CVS, Aetna and REM: It’s The End Of The {Healthcare} World As We Know it

This week, it was announced that two of the largest players in the American healthcare market have agreed to merge in a deal worth nearly 70 billion dollars.  This merger represents a departure from the traditional way in which doctors, patients, insurers and pharmacists have interacted for decades.  In the past, insurers and pharmacies have existed in separate silos.  As I discussed in a recent Op Ed, this old system was far from perfect.  Pharmacy benefit managers (PBMs) have taken advantage of patients, doctors and drug manufacturers and have served to raise the cost of medicines through demanding kickbacks known as “rebates”.  As bad as PBMs have been for healthcare, this new merger may actually be WORSE.  Now, mergers such as the CVS/Aetna deal will essentially bring the “Soprano-like” PBMs in house.  In addition, in the last several years, CVS has ventured into the healthcare provider market as well—staffing primary care “clinics” with pharmacists and nurse practitioners in retail stores (note the glaring absences of physicians in the CVS care model).  While CVS argues that the combination of a health insurance company and a pharmacy (that provides primary care services) will streamline patient care and lower costs, I believe it is likely to do just the opposite.

What IS the Likely  Impact of the Insurance Company/Pharmacy/Clinical Services Mega Store on Healthcare?

If this merger is allowed to proceed, all players (except for the mega CVS/Aetna conglomerate) in the US healthcare system will suffer negative consequences.

  1. Diminished Choice

Currently, many patients have limited access to drugs due to the role in which PBMs play in negotiating prices and determining what is on “formulary”.  This less than transparent process basically involves a system of bids from manufacturers where the highest bidder (for a rebate that is pocketed by the PBM) wins the preferred formulary status.  In addition, the PBMs can require patients to deal with a process of “step therapy” where they are forced to use less expensive (and potentially less effective drugs) than originally prescribed by their physician prior to being allowed to take the intended therapy.  If this acquisition is allowed to proceed, we will see even less choice.  Now, an insurer (who is motivated financially to prohibit access to more expensive therapies) will be partnered with a pharmacy who can potentially decide to only stock certain medications.  Price fixing may become the norm—if you are an Aetna customer, you may be only allowed to purchase your medications from CVS—even if there are cheaper options for you elsewhere.

  1. Rising Costs

When there is less competition, the consumer always suffers.  If we allow CVS and Aetna to merge, we are likely to see costs rise.  Healthcare consumers will not be allowed to shop around for less costly purchasing options.  I foresee a system where Aetna is able to dictate that ALL covered medications must be purchased from CVS.  If

  1. The Demise of the Doctor Patient Relationship

Medicine is defined by the way in which doctors and patients interact.  Trust is built over years of interactions—not in a minute clinic.  By removing the physician from the healthcare equation (as this merger is likely to do), patients will no longer be able to bond with a provider who can help them make difficult healthcare choices as they age.  Minute clinic staff tends to be more transient that physicians that work in long standing practices and medical groups.  While minute clinics can certainly be a great way to triage and treat simple, common primary care issues such as colds and flu, it is not a great venue for long term care of chronic disease.  Highly trained physicians who have completed between 3 and 10 years of Residency and Fellowship training AFTER the completion of their medical degrees are better equipped to make difficult diagnoses and manage complex diseases over time.  As a for profit entity, CVS is focused on cost containment—and Nurse Practitioners are far cheaper staff than board certified physicians.  In an ideal world, NPs and physicians work together and co-manage patients as each professional brings a unique perspective and a unique skill set to the clinical arena.

  1. Poorer Outcomes

When we focus purely on the economics of healthcare rather than evidence based medicine for therapy choice, outcomes will most certainly be less favorable.  If the CVS/Aetna merger is allowed to proceed, I expect all clinical decisions by CVS minute clinic staff will be based on treatment protocols and algorithms that are developed to contain cost.  Let’s be realistic—CVS and Aetna are in this to make money for their executives and their stockholders—the patient is really not their top priority.  Care delivered only by a Nurse Practitioner in a minute clinic is not the same as the care delivered by a Residency and/or Fellowship trained physician in a continuity clinic.

Ultimately, it is my hope that regulatory bodies in Washington DC will recognize this planned acquisition for what it is—an assault on the way in which medicine is practiced in the United States.  We continue to allow for profit corporations to dominate the decision making when it comes to healthcare policy.  WE must act to change this paradigm and PUT PATIENTS FIRST.  As Michael Stipe of the rock band R.E.M. wrote in his song, “world serves its own needs , don’t mis-serve your own needs”  If we do not act, this merger will be the first of many and will likely be “The End of  The {Healthcare} World As We Know It”

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The “Sopranos” of The Pharmaceutical Industry: Pharmacy Benefit Managers (PBMs) and How THEY Drive Costs UP.

Kevin R. Campbell, MD, FACC

CEO, PaceMate

Today, the New York Times reported that drug companies, insurers and pharmacies may “team up” to create effective monopolies.  Company executives argue that this would be better for patients and would improve care and outcomes—however, nothing could be further than the truth.  These conglomerates would further limit access and drive up costs.

Many patients and physicians have found frustration when attempting to prescribe a particular medication for a particular condition.  Often only certain drugs are “on formulary” (which means they are on contract) at a particular institution.  In the world of drug prices and availability, pharmacy benefit managers or PBMs serve as intermediaries between health plans, manufacturers and pharmacies.  PBMs are companies—such as Express Scripts, CVS CareMark and others–that are hired by health care plans and tasked with determine what drugs are available in a certain plan and which covered patients have access.  According to Forbes, Express Scripts, the leader in PBM market share generated 101 billion dollars in 2015.

How The PBM Mafia Works

Most PBM decision makers have absolutely NO medical training and have no idea how or why a particular therapy works.  They are simply there to manage cost—AND to fatten their own wallets during the process.  For every drug transaction, PBMs receive BOTH a reimbursement fee as well as an administrative fee.  In addition, when PBMs place a particular drug on formulary, they receive rebates and more fees from manufacturers which are NOT passed on to the consumer.  PBMs operate in a world with little oversight and even less transparency.  In other words, PBMs are middle men who are paid on both sides of the transaction—similar to the way in which Tony Soprano and his Captains ran their garbage business in New Jersey.

PBMs claim to drive down costs in healthcare by negotiating discounts, managing formularies to obtain rebates, encouraging generics and non specialty medications as well as increasing the use of their own mail order pharmacies.  In reality, however, PBMs actually drive costs up by using their “middle man” position to increase their own profits.  They work to negotiate contracts with drug manufacturers, health plans and pharmacies that maximize THEIR profits at expense of patients and physicians.  PBMs rely on a shady business maneuver known as “spread pricing”—which is the difference between what PBM charges a health plan for a certain drug and what it reimburses a pharmacy for dispensing it.  The PBM, in turn, is able to increase its margins as neither the health plan or pharmacy has any idea what the other is paid.  PBMs have a great deal of power to determine how YOU, the patient, is treated by your physician through determining tiers of drugs, formularies and preferred drugs.  One would think that efficacy, safety and actual DATA would determine which drugs get “preferred” status—but in the PBM world, its all about which drugs pay the best REBATES.  (Sound familiar? Remember Tony Soprano and all of the bribery, intimidation and other misdeeds? Similar to Tony’s “businesses”, every year, there is a bidding war among manufacturers and the company with the largest rebate (chunk of money to be paid to the PBM) always gets the preferred tier.

How Does This Affect Doctors and Patients?

Once a formulary is set, PBMs work to make it difficult to deviate from its tiers of offerings.  This can have a substantial impact on the doctor-patient relationship and can impact the way patients are treated.  For example, most PBMs put “step edits” in place in order to force physicians and patients to go through a series of preferred drugs prior to getting the drug that the physician originally intended for the patient.  This can result in unwanted side effects and significant delays in treatment.  If a PBM decides to switch to another drug mid year (which is almost always due to a more profitable contract with a different manufacturer), patients are forced to give up a stable therapy for a non-medical reason.  This can lead to disruption in therapy and negative patient outcomes.  The PBM system often stifles innovation as it makes it much harder for new drugs and biosimilar drugs to enter the market.  This can also lead to a non-acceptable lag in getting new therapies to the patients who need them most.  Ultimately, the PBM system and rebates related to PBM profits incentivizes higher drug prices—the higher the list price, the higher the rebate to the PBM.

What Can Be Done?

First of all, we must shed light on the activities of the PBMs and expose them for the mobsters that they are.  We must educate the public, patients, physicians and our legislators in Washington.  While healthcare reform seems unlikely at this time, Congress could act to limit the power and price gouging associated with PBM activities.  Transparency must be mandated—we should all be able to see the flow of cash between manufacturers, PBMs and pharmacies and identify areas of abuse.  In addition, transparency would allow prescribers to see exactly what each prescription really does cost.  Most importantly, we must allow doctors to use the drugs that are best indicated for their patients based on scientific data—NOT based on what generates the most profit for PBM executives.

Acknowledgments:  I would like to thank Dr. Madelaine Feldman–a practicing rheumatologist in New Orleans, Louisiana and leader in the fight against PBMs for her assistance in researching this particular piece.

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(photo via screenshot, HBO, The Sopranos)

 

 

 

 

 

 

Calling A Code Blue on the US Healthcare Reform Initiative:  My Visit to Capitol Hill

Kevin R. Campbell, MD, FACC

 

In the past month, I made yet another trip to Washington DC in order to make the case for meaningful healthcare reform.  While Congress continues to play partisan politics, patients and doctors continue to suffer. According to the Mayo Clinic, physician burnout is at an all-time high with nearly 50% of all US physicians reporting experiencing the symptoms of burnout in the last 3 years.  The Journal of the American Medical Association (JAMA) reported in 2015 that 30% of young physicians had symptoms of depression or suicidal ideations.  In fact, Suicide accounts for 26% of deaths in physicians ages 25-39 as compared to 11% of deaths in individuals of the same age in the general population.  Physicians are leaving practice at an alarming rate, with a shortage of over 100K physicians expected in the next decade. For patients, frustrations continue to mount.  Rising premiums, diminished choice (only one choice in nearly 23% of counties in the US and only 1 or 2 choices in 41%), and limited access have patients scrambling for their basic healthcare needs.  Medicaid expansion has not happened in over 1/3 of the States and many are left uninsured—millions more are underinsured.  Medicine continues to focus on the treatment of disease rather than on prevention. Patients are not getting proven screening therapies and many cannot afford necessary medication due to rising costs.   Clearly, something MUST be done.  Healthcare in the US is on the verge of a major collapse—poor care, poor access and likely physician shortages are looming.

Dr. Campbell Goes to Washington

I began making phone calls about a month before my visit in order to set up meetings with key Congressional influencers and leaders.  I was able to secure a few meetings and set off for DC.  On arrival on Capitol Hill, I was amazed by the general lack of interest in the healthcare debate (other than when cameras are rolling for the mainstream media).  On the day I entered the Rayburn Building (which houses most of the House of Representatives offices), there was a long line of people and politicians were buzzing around in the hallways—all due to more hearings on Russia and our election as well as President Trump’s tax proposal announcement—almost no one was interested in discussing healthcare.  I was able to secure meetings with a few Congressional offices and staff, including the Deputy Whip, Patrick McHenry from North Carolina.  I was able to meet with Congressman McHenry’s team and spent nearly an hour going over issues with healthcare.  They listened, took notes, and promised to follow up in the coming weeks.  They seemed truly interested and empathized with the plight of patients throughout the United States.  I also met with staff from Vern Buchanan’s (R-Florida) office and shared more of my concerns. Mr Buchannan sits on the Ways and Means Committee and is influential in discussions concerning healthcare expenditures and funding of healthcare related programs.   Interestingly, both of the Congressional staffs that I met with seemed genuinely surprised about my report of the “real” state of healthcare, particularly when I discussed issues of billing, reimbursement for physicians and the cost of drugs and medical devices.  I really think that many of our Congressmen and women are not adequately informed about healthcare related issues because they do not have to deal with the system in the same way that doctors and the average American patient have to on a daily basis.

Healthcare and Congress, On Life Support

I really believe that there is little hope for saving the US healthcare system during the next 4 years.  After more than 7 years of criticizing the ACA and campaigning on promises to repeal and replace, the Republicans have little to offer.  One would think that during the two Obama terms, the Republicans could have been working on a viable replacement plan—but clearly they have not.  In Medicine, we are always taught to be prepared, to be able to be flexible, and respond to unforeseen circumstances.  We meticulously plan our treatment, or surgical approach and our next steps.  Congress, after winning majorities in both Houses and also taking the White House, has shown a lack of preparation to actually govern—particularly when it comes to healthcare.  The Democrats, always simply satisfied with the status quo, refuse to admit that Obamacare is not viable in the long term and have not put forward ANY plans to address its failings.  Most of their energy has been put in to thwarting any legislation put forward by the opposition.  The Republicans, due to bitter infighting within the party, have crafted piecemeal replacement plans that are likely to show no real improvement—in short, these plans simply “rearrange deck chairs on the Titanic”.

What MUST Happen Now?

In the hospital, when a CODE BLUE is called, all available staff rush to the bedside of a patient who is in distress.  In most cases this means the initiation of CPR of cardio pulmonary resuscitation and any necessary heroic measures are employed in order to save the patient’s life. Any indecision or any delay in treatment can result in death for the patient.  However, if the CODE team works in concert, with a single goal (of saving the patient’s life), comes together quickly and effectively, a positive outcome is far more likely.   It is now time to call a CODE BLUE on healthcare in Washington DC.  We must demand that both Houses of Congress focus on real, meaningful healthcare reform.  Any delay, much like with a patient who is in distress, will lead to disaster and ultimately, death.  Not only for healthcare as we know it, but ultiamtely for doctors and patients as well.

 

Lessons Learned from The South Pacific: Implications for US Healthcare

Kevin R. Campbell, MD, FACC

For the last several weeks I have been working as a medical volunteer on a remote island off the coast of Fiji called Batiki.  Home to 234 natives, Batiki has no running water, and no electricity (other than solar generated power).  The inhabitants are subsistence fishermen and farmers and are filled with joy and a real sense of community.  While on the island, I found extremely high rates of high blood pressure and moderate rates of type 2 diabetes, but overall, I found a very happy and healthy indigenous population.  Previous research has shown that the South Pacific islands have the second highest rates of type 2 diabetes in the world–but there were fewer cases on Batiki than I expected.  My time on Batiki has led me to reflect on the beauty and passion of its people and how we, as Americans, can learn so much from them when it comes to living a happy and healthy life…

 

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(Image with permission, courtesy of Sea Mercy)

Life on Batiki: Back to Basics

I traveled to the South Pacific as the medical director of a charitable organization known as Sea Mercy.  This organization was formed by businessman Richard Hackett as a way to respond to the devastation caused by tropical cyclones over the last several years.  Many islanders lost everything—homes, families, possessions and many still struggle to survive. Yet they are incredibly resilient and continue to enjoy the simple lives that they have

During my time on the island, I was fortunate enough to spend two weeks living with the villagers in Mua (one of four villages on Batiki) as a guest in the home of the island Chief.  I was able to learn a great deal about the culture and values of the Fijians and I gained a great deal of insight into what really makes us healthy—its not always expensive healthcare plans and pricey name brand medications.  In the case of the villagers of Batiki, much of what makes them healthy is their ability to do so much with so little.  They live off of the land around them and they do not seek care for routine aches and pains.  It was not uncommon for me to see patients in my makeshift clinic that were suffering from orthopedic injuries for months or years.  Many had sprains, healed bone breaks and old cuts—but all continued to work and play.

In addition, the focus on family and community—on supporting one another—seems to result in an increased emphasis on group activities and family meals.  For example, almost every night, the men of the village—both young and old—played rugby games for hours.  The girls played a game called “net ball” and also enjoyed volleyball.  The children loved to swim and run up and down the beach.  Dinners are family events and everyone gathers around a tablecloth placed on the floor to eat together.  While the meals are NOT well balanced—far too carbohydrate heavy and lacking in proteins and vegetables—they are family events.

In the clinic on Batiki, a government paid nurse provides healthcare services for the entire island (four villages) with very limited supplies.  She has no running water or power in the clinic and has a variable stock of diabetes medications, Blood pressure medications, anti inflammatory medications and vaccines.  Due to cultural stigma with seeing a doctor or nurse, it is often difficult to get villagers to come to the clinic and many diseases go undiagnosed and untreated.  In order to overcome this when I was on the island, I made house calls to protect patient privacy.  Rather than use imaging tools and expensive tests, I made complex diagnoses such as Lupus, Neurofibromatosis and others, simply by history and physical examination.  I spent more time talking to patients and their families and did not spend any time imputing data into a medical record or filling out billing forms.  The focus was on the PATIENT.  Imperical treatment and follow up helped confirm most diagnosis and also resulted in a refinement of a patient’s therapy.  In the US, we are far too obsessed on testing and often forget about the power of the patient interaction.

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(Batiki nurses station–photo courtesy of Dr Kevin Campbell)

So, What Can We Learn from Healthcare on Batiki?

One of the founders of modern medicine, Sir William Osler once said that “if you listen to the patient long enough, he will tell you what he has”.  This has been proven to be very true over the years and has been the basis for the doctor patient relationship for decades in the US healthcare system.  Unfortunately, we no longer value the doctor-patient relationship in the US.  Those that mandate the way in which healthcare is delivered (not doctors, mind you), value billing and coding documentation via electronic medical records far more than they value the time a physician spends with a patient connecting on an interpersonal and very human level.  On Batiki, healthcare is both more complicated and actually a lot simpler, all at the same time.  While resources are scarce and you must carefully choose when to use antibiotics or other drugs that are common in the US (and in short supply there), you also are not weighed down by bureaucratic paperwork, rules and regulations.  The patient is the focus of the interaction, not the computer.  There are no practice or hospital administrators—only a team of nurses and doctors who want to get a job done.  On the island, medicine returns to its purest form—listening to symptoms, observing the patient and making a best guess as to the diagnosis based on available data.  Patients heed the advice of the physician and actually WANT to follow the treatment plan.  They do not come in to the clinic as the “worried well” or looking for pain medications—they seek care for problems that they cannot manage any other way.  Both doctors and patients benefit from every single interaction because each and every interaction is unique and unrushed.  Doctors are not stressed due to unmanageable patient volumes and patients are not upset at wait times.  Everyone is happy to be alive and everyone is working towards a common goal—better health and a happy life.  Those in power in Washington DC could learn a lot about healthcare from my friends in Batiki.  Rather than catering to special interests and allowing costs to spiral out of control, focus on what matters most—THE WELLNESS of the PATIENT and the PREVENTION of disease.  If we shift gears and change our paradigm, we all be better for it.  I expect that healthcare costs will stabilize and that outcomes may even improve.  Currently we spend more money per capita on healthcare than any other industrialized nation yet our outcomes are not nearly the best in the world—so, in my mind, something has to change.  I think we must look to the far away parts of the world for guidance.

How Has Batiki Changed Me?

After my experience on the island, I am forever changed—I like to believe that I am now a better physician, a better person as well as a better husband and father.  My brothers on the island of Batiki have taught me many valuable lessons—most importantly, I have learned to live in the moment and to appreciate the little things in life.  I am grateful for many things that I once took for granted—a warm shower, a soft bed, a healthy meal and time spent with family and friends.  For now, it is my hope that my “Batiki transformation” will allow me to do a better job advocating for my patients and will allow me to  inspire others to continue to fight for a better healthcare system in the US today.

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(Photo of Batiki, Courtesy Dr Kevin Campbell)

 

 

 

 

Nothing Really Changes: David Bowie was Right…..

Kevin R. Campbell, MD, FACC

CEO, K-Roc HealthCare Consulting, LLC

In one of his famous songs, “Changes”, David Bowie wrote: “where’s your shame, you’ve left us up to our necks in it” This lyric seems just as appropriate today as it did when he first published the lyric in 1971. Our leaders in Washington have done little this year other than bicker, obstruct the legislative process and stir controversy via twitter. All this is happening as the world is becoming an even more dangerous place—North Korea has ICBM capabilities, Syria continues to murder its own people and millions of Americans are suffering without adequate healthcare. Both parties are to blame. When I study history, there are always inspiring leaders that become the icons of their time—today there are NO heroes in DC.

The last week has been particularly disappointing. After 8 years of criticizing Obamacare and even putting legislation on Obama’s desk to repeal the ACA (which was promptly vetoed), a now Republican controlled Congress has not fulfilled its most central promise—reform healthcare. In addition, President Trump, who promised to protect the LBGTQ community when on the campaign trail, has now unilaterally banned transgender Americans from serving in the military. Infighting and leaks within Trump’s White House staff have created even larger distractions—and unparalleled provided fodder for light night television. All the while, our nation’s problems continue to grow without ANY real solutions on the horizon.

Just when I thought Washington could not get any worse, our elected officials have found a way to sink even lower.

As a lifelong conservative and registered Republican, I made a difficult decision this past week. I revised my party affiliation.

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(Photo courtesy of Dr Kevin Campbell)

My disgust crosses party lines—Democrats such as Hilary Clinton, Nancy Pelosi and Chuck Schumer represent all that is wrong with politics. Self-serving, out of touch long time politicians who care more about their own personal gain than those who the supposedly represent. The Republicans—who promised immediate action if they were given the power to pass legislation—have provided the American people with the biggest “bait and switch” in history. Rather than focus on moving on important legislative matters, both Republican controlled houses of Congress have simply stalled any progress due to intra party disagreements.

Ultimately, those in Washington need to be held accountable for their inaction. No longer should we, as voters, focus on a two party system and work towards protecting a majority or voting along party lines. I believe that each of us must carefully evaluate the job our leaders are doing and clearly call them out on any missteps. When Senators and Congressmen and women are up for re-election in our districts—and it is clear that they have not worked to move our country forward—we MUST vote them out. WE, as AMERICANS, can impose our own term limits. No longer do we have to tolerate the same disgusting politicians every single year. WE have the ability to invoke CHANGE—and, as David Bowie writes, “Time may change me, but I can’t trace time…” Simply put, we don’t have to retrace the past in Washington year after year—vote for change.

 

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(Screenshot via Wikipedia)

Wake UP Congress: America is WAITING for Healthcare Certainty

Kevin R. Campbell, MD, FACC

Cardiologist and CEO, K-Roc Consulting LLC

In the last week, the Senate has failed to produce a viable bill to reform healthcare in the US. BOTH parties are to blame. The Democrats, led by Chuck Schumer have made it clear that they are focused on obstruction of ANY legislation. The Republicans, who own a majority in both houses, cannot seem to come to any consensus—infighting has crippled Republican leadership and severely limited their ability to pass any significant legislation. Sound bites are dominating the news with each side of the aisle pointing fingers at the other. Political posturing is consuming the time of our Congress and very little cooperation and progress is apparent. Democrats accuse the Republican majority of secrecy and a lack of transparency during the development of the healthcare bill—the exact same behavior exhibited by the Democratic majority during the creation of Obamacare more than eight years ago. All of the men and women in Congress were elected to do a job—unfortunately, most are spending more time championing individual causes and playing to cameras than they are actually working to negotiate solutions to legislative problems. As we celebrate the 4th of July holiday this week, I expect better from those who are elected to represent the people of this great country.

 

The Current Issues:

  1. Obamacare is no longer viable. While the ACA legislation does insure large numbers of Americans on paper, the reality is that many of the newly insured have been left with minimal access, high costs (that continue to rise) and very limited choice. If Congress chooses to do nothing, it is likely that more insurers will abandon the exchanges and leave even more Americans will be left without any insurance choices—AND, under current law, be fined for not having insurance (even though there may be nowhere to purchase a plan). Moreover, the uncertainty in the insurance market has resulted not only in a mass exodus of insurers but has also driven up premiums to levels that prohibit many from affording anything more than “catastrophic” type plans with high deductibles and minimal coverage. There is no focus on preventative care and many Americans continue to go without any care at all.

 

  1. The current Republican proposal in the Senate does some—but not nearly enough– to fix the problems with the ACA. While the Senate bill does eliminate the individual mandate and many of the taxes associated with Obamacare, it does not address many of the core issues that both doctors and patients consider vital to any meaningful reform. For instance, there is nothing that addresses the rising prices of pharmaceuticals (and price gouging by pharma CEOs). Americans pay more than any other country in the world for drugs—Why can’t Medicare negotiate prices with pharma? In addition, there is no provision to allow for the purchase of drugs from foreign pharmacies such as those in Canada. Allowing foreign competition will certainly lead to lower prices within the US. Additionally, the plan does little to limit insurance costs—we were promised legislation that would provide for free competition among insurance companies across state lines—in order to allow free market forces to lower prices and improve services. This has not occurred and is not part of any Republican proposal in the Senate. Most significantly, there is no attempt to address tort reform in order to lower healthcare costs. Doctors continue to drive costs by ordering unnecessary tests in order to avoid frivolous litigation by trial lawyers.

 

My “4th of July” Take

It is clear that neither Democrats nor Republicans are ready to come to the table to work together towards meaningful reform. The President has offered little leadership of substance in the healthcare debate other than making vague statements such as “we are going to get this [healthcare] deal done and its going to be great”. Both sides are to blame for the rising cost of insurance and the runaway prices of pharmaceuticals. While the Democrats are unified on a plan of ‘legislative resistance’, Republicans continue to bicker about whether or not the healthcare bill is ‘too moderate’ or too conservative’. At this point, I do not believe the Republican proposal goes far enough to fix the pending healthcare crisis in our country today. Ultimately, doctors want to be able to take care of patients without government interference and patients want the freedom to choose their healthcare and purchase an affordable insurance plan that best meets their individual needs. We must get Congress to act—we need transparency in healthcare pricing and we need to hold both pharma and insurers accountable. We must also hold lawmakers accountable in November—either get the job done, or get out. America can no longer tolerate the status quo in Washington. The 4th of July symbolizes our right as Americans to determine our own destiny. Remember, the election of 2016 was all about disruption and a rejection of business as usual—Wake Up Congress, you have been put on notice. Fix healthcare or the voters will once again speak loudly during the next election cycle.

 

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The VA System Should Address the Physician Shortage By Hiring More Physicians, NOT by replacing them with NPs.

Kevin R. Campbell, MD, FACC

Cardiologist and CEO, K-Roc Consulting LLC

Contributor, Washington Examiner

 

In January of this year, the Veteran’s Administration (VA) made the decision to allow Nurse Practitioners (NP) to practice without any physician supervision. While NPs have a vital role to play within the healthcare system, they are NOT doctors and they are not qualified to replace physicians—even in a primary care environment. Those in leadership within the VA system argue that the physician shortage has left them with no choice but to allow NPs to practice unsupervised. However, I believe that we should be addressing the physician shortage by actually recruiting more physicians to care for primary care in the VA system. Our veterans deserve the very best care—and while NPs are caring, competent members of the healthcare team, they do not have the same training as physicians and are not equipped to fill the role of an independent physician. According to current VA statistics, there are roughly 93,500 nurses employed by the VA—of these 5,700 of them are advanced practice, meaning they have a master’s or doctoral degree in a nursing specialty. In the past, individual states are able to determine whether or not NPs are able to practice independently and 22 states already allow unsupervised practice.

How are NPs and Physicians Different?

Nurse practitioners and physicians are trained in very different ways. Physicians first must obtain a four-year undergraduate degree and then attend a four year medical school. Following medical school, physicians must complete an Internship and Residency with more than 21,000 hours of a standardized educational and training process. The minimum residency program is three years, and some specialties require almost 10 years of post-graduate training—all before ANY independent and unsupervised practice is allowed. By contrast, advanced practice nurses obtain around range from 3,500 to 6,600 hours of coursework and formal training—including Master’s or Doctoral degrees.

Physicians complete endless years of “in house” training in hospitals (taking overnight call as frequently as every third night). During these overnight shifts, physicians learn—while being supervised by an endless hierarchy of medical professionals—how to diagnose and manage very complex diseases. Nurse practitioners do perform time training in a clinical setting but they do not have the same responsibilities nor autonomy. Residency and other practical on the job training teaches young doctors judgment and improves clinical acumen—and this takes years of practice. Nurse practitioners simply do not have the same opportunity to gain these insights.

Before The Angry Response Begins—Everyone Has an Important Role to Play on the Healthcare Team

When I write articles such as this, I am often met with harsh criticism from professional organizations that represent advance practice nurses. Let me say at the outset that this is not a turf war—it is about making sure that every patient has access to BOTH a competent caring and well trained physician as well as an exceptional advance practice nurse. Rather I am arguing that we should continue to develop the idea of a TEAM approach to healthcare. Advance practice nurses are very good at developing meaningful relationships with patients and they are very good at treating common ailments and disease. Patients enjoy the time that NPs are able to devote to them in the office or hospital. Physicians are often rushed from patient to patient and procedure-to-procedure and do not have the same luxury of time to spend with the patients who need us. Physicians are exceptional at recognizing clues and symptoms and DIAGNOSING disease. Advance practice nurses, while exceptional in their role as caregivers and in the treatment of common primary care ailments, they simply do not have the experience needed to make complex diagnoses. While many NPs will argue that there are data from 2014 to show similar outcomes in patients managed by NPs versus physicians, the devil is in the details. The studies did not report whether or not the NPs were consulting with physicians in the management of their patients or whether they were practicing alone. In addition, none of these studies actually looked at DIAGNOSITC accuracy. Making the correct diagnosis and choosing the most appropriate treatment is the most important job of primary care physicians. As diseases do not always present as they do in a textbook, this is where experience and extensive training can make all the difference in the life of a patient. Physicians are used to working in packs—different doctors have different specialties and areas of expertise—we refer to others when we are outside of our specialties. Nurse Practitioners are asked to work with a wide variety of patients and often, in my experience, they do not know when to refer for a higher level of care or for more advanced treatments by a specialist physician—these instincts come from years of experience—like the experience gained during post graduate residency training.

The Bottom Line—Don’t Replace Physicians, Augment the TEAM

The VA and other states that are allowing independent NP practice are looking for a quick fix for the doctor shortage. However, those in charge are not putting the best interests of patients first—they are simply “filling coverage holes”. Rather than allowing NPs to practice outside of their scope of training (ie without MD supervision) we should be working to figure out why doctors are leaving the healthcare industry. We need to examine quality of life and burnout and we need to begin to listen to the needs of our healthcare providers. We must recruit more young dedicated primary care doctors AND, at the same time, expand the role and significance of NPs on the healthcare team. Until we do this, doctor shortages will continue to mount. Inadequacies in the VA system such as long wait times, fraud and abuse are more about the VA leadership and administration than they are about physician shortages.

 

We must also work to promote more understanding between physicians and advanced practice nurses. We must all work with a single goal in mind—providing patients with outstanding care and improved health outcomes.

So, for now, I must strongly object to the decision made by the VA system. Patients definitely need nurses—and advance practice nurses—BUT they also deserve access to a licensed, board certified, residency trained Doctor as well.

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(image via screenshot of VA.gov website)