Tuesday, September 27, 2016

TMA Tries to Lift New Medicare Burden from Small Practices

Patients in some Texas communities may not know their doctor is under immense pressure to adapt to a new law that will determine how they provide care and get paid. According to Texas Medicine magazine, the new government requirement is putting a strain on smaller medical practices — and over time, could force some doctors to retire or surrender their small medical practice. That could reduce patients’ access to doctors’ care.

Congress passed the new law, the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, primarily to replace Medicare’s controversial Sustainable Growth Rate (SGR) formula. Physicians argued the SGR payment formula was flawed because it ignored the cost to care for Medicare patients. Congress passed emergency funding patches each year for a decade to avoid cutting physicians’ pay significantly for caring for America’s seniors and people with disabilities. The SGR forced doctors out of Medicare, leaving patients uncertain over whether their doctor would be there to care for them. MACRA ended that uncertainty.

However, Texas Medical Association (TMA) President Don R. Read, MD, said MACRA is “not what Congress ordered.” It forces doctors to deal with a new set of bureaucratic hassles and payment hurdles. The new law incorporated existing government programs intended to measure physicians’ health care quality — programs doctors also saw as problematic. “When MACRA legislation was enacted, TMA had no reason to expect CMS [Centers for Medicare & Medicaid Services, which oversees Medicare] would propose to continue flawed concepts from the current quality programs along with plans to diminish a physician’s worth down to a complex point system. More disappointing is to learn that CMS proposes to design a program that is stacked against solo physicians and small group practices in its first year of implementation,” said Dr. Read.

MACRA’s two payment options for physicians came with new quality-reporting requirements. Doctors are forced to invest in computer software to capture and report data, and in training to comply by Jan. 1, 2017 — too little time to prepare, in physicians’ minds.

The government’s draft MACRA rule forecast that nearly all smaller physician practices would struggle to adapt. It estimated in the first year MACRA would cut Medicare payments for almost nine in 10 solo doctors, almost three-quarters of small practices (two to nine eligible clinicians), and 59 percent of practices with 10 to 24 eligible physicians.

In Texas, more than 60 percent of patient care physicians are in very small practices of one to three physicians,” TMA wrote CMS in response to the MACRA forecast. “MACRA is very likely to levy penalties on most of them, pushing some or all of them over time to retire, or join large groups or hospitals.”

Some doctors, like Dallas cardiologist Rick Snyder, MD, (a member of TMA’s Board of Trustees) insist even his large and sophisticated practice can’t make it under Medicare’s proposed new pay-for-quality rule. “We pride ourselves on being cutting-edge on regulatory compliance, [but] there’s no way in the world we are going to be ready Jan. 1. Our goal is just not to lose money.”

So in its letter to CMS, TMA recommended the government delay the deadline to start collecting physicians’ data six months, until July 2017, to give doctors more time to prepare. In response to TMA’s letter and a top CMS officer’s meeting with Drs. Read, Snyder and other TMA leaders, federal officials say they will temporarily exempt physicians from penalties if they simply choose one of three reporting options in 2017. Practices struggling to adopt the changes can avoid pay cuts in 2019 by at least attempting to report some data in 2017.

Immediate crisis averted perhaps, but TMA and physician leaders say significant amounts of work remain to make the new law tenable for physicians and the patients in their care.

U.S. Rep. Michael Burgess, MD (R-Lewisville), the primary House author of the MACRA bill and a TMA-member obstetrician-gynecologist, says it’s up to organizations like TMA to show physicians how to be successful in the post-SGR world. “My hope is, people will look at 2019, see the risk of a ding, and realize with a little bit of work they can get a payment bump up. So instead of a ding, you get a bump. How’s that? That would be good,” Rep. Burgess said.

Dr. Read said TMA will continue to offer CMS and Congress recommendations to improve MACRA and protect physicians and their patients. “We strongly believe Congress did not intend many of the adverse consequences that will be the result of the new payment formula. We are hopeful that CMS will use its considerable discretion to act in every way possible to minimize the adverse impact.”

Thursday, September 15, 2016

Improve Naloxone Distribution to Curb Overdoses

By Don R. Read, MD
President, Texas Medical Association

It is now one year since Texas doctors have been able to get the lifesaving drug naloxone to people who can use it to help themselves and others avoid the effects of a drug overdose. Giving people access to a drug that can save someone else’s life is a huge opportunity to prevent overdoses. However, are we doing enough to get this drug to the people who need it?

Naloxone prevents a drug overdose by blocking another drug’s bad effects. The 2015 Texas Legislature permitted doctors to write standing orders, or prescriptions, for naloxone. The law allows any pharmacy that has a standing order to dispense naloxone to anyone who asks for it, to keep on hand as a precaution.

This can help people in danger of overdosing — and people who could save others from overdosing, like people who work with the public, or those with friends or family members who use potentially dangerous drugs.

Drug addiction and overdose are serious problems in Texas, and a top cause of accidental injury and death among adults. Overdoses from prescription opioids (painkillers) such as fentanyl, hydrocodone, and oxycodone, or illegal opiates such as heroin, affect Texans of every class, ethnicity, sex, and age.

Not everyone who overdoses is addicted to drugs. Sometimes people who take prescription pain medication accidentally take too much. Naloxone could help anyone in an emergency. Naloxone can prevent death if the victim takes it in time to stop the imminent threat, and then receive more extensive, necessary emergency care.

Nevertheless, true drug addiction is a complex disease, and our response for our patients should be as well. Here is what we need in Texas to accomplish this:

  • We must get naloxone to more people who need it — in their own community.
  • We must raise public awareness about overdosing — especially from prescription drugs. We need community training to handle overdoses so emergency responders and others can recognize overdose symptoms and give the victim naloxone.
  • We must get more people into effective treatment. Recovery from drug addiction takes a long time, and a person may need more than one approach to succeed.
  • We physicians must be fully informed about prescribing opioids and naloxone. Doctors who prescribe painkillers must talk to patients about drug risks, learn the best ways to treat pain safely, and prescribe naloxone.
  • We must keep better track of prescriptions for opioids. Physicians and others can make better use of our state’s prescription database of controlled drugs like opioids to make sure patients aren’t “doctor shopping” for them.
  • We must improve information-gathering. Not all prescription drug deaths are counted because Texas does not have a standard way to report them. Better reporting would help us understand what is happening in our state.

Physicians applaud and support everyone working to solve our state’s opioid overdose problem, like groups that raise awareness about opioids and drug addiction, and lawmakers and regulators seeking to shut down unethical pain clinics, or “pill mills.”

We also urge others to be leaders in this effort. We need a statewide dialogue on working together to find solutions. We need community partners willing to make sure naloxone is available to treatment programs and emergency medical services. Texas must fund treatment based on scientific evidence. State leaders, and state and local health departments can be important partners in saving lives.

Texas is not alone in passing laws to make naloxone more available to people; all but three states have such laws. We can follow other states’ methods for cutting overdoses and getting naloxone to those who need it: pilot programs to distribute the drug; local or statewide opioid prevention plans; Good Samaritan protections for anyone who witnesses an overdose and calls 911; and public awareness campaigns.

The health — and lives — of many Texans is at stake.

Monday, September 12, 2016

Physicians Urge Greater Patient Access to Anti-Overdose Drug

As opioid drug overdoses continue to take a toll nationally, Texas physicians continue the push to spread naloxone ― a medication to reverse the effects of an opioid overdose — to every corner of the state, according to the Texas Medical Association’s (TMA’s) September Texas Medicine magazine.

Last year, the Texas Legislature passed Senate Bill 1462 by Sen. Royce West (D-Dallas), making it legal for laypeople to administer naloxone outside a medical care setting. The law cleared the way for physicians to prescribe naloxone not only to patients but also to family members or friends of those who might be at risk of an overdose. The law also allows a person or organization acting under a standing order to distribute naloxone and allows pharmacies to dispense the drug. TMA strongly supported the life-saving law.

Drug addiction and overdose are top causes of accidental injury and death among adults. Texans overdose on illegal opiates such as heroin, as well as legal prescription opioids (painkillers) such as fentanyl, hydrocodone, and oxycodone. Many deaths can be prevented if the overdose victim can take naloxone and receive emergency care, because the drug rapidly blocks the effects of the opioid, even heroin, long enough for patients to get more advanced treatment.

Since the law’s passing, Texas physicians have issued several standing orders for pharmacies to allow anyone to get the drug without a prescription from their doctor. Texas Walgreens and CVS pharmacies both have obtained standing orders for naloxone because of the new law. This summer, the Texas Pharmacy Association (TPA) announced it would implement a physician’s standing order authorizing pharmacists to dispense naloxone after they had completed a one-hour training course.

“I felt the standing order was important because we’re currently in a historic opioid epidemic in our country and our state,” said Austin addiction psychiatrist Carlos Tirado, MD, who issued the standing order for TPA.

Alicia Kowalchuk, DO, an assistant professor in Baylor College of Medicine’s Department of Family and Community Medicine, wrote the blanket order for Walgreens. But she cautions that naloxone is not a “be-all, end-all,” as the effects of the overdose kit last only 30 to 90 minutes, while the effects of opioids can last four hours to 12 hours or more.

“They still need treatment immediately after this kit is used for them,” Dr. Kowalchuk said. “That’s where you really need the education of the person who’s going to be using the overdose kit for their loved one or their associate, … that they do need to stay with the person, encourage them to not use [the opiate] on top of it, and get them appropriate medical care emergently.”

While the law theoretically makes naloxone more available, the rising cost of the drug in recent years has physicians concerned that lower-income Texans are being priced out of the life-saving medication.

“The price has certainly gone up quite a bit, and health plans, regulators, and consumers should certainly demand that the price of this medication does not become inflated. There is too much at stake for people not to have access to this medication,” said Dr. Tirado.

TMA has adopted comprehensive policy on opioid overdose prevention and prescription drug monitoring. TMA supports “Good Samaritan” legislation that would in certain situations legally protect drug users who request emergency assistance for a fellow user who overdoses. TMA wants to continue working with lawmakers to develop a Good Samaritan law for Texas.

Meanwhile, Texas physicians are working to raise awareness of prescription drug abuse and lessen the stigma associated with opioid addicts.

“The medical community by and large understands that this disorder is more than just having a weak will or being an unfit or delinquent person or a person fundamentally lacking in moral character,” Dr. Tirado said. “As more good research on the neurobiology of addiction comes out, we’re going to see even more awareness and acceptance of the fact that addiction, if we’re really going to deal with it effectively in our culture, is better addressed as a chronic relapsing condition, as a public health matter, and not necessarily as a legal and moral matter.”

Thursday, September 8, 2016

Prostate Cancer Screening Saves Lives

By Sid Roberts, MD
Lufkin Radiation Oncologist

This article originally appeared on Dr. Roberts' blog

Over the last 30 years, I have been witness to a remarkable change in how we diagnose and treat prostate cancer. Prior to the mid-1980s, prostate cancer was detected most often when symptoms of advanced prostate cancer were present, such as bone pain from metastatic disease. Very few patients were diagnosed at a curable stage.

The PSA (prostate-specific antigen) blood test came into wide use around 1986 when the FDA approved it for monitoring known prostate cancer. In the early 1990s, physicians started ordering it to detect early, asymptomatic prostate cancer. A spike in prostate cancer diagnosis happened. This wave of patients was a boon to treating physicians, primarily urologists who operate on prostate cancer, but also for radiation oncologists who treat cancer with various types of radiation. More early diagnoses also led to more clinical trials about how best to treat prostate cancer.

We learned a lot. Techniques for removing the prostate got better with the advent of robotic-assisted prostatectomy, as did precision and dose of radiation delivery with intensity modulated radiation treatment. The 15-year relative survival rate for prostate cancer is now an astounding 95%.

But we also learned that not every man with prostate cancer needs treatment.

How can we say this? How can we diagnose someone with cancer and then say, “Oh, by the way, you don't need to do anything about it”? Add to this confusion the 2012 US Preventive Services Task Force recommendation to do away with screening altogether because of the risk of over-diagnosis and harm. In my opinion, that is a dangerous step backward for many of us guys who will get prostate cancer.

Granted, we are too aggressive about treating some prostate cancers. It is easy to vilify doctors who are incentivized to treat rather than watch and wait. But I think a big part of the problem in the US is that patients don't want to be told they have cancer and nothing needs to be done about it, especially when all this wonderful technology exists and insurance will pay for it.

What’s the solution?

We have very good tools now for determining aggressiveness of an individual patient's prostate cancer. That, along with evaluation of a patient's age and overall health status, helps us predict quite well whether or not a particular patient's prostate cancer will ever be a problem for them without treatment. Over treatment can be just as much of an error as under treatment or the wrong treatment. Know all your options for treatment if you need it; no single treatment is right for everyone. Get a second opinion if you haven’t gotten a good explanation about your need for treatment and what your full options are. And, yes, don’t even get screened for prostate cancer if your age and health status are such that you wouldn’t benefit from treatment anyway.

In the near future, there are certain pathologies that we call cancer now that we will no longer label as malignant, as they simply don't act like cancer. (It is a lot easier to say we don't need to treat a condition if we don't call it cancer.) In addition, genetic testing may add to our ability to individualize decision-making based on aggressiveness and risk of spread and progression of disease.

The American Cancer Society continues to support screening for prostate cancer, because they know that screening saves lives. If you are 50 or older – 45 for African American men – and are likely to live for ten years or more, get a PSA blood test. Do it regularly. Go to www.cancer.org for more information. Man up; take charge of your health.


Dr. Sid Roberts is a radiation oncologist at the Arthur Temple, Sr. Regional Cancer Center in Lufkin. He is a contributing writer for the Lufkin Daily News and blogs at SRob61.blogspot.com

Wednesday, September 7, 2016

American Academy of Pediatrics: End Nonmedical Vaccine Exemptions for Child Care and School Attendance

By Lisa Swanson, MD
Mesquite Pediatrician
Chair of the Texas Medical Association Council on Child and Adolescent Health

The American Academy of Pediatrics (AAP) recently issued a statement calling for governments to enact policies that allow only medical exemptions to vaccinations required for child care and school. The desired result of high vaccination rates will help ensure no child has to suffer through a disease that could have been prevented by a vaccine.

The AAP statement is in response to a growing number of pockets of unvaccinated children around the country. Many of the parents who choose not to vaccinate their children have received misleading or untrue information. And many vaccine refusers think the diseases against which we vaccinate no longer exist, even though they are circulating worldwide.

Low vaccination rates put children who cannot be vaccinated — such as those with medical problems or those who are too young to be vaccinated — at high risk for becoming ill or dying from a vaccine-preventable illness.

For babies born in United States in 2009, routine childhood immunization will prevent about 42,000 early deaths and 20 million cases of disease, according to a report published in the medical journal Pediatrics, saving $13.5 billion in direct costs and $68.8 billion in societal costs.

Vaccinating children makes sense from both a humanitarian and a financial viewpoint. It is time for Texas to eliminate nonmedical exemptions to vaccines.

Tuesday, August 30, 2016

Infographic: Adults Need Vaccinations, Too

It’s not just kids who need protection against the deadly diseases vaccines prevent — grown-ups need to get vaccinated, too. Whether it is the yearly flu shot, a booster shot to maintain immunity against diseases (like tetanus and diphtheria), the whooping cough vaccine to protect the littlest loved ones from the infection’s deadly complications, or shots for diseases specific to adults (like shingles), vaccinations should be a top health priority for all adults.

Check out TMA’s latest infographic on adult immunizations, why they are necessary, and who should get which vaccines. The graphic is also available in Spanish.

Ask your doctor if you’ve had all the shots you need. Most insurance plans now pay for vaccinations at no cost to you.

(Click image for higher resolution.)

Friday, August 26, 2016

The Humble Flu Shot Protects Seniors From a Host of Illnesses

By Erica Swegler, MD, Austin Family Physician
Member, TMA Be Wise — ImmunizeSM Advisory Panel

Imagine the headlines: "If you’re over age 65, you’re half as likely to die in the next year if you take (product XYZ)!"

"What?" you ask, "We have such a thing?" The answer is YES. If you are over age 65, you can decrease your risk of dying of any cause by about 50 percent in the coming year if you get an immunization of the high-dose flu vaccine (HD flu vaccine).

This HD flu vaccine is four times as potent as a traditional flu shot. For a year after getting the high-dose vaccine, you will:

  • Decrease your chance of dying of a stroke by 65 percent,
  • Decrease your risk of dying of kidney disease by 60 percent,
  • Decrease your risk of death from diabetes by 55 percent,
  • Decrease your risk of dying of pneumonia by 53 percent, and
  • Decrease your risk of dying of heart disease by 22 percent.

Two studies published during the past two years say you are less likely to have a heart attack (or die from one) if you had a flu shot in the year preceding it. Given this excellent data, as a physician interested in prevention, it puzzles me that only 70 percent of people over age 65 get a flu shot each year.

This vaccine rate has not changed in decades, despite a universal recommendation for people aged 65 and older to get the flu shot every year. Doctors and other health care experts have recommended this for longer than my entire 30 years as a physician. We fall far short of medicine’s Healthy People 2020 goal of 90 percent of the population immunized against flu. (Unfortunately, this was the same goal we had in 2010. Because we made no progress toward it, the goal was not increased.)

Why is this vaccination so important? The answer: These are potentially preventable deaths. When we’re over the age of 65, our bodies do not fight infection as well. Although seniors make up only 14.5 percent of the U.S. population, they represent more than one-third (35 percent) of hospital admissions. More importantly, seniors represent 60 percent of flu-related hospitalizations and 90 percent of flu-related deaths. On average, 36,000 people die each year in the United States from influenza, or flu, and pneumonia.

One published study shows the high-dose flu shot prevents 25 percent more people from getting the flu than the traditional flu shot, as well as decreasing their hospitalization and death rate by 25 percent. The high-dose flu shot is individually dosed, each in its own syringe, with no preservatives or thimerosol/mercury-like substance. Additionally, the flu shot has few true drawbacks; this is an extremely safe vaccine. (There was a concern about the flu shot by some people with egg allergies, but, as of last year, that is no longer an issue.) We understand the flu shot’s effectiveness varies year-by-year. However, I believe preventing even one out of five flu cases would be worthwhile, and last year it was better — we estimate the vaccine protected two out of three individuals.

The flu is not just a bad cold. It can leave you miserable and incapacitated for five to 10 days with symptoms like fever, body aches, sore throat, and cough. In some people, it can lead to pneumonia. Some die.

The flu vaccine should begin to be available by the end of this month and should become more widely available throughout September and October. You can get your shot as soon as it’s available to protect you throughout the 2016-17 flu season.

So, like any good barker at the county fair, I say "HEAR YE, HEAR YE!! Step right up to receive the shot proven to allow you to live longer!”

Let’s all roll up our sleeves!

Dr. Swegler is a family physician in Austin. Because adult vaccines in particular are so underutilized and because Dr. Swegler is a firm believer in vaccines and what they do for prevention, she speaks for both Merck and Sanofi Pasteur, the latter of which makes flu vaccines.

Be Wise — Immunize is a service mark of the Texas Medical Association.

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