enhance our lives by simplifying tasks and streamlining our routines.
A key factor contributing to ChatGPT’s popularity is its ability to accept input in the form of prompts in plain English. Our team published a comprehensive journal article showcasing examples of how this technology can be utilized by general ob.gyn. practitioners. ChatGPT has the potential to streamline work flow, generate letters to insurance companies, draft clinical plans, and assist with various other routine tasks in any ob.gyn. practice environment.
As with any new technology, it is essential for users to familiarize themselves with its capabilities and understand its limitations. A critical aspect to consider with the current version of ChatGPT is that it was developed using information primarily sourced from the Internet up until September 2021. This limitation is especially significant in the field of medicine, where practitioners consistently seek the most up-to-date and current information to inform their decisions.
However, it is expected that, in the near future, these programs will gain access to real-time information from a diverse range of sources, including but not limited to the Internet. This development will enhance the program’s utility and relevance in medical contexts.
Another limitation of ChatGPT is its propensity to “hallucinate.” Large language models are trained to respond to the best of their abilities, occasionally attempting to fill knowledge gaps with fabricated information. Being aware of these limitations enables users to recognize the program’s potential while also understanding the need for careful monitoring.
Our expertise and clinical knowledge are crucial in guiding and refining this technology, ensuring that it serves as a valuable tool in the ever-evolving landscape of medicine.
Another crucial factor to consider is that users must adhere to all guidelines and policies established within their work environment. This entails complying with HIPAA regulations and ensuring that any information generated by these programs is thoroughly examined before being integrated into practice work flows. As an increasing number of organizations develop specific guidelines for such technologies, the aim is to safeguard patients, users, and the organization itself. The individuals utilizing these technologies must exercise utmost caution and refrain from storing or sharing any sensitive or proprietary information.
The aim of this article is not to provide an exhaustive overview, but rather to offer a selection of examples and inspire readers to consider adopting these programs. By doing so, we hope to facilitate the exploration of innovative approaches that can improve the practice of ob.gyn.
The first example illustrates a common scenario that we frequently encounter – the situation in which an insurance company denies coverage for specific care or treatment for a patient. In fact, this was one of the first examples that was demonstrated by others on social media as a possible benefit for this technology. It effectively demonstrated the ability to save time and surmount the challenges of writer’s block that we occasionally encounter.
Prompt input:
“Write a letter to the insurance company who is denying cervical length surveillance for a patient with a short cervix and add references.”
ChatGPT response:
[Your Name]
[Your Address]
[City, State, Zip Code]
[Date]
[Insurance Company Name]
[Claims Department]
[Insurance Company Address]
[City, State, Zip Code]
Re: Request for Reconsideration – Cervical Length Surveillance
Policy Number: [Policy Number]
Insured: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Claim Number: [Claim Number]
Date of Service: [Date of Service]
Dear Claims Reviewer,
I am writing to request a reconsideration of the denial for cervical length surveillance for my patient, [Patient’s Name], who has been diagnosed with a short cervix. As a healthcare provider, I strongly believe that this is a medically necessary service for the patient in order to prevent preterm birth and its associated complications.
A short cervix is a well-established risk factor for preterm birth, and numerous studies have shown the efficacy of cervical length surveillance in the prevention and management of preterm birth. I kindly request that you reconsider the coverage for this essential service and refer to the following authoritative sources:
Berghella, V., & Saccone, G. (2019). Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews, 2019(7). doi:10.1002/14651858.CD004843.pub3
American College of Obstetricians and Gynecologists (2016). Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology, 128(4), e155-e164. doi:10.1097/AOG.0000000000001711
Society for Maternal-Fetal Medicine (SMFM), McIntosh, J., Feltovich, H., Berghella, V., & Manuck, T. (2016). The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. American Journal of Obstetrics & Gynecology, 215(3), B2-B7. doi:10.1016/j.ajog.2016.03.015
By denying coverage for cervical length surveillance, the insurance company is putting [Patient’s Name] at an increased risk for preterm birth and the numerous health complications that can accompany it, both for the mother and the infant. It is crucial to provide this service in order to improve health outcomes and reduce the risk of costly neonatal intensive care unit (NICU) admissions and long-term medical issues.
I kindly request that you review this case with the provided references and reconsider the coverage for cervical length surveillance for [Patient’s Name]. Thank you for your attention to this matter. Please feel free to contact me if you require any further information or clarification.
Sincerely,
[Your Name]
[Your Title]
[Your Phone Number]
[Your Email Address]
The document took less than 15 seconds to generate, it is well written and concise, and can also be utilized as a template for future use. But as mentioned above, it is important to confirm all the information within the document. For example, references 1 and 3 in the ChatGPT-generated letter above include document objective identifiers that do not correctly correspond to the reference.
Other uses that the reader might consider: patient education, helping to answer a patient question utilizing appropriate grade-level language, dietary plans for a patient - the potential list is endless. Another key aspect of utilizing these types of programs is understanding how to effectively ask a question. This involves providing ample detail about the inquiry you wish to have answered by the program. With some practice and review of guidance on how to do this from the Internet, one can become highly proficient at crafting questions and generating relevant responses. But as mentioned above, it is important to keep in mind that all information generated by this program needs to be vetted prior to utilization.
This groundbreaking technology is not only here to stay but will continue to become increasingly pervasive. It is already being integrated into conventional search engines such as Google and Bing. Microsoft has ambitious plans to incorporate this innovation into its entire suite of Office products. Just imagine working on a document and seeking assistance for editing or rephrasing, effortlessly searching your inbox for all emails containing a specific phrase or topic, or even crafting a PowerPoint presentation for a lecture while receiving help with both content and formatting. These scenarios offer just a glimpse of how AI programs can significantly assist and enhance our workflow.
I also anticipate that our patients will increasingly adopt this type of technology to generate customized lists of questions tailored to their specific medical conditions, which they can then ask their health care providers. Often, our patients express uncertainty about the appropriate questions to ask during a particular visit. Now envision a scenario in which they can effortlessly obtain a comprehensive list of relevant questions, specifically designed for their office consultation. This would empower them to engage more actively in their health care and enhance communication with their clinical team.
I highly recommend that readers explore and experiment with these programs. By doing so, we can provide valuable assistance and guidance not only within our specific medical specialties but also for our patients. In this way, we can effectively harness the power of technology to improve patient care and optimize our office work flow, ultimately benefiting both our patients and our practices.
Dr. Chavez is professor, department of obstetrics and gynecology, at NYU Long Island School of Medicine and director of maternal and fetal medicine at NYU Langone Hospital–Long Island, both in Mineola, N.Y. He has no disclosures.
Suicidal thoughts decline in endocrinologists: Survey
Rates of suicidal thoughts and attempted suicide among endocrinologists declined from 2022 and now rank similar to the average rate among physicians overall, but these rates are still higher than the general public, according to survey findings.
The current report about suicide among endocrinologists, titled, “Doctors’ Burden: Endocrinologist Suicide Report 2023,” was recently published.
A report about suicide among physicians overall, based on the same survey, titled, “Doctors’ Burden: Medscape Physician Suicide Report 2023,” was published previously.
Improved rates among 28 medical specialties
In the 2022 survey of a representative national sample of 13,069 U.S. physicians, 10% of endocrinologists reported having suicidal thoughts, ranking the specialty sixth among 29 medical specialties that year.
The 2023 survey found that in a representative national sample of 9,175 U.S. physicians, 8% of endocrinologists reported having suicidal thoughts, roughly the average rate among clinicians overall, ranking it 20th among 29 medical specialties.
The highest rates of thoughts of suicide in the latest survey were reported by physicians in otolaryngology (13%), followed by physicians in psychiatry, family medicine, anesthesiology, obstetrics/gynecology, and emergency medicine (roughly 12% in each specialty).
The rate of attempted suicide was 1% among endocrinologists, which was also the rate among physicians overall.
More female than male endocrinologists reported contemplating suicide (8% versus 5%). In addition, 1% of male endocrinologists reported that they had attempted suicide and 2% of female endocrinologists replied they preferred not to answer the question about attempted suicide.
In contrast, in 2020, an estimated 4.9% of U.S. adults aged 18 and older had serious thoughts about suicide and 0.5% attempted suicide, according to the National Institutes of Health website, the latest report states.
Rates of suicidal thoughts and suicide attempts among physicians overall “are worryingly high numbers,” Peter Yellowlees, MBBS, MD, emeritus professor of psychiatry at University of California, Davis, Health, and chief executive officer, Asynchealth, said in the report.
Confiding in others, good mental health habits, resources
In the 2023 survey, half of the endocrinologists who had thought about suicide had confided in a therapist and 41% had spoken to a family member, but none had told a colleague or a friend, or phoned a suicide hotline.
On the other hand, 7% of male and 10% of female endocrinologists, and 9% of male and 11% of female physicians overall, reported that a colleague had shared suicidal thoughts with them.
“It’s pleasing that physicians overall have shown themselves slightly more likely to bring ideas about suicide to a therapist and less likely to keep their distress entirely to themselves,” Dr. Yellowlees said.
“It’s possible that the need for health care is becoming less stigmatized nationally, with large and increasing emphasis on physician well-being during and after the COVID-19 pandemic,” he suggested.
Endocrinologists reported that to keep happy and have good mental health, they engaged in activities and hobbies (70%), exercised (66%), spent time with family and friends (63%), got enough sleep (56%), ate healthy (48%), went to therapy (11%), or did other things (8%), which was similar to that reported by physicians overall.
The report lists several resources that are specific for physicians having suicidal thoughts (Physician Support Line, 988 Suicide and Crisis Lifeline, Peer RxMed, International Association for Suicide Prevention, and the American Foundation for Suicide Prevention) along with contact information.
The 2023 survey was conducted from June 28, 2022, to Oct. 3, 2022, and the 2022 survey was conducted from June 29, 2021, to Sept. 26, 2021.
A version of this article first appeared on Medscape.com.
Rates of suicidal thoughts and attempted suicide among endocrinologists declined from 2022 and now rank similar to the average rate among physicians overall, but these rates are still higher than the general public, according to survey findings.
The current report about suicide among endocrinologists, titled, “Doctors’ Burden: Endocrinologist Suicide Report 2023,” was recently published.
A report about suicide among physicians overall, based on the same survey, titled, “Doctors’ Burden: Medscape Physician Suicide Report 2023,” was published previously.
Improved rates among 28 medical specialties
In the 2022 survey of a representative national sample of 13,069 U.S. physicians, 10% of endocrinologists reported having suicidal thoughts, ranking the specialty sixth among 29 medical specialties that year.
The 2023 survey found that in a representative national sample of 9,175 U.S. physicians, 8% of endocrinologists reported having suicidal thoughts, roughly the average rate among clinicians overall, ranking it 20th among 29 medical specialties.
The highest rates of thoughts of suicide in the latest survey were reported by physicians in otolaryngology (13%), followed by physicians in psychiatry, family medicine, anesthesiology, obstetrics/gynecology, and emergency medicine (roughly 12% in each specialty).
The rate of attempted suicide was 1% among endocrinologists, which was also the rate among physicians overall.
More female than male endocrinologists reported contemplating suicide (8% versus 5%). In addition, 1% of male endocrinologists reported that they had attempted suicide and 2% of female endocrinologists replied they preferred not to answer the question about attempted suicide.
In contrast, in 2020, an estimated 4.9% of U.S. adults aged 18 and older had serious thoughts about suicide and 0.5% attempted suicide, according to the National Institutes of Health website, the latest report states.
Rates of suicidal thoughts and suicide attempts among physicians overall “are worryingly high numbers,” Peter Yellowlees, MBBS, MD, emeritus professor of psychiatry at University of California, Davis, Health, and chief executive officer, Asynchealth, said in the report.
Confiding in others, good mental health habits, resources
In the 2023 survey, half of the endocrinologists who had thought about suicide had confided in a therapist and 41% had spoken to a family member, but none had told a colleague or a friend, or phoned a suicide hotline.
On the other hand, 7% of male and 10% of female endocrinologists, and 9% of male and 11% of female physicians overall, reported that a colleague had shared suicidal thoughts with them.
“It’s pleasing that physicians overall have shown themselves slightly more likely to bring ideas about suicide to a therapist and less likely to keep their distress entirely to themselves,” Dr. Yellowlees said.
“It’s possible that the need for health care is becoming less stigmatized nationally, with large and increasing emphasis on physician well-being during and after the COVID-19 pandemic,” he suggested.
Endocrinologists reported that to keep happy and have good mental health, they engaged in activities and hobbies (70%), exercised (66%), spent time with family and friends (63%), got enough sleep (56%), ate healthy (48%), went to therapy (11%), or did other things (8%), which was similar to that reported by physicians overall.
The report lists several resources that are specific for physicians having suicidal thoughts (Physician Support Line, 988 Suicide and Crisis Lifeline, Peer RxMed, International Association for Suicide Prevention, and the American Foundation for Suicide Prevention) along with contact information.
The 2023 survey was conducted from June 28, 2022, to Oct. 3, 2022, and the 2022 survey was conducted from June 29, 2021, to Sept. 26, 2021.
A version of this article first appeared on Medscape.com.
Rates of suicidal thoughts and attempted suicide among endocrinologists declined from 2022 and now rank similar to the average rate among physicians overall, but these rates are still higher than the general public, according to survey findings.
The current report about suicide among endocrinologists, titled, “Doctors’ Burden: Endocrinologist Suicide Report 2023,” was recently published.
A report about suicide among physicians overall, based on the same survey, titled, “Doctors’ Burden: Medscape Physician Suicide Report 2023,” was published previously.
Improved rates among 28 medical specialties
In the 2022 survey of a representative national sample of 13,069 U.S. physicians, 10% of endocrinologists reported having suicidal thoughts, ranking the specialty sixth among 29 medical specialties that year.
The 2023 survey found that in a representative national sample of 9,175 U.S. physicians, 8% of endocrinologists reported having suicidal thoughts, roughly the average rate among clinicians overall, ranking it 20th among 29 medical specialties.
The highest rates of thoughts of suicide in the latest survey were reported by physicians in otolaryngology (13%), followed by physicians in psychiatry, family medicine, anesthesiology, obstetrics/gynecology, and emergency medicine (roughly 12% in each specialty).
The rate of attempted suicide was 1% among endocrinologists, which was also the rate among physicians overall.
More female than male endocrinologists reported contemplating suicide (8% versus 5%). In addition, 1% of male endocrinologists reported that they had attempted suicide and 2% of female endocrinologists replied they preferred not to answer the question about attempted suicide.
In contrast, in 2020, an estimated 4.9% of U.S. adults aged 18 and older had serious thoughts about suicide and 0.5% attempted suicide, according to the National Institutes of Health website, the latest report states.
Rates of suicidal thoughts and suicide attempts among physicians overall “are worryingly high numbers,” Peter Yellowlees, MBBS, MD, emeritus professor of psychiatry at University of California, Davis, Health, and chief executive officer, Asynchealth, said in the report.
Confiding in others, good mental health habits, resources
In the 2023 survey, half of the endocrinologists who had thought about suicide had confided in a therapist and 41% had spoken to a family member, but none had told a colleague or a friend, or phoned a suicide hotline.
On the other hand, 7% of male and 10% of female endocrinologists, and 9% of male and 11% of female physicians overall, reported that a colleague had shared suicidal thoughts with them.
“It’s pleasing that physicians overall have shown themselves slightly more likely to bring ideas about suicide to a therapist and less likely to keep their distress entirely to themselves,” Dr. Yellowlees said.
“It’s possible that the need for health care is becoming less stigmatized nationally, with large and increasing emphasis on physician well-being during and after the COVID-19 pandemic,” he suggested.
Endocrinologists reported that to keep happy and have good mental health, they engaged in activities and hobbies (70%), exercised (66%), spent time with family and friends (63%), got enough sleep (56%), ate healthy (48%), went to therapy (11%), or did other things (8%), which was similar to that reported by physicians overall.
The report lists several resources that are specific for physicians having suicidal thoughts (Physician Support Line, 988 Suicide and Crisis Lifeline, Peer RxMed, International Association for Suicide Prevention, and the American Foundation for Suicide Prevention) along with contact information.
The 2023 survey was conducted from June 28, 2022, to Oct. 3, 2022, and the 2022 survey was conducted from June 29, 2021, to Sept. 26, 2021.
A version of this article first appeared on Medscape.com.
OSHA revisited
Time for my periodic reminder about your Occupational Health and Safety Administration (OSHA) obligations. The health care field still has the most work-related illness and injury reports of any industry in the United States, and OSHA standards are in place to minimize potential workplace incidents.
Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain sight, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s website or order one at no charge by calling 800-321-OSHA.
The poster discusses the “general standards” that all workplaces must comply with to avoid work-related illnesses and injuries. The standards most applicable to medical offices are those dealing with personal protective equipment (PPE), bloodborne pathogens, hazard communication, and – increasingly, of late – ionizing radiation.
Physicians have become all too familiar with the PPE standard as a result of the COVID pandemic. Ironically, OSHA considers PPE a less acceptable means of employee protection than the other standards, as safe work practices should always supersede safety equipment. Nevertheless, employers must have a PPE program in place to train employees on what equipment is necessary, and under which conditions.
You also need a written exposure control plan for bloodborne pathogens. It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology. You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at that decision, and why you feel that your current protocol is as good or better.
The hazard communication (or right-to-know) standard involves compiling a list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
If your office has x-ray equipment, or you are considering one of the new image-guided superficial radiotherapy machines, you must be in compliance with the ionizing radiation standard, which entails shielding, radiation monitors, and clear labeling of equipment.
Other, more general regulations include the physical setup of your office. Everyone must be able to evacuate quickly in case of fire or other emergencies. At a minimum, you (or the owner of the office building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it, and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars. How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Time for my periodic reminder about your Occupational Health and Safety Administration (OSHA) obligations. The health care field still has the most work-related illness and injury reports of any industry in the United States, and OSHA standards are in place to minimize potential workplace incidents.
Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain sight, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s website or order one at no charge by calling 800-321-OSHA.
The poster discusses the “general standards” that all workplaces must comply with to avoid work-related illnesses and injuries. The standards most applicable to medical offices are those dealing with personal protective equipment (PPE), bloodborne pathogens, hazard communication, and – increasingly, of late – ionizing radiation.
Physicians have become all too familiar with the PPE standard as a result of the COVID pandemic. Ironically, OSHA considers PPE a less acceptable means of employee protection than the other standards, as safe work practices should always supersede safety equipment. Nevertheless, employers must have a PPE program in place to train employees on what equipment is necessary, and under which conditions.
You also need a written exposure control plan for bloodborne pathogens. It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology. You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at that decision, and why you feel that your current protocol is as good or better.
The hazard communication (or right-to-know) standard involves compiling a list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
If your office has x-ray equipment, or you are considering one of the new image-guided superficial radiotherapy machines, you must be in compliance with the ionizing radiation standard, which entails shielding, radiation monitors, and clear labeling of equipment.
Other, more general regulations include the physical setup of your office. Everyone must be able to evacuate quickly in case of fire or other emergencies. At a minimum, you (or the owner of the office building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it, and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars. How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Time for my periodic reminder about your Occupational Health and Safety Administration (OSHA) obligations. The health care field still has the most work-related illness and injury reports of any industry in the United States, and OSHA standards are in place to minimize potential workplace incidents.
Even if you hold regular safety meetings (which all too often is not the case), the occasional comprehensive review is always a good idea, and could save you a bundle in fines.
For starters, do you have an official OSHA poster, enumerating employee rights and explaining how to file complaints? Every office must have one posted in plain sight, and it is the first thing an OSHA inspector will look for. You can download one from OSHA’s website or order one at no charge by calling 800-321-OSHA.
The poster discusses the “general standards” that all workplaces must comply with to avoid work-related illnesses and injuries. The standards most applicable to medical offices are those dealing with personal protective equipment (PPE), bloodborne pathogens, hazard communication, and – increasingly, of late – ionizing radiation.
Physicians have become all too familiar with the PPE standard as a result of the COVID pandemic. Ironically, OSHA considers PPE a less acceptable means of employee protection than the other standards, as safe work practices should always supersede safety equipment. Nevertheless, employers must have a PPE program in place to train employees on what equipment is necessary, and under which conditions.
You also need a written exposure control plan for bloodborne pathogens. It should document your use of such protective equipment as gloves, face and eye protection, needle guards, and gowns, and your implementation of universal precautions – and it is supposed to be updated annually, to reflect changes in technology. You must provide all at-risk employees with hepatitis B vaccine at no cost to them. You also must provide and pay for appropriate medical treatment and follow-up after any exposure to a dangerous pathogen.
You need not adopt every new safety device as it comes on the market, but you should document which ones you are using – and which you pass up – and why. For example, you and your employees may decide not to purchase a new safety needle because you don’t think it will improve safety, or that it will be more trouble than it’s worth; but you should document how you arrived at that decision, and why you feel that your current protocol is as good or better.
The hazard communication (or right-to-know) standard involves compiling a list of hazardous substances, which all employees have a right to know about. Keep in mind that OSHA’s list includes alcohol, hydrogen peroxide, acetone, liquid nitrogen, and other substances that you might not consider particularly dangerous, but are nevertheless classified as “hazardous.” For each substance, your employees must have access to the manufacturer-supplied Material Safety Data Sheet, which outlines the proper procedures for working with a specific material, and for handling and containing it in a spill or other emergency.
If your office has x-ray equipment, or you are considering one of the new image-guided superficial radiotherapy machines, you must be in compliance with the ionizing radiation standard, which entails shielding, radiation monitors, and clear labeling of equipment.
Other, more general regulations include the physical setup of your office. Everyone must be able to evacuate quickly in case of fire or other emergencies. At a minimum, you (or the owner of the office building) are expected to establish exit routes to accommodate all employees and to post easily visible evacuation diagrams.
Examine all electrical devices and their power sources. All electrically powered equipment – medical, clerical, or anything else in the office – must operate safely. Pay particular attention to the way wall outlets are set up. Make sure each outlet has sufficient power to run the equipment plugged into it, and that circuit breakers are present and functioning. And beware the common situation of too many gadgets running off a single circuit.
Other components of the rule include proper containment of regulated medical waste, identification of regulated-waste containers, sharps disposal boxes, and periodic employee training regarding all of these things.
Federal OSHA regulations do not require medical and dental offices to keep an injury and illness log, as other businesses must; but your state may have a requirement that supersedes the federal law. Check with your state, or with your local OSHA office, regarding any such requirements.
It is a mistake to take OSHA regulations lightly; failure to comply with them can result in stiff penalties running into many thousands of dollars. How can you be certain you are complying with all the rules? The easiest and cheapest way is to call your local OSHA office and request an inspection. Why would you do that? Because OSHA issues no citations during voluntary inspections as long as you agree to remedy any violations they find.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
Hospital misdiagnoses blood clot as sciatica; must pay millions
according to a story posted on boston.com, the news site of The Boston Globe.
On March 7, 2015, Steven Luppold, at the time a construction worker, went to the emergency department at Lowell General Hospital, in Lowell, Mass. He had a long history of sciatica. The pain often radiated down his left leg. This time, though, his discomfort in his left foot felt different.
At the ED, Mr. Luppold was initially examined by two nurses, who wrote in the patient’s chart that his foot was turning purple and felt cool to the touch. He was next examined by a physician assistant, Charles Loucraft, who made a diagnosis of worsening sciatica and sent the patient home. Court records suggest Mr. Loucraft made this diagnosis without having read the patient’s chart.
Six days later, Mr. Luppold returned to the ED with severe pain – a 9 on a scale of 10, as he reported at the time. Again, he was seen by two nurses, one of whom had examined him the previous week. He was then examined by Carlos Flores, a nurse practitioner, who reiterated the PA’s initial diagnosis of sciatica. Once more, Mr. Luppold was sent home.
Four days later, on March 17, Mr. Luppold placed a call to his primary care physician (PCP), who worked at Lahey Hospital and Medical Center, in Burlington, Mass., about 18 miles south of Lowell.
The PCP administered an ultrasound and diagnosed the patient as having a deep-vein thrombosis and an arterial thrombosis in his left leg. Mr. Luppold was taken immediately to the Lahey Hospital ED. A vascular surgeon ordered a CT scan, which indicated that the tissue in the patient’s left leg was necrotic. The following day, with few options open to them, surgeons amputated the patient’s left leg above the knee.
At some point after the surgery, Mr. Luppold filed a medical malpractice suit that named the PA, NP, and their physician-group employer, Merrimack Valley Emergency Associates, in Lowell. Also named in the suit were the three ED nurses who had examined him.
“Honestly, the reason this happened was because the communication ... in the emergency department between the nurses and providers was nonexistent,” says Robert M. Higgins, a partner at Lubin & Meyer, in Boston, who represented the plaintiff. Had providers ordered “a simple ultrasound” during either of Mr. Luppold’s visits to the ED, Mr. Higgins added, his leg could have been saved.
The jury agreed. It awarded Mr. Luppold $10 million for pain and suffering and another $10 million in compensatory damages.
At press time, there was no word on whether the defendants planned to appeal.
Doctors at risk for providing trans care to minors
Arkansas doctors who “perform a gender transition procedure” for persons younger than 18 years could be in legal jeopardy for well beyond the date of treatment, reports a story in the Arkansas Advocate, among other news sites.
That prospect is the result of a bill signed into law in March by Arkansas Gov. Sarah Huckabee Sanders. Under the law, slated to take effect this summer, a doctor who provides gender-affirming care to a minor can be sued for a period of up to 15 years after that patient turns 18. (Under current state law, plaintiffs must file a med-mal claim within 2 years of an injury.)
A federal judge is considering whether to strike down a similar measure that was signed into law by Gov. Sanders’s predecessor, Asa Hutchinson, in 2021. That statute prohibits doctors from providing or from referring a minor to someone who would provide gender-affirming hormone or puberty blockers. (Minors in the state do not qualify for gender-related surgery.)
Opponents of such care are hopeful that the 2021 statute will survive judicial review. Even if it doesn’t, though, they believe the new med-mal law will have a similar effect: to dissuade Arkansas doctors from treating minors seeking gender-related treatment.
It’s possible that the new law could itself be subject to a court review. But at least one of the bill’s sponsors, Sen. Gary Stubblefield, a Republican member of the Arkansas senate, is cautiously optimistic: “I know what we did was what we thought was best for our children.”
Opponents argue, though, that the new law will end up harming children who identify as transgender.
“You might not understand what it means to be gay or trans or a member of the LGBTQ community,” explained House Minority Leader Tippi McCullough during debate over the bill in the GOP-led chamber. “I get that, but I’m standing here as the only member of that community in the entire General Assembly, a caucus of one, telling you ... [the bill] denies trans kids the most affirming care they may ever receive in their lives, and that’s cruel.”
Appeals court slashes jury award
A Pennsylvania doctor who faced paying a $2.7 million award has had it cut nearly in half by a three-judge Superior Court panel, as a story in the Claims Journal reports.
The underlying case stems from a suit brought by the estate of a man who died in 2018. At the time of his death, he had been diagnosed with advanced prostate cancer and liver cancer. The suit by the family estate was initially centered on the doctor’s alleged negligence in treating the man’s prostate cancer. At some point during the 2021 trial, though, the suit was amended to include a second claim – an allegation that the doctor had also been negligent in treating the patient’s liver cancer, which had been belatedly diagnosed. The doctor’s medical practice was also a named defendant in the suit.
On March 2, 2022, a jury sided with the plaintiffs, awarding them compensatory damages of $1.5 million for the prostate cancer claim and $1.2 million for the liver cancer claim.
The doctor and other defendants appealed, arguing two essential points: first, the liver cancer claim amounted to a new cause of action, one for which they had not been given adequate notice.
Second, and more significantly, plaintiff action relating to this second claim had only begun in earnest on July 6, 2021, when an expert report was first filed with the court. But this filing was nearly a full year beyond the state’s 2-year statute of limitations, which, given the patient’s death in 2018, was at the very limit, said defendants. For these reasons, they argued, the appeals court should forthwith order a new trial.
That court, however, ended up walking a middle road. Although the court found that the liver claim was “time-barred,” since it had exceeded the 2-year statute of limitations, the court denied the defendants’ motion for a new trial.
Instead, the court cut $1.2 million from the portion of the jury award that applied to the liver cancer claim but left intact the $1.5 million that related to the cause of action regarding prostate cancer.
It was a Solomonic decision that undoubtedly displeased both sides equally.
A version of this article first appeared on Medscape.com.
according to a story posted on boston.com, the news site of The Boston Globe.
On March 7, 2015, Steven Luppold, at the time a construction worker, went to the emergency department at Lowell General Hospital, in Lowell, Mass. He had a long history of sciatica. The pain often radiated down his left leg. This time, though, his discomfort in his left foot felt different.
At the ED, Mr. Luppold was initially examined by two nurses, who wrote in the patient’s chart that his foot was turning purple and felt cool to the touch. He was next examined by a physician assistant, Charles Loucraft, who made a diagnosis of worsening sciatica and sent the patient home. Court records suggest Mr. Loucraft made this diagnosis without having read the patient’s chart.
Six days later, Mr. Luppold returned to the ED with severe pain – a 9 on a scale of 10, as he reported at the time. Again, he was seen by two nurses, one of whom had examined him the previous week. He was then examined by Carlos Flores, a nurse practitioner, who reiterated the PA’s initial diagnosis of sciatica. Once more, Mr. Luppold was sent home.
Four days later, on March 17, Mr. Luppold placed a call to his primary care physician (PCP), who worked at Lahey Hospital and Medical Center, in Burlington, Mass., about 18 miles south of Lowell.
The PCP administered an ultrasound and diagnosed the patient as having a deep-vein thrombosis and an arterial thrombosis in his left leg. Mr. Luppold was taken immediately to the Lahey Hospital ED. A vascular surgeon ordered a CT scan, which indicated that the tissue in the patient’s left leg was necrotic. The following day, with few options open to them, surgeons amputated the patient’s left leg above the knee.
At some point after the surgery, Mr. Luppold filed a medical malpractice suit that named the PA, NP, and their physician-group employer, Merrimack Valley Emergency Associates, in Lowell. Also named in the suit were the three ED nurses who had examined him.
“Honestly, the reason this happened was because the communication ... in the emergency department between the nurses and providers was nonexistent,” says Robert M. Higgins, a partner at Lubin & Meyer, in Boston, who represented the plaintiff. Had providers ordered “a simple ultrasound” during either of Mr. Luppold’s visits to the ED, Mr. Higgins added, his leg could have been saved.
The jury agreed. It awarded Mr. Luppold $10 million for pain and suffering and another $10 million in compensatory damages.
At press time, there was no word on whether the defendants planned to appeal.
Doctors at risk for providing trans care to minors
Arkansas doctors who “perform a gender transition procedure” for persons younger than 18 years could be in legal jeopardy for well beyond the date of treatment, reports a story in the Arkansas Advocate, among other news sites.
That prospect is the result of a bill signed into law in March by Arkansas Gov. Sarah Huckabee Sanders. Under the law, slated to take effect this summer, a doctor who provides gender-affirming care to a minor can be sued for a period of up to 15 years after that patient turns 18. (Under current state law, plaintiffs must file a med-mal claim within 2 years of an injury.)
A federal judge is considering whether to strike down a similar measure that was signed into law by Gov. Sanders’s predecessor, Asa Hutchinson, in 2021. That statute prohibits doctors from providing or from referring a minor to someone who would provide gender-affirming hormone or puberty blockers. (Minors in the state do not qualify for gender-related surgery.)
Opponents of such care are hopeful that the 2021 statute will survive judicial review. Even if it doesn’t, though, they believe the new med-mal law will have a similar effect: to dissuade Arkansas doctors from treating minors seeking gender-related treatment.
It’s possible that the new law could itself be subject to a court review. But at least one of the bill’s sponsors, Sen. Gary Stubblefield, a Republican member of the Arkansas senate, is cautiously optimistic: “I know what we did was what we thought was best for our children.”
Opponents argue, though, that the new law will end up harming children who identify as transgender.
“You might not understand what it means to be gay or trans or a member of the LGBTQ community,” explained House Minority Leader Tippi McCullough during debate over the bill in the GOP-led chamber. “I get that, but I’m standing here as the only member of that community in the entire General Assembly, a caucus of one, telling you ... [the bill] denies trans kids the most affirming care they may ever receive in their lives, and that’s cruel.”
Appeals court slashes jury award
A Pennsylvania doctor who faced paying a $2.7 million award has had it cut nearly in half by a three-judge Superior Court panel, as a story in the Claims Journal reports.
The underlying case stems from a suit brought by the estate of a man who died in 2018. At the time of his death, he had been diagnosed with advanced prostate cancer and liver cancer. The suit by the family estate was initially centered on the doctor’s alleged negligence in treating the man’s prostate cancer. At some point during the 2021 trial, though, the suit was amended to include a second claim – an allegation that the doctor had also been negligent in treating the patient’s liver cancer, which had been belatedly diagnosed. The doctor’s medical practice was also a named defendant in the suit.
On March 2, 2022, a jury sided with the plaintiffs, awarding them compensatory damages of $1.5 million for the prostate cancer claim and $1.2 million for the liver cancer claim.
The doctor and other defendants appealed, arguing two essential points: first, the liver cancer claim amounted to a new cause of action, one for which they had not been given adequate notice.
Second, and more significantly, plaintiff action relating to this second claim had only begun in earnest on July 6, 2021, when an expert report was first filed with the court. But this filing was nearly a full year beyond the state’s 2-year statute of limitations, which, given the patient’s death in 2018, was at the very limit, said defendants. For these reasons, they argued, the appeals court should forthwith order a new trial.
That court, however, ended up walking a middle road. Although the court found that the liver claim was “time-barred,” since it had exceeded the 2-year statute of limitations, the court denied the defendants’ motion for a new trial.
Instead, the court cut $1.2 million from the portion of the jury award that applied to the liver cancer claim but left intact the $1.5 million that related to the cause of action regarding prostate cancer.
It was a Solomonic decision that undoubtedly displeased both sides equally.
A version of this article first appeared on Medscape.com.
according to a story posted on boston.com, the news site of The Boston Globe.
On March 7, 2015, Steven Luppold, at the time a construction worker, went to the emergency department at Lowell General Hospital, in Lowell, Mass. He had a long history of sciatica. The pain often radiated down his left leg. This time, though, his discomfort in his left foot felt different.
At the ED, Mr. Luppold was initially examined by two nurses, who wrote in the patient’s chart that his foot was turning purple and felt cool to the touch. He was next examined by a physician assistant, Charles Loucraft, who made a diagnosis of worsening sciatica and sent the patient home. Court records suggest Mr. Loucraft made this diagnosis without having read the patient’s chart.
Six days later, Mr. Luppold returned to the ED with severe pain – a 9 on a scale of 10, as he reported at the time. Again, he was seen by two nurses, one of whom had examined him the previous week. He was then examined by Carlos Flores, a nurse practitioner, who reiterated the PA’s initial diagnosis of sciatica. Once more, Mr. Luppold was sent home.
Four days later, on March 17, Mr. Luppold placed a call to his primary care physician (PCP), who worked at Lahey Hospital and Medical Center, in Burlington, Mass., about 18 miles south of Lowell.
The PCP administered an ultrasound and diagnosed the patient as having a deep-vein thrombosis and an arterial thrombosis in his left leg. Mr. Luppold was taken immediately to the Lahey Hospital ED. A vascular surgeon ordered a CT scan, which indicated that the tissue in the patient’s left leg was necrotic. The following day, with few options open to them, surgeons amputated the patient’s left leg above the knee.
At some point after the surgery, Mr. Luppold filed a medical malpractice suit that named the PA, NP, and their physician-group employer, Merrimack Valley Emergency Associates, in Lowell. Also named in the suit were the three ED nurses who had examined him.
“Honestly, the reason this happened was because the communication ... in the emergency department between the nurses and providers was nonexistent,” says Robert M. Higgins, a partner at Lubin & Meyer, in Boston, who represented the plaintiff. Had providers ordered “a simple ultrasound” during either of Mr. Luppold’s visits to the ED, Mr. Higgins added, his leg could have been saved.
The jury agreed. It awarded Mr. Luppold $10 million for pain and suffering and another $10 million in compensatory damages.
At press time, there was no word on whether the defendants planned to appeal.
Doctors at risk for providing trans care to minors
Arkansas doctors who “perform a gender transition procedure” for persons younger than 18 years could be in legal jeopardy for well beyond the date of treatment, reports a story in the Arkansas Advocate, among other news sites.
That prospect is the result of a bill signed into law in March by Arkansas Gov. Sarah Huckabee Sanders. Under the law, slated to take effect this summer, a doctor who provides gender-affirming care to a minor can be sued for a period of up to 15 years after that patient turns 18. (Under current state law, plaintiffs must file a med-mal claim within 2 years of an injury.)
A federal judge is considering whether to strike down a similar measure that was signed into law by Gov. Sanders’s predecessor, Asa Hutchinson, in 2021. That statute prohibits doctors from providing or from referring a minor to someone who would provide gender-affirming hormone or puberty blockers. (Minors in the state do not qualify for gender-related surgery.)
Opponents of such care are hopeful that the 2021 statute will survive judicial review. Even if it doesn’t, though, they believe the new med-mal law will have a similar effect: to dissuade Arkansas doctors from treating minors seeking gender-related treatment.
It’s possible that the new law could itself be subject to a court review. But at least one of the bill’s sponsors, Sen. Gary Stubblefield, a Republican member of the Arkansas senate, is cautiously optimistic: “I know what we did was what we thought was best for our children.”
Opponents argue, though, that the new law will end up harming children who identify as transgender.
“You might not understand what it means to be gay or trans or a member of the LGBTQ community,” explained House Minority Leader Tippi McCullough during debate over the bill in the GOP-led chamber. “I get that, but I’m standing here as the only member of that community in the entire General Assembly, a caucus of one, telling you ... [the bill] denies trans kids the most affirming care they may ever receive in their lives, and that’s cruel.”
Appeals court slashes jury award
A Pennsylvania doctor who faced paying a $2.7 million award has had it cut nearly in half by a three-judge Superior Court panel, as a story in the Claims Journal reports.
The underlying case stems from a suit brought by the estate of a man who died in 2018. At the time of his death, he had been diagnosed with advanced prostate cancer and liver cancer. The suit by the family estate was initially centered on the doctor’s alleged negligence in treating the man’s prostate cancer. At some point during the 2021 trial, though, the suit was amended to include a second claim – an allegation that the doctor had also been negligent in treating the patient’s liver cancer, which had been belatedly diagnosed. The doctor’s medical practice was also a named defendant in the suit.
On March 2, 2022, a jury sided with the plaintiffs, awarding them compensatory damages of $1.5 million for the prostate cancer claim and $1.2 million for the liver cancer claim.
The doctor and other defendants appealed, arguing two essential points: first, the liver cancer claim amounted to a new cause of action, one for which they had not been given adequate notice.
Second, and more significantly, plaintiff action relating to this second claim had only begun in earnest on July 6, 2021, when an expert report was first filed with the court. But this filing was nearly a full year beyond the state’s 2-year statute of limitations, which, given the patient’s death in 2018, was at the very limit, said defendants. For these reasons, they argued, the appeals court should forthwith order a new trial.
That court, however, ended up walking a middle road. Although the court found that the liver claim was “time-barred,” since it had exceeded the 2-year statute of limitations, the court denied the defendants’ motion for a new trial.
Instead, the court cut $1.2 million from the portion of the jury award that applied to the liver cancer claim but left intact the $1.5 million that related to the cause of action regarding prostate cancer.
It was a Solomonic decision that undoubtedly displeased both sides equally.
A version of this article first appeared on Medscape.com.
Artificial intelligence versus real patients
STAT recently published an article on a new aspect of managed medical care.
They found that
That’s ... kind of scary.
Certainly, computers aren’t bad things. In 2023 America you can’t practice medicine without them. They aren’t malicious. They can analyze a lot of data faster than we can (for the record, the average memory capacity of a human brain is 1 petabyte, so we’re still ahead of the average desktop in that regard).
Computers, though, are pretty uniform. I’m a Mac person, and I can go into any Apple store and buy one. Right off the shelf I know how to work it, how it will run a given program, and can predict how it will handle different commands and such. They’re pretty much the same.
People are not quite as easy. Anatomically and chemically we’re similar, but that’s not the same. There are immune, genetic, and multiple other factors that put a lot of variables into the equation. Part of our training is knowing that and taking it into account when making treatment plans.
Algorithms, and artificial intelligence, can only do so much of that. If they were right all the time sports betting wouldn’t exist. But it does, because sports depends on the participants, who are people (or horses), and they’re not exactly alike ... for that matter how they’ll perform varies from day to day for the same individual.
But medical care isn’t a sport (even though hospital call can seem like a marathon). The data we give computers to use is generally based on averages – a rehab stay of 16.6 days for an 85-year-old woman with a broken shoulder (per the above article). But they don’t realize that averages are actually a collection of data on a bell-shaped curve. An insurance company will be only too happy when one person completes their rehabilitation in 11.6 days, and then feel it’s unreasonable when another takes 21.6.
That said, many of the companies involved say the final decisions are made by humans and that the algorithms are just guidelines.
Maybe so, but the STAT article suggests they’re putting too much credence in what the computer says, and not the specific circumstances of the individual involved.
That ain’t good, at least not for the patients.
Medicine, for better or worse, is a business. In an ideal world it probably wouldn’t be, but we don’t live in one.
But it’s unlike any other business out there, and shouldn’t be run like one. A car repair shop knows what parts to order and generally how long repairs will take. Once they’re done the car should be ready to roll out of the shop.
People aren’t like that.
I understand the need to prevent abuse and overbilling for unnecessary days and services. Medicine, unfortunately, has plenty of opportunities for the dishonest to take advantage of.
It’s a thin line, but, at least today, turning treatment decisions over to algorithms and computers is a bad idea for the people we’re supposed to be caring for.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
STAT recently published an article on a new aspect of managed medical care.
They found that
That’s ... kind of scary.
Certainly, computers aren’t bad things. In 2023 America you can’t practice medicine without them. They aren’t malicious. They can analyze a lot of data faster than we can (for the record, the average memory capacity of a human brain is 1 petabyte, so we’re still ahead of the average desktop in that regard).
Computers, though, are pretty uniform. I’m a Mac person, and I can go into any Apple store and buy one. Right off the shelf I know how to work it, how it will run a given program, and can predict how it will handle different commands and such. They’re pretty much the same.
People are not quite as easy. Anatomically and chemically we’re similar, but that’s not the same. There are immune, genetic, and multiple other factors that put a lot of variables into the equation. Part of our training is knowing that and taking it into account when making treatment plans.
Algorithms, and artificial intelligence, can only do so much of that. If they were right all the time sports betting wouldn’t exist. But it does, because sports depends on the participants, who are people (or horses), and they’re not exactly alike ... for that matter how they’ll perform varies from day to day for the same individual.
But medical care isn’t a sport (even though hospital call can seem like a marathon). The data we give computers to use is generally based on averages – a rehab stay of 16.6 days for an 85-year-old woman with a broken shoulder (per the above article). But they don’t realize that averages are actually a collection of data on a bell-shaped curve. An insurance company will be only too happy when one person completes their rehabilitation in 11.6 days, and then feel it’s unreasonable when another takes 21.6.
That said, many of the companies involved say the final decisions are made by humans and that the algorithms are just guidelines.
Maybe so, but the STAT article suggests they’re putting too much credence in what the computer says, and not the specific circumstances of the individual involved.
That ain’t good, at least not for the patients.
Medicine, for better or worse, is a business. In an ideal world it probably wouldn’t be, but we don’t live in one.
But it’s unlike any other business out there, and shouldn’t be run like one. A car repair shop knows what parts to order and generally how long repairs will take. Once they’re done the car should be ready to roll out of the shop.
People aren’t like that.
I understand the need to prevent abuse and overbilling for unnecessary days and services. Medicine, unfortunately, has plenty of opportunities for the dishonest to take advantage of.
It’s a thin line, but, at least today, turning treatment decisions over to algorithms and computers is a bad idea for the people we’re supposed to be caring for.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
STAT recently published an article on a new aspect of managed medical care.
They found that
That’s ... kind of scary.
Certainly, computers aren’t bad things. In 2023 America you can’t practice medicine without them. They aren’t malicious. They can analyze a lot of data faster than we can (for the record, the average memory capacity of a human brain is 1 petabyte, so we’re still ahead of the average desktop in that regard).
Computers, though, are pretty uniform. I’m a Mac person, and I can go into any Apple store and buy one. Right off the shelf I know how to work it, how it will run a given program, and can predict how it will handle different commands and such. They’re pretty much the same.
People are not quite as easy. Anatomically and chemically we’re similar, but that’s not the same. There are immune, genetic, and multiple other factors that put a lot of variables into the equation. Part of our training is knowing that and taking it into account when making treatment plans.
Algorithms, and artificial intelligence, can only do so much of that. If they were right all the time sports betting wouldn’t exist. But it does, because sports depends on the participants, who are people (or horses), and they’re not exactly alike ... for that matter how they’ll perform varies from day to day for the same individual.
But medical care isn’t a sport (even though hospital call can seem like a marathon). The data we give computers to use is generally based on averages – a rehab stay of 16.6 days for an 85-year-old woman with a broken shoulder (per the above article). But they don’t realize that averages are actually a collection of data on a bell-shaped curve. An insurance company will be only too happy when one person completes their rehabilitation in 11.6 days, and then feel it’s unreasonable when another takes 21.6.
That said, many of the companies involved say the final decisions are made by humans and that the algorithms are just guidelines.
Maybe so, but the STAT article suggests they’re putting too much credence in what the computer says, and not the specific circumstances of the individual involved.
That ain’t good, at least not for the patients.
Medicine, for better or worse, is a business. In an ideal world it probably wouldn’t be, but we don’t live in one.
But it’s unlike any other business out there, and shouldn’t be run like one. A car repair shop knows what parts to order and generally how long repairs will take. Once they’re done the car should be ready to roll out of the shop.
People aren’t like that.
I understand the need to prevent abuse and overbilling for unnecessary days and services. Medicine, unfortunately, has plenty of opportunities for the dishonest to take advantage of.
It’s a thin line, but, at least today, turning treatment decisions over to algorithms and computers is a bad idea for the people we’re supposed to be caring for.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Prior authorizations: Time to rebel?
I imagine I am not alone when I tell you that my blood pressure rises every time I receive an email from CoverMyMeds, or worse, a phone call from a patient to tell me the pharmacist says I need to call their insurance company to get a medication authorized. Prior authorizations (PAs) are the bane of every physician’s existence.
They ask providers to jump through hoops, and no one oversees the placement of these hoops. The process puts patients at risk and sucks the joy from the practice of medicine.
In fall 2021, the legislative committee of the Maryland Psychiatric Society, with the help of Kathy Orellana and Tim Clement from the American Psychiatric Association, drafted a bill to modify the use of PAs. Unfortunately, the bill died in committee during the 2022 Maryland General Assembly legislative session.
Robert Herman, MD, who helped draft the initial legislation, was delighted when he learned that MedChi, the Maryland State Medical Society, had taken the proposed legislation and expanded it. “It was everything we wished for and more,” Dr. Herman said.
During this year’s legislative session, House Bill 305/Senate Bill 308, Health Insurance – Utilization Review – Revisions, was sponsored by 19 delegates and two senators. Fifty medical associations, including dentists and physical therapists, endorsed the bill. Many people, including Dr. Herman, testified before the Health and Government Operations Committee on Feb. 16.
Delegate Kenneth Kerr introduced the legislation to the committee.
“Before I begin, let me make two points. First, the bill does not do away with prior authorization or other utilization review techniques; rather, it tries to make a more balanced approach for both patients and physicians by attempting to reduce the volume that’s subject to prior authorization, by increasing transparency and communication, and by studying how the process can be improved overall. Second, we have over 50 organizations representing health care providers and patient advocacy organizations supporting this legislation. This is a systemic issue across the entire spectrum of healthcare,” said Mr. Kerr.
Mr. Kerr went on to say there were 81,143 denials for treatment in 2021. The three areas with the highest rate of denials were pharmacy, dental, and the combination of labs and radiology.
He further noted that, when consumers filed a complaint with the Maryland Insurance Administration, 72.4% of denials were reversed in 2022.
“This resulted in more benefits that could have, and should have, been given to the patient at the first request. These reversals indicate there is a problem,” Mr. Kerr said. He discussed increased administrative costs, the enormous workload burden this incurs, and the problem of burnout among medical providers.
The proposed legislation includes a ban on PA requirements for generic medications, for dose changes of previously authorized medication, and ends the requirement for yearly authorizations. It requires that a physician of the same specialty be on the panel that denies care and shortens the time periods allowed for responses and appeals.
Testimony began with those supporting the legislation. Doctors highlighted the harm inflicted on their patients by the PA process. An oncologist spoke of how it took weeks to get approval for chemotherapy for a patient with an aggressive cancer, a gastroenterologist discussed a patient who became ill and lost her job when successful treatment for inflammatory bowel disease was stopped while she waited for the yearly medication reapproval, and another physician told of a patient who died of an exacerbation of obstructive lung disease, also while awaiting a yearly reapproval for an effective medication.
A dentist spoke about how he was not authorized to place a crown on a patient’s tooth. Instead, he was instructed to try a filling first, and when the filling failed, he was told he would not be authorized to work on the same tooth twice in one year.
A physical therapist testified that PA was required every two to four sessions, and each request took up half of a session – a significant portion of time that was not used for treatment.
Three people testified in opposition to the bill. Matthew Celantano, executive director of the League of Life and Health Insurers of Maryland, called the legislation “drastic” and testified that the cost would be prohibitive.
“From our end, it’s important for you to hear that prior authorization is care coordination. It’s protection that keeps [patients] safe, but helps control skyrocketing health care costs,” said Mr. Celantano.
Deb Rivkin, vice president of government affairs for CareFirst Blue Cross Blue Shield, testified in favor of using better technology. She cited legislation under consideration in Virginia that would give clinicians more information about the specific medications that require PAs, price information, and real-time authorizations.
Finally, representing the Pharmaceutical Care Management Association, Heather Cascone testified about PAs for generic medications. Her testimony focused on prior authorization for generic medications. She claimed that “... by allowing unrestricted dispensing of generic drugs, or an override based on the subjective opinion of the prescriber, prior authorization can protect patients from drugs with a safety risk; they can catch things like drug-disease contraindications, dosage errors, pregnancy-related contraindications, and a variety of cost-savings protections.”
I found this testimony particularly difficult because the “protector” is generally not a physician and has neither seen, nor examined, the patient. The implication that patients need protection from their doctors who would be unaware aware that they are pregnant, or are ill, was offensive. It also implies that PBMs are lax by not requiring PA on all medications, ignoring the fact that patients often bypass such denials by paying out of pocket for treatment.
If this had been a high school debate, there would be no doubt the enthusiasm for the bill for HB305 was strong, the committee chair was eager, and the arguments in favor of the legislation robust. There are no public minutes for the subsequent meetings with stakeholders, and I was somewhat heartbroken to learn that once again, the bill died in committee.
Annette Hanson, MD, chair of the MPS legislative committee, remains optimistic for the future. “Since then, the APA [American Psychiatric Association] has taken our bill and used it as model legislation now being offered to other district branches. MPS has created something that is going to spread across the country. Change may be slow, but it is not inevitable. And when it happens, I want you to remember that it started here,” she said.
However, the pressure is on. A recent ProPublica article documented how Cigna rejects claims by the batch without ever reviewing them. Soon after that piece was published, it was announced that several of the large insurers, including Cigna, would be cutting back on PA demands. It remains to be seen whether this is a token move to placate legislators, and whether it will provide meaningful relief to physicians and patients. I remain skeptical.
In the meantime, physicians’ ability to help their patients remains compromised and administrative tasks consume valuable time. I have started to wonder whether there may be some other way to push this issue to action. PA is about cost containment, but perhaps there are other ways to economize.
Why do medications cost less in other countries? Why does a medication cost hundreds of dollars more at one pharmacy versus another? Why do medicines sometimes have a copay that is two or three times higher than the cash price? Why do some covered medications have copays of thousands of dollars a year? I wonder if physicians shouldn’t come together and collectively agree not to comply and refuse to complete PAs in organized rebellion.
The fear, of course, is that such an endeavor would hurt patients, but if we all agreed in concert, then for better or for worse, something would have to give. The existing system is already hurting everyone, and physicians, by agreeing to play this awful game, are complicit in letting insurers dictate the care our patients receive.
Dinah Miller, MD, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016) and has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.
A version of this article first appeared on Medscape.com.
I imagine I am not alone when I tell you that my blood pressure rises every time I receive an email from CoverMyMeds, or worse, a phone call from a patient to tell me the pharmacist says I need to call their insurance company to get a medication authorized. Prior authorizations (PAs) are the bane of every physician’s existence.
They ask providers to jump through hoops, and no one oversees the placement of these hoops. The process puts patients at risk and sucks the joy from the practice of medicine.
In fall 2021, the legislative committee of the Maryland Psychiatric Society, with the help of Kathy Orellana and Tim Clement from the American Psychiatric Association, drafted a bill to modify the use of PAs. Unfortunately, the bill died in committee during the 2022 Maryland General Assembly legislative session.
Robert Herman, MD, who helped draft the initial legislation, was delighted when he learned that MedChi, the Maryland State Medical Society, had taken the proposed legislation and expanded it. “It was everything we wished for and more,” Dr. Herman said.
During this year’s legislative session, House Bill 305/Senate Bill 308, Health Insurance – Utilization Review – Revisions, was sponsored by 19 delegates and two senators. Fifty medical associations, including dentists and physical therapists, endorsed the bill. Many people, including Dr. Herman, testified before the Health and Government Operations Committee on Feb. 16.
Delegate Kenneth Kerr introduced the legislation to the committee.
“Before I begin, let me make two points. First, the bill does not do away with prior authorization or other utilization review techniques; rather, it tries to make a more balanced approach for both patients and physicians by attempting to reduce the volume that’s subject to prior authorization, by increasing transparency and communication, and by studying how the process can be improved overall. Second, we have over 50 organizations representing health care providers and patient advocacy organizations supporting this legislation. This is a systemic issue across the entire spectrum of healthcare,” said Mr. Kerr.
Mr. Kerr went on to say there were 81,143 denials for treatment in 2021. The three areas with the highest rate of denials were pharmacy, dental, and the combination of labs and radiology.
He further noted that, when consumers filed a complaint with the Maryland Insurance Administration, 72.4% of denials were reversed in 2022.
“This resulted in more benefits that could have, and should have, been given to the patient at the first request. These reversals indicate there is a problem,” Mr. Kerr said. He discussed increased administrative costs, the enormous workload burden this incurs, and the problem of burnout among medical providers.
The proposed legislation includes a ban on PA requirements for generic medications, for dose changes of previously authorized medication, and ends the requirement for yearly authorizations. It requires that a physician of the same specialty be on the panel that denies care and shortens the time periods allowed for responses and appeals.
Testimony began with those supporting the legislation. Doctors highlighted the harm inflicted on their patients by the PA process. An oncologist spoke of how it took weeks to get approval for chemotherapy for a patient with an aggressive cancer, a gastroenterologist discussed a patient who became ill and lost her job when successful treatment for inflammatory bowel disease was stopped while she waited for the yearly medication reapproval, and another physician told of a patient who died of an exacerbation of obstructive lung disease, also while awaiting a yearly reapproval for an effective medication.
A dentist spoke about how he was not authorized to place a crown on a patient’s tooth. Instead, he was instructed to try a filling first, and when the filling failed, he was told he would not be authorized to work on the same tooth twice in one year.
A physical therapist testified that PA was required every two to four sessions, and each request took up half of a session – a significant portion of time that was not used for treatment.
Three people testified in opposition to the bill. Matthew Celantano, executive director of the League of Life and Health Insurers of Maryland, called the legislation “drastic” and testified that the cost would be prohibitive.
“From our end, it’s important for you to hear that prior authorization is care coordination. It’s protection that keeps [patients] safe, but helps control skyrocketing health care costs,” said Mr. Celantano.
Deb Rivkin, vice president of government affairs for CareFirst Blue Cross Blue Shield, testified in favor of using better technology. She cited legislation under consideration in Virginia that would give clinicians more information about the specific medications that require PAs, price information, and real-time authorizations.
Finally, representing the Pharmaceutical Care Management Association, Heather Cascone testified about PAs for generic medications. Her testimony focused on prior authorization for generic medications. She claimed that “... by allowing unrestricted dispensing of generic drugs, or an override based on the subjective opinion of the prescriber, prior authorization can protect patients from drugs with a safety risk; they can catch things like drug-disease contraindications, dosage errors, pregnancy-related contraindications, and a variety of cost-savings protections.”
I found this testimony particularly difficult because the “protector” is generally not a physician and has neither seen, nor examined, the patient. The implication that patients need protection from their doctors who would be unaware aware that they are pregnant, or are ill, was offensive. It also implies that PBMs are lax by not requiring PA on all medications, ignoring the fact that patients often bypass such denials by paying out of pocket for treatment.
If this had been a high school debate, there would be no doubt the enthusiasm for the bill for HB305 was strong, the committee chair was eager, and the arguments in favor of the legislation robust. There are no public minutes for the subsequent meetings with stakeholders, and I was somewhat heartbroken to learn that once again, the bill died in committee.
Annette Hanson, MD, chair of the MPS legislative committee, remains optimistic for the future. “Since then, the APA [American Psychiatric Association] has taken our bill and used it as model legislation now being offered to other district branches. MPS has created something that is going to spread across the country. Change may be slow, but it is not inevitable. And when it happens, I want you to remember that it started here,” she said.
However, the pressure is on. A recent ProPublica article documented how Cigna rejects claims by the batch without ever reviewing them. Soon after that piece was published, it was announced that several of the large insurers, including Cigna, would be cutting back on PA demands. It remains to be seen whether this is a token move to placate legislators, and whether it will provide meaningful relief to physicians and patients. I remain skeptical.
In the meantime, physicians’ ability to help their patients remains compromised and administrative tasks consume valuable time. I have started to wonder whether there may be some other way to push this issue to action. PA is about cost containment, but perhaps there are other ways to economize.
Why do medications cost less in other countries? Why does a medication cost hundreds of dollars more at one pharmacy versus another? Why do medicines sometimes have a copay that is two or three times higher than the cash price? Why do some covered medications have copays of thousands of dollars a year? I wonder if physicians shouldn’t come together and collectively agree not to comply and refuse to complete PAs in organized rebellion.
The fear, of course, is that such an endeavor would hurt patients, but if we all agreed in concert, then for better or for worse, something would have to give. The existing system is already hurting everyone, and physicians, by agreeing to play this awful game, are complicit in letting insurers dictate the care our patients receive.
Dinah Miller, MD, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016) and has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.
A version of this article first appeared on Medscape.com.
I imagine I am not alone when I tell you that my blood pressure rises every time I receive an email from CoverMyMeds, or worse, a phone call from a patient to tell me the pharmacist says I need to call their insurance company to get a medication authorized. Prior authorizations (PAs) are the bane of every physician’s existence.
They ask providers to jump through hoops, and no one oversees the placement of these hoops. The process puts patients at risk and sucks the joy from the practice of medicine.
In fall 2021, the legislative committee of the Maryland Psychiatric Society, with the help of Kathy Orellana and Tim Clement from the American Psychiatric Association, drafted a bill to modify the use of PAs. Unfortunately, the bill died in committee during the 2022 Maryland General Assembly legislative session.
Robert Herman, MD, who helped draft the initial legislation, was delighted when he learned that MedChi, the Maryland State Medical Society, had taken the proposed legislation and expanded it. “It was everything we wished for and more,” Dr. Herman said.
During this year’s legislative session, House Bill 305/Senate Bill 308, Health Insurance – Utilization Review – Revisions, was sponsored by 19 delegates and two senators. Fifty medical associations, including dentists and physical therapists, endorsed the bill. Many people, including Dr. Herman, testified before the Health and Government Operations Committee on Feb. 16.
Delegate Kenneth Kerr introduced the legislation to the committee.
“Before I begin, let me make two points. First, the bill does not do away with prior authorization or other utilization review techniques; rather, it tries to make a more balanced approach for both patients and physicians by attempting to reduce the volume that’s subject to prior authorization, by increasing transparency and communication, and by studying how the process can be improved overall. Second, we have over 50 organizations representing health care providers and patient advocacy organizations supporting this legislation. This is a systemic issue across the entire spectrum of healthcare,” said Mr. Kerr.
Mr. Kerr went on to say there were 81,143 denials for treatment in 2021. The three areas with the highest rate of denials were pharmacy, dental, and the combination of labs and radiology.
He further noted that, when consumers filed a complaint with the Maryland Insurance Administration, 72.4% of denials were reversed in 2022.
“This resulted in more benefits that could have, and should have, been given to the patient at the first request. These reversals indicate there is a problem,” Mr. Kerr said. He discussed increased administrative costs, the enormous workload burden this incurs, and the problem of burnout among medical providers.
The proposed legislation includes a ban on PA requirements for generic medications, for dose changes of previously authorized medication, and ends the requirement for yearly authorizations. It requires that a physician of the same specialty be on the panel that denies care and shortens the time periods allowed for responses and appeals.
Testimony began with those supporting the legislation. Doctors highlighted the harm inflicted on their patients by the PA process. An oncologist spoke of how it took weeks to get approval for chemotherapy for a patient with an aggressive cancer, a gastroenterologist discussed a patient who became ill and lost her job when successful treatment for inflammatory bowel disease was stopped while she waited for the yearly medication reapproval, and another physician told of a patient who died of an exacerbation of obstructive lung disease, also while awaiting a yearly reapproval for an effective medication.
A dentist spoke about how he was not authorized to place a crown on a patient’s tooth. Instead, he was instructed to try a filling first, and when the filling failed, he was told he would not be authorized to work on the same tooth twice in one year.
A physical therapist testified that PA was required every two to four sessions, and each request took up half of a session – a significant portion of time that was not used for treatment.
Three people testified in opposition to the bill. Matthew Celantano, executive director of the League of Life and Health Insurers of Maryland, called the legislation “drastic” and testified that the cost would be prohibitive.
“From our end, it’s important for you to hear that prior authorization is care coordination. It’s protection that keeps [patients] safe, but helps control skyrocketing health care costs,” said Mr. Celantano.
Deb Rivkin, vice president of government affairs for CareFirst Blue Cross Blue Shield, testified in favor of using better technology. She cited legislation under consideration in Virginia that would give clinicians more information about the specific medications that require PAs, price information, and real-time authorizations.
Finally, representing the Pharmaceutical Care Management Association, Heather Cascone testified about PAs for generic medications. Her testimony focused on prior authorization for generic medications. She claimed that “... by allowing unrestricted dispensing of generic drugs, or an override based on the subjective opinion of the prescriber, prior authorization can protect patients from drugs with a safety risk; they can catch things like drug-disease contraindications, dosage errors, pregnancy-related contraindications, and a variety of cost-savings protections.”
I found this testimony particularly difficult because the “protector” is generally not a physician and has neither seen, nor examined, the patient. The implication that patients need protection from their doctors who would be unaware aware that they are pregnant, or are ill, was offensive. It also implies that PBMs are lax by not requiring PA on all medications, ignoring the fact that patients often bypass such denials by paying out of pocket for treatment.
If this had been a high school debate, there would be no doubt the enthusiasm for the bill for HB305 was strong, the committee chair was eager, and the arguments in favor of the legislation robust. There are no public minutes for the subsequent meetings with stakeholders, and I was somewhat heartbroken to learn that once again, the bill died in committee.
Annette Hanson, MD, chair of the MPS legislative committee, remains optimistic for the future. “Since then, the APA [American Psychiatric Association] has taken our bill and used it as model legislation now being offered to other district branches. MPS has created something that is going to spread across the country. Change may be slow, but it is not inevitable. And when it happens, I want you to remember that it started here,” she said.
However, the pressure is on. A recent ProPublica article documented how Cigna rejects claims by the batch without ever reviewing them. Soon after that piece was published, it was announced that several of the large insurers, including Cigna, would be cutting back on PA demands. It remains to be seen whether this is a token move to placate legislators, and whether it will provide meaningful relief to physicians and patients. I remain skeptical.
In the meantime, physicians’ ability to help their patients remains compromised and administrative tasks consume valuable time. I have started to wonder whether there may be some other way to push this issue to action. PA is about cost containment, but perhaps there are other ways to economize.
Why do medications cost less in other countries? Why does a medication cost hundreds of dollars more at one pharmacy versus another? Why do medicines sometimes have a copay that is two or three times higher than the cash price? Why do some covered medications have copays of thousands of dollars a year? I wonder if physicians shouldn’t come together and collectively agree not to comply and refuse to complete PAs in organized rebellion.
The fear, of course, is that such an endeavor would hurt patients, but if we all agreed in concert, then for better or for worse, something would have to give. The existing system is already hurting everyone, and physicians, by agreeing to play this awful game, are complicit in letting insurers dictate the care our patients receive.
Dinah Miller, MD, is a coauthor of Committed: The Battle Over Involuntary Psychiatric Care (Johns Hopkins University Press, 2016) and has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins in Baltimore.
A version of this article first appeared on Medscape.com.
Integrating addiction medicine with primary care cost effective: Study
Integrating buprenorphine and harm eduction tools into primary care may improve clinical outcomes, increase costs only modestly, and be cost effective in health systems, authors conclude in an original investigation in JAMA Network Open.
A team led by Raagini Jawa, MD, MPH, with the Center for Research on Healthcare, University of Pittsburgh, set out to analyze costs of the interventions versus increased benefit in extending life expectancy.
Their analysis found that, compared with the status quo, integrating buprenorphine and harm reduction kits (syringes, wound care supplies, etc.) reduced drug use–related deaths by 33% and was cost effective.
“Our results suggest that integrated addiction care in primary care has the potential to save lives and increase nonemergency health care use, which is consistent with prior literature,” the authors write. “Colocated addiction services within primary care is pragmatic and effective and has comparable quality to specialty care. We found that onsite BUP [buprenorphine prescribing] plus HR [harm reduction] provides better outcomes than BUP alone at a lower cost.”
Three strategies compared
Using a microsimulation model of 2.25 million people in the United States who inject opioids, with an average age of 44 (69% of them male), the researchers tested three strategies:
- Status quo. PCP refers to addiction care.
- BUP. PCP services plus onsite buprenorphine prescribing with referral to off-site harm reduction kits.
- BUP plus HR. PCP services plus on-site buprenorphine prescribing and harm reduction kits.
The model is the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death.
The status quo (referral for treatment) resulted in 1,162 overdose deaths per 10,000 people (95% credible interval, 1,144-2,303), whereas both BUP and BUP plus HR resulted in about 160 fewer deaths per 10,000 people (95% Crl for BUP, 802-1718; 95% CrI for BUP plus HR, 692-1,810).
Compared with the status quo strategy, life expectancy was lengthened with the BUP strategy by 2.65 years and BUP plus HR by 2.71 years.
Researchers found the average discounted lifetime cost per person of both the BUP strategy and the BUP plus HR strategy were higher than the average status quo.
“The dominating strategy was BUP plus HR,” the authors write. “Compared with status quo, BUP plus HR was cost effective (incremental cost-effectiveness ratio [ICER], $34,400 per life year).”
Cost for primary care practices
Comparatively, over a 5-year period, BUP plus HR was found to cost an individual PCP practice approximately $13,000.
That cost includes direct costs for resources and opportunity costs, the authors write. These costs could be offset by health care system savings.
“These costs included those for X-waiver training, which has been eliminated; thus, we expect this to cost less. Put another way, our findings inform ways to reinvest health care dollars as financial incentives for PCPs to adopt this new paradigm. Public health departments could provide grants or harm reduction kit supplies directly to PCPs to offset these costs as they do in some places with syringe service programs and/or increase Medicaid reimbursements for providing addiction care in primary care,” they write.
Data help make the case
Dinah Applewhite, MD, a primary care physician and addiction medicine specialist at Massachusetts General Hospital in Boston, who was not part of the study, said clinicians there have seen the benefits of integrating various aspects of addiction medicine into primary care but these data on outcomes and cost-effectiveness can help make the case to hospital leaders, legislators, and grant providers.
The primary care setting also provides a chance to engage patients around their injection practice and explore ways to minimize risk, she said.
“By offering them these kits, it lets them know your priority is their safety and well-being,” Dr. Applewhite said.
She noted that the linkage to primary care was low for patients who inject drugs, which speaks to the need for models in addition to this one, such as bringing primary care clinicians into syringe service programs.
“The medical establishment has a lot to learn from these programs,” she said.
Practices need support
She said it’s important to note that primary care practices need support from administrative leaders, philanthropists, and grant providers to help cover the costs.
“It’s one of the barriers to doing this,” she said. “There isn’t a mechanism to pay for this.”
Sarah Bagley, MD, a primary care physician at Boston Medical Center and medical director of BMC’s Center for Addiction Treatment for Adolescents/Young Adults Who Use Substances told this publication she was excited to see that the addition of harm reduction kits to buprenorphine seemed to have the optimal effect in improving outcomes. People with substance abuse disorders should feel they are welcome in primary care even if they are not yet ready to stop drug use, she said.
She said she was also glad to see increased life expectancy with these interventions. The news of overdose deaths contributing to a decrease in life expectancy can be overwhelming, she said.
But this study, she says, offers a road map for addressing the overdose crisis “by including harm reduction in the substance abuse care we provide.”
She pointed out that the study showed that costs increase per patient with both interventions, compared with the status quo. The study found that health care costs per person during a lifetime increased, compared with the status quo, by 69.1% for BUP and 74.3% for BUP plus HR.
But it’s important to understand the reason for that, she said: “The cost was higher because people were staying alive.”
She said it may help to compare giving optimal care to people who have substance abuse disorders with giving optimal care to people with other chronic conditions, such as diabetes, who may not always adhere to recommended diets or treatment regimens.
“We still invite those patients in and work with them based on where they are,” she said.
Growing epidemic
The researchers point to the urgent need for solutions given the U.S. opioid epidemic, which has led to increasing numbers of overdoses and injection drug use–related infections, such as infective endocarditis, and severe skin and soft tissue infections.
They point out that primary care providers are the largest clinical workforce in the United States, but few of their practices offer comprehensive addiction care onsite.
“Primary care practices are a practical place to integrate addiction services, where PCPs can prescribe buprenorphine and deliver harm reduction kits,” they write.
Coauthor Dr. Kimmel reports personal fees from Massachusetts Department of Public Health, Bureau of Substance Addiction Services Overdose Education and Prevention Program, and American Academy of Addiction Psychiatry, Opioid Response Network for harm reduction education outside the submitted work and previous consulting with Abt Associates on a Massachusetts Department of Public Health–funded project to improve access to medications for opioid use disorder treatment. Dr. Applewhite and Dr. Bagley report no relevant financial relationships.
Integrating buprenorphine and harm eduction tools into primary care may improve clinical outcomes, increase costs only modestly, and be cost effective in health systems, authors conclude in an original investigation in JAMA Network Open.
A team led by Raagini Jawa, MD, MPH, with the Center for Research on Healthcare, University of Pittsburgh, set out to analyze costs of the interventions versus increased benefit in extending life expectancy.
Their analysis found that, compared with the status quo, integrating buprenorphine and harm reduction kits (syringes, wound care supplies, etc.) reduced drug use–related deaths by 33% and was cost effective.
“Our results suggest that integrated addiction care in primary care has the potential to save lives and increase nonemergency health care use, which is consistent with prior literature,” the authors write. “Colocated addiction services within primary care is pragmatic and effective and has comparable quality to specialty care. We found that onsite BUP [buprenorphine prescribing] plus HR [harm reduction] provides better outcomes than BUP alone at a lower cost.”
Three strategies compared
Using a microsimulation model of 2.25 million people in the United States who inject opioids, with an average age of 44 (69% of them male), the researchers tested three strategies:
- Status quo. PCP refers to addiction care.
- BUP. PCP services plus onsite buprenorphine prescribing with referral to off-site harm reduction kits.
- BUP plus HR. PCP services plus on-site buprenorphine prescribing and harm reduction kits.
The model is the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death.
The status quo (referral for treatment) resulted in 1,162 overdose deaths per 10,000 people (95% credible interval, 1,144-2,303), whereas both BUP and BUP plus HR resulted in about 160 fewer deaths per 10,000 people (95% Crl for BUP, 802-1718; 95% CrI for BUP plus HR, 692-1,810).
Compared with the status quo strategy, life expectancy was lengthened with the BUP strategy by 2.65 years and BUP plus HR by 2.71 years.
Researchers found the average discounted lifetime cost per person of both the BUP strategy and the BUP plus HR strategy were higher than the average status quo.
“The dominating strategy was BUP plus HR,” the authors write. “Compared with status quo, BUP plus HR was cost effective (incremental cost-effectiveness ratio [ICER], $34,400 per life year).”
Cost for primary care practices
Comparatively, over a 5-year period, BUP plus HR was found to cost an individual PCP practice approximately $13,000.
That cost includes direct costs for resources and opportunity costs, the authors write. These costs could be offset by health care system savings.
“These costs included those for X-waiver training, which has been eliminated; thus, we expect this to cost less. Put another way, our findings inform ways to reinvest health care dollars as financial incentives for PCPs to adopt this new paradigm. Public health departments could provide grants or harm reduction kit supplies directly to PCPs to offset these costs as they do in some places with syringe service programs and/or increase Medicaid reimbursements for providing addiction care in primary care,” they write.
Data help make the case
Dinah Applewhite, MD, a primary care physician and addiction medicine specialist at Massachusetts General Hospital in Boston, who was not part of the study, said clinicians there have seen the benefits of integrating various aspects of addiction medicine into primary care but these data on outcomes and cost-effectiveness can help make the case to hospital leaders, legislators, and grant providers.
The primary care setting also provides a chance to engage patients around their injection practice and explore ways to minimize risk, she said.
“By offering them these kits, it lets them know your priority is their safety and well-being,” Dr. Applewhite said.
She noted that the linkage to primary care was low for patients who inject drugs, which speaks to the need for models in addition to this one, such as bringing primary care clinicians into syringe service programs.
“The medical establishment has a lot to learn from these programs,” she said.
Practices need support
She said it’s important to note that primary care practices need support from administrative leaders, philanthropists, and grant providers to help cover the costs.
“It’s one of the barriers to doing this,” she said. “There isn’t a mechanism to pay for this.”
Sarah Bagley, MD, a primary care physician at Boston Medical Center and medical director of BMC’s Center for Addiction Treatment for Adolescents/Young Adults Who Use Substances told this publication she was excited to see that the addition of harm reduction kits to buprenorphine seemed to have the optimal effect in improving outcomes. People with substance abuse disorders should feel they are welcome in primary care even if they are not yet ready to stop drug use, she said.
She said she was also glad to see increased life expectancy with these interventions. The news of overdose deaths contributing to a decrease in life expectancy can be overwhelming, she said.
But this study, she says, offers a road map for addressing the overdose crisis “by including harm reduction in the substance abuse care we provide.”
She pointed out that the study showed that costs increase per patient with both interventions, compared with the status quo. The study found that health care costs per person during a lifetime increased, compared with the status quo, by 69.1% for BUP and 74.3% for BUP plus HR.
But it’s important to understand the reason for that, she said: “The cost was higher because people were staying alive.”
She said it may help to compare giving optimal care to people who have substance abuse disorders with giving optimal care to people with other chronic conditions, such as diabetes, who may not always adhere to recommended diets or treatment regimens.
“We still invite those patients in and work with them based on where they are,” she said.
Growing epidemic
The researchers point to the urgent need for solutions given the U.S. opioid epidemic, which has led to increasing numbers of overdoses and injection drug use–related infections, such as infective endocarditis, and severe skin and soft tissue infections.
They point out that primary care providers are the largest clinical workforce in the United States, but few of their practices offer comprehensive addiction care onsite.
“Primary care practices are a practical place to integrate addiction services, where PCPs can prescribe buprenorphine and deliver harm reduction kits,” they write.
Coauthor Dr. Kimmel reports personal fees from Massachusetts Department of Public Health, Bureau of Substance Addiction Services Overdose Education and Prevention Program, and American Academy of Addiction Psychiatry, Opioid Response Network for harm reduction education outside the submitted work and previous consulting with Abt Associates on a Massachusetts Department of Public Health–funded project to improve access to medications for opioid use disorder treatment. Dr. Applewhite and Dr. Bagley report no relevant financial relationships.
Integrating buprenorphine and harm eduction tools into primary care may improve clinical outcomes, increase costs only modestly, and be cost effective in health systems, authors conclude in an original investigation in JAMA Network Open.
A team led by Raagini Jawa, MD, MPH, with the Center for Research on Healthcare, University of Pittsburgh, set out to analyze costs of the interventions versus increased benefit in extending life expectancy.
Their analysis found that, compared with the status quo, integrating buprenorphine and harm reduction kits (syringes, wound care supplies, etc.) reduced drug use–related deaths by 33% and was cost effective.
“Our results suggest that integrated addiction care in primary care has the potential to save lives and increase nonemergency health care use, which is consistent with prior literature,” the authors write. “Colocated addiction services within primary care is pragmatic and effective and has comparable quality to specialty care. We found that onsite BUP [buprenorphine prescribing] plus HR [harm reduction] provides better outcomes than BUP alone at a lower cost.”
Three strategies compared
Using a microsimulation model of 2.25 million people in the United States who inject opioids, with an average age of 44 (69% of them male), the researchers tested three strategies:
- Status quo. PCP refers to addiction care.
- BUP. PCP services plus onsite buprenorphine prescribing with referral to off-site harm reduction kits.
- BUP plus HR. PCP services plus on-site buprenorphine prescribing and harm reduction kits.
The model is the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death.
The status quo (referral for treatment) resulted in 1,162 overdose deaths per 10,000 people (95% credible interval, 1,144-2,303), whereas both BUP and BUP plus HR resulted in about 160 fewer deaths per 10,000 people (95% Crl for BUP, 802-1718; 95% CrI for BUP plus HR, 692-1,810).
Compared with the status quo strategy, life expectancy was lengthened with the BUP strategy by 2.65 years and BUP plus HR by 2.71 years.
Researchers found the average discounted lifetime cost per person of both the BUP strategy and the BUP plus HR strategy were higher than the average status quo.
“The dominating strategy was BUP plus HR,” the authors write. “Compared with status quo, BUP plus HR was cost effective (incremental cost-effectiveness ratio [ICER], $34,400 per life year).”
Cost for primary care practices
Comparatively, over a 5-year period, BUP plus HR was found to cost an individual PCP practice approximately $13,000.
That cost includes direct costs for resources and opportunity costs, the authors write. These costs could be offset by health care system savings.
“These costs included those for X-waiver training, which has been eliminated; thus, we expect this to cost less. Put another way, our findings inform ways to reinvest health care dollars as financial incentives for PCPs to adopt this new paradigm. Public health departments could provide grants or harm reduction kit supplies directly to PCPs to offset these costs as they do in some places with syringe service programs and/or increase Medicaid reimbursements for providing addiction care in primary care,” they write.
Data help make the case
Dinah Applewhite, MD, a primary care physician and addiction medicine specialist at Massachusetts General Hospital in Boston, who was not part of the study, said clinicians there have seen the benefits of integrating various aspects of addiction medicine into primary care but these data on outcomes and cost-effectiveness can help make the case to hospital leaders, legislators, and grant providers.
The primary care setting also provides a chance to engage patients around their injection practice and explore ways to minimize risk, she said.
“By offering them these kits, it lets them know your priority is their safety and well-being,” Dr. Applewhite said.
She noted that the linkage to primary care was low for patients who inject drugs, which speaks to the need for models in addition to this one, such as bringing primary care clinicians into syringe service programs.
“The medical establishment has a lot to learn from these programs,” she said.
Practices need support
She said it’s important to note that primary care practices need support from administrative leaders, philanthropists, and grant providers to help cover the costs.
“It’s one of the barriers to doing this,” she said. “There isn’t a mechanism to pay for this.”
Sarah Bagley, MD, a primary care physician at Boston Medical Center and medical director of BMC’s Center for Addiction Treatment for Adolescents/Young Adults Who Use Substances told this publication she was excited to see that the addition of harm reduction kits to buprenorphine seemed to have the optimal effect in improving outcomes. People with substance abuse disorders should feel they are welcome in primary care even if they are not yet ready to stop drug use, she said.
She said she was also glad to see increased life expectancy with these interventions. The news of overdose deaths contributing to a decrease in life expectancy can be overwhelming, she said.
But this study, she says, offers a road map for addressing the overdose crisis “by including harm reduction in the substance abuse care we provide.”
She pointed out that the study showed that costs increase per patient with both interventions, compared with the status quo. The study found that health care costs per person during a lifetime increased, compared with the status quo, by 69.1% for BUP and 74.3% for BUP plus HR.
But it’s important to understand the reason for that, she said: “The cost was higher because people were staying alive.”
She said it may help to compare giving optimal care to people who have substance abuse disorders with giving optimal care to people with other chronic conditions, such as diabetes, who may not always adhere to recommended diets or treatment regimens.
“We still invite those patients in and work with them based on where they are,” she said.
Growing epidemic
The researchers point to the urgent need for solutions given the U.S. opioid epidemic, which has led to increasing numbers of overdoses and injection drug use–related infections, such as infective endocarditis, and severe skin and soft tissue infections.
They point out that primary care providers are the largest clinical workforce in the United States, but few of their practices offer comprehensive addiction care onsite.
“Primary care practices are a practical place to integrate addiction services, where PCPs can prescribe buprenorphine and deliver harm reduction kits,” they write.
Coauthor Dr. Kimmel reports personal fees from Massachusetts Department of Public Health, Bureau of Substance Addiction Services Overdose Education and Prevention Program, and American Academy of Addiction Psychiatry, Opioid Response Network for harm reduction education outside the submitted work and previous consulting with Abt Associates on a Massachusetts Department of Public Health–funded project to improve access to medications for opioid use disorder treatment. Dr. Applewhite and Dr. Bagley report no relevant financial relationships.
JAMA NETWORK OPEN