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Q&A: CDC director Brenda Fitzgerald stresses ‘science and service’
Brenda Fitzgerald, MD, an ob.gyn. and most recently the public health commissioner for Georgia, was named the 17th director of the Centers for Disease Control and Prevention in July.
Dr. Fitzgerald comes to the CDC after 6 years as commissioner and state health officer for the Georgia Department of Public Health. She also has been a health care policy adviser to former House Speaker Newt Gingrich (R-Ga.) and ran for Congress herself in the 1990s. In addition to practicing medicine for 3 decades, she has served on the board and as president of the Georgia Obstetrical and Gynecological Society.
Question: What are you looking forward to as the new CDC director, and what are some of your top goals during your tenure?
Answer: The federal government holds responsibility to provide for the common defense. And CDC provides the common defense of the country against health threats. That’s why CDC’s mission of saving lives and protecting people means so much to me. As a doctor and a mother, I want to do everything I can to protect our future generations and keep them safe, whether it be from infectious or chronic diseases, natural or man-made disasters.
We are going to continue a legacy of protecting Americans from the things that we’ve been fighting for a long time, like heart disease and cancer, and from newer things like opioid overdose and the Zika virus. And we’ll continue to prepare for the next health threat, whatever it may be.
Q: How does your experience as an ob.gyn. shape your approach to this job?
A: There are two things that are important at CDC: science and service. CDC researchers are at the forefront of scientific research – and also provide a service by using scientific discoveries to improve health. That is the same approach I used as a practicing ob.gyn.: I brought the clinical lens that looked at the science, and then my work with my patients emphasized the service part.
As a practicing ob.gyn., it was my responsibility to address the questions and concerns of my patients. At CDC, I am just as committed to making science-based decisions and working with our experts to make sure doctors and patients have the state-of-the-art health information they need. I said when I went from being a clinician to being the state health official for Georgia that I went from treating one patient at a time to treating 10 million at a time. Now that’s changed to over 300 million.
Even though I am now CDC director and protecting the health of millions of people, my experiences as an ob.gyn. for 3 decades will forever shape how I work to improve the health of individual people and patients.
Q: What are the next steps for the agency in terms of its response to Zika virus?
A: Zika is the first infectious disease in 50 years that has been linked to birth defects. We know that the virus attacks neural tissue. We know that about 10% of babies are born with severe birth defects – and some babies born apparently normal later turned out to have neurologic problems, like blindness or deafness. And we suspect that there may be other problems we don’t know about yet.
I’m particularly concerned about developmental delays, as we know that early brain development is key to health and achievement for a child’s future. We are still learning more about Zika every day. It’s crucial that we – the health care and public health communities – work together and remain vigilant to ensure these babies receive the care they need. What Zika has taught us is that we need to establish a pregnancy and infant registry that can flag patterns of concerning health issues so that we can work together with health officials and clinicians to get ahead of emerging health threats.
Q: How can clinicians stay up to date on the rapidly changing guidance during an outbreak like Zika?
A: During outbreaks like Zika, public health officials are continually updating guidance so clinicians can get the latest information. You can check the latest CDC guidance about testing and follow-up care for pregnant women at www.cdc.gov/zika/hc-providers. Health care providers can also contact their state, local, or territorial health department to ensure the appropriate tests are ordered and interpreted correctly. CDC also maintains a 24/7 Zika consultation service for health officials and healthcare providers caring for pregnant women with possible Zika exposure.
Q: What steps will you take to decrease maternal mortality and to understand why this number is rising?
A: As an obstetrician, survival of mothers and babies is paramount to me. It’s so basic: mothers shouldn’t die. Sadly, about 700 women die each year in the U.S. as a result of pregnancy or delivery complications.
We know the leading causes of maternal mortality: cardiovascular disease, infections or sepsis, hemorrhage, and cardiomyopathy. We also know that an increasing number of pregnant women in the U.S. have chronic health conditions such as high blood pressure, diabetes, or heart disease that puts them at risk of pregnancy complications or death.
CDC is committed to preventing pregnancy-related deaths and ensuring the best possible birth outcomes. We do this by conducting surveillance, supporting states in developing recommendations, and working with partners to promote evidence-based recommendations and best practices. State-based initiatives are important allies in bringing together OBs and the public health sector to show the importance of statewide efforts to reduce maternal mortality. There has been some exciting work done by the California Maternal Quality Care Collaborative, which has created a series of toolkits designed to help health care providers with pregnancy or childbirth complications. CMQCC’s work is inspiring other states to follow suit.
The best coalitions are between ob.gyns., public health, and hospital associations. For example, AWHONN’s [Association of Women’s Health, Obstetric and Neonatal Nurses] Postpartum Hemorrhage initiative in Georgia, New Jersey, and the District of Columbia aimed to improve the treatment of obstetric hemorrhage. Even though 54% to 93% of maternal hemorrhage-related deaths are preventable with improved clinical response, not one single hospital in Georgia or New Jersey had implemented all the recommended preparedness elements for postpartum hemorrhage events. We can save mothers’ lives – we know what to do. It just takes all of us – ob.gyns., public health and hospital associations – leading the way to make sure it happens.
Q: How can we increase HPV vaccination?
A: The latest news is that more girls and boys are getting the HPV vaccine. New CDC data showed that 60% of teens aged 13-17 had received one or more doses of HPV vaccine in 2016 – an increase of 4% from 2015. Plus, the latest statistics show that HPV vaccination has led to significant drops in HPV infections: HPV-related cancers and genital warts dropped by 71% among teen girls and 61% among young women. Still, too many children aren’t completing the HPV vaccine series, leaving them vulnerable to cancers caused by HPV infection.
Providers can help increase HPV vaccination rates by using every patient visit to review vaccination histories, providing strong clinical recommendations and education to parents for HPV and other recommended vaccines, and implementing systems to minimize missed opportunities.
[email protected]
On Twitter @legal_med
Brenda Fitzgerald, MD, an ob.gyn. and most recently the public health commissioner for Georgia, was named the 17th director of the Centers for Disease Control and Prevention in July.
Dr. Fitzgerald comes to the CDC after 6 years as commissioner and state health officer for the Georgia Department of Public Health. She also has been a health care policy adviser to former House Speaker Newt Gingrich (R-Ga.) and ran for Congress herself in the 1990s. In addition to practicing medicine for 3 decades, she has served on the board and as president of the Georgia Obstetrical and Gynecological Society.
Question: What are you looking forward to as the new CDC director, and what are some of your top goals during your tenure?
Answer: The federal government holds responsibility to provide for the common defense. And CDC provides the common defense of the country against health threats. That’s why CDC’s mission of saving lives and protecting people means so much to me. As a doctor and a mother, I want to do everything I can to protect our future generations and keep them safe, whether it be from infectious or chronic diseases, natural or man-made disasters.
We are going to continue a legacy of protecting Americans from the things that we’ve been fighting for a long time, like heart disease and cancer, and from newer things like opioid overdose and the Zika virus. And we’ll continue to prepare for the next health threat, whatever it may be.
Q: How does your experience as an ob.gyn. shape your approach to this job?
A: There are two things that are important at CDC: science and service. CDC researchers are at the forefront of scientific research – and also provide a service by using scientific discoveries to improve health. That is the same approach I used as a practicing ob.gyn.: I brought the clinical lens that looked at the science, and then my work with my patients emphasized the service part.
As a practicing ob.gyn., it was my responsibility to address the questions and concerns of my patients. At CDC, I am just as committed to making science-based decisions and working with our experts to make sure doctors and patients have the state-of-the-art health information they need. I said when I went from being a clinician to being the state health official for Georgia that I went from treating one patient at a time to treating 10 million at a time. Now that’s changed to over 300 million.
Even though I am now CDC director and protecting the health of millions of people, my experiences as an ob.gyn. for 3 decades will forever shape how I work to improve the health of individual people and patients.
Q: What are the next steps for the agency in terms of its response to Zika virus?
A: Zika is the first infectious disease in 50 years that has been linked to birth defects. We know that the virus attacks neural tissue. We know that about 10% of babies are born with severe birth defects – and some babies born apparently normal later turned out to have neurologic problems, like blindness or deafness. And we suspect that there may be other problems we don’t know about yet.
I’m particularly concerned about developmental delays, as we know that early brain development is key to health and achievement for a child’s future. We are still learning more about Zika every day. It’s crucial that we – the health care and public health communities – work together and remain vigilant to ensure these babies receive the care they need. What Zika has taught us is that we need to establish a pregnancy and infant registry that can flag patterns of concerning health issues so that we can work together with health officials and clinicians to get ahead of emerging health threats.
Q: How can clinicians stay up to date on the rapidly changing guidance during an outbreak like Zika?
A: During outbreaks like Zika, public health officials are continually updating guidance so clinicians can get the latest information. You can check the latest CDC guidance about testing and follow-up care for pregnant women at www.cdc.gov/zika/hc-providers. Health care providers can also contact their state, local, or territorial health department to ensure the appropriate tests are ordered and interpreted correctly. CDC also maintains a 24/7 Zika consultation service for health officials and healthcare providers caring for pregnant women with possible Zika exposure.
Q: What steps will you take to decrease maternal mortality and to understand why this number is rising?
A: As an obstetrician, survival of mothers and babies is paramount to me. It’s so basic: mothers shouldn’t die. Sadly, about 700 women die each year in the U.S. as a result of pregnancy or delivery complications.
We know the leading causes of maternal mortality: cardiovascular disease, infections or sepsis, hemorrhage, and cardiomyopathy. We also know that an increasing number of pregnant women in the U.S. have chronic health conditions such as high blood pressure, diabetes, or heart disease that puts them at risk of pregnancy complications or death.
CDC is committed to preventing pregnancy-related deaths and ensuring the best possible birth outcomes. We do this by conducting surveillance, supporting states in developing recommendations, and working with partners to promote evidence-based recommendations and best practices. State-based initiatives are important allies in bringing together OBs and the public health sector to show the importance of statewide efforts to reduce maternal mortality. There has been some exciting work done by the California Maternal Quality Care Collaborative, which has created a series of toolkits designed to help health care providers with pregnancy or childbirth complications. CMQCC’s work is inspiring other states to follow suit.
The best coalitions are between ob.gyns., public health, and hospital associations. For example, AWHONN’s [Association of Women’s Health, Obstetric and Neonatal Nurses] Postpartum Hemorrhage initiative in Georgia, New Jersey, and the District of Columbia aimed to improve the treatment of obstetric hemorrhage. Even though 54% to 93% of maternal hemorrhage-related deaths are preventable with improved clinical response, not one single hospital in Georgia or New Jersey had implemented all the recommended preparedness elements for postpartum hemorrhage events. We can save mothers’ lives – we know what to do. It just takes all of us – ob.gyns., public health and hospital associations – leading the way to make sure it happens.
Q: How can we increase HPV vaccination?
A: The latest news is that more girls and boys are getting the HPV vaccine. New CDC data showed that 60% of teens aged 13-17 had received one or more doses of HPV vaccine in 2016 – an increase of 4% from 2015. Plus, the latest statistics show that HPV vaccination has led to significant drops in HPV infections: HPV-related cancers and genital warts dropped by 71% among teen girls and 61% among young women. Still, too many children aren’t completing the HPV vaccine series, leaving them vulnerable to cancers caused by HPV infection.
Providers can help increase HPV vaccination rates by using every patient visit to review vaccination histories, providing strong clinical recommendations and education to parents for HPV and other recommended vaccines, and implementing systems to minimize missed opportunities.
[email protected]
On Twitter @legal_med
Brenda Fitzgerald, MD, an ob.gyn. and most recently the public health commissioner for Georgia, was named the 17th director of the Centers for Disease Control and Prevention in July.
Dr. Fitzgerald comes to the CDC after 6 years as commissioner and state health officer for the Georgia Department of Public Health. She also has been a health care policy adviser to former House Speaker Newt Gingrich (R-Ga.) and ran for Congress herself in the 1990s. In addition to practicing medicine for 3 decades, she has served on the board and as president of the Georgia Obstetrical and Gynecological Society.
Question: What are you looking forward to as the new CDC director, and what are some of your top goals during your tenure?
Answer: The federal government holds responsibility to provide for the common defense. And CDC provides the common defense of the country against health threats. That’s why CDC’s mission of saving lives and protecting people means so much to me. As a doctor and a mother, I want to do everything I can to protect our future generations and keep them safe, whether it be from infectious or chronic diseases, natural or man-made disasters.
We are going to continue a legacy of protecting Americans from the things that we’ve been fighting for a long time, like heart disease and cancer, and from newer things like opioid overdose and the Zika virus. And we’ll continue to prepare for the next health threat, whatever it may be.
Q: How does your experience as an ob.gyn. shape your approach to this job?
A: There are two things that are important at CDC: science and service. CDC researchers are at the forefront of scientific research – and also provide a service by using scientific discoveries to improve health. That is the same approach I used as a practicing ob.gyn.: I brought the clinical lens that looked at the science, and then my work with my patients emphasized the service part.
As a practicing ob.gyn., it was my responsibility to address the questions and concerns of my patients. At CDC, I am just as committed to making science-based decisions and working with our experts to make sure doctors and patients have the state-of-the-art health information they need. I said when I went from being a clinician to being the state health official for Georgia that I went from treating one patient at a time to treating 10 million at a time. Now that’s changed to over 300 million.
Even though I am now CDC director and protecting the health of millions of people, my experiences as an ob.gyn. for 3 decades will forever shape how I work to improve the health of individual people and patients.
Q: What are the next steps for the agency in terms of its response to Zika virus?
A: Zika is the first infectious disease in 50 years that has been linked to birth defects. We know that the virus attacks neural tissue. We know that about 10% of babies are born with severe birth defects – and some babies born apparently normal later turned out to have neurologic problems, like blindness or deafness. And we suspect that there may be other problems we don’t know about yet.
I’m particularly concerned about developmental delays, as we know that early brain development is key to health and achievement for a child’s future. We are still learning more about Zika every day. It’s crucial that we – the health care and public health communities – work together and remain vigilant to ensure these babies receive the care they need. What Zika has taught us is that we need to establish a pregnancy and infant registry that can flag patterns of concerning health issues so that we can work together with health officials and clinicians to get ahead of emerging health threats.
Q: How can clinicians stay up to date on the rapidly changing guidance during an outbreak like Zika?
A: During outbreaks like Zika, public health officials are continually updating guidance so clinicians can get the latest information. You can check the latest CDC guidance about testing and follow-up care for pregnant women at www.cdc.gov/zika/hc-providers. Health care providers can also contact their state, local, or territorial health department to ensure the appropriate tests are ordered and interpreted correctly. CDC also maintains a 24/7 Zika consultation service for health officials and healthcare providers caring for pregnant women with possible Zika exposure.
Q: What steps will you take to decrease maternal mortality and to understand why this number is rising?
A: As an obstetrician, survival of mothers and babies is paramount to me. It’s so basic: mothers shouldn’t die. Sadly, about 700 women die each year in the U.S. as a result of pregnancy or delivery complications.
We know the leading causes of maternal mortality: cardiovascular disease, infections or sepsis, hemorrhage, and cardiomyopathy. We also know that an increasing number of pregnant women in the U.S. have chronic health conditions such as high blood pressure, diabetes, or heart disease that puts them at risk of pregnancy complications or death.
CDC is committed to preventing pregnancy-related deaths and ensuring the best possible birth outcomes. We do this by conducting surveillance, supporting states in developing recommendations, and working with partners to promote evidence-based recommendations and best practices. State-based initiatives are important allies in bringing together OBs and the public health sector to show the importance of statewide efforts to reduce maternal mortality. There has been some exciting work done by the California Maternal Quality Care Collaborative, which has created a series of toolkits designed to help health care providers with pregnancy or childbirth complications. CMQCC’s work is inspiring other states to follow suit.
The best coalitions are between ob.gyns., public health, and hospital associations. For example, AWHONN’s [Association of Women’s Health, Obstetric and Neonatal Nurses] Postpartum Hemorrhage initiative in Georgia, New Jersey, and the District of Columbia aimed to improve the treatment of obstetric hemorrhage. Even though 54% to 93% of maternal hemorrhage-related deaths are preventable with improved clinical response, not one single hospital in Georgia or New Jersey had implemented all the recommended preparedness elements for postpartum hemorrhage events. We can save mothers’ lives – we know what to do. It just takes all of us – ob.gyns., public health and hospital associations – leading the way to make sure it happens.
Q: How can we increase HPV vaccination?
A: The latest news is that more girls and boys are getting the HPV vaccine. New CDC data showed that 60% of teens aged 13-17 had received one or more doses of HPV vaccine in 2016 – an increase of 4% from 2015. Plus, the latest statistics show that HPV vaccination has led to significant drops in HPV infections: HPV-related cancers and genital warts dropped by 71% among teen girls and 61% among young women. Still, too many children aren’t completing the HPV vaccine series, leaving them vulnerable to cancers caused by HPV infection.
Providers can help increase HPV vaccination rates by using every patient visit to review vaccination histories, providing strong clinical recommendations and education to parents for HPV and other recommended vaccines, and implementing systems to minimize missed opportunities.
[email protected]
On Twitter @legal_med
States pass tougher abortion restrictions
A number of states are tightening restrictions for women seeking abortions, while one state – Oregon – has enacted a law that could expand access. Here’s a breakdown of the latest state actions and how they could impact women and physicians.
Texas
Under a new Texas law, insurers are banned from covering abortions in most health plans. House Bill 214, signed into law by Texas Gov. Greg Abbott (R) in August, prohibits private, state-offered, and Affordable Care Act insurance plans from including abortion procedures as part of their general coverage. Women must buy additional policies to get the procedure covered. The only exemption is for abortions performed because of a medical emergency.
Another recently enacted Texas law, House Bill 13, requires doctors to report abortion complications to the state within 3 days, and to report personal information about patients such as their age, race, and marital status.
Missouri
Missouri Gov. Eric Greitens (R) has signed into law a measure that will tighten consent procedures for health providers who offer abortions. Senate Bill 5 requires that all discussions related to abortion risks, methods, and other medical factors be conducted only by the doctor who will perform the abortion. Another part of the bill requires that all tissue removed during an abortion be sent to a pathologist for examination within 72 hours. Current law allows facilities to send just a representative sample of the tissue removed.
Arkansas
A federal judge in Arkansas has temporarily blocked four abortion restrictions that were set to go into effect in August. One of the laws – House Bill 1032 – would bar physicians from performing dilation and evacuation procedures, while House Bill 1566 would require that fetal remains are not used for research. House Bill 1434 would ban abortions performed solely for sex selection and mandates that abortions not be performed until “reasonable time and effort” is spent by health providers to obtain the medical records of the pregnant woman. The fourth law, House Bill 2024, requires physicians who perform abortions on girls under age 17 to preserve fetal tissue in accordance with rules from the Office of the State Crime Laboratory.
Oregon
Oregon meanwhile appears to be moving in the opposite direction when it comes to abortion regulation. A new law signed by Oregon Gov. Kate Brown (D) in August requires that insurers cover abortion procedures and contraception without charging women a copayment. The Reproductive Health Equity Act also dedicates state funds to provide reproductive health care to noncitizens living in Oregon who are excluded from Medicaid.
[email protected]
On Twitter @legal_med
A number of states are tightening restrictions for women seeking abortions, while one state – Oregon – has enacted a law that could expand access. Here’s a breakdown of the latest state actions and how they could impact women and physicians.
Texas
Under a new Texas law, insurers are banned from covering abortions in most health plans. House Bill 214, signed into law by Texas Gov. Greg Abbott (R) in August, prohibits private, state-offered, and Affordable Care Act insurance plans from including abortion procedures as part of their general coverage. Women must buy additional policies to get the procedure covered. The only exemption is for abortions performed because of a medical emergency.
Another recently enacted Texas law, House Bill 13, requires doctors to report abortion complications to the state within 3 days, and to report personal information about patients such as their age, race, and marital status.
Missouri
Missouri Gov. Eric Greitens (R) has signed into law a measure that will tighten consent procedures for health providers who offer abortions. Senate Bill 5 requires that all discussions related to abortion risks, methods, and other medical factors be conducted only by the doctor who will perform the abortion. Another part of the bill requires that all tissue removed during an abortion be sent to a pathologist for examination within 72 hours. Current law allows facilities to send just a representative sample of the tissue removed.
Arkansas
A federal judge in Arkansas has temporarily blocked four abortion restrictions that were set to go into effect in August. One of the laws – House Bill 1032 – would bar physicians from performing dilation and evacuation procedures, while House Bill 1566 would require that fetal remains are not used for research. House Bill 1434 would ban abortions performed solely for sex selection and mandates that abortions not be performed until “reasonable time and effort” is spent by health providers to obtain the medical records of the pregnant woman. The fourth law, House Bill 2024, requires physicians who perform abortions on girls under age 17 to preserve fetal tissue in accordance with rules from the Office of the State Crime Laboratory.
Oregon
Oregon meanwhile appears to be moving in the opposite direction when it comes to abortion regulation. A new law signed by Oregon Gov. Kate Brown (D) in August requires that insurers cover abortion procedures and contraception without charging women a copayment. The Reproductive Health Equity Act also dedicates state funds to provide reproductive health care to noncitizens living in Oregon who are excluded from Medicaid.
[email protected]
On Twitter @legal_med
A number of states are tightening restrictions for women seeking abortions, while one state – Oregon – has enacted a law that could expand access. Here’s a breakdown of the latest state actions and how they could impact women and physicians.
Texas
Under a new Texas law, insurers are banned from covering abortions in most health plans. House Bill 214, signed into law by Texas Gov. Greg Abbott (R) in August, prohibits private, state-offered, and Affordable Care Act insurance plans from including abortion procedures as part of their general coverage. Women must buy additional policies to get the procedure covered. The only exemption is for abortions performed because of a medical emergency.
Another recently enacted Texas law, House Bill 13, requires doctors to report abortion complications to the state within 3 days, and to report personal information about patients such as their age, race, and marital status.
Missouri
Missouri Gov. Eric Greitens (R) has signed into law a measure that will tighten consent procedures for health providers who offer abortions. Senate Bill 5 requires that all discussions related to abortion risks, methods, and other medical factors be conducted only by the doctor who will perform the abortion. Another part of the bill requires that all tissue removed during an abortion be sent to a pathologist for examination within 72 hours. Current law allows facilities to send just a representative sample of the tissue removed.
Arkansas
A federal judge in Arkansas has temporarily blocked four abortion restrictions that were set to go into effect in August. One of the laws – House Bill 1032 – would bar physicians from performing dilation and evacuation procedures, while House Bill 1566 would require that fetal remains are not used for research. House Bill 1434 would ban abortions performed solely for sex selection and mandates that abortions not be performed until “reasonable time and effort” is spent by health providers to obtain the medical records of the pregnant woman. The fourth law, House Bill 2024, requires physicians who perform abortions on girls under age 17 to preserve fetal tissue in accordance with rules from the Office of the State Crime Laboratory.
Oregon
Oregon meanwhile appears to be moving in the opposite direction when it comes to abortion regulation. A new law signed by Oregon Gov. Kate Brown (D) in August requires that insurers cover abortion procedures and contraception without charging women a copayment. The Reproductive Health Equity Act also dedicates state funds to provide reproductive health care to noncitizens living in Oregon who are excluded from Medicaid.
[email protected]
On Twitter @legal_med
Tele-neurology visits deemed as effective as office visits for Parkinson’s patients
A new study finds tele-neurology visits are just as effective as in-person visits for patients with Parkinson’s disease, while also saving time and mileage.
Lead author Christopher A. Beck, PhD, of the University of Rochester (N.Y.), and his colleagues studied 195 patients for 1 year who were either provided with their usual medical care or their usual medical care supplemented by four virtual visits via video conferencing from a remote specialist. Investigators evaluated the feasibility of telemedicine visits, as measured by the proportion of patients who completed at least one virtual visit and the proportion of virtual visits completed on time. Efficacy was also evaluated, as measured by the change in the Parkinson’s Disease Questionnaire–39, a quality of life scale. Secondary outcomes included quality of care, caregiver burden, and time and travel savings.
Eligible participants had a clinical diagnosis of Parkinson’s disease, had a private, Internet-enabled device, and lived in a state where a site investigator was licensed to practice. Patients randomized to the telemedicine group received up to four virtual visits over 12 months from a neurologist. Physicians and patients determined the specific content and frequency of each visit, but the format generally included a medical history, a Parkinson’s disease–specific examination (including assessment of tremor and gait), physician recommendations, and time to address patients’ concerns (Neurology. 2017 Aug 16. doi: 10.1212/WNL.0000000000004357).
The study findings showed that the virtual house calls were as effective as were in-person visits, with quality of life no better or worse for patients receiving care at home than for those receiving care in the office. Of telemedicine patients, 98% completed at least one virtual visit, and 91% of all virtual visits scheduled were completed. Researchers also found that participants’ overall quality of care and the burden felt by caregivers was no different whether they had virtual or in-person visits. Each virtual house call saved patients a median of 88 minutes and 38 miles per visit.
Ninety-seven percent of patients and 86% of participating neurologists said they were satisfied with the virtual visits, with 55% of patients stating they preferred virtual visits over in-person visits.
The study – the first national randomized controlled trial of telemedicine to connect remote specialists to patients at home – shows that tele-neurology is a practical and effective model of care for Parkinson patients, said study coauthor E. Ray Dorsey, MD, of the University of Rochester.
“People were very interested in taking part in this study, and the results showed that these virtual house calls were feasible for people with Parkinson’s disease,” Dr. Dorsey said in a statement. “People’s care was as effective as with the in-office visits, and the virtual house calls provided the participants with convenience and comfort.”
Dr. Dorsey noted that 73% of the study participants had visited a Parkinson’s disease specialist in the past year and 83% said they were satisfied with their care, which may have impacted the quality of life finding.
“The fact that adding the virtual house calls to people’s care did not improve their quality of life could be because a large proportion were already seeing a specialist and were satisfied with that care,” he said. “Of course, it’s also possible that virtual house calls are not enough to improve quality of life.”
Limitations of the study included that study participants were primarily well-educated and more familiar with the Internet than was the general population, so results may not be relevant for all people with Parkinson’s disease. In addition, the study population, of whom 96% were white with a mean age of 66 years, did not include people with the disease who live in nursing homes, who account for nearly 25% of all Medicare beneficiaries with Parkinson’s disease.
The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Dorsey serves on the medical advisory board of, and has stock options in, Grand Rounds. No other relevant disclosures relevant were reported by study authors.
[email protected]
On Twitter @legal_med
Patients with Parkinson’s disease (PD) show more improvements in motor symptoms and less frequently receive inappropriate medications when treated by a specialist. However, reduced mobility due to PD, combined with the physical distance to the specialist’s office, poses substantial travel burdens and may limit access to care.
Telemedicine, utilizing video and audio conferencing technology to connect patients and clinicians, can mitigate this problem. However, the Centers for Medicare & Medicaid Services currently only covers telemedicine encounters under specific criteria: The patient lives in a rural area seen in a covered entity by a consulting physician licensed in the state in which the patient resides. Even if the rural designation were removed, requiring travel to a center that offers telemedicine consultation may preclude many patients from using this approach.
The study by Dr. Beck and his colleagues provides a good first step in demonstrating how neurologists can use available technology to reduce patient burdens while still maintaining high-quality neurologic care. If more evidence mounts, and the regulatory environment improves, home-based telemedicine has the potential to revolutionize modern health care for PD and other chronic debilitating diseases.
David Shprecher, DO, is with Banner Sun Health Research Institute in Sun City, Ariz. Jennifer Majersik, MD, is with the University of Utah, Salt Lake City. Dr. Shprecher reported financial relationships with a variety of companies that market or are developing drugs for Parkinson’s disease. Dr. Majersik reported receiving significant research support from the National Institute of Neurological Disorders and Stroke. These comments are adapted from an accompanying editorial (Neurology. 2017 Aug 16. doi: 10.1212/WNL.0000000000004366).
Patients with Parkinson’s disease (PD) show more improvements in motor symptoms and less frequently receive inappropriate medications when treated by a specialist. However, reduced mobility due to PD, combined with the physical distance to the specialist’s office, poses substantial travel burdens and may limit access to care.
Telemedicine, utilizing video and audio conferencing technology to connect patients and clinicians, can mitigate this problem. However, the Centers for Medicare & Medicaid Services currently only covers telemedicine encounters under specific criteria: The patient lives in a rural area seen in a covered entity by a consulting physician licensed in the state in which the patient resides. Even if the rural designation were removed, requiring travel to a center that offers telemedicine consultation may preclude many patients from using this approach.
The study by Dr. Beck and his colleagues provides a good first step in demonstrating how neurologists can use available technology to reduce patient burdens while still maintaining high-quality neurologic care. If more evidence mounts, and the regulatory environment improves, home-based telemedicine has the potential to revolutionize modern health care for PD and other chronic debilitating diseases.
David Shprecher, DO, is with Banner Sun Health Research Institute in Sun City, Ariz. Jennifer Majersik, MD, is with the University of Utah, Salt Lake City. Dr. Shprecher reported financial relationships with a variety of companies that market or are developing drugs for Parkinson’s disease. Dr. Majersik reported receiving significant research support from the National Institute of Neurological Disorders and Stroke. These comments are adapted from an accompanying editorial (Neurology. 2017 Aug 16. doi: 10.1212/WNL.0000000000004366).
Patients with Parkinson’s disease (PD) show more improvements in motor symptoms and less frequently receive inappropriate medications when treated by a specialist. However, reduced mobility due to PD, combined with the physical distance to the specialist’s office, poses substantial travel burdens and may limit access to care.
Telemedicine, utilizing video and audio conferencing technology to connect patients and clinicians, can mitigate this problem. However, the Centers for Medicare & Medicaid Services currently only covers telemedicine encounters under specific criteria: The patient lives in a rural area seen in a covered entity by a consulting physician licensed in the state in which the patient resides. Even if the rural designation were removed, requiring travel to a center that offers telemedicine consultation may preclude many patients from using this approach.
The study by Dr. Beck and his colleagues provides a good first step in demonstrating how neurologists can use available technology to reduce patient burdens while still maintaining high-quality neurologic care. If more evidence mounts, and the regulatory environment improves, home-based telemedicine has the potential to revolutionize modern health care for PD and other chronic debilitating diseases.
David Shprecher, DO, is with Banner Sun Health Research Institute in Sun City, Ariz. Jennifer Majersik, MD, is with the University of Utah, Salt Lake City. Dr. Shprecher reported financial relationships with a variety of companies that market or are developing drugs for Parkinson’s disease. Dr. Majersik reported receiving significant research support from the National Institute of Neurological Disorders and Stroke. These comments are adapted from an accompanying editorial (Neurology. 2017 Aug 16. doi: 10.1212/WNL.0000000000004366).
A new study finds tele-neurology visits are just as effective as in-person visits for patients with Parkinson’s disease, while also saving time and mileage.
Lead author Christopher A. Beck, PhD, of the University of Rochester (N.Y.), and his colleagues studied 195 patients for 1 year who were either provided with their usual medical care or their usual medical care supplemented by four virtual visits via video conferencing from a remote specialist. Investigators evaluated the feasibility of telemedicine visits, as measured by the proportion of patients who completed at least one virtual visit and the proportion of virtual visits completed on time. Efficacy was also evaluated, as measured by the change in the Parkinson’s Disease Questionnaire–39, a quality of life scale. Secondary outcomes included quality of care, caregiver burden, and time and travel savings.
Eligible participants had a clinical diagnosis of Parkinson’s disease, had a private, Internet-enabled device, and lived in a state where a site investigator was licensed to practice. Patients randomized to the telemedicine group received up to four virtual visits over 12 months from a neurologist. Physicians and patients determined the specific content and frequency of each visit, but the format generally included a medical history, a Parkinson’s disease–specific examination (including assessment of tremor and gait), physician recommendations, and time to address patients’ concerns (Neurology. 2017 Aug 16. doi: 10.1212/WNL.0000000000004357).
The study findings showed that the virtual house calls were as effective as were in-person visits, with quality of life no better or worse for patients receiving care at home than for those receiving care in the office. Of telemedicine patients, 98% completed at least one virtual visit, and 91% of all virtual visits scheduled were completed. Researchers also found that participants’ overall quality of care and the burden felt by caregivers was no different whether they had virtual or in-person visits. Each virtual house call saved patients a median of 88 minutes and 38 miles per visit.
Ninety-seven percent of patients and 86% of participating neurologists said they were satisfied with the virtual visits, with 55% of patients stating they preferred virtual visits over in-person visits.
The study – the first national randomized controlled trial of telemedicine to connect remote specialists to patients at home – shows that tele-neurology is a practical and effective model of care for Parkinson patients, said study coauthor E. Ray Dorsey, MD, of the University of Rochester.
“People were very interested in taking part in this study, and the results showed that these virtual house calls were feasible for people with Parkinson’s disease,” Dr. Dorsey said in a statement. “People’s care was as effective as with the in-office visits, and the virtual house calls provided the participants with convenience and comfort.”
Dr. Dorsey noted that 73% of the study participants had visited a Parkinson’s disease specialist in the past year and 83% said they were satisfied with their care, which may have impacted the quality of life finding.
“The fact that adding the virtual house calls to people’s care did not improve their quality of life could be because a large proportion were already seeing a specialist and were satisfied with that care,” he said. “Of course, it’s also possible that virtual house calls are not enough to improve quality of life.”
Limitations of the study included that study participants were primarily well-educated and more familiar with the Internet than was the general population, so results may not be relevant for all people with Parkinson’s disease. In addition, the study population, of whom 96% were white with a mean age of 66 years, did not include people with the disease who live in nursing homes, who account for nearly 25% of all Medicare beneficiaries with Parkinson’s disease.
The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Dorsey serves on the medical advisory board of, and has stock options in, Grand Rounds. No other relevant disclosures relevant were reported by study authors.
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On Twitter @legal_med
A new study finds tele-neurology visits are just as effective as in-person visits for patients with Parkinson’s disease, while also saving time and mileage.
Lead author Christopher A. Beck, PhD, of the University of Rochester (N.Y.), and his colleagues studied 195 patients for 1 year who were either provided with their usual medical care or their usual medical care supplemented by four virtual visits via video conferencing from a remote specialist. Investigators evaluated the feasibility of telemedicine visits, as measured by the proportion of patients who completed at least one virtual visit and the proportion of virtual visits completed on time. Efficacy was also evaluated, as measured by the change in the Parkinson’s Disease Questionnaire–39, a quality of life scale. Secondary outcomes included quality of care, caregiver burden, and time and travel savings.
Eligible participants had a clinical diagnosis of Parkinson’s disease, had a private, Internet-enabled device, and lived in a state where a site investigator was licensed to practice. Patients randomized to the telemedicine group received up to four virtual visits over 12 months from a neurologist. Physicians and patients determined the specific content and frequency of each visit, but the format generally included a medical history, a Parkinson’s disease–specific examination (including assessment of tremor and gait), physician recommendations, and time to address patients’ concerns (Neurology. 2017 Aug 16. doi: 10.1212/WNL.0000000000004357).
The study findings showed that the virtual house calls were as effective as were in-person visits, with quality of life no better or worse for patients receiving care at home than for those receiving care in the office. Of telemedicine patients, 98% completed at least one virtual visit, and 91% of all virtual visits scheduled were completed. Researchers also found that participants’ overall quality of care and the burden felt by caregivers was no different whether they had virtual or in-person visits. Each virtual house call saved patients a median of 88 minutes and 38 miles per visit.
Ninety-seven percent of patients and 86% of participating neurologists said they were satisfied with the virtual visits, with 55% of patients stating they preferred virtual visits over in-person visits.
The study – the first national randomized controlled trial of telemedicine to connect remote specialists to patients at home – shows that tele-neurology is a practical and effective model of care for Parkinson patients, said study coauthor E. Ray Dorsey, MD, of the University of Rochester.
“People were very interested in taking part in this study, and the results showed that these virtual house calls were feasible for people with Parkinson’s disease,” Dr. Dorsey said in a statement. “People’s care was as effective as with the in-office visits, and the virtual house calls provided the participants with convenience and comfort.”
Dr. Dorsey noted that 73% of the study participants had visited a Parkinson’s disease specialist in the past year and 83% said they were satisfied with their care, which may have impacted the quality of life finding.
“The fact that adding the virtual house calls to people’s care did not improve their quality of life could be because a large proportion were already seeing a specialist and were satisfied with that care,” he said. “Of course, it’s also possible that virtual house calls are not enough to improve quality of life.”
Limitations of the study included that study participants were primarily well-educated and more familiar with the Internet than was the general population, so results may not be relevant for all people with Parkinson’s disease. In addition, the study population, of whom 96% were white with a mean age of 66 years, did not include people with the disease who live in nursing homes, who account for nearly 25% of all Medicare beneficiaries with Parkinson’s disease.
The study was supported by the Patient-Centered Outcomes Research Institute. Dr. Dorsey serves on the medical advisory board of, and has stock options in, Grand Rounds. No other relevant disclosures relevant were reported by study authors.
[email protected]
On Twitter @legal_med
FROM NEUROLOGY
Key clinical point:
Major finding: Overall, 98% of tele-neurology patients completed at least one virtual visit, and 91% of all virtual visits scheduled were completed.
Data source: National randomized controlled trial of 195 patients with Parkinson’s disease.
Disclosures: E. Ray Dorsey, MD, serves on the medical advisory board of and has stock options in Grand Rounds. No other relevant disclosures were reported by the researchers. The study was supported by the Patient-Centered Outcomes Research Institute.
Physicians express mixed views on new FDA tobacco plan
Physicians associations are expressing mixed opinions about the Food and Drug Administration’s new plan for regulating tobacco products, such as flavored cigars, hookah tobacco, and e-cigarettes.
As part of the new plan, announced July 28, the FDA will relax previous application deadlines set for makers of newer tobacco products. The agency will also seek more public input on the role of flavors in tobacco products before moving forward with specific regulations.
“The delay outlined in [FDA Commissioner Scott Gottlieb’s] vision will cost the American public continued death and disease as a result of tobacco use,” Enid Neptune, MD, vice chair of the ATS Tobacco Action Committee said in the statement. “In short, Dr. Gottlieb’s announcement of the FDA’s new vision for regulating tobacco products is long on delay and short on action. The health of the American public, and particularly today’s youth, will suffer as a result of the FDA’s failure to act.”
The American College of Chest Physicians, meanwhile, applauded the FDA’s plan and expressed its support of the actions outlined.
“We welcome opportunities and actions that reduce tobacco use, addiction, and tobacco-related disease and death,” said Gerard Silvestri, MD, president for the college, in a statement. “We support the actions proposed by the FDA, which are likely to improve public health and reduce the burden of disease on patients and our country.”
As part of the FDA’s revised plan, the agency intends to begin a public dialogue about lowering nicotine levels in combustible cigarettes to nonaddictive levels through “achievable product standards.” The agency also plans to issue an advance notice of proposed rule making to seek input on the potential public health benefits and possible adverse effects of lowering nicotine in cigarettes.
Under revised time lines, applications for newly regulated combustible products, such as cigars, pipe tobacco, and hookah tobacco, must be submitted by makers to the FDA by Aug. 8, 2021, and applications for noncombustible products, such as e-cigarettes, must be submitted by Aug. 8, 2022. Manufacturers can continue to market their products while the agency reviews their product applications. The time frames push back previous deadlines that were established in a May 2016 final rule by the FDA. In the prior rule, manufacturers of all new tobacco products had 12-24 months to prepare and send applications for marketing authorization to the FDA and a 12-month continued compliance period after those dates in which to obtain FDA authorization.
“This comprehensive plan and sweeping approach to tobacco and nicotine allows the FDA to apply the powerful tools given by Congress to achieve the most significant public health impact,” Mitch Zeller, director of the FDA’s Center for Tobacco Products said in a statement. “Public input on these complex issues will help ensure the agency has the proper science-based policies in place to meaningfully reduce the harms caused by tobacco use.”
However, the ATS said that many of the issues raised in the FDA’s revised plan have already been discussed at length in the scientific literature and with the public.
“Scientific literature documenting the role cigars play in tobacco-related disease is extensive,” said Harold J. Farber, MD, chair of the ATS Tobacco Action Committee. “The FDA sought and received extensive public and industry input regarding exempting cigars during the proposed deeming rule. The FDA provided an extensive rational for why premium cigars should be regulated in its final deeming rule.”
In addition, the role of flavoring agents in tobacco products has also been discussed by the FDA, Dr. Neptune added. The agency previously sought, and received, extensive scientific, industry, and public input on the role of flavoring agents in tobacco products, she said. In addition, multiple reports have been issued on the role of flavoring agents, showing that flavoring agents increase tobacco initiation and make tobacco cessation harder, she noted.
“While more scientific information is always welcomed, Commissioner Gottlieb’s call for a new public discussion seeks to hide or ignore the extensive public discussion that has already occurred,” Dr. Neptune said. “In short, Commissioner Gottlieb has more than enough information to take action on flavored nicotine products today.”
[email protected]
On Twitter @legal_med
Physicians associations are expressing mixed opinions about the Food and Drug Administration’s new plan for regulating tobacco products, such as flavored cigars, hookah tobacco, and e-cigarettes.
As part of the new plan, announced July 28, the FDA will relax previous application deadlines set for makers of newer tobacco products. The agency will also seek more public input on the role of flavors in tobacco products before moving forward with specific regulations.
“The delay outlined in [FDA Commissioner Scott Gottlieb’s] vision will cost the American public continued death and disease as a result of tobacco use,” Enid Neptune, MD, vice chair of the ATS Tobacco Action Committee said in the statement. “In short, Dr. Gottlieb’s announcement of the FDA’s new vision for regulating tobacco products is long on delay and short on action. The health of the American public, and particularly today’s youth, will suffer as a result of the FDA’s failure to act.”
The American College of Chest Physicians, meanwhile, applauded the FDA’s plan and expressed its support of the actions outlined.
“We welcome opportunities and actions that reduce tobacco use, addiction, and tobacco-related disease and death,” said Gerard Silvestri, MD, president for the college, in a statement. “We support the actions proposed by the FDA, which are likely to improve public health and reduce the burden of disease on patients and our country.”
As part of the FDA’s revised plan, the agency intends to begin a public dialogue about lowering nicotine levels in combustible cigarettes to nonaddictive levels through “achievable product standards.” The agency also plans to issue an advance notice of proposed rule making to seek input on the potential public health benefits and possible adverse effects of lowering nicotine in cigarettes.
Under revised time lines, applications for newly regulated combustible products, such as cigars, pipe tobacco, and hookah tobacco, must be submitted by makers to the FDA by Aug. 8, 2021, and applications for noncombustible products, such as e-cigarettes, must be submitted by Aug. 8, 2022. Manufacturers can continue to market their products while the agency reviews their product applications. The time frames push back previous deadlines that were established in a May 2016 final rule by the FDA. In the prior rule, manufacturers of all new tobacco products had 12-24 months to prepare and send applications for marketing authorization to the FDA and a 12-month continued compliance period after those dates in which to obtain FDA authorization.
“This comprehensive plan and sweeping approach to tobacco and nicotine allows the FDA to apply the powerful tools given by Congress to achieve the most significant public health impact,” Mitch Zeller, director of the FDA’s Center for Tobacco Products said in a statement. “Public input on these complex issues will help ensure the agency has the proper science-based policies in place to meaningfully reduce the harms caused by tobacco use.”
However, the ATS said that many of the issues raised in the FDA’s revised plan have already been discussed at length in the scientific literature and with the public.
“Scientific literature documenting the role cigars play in tobacco-related disease is extensive,” said Harold J. Farber, MD, chair of the ATS Tobacco Action Committee. “The FDA sought and received extensive public and industry input regarding exempting cigars during the proposed deeming rule. The FDA provided an extensive rational for why premium cigars should be regulated in its final deeming rule.”
In addition, the role of flavoring agents in tobacco products has also been discussed by the FDA, Dr. Neptune added. The agency previously sought, and received, extensive scientific, industry, and public input on the role of flavoring agents in tobacco products, she said. In addition, multiple reports have been issued on the role of flavoring agents, showing that flavoring agents increase tobacco initiation and make tobacco cessation harder, she noted.
“While more scientific information is always welcomed, Commissioner Gottlieb’s call for a new public discussion seeks to hide or ignore the extensive public discussion that has already occurred,” Dr. Neptune said. “In short, Commissioner Gottlieb has more than enough information to take action on flavored nicotine products today.”
[email protected]
On Twitter @legal_med
Physicians associations are expressing mixed opinions about the Food and Drug Administration’s new plan for regulating tobacco products, such as flavored cigars, hookah tobacco, and e-cigarettes.
As part of the new plan, announced July 28, the FDA will relax previous application deadlines set for makers of newer tobacco products. The agency will also seek more public input on the role of flavors in tobacco products before moving forward with specific regulations.
“The delay outlined in [FDA Commissioner Scott Gottlieb’s] vision will cost the American public continued death and disease as a result of tobacco use,” Enid Neptune, MD, vice chair of the ATS Tobacco Action Committee said in the statement. “In short, Dr. Gottlieb’s announcement of the FDA’s new vision for regulating tobacco products is long on delay and short on action. The health of the American public, and particularly today’s youth, will suffer as a result of the FDA’s failure to act.”
The American College of Chest Physicians, meanwhile, applauded the FDA’s plan and expressed its support of the actions outlined.
“We welcome opportunities and actions that reduce tobacco use, addiction, and tobacco-related disease and death,” said Gerard Silvestri, MD, president for the college, in a statement. “We support the actions proposed by the FDA, which are likely to improve public health and reduce the burden of disease on patients and our country.”
As part of the FDA’s revised plan, the agency intends to begin a public dialogue about lowering nicotine levels in combustible cigarettes to nonaddictive levels through “achievable product standards.” The agency also plans to issue an advance notice of proposed rule making to seek input on the potential public health benefits and possible adverse effects of lowering nicotine in cigarettes.
Under revised time lines, applications for newly regulated combustible products, such as cigars, pipe tobacco, and hookah tobacco, must be submitted by makers to the FDA by Aug. 8, 2021, and applications for noncombustible products, such as e-cigarettes, must be submitted by Aug. 8, 2022. Manufacturers can continue to market their products while the agency reviews their product applications. The time frames push back previous deadlines that were established in a May 2016 final rule by the FDA. In the prior rule, manufacturers of all new tobacco products had 12-24 months to prepare and send applications for marketing authorization to the FDA and a 12-month continued compliance period after those dates in which to obtain FDA authorization.
“This comprehensive plan and sweeping approach to tobacco and nicotine allows the FDA to apply the powerful tools given by Congress to achieve the most significant public health impact,” Mitch Zeller, director of the FDA’s Center for Tobacco Products said in a statement. “Public input on these complex issues will help ensure the agency has the proper science-based policies in place to meaningfully reduce the harms caused by tobacco use.”
However, the ATS said that many of the issues raised in the FDA’s revised plan have already been discussed at length in the scientific literature and with the public.
“Scientific literature documenting the role cigars play in tobacco-related disease is extensive,” said Harold J. Farber, MD, chair of the ATS Tobacco Action Committee. “The FDA sought and received extensive public and industry input regarding exempting cigars during the proposed deeming rule. The FDA provided an extensive rational for why premium cigars should be regulated in its final deeming rule.”
In addition, the role of flavoring agents in tobacco products has also been discussed by the FDA, Dr. Neptune added. The agency previously sought, and received, extensive scientific, industry, and public input on the role of flavoring agents in tobacco products, she said. In addition, multiple reports have been issued on the role of flavoring agents, showing that flavoring agents increase tobacco initiation and make tobacco cessation harder, she noted.
“While more scientific information is always welcomed, Commissioner Gottlieb’s call for a new public discussion seeks to hide or ignore the extensive public discussion that has already occurred,” Dr. Neptune said. “In short, Commissioner Gottlieb has more than enough information to take action on flavored nicotine products today.”
[email protected]
On Twitter @legal_med
ACA lawsuits progress through the courts
While Republican efforts to repeal and/or replace the Affordable Care Act are likely to resurface after the congressional summer recess, lawsuits challenging the health law continue to wind their way through the courts.
Judges recently ruled in three ACA cases regarding the contraceptive mandate, risk corridors program, and cost-sharing reduction payments.
Real Alternatives Inc. v. HHS
Secular groups are not entitled to a religious exemption to the ACA’s contraceptive mandate and must offer plans to employees that cover birth control, the United States Court of Appeals for the Third Circuit ruled in an Aug. 4 opinion.
But a majority of appeal judges disagreed, concluding that Real Alternatives is not similar to a religious denomination or one of its nontheistic counterparts, “not in structure, not in aim, not in purpose, and not in function.”
“We do not doubt that Real Alternative’s stance on contraceptives is grounded in sincerely-held moral values, but religion is not generally confined to one question or one moral teaching, it has a broader scope,” Judge Marjorie O. Rendell wrote in the majority opinion. “Real Alternatives is functionally similar not to a church, but to the countless nonreligious nonprofit organizations that take morally informed positions on some discrete set of issues ... While commitment to an anti-abortion platform may be important to the people who hold them, that commitment is not a religion in any legally or theologically accepted sense; and organizations do not become quasi-churches for equal-protection purposes merely by espousing a commitment of that sort.”
Molina Healthcare v. HHS
The federal Heath & Human Services department may have to dish out millions to marketplace insurers after a recent decision by the U.S. Court of Federal Claims. In an Aug. 4 opinion, a federal claims judge ruled the federal government owes Long Beach, Calif.–based insurer Molina Healthcare $52 million in risk corridor payments under the ACA.
The decision stems from a lawsuit by Molina and dozens of other insurers against HHS over the ACA’s risk corridor program. The program requires HHS to collect funds from excessively profitable insurers that offer qualified health plans (QHP) under the exchanges, while paying out funds to QHP insurers with excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
Insurers allege they’ve been shortchanged and that the government must reimburse them full payments for 2014 and 2015. Under the Obama administration, the Department of Justice requested to dismiss the cases, arguing that riders attached to appropriations bills in 2015 and 2016 barred it from making full risk corridor payments.
In his decision, Judge Thomas Wheeler said the ACA mandates that HHS pay insurers what they are owed under the risk corridor program, regardless of the riders.
“The undisputed facts show the government entered into an implied-in-fact contract with Molina and subsequently breached the contract when it failed to make full risk corridor payments,” Judge Wheeler wrote. “Importantly, Molina prevails on its argument of breach of an implied-in-fact contract regardless of the government’s appropriation law defenses – later appropriation restrictions cannot erase a previously created contractual obligation ...The government is liable for its breach of a statutory and contractual obligation to make full annual payments to insurers who participated in the risk corridor program.”
Judge Wheeler ruled similarly in February when he concluded the federal government owes Portland, Ore.–based Moda Health $214 million in risk corridor payments.
The issue is far from over. More than 25 lawsuits have been filed in the Court of Federal Claims by insurers seeking risk corridor money. Several of the cases have moved onto federal appeals courts, while other cases have been dismissed. Analysts say the issue is likely to reach the U.S. Supreme Court. It’s unclear where the Trump administration would get the funds to reimburse insurers if the payback rulings stand. About $19.3 billion in risk corridor payments are at stake for 2014 and 2015 and an estimated $3 billion is in play for 2016, the final risk corridor year.
House v. Price
A U.S. appeals court has allowed 16 states to intervene in a lawsuit over whether subsidy payments made to insurers under the ACA are legal. The decision comes as President Trump recently threatened to cut off the cost sharing reduction (CSR) payments to marketplace insurers, calling them a “bailout.”
On Aug. 1, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by 18 attorneys general to enter the lawsuit. The attorneys general represent California, New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, Washington, and the District of Columbia.
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for low-income patients.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue. President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
On July 29, President Trump tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
The state attorneys general are ready to defend the ACA and the cost sharing reduction payments, California Attorney General Xavier Becerra said in a statement.
“If Donald Trump won’t defend these vital subsidies for American families, then we will,” Mr. Becerra said in the statement. “This ruling gives my fellow attorneys general and me the ability to stand up for the millions of families who otherwise would lack access to affordable health care. It’s time Americans knew we were working for them, not against them.”
[email protected]
On Twitter @legal_med
While Republican efforts to repeal and/or replace the Affordable Care Act are likely to resurface after the congressional summer recess, lawsuits challenging the health law continue to wind their way through the courts.
Judges recently ruled in three ACA cases regarding the contraceptive mandate, risk corridors program, and cost-sharing reduction payments.
Real Alternatives Inc. v. HHS
Secular groups are not entitled to a religious exemption to the ACA’s contraceptive mandate and must offer plans to employees that cover birth control, the United States Court of Appeals for the Third Circuit ruled in an Aug. 4 opinion.
But a majority of appeal judges disagreed, concluding that Real Alternatives is not similar to a religious denomination or one of its nontheistic counterparts, “not in structure, not in aim, not in purpose, and not in function.”
“We do not doubt that Real Alternative’s stance on contraceptives is grounded in sincerely-held moral values, but religion is not generally confined to one question or one moral teaching, it has a broader scope,” Judge Marjorie O. Rendell wrote in the majority opinion. “Real Alternatives is functionally similar not to a church, but to the countless nonreligious nonprofit organizations that take morally informed positions on some discrete set of issues ... While commitment to an anti-abortion platform may be important to the people who hold them, that commitment is not a religion in any legally or theologically accepted sense; and organizations do not become quasi-churches for equal-protection purposes merely by espousing a commitment of that sort.”
Molina Healthcare v. HHS
The federal Heath & Human Services department may have to dish out millions to marketplace insurers after a recent decision by the U.S. Court of Federal Claims. In an Aug. 4 opinion, a federal claims judge ruled the federal government owes Long Beach, Calif.–based insurer Molina Healthcare $52 million in risk corridor payments under the ACA.
The decision stems from a lawsuit by Molina and dozens of other insurers against HHS over the ACA’s risk corridor program. The program requires HHS to collect funds from excessively profitable insurers that offer qualified health plans (QHP) under the exchanges, while paying out funds to QHP insurers with excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
Insurers allege they’ve been shortchanged and that the government must reimburse them full payments for 2014 and 2015. Under the Obama administration, the Department of Justice requested to dismiss the cases, arguing that riders attached to appropriations bills in 2015 and 2016 barred it from making full risk corridor payments.
In his decision, Judge Thomas Wheeler said the ACA mandates that HHS pay insurers what they are owed under the risk corridor program, regardless of the riders.
“The undisputed facts show the government entered into an implied-in-fact contract with Molina and subsequently breached the contract when it failed to make full risk corridor payments,” Judge Wheeler wrote. “Importantly, Molina prevails on its argument of breach of an implied-in-fact contract regardless of the government’s appropriation law defenses – later appropriation restrictions cannot erase a previously created contractual obligation ...The government is liable for its breach of a statutory and contractual obligation to make full annual payments to insurers who participated in the risk corridor program.”
Judge Wheeler ruled similarly in February when he concluded the federal government owes Portland, Ore.–based Moda Health $214 million in risk corridor payments.
The issue is far from over. More than 25 lawsuits have been filed in the Court of Federal Claims by insurers seeking risk corridor money. Several of the cases have moved onto federal appeals courts, while other cases have been dismissed. Analysts say the issue is likely to reach the U.S. Supreme Court. It’s unclear where the Trump administration would get the funds to reimburse insurers if the payback rulings stand. About $19.3 billion in risk corridor payments are at stake for 2014 and 2015 and an estimated $3 billion is in play for 2016, the final risk corridor year.
House v. Price
A U.S. appeals court has allowed 16 states to intervene in a lawsuit over whether subsidy payments made to insurers under the ACA are legal. The decision comes as President Trump recently threatened to cut off the cost sharing reduction (CSR) payments to marketplace insurers, calling them a “bailout.”
On Aug. 1, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by 18 attorneys general to enter the lawsuit. The attorneys general represent California, New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, Washington, and the District of Columbia.
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for low-income patients.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue. President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
On July 29, President Trump tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
The state attorneys general are ready to defend the ACA and the cost sharing reduction payments, California Attorney General Xavier Becerra said in a statement.
“If Donald Trump won’t defend these vital subsidies for American families, then we will,” Mr. Becerra said in the statement. “This ruling gives my fellow attorneys general and me the ability to stand up for the millions of families who otherwise would lack access to affordable health care. It’s time Americans knew we were working for them, not against them.”
[email protected]
On Twitter @legal_med
While Republican efforts to repeal and/or replace the Affordable Care Act are likely to resurface after the congressional summer recess, lawsuits challenging the health law continue to wind their way through the courts.
Judges recently ruled in three ACA cases regarding the contraceptive mandate, risk corridors program, and cost-sharing reduction payments.
Real Alternatives Inc. v. HHS
Secular groups are not entitled to a religious exemption to the ACA’s contraceptive mandate and must offer plans to employees that cover birth control, the United States Court of Appeals for the Third Circuit ruled in an Aug. 4 opinion.
But a majority of appeal judges disagreed, concluding that Real Alternatives is not similar to a religious denomination or one of its nontheistic counterparts, “not in structure, not in aim, not in purpose, and not in function.”
“We do not doubt that Real Alternative’s stance on contraceptives is grounded in sincerely-held moral values, but religion is not generally confined to one question or one moral teaching, it has a broader scope,” Judge Marjorie O. Rendell wrote in the majority opinion. “Real Alternatives is functionally similar not to a church, but to the countless nonreligious nonprofit organizations that take morally informed positions on some discrete set of issues ... While commitment to an anti-abortion platform may be important to the people who hold them, that commitment is not a religion in any legally or theologically accepted sense; and organizations do not become quasi-churches for equal-protection purposes merely by espousing a commitment of that sort.”
Molina Healthcare v. HHS
The federal Heath & Human Services department may have to dish out millions to marketplace insurers after a recent decision by the U.S. Court of Federal Claims. In an Aug. 4 opinion, a federal claims judge ruled the federal government owes Long Beach, Calif.–based insurer Molina Healthcare $52 million in risk corridor payments under the ACA.
The decision stems from a lawsuit by Molina and dozens of other insurers against HHS over the ACA’s risk corridor program. The program requires HHS to collect funds from excessively profitable insurers that offer qualified health plans (QHP) under the exchanges, while paying out funds to QHP insurers with excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
Insurers allege they’ve been shortchanged and that the government must reimburse them full payments for 2014 and 2015. Under the Obama administration, the Department of Justice requested to dismiss the cases, arguing that riders attached to appropriations bills in 2015 and 2016 barred it from making full risk corridor payments.
In his decision, Judge Thomas Wheeler said the ACA mandates that HHS pay insurers what they are owed under the risk corridor program, regardless of the riders.
“The undisputed facts show the government entered into an implied-in-fact contract with Molina and subsequently breached the contract when it failed to make full risk corridor payments,” Judge Wheeler wrote. “Importantly, Molina prevails on its argument of breach of an implied-in-fact contract regardless of the government’s appropriation law defenses – later appropriation restrictions cannot erase a previously created contractual obligation ...The government is liable for its breach of a statutory and contractual obligation to make full annual payments to insurers who participated in the risk corridor program.”
Judge Wheeler ruled similarly in February when he concluded the federal government owes Portland, Ore.–based Moda Health $214 million in risk corridor payments.
The issue is far from over. More than 25 lawsuits have been filed in the Court of Federal Claims by insurers seeking risk corridor money. Several of the cases have moved onto federal appeals courts, while other cases have been dismissed. Analysts say the issue is likely to reach the U.S. Supreme Court. It’s unclear where the Trump administration would get the funds to reimburse insurers if the payback rulings stand. About $19.3 billion in risk corridor payments are at stake for 2014 and 2015 and an estimated $3 billion is in play for 2016, the final risk corridor year.
House v. Price
A U.S. appeals court has allowed 16 states to intervene in a lawsuit over whether subsidy payments made to insurers under the ACA are legal. The decision comes as President Trump recently threatened to cut off the cost sharing reduction (CSR) payments to marketplace insurers, calling them a “bailout.”
On Aug. 1, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by 18 attorneys general to enter the lawsuit. The attorneys general represent California, New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, Washington, and the District of Columbia.
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for low-income patients.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue. President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
On July 29, President Trump tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
The state attorneys general are ready to defend the ACA and the cost sharing reduction payments, California Attorney General Xavier Becerra said in a statement.
“If Donald Trump won’t defend these vital subsidies for American families, then we will,” Mr. Becerra said in the statement. “This ruling gives my fellow attorneys general and me the ability to stand up for the millions of families who otherwise would lack access to affordable health care. It’s time Americans knew we were working for them, not against them.”
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On Twitter @legal_med
Patrick Conway leaves CMS for Blue Cross and Blue Shield
Patrick Conway, MD deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services, is departing his government post to take the reigns of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
In an Aug. 8 statement, Blue Cross NC announced that Dr. Conway will start as the insurer’s new president and CEO on Oct. 1. Blue Cross NC’s role in transforming the health care system in North Carolina is both a model for other plans and a system that Dr. Conway is excited to further improve, he said in a statement.
Blue Cross NC Board of Trustees Chair Frank Holding Jr. called Dr. Conway a national and international leader in health system transformation, quality, and innovation who will further advance Blue Cross NC’s goals.
“His unique experiences as a health care provider and as a leader of the world’s largest health care payor will help Blue Cross NC fulfill its mission to improve the health and well-being of our customers and communities,” Mr. Holding said in the statement.
Dr. Conway joined CMS in 2011 as the agency’s chief medical officer and ultimately became the agency’s deputy administrator for innovation and quality and director of the Center for Medicare and Medicaid Innovation. Following President Obama’s departure from office, Dr. Conway took over as acting CMS administrator for then-CMS principal deputy administrator Andy Slavitt until new administrator Seema Verma assumed the position in March.
A longtime pediatric hospitalist, Dr. Conway was selected as a Master of Hospital Medicine by the Society of Hospital Medicine. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014. Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
[email protected]
On Twitter @legal_med
Patrick Conway, MD deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services, is departing his government post to take the reigns of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
In an Aug. 8 statement, Blue Cross NC announced that Dr. Conway will start as the insurer’s new president and CEO on Oct. 1. Blue Cross NC’s role in transforming the health care system in North Carolina is both a model for other plans and a system that Dr. Conway is excited to further improve, he said in a statement.
Blue Cross NC Board of Trustees Chair Frank Holding Jr. called Dr. Conway a national and international leader in health system transformation, quality, and innovation who will further advance Blue Cross NC’s goals.
“His unique experiences as a health care provider and as a leader of the world’s largest health care payor will help Blue Cross NC fulfill its mission to improve the health and well-being of our customers and communities,” Mr. Holding said in the statement.
Dr. Conway joined CMS in 2011 as the agency’s chief medical officer and ultimately became the agency’s deputy administrator for innovation and quality and director of the Center for Medicare and Medicaid Innovation. Following President Obama’s departure from office, Dr. Conway took over as acting CMS administrator for then-CMS principal deputy administrator Andy Slavitt until new administrator Seema Verma assumed the position in March.
A longtime pediatric hospitalist, Dr. Conway was selected as a Master of Hospital Medicine by the Society of Hospital Medicine. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014. Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
[email protected]
On Twitter @legal_med
Patrick Conway, MD deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services, is departing his government post to take the reigns of Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
In an Aug. 8 statement, Blue Cross NC announced that Dr. Conway will start as the insurer’s new president and CEO on Oct. 1. Blue Cross NC’s role in transforming the health care system in North Carolina is both a model for other plans and a system that Dr. Conway is excited to further improve, he said in a statement.
Blue Cross NC Board of Trustees Chair Frank Holding Jr. called Dr. Conway a national and international leader in health system transformation, quality, and innovation who will further advance Blue Cross NC’s goals.
“His unique experiences as a health care provider and as a leader of the world’s largest health care payor will help Blue Cross NC fulfill its mission to improve the health and well-being of our customers and communities,” Mr. Holding said in the statement.
Dr. Conway joined CMS in 2011 as the agency’s chief medical officer and ultimately became the agency’s deputy administrator for innovation and quality and director of the Center for Medicare and Medicaid Innovation. Following President Obama’s departure from office, Dr. Conway took over as acting CMS administrator for then-CMS principal deputy administrator Andy Slavitt until new administrator Seema Verma assumed the position in March.
A longtime pediatric hospitalist, Dr. Conway was selected as a Master of Hospital Medicine by the Society of Hospital Medicine. He also was elected to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine in 2014. Prior to joining CMS, Dr. Conway oversaw clinical operations and research at Cincinnati Children’s Hospital Medical Center as director of hospital medicine, with a focus on improving patient outcomes across the health system.
[email protected]
On Twitter @legal_med
ACA: Five tactics could lead to implosion
With legislative efforts to repeal and/or replace the Affordable Care Act shelved for now, President Trump has tweeted that he wants to “let ObamaCare implode, then deal.” But just what can – and is – his administration doing to foster an implosion? Policy experts help us count the ways:
1. Lax enforcement of the individual mandate
Shortly after he took office, President Trump issued an executive order aimed at “minimizing the economic burden” of the ACA. The order directed all federal agencies to take legal steps to waive, defer, grant exemptions from, or delay the implementation of any ACA provision or requirement that would impose a fiscal burden on states, patients, providers, or health insurers.
As a result, the Internal Revenue Service announced that it would not reject tax returns that do not indicate whether the taxpayer has health insurance. That question is included to determine whether taxpayers will incur a financial penalty under the individual mandate.
“What the Trump administration has done has weakened it even further by effectively saying that they will not enforce the mandate if anyone challenges it,” said Dr. Forman, a practicing radiologist and operational chief for radiology at Yale New Haven Hospital. “So if an individual claims that they shouldn’t have to face the mandate for religious reasons or other objections, that they would be allowed out. By encouraging that, you’re basically weakening the mandate even more, [which] hurts the exchanges and ultimately drives up prices.”
2. Little advertising, outreach
The Trump administration canceled advertising and outreach efforts in the final week of the 2017 open enrollment period. As many as half a million people missed out on enrolling in a health insurance plan as a result, Joshua Peck, former chief marketing officer for healthcare.gov, estimated in a recent blog post.
In the past, the federal government has played a significant role in informing the public about marketplace coverage, their rights and responsibilities under the ACA, and the process of enrollment, said Sarah Lueck, a senior policy analyst for the Center on Budget and Policy Priorities, a nonpartisan research and policy institute. The last week of enrollment is known as a critical time to enroll patients, she said. In 2016 for example, about 700,000 people enrolled during the final week. It’s often the healthiest patients who wait until the last minute, Ms. Lueck added. 
“One way you discourage healthy people from enrolling is by pulling back on advertising at the very moment they may be paying attention,” she said in an interview. “It sends a bad signal. Now as the next enrollment period is about to come up in November, it raises a concern about – what are the plans for outreach?”
Without sufficient promotion, the number of patients who learn about the ACA and enroll could drop off, and the percentage of sicker enrollees in the marketplace could rise, according to analysts. The Trump administration has not said whether it plans to advertise or promote enrollment during the upcoming November enrollment period. The Centers for Medicare & Medicaid Services recently shortened open enrollment from the previous 3 months to 45 days.
In a final rule issued in April, the CMS stated the change will “improve individual market risk pools by reducing opportunities for adverse selection ... and will encourage healthier individuals who might have previously enrolled in partial year coverage after December 15th to instead enroll in coverage for the full year.”
3. Highlight what’s “wrong” with the ACA
In addition to pulling positive advertisements about ACA, the Trump administration has also launched a campaign that criticizes the law.
Since January, the Department of Health & Human Services has published more than 20 videos featuring stories about how the ACA has harmed patients. The HHS has also used its Twitter account to advocate repeal and replacement of the ACA. Sen. Ron Wyden (D-Ore.), ranking member of the Finance Committee, and other legislators have raised concerns that the HHS is misusing federal resources to advance partisan legislation by funding the messages.
“It’s not just pulling advertisements and going dark and not telling people [information], but it’s also putting things out there that talk about people who don’t like the law,” Ms. Lueck said. “It’s counterproductive propaganda if you’re coming from the perspective of wanting people to sign up for coverage. The agencies that have been very engaged in trying to get people through the process and covered, are now working in cross purposes with that.”
Ms. Lueck said that the federal government is also putting a negative spin on the current participation of marketplace insurers and the future of the exchanges. On Aug. 2, the CMS released a map on projected insurer participation in the ACA’s 2018 health insurance exchanges. The map shows that 19 counties are projected to have no insurers in 2018, meaning that patients in those counties could be without marketplace options.
“For 2018, at least 13,008 Americans currently enrolled for health coverage on the exchanges live in the counties projected to be without coverage in 2018,” according to the CMS announcement. “In addition to overall issuer participation, increasing rates have also been a concern for the health insurance exchanges. ... A number of insurers in several states requested rate increases of 30% or more. Consumers in the 39 healthcare.gov states have already seen their premiums increase more than 100% since 2013.”
Unmentioned however, is that the number of potential “bare counties” has dropped in half from about a month ago. A similar map by the Kaiser Family Foundation shows that in June, 44 counties were at risk of having no marketplace insurer in 2018, a number that fell to 17 counties as of Aug. 4, according to Kaiser’s most recent map.
Kristine Grow, senior vice president of communications for America’s Health Insurance Plans (AHIP), noted that based on CMS’ projections thus far, the overall percentage of enrollees without an insurer for 2018 is 0.15%. 
“We’re talking pretty small numbers, that’s about 15,000 people out of 10 million or so who get their coverage through an exchange,” Ms. Grow said in an interview. “It’s important for those people to have options, so the health plans have been working very hard to try to get into those counties.”
4. Work for Medicaid recipients
Potential work requirements for Medicaid beneficiaries may harm the Medicaid expansions that were part of the ACA.
On March 14, the HHS sent a letter to 50 U.S. governors encouraging states to come up with innovative ideas for their Medicaid programs, including the possibility of work requirements. The letter included specific suggestions, such as introducing plans that include health savings account–like features, encouraging Medicaid patients to secure employer-provided insurance, and requiring small premiums or other contributions from patients to encourage personal responsibility. The letter noted that the HHS would be open to states proposing work requirements for some Medicaid recipients, an approach that has “produced proven results for Americans enrolled in other federal, state, and local programs.”
Four states – Arizona, Indiana, Kentucky, and Pennsylvania – have formally submitted waiver requests to the HHS that would require work as an eligibility condition. To date, none has been approved. Arkansas also recently announced that it would seek changes to its waiver, including a work requirement.
Imposing work requirements would hurt access to Medicaid for patients who need health assistance, but who cannot work, Dr. Forman said. Under the ACA, 31 states and the District of Columbia have expanded their Medicaid coverage to people previously uncovered. Dr. Forman stresses that the bulk of Medicaid funding is spent on elderly, disabled, and mentally ill patients.
5. Withhold cost sharing reduction payments
For months, President Trump has threatened to stop making cost saving reduction (CSR) payments to insurers in the marketplace, a move that analysts say would raise premiums and cause insurers to exit the marketplaces. Most recently, the President on July 29 tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for poorer patients. Because insurers lose money on these plans, the ACA provides about $7 billion to insurers through CSR payments.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue.
President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
“If the funding for the CSR benefits goes away, premiums will go up, taxpayer dollars will go up, and choices will go down,” Ms. Grow of AHIP said in an interview. “The benefits as we understand them are still required to be offered on the exchanges. In order to cover those benefits, the premiums for everybody in the individual market will have to go up, and they will go up by about 20%.”
While the federal government would save money by ending the CSR payments, it would face increased costs for tax credits that subsidize premiums for marketplace enrollees with incomes that are 100% to 400% of the poverty level, according to an analysis by the Kaiser Family Foundation.
Following President Trump’s most recent threat to stop the CSR payments, AHIP issued a joint statement with the American Academy of Family Physicians, the American Medical Association, and several others underscoring the importance of the payments.
“Cost-sharing reductions are used to help those who need it most – low- and moderate-income consumers,” the associations said in the Aug. 2 statement. “Without these funds, consumers’ access to care is jeopardized, their premiums will increase dramatically, and they will be left with even fewer coverage options ... As medical professionals, insurers providing health care services and coverage to hundreds of millions of Americans, and business leaders concerned with maintaining a stable health insurance marketplace for consumers, we believe it is imperative that the administration fund the cost-sharing reduction program.”
[email protected]
On Twitter @legal_med
With legislative efforts to repeal and/or replace the Affordable Care Act shelved for now, President Trump has tweeted that he wants to “let ObamaCare implode, then deal.” But just what can – and is – his administration doing to foster an implosion? Policy experts help us count the ways:
1. Lax enforcement of the individual mandate
Shortly after he took office, President Trump issued an executive order aimed at “minimizing the economic burden” of the ACA. The order directed all federal agencies to take legal steps to waive, defer, grant exemptions from, or delay the implementation of any ACA provision or requirement that would impose a fiscal burden on states, patients, providers, or health insurers.
As a result, the Internal Revenue Service announced that it would not reject tax returns that do not indicate whether the taxpayer has health insurance. That question is included to determine whether taxpayers will incur a financial penalty under the individual mandate.
“What the Trump administration has done has weakened it even further by effectively saying that they will not enforce the mandate if anyone challenges it,” said Dr. Forman, a practicing radiologist and operational chief for radiology at Yale New Haven Hospital. “So if an individual claims that they shouldn’t have to face the mandate for religious reasons or other objections, that they would be allowed out. By encouraging that, you’re basically weakening the mandate even more, [which] hurts the exchanges and ultimately drives up prices.”
2. Little advertising, outreach
The Trump administration canceled advertising and outreach efforts in the final week of the 2017 open enrollment period. As many as half a million people missed out on enrolling in a health insurance plan as a result, Joshua Peck, former chief marketing officer for healthcare.gov, estimated in a recent blog post.
In the past, the federal government has played a significant role in informing the public about marketplace coverage, their rights and responsibilities under the ACA, and the process of enrollment, said Sarah Lueck, a senior policy analyst for the Center on Budget and Policy Priorities, a nonpartisan research and policy institute. The last week of enrollment is known as a critical time to enroll patients, she said. In 2016 for example, about 700,000 people enrolled during the final week. It’s often the healthiest patients who wait until the last minute, Ms. Lueck added.
“One way you discourage healthy people from enrolling is by pulling back on advertising at the very moment they may be paying attention,” she said in an interview. “It sends a bad signal. Now as the next enrollment period is about to come up in November, it raises a concern about – what are the plans for outreach?”
Without sufficient promotion, the number of patients who learn about the ACA and enroll could drop off, and the percentage of sicker enrollees in the marketplace could rise, according to analysts. The Trump administration has not said whether it plans to advertise or promote enrollment during the upcoming November enrollment period. The Centers for Medicare & Medicaid Services recently shortened open enrollment from the previous 3 months to 45 days.
In a final rule issued in April, the CMS stated the change will “improve individual market risk pools by reducing opportunities for adverse selection ... and will encourage healthier individuals who might have previously enrolled in partial year coverage after December 15th to instead enroll in coverage for the full year.”
3. Highlight what’s “wrong” with the ACA
In addition to pulling positive advertisements about ACA, the Trump administration has also launched a campaign that criticizes the law.
Since January, the Department of Health & Human Services has published more than 20 videos featuring stories about how the ACA has harmed patients. The HHS has also used its Twitter account to advocate repeal and replacement of the ACA. Sen. Ron Wyden (D-Ore.), ranking member of the Finance Committee, and other legislators have raised concerns that the HHS is misusing federal resources to advance partisan legislation by funding the messages.
“It’s not just pulling advertisements and going dark and not telling people [information], but it’s also putting things out there that talk about people who don’t like the law,” Ms. Lueck said. “It’s counterproductive propaganda if you’re coming from the perspective of wanting people to sign up for coverage. The agencies that have been very engaged in trying to get people through the process and covered, are now working in cross purposes with that.”
Ms. Lueck said that the federal government is also putting a negative spin on the current participation of marketplace insurers and the future of the exchanges. On Aug. 2, the CMS released a map on projected insurer participation in the ACA’s 2018 health insurance exchanges. The map shows that 19 counties are projected to have no insurers in 2018, meaning that patients in those counties could be without marketplace options.
“For 2018, at least 13,008 Americans currently enrolled for health coverage on the exchanges live in the counties projected to be without coverage in 2018,” according to the CMS announcement. “In addition to overall issuer participation, increasing rates have also been a concern for the health insurance exchanges. ... A number of insurers in several states requested rate increases of 30% or more. Consumers in the 39 healthcare.gov states have already seen their premiums increase more than 100% since 2013.”
Unmentioned however, is that the number of potential “bare counties” has dropped in half from about a month ago. A similar map by the Kaiser Family Foundation shows that in June, 44 counties were at risk of having no marketplace insurer in 2018, a number that fell to 17 counties as of Aug. 4, according to Kaiser’s most recent map.
Kristine Grow, senior vice president of communications for America’s Health Insurance Plans (AHIP), noted that based on CMS’ projections thus far, the overall percentage of enrollees without an insurer for 2018 is 0.15%.
“We’re talking pretty small numbers, that’s about 15,000 people out of 10 million or so who get their coverage through an exchange,” Ms. Grow said in an interview. “It’s important for those people to have options, so the health plans have been working very hard to try to get into those counties.”
4. Work for Medicaid recipients
Potential work requirements for Medicaid beneficiaries may harm the Medicaid expansions that were part of the ACA.
On March 14, the HHS sent a letter to 50 U.S. governors encouraging states to come up with innovative ideas for their Medicaid programs, including the possibility of work requirements. The letter included specific suggestions, such as introducing plans that include health savings account–like features, encouraging Medicaid patients to secure employer-provided insurance, and requiring small premiums or other contributions from patients to encourage personal responsibility. The letter noted that the HHS would be open to states proposing work requirements for some Medicaid recipients, an approach that has “produced proven results for Americans enrolled in other federal, state, and local programs.”
Four states – Arizona, Indiana, Kentucky, and Pennsylvania – have formally submitted waiver requests to the HHS that would require work as an eligibility condition. To date, none has been approved. Arkansas also recently announced that it would seek changes to its waiver, including a work requirement.
Imposing work requirements would hurt access to Medicaid for patients who need health assistance, but who cannot work, Dr. Forman said. Under the ACA, 31 states and the District of Columbia have expanded their Medicaid coverage to people previously uncovered. Dr. Forman stresses that the bulk of Medicaid funding is spent on elderly, disabled, and mentally ill patients.
5. Withhold cost sharing reduction payments
For months, President Trump has threatened to stop making cost saving reduction (CSR) payments to insurers in the marketplace, a move that analysts say would raise premiums and cause insurers to exit the marketplaces. Most recently, the President on July 29 tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for poorer patients. Because insurers lose money on these plans, the ACA provides about $7 billion to insurers through CSR payments.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue.
President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
“If the funding for the CSR benefits goes away, premiums will go up, taxpayer dollars will go up, and choices will go down,” Ms. Grow of AHIP said in an interview. “The benefits as we understand them are still required to be offered on the exchanges. In order to cover those benefits, the premiums for everybody in the individual market will have to go up, and they will go up by about 20%.”
While the federal government would save money by ending the CSR payments, it would face increased costs for tax credits that subsidize premiums for marketplace enrollees with incomes that are 100% to 400% of the poverty level, according to an analysis by the Kaiser Family Foundation.
Following President Trump’s most recent threat to stop the CSR payments, AHIP issued a joint statement with the American Academy of Family Physicians, the American Medical Association, and several others underscoring the importance of the payments.
“Cost-sharing reductions are used to help those who need it most – low- and moderate-income consumers,” the associations said in the Aug. 2 statement. “Without these funds, consumers’ access to care is jeopardized, their premiums will increase dramatically, and they will be left with even fewer coverage options ... As medical professionals, insurers providing health care services and coverage to hundreds of millions of Americans, and business leaders concerned with maintaining a stable health insurance marketplace for consumers, we believe it is imperative that the administration fund the cost-sharing reduction program.”
[email protected]
On Twitter @legal_med
With legislative efforts to repeal and/or replace the Affordable Care Act shelved for now, President Trump has tweeted that he wants to “let ObamaCare implode, then deal.” But just what can – and is – his administration doing to foster an implosion? Policy experts help us count the ways:
1. Lax enforcement of the individual mandate
Shortly after he took office, President Trump issued an executive order aimed at “minimizing the economic burden” of the ACA. The order directed all federal agencies to take legal steps to waive, defer, grant exemptions from, or delay the implementation of any ACA provision or requirement that would impose a fiscal burden on states, patients, providers, or health insurers.
As a result, the Internal Revenue Service announced that it would not reject tax returns that do not indicate whether the taxpayer has health insurance. That question is included to determine whether taxpayers will incur a financial penalty under the individual mandate.
“What the Trump administration has done has weakened it even further by effectively saying that they will not enforce the mandate if anyone challenges it,” said Dr. Forman, a practicing radiologist and operational chief for radiology at Yale New Haven Hospital. “So if an individual claims that they shouldn’t have to face the mandate for religious reasons or other objections, that they would be allowed out. By encouraging that, you’re basically weakening the mandate even more, [which] hurts the exchanges and ultimately drives up prices.”
2. Little advertising, outreach
The Trump administration canceled advertising and outreach efforts in the final week of the 2017 open enrollment period. As many as half a million people missed out on enrolling in a health insurance plan as a result, Joshua Peck, former chief marketing officer for healthcare.gov, estimated in a recent blog post.
In the past, the federal government has played a significant role in informing the public about marketplace coverage, their rights and responsibilities under the ACA, and the process of enrollment, said Sarah Lueck, a senior policy analyst for the Center on Budget and Policy Priorities, a nonpartisan research and policy institute. The last week of enrollment is known as a critical time to enroll patients, she said. In 2016 for example, about 700,000 people enrolled during the final week. It’s often the healthiest patients who wait until the last minute, Ms. Lueck added.
“One way you discourage healthy people from enrolling is by pulling back on advertising at the very moment they may be paying attention,” she said in an interview. “It sends a bad signal. Now as the next enrollment period is about to come up in November, it raises a concern about – what are the plans for outreach?”
Without sufficient promotion, the number of patients who learn about the ACA and enroll could drop off, and the percentage of sicker enrollees in the marketplace could rise, according to analysts. The Trump administration has not said whether it plans to advertise or promote enrollment during the upcoming November enrollment period. The Centers for Medicare & Medicaid Services recently shortened open enrollment from the previous 3 months to 45 days.
In a final rule issued in April, the CMS stated the change will “improve individual market risk pools by reducing opportunities for adverse selection ... and will encourage healthier individuals who might have previously enrolled in partial year coverage after December 15th to instead enroll in coverage for the full year.”
3. Highlight what’s “wrong” with the ACA
In addition to pulling positive advertisements about ACA, the Trump administration has also launched a campaign that criticizes the law.
Since January, the Department of Health & Human Services has published more than 20 videos featuring stories about how the ACA has harmed patients. The HHS has also used its Twitter account to advocate repeal and replacement of the ACA. Sen. Ron Wyden (D-Ore.), ranking member of the Finance Committee, and other legislators have raised concerns that the HHS is misusing federal resources to advance partisan legislation by funding the messages.
“It’s not just pulling advertisements and going dark and not telling people [information], but it’s also putting things out there that talk about people who don’t like the law,” Ms. Lueck said. “It’s counterproductive propaganda if you’re coming from the perspective of wanting people to sign up for coverage. The agencies that have been very engaged in trying to get people through the process and covered, are now working in cross purposes with that.”
Ms. Lueck said that the federal government is also putting a negative spin on the current participation of marketplace insurers and the future of the exchanges. On Aug. 2, the CMS released a map on projected insurer participation in the ACA’s 2018 health insurance exchanges. The map shows that 19 counties are projected to have no insurers in 2018, meaning that patients in those counties could be without marketplace options.
“For 2018, at least 13,008 Americans currently enrolled for health coverage on the exchanges live in the counties projected to be without coverage in 2018,” according to the CMS announcement. “In addition to overall issuer participation, increasing rates have also been a concern for the health insurance exchanges. ... A number of insurers in several states requested rate increases of 30% or more. Consumers in the 39 healthcare.gov states have already seen their premiums increase more than 100% since 2013.”
Unmentioned however, is that the number of potential “bare counties” has dropped in half from about a month ago. A similar map by the Kaiser Family Foundation shows that in June, 44 counties were at risk of having no marketplace insurer in 2018, a number that fell to 17 counties as of Aug. 4, according to Kaiser’s most recent map.
Kristine Grow, senior vice president of communications for America’s Health Insurance Plans (AHIP), noted that based on CMS’ projections thus far, the overall percentage of enrollees without an insurer for 2018 is 0.15%.
“We’re talking pretty small numbers, that’s about 15,000 people out of 10 million or so who get their coverage through an exchange,” Ms. Grow said in an interview. “It’s important for those people to have options, so the health plans have been working very hard to try to get into those counties.”
4. Work for Medicaid recipients
Potential work requirements for Medicaid beneficiaries may harm the Medicaid expansions that were part of the ACA.
On March 14, the HHS sent a letter to 50 U.S. governors encouraging states to come up with innovative ideas for their Medicaid programs, including the possibility of work requirements. The letter included specific suggestions, such as introducing plans that include health savings account–like features, encouraging Medicaid patients to secure employer-provided insurance, and requiring small premiums or other contributions from patients to encourage personal responsibility. The letter noted that the HHS would be open to states proposing work requirements for some Medicaid recipients, an approach that has “produced proven results for Americans enrolled in other federal, state, and local programs.”
Four states – Arizona, Indiana, Kentucky, and Pennsylvania – have formally submitted waiver requests to the HHS that would require work as an eligibility condition. To date, none has been approved. Arkansas also recently announced that it would seek changes to its waiver, including a work requirement.
Imposing work requirements would hurt access to Medicaid for patients who need health assistance, but who cannot work, Dr. Forman said. Under the ACA, 31 states and the District of Columbia have expanded their Medicaid coverage to people previously uncovered. Dr. Forman stresses that the bulk of Medicaid funding is spent on elderly, disabled, and mentally ill patients.
5. Withhold cost sharing reduction payments
For months, President Trump has threatened to stop making cost saving reduction (CSR) payments to insurers in the marketplace, a move that analysts say would raise premiums and cause insurers to exit the marketplaces. Most recently, the President on July 29 tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for poorer patients. Because insurers lose money on these plans, the ACA provides about $7 billion to insurers through CSR payments.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue.
President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
“If the funding for the CSR benefits goes away, premiums will go up, taxpayer dollars will go up, and choices will go down,” Ms. Grow of AHIP said in an interview. “The benefits as we understand them are still required to be offered on the exchanges. In order to cover those benefits, the premiums for everybody in the individual market will have to go up, and they will go up by about 20%.”
While the federal government would save money by ending the CSR payments, it would face increased costs for tax credits that subsidize premiums for marketplace enrollees with incomes that are 100% to 400% of the poverty level, according to an analysis by the Kaiser Family Foundation.
Following President Trump’s most recent threat to stop the CSR payments, AHIP issued a joint statement with the American Academy of Family Physicians, the American Medical Association, and several others underscoring the importance of the payments.
“Cost-sharing reductions are used to help those who need it most – low- and moderate-income consumers,” the associations said in the Aug. 2 statement. “Without these funds, consumers’ access to care is jeopardized, their premiums will increase dramatically, and they will be left with even fewer coverage options ... As medical professionals, insurers providing health care services and coverage to hundreds of millions of Americans, and business leaders concerned with maintaining a stable health insurance marketplace for consumers, we believe it is imperative that the administration fund the cost-sharing reduction program.”
[email protected]
On Twitter @legal_med
Tips and tricks for appealing an audit
CHICAGO – The question is not if a physician will face a Medicare or Medicaid billing audit, but when, according to Abby Pendleton, a New York–based health law attorney. That’s why it pays to know how to handle an audit before one probe disrupts your practice. At a recent American Bar Association meeting, Ms. Pendleton and H. Rusty Comley, a Jackson, Mississippi–based health law attorney, offered answers to top audit questions and provided guidance on how physicians can successfully appeal an audit.
When should you appeal?
There are a number of factors to consider when deciding whether to appeal audit findings. For starters, consider the cost of the payback amount and the basis of the findings.
“In other words, the provider would spend more money and time to appeal the audit than to pay the audit, and the issue or mistake is not likely repeated in past or future claims,” it might make sense to just pay, he said.
If the basis of the findings stem from an interpretation of a local coverage decision that the physician disagrees with, he or she may also want to appeal, Ms. Pendleton added.
“If you don’t fight it, there’s an argument that, ‘Well, guess what? You had that issue going back 6 years for all these other claims, and now we get into the [Medicare] 60 day overpayment identification [rule],’ ” she said at the meeting. “If a physician is [not] aware of payments they’re not entitled to, even if they think they were right on the front end, but they later become aware, they have 60 days to refund it or its a false claim. Those are considerations that really need to be looked at.”
What should you expect from an appeal?
Expect to go through more than one appeals process step to succeed. There are five stages to the appeals process .
“At the redetermination stage, I don’t see a whole lot of movement in terms of great success at that first stage,” Ms. Pendleton said. “So, don’t think, ‘If we get to that first level of appeal, we’re expecting to win.’ If you look at the statistics, it’s not really that realistic.”
Although a provider has 120 days to file an appeal, it’s smarter to file within the first 30 days, Ms. Pendleton advised. If an appeal is filed within 30 days, the government cannot recoup it’s demand from a doctor’s current Medicare payments.
Expect a lengthy time frame for a final outcome. Under federal law, once an appeal gets to the administrative law judge (ALJ) stage (the third stage), the appellant should receive a hearing decision within 90 days. However, because of heavy case backlogs, physicians typically don’t get a hearing for 3 years, Ms. Pendleton said.
“The problem is, your MAC [Medicare administrative contractor] can start taking your money after the [second] stage,” she said. “If it’s a huge dollar amount, you’re probably going to have to enter into a payment plan [with the government]. You will eventually get your money back, if you win, three to four years later.”
Note that physicians generally experience a higher degree of success at the ALJ stage, so it may be worth continuing the appeal through this stage, she noted.
Overall, more than one-third of audit findings are reversed in providers’ favor during the appeals process. Of 170,482 Medicare appeal decisions in 2015, 37% were made in favor of the health provider, an increase from 23% in 2014, according to 2015 Medicare data and 2014 reports.
The cost to appeal varies significantly between Medicaid and Medicare and depends largely on the complexity of the audit, Mr. Comley said. A Medicaid audit appeal, through an ALJ hearing and written appeal to a court, may cost between $20,000 to $60,000 depending on the circumstances, he said. By contrast, a Medicare appeal resolved in the first stage of appeal may only cost a few thousand dollars for a relatively simple audit.
“Of course, the costs will rise at each level of the Medicare appeal process, especially in the third stage involving the ALJ telephonic hearing, but, in most cases, the Medicare appeal costs will still be below a similar Medicaid appeal,” he said.
What strategies can help you win?
Consider reaching out to your congressional representative or senators, Mr. Comley advised. Particularly if the issue involves a medical treatment decision or a medically necessary determination, it may be helpful to copy “your favorite Congressman or senator’s office” on correspondence with the MAC. Clearly state your argument against the findings and how/why the medical decision was made. Legislators will often get involved and could help your appeal, Mr. Comley said.
Further, don’t just review the claims that auditors denied. Also evaluate the claims they have approved in the past, he added.
“In almost every case I’ve been involved in, they’ll approve claims that, on the other hand, they deny,” Mr. Comley said. “Under most legal standards, that’s a good way to win – it’s called arbitrary and capricious.”
Find the best experts to back your case, Ms. Pendleton advised. Consider including expert opinions in written responses to the government that support the services provided and/or have medical experts ready to testify during hearings. If the government based its findings on statistics or cited statistics in its review, involve a statistical expert who can argue against the government’s conclusion.
If the case is significant enough, consider skipping steps in the appeals process to get the case before a federal court sooner. Appellants can escalate their appeal through the process at nearly every stage if the government fails to respond within a timely manner. At the second stage, for example, if the qualified independent contractor does not issue a decision within 60 days, an appellant generally has the right to escalate the case to an administrative law judge. If the ALJ does not issue a decision within 90 days, the appeal can generally be escalated to the Appeals Council level, and, if the council does not issue a decision within 90 days, appellants can seek judicial review.
It may be worth it to have your day in court sooner, Ms. Pendleton said.
“It might be an option for providers if you have a large audit with a lot at stake,” she said. “Escalate it through. Get it to federal court and argue it.”
The 5 steps of the Medicare appeals process
There are five stages of the Medicare audit appeals process, according to the Centers for Medicare & Medicaid Services. They include:
1. Redetermination by the Fiscal Intermediary. A redetermination is an examination of a claim by a Medicare administrative contractor (MAC) separate from the personnel who made the initial claim determination. The appellant has 120 days from the date of initial claim determination receipt to file an appeal.
2. Reconsideration by a Qualified Independent Contractor (QIC). A QIC is an independent contractor who didn’t take part in the level 1 decision. The QIC will review the request for a reconsideration and make a decision. An appellant must file a request for reconsideration within 180 days of Medicare redetermination notice or remittance advice receipt.
3. Administrative Law Judge (ALJ) hearing. Appellants present their case to an ALJ who will review the facts of the appeal and listen to testimony before making a decision. An ALJ hearing is usually held by phone or video conference. Appellants can ask the ALJ to make a decision without a hearing. The ALJ may also issue a decision without holding a hearing if evidence in the record supports a decision that’s fully in the appellant’s favor.
4. Medicare Appeals Council review. If you disagree with the ALJ decision or wish to escalate the appeal because the ALJ ruling time frame has passed, a request for a Medicare Appeals Council review can be made. A request for a Medicare Appeals Council review must be made within 60 days of receipt of the ALJ’s decision or after the ALJ ruling time frame expires.
5. Judicial review in U.S. District Court. A party may file an action in federal district court within 60 calendar days after the date receiving notice of the Medicare Appeals Council’s decision or after a council notice that it is not able to reach a decision. To get a judicial review in federal district court, the case amount must meet a minimum dollar amount ($1,560 in 2017).
Each state has its own Medicaid appeals process. Contact your state’s Medicaid office to find out how to appeal a Medicaid audit finding.
[email protected]
On Twitter @legal_med
CHICAGO – The question is not if a physician will face a Medicare or Medicaid billing audit, but when, according to Abby Pendleton, a New York–based health law attorney. That’s why it pays to know how to handle an audit before one probe disrupts your practice. At a recent American Bar Association meeting, Ms. Pendleton and H. Rusty Comley, a Jackson, Mississippi–based health law attorney, offered answers to top audit questions and provided guidance on how physicians can successfully appeal an audit.
When should you appeal?
There are a number of factors to consider when deciding whether to appeal audit findings. For starters, consider the cost of the payback amount and the basis of the findings.
“In other words, the provider would spend more money and time to appeal the audit than to pay the audit, and the issue or mistake is not likely repeated in past or future claims,” it might make sense to just pay, he said.
If the basis of the findings stem from an interpretation of a local coverage decision that the physician disagrees with, he or she may also want to appeal, Ms. Pendleton added.
“If you don’t fight it, there’s an argument that, ‘Well, guess what? You had that issue going back 6 years for all these other claims, and now we get into the [Medicare] 60 day overpayment identification [rule],’ ” she said at the meeting. “If a physician is [not] aware of payments they’re not entitled to, even if they think they were right on the front end, but they later become aware, they have 60 days to refund it or its a false claim. Those are considerations that really need to be looked at.”
What should you expect from an appeal?
Expect to go through more than one appeals process step to succeed. There are five stages to the appeals process .
“At the redetermination stage, I don’t see a whole lot of movement in terms of great success at that first stage,” Ms. Pendleton said. “So, don’t think, ‘If we get to that first level of appeal, we’re expecting to win.’ If you look at the statistics, it’s not really that realistic.”
Although a provider has 120 days to file an appeal, it’s smarter to file within the first 30 days, Ms. Pendleton advised. If an appeal is filed within 30 days, the government cannot recoup it’s demand from a doctor’s current Medicare payments.
Expect a lengthy time frame for a final outcome. Under federal law, once an appeal gets to the administrative law judge (ALJ) stage (the third stage), the appellant should receive a hearing decision within 90 days. However, because of heavy case backlogs, physicians typically don’t get a hearing for 3 years, Ms. Pendleton said.
“The problem is, your MAC [Medicare administrative contractor] can start taking your money after the [second] stage,” she said. “If it’s a huge dollar amount, you’re probably going to have to enter into a payment plan [with the government]. You will eventually get your money back, if you win, three to four years later.”
Note that physicians generally experience a higher degree of success at the ALJ stage, so it may be worth continuing the appeal through this stage, she noted.
Overall, more than one-third of audit findings are reversed in providers’ favor during the appeals process. Of 170,482 Medicare appeal decisions in 2015, 37% were made in favor of the health provider, an increase from 23% in 2014, according to 2015 Medicare data and 2014 reports.
The cost to appeal varies significantly between Medicaid and Medicare and depends largely on the complexity of the audit, Mr. Comley said. A Medicaid audit appeal, through an ALJ hearing and written appeal to a court, may cost between $20,000 to $60,000 depending on the circumstances, he said. By contrast, a Medicare appeal resolved in the first stage of appeal may only cost a few thousand dollars for a relatively simple audit.
“Of course, the costs will rise at each level of the Medicare appeal process, especially in the third stage involving the ALJ telephonic hearing, but, in most cases, the Medicare appeal costs will still be below a similar Medicaid appeal,” he said.
What strategies can help you win?
Consider reaching out to your congressional representative or senators, Mr. Comley advised. Particularly if the issue involves a medical treatment decision or a medically necessary determination, it may be helpful to copy “your favorite Congressman or senator’s office” on correspondence with the MAC. Clearly state your argument against the findings and how/why the medical decision was made. Legislators will often get involved and could help your appeal, Mr. Comley said.
Further, don’t just review the claims that auditors denied. Also evaluate the claims they have approved in the past, he added.
“In almost every case I’ve been involved in, they’ll approve claims that, on the other hand, they deny,” Mr. Comley said. “Under most legal standards, that’s a good way to win – it’s called arbitrary and capricious.”
Find the best experts to back your case, Ms. Pendleton advised. Consider including expert opinions in written responses to the government that support the services provided and/or have medical experts ready to testify during hearings. If the government based its findings on statistics or cited statistics in its review, involve a statistical expert who can argue against the government’s conclusion.
If the case is significant enough, consider skipping steps in the appeals process to get the case before a federal court sooner. Appellants can escalate their appeal through the process at nearly every stage if the government fails to respond within a timely manner. At the second stage, for example, if the qualified independent contractor does not issue a decision within 60 days, an appellant generally has the right to escalate the case to an administrative law judge. If the ALJ does not issue a decision within 90 days, the appeal can generally be escalated to the Appeals Council level, and, if the council does not issue a decision within 90 days, appellants can seek judicial review.
It may be worth it to have your day in court sooner, Ms. Pendleton said.
“It might be an option for providers if you have a large audit with a lot at stake,” she said. “Escalate it through. Get it to federal court and argue it.”
The 5 steps of the Medicare appeals process
There are five stages of the Medicare audit appeals process, according to the Centers for Medicare & Medicaid Services. They include:
1. Redetermination by the Fiscal Intermediary. A redetermination is an examination of a claim by a Medicare administrative contractor (MAC) separate from the personnel who made the initial claim determination. The appellant has 120 days from the date of initial claim determination receipt to file an appeal.
2. Reconsideration by a Qualified Independent Contractor (QIC). A QIC is an independent contractor who didn’t take part in the level 1 decision. The QIC will review the request for a reconsideration and make a decision. An appellant must file a request for reconsideration within 180 days of Medicare redetermination notice or remittance advice receipt.
3. Administrative Law Judge (ALJ) hearing. Appellants present their case to an ALJ who will review the facts of the appeal and listen to testimony before making a decision. An ALJ hearing is usually held by phone or video conference. Appellants can ask the ALJ to make a decision without a hearing. The ALJ may also issue a decision without holding a hearing if evidence in the record supports a decision that’s fully in the appellant’s favor.
4. Medicare Appeals Council review. If you disagree with the ALJ decision or wish to escalate the appeal because the ALJ ruling time frame has passed, a request for a Medicare Appeals Council review can be made. A request for a Medicare Appeals Council review must be made within 60 days of receipt of the ALJ’s decision or after the ALJ ruling time frame expires.
5. Judicial review in U.S. District Court. A party may file an action in federal district court within 60 calendar days after the date receiving notice of the Medicare Appeals Council’s decision or after a council notice that it is not able to reach a decision. To get a judicial review in federal district court, the case amount must meet a minimum dollar amount ($1,560 in 2017).
Each state has its own Medicaid appeals process. Contact your state’s Medicaid office to find out how to appeal a Medicaid audit finding.
[email protected]
On Twitter @legal_med
CHICAGO – The question is not if a physician will face a Medicare or Medicaid billing audit, but when, according to Abby Pendleton, a New York–based health law attorney. That’s why it pays to know how to handle an audit before one probe disrupts your practice. At a recent American Bar Association meeting, Ms. Pendleton and H. Rusty Comley, a Jackson, Mississippi–based health law attorney, offered answers to top audit questions and provided guidance on how physicians can successfully appeal an audit.
When should you appeal?
There are a number of factors to consider when deciding whether to appeal audit findings. For starters, consider the cost of the payback amount and the basis of the findings.
“In other words, the provider would spend more money and time to appeal the audit than to pay the audit, and the issue or mistake is not likely repeated in past or future claims,” it might make sense to just pay, he said.
If the basis of the findings stem from an interpretation of a local coverage decision that the physician disagrees with, he or she may also want to appeal, Ms. Pendleton added.
“If you don’t fight it, there’s an argument that, ‘Well, guess what? You had that issue going back 6 years for all these other claims, and now we get into the [Medicare] 60 day overpayment identification [rule],’ ” she said at the meeting. “If a physician is [not] aware of payments they’re not entitled to, even if they think they were right on the front end, but they later become aware, they have 60 days to refund it or its a false claim. Those are considerations that really need to be looked at.”
What should you expect from an appeal?
Expect to go through more than one appeals process step to succeed. There are five stages to the appeals process .
“At the redetermination stage, I don’t see a whole lot of movement in terms of great success at that first stage,” Ms. Pendleton said. “So, don’t think, ‘If we get to that first level of appeal, we’re expecting to win.’ If you look at the statistics, it’s not really that realistic.”
Although a provider has 120 days to file an appeal, it’s smarter to file within the first 30 days, Ms. Pendleton advised. If an appeal is filed within 30 days, the government cannot recoup it’s demand from a doctor’s current Medicare payments.
Expect a lengthy time frame for a final outcome. Under federal law, once an appeal gets to the administrative law judge (ALJ) stage (the third stage), the appellant should receive a hearing decision within 90 days. However, because of heavy case backlogs, physicians typically don’t get a hearing for 3 years, Ms. Pendleton said.
“The problem is, your MAC [Medicare administrative contractor] can start taking your money after the [second] stage,” she said. “If it’s a huge dollar amount, you’re probably going to have to enter into a payment plan [with the government]. You will eventually get your money back, if you win, three to four years later.”
Note that physicians generally experience a higher degree of success at the ALJ stage, so it may be worth continuing the appeal through this stage, she noted.
Overall, more than one-third of audit findings are reversed in providers’ favor during the appeals process. Of 170,482 Medicare appeal decisions in 2015, 37% were made in favor of the health provider, an increase from 23% in 2014, according to 2015 Medicare data and 2014 reports.
The cost to appeal varies significantly between Medicaid and Medicare and depends largely on the complexity of the audit, Mr. Comley said. A Medicaid audit appeal, through an ALJ hearing and written appeal to a court, may cost between $20,000 to $60,000 depending on the circumstances, he said. By contrast, a Medicare appeal resolved in the first stage of appeal may only cost a few thousand dollars for a relatively simple audit.
“Of course, the costs will rise at each level of the Medicare appeal process, especially in the third stage involving the ALJ telephonic hearing, but, in most cases, the Medicare appeal costs will still be below a similar Medicaid appeal,” he said.
What strategies can help you win?
Consider reaching out to your congressional representative or senators, Mr. Comley advised. Particularly if the issue involves a medical treatment decision or a medically necessary determination, it may be helpful to copy “your favorite Congressman or senator’s office” on correspondence with the MAC. Clearly state your argument against the findings and how/why the medical decision was made. Legislators will often get involved and could help your appeal, Mr. Comley said.
Further, don’t just review the claims that auditors denied. Also evaluate the claims they have approved in the past, he added.
“In almost every case I’ve been involved in, they’ll approve claims that, on the other hand, they deny,” Mr. Comley said. “Under most legal standards, that’s a good way to win – it’s called arbitrary and capricious.”
Find the best experts to back your case, Ms. Pendleton advised. Consider including expert opinions in written responses to the government that support the services provided and/or have medical experts ready to testify during hearings. If the government based its findings on statistics or cited statistics in its review, involve a statistical expert who can argue against the government’s conclusion.
If the case is significant enough, consider skipping steps in the appeals process to get the case before a federal court sooner. Appellants can escalate their appeal through the process at nearly every stage if the government fails to respond within a timely manner. At the second stage, for example, if the qualified independent contractor does not issue a decision within 60 days, an appellant generally has the right to escalate the case to an administrative law judge. If the ALJ does not issue a decision within 90 days, the appeal can generally be escalated to the Appeals Council level, and, if the council does not issue a decision within 90 days, appellants can seek judicial review.
It may be worth it to have your day in court sooner, Ms. Pendleton said.
“It might be an option for providers if you have a large audit with a lot at stake,” she said. “Escalate it through. Get it to federal court and argue it.”
The 5 steps of the Medicare appeals process
There are five stages of the Medicare audit appeals process, according to the Centers for Medicare & Medicaid Services. They include:
1. Redetermination by the Fiscal Intermediary. A redetermination is an examination of a claim by a Medicare administrative contractor (MAC) separate from the personnel who made the initial claim determination. The appellant has 120 days from the date of initial claim determination receipt to file an appeal.
2. Reconsideration by a Qualified Independent Contractor (QIC). A QIC is an independent contractor who didn’t take part in the level 1 decision. The QIC will review the request for a reconsideration and make a decision. An appellant must file a request for reconsideration within 180 days of Medicare redetermination notice or remittance advice receipt.
3. Administrative Law Judge (ALJ) hearing. Appellants present their case to an ALJ who will review the facts of the appeal and listen to testimony before making a decision. An ALJ hearing is usually held by phone or video conference. Appellants can ask the ALJ to make a decision without a hearing. The ALJ may also issue a decision without holding a hearing if evidence in the record supports a decision that’s fully in the appellant’s favor.
4. Medicare Appeals Council review. If you disagree with the ALJ decision or wish to escalate the appeal because the ALJ ruling time frame has passed, a request for a Medicare Appeals Council review can be made. A request for a Medicare Appeals Council review must be made within 60 days of receipt of the ALJ’s decision or after the ALJ ruling time frame expires.
5. Judicial review in U.S. District Court. A party may file an action in federal district court within 60 calendar days after the date receiving notice of the Medicare Appeals Council’s decision or after a council notice that it is not able to reach a decision. To get a judicial review in federal district court, the case amount must meet a minimum dollar amount ($1,560 in 2017).
Each state has its own Medicaid appeals process. Contact your state’s Medicaid office to find out how to appeal a Medicaid audit finding.
[email protected]
On Twitter @legal_med
AT THE PHYSICIAN LEGAL ISSUES CONFERENCE
50 years of pediatrics: What has changed for female pediatricians?
In the last 50 years, the field of pediatrics has vastly changed, particularly for female physicians.
For starters, the number of female pediatricians has rapidly grown over the last few decades. In 1970, 21% of pediatricians were women, compared with 59% in 2013, according to the American Medical Association physician characteristics and distribution data 2015 edition. The overall pediatric workforce also has increased: A total of 18,332 pediatricians were practicing in 1970, and 84,559 pediatricians were in practice in 2013.
Along with numbers, the field of pediatrics has seen significant changes in practice size, technology, clinical responsibilities, and record keeping, to name a few. However, longtime pediatricians say there are also many ways that the specialty has stayed the same.
Dr. Bennett’s story
When Jean L. Bennett, MD, opened her solo pediatric practice in 1963, she initially had no nurses or team of assistants to help carry out clinical duties. With one receptionist answering phones and Dr. Bennett in the exam room, the Clearwater, Fla., practice opened for business. There was no shortage of patients, Dr. Bennett recalls.
“There was no such thing as neonatology. As a pediatrician, one took care of well and sick newborns and of course, saw a variety of infectious diseases in the office,” Dr. Bennett said in an interview. “We started our own IVs, we did our own lumbar punctures, we did subdural taps, we did exchange transfusions. We did all of those ourselves.”
Dr. Bennett was no stranger to being the lone woman on the job. She was the first woman to graduate from the University of Florida College of Medicine in Gainesville, the first woman to serve as chief of staff at Morton F. Plant Hospital in Clearwater, and the first woman to chair the hospital’s department of pediatrics. Despite being the first in many cases, Dr. Bennett does not remember facing discrimination from colleagues or community members, nor experiencing prejudice against her gender as a medical student or young resident
“My experience was different, of course, than other people graduating at that time, but I can truly say that I always felt the playing field was level,” Dr. Bennett said. “Nobody gave me anything for being a woman, and nobody took anything away.”
Compared with concerns that physicians have today, such as electronic medical records and increasing regulations, Dr. Bennett remembers a relatively worry-free career. She recalls some concern over the medical malpractice crisis in the 1970s and 1980s, but said the majority of her tenure was spent with a clear mind and positive attitude.
“In the 60s, I was naive enough not to worry a whole lot,” she said. “I was in the process of getting my practice started, and I was raising in a family at the same time. I would struggle to tell you the things I spent time worrying about. I went to work every day with a joyful attitude, grateful that I was in a community where I could serve.”
Two of the most significant changes Dr. Bennett witnessed during her career were the development of pediatric subspecialists and the establishment of children’s hospitals. Both markedly altered the field of pediatrics and the way in which children were cared for, she said.
“Early in medicine, children were thought of as the stepchildren of medicine, if you will,” she said. “All the attention research-wise and provision-wise was for adults. During my tenure, I saw that attitude change. The attitude that children were just little adults certainly changed, and the development of specialty hospitals for children, that was a real plus.”
Dr. Bennett spent 27 years in solo practice before hiring additional doctors at what is now Myrtle Avenue Pediatrics, a group practice in Clearwater. She retired in 2003 after a career spanning 40 years. The best advice she would offer young pediatricians is to treat their staff well, especially the front office staff who answer phones and make appointments. Pay them well, train them, and treat them right in order to retain loyal employees and reduce turnover.
In addition, Dr. Bennett stresses that young women who want to be pediatricians should not focus on their gender. “I would remind them that they are physicians who happen to be women,” and they should not think of themselves as female physicians, she said. “Personally I believe becoming a physician is a calling, and I don’t think it is gender oriented. I think males and females can have that calling. I see no difference.”
Dr. Eaton’s story
In the 1960s, when most young pediatricians were opening practices or joining small groups, Antoinette P. Eaton, MD, chose an different path. A passion for serving undeserved families led her to back to what is now Nationwide Children’s Hospital in Columbus, Ohio, where she had completed her residency. In the early 60s, Dr. Eaton served as assistant medical director at the hospital, and in 1965 she become director of the hospital’s birth defect center.
Back then, insurers operated much differently, Dr. Eaton recalled. Insurance companies would not pay for outpatient care, and so children with developmental or congenital disorders would have to be admitted to the hospital for treatment. “It was a complete reversal of what it is like now,” she said.
“We all saw each patient, and then we would get together and conference on the patient and decide on the best approach,” Dr. Eaton said in an interview. “I would definitely say it was unique. It certainly ingrained in me how valuable the team approach to medicine was then and is now. It’s become a very popular approach, and I’m happy to see that, but that was my approach way back in the mid-60s and mid-70s.”
Like female pediatricians of today, Dr. Eaton worked to juggle her career and her role as a mother to four children. She found balance by working part time when necessary and getting off early when her children were school-aged. “Being a mother and being a physician, especially in leadership, there’s always going to be pressure for allocating your time appropriately between all of those demands, but I can tell you I always made being a mother my top priority, and I don’t think I sacrificed my professional duties as a result,” she said. “I think it was possible to combine them, although it’s certainly challenging at times.”
Dr. Eaton went on to become director for maternal health at the Ohio Department of Health and later served as president for the AAP Ohio Chapter and as AAP president from 1990 to 1991.
Her most important achievement however, was being a strong voice for children, she said. “My biggest accomplishment, I hope, was standing up for children and speaking out for children and assuming leadership roles in organizations like AAP to underscore that important role as an advocate.”
[email protected]
On Twitter @legal_med
In the last 50 years, the field of pediatrics has vastly changed, particularly for female physicians.
For starters, the number of female pediatricians has rapidly grown over the last few decades. In 1970, 21% of pediatricians were women, compared with 59% in 2013, according to the American Medical Association physician characteristics and distribution data 2015 edition. The overall pediatric workforce also has increased: A total of 18,332 pediatricians were practicing in 1970, and 84,559 pediatricians were in practice in 2013.
Along with numbers, the field of pediatrics has seen significant changes in practice size, technology, clinical responsibilities, and record keeping, to name a few. However, longtime pediatricians say there are also many ways that the specialty has stayed the same.
Dr. Bennett’s story
When Jean L. Bennett, MD, opened her solo pediatric practice in 1963, she initially had no nurses or team of assistants to help carry out clinical duties. With one receptionist answering phones and Dr. Bennett in the exam room, the Clearwater, Fla., practice opened for business. There was no shortage of patients, Dr. Bennett recalls.
“There was no such thing as neonatology. As a pediatrician, one took care of well and sick newborns and of course, saw a variety of infectious diseases in the office,” Dr. Bennett said in an interview. “We started our own IVs, we did our own lumbar punctures, we did subdural taps, we did exchange transfusions. We did all of those ourselves.”
Dr. Bennett was no stranger to being the lone woman on the job. She was the first woman to graduate from the University of Florida College of Medicine in Gainesville, the first woman to serve as chief of staff at Morton F. Plant Hospital in Clearwater, and the first woman to chair the hospital’s department of pediatrics. Despite being the first in many cases, Dr. Bennett does not remember facing discrimination from colleagues or community members, nor experiencing prejudice against her gender as a medical student or young resident
“My experience was different, of course, than other people graduating at that time, but I can truly say that I always felt the playing field was level,” Dr. Bennett said. “Nobody gave me anything for being a woman, and nobody took anything away.”
Compared with concerns that physicians have today, such as electronic medical records and increasing regulations, Dr. Bennett remembers a relatively worry-free career. She recalls some concern over the medical malpractice crisis in the 1970s and 1980s, but said the majority of her tenure was spent with a clear mind and positive attitude.
“In the 60s, I was naive enough not to worry a whole lot,” she said. “I was in the process of getting my practice started, and I was raising in a family at the same time. I would struggle to tell you the things I spent time worrying about. I went to work every day with a joyful attitude, grateful that I was in a community where I could serve.”
Two of the most significant changes Dr. Bennett witnessed during her career were the development of pediatric subspecialists and the establishment of children’s hospitals. Both markedly altered the field of pediatrics and the way in which children were cared for, she said.
“Early in medicine, children were thought of as the stepchildren of medicine, if you will,” she said. “All the attention research-wise and provision-wise was for adults. During my tenure, I saw that attitude change. The attitude that children were just little adults certainly changed, and the development of specialty hospitals for children, that was a real plus.”
Dr. Bennett spent 27 years in solo practice before hiring additional doctors at what is now Myrtle Avenue Pediatrics, a group practice in Clearwater. She retired in 2003 after a career spanning 40 years. The best advice she would offer young pediatricians is to treat their staff well, especially the front office staff who answer phones and make appointments. Pay them well, train them, and treat them right in order to retain loyal employees and reduce turnover.
In addition, Dr. Bennett stresses that young women who want to be pediatricians should not focus on their gender. “I would remind them that they are physicians who happen to be women,” and they should not think of themselves as female physicians, she said. “Personally I believe becoming a physician is a calling, and I don’t think it is gender oriented. I think males and females can have that calling. I see no difference.”
Dr. Eaton’s story
In the 1960s, when most young pediatricians were opening practices or joining small groups, Antoinette P. Eaton, MD, chose an different path. A passion for serving undeserved families led her to back to what is now Nationwide Children’s Hospital in Columbus, Ohio, where she had completed her residency. In the early 60s, Dr. Eaton served as assistant medical director at the hospital, and in 1965 she become director of the hospital’s birth defect center.
Back then, insurers operated much differently, Dr. Eaton recalled. Insurance companies would not pay for outpatient care, and so children with developmental or congenital disorders would have to be admitted to the hospital for treatment. “It was a complete reversal of what it is like now,” she said.
“We all saw each patient, and then we would get together and conference on the patient and decide on the best approach,” Dr. Eaton said in an interview. “I would definitely say it was unique. It certainly ingrained in me how valuable the team approach to medicine was then and is now. It’s become a very popular approach, and I’m happy to see that, but that was my approach way back in the mid-60s and mid-70s.”
Like female pediatricians of today, Dr. Eaton worked to juggle her career and her role as a mother to four children. She found balance by working part time when necessary and getting off early when her children were school-aged. “Being a mother and being a physician, especially in leadership, there’s always going to be pressure for allocating your time appropriately between all of those demands, but I can tell you I always made being a mother my top priority, and I don’t think I sacrificed my professional duties as a result,” she said. “I think it was possible to combine them, although it’s certainly challenging at times.”
Dr. Eaton went on to become director for maternal health at the Ohio Department of Health and later served as president for the AAP Ohio Chapter and as AAP president from 1990 to 1991.
Her most important achievement however, was being a strong voice for children, she said. “My biggest accomplishment, I hope, was standing up for children and speaking out for children and assuming leadership roles in organizations like AAP to underscore that important role as an advocate.”
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On Twitter @legal_med
In the last 50 years, the field of pediatrics has vastly changed, particularly for female physicians.
For starters, the number of female pediatricians has rapidly grown over the last few decades. In 1970, 21% of pediatricians were women, compared with 59% in 2013, according to the American Medical Association physician characteristics and distribution data 2015 edition. The overall pediatric workforce also has increased: A total of 18,332 pediatricians were practicing in 1970, and 84,559 pediatricians were in practice in 2013.
Along with numbers, the field of pediatrics has seen significant changes in practice size, technology, clinical responsibilities, and record keeping, to name a few. However, longtime pediatricians say there are also many ways that the specialty has stayed the same.
Dr. Bennett’s story
When Jean L. Bennett, MD, opened her solo pediatric practice in 1963, she initially had no nurses or team of assistants to help carry out clinical duties. With one receptionist answering phones and Dr. Bennett in the exam room, the Clearwater, Fla., practice opened for business. There was no shortage of patients, Dr. Bennett recalls.
“There was no such thing as neonatology. As a pediatrician, one took care of well and sick newborns and of course, saw a variety of infectious diseases in the office,” Dr. Bennett said in an interview. “We started our own IVs, we did our own lumbar punctures, we did subdural taps, we did exchange transfusions. We did all of those ourselves.”
Dr. Bennett was no stranger to being the lone woman on the job. She was the first woman to graduate from the University of Florida College of Medicine in Gainesville, the first woman to serve as chief of staff at Morton F. Plant Hospital in Clearwater, and the first woman to chair the hospital’s department of pediatrics. Despite being the first in many cases, Dr. Bennett does not remember facing discrimination from colleagues or community members, nor experiencing prejudice against her gender as a medical student or young resident
“My experience was different, of course, than other people graduating at that time, but I can truly say that I always felt the playing field was level,” Dr. Bennett said. “Nobody gave me anything for being a woman, and nobody took anything away.”
Compared with concerns that physicians have today, such as electronic medical records and increasing regulations, Dr. Bennett remembers a relatively worry-free career. She recalls some concern over the medical malpractice crisis in the 1970s and 1980s, but said the majority of her tenure was spent with a clear mind and positive attitude.
“In the 60s, I was naive enough not to worry a whole lot,” she said. “I was in the process of getting my practice started, and I was raising in a family at the same time. I would struggle to tell you the things I spent time worrying about. I went to work every day with a joyful attitude, grateful that I was in a community where I could serve.”
Two of the most significant changes Dr. Bennett witnessed during her career were the development of pediatric subspecialists and the establishment of children’s hospitals. Both markedly altered the field of pediatrics and the way in which children were cared for, she said.
“Early in medicine, children were thought of as the stepchildren of medicine, if you will,” she said. “All the attention research-wise and provision-wise was for adults. During my tenure, I saw that attitude change. The attitude that children were just little adults certainly changed, and the development of specialty hospitals for children, that was a real plus.”
Dr. Bennett spent 27 years in solo practice before hiring additional doctors at what is now Myrtle Avenue Pediatrics, a group practice in Clearwater. She retired in 2003 after a career spanning 40 years. The best advice she would offer young pediatricians is to treat their staff well, especially the front office staff who answer phones and make appointments. Pay them well, train them, and treat them right in order to retain loyal employees and reduce turnover.
In addition, Dr. Bennett stresses that young women who want to be pediatricians should not focus on their gender. “I would remind them that they are physicians who happen to be women,” and they should not think of themselves as female physicians, she said. “Personally I believe becoming a physician is a calling, and I don’t think it is gender oriented. I think males and females can have that calling. I see no difference.”
Dr. Eaton’s story
In the 1960s, when most young pediatricians were opening practices or joining small groups, Antoinette P. Eaton, MD, chose an different path. A passion for serving undeserved families led her to back to what is now Nationwide Children’s Hospital in Columbus, Ohio, where she had completed her residency. In the early 60s, Dr. Eaton served as assistant medical director at the hospital, and in 1965 she become director of the hospital’s birth defect center.
Back then, insurers operated much differently, Dr. Eaton recalled. Insurance companies would not pay for outpatient care, and so children with developmental or congenital disorders would have to be admitted to the hospital for treatment. “It was a complete reversal of what it is like now,” she said.
“We all saw each patient, and then we would get together and conference on the patient and decide on the best approach,” Dr. Eaton said in an interview. “I would definitely say it was unique. It certainly ingrained in me how valuable the team approach to medicine was then and is now. It’s become a very popular approach, and I’m happy to see that, but that was my approach way back in the mid-60s and mid-70s.”
Like female pediatricians of today, Dr. Eaton worked to juggle her career and her role as a mother to four children. She found balance by working part time when necessary and getting off early when her children were school-aged. “Being a mother and being a physician, especially in leadership, there’s always going to be pressure for allocating your time appropriately between all of those demands, but I can tell you I always made being a mother my top priority, and I don’t think I sacrificed my professional duties as a result,” she said. “I think it was possible to combine them, although it’s certainly challenging at times.”
Dr. Eaton went on to become director for maternal health at the Ohio Department of Health and later served as president for the AAP Ohio Chapter and as AAP president from 1990 to 1991.
Her most important achievement however, was being a strong voice for children, she said. “My biggest accomplishment, I hope, was standing up for children and speaking out for children and assuming leadership roles in organizations like AAP to underscore that important role as an advocate.”
[email protected]
On Twitter @legal_med
HHS eliminates funding for teen pregnancy prevention programs
The Trump administration’s sudden funding cut to the Teen Pregnancy Prevention Program will not only halt research and programming efforts at more than 80 institutions across the country, but also will likely unravel recent progress made in reducing teen pregnancies, physicians and program advocates say.
In early July, officials at the U.S. Department of Health & Human Services notified program grantees that the administration would be eliminating funding for the Teen Pregnancy Prevention Program (TPP Program) and that 5-year grants awarded under the Obama administration would be ending in June 2018, 2 years earlier than planned.
The TPP Program is a national, evidence-based initiative established in 2010 to fund medically accurate and age-appropriate programs that work to prevent teen pregnancy in the United States.
“Those programs serve many youth across the country, so of course the individuals in the programs are going to be impacted,” Dr. Oelschlager said in an interview. “It’s demoralizing for the educators, [and] the researchers, who are looking at innovative methods, to have their funding cut in the middle of evaluating whether their programs are effective.”
An HHS spokeswoman confirmed that on July 1, the agency informed TPP Program grantees that funding for the program would be eliminated as detailed in President Trump’s fiscal 2018 budget proposal. The HHS awarded 81 continuations for TPP Program Tier 1 and Tier 2 grant awards for a total of $89 million through June 30, 2018, according to the spokeswoman. The HHS informed the grantees of their June 30, 2018, end date “to give them an opportunity to adjust their programs and plan for an orderly closeout,” she said.
The University of Southern California, Los Angeles, is one of many institutions impacted by the funding cut. The primary objectives of the Keeping it Real Together project are to implement evidence-based sexual health education programs for youth in middle and alternative high schools and provide an education program for parents of middle school–aged youth, said Luanne Rohrbach, PhD, associate professor of clinical preventive medicine at the university’s Institute for Health Promotion & Disease Prevention and principal investigator for the program.
Dr. Rohrbach said she anticipated pushback from the new administration as far as receiving the full 5-year funding, but the sudden program elimination was unexpected.
In March, when President Trump announced his budget priorities for fiscal 2016 and 2017, it was clear that the TPP Program was on the chopping block, Dr. Rohrbach said. However, when Congress passed a continuing resolution for the remainder of fiscal 2016 and 2017, the program remained intact. In his budget recommendations for fiscal 2017 and 2018, the President proposed that the TPP Program be eliminated.
“Despite this recommendation, it was our understanding that the program would be debated in Congress as they developed their recommendations for FY 2017-18 funding,” she said. “That is, we expected there would at least be discussion about it in Congressional budget committees. We did not expect that the program would be eliminated by the Office of the Secretary of HHS.”
Haywood L. Brown, MD, president of the American Congress of Obstetricians and Gynecologists (ACOG) called the administration’s decision “highly unusual” and said it is a step backward for ensuring healthy moms and healthy babies.
“This program and others provide vital research and programming that successfully brought our nation to an all-time low rate of teen pregnancies – progress we cannot afford to jeopardize,” Dr. Brown said in a statement.
Federal data show that the teen pregnancy rate has steadily declined over the last decade. In 2015, the birth rate for girls and young women aged 15-19 years fell by nearly 8% from 2014, according to data from the National Center for Health Statistics. Since 1991, the rate has fallen by 64%. The rate for the younger half of the age group, girls aged 15-17 years, was down 9% from 2014.
Researchers attribute the decline to a combination of economic, cultural, and social factors, as well as a lower prevalence of sexual activity among youth, the use of more effective contraception, and the provision of more information about pregnancy prevention, Dr. Rohrbach said.
“The [TPP Program] has been focused on implementation of evidence-based, comprehensive sexual health education,” she said. “Elimination of these efforts endangers the progress that has been made in reducing teen pregnancies.”
Dr. Oelschlager noted that between 2008 and 2015, the teen birth rate in King County, Washington, declined by 55%. She attributed the reduction to multiple drivers, including a program called Flash, that incorporates a sexual health education curriculum in Seattle-area public schools. Some TPP programs in Northwest Seattle are using the FLASH curriculum, she said.
“This is a very comprehensive program, which includes discussion about reproductive health, sexual violence, prevention of teen pregnancy, sexually transmitted infections, [and] harm reduction,” she said. “That’s been a very effective method of educating our teens about these issues.”
[email protected]
On Twitter @legal_med
The Trump administration’s sudden funding cut to the Teen Pregnancy Prevention Program will not only halt research and programming efforts at more than 80 institutions across the country, but also will likely unravel recent progress made in reducing teen pregnancies, physicians and program advocates say.
In early July, officials at the U.S. Department of Health & Human Services notified program grantees that the administration would be eliminating funding for the Teen Pregnancy Prevention Program (TPP Program) and that 5-year grants awarded under the Obama administration would be ending in June 2018, 2 years earlier than planned.
The TPP Program is a national, evidence-based initiative established in 2010 to fund medically accurate and age-appropriate programs that work to prevent teen pregnancy in the United States.
“Those programs serve many youth across the country, so of course the individuals in the programs are going to be impacted,” Dr. Oelschlager said in an interview. “It’s demoralizing for the educators, [and] the researchers, who are looking at innovative methods, to have their funding cut in the middle of evaluating whether their programs are effective.”
An HHS spokeswoman confirmed that on July 1, the agency informed TPP Program grantees that funding for the program would be eliminated as detailed in President Trump’s fiscal 2018 budget proposal. The HHS awarded 81 continuations for TPP Program Tier 1 and Tier 2 grant awards for a total of $89 million through June 30, 2018, according to the spokeswoman. The HHS informed the grantees of their June 30, 2018, end date “to give them an opportunity to adjust their programs and plan for an orderly closeout,” she said.
The University of Southern California, Los Angeles, is one of many institutions impacted by the funding cut. The primary objectives of the Keeping it Real Together project are to implement evidence-based sexual health education programs for youth in middle and alternative high schools and provide an education program for parents of middle school–aged youth, said Luanne Rohrbach, PhD, associate professor of clinical preventive medicine at the university’s Institute for Health Promotion & Disease Prevention and principal investigator for the program.
Dr. Rohrbach said she anticipated pushback from the new administration as far as receiving the full 5-year funding, but the sudden program elimination was unexpected.
In March, when President Trump announced his budget priorities for fiscal 2016 and 2017, it was clear that the TPP Program was on the chopping block, Dr. Rohrbach said. However, when Congress passed a continuing resolution for the remainder of fiscal 2016 and 2017, the program remained intact. In his budget recommendations for fiscal 2017 and 2018, the President proposed that the TPP Program be eliminated.
“Despite this recommendation, it was our understanding that the program would be debated in Congress as they developed their recommendations for FY 2017-18 funding,” she said. “That is, we expected there would at least be discussion about it in Congressional budget committees. We did not expect that the program would be eliminated by the Office of the Secretary of HHS.”
Haywood L. Brown, MD, president of the American Congress of Obstetricians and Gynecologists (ACOG) called the administration’s decision “highly unusual” and said it is a step backward for ensuring healthy moms and healthy babies.
“This program and others provide vital research and programming that successfully brought our nation to an all-time low rate of teen pregnancies – progress we cannot afford to jeopardize,” Dr. Brown said in a statement.
Federal data show that the teen pregnancy rate has steadily declined over the last decade. In 2015, the birth rate for girls and young women aged 15-19 years fell by nearly 8% from 2014, according to data from the National Center for Health Statistics. Since 1991, the rate has fallen by 64%. The rate for the younger half of the age group, girls aged 15-17 years, was down 9% from 2014.
Researchers attribute the decline to a combination of economic, cultural, and social factors, as well as a lower prevalence of sexual activity among youth, the use of more effective contraception, and the provision of more information about pregnancy prevention, Dr. Rohrbach said.
“The [TPP Program] has been focused on implementation of evidence-based, comprehensive sexual health education,” she said. “Elimination of these efforts endangers the progress that has been made in reducing teen pregnancies.”
Dr. Oelschlager noted that between 2008 and 2015, the teen birth rate in King County, Washington, declined by 55%. She attributed the reduction to multiple drivers, including a program called Flash, that incorporates a sexual health education curriculum in Seattle-area public schools. Some TPP programs in Northwest Seattle are using the FLASH curriculum, she said.
“This is a very comprehensive program, which includes discussion about reproductive health, sexual violence, prevention of teen pregnancy, sexually transmitted infections, [and] harm reduction,” she said. “That’s been a very effective method of educating our teens about these issues.”
[email protected]
On Twitter @legal_med
The Trump administration’s sudden funding cut to the Teen Pregnancy Prevention Program will not only halt research and programming efforts at more than 80 institutions across the country, but also will likely unravel recent progress made in reducing teen pregnancies, physicians and program advocates say.
In early July, officials at the U.S. Department of Health & Human Services notified program grantees that the administration would be eliminating funding for the Teen Pregnancy Prevention Program (TPP Program) and that 5-year grants awarded under the Obama administration would be ending in June 2018, 2 years earlier than planned.
The TPP Program is a national, evidence-based initiative established in 2010 to fund medically accurate and age-appropriate programs that work to prevent teen pregnancy in the United States.
“Those programs serve many youth across the country, so of course the individuals in the programs are going to be impacted,” Dr. Oelschlager said in an interview. “It’s demoralizing for the educators, [and] the researchers, who are looking at innovative methods, to have their funding cut in the middle of evaluating whether their programs are effective.”
An HHS spokeswoman confirmed that on July 1, the agency informed TPP Program grantees that funding for the program would be eliminated as detailed in President Trump’s fiscal 2018 budget proposal. The HHS awarded 81 continuations for TPP Program Tier 1 and Tier 2 grant awards for a total of $89 million through June 30, 2018, according to the spokeswoman. The HHS informed the grantees of their June 30, 2018, end date “to give them an opportunity to adjust their programs and plan for an orderly closeout,” she said.
The University of Southern California, Los Angeles, is one of many institutions impacted by the funding cut. The primary objectives of the Keeping it Real Together project are to implement evidence-based sexual health education programs for youth in middle and alternative high schools and provide an education program for parents of middle school–aged youth, said Luanne Rohrbach, PhD, associate professor of clinical preventive medicine at the university’s Institute for Health Promotion & Disease Prevention and principal investigator for the program.
Dr. Rohrbach said she anticipated pushback from the new administration as far as receiving the full 5-year funding, but the sudden program elimination was unexpected.
In March, when President Trump announced his budget priorities for fiscal 2016 and 2017, it was clear that the TPP Program was on the chopping block, Dr. Rohrbach said. However, when Congress passed a continuing resolution for the remainder of fiscal 2016 and 2017, the program remained intact. In his budget recommendations for fiscal 2017 and 2018, the President proposed that the TPP Program be eliminated.
“Despite this recommendation, it was our understanding that the program would be debated in Congress as they developed their recommendations for FY 2017-18 funding,” she said. “That is, we expected there would at least be discussion about it in Congressional budget committees. We did not expect that the program would be eliminated by the Office of the Secretary of HHS.”
Haywood L. Brown, MD, president of the American Congress of Obstetricians and Gynecologists (ACOG) called the administration’s decision “highly unusual” and said it is a step backward for ensuring healthy moms and healthy babies.
“This program and others provide vital research and programming that successfully brought our nation to an all-time low rate of teen pregnancies – progress we cannot afford to jeopardize,” Dr. Brown said in a statement.
Federal data show that the teen pregnancy rate has steadily declined over the last decade. In 2015, the birth rate for girls and young women aged 15-19 years fell by nearly 8% from 2014, according to data from the National Center for Health Statistics. Since 1991, the rate has fallen by 64%. The rate for the younger half of the age group, girls aged 15-17 years, was down 9% from 2014.
Researchers attribute the decline to a combination of economic, cultural, and social factors, as well as a lower prevalence of sexual activity among youth, the use of more effective contraception, and the provision of more information about pregnancy prevention, Dr. Rohrbach said.
“The [TPP Program] has been focused on implementation of evidence-based, comprehensive sexual health education,” she said. “Elimination of these efforts endangers the progress that has been made in reducing teen pregnancies.”
Dr. Oelschlager noted that between 2008 and 2015, the teen birth rate in King County, Washington, declined by 55%. She attributed the reduction to multiple drivers, including a program called Flash, that incorporates a sexual health education curriculum in Seattle-area public schools. Some TPP programs in Northwest Seattle are using the FLASH curriculum, she said.
“This is a very comprehensive program, which includes discussion about reproductive health, sexual violence, prevention of teen pregnancy, sexually transmitted infections, [and] harm reduction,” she said. “That’s been a very effective method of educating our teens about these issues.”
[email protected]
On Twitter @legal_med
