The Leg.Up Local, state and national news of interest to the physician community

January 25, 2017

Dr. Atul Gawande on "The Heroism of Incremental Care"

Click here to read "The Heroism of Incremental Care," the latest New Yorker essay by Dr. Atul Gawande - a past speaker at RAM.

Gawande describes the case of a patient who has "spent almost four decades under attack from the inside of his skull" from "severe migraines that felt as if a drill were working behind his eyes, across his forehead, and down the back of his head and neck."

"He saw all kinds of doctors - primary-care physicians, neurologists, psychiatrists - who told him what he already knew: he had chronic migraine headaches. And what little the doctors had to offer didn't do him much good."

Gawande describes the many symptoms of migraines -- whose cause he says "remains unknown" -- and the multiple treatments the patient tried. At the John Graham Headache Center in , Gawande explores a process where "success meant that the headaches became less frequent and less intense," and "that the patients grew more confident in handling them."

Bottom line: "Success would be incremental." Click here to read Gawande's essay on the power of "incremental care," which often clashes with our "heroic expectations of how medicine works."

Atul Gawande is a surgeon at Brigham and Women's Hospital in Boston, a professor at Harvard T.H. Chan School of and the director of Ariandne Labs. His latest book is "Being There."

Trump's ACA Order Rattles System

President Trump's executive order instructing federal agencies to grant relief to constituencies affected by Obamacare "has begun to reverberate throughout the nation's healthcare system, injecting further uncertainty into an already unsettled insurance landscape," reports The Washington Post.

The order Trump signed several hours after he was sworn into office Friday signaled that his administration will move quickly "to unwind as many elements at it can on its own - elements that have changed how 20 million Americans get health coverage and what benefits insurers must offer some of their customers."

But, the Post notes, "the practical implications of Trump's action on Friday are harder to decipher." The order instructs all federal agencies to "waive, defer, grant exemptions or delay" any part of the Affordable Care Act that imposes a financial or regulatory burden on those affected by it.

"That would cover consumers, doctors, hospitals and other providers, as well as insurers and drug companies," the Post reports, adding that "the prospect of what could flow from pulling back or eliminating administrative rules - including no longer enforcing the individual mandate, which requires Americans to get coverage or pay an annual penalty, and ending health plans' 'essential benefits' - could affect how many people sign up on the [ACA] marketplaces before open enrollment ends Jan. 31 for 2017 coverage, as well as how many companies decide to participate next year."

Click here to read more about what one health policy consultant called a "bomb" lobbed into the law's "already shaky" insurance market, which is expected to operate at least through 2018. After that, hold on to your laptops!

And click here to read how Trump's first order has strong words on health, but it's "actual impact my be weak" for now. The $64,000 question is what happens after all of Trump's cabinet picks -- at HHS, Labor and Treasury -- get to work. "Many of the administration's options might be more difficult than they first appear," Kaiser Health News reports.

Kaiser quotes Washington & Lee University emeritus professor of law Timothy Jost who said any major stripping of federal health insurance benefits would have a ripple effect across all 50 states, nearly all of which have enacted new laws to come into compliance with the ACA.

Those states "might have to repeal or amend their laws if the ACA were repealed," Jost said. Then there's the no-small matter of complying with public notice provisions.

Meanwhile, "Several Republican senators on Monday proposed a partial replacement for the [ACA] that would allow states to continue operating under the law if they choose, a proposal meant to appeal to critics and supporters of former President 's signature health law," reports The Times.

But the plan was attacked by Democrats as a step backward from the ACA and snubbed by conservative Republicans "who want to get rid of the law and its tax increases as soon as possible."

The Times notes that the proposal - by Dr. Bill Cassidy, a Republican senator from Louisiana, and Sen. Susan Collins of Maine, "a moderate Republican" - may "show how difficult it will be for Republicans to enact a replacement" for the ACA.

Read this column in Sunday's RTD by Dr. Michael D. Williams, a surgeon and director of UVa.'s Center for Health Policy. He advocates paying attention to "the social determinants of health," saying, "If we don't pivot our attention and resources to affecting the social factors that have much more to do with wellness than insurance, we will continue to spend too much money without improving our nation's health and remain a nation that wastes time on discussions about who's paying for it and not what we're paying for."

Dr. Price Grilled by Senate Panel

At a testy Senate confirmation hearing Tuesday, Dr. Tom Price - President Trump's pick as the next secretary of HHS - declined "to promise that no Americans would be worse off under [the president's] executive order to ease provisions" of the ACA - "and distanced himself from the president's claim to have an almost- finished plan to replace the law," reports The Washington Post.

Price, a six-term Georgia congressman and an orthopedic surgeon, "sought to play down the influence he could have on reshaping the health-care system along conservative lines, while attempting to deflect accusations from Democrats about his ethics."

Asked about Trump's recent statements that his healthcare plan would provide "insurance for everybody," with a plan ready to be released after the HHS chief is confirmed, Price would only say, "It's true that he said that, yes."

No date has been set for Price's confirmation by the full Senate.

Price did say that he does not support the privatization of Medicare (click here to read more) and defended his fellow Republicans' plans to create a block grant system for Medicaid. Click here to read "Everything You Need to Know About Block Grants - the Heart of GOP's Medicaid plans."

Last week, Price came under fire for his extensive investment portfolio. Click here to read more.

"Some exchanges were particularly sharp," as progressive Sen. Elizabeth Warren (D-Mass) "lectured Price so persistently on his stock trading that he declared himself 'offended.""

Price maintained that he hadn't tried to take advantage of his public position and wasn't aware of what precise stocks he held. "Everything that I have done has been aboveboard, ethical, transparent and legal," he said, denying any conflict stemming from the stock purchases.

The Wall Street Journal reported in December that since 2012, Price had traded more than $300,000 in shares about 40 health, biomedical and pharmaceutical companies while he was involved with legislation that might affect those firms' stocks." Click here to read more.

Kaiser Health News noted that while Price "is taking the heat for his controversial stock holdings," federal records show several senators who will take part in his confirmation hearing have substantial health-related holdings as well." Among them: both Virginia senators, Tim Kaine and Mark Warner.

Rick Mayes on TrumpCare

Click here if you'd like to see a slide show of Dr. Rick Mayes' recent talk to RAM members at the January General Membership meeting. The UR political science professor and health economist began by laying out the complex political calculus facing Trump and the GOP leadership in Congress.

A theme of his talk came from a slide showing Gen. Colin Powell's signature line about invading Iraq, otherwise known as "the pottery barn rule": "You break it, you own it."

As he pondered the choices ahead for Team Trump, Mayes mentioned a couple of his favorite authors on healthcare reform: Dr. Atul Gawande, and "Overkill" in ; and Avik Roy, who wrote "Transcending Obamacare: A Patient-Centered Plan for Near-Universal Coverage and Permanent Fiscal Solvency."

By keying on income-based tax subsidies and giving states more leeway in how they spend Medicaid block grants, Mayes said of Roy, "If you took his plan, you could replace Obamcare today."

But Roy - who's been an adviser to other Republicans such as Sen. Marco Rubio and Mitt Romney - also wrote a strongly-worded essay, "Saving Conservatism from Trump's GOP" in the November issue of The Atlantic. Click here to read that.

"Trump hates this guy and he won't be getting any appointments," Mayes said. "I think it's a tragedy."

House GOP Plans Push on Direct Primary Care Plan

In a reprise of a bill from last year's legislature, "Republicans in the Virginia House of Delegates will be pushing legislation again this session to promote direct primary care agreements, in which patients pay a fee for unlimited primary care," reports The Washington Post.

Del. Steven Landes (R-Augusta) outlined state GOP healthcare priorities last Thursday. The direct care bill was among them as he argued that such agreements would increase access to care.

Gov. Terry McAuliffe vetoed the measure last year last year, saying such primary care agreements are not insurance and cannot be regulated as such.

Supporters of the bill countered that the measure was needed to provide legal clarity for doctors and patients alike.

In another matter, click here to read McAuliffe's interview with NPR's Robert Siegel about the impact on Virginia if Congress approves block grants for Medicaid - a move the governor says would penalize the Old Dominion for running an already pared-down, efficient program.

Don't Miss Your Chance to be Heard!

Register now for RAM's January 30th White Coat Day!

Make plans now to attend RAM's 2017 Lobby Day at the General Assembly NEXT MONDAY, January 30th. Join your colleagues for breakfast and a legislative briefing before meeting with local legislators and sharing your valuable input and perspective with them.

WHAT WILL YOU HAVE TO DO?

Take the morning off from your duties on January 30th (from 8:00 AM to 1:00 PM). Meet us at the Hilton Richmond Downtown at 8:00 a.m. Attend a morning briefing about what's happening on that day at the General Assembly. In small groups, visit one or more elected officials (RAM staff will arrange the meetings and take you there). Wear a white coat!

WHAT WILL RAM/MSV DO FOR YOU?

Arrange meetings for small groups of physicians with elected officials. Give you background information so you can discuss issues with elected officials. Feed you breakfast and lunch. Lend you a white coat if you don't have one!

CLICK HERE to sign up for our January 30th White Coat Day

or call Lara at 804-622-8137 or email her at [email protected] to register!

Clean Needle Bill Moving Along in G.A.

After some debate, a bill that could help mitigate some of the deadly side effects of Virginia's opioid epidemic took a step forward last week in the General Assembly, reports the Times-Dispatch.

The bill, brought forward by former RAM president Del. John M. O'Bannon III, would legalize syringe-services in the state by allowing the Virginia Department of Health to provide clean equipment such as needles and syringes to injection drug users in areas of the state, such as Southwest Virginia, where the epidemic is particularly strong.

The needle-exchange program is part of a public health effort to prevent outbreaks of hepatitis C and HIV. The rate of hepatitis C has skyrocketed in Virginia, with 8,000 cases in 2015 compared to only 2,800 cases in 2010.

"The problem is that we're losing this battle," O'Bannon told the House Health, Welfare and Institutions Committee. "One in every 100 to 200 citizens has hepatitis C in Southwest Virginia."

O'Bannon stressed that his bill is not a statewide initiative, and would focus on counties targeted by the Health Department. Del. Chris Stolle, (R-Virginia Beach) who like O'Bannon is one of the few physicians in the legislature, also spoke in favor of the bill.

The State of Trump's Health

The 45th president of the got a mixed health review in this Washington Post article, "Age injects unpredictability into Trump's tenure."

On the one hand, President Trump is "a burger-gobbling, exercise- averse 70-year-old who can expect to live 15 more years, according to actuarial data."

But he "apparently has never smoked tobacco," doesn't drink, and "as a wealthy American, he has presumably spent much of his life with access to excellent ."

Facing perhaps the most grueling four-year assignment in the nation, "experts agree there is no reason why a healthy man in his 70s cannot carry out the demanding responsibilities of president of the United States," especially since he's just been "tested by the rigors of a 16-month campaign."

"The key thing is how any person lives with the stress," said Gordon Lithgow, a professor of geroscience at the Buck Institute for Research on Aging in California. "Some people absolutely thrive on the edge of stress."

Click here for more about what's known (and not) about the chief executive's health. "Trump has acknowledged a poor diet heavy on fast food and admits he would like to lose some weight."

The Doctor's Dilemma

Click here to read a new study of malpractice claims by The Doctors Company that "found that the top allegation, representing 39 percent of claims against internists, was diagnosis related and resulted from a delay or failure to diagnosis."

The finding is consistent with a previous study by the National Academies of Sciences, Engineering and Medicine "which found that 34 percent of nonsurgical specialty claims are diagnosis related."

Click here to read about what The Doctors Company report calls "the doctor's dilemma" when it comes to reasons why physicians fail to diagnose particular diseases," noting that "diagnostic accuracy can be improved with a better understanding of how to avoid pitfalls in decision making."

The Doctors Company is the nation's largest physician-owned malpractice insurance company. Your RAM membership gets you a 5% discount in premiums in addition to receiving financial rewards for practicing good medicine upon your retirement. To learn more, or for a price quote, contact the Academy's endorsed insurance partner - the Medical Society of Virginia Insurance Agency (MSVIA) - at (804) 422-3100.

Opioid Prescribers Confront "Doctor Shopping"

State-run opioid prescription systems have created a "patchwork of rules that vary considerably, despite evidence that opioid abusers will cross state lines and travel great distances to illegally obtain prescription drugs," The Washington Post reports.

Dr. Steven Stack, immediate past president of the AMA, and an emergency physician in Kentucky, said various mandates "create other consequences that you sometimes don't want."

In his own hospital ER room, Stack said, Kentucky has put time-consuming mandates on already-overworked doctors and their staffs that take them away from their patients.

"We have taken doctors and turned them into clerical staff and typists," he said.

Meanwhile, click here for a report on how the search for an addiction-free painkiller goes back more than 200 years. And click here for the Smithsonian article quoted in the report. It goes back to 1805, which arguably marks the start of our nation's opioid crisis, "Pretty much as soon as a German pharmacists isolated morphine from opium in 1805."

At that point, writes a medical historian, in the 19th century "addiction among soldiers was reportedly prevalent enough to earn the moniker, 'the soldier's disease.'"

Western Tidewater Free Clinic Seeks M.D.

Western Tidewater Free Clinic in Suffolk is hiring a Medical Director whose main function is to serve as primary care physician for the clinic and to provide oversight for all patient care services.

Click here for a job description and here to learn more about the clinic, and here for a news item about the departing director.

Estimated weekly schedule: 32 hours to provide direct health care services and eight hours a week for administration.

Applicants should have 2-5 years of clinical practice experience. The clinic serves uninsured, low-income adults in Western Tidewater.

Interested? Contact Executive Director Chet M. Hart at: (757) 923- 1060 ext. 7001 or at [email protected]

Aetna-Humana Merger Blocked. Whither Anthem?

A federal judge rejected health insurer Aetna's bid to buy rival Humana on the grounds that the deal would hurt competition in hundreds of Medicare Advantage markets, ultimately bringing higher premiums for healthcare consumers, reports the Associated Press.

The Los Angeles Times reports that Judge John D. Bates criticized Aetna for claiming that it was pulling out of all but four of the 15 states where it was providing Obamacare individual insurance because of a business decision tied to losses on the federal exchanges.

In fact, the judge said, Aetna made its decision "at least partially in response to a federal antitrust suit blocking its proposed $37 billion merger with Humana," the Times reports, noting that "Aetna threatened federal officials with the pullout before the lawsuit was filed and followed through with its threat once it was filed. "

Commenting on how Aetna executives had tried to hide their internal decision-making process from the court, Bates said they had come close to "malfeasance" in the case.

Aetna's exchange pullout has been "exploited by Republicans to justify repealing" the Affordable Care Act, the Times notes. "Just last week, House Speaker Paul Ryan (R-Wisc.) cited Aetna's action on the 'Charlie Rose' show, saying that it proved how shaky the exchanges were."

According to the Times, "Bates found that rationalization was largely untrue."

The Justice Department has also sued to block a separate merger between Anthem and Cigna. That case is still pending.

Locum Tenens on the March

Temporary physicians - AKA locum tenens - are getting more work, according to a new survey by the medical recruitment company, Staff Care.

94% of healthcare facility managers surveyed indicated they had used locum tenens doctors sometime over the last 12 months - up from 74% in 2012.

According to the journal Staffing Industry Analysts, the locum tenens staffing grew by 17% in 2015 and was projected to grow by 10% in 2016.

They're being used primarily to maintain services while hospitals and other healthcare facilities seek to hire more permanent staff or to fill openings created by turnover, according to a survey summary. Click here to read more.

"They are emerging as a key part of the medical workforce in an era of physician shortages and evolving delivery models," said Sean Ebner, president of Dallas-based Staff Care.

Touché!

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Chip Jones RAM Communications & Marketing Director