User login
When the benchwarmer is a slugger
I still, on occasion, use Felbatol (felbamate).
Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.
That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”
Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.
Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).
None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.
And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.
Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.
Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.
With those odds, In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.
As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.
Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.
Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I still, on occasion, use Felbatol (felbamate).
Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.
That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”
Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.
Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).
None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.
And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.
Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.
Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.
With those odds, In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.
As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.
Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.
Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I still, on occasion, use Felbatol (felbamate).
Thirty years since its explosive entrance to the market, then even more explosive collapse, it remains, in my opinion, the most effective of the second generation of anti-seizure medications. Arguably, even more effective than any of the third generation, too.
That’s not to say I use a lot of it. I don’t. It’s like handling unstable dynamite. Tremendous power, but also an above-average degree of risk. Even after things hit the fan with it in the mid-90s, I remember one of my epilepsy clinic attendings telling me, “This is a home-run drug. In refractory patients you might see some benefit by adding another agent, but with this one, you could stop their seizures and hit it out of the park.”
Like most neurologists, I use other epilepsy options first and second line. But sometimes you get the patient who’s failed the usual ones. Then I start to think about Felbatol. I explain the situation to the patients and their families and let them make the final decision. I worry and watch labs very closely for a while. I probably have no more than three to five patients on it in the practice. But when it works, it’s amazing stuff.
Now, let’s jump ahead to 2021. The year of Aduhelm (and several similar agents racing up behind it).
None of these drugs are even close to hitting home runs. For that matter, I’m not convinced they’re even able to get a man on base. To stretch my baseball analogy a bit, imagine watching a game by looking only at the RBI and ERA stats changing. The numbers change slightly, but you have no evidence that either team is winning. Which is, after all, the whole point.
And, to some extent, that’s the basis of Aduhelm’s approval, and likely the same standards its competitors will be held to.
Although they treat different conditions, and are chemically unrelated, the similarities between Felbatol and the currently advancing bunch of monoclonal antibody (MAB) agents for Alzheimer’s disease make an interesting contrast.
Unlike Felbatol’s proven efficacy for epilepsy, the current MABs offer minimal statistically significant clinical benefit for Alzheimer’s disease. At the same time the risk of amyloid-related imaging abnormalities (ARIA) and its complications with them is significantly higher than that of either of Felbatol’s known, potentially lethal, idiosyncratic effects.
With those odds, In medicine, every day is an exercise in working through the risks and benefits of each patient’s individual situation.
As I’ve stated before, I’m not in the grandstand rooting for these Alzheimer’s drugs to fail. I’ve lost a few family members, and certainly my share of patients, to dementia. I’d be thrilled, and more than willing to prescribe it, if something truly effective came along for it.
Nor do I take any kind of pleasure in the recent news that, because of Aduhelm’s failings, around 1,000 Biogen employees will lose their jobs. I feel terrible for them, as most had nothing to do with the decision to forge ahead with the product. More may soon follow at other companies working with similar agents.
Here we are, though, going into 2022. I’m still, albeit rarely, writing for Felbatol 30 years after it came to market for one reason: It works. But it seems pretty unlikely that future neurologists in 2052 will say the same about the current crops of MABs for Alzheimer’s disease.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Is it OK to just be satisfied?
It is possible to talk to a patient for a brief moment and just know if he or she is a satisficer or a maximizer. A “satisficer” when presented with treatment options will invariably say: “I’ll do whatever you say, Doctor.” A “maximizer,” in contrast, would like a printed copy of treatment choices, then would seek a second opinion before ultimately buying an UpToDate subscription to research treatments for him or herself.
.
This notion that we have tendencies toward maximizing or satisficing is thanks to Nobel Memorial Prize winner and all-around smart guy, Herbert A. Simon, PhD. Dr. Simon recognized that, although each person might be expected to make optimal decisions to benefit himself or herself, this is practically impossible. To do so would require an infinite amount of time and energy. He found therefore that we actually exhibit “bounded rationality;” that is, we make the best decision given the limits of time, the price of acquiring information, and even our cognitive abilities. The amount of effort we give to make a decision also depends on the situation: You might be very invested in choosing the right spouse, but not at all invested in choosing soup or salad. (Although, we all have friends who are: “Um, is there any thyme in the soup?”)
You’ll certainly recognize that people have different set points on the spectrum between being a satisficer, one who will take the first option that meets a standard, and a maximizer, one who will seek and accept only the best, even if choosing is at great cost. There are risks and benefits of each. In getting the best job, maximizers might be more successful, but satisficers seem to be happier.
How much this extends into other spheres of life is unclear. It is clear, though, that the work of choosing can come at a cost.
The psychologist Barry Schwartz, PhD, believes that, in general, having more choices leads to more anxiety, not more contentment. For example, which Christmas tree lot would you rather visit: One with hundreds of trees of half a dozen varieties? Or one with just a few trees each of Balsam and Douglas Firs? Dr. Schwartz would argue that you might waste an entire afternoon in the first lot only to bring it home and have remorse when you realize it’s a little lopsided. Or let’s say your child applied to all the Ivy League and Public Ivy schools and also threw in all the top liberal arts colleges. The anxiety of selecting the best and the terror that the “best one” might not choose him or her could be overwhelming. A key lesson is that more in life is by chance than we realize, including how straight your tree is and who gets into Princeton this year. Yet, our expectation that things will work out perfectly if only we maximize is ubiquitous. That confidence in our ability to choose correctly is, however, unwarranted. Better to do your best and know that your tree will be festive and there are many colleges which would lead to a happy life than to fret in choosing and then suffer from dashed expectations. Sometimes good enough is good enough.
Being a satisficer or maximizer is probably somewhat fixed, a personality trait, like being extroverted or conscientious. Yet, having insight can be helpful. If choosing a restaurant in Manhattan becomes an actual project for you with spreadsheets and your own statistical analysis, then go for it! Just know that if that process causes you angst and apprehension, then there is another way. Go to Eleven Madison Park, just because I say so. You might have the best dinner of your life or maybe not. At least by not choosing you’ll have the gift of time to spend picking out a tree instead.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
It is possible to talk to a patient for a brief moment and just know if he or she is a satisficer or a maximizer. A “satisficer” when presented with treatment options will invariably say: “I’ll do whatever you say, Doctor.” A “maximizer,” in contrast, would like a printed copy of treatment choices, then would seek a second opinion before ultimately buying an UpToDate subscription to research treatments for him or herself.
.
This notion that we have tendencies toward maximizing or satisficing is thanks to Nobel Memorial Prize winner and all-around smart guy, Herbert A. Simon, PhD. Dr. Simon recognized that, although each person might be expected to make optimal decisions to benefit himself or herself, this is practically impossible. To do so would require an infinite amount of time and energy. He found therefore that we actually exhibit “bounded rationality;” that is, we make the best decision given the limits of time, the price of acquiring information, and even our cognitive abilities. The amount of effort we give to make a decision also depends on the situation: You might be very invested in choosing the right spouse, but not at all invested in choosing soup or salad. (Although, we all have friends who are: “Um, is there any thyme in the soup?”)
You’ll certainly recognize that people have different set points on the spectrum between being a satisficer, one who will take the first option that meets a standard, and a maximizer, one who will seek and accept only the best, even if choosing is at great cost. There are risks and benefits of each. In getting the best job, maximizers might be more successful, but satisficers seem to be happier.
How much this extends into other spheres of life is unclear. It is clear, though, that the work of choosing can come at a cost.
The psychologist Barry Schwartz, PhD, believes that, in general, having more choices leads to more anxiety, not more contentment. For example, which Christmas tree lot would you rather visit: One with hundreds of trees of half a dozen varieties? Or one with just a few trees each of Balsam and Douglas Firs? Dr. Schwartz would argue that you might waste an entire afternoon in the first lot only to bring it home and have remorse when you realize it’s a little lopsided. Or let’s say your child applied to all the Ivy League and Public Ivy schools and also threw in all the top liberal arts colleges. The anxiety of selecting the best and the terror that the “best one” might not choose him or her could be overwhelming. A key lesson is that more in life is by chance than we realize, including how straight your tree is and who gets into Princeton this year. Yet, our expectation that things will work out perfectly if only we maximize is ubiquitous. That confidence in our ability to choose correctly is, however, unwarranted. Better to do your best and know that your tree will be festive and there are many colleges which would lead to a happy life than to fret in choosing and then suffer from dashed expectations. Sometimes good enough is good enough.
Being a satisficer or maximizer is probably somewhat fixed, a personality trait, like being extroverted or conscientious. Yet, having insight can be helpful. If choosing a restaurant in Manhattan becomes an actual project for you with spreadsheets and your own statistical analysis, then go for it! Just know that if that process causes you angst and apprehension, then there is another way. Go to Eleven Madison Park, just because I say so. You might have the best dinner of your life or maybe not. At least by not choosing you’ll have the gift of time to spend picking out a tree instead.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
It is possible to talk to a patient for a brief moment and just know if he or she is a satisficer or a maximizer. A “satisficer” when presented with treatment options will invariably say: “I’ll do whatever you say, Doctor.” A “maximizer,” in contrast, would like a printed copy of treatment choices, then would seek a second opinion before ultimately buying an UpToDate subscription to research treatments for him or herself.
.
This notion that we have tendencies toward maximizing or satisficing is thanks to Nobel Memorial Prize winner and all-around smart guy, Herbert A. Simon, PhD. Dr. Simon recognized that, although each person might be expected to make optimal decisions to benefit himself or herself, this is practically impossible. To do so would require an infinite amount of time and energy. He found therefore that we actually exhibit “bounded rationality;” that is, we make the best decision given the limits of time, the price of acquiring information, and even our cognitive abilities. The amount of effort we give to make a decision also depends on the situation: You might be very invested in choosing the right spouse, but not at all invested in choosing soup or salad. (Although, we all have friends who are: “Um, is there any thyme in the soup?”)
You’ll certainly recognize that people have different set points on the spectrum between being a satisficer, one who will take the first option that meets a standard, and a maximizer, one who will seek and accept only the best, even if choosing is at great cost. There are risks and benefits of each. In getting the best job, maximizers might be more successful, but satisficers seem to be happier.
How much this extends into other spheres of life is unclear. It is clear, though, that the work of choosing can come at a cost.
The psychologist Barry Schwartz, PhD, believes that, in general, having more choices leads to more anxiety, not more contentment. For example, which Christmas tree lot would you rather visit: One with hundreds of trees of half a dozen varieties? Or one with just a few trees each of Balsam and Douglas Firs? Dr. Schwartz would argue that you might waste an entire afternoon in the first lot only to bring it home and have remorse when you realize it’s a little lopsided. Or let’s say your child applied to all the Ivy League and Public Ivy schools and also threw in all the top liberal arts colleges. The anxiety of selecting the best and the terror that the “best one” might not choose him or her could be overwhelming. A key lesson is that more in life is by chance than we realize, including how straight your tree is and who gets into Princeton this year. Yet, our expectation that things will work out perfectly if only we maximize is ubiquitous. That confidence in our ability to choose correctly is, however, unwarranted. Better to do your best and know that your tree will be festive and there are many colleges which would lead to a happy life than to fret in choosing and then suffer from dashed expectations. Sometimes good enough is good enough.
Being a satisficer or maximizer is probably somewhat fixed, a personality trait, like being extroverted or conscientious. Yet, having insight can be helpful. If choosing a restaurant in Manhattan becomes an actual project for you with spreadsheets and your own statistical analysis, then go for it! Just know that if that process causes you angst and apprehension, then there is another way. Go to Eleven Madison Park, just because I say so. You might have the best dinner of your life or maybe not. At least by not choosing you’ll have the gift of time to spend picking out a tree instead.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Physician gender pay gap isn’t news; health inequity is rampant
A recent study examined projected career earnings between the genders in a largely community-based physician population, finding a difference of about $2 million in career earnings. That a gender pay gap exists in medicine is not news – but the manner in which this study was done, the investigators’ ability to control for a number of confounding variables, and the size of the study group (over 80,000) are newsworthy.
Some of the key findings include that gender pay gaps start with your first job, and you never close the gap, even as you gain experience and efficiency. Also, the more highly remunerated your specialty, the larger the gap. The gender pay gap joins a growing list of inequities within health care. Although physician compensation is not the most important, given that nearly all physicians are well-paid, and we have much more significant inequities that lead to direct patient harm, the reasons for this discrepancy warrant further consideration.
When I was first being educated about social inequity as part of work in social determinants of health, I made the error of using “inequality” and “inequity” interchangeably. The subtle yet important difference between the two terms was quickly described to me. Inequality is a gastroenterologist getting paid more money to do a colonoscopy than a family physician. Inequity is a female gastroenterologist getting paid less than a male gastroenterologist. Global Health Europe boldly identifies that “inequity is the result of failure.” In looking at the inequity inherent in the gender pay gap, I consider what failed and why.
I’m currently making a major career change, leaving an executive leadership position to return to full-time clinical practice. There is a significant pay decrease that will accompany this change because I am in a primary care specialty. Beyond that, I am considering two employment contracts from different systems to do a similar clinical role.
One of the questions my husband asked was which will pay more over the long run. This is difficult to discern because the compensation formula each health system uses is different, even though they are based on standard national benchmarking data. It is possible that women, in general, are like I am and look for factors other than compensation to make a job decision – assuming, like I do, that it will be close enough to not matter or is generally fair. In fact, while compensation is most certainly a consideration for me, once I determined that it was likely to be in the same ballpark, I stopped comparing. Even as the sole breadwinner in our family, I take this (probably faulty) approach.
It’s time to reconsider how we pay physicians
Women may be more likely to gloss over compensation details that men evaluate and negotiate carefully. To change this, women must first take responsibility for being an active, informed, and engaged part of compensation negotiations. In addition, employers who value gender pay equity must negotiate in good faith, keeping in mind the well-described vulnerabilities in discussions about pay. Finally, male and female mentors and leaders should actively coach female physicians on how to approach these conversations with confidence and skill.
In primary care, female physicians spend, on average, about 15% more time with their patients during a visit. Despite spending as much time in clinic seeing patients per week, they see fewer patients, thereby generating less revenue. For compensation plans that are based on productivity, the extra time spent costs money. In this case, it costs the female physicians lost compensation.
The way in which women are more likely to practice medicine, which includes the amount of time they spend with patients, may affect clinical outcomes without directly increasing productivity. A 2017 study demonstrated that elderly patients had lower rates of mortality and readmission when cared for by a female rather than a male physician. These findings require health systems to critically evaluate what compensation plans value and to promote an appropriate balance between quality of care, quantity of care, and style of care.
Although I’ve seen gender pay inequity as blatant as two different salaries for physicians doing the same work – one male and one female – I think this is uncommon. Like many forms of inequity, the outputs are often related to a failed system rather than solely a series of individual failures. Making compensation formulas gender-blind is an important step – but it is only the first step, not the last. Recognizing that the structure of a compensation formula may be biased toward a style of medical practice more likely to be espoused by one gender is necessary as well.
The data, including the findings of this recent study, clearly identify the gender pay gap that exists in medicine, as it does in many other fields, and that it is not explainable solely by differences in specialties, work hours, family status, or title.
To address the inequity, it is imperative that women engage with employers and leaders to both understand and develop skills around effective and appropriate compensation negotiation. Recognizing that compensation plans, especially those built on productivity models, may fail to place adequate value on gender-specific practice styles.
Jennifer Frank is a family physician, physician leader, wife, and mother in Northeast Wisconsin.
A version of this article first appeared on Medscape.com.
A recent study examined projected career earnings between the genders in a largely community-based physician population, finding a difference of about $2 million in career earnings. That a gender pay gap exists in medicine is not news – but the manner in which this study was done, the investigators’ ability to control for a number of confounding variables, and the size of the study group (over 80,000) are newsworthy.
Some of the key findings include that gender pay gaps start with your first job, and you never close the gap, even as you gain experience and efficiency. Also, the more highly remunerated your specialty, the larger the gap. The gender pay gap joins a growing list of inequities within health care. Although physician compensation is not the most important, given that nearly all physicians are well-paid, and we have much more significant inequities that lead to direct patient harm, the reasons for this discrepancy warrant further consideration.
When I was first being educated about social inequity as part of work in social determinants of health, I made the error of using “inequality” and “inequity” interchangeably. The subtle yet important difference between the two terms was quickly described to me. Inequality is a gastroenterologist getting paid more money to do a colonoscopy than a family physician. Inequity is a female gastroenterologist getting paid less than a male gastroenterologist. Global Health Europe boldly identifies that “inequity is the result of failure.” In looking at the inequity inherent in the gender pay gap, I consider what failed and why.
I’m currently making a major career change, leaving an executive leadership position to return to full-time clinical practice. There is a significant pay decrease that will accompany this change because I am in a primary care specialty. Beyond that, I am considering two employment contracts from different systems to do a similar clinical role.
One of the questions my husband asked was which will pay more over the long run. This is difficult to discern because the compensation formula each health system uses is different, even though they are based on standard national benchmarking data. It is possible that women, in general, are like I am and look for factors other than compensation to make a job decision – assuming, like I do, that it will be close enough to not matter or is generally fair. In fact, while compensation is most certainly a consideration for me, once I determined that it was likely to be in the same ballpark, I stopped comparing. Even as the sole breadwinner in our family, I take this (probably faulty) approach.
It’s time to reconsider how we pay physicians
Women may be more likely to gloss over compensation details that men evaluate and negotiate carefully. To change this, women must first take responsibility for being an active, informed, and engaged part of compensation negotiations. In addition, employers who value gender pay equity must negotiate in good faith, keeping in mind the well-described vulnerabilities in discussions about pay. Finally, male and female mentors and leaders should actively coach female physicians on how to approach these conversations with confidence and skill.
In primary care, female physicians spend, on average, about 15% more time with their patients during a visit. Despite spending as much time in clinic seeing patients per week, they see fewer patients, thereby generating less revenue. For compensation plans that are based on productivity, the extra time spent costs money. In this case, it costs the female physicians lost compensation.
The way in which women are more likely to practice medicine, which includes the amount of time they spend with patients, may affect clinical outcomes without directly increasing productivity. A 2017 study demonstrated that elderly patients had lower rates of mortality and readmission when cared for by a female rather than a male physician. These findings require health systems to critically evaluate what compensation plans value and to promote an appropriate balance between quality of care, quantity of care, and style of care.
Although I’ve seen gender pay inequity as blatant as two different salaries for physicians doing the same work – one male and one female – I think this is uncommon. Like many forms of inequity, the outputs are often related to a failed system rather than solely a series of individual failures. Making compensation formulas gender-blind is an important step – but it is only the first step, not the last. Recognizing that the structure of a compensation formula may be biased toward a style of medical practice more likely to be espoused by one gender is necessary as well.
The data, including the findings of this recent study, clearly identify the gender pay gap that exists in medicine, as it does in many other fields, and that it is not explainable solely by differences in specialties, work hours, family status, or title.
To address the inequity, it is imperative that women engage with employers and leaders to both understand and develop skills around effective and appropriate compensation negotiation. Recognizing that compensation plans, especially those built on productivity models, may fail to place adequate value on gender-specific practice styles.
Jennifer Frank is a family physician, physician leader, wife, and mother in Northeast Wisconsin.
A version of this article first appeared on Medscape.com.
A recent study examined projected career earnings between the genders in a largely community-based physician population, finding a difference of about $2 million in career earnings. That a gender pay gap exists in medicine is not news – but the manner in which this study was done, the investigators’ ability to control for a number of confounding variables, and the size of the study group (over 80,000) are newsworthy.
Some of the key findings include that gender pay gaps start with your first job, and you never close the gap, even as you gain experience and efficiency. Also, the more highly remunerated your specialty, the larger the gap. The gender pay gap joins a growing list of inequities within health care. Although physician compensation is not the most important, given that nearly all physicians are well-paid, and we have much more significant inequities that lead to direct patient harm, the reasons for this discrepancy warrant further consideration.
When I was first being educated about social inequity as part of work in social determinants of health, I made the error of using “inequality” and “inequity” interchangeably. The subtle yet important difference between the two terms was quickly described to me. Inequality is a gastroenterologist getting paid more money to do a colonoscopy than a family physician. Inequity is a female gastroenterologist getting paid less than a male gastroenterologist. Global Health Europe boldly identifies that “inequity is the result of failure.” In looking at the inequity inherent in the gender pay gap, I consider what failed and why.
I’m currently making a major career change, leaving an executive leadership position to return to full-time clinical practice. There is a significant pay decrease that will accompany this change because I am in a primary care specialty. Beyond that, I am considering two employment contracts from different systems to do a similar clinical role.
One of the questions my husband asked was which will pay more over the long run. This is difficult to discern because the compensation formula each health system uses is different, even though they are based on standard national benchmarking data. It is possible that women, in general, are like I am and look for factors other than compensation to make a job decision – assuming, like I do, that it will be close enough to not matter or is generally fair. In fact, while compensation is most certainly a consideration for me, once I determined that it was likely to be in the same ballpark, I stopped comparing. Even as the sole breadwinner in our family, I take this (probably faulty) approach.
It’s time to reconsider how we pay physicians
Women may be more likely to gloss over compensation details that men evaluate and negotiate carefully. To change this, women must first take responsibility for being an active, informed, and engaged part of compensation negotiations. In addition, employers who value gender pay equity must negotiate in good faith, keeping in mind the well-described vulnerabilities in discussions about pay. Finally, male and female mentors and leaders should actively coach female physicians on how to approach these conversations with confidence and skill.
In primary care, female physicians spend, on average, about 15% more time with their patients during a visit. Despite spending as much time in clinic seeing patients per week, they see fewer patients, thereby generating less revenue. For compensation plans that are based on productivity, the extra time spent costs money. In this case, it costs the female physicians lost compensation.
The way in which women are more likely to practice medicine, which includes the amount of time they spend with patients, may affect clinical outcomes without directly increasing productivity. A 2017 study demonstrated that elderly patients had lower rates of mortality and readmission when cared for by a female rather than a male physician. These findings require health systems to critically evaluate what compensation plans value and to promote an appropriate balance between quality of care, quantity of care, and style of care.
Although I’ve seen gender pay inequity as blatant as two different salaries for physicians doing the same work – one male and one female – I think this is uncommon. Like many forms of inequity, the outputs are often related to a failed system rather than solely a series of individual failures. Making compensation formulas gender-blind is an important step – but it is only the first step, not the last. Recognizing that the structure of a compensation formula may be biased toward a style of medical practice more likely to be espoused by one gender is necessary as well.
The data, including the findings of this recent study, clearly identify the gender pay gap that exists in medicine, as it does in many other fields, and that it is not explainable solely by differences in specialties, work hours, family status, or title.
To address the inequity, it is imperative that women engage with employers and leaders to both understand and develop skills around effective and appropriate compensation negotiation. Recognizing that compensation plans, especially those built on productivity models, may fail to place adequate value on gender-specific practice styles.
Jennifer Frank is a family physician, physician leader, wife, and mother in Northeast Wisconsin.
A version of this article first appeared on Medscape.com.
Alternative rheumatology practice models aim to avoid traditional limitations
Elizabeth Ortiz, MD, knew she needed a change. Working at an academic county clinic, she was often worn down and pulled in different directions. “When I thought about what I really liked about my job, it was patient care and spending time with my patients, which I wasn’t able to do,” Dr. Ortiz said during the annual meeting of the American College of Rheumatology.
She’d heard of direct or concierge care but wasn’t sure if it was a good fit for her. COVID-19 offered a catalyst of sorts for a move to a new care model.
Ten weeks after she moved to Dallas, the pandemic hit full force. Seeing how telehealth was taking off, Dr. Ortiz began crafting a new model of care, a hybrid of telemedicine and house calls that offered multiple venues to connect with patients. The practice is just a year old, and “it’s working and it’s a constant experiment,” said Dr. Ortiz, who offers membership plans and prepaid appointments. She also does “a la carte” visits where established patients can see her at a one-off price. Her goal is to achieve 100% membership.
Although she operates through a direct pay and cash-only model, only recently has she become comfortable with the word “concierge.” There’s a preconceived notion of what that word means, she said.
Direct care: A definition
Following the trend of some primary care practices, more rheumatologists who are dissatisfied with the status quo are embracing these models of care.
Direct and concierge care are often mentioned in tandem, but there are nuanced differences. Direct specialty care removes third-party payers to protect the best interests of patients, according to Diana Girnita, MD, founder and CEO of Rheumatologist OnCall, a direct care practice. Her patient base hails from rural and urban areas in least 10 states. She also created a Facebook group for specialists in direct care and is the cofounder of the Direct Specialty Care Alliance.
Direct care offers a membership fee and additional fees for “as needed” services. “As the physician, I do not have to be contracted to an insurance company to see patients. I contract directly with patients. It is the patient’s choice to contract with an insurance and use the insurance for ancillary services and medication,” Dr. Girnita said. Patients with out-of-network benefits can claim the insurance to cover part of the consultation cost, she added.
In concierge or retainer medicine, a patient pays an annual or monthly fee or retainer to get access to the physician practice. In addition to this fee, the practice can bill the patient’s insurance for consultations or other services. “The concierge model does not eliminate the sub payer. You still contract with the patient’s insurance,” explained Dr. Girnita.
Physicians who establish these models sometimes do a hybrid of cash only and insurance. Micah Yu, MD, who practices rheumatology in Newport Beach, Calif., only takes Medicare. “Otherwise, patients are private pay. I am mainly fee for service, so patients are paying me for my time,” he said.
By tailoring their patient base and services, adopters find they have more time to spend with patients. “In my model, I spend 30 minutes for follow-up and 1 hour for new patients,” Dr. Yu said.
Limitations of traditional care
Carrying insurance doesn’t guarantee you the right care, Dr. Girnita said. Wait times to see a rheumatologist range from 4 to 6 months. For physicians who contract with insurance companies, reimbursement for services isn’t always paid promptly and decreases every year. A new cut in reimbursement is expected for rheumatology services in 2022.
Patients in direct care “pay a small amount for memberships that cover the cost of their visits and the time physicians spend in coordinating their additional care between the visits. The cost of the visits is always transparent,” Dr. Girnita said.
Irene Kazmers, MD, a solo private rheumatology practitioner in northern Michigan, was seeing 20-plus patients a day before she made the leap to a concierge model. “The paperwork and administrative burdens of practicing rheumatology as a solo [physician] have mushroomed in the last 10 years,” she said during the ACR meeting. She and staff were spending an inordinate amount of time on prior authorizations, step therapy requirements, electronic health record documentation, and other administrative burdens.
Reimbursements from payers have progressively declined as administrative challenges have necessitated more staff. “I was struggling to maintain an ample financial margin,” she said.
Improved communication, unlimited visits
Dr. Kazmers attests that the transition to the concierge model has enabled and fostered a higher level of communication and specialty care for her patients.
Patients who enroll in the practice pay an annual membership fee and get access to her personal cell phone number and email address. “If they need an urgent appointment, it is typically arranged the same or next day,” she said in an interview. “Visits are not as rushed as in the traditional model, conducive to incorporating beneficial integrative medicine modalities such as dietary, exercise, and mind-body approaches as appropriate, in addition to state-of-the-art treatment.”
She also has more time to coordinate care with her patients’ primary care providers and other care team professionals and to give patients feedback on lab and study results.
Dr. Girnita has ramped down from 28 to 15 patients a day. She’s able to spend 60 minutes for new patients and 30 minutes for follow-ups. Like Dr. Kazmers, she feels she has more time to address patient needs and listen to their concerns.
She’s kept her hospital affiliations but finds that she doesn’t have to go to the hospital as much as she used to. Direct care “reduces hospital visits because physicians significantly have much more time to spend with the patient and address the needs of the patient.” A patient with a gout flare, for example, may end up in the hospital under traditional care because there’s no room in the physician’s schedule to address the patient’s needs.
Dr. Girnita recalled when she assisted a patient who had developed inflammatory arthritis and was desperate to see a doctor. The patient had good insurance, but appointments in her area weren’t available for at least 6 months. “Her primary care physician called me. I saw her and provided her with the appropriate care. A couple of months later she is doing great.”
What insurance does and doesn’t cover
Many patients who seek out direct or concierge models retain their insurance. At least 90% of Dr. Girnita’s patients have insurance with high deductibles. The other 10% have other types of insurance or no insurance.
Ellen McKnight, MD, who has a hybrid rheumatology practice in Pensacola, Fla., still accepts commercial insurance, but has opted out of Medicare. Her patients mostly come from rural areas in Florida, and their insurance situations vary widely. “In my practice, I estimate that 65% have insurance and 35% do not. Most of my patients have commercial insurance, and a substantial portion, about 40%, are just paying cash. My cash pay patients have Medicare, HMOs, and others are uninsured,” she said in an interview.
Direct care practices may continue to bill traditional insurance for items like visits, injections, and ultrasound.
Dr. Girnita’s patients have the option of submitting a “superbill” or invoice to insurance companies for patients to be reimbursed by their insurance for the cost of the visit. It contains the CPT code for the visit along with the ICD-10 codes for diagnoses. “I use a company called Reimbursify to help patients submit their invoice to their insurance company,” Dr. Girnita said.
Dr. Ortiz takes a different approach, offering superbills for consults and individual appointments, but not for patients enrolled in her membership program.
Some in the payer industry contend that direct care arrangements increase costs and distort risk pools. If most direct care patients already have a comprehensive health insurance policy, it’s likely they’re being billed twice for services, said David Allen, spokesperson for America’s Health Insurance Plans.
“Duplicative payments inflate the cost of care at a convenience to the providers and increase the cost of insurance premiums when insurers receive bills for those same services from providers. In other words, patients are being double billed,” Mr. Allen said.
These providers are assuming risk without state insurance oversight or regulations to ensure patient protections and safeguards are in place, he continued. “If utilization of services outpaces capacity, the provider may ultimately be unable to provide the amount of care expected by the patient because their practice agreed to unlimited visits and services with little or no restrictions.”
Eliminating ‘surprise’ bills
Adopters of direct care/concierge services counter that it’s the insurance and pharmaceutical companies driving up costs. Patients – especially those who have high-deductible plans – save money through these models. “In the direct care model, doctors have worked out advocacy for patients that are unsurpassed. Insurance companies don’t do that,” Dr. McKnight said.
Consumers know up front what the price is for other services. When you go to a restaurant, you always look on the menu to see what the price is for a bottle of wine or steak, Dr. Girnita said. “Only in the medical field you don’t know anything. And you’re shocked about the price you must pay.” Not many practices list their prices on their website, although federal rules seek to further increase price transparency in hospitals and among insurers.
Patients will sometimes get a “surprise” bill for their visit, laboratory, or imaging tests. According to Dr. Girnita, “that doesn’t happen in my practice. I discuss all prices with them before they get to the lab or MRI. I don’t charge copayments or anything extra.” Without a copayment – usually $50-$75 for specialist services – or a surprise bill, patients are always paying less, she said.
Costs through insurance are oftentimes higher, she continued. For routine lab work, a patient in a direct care practice pays about $30-$40. If they request this work through a lab, they’re likely to pay $150. “Think about an MRI. Through a direct care practice like mine, you pay $450-$700. In a hospital setting, you pay at least $5,000.”
Patients with high-deductible insurance plans often pay thousands of dollars before meeting their deductible, Dr. Girnita and others noted. A patient with this type of plan may pay $250 for a vitamin D lab if they haven’t met their deductible, Dr. McKnight explained. “With direct care, you’ll be paying $12.50.”
Dr. Girnita said her members get excellent discounts for labs and imaging. In the direct care models, physicians can help with this by contracting directly with labs, imaging centers, and independent pharmacies, giving patients access to affordable and transparent prices for their medical care.
What patients pay for services
In direct and concierge care membership models, coverage for services and fees vary widely from practice to practice.
Dr. Girnita offers several membership options. One package, which is $199 a month, is for patients with stable symptoms that guarantee continuity of care. It includes four visits a year and immediate access to the practice in case of emergency (including two additional urgent visits). “This works for a lot of patients. They consider that affordable, and they have all the benefits of a concierge practice. They can have direct communication with me, and they have guaranteed continuity of care,” Dr. Girnita said.
The other model, which is $299 per month, is for patients who need monthly contact with the rheumatologist for visits, telephone and email communications, urgent appointments, integrative medicine consultations, and many other benefits. For 1-hour consultations, Dr. Girnita charges $399.
Dr. Ortiz, who offers a direct pay model, charges $899 for an initial consult, which covers 3.5 hours of her time. “We do an hour of telemedicine, and we do a house call, which is 1.5-2 hours.” She follows up with a telehealth visit. Labs and x-rays are not included and go through the patient’s insurance.
Once the consult takes place, she assesses what a patient needs and offers them either a 6- or 12-month membership, which includes unlimited visits.
Patients can also buy a prepaid, six-appointment package with a 12% discount. Dr. Ortiz prices her telehealth visits at $350 and house calls at $550.
Dr. McKnight’s cash-only model for established patients offers four visits a year, reducing the fee for each visit. For example, a patient will pay $95 for the first visit, then $90, $85, and $80 for subsequent visits.
Accessing medications through direct care
One challenge with this model is finding affordable medications for patients outside of insurance.
Insurance dictates what’s covered, leaving fewer options for patients, Dr. McKnight said. “You have to jump through hoops, and there’s prior authorizations.” For a condition like severe osteoporosis, treatment should start sequentially with the true bone builders first, then move on to a medication like alendronate (Fosamax).
“Insurers will make you go to Fosamax first and then fail it,” she said. This results in the patient potentially developing worsening bone loss or possibly even sustaining a fracture.
Prior authorization requirements demand excessive staff time and effort, Dr. Kazmers said. This can translate to more than $90,000 a year in human resource costs for rheumatologists, who often deal with many specialty drug authorizations. “Every practice needs to hire staff to handle prior authorizations. We receive no compensation for this from the pharmaceutical companies and middlemen who ultimately profit from this cumbersome process,” she added.
Among the two big classes for rheumatology patients, conventional synthetic disease-modifying antirheumatic drugs (DMARDs) are the most widely available. Pharmacies can offer DMARDs for cash, although some are limited in terms of where they can ship, Dr. Girnita said.
The other class, biologic DMARDs, are the most expensive medications rheumatologists use for conditions such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.
With biologics, it’s more difficult, as they’re very expensive, typically $6,000 a month or more, sources told this news organization.
“Unfortunately, we can’t partner at this time with pharmaceutical companies that produce biologics or independent pharmacies,” Dr. Girnita said. Physicians can’t control biologic prices either. “Insurance companies and pharmacy benefit managers have the control on these prices.”
Physicians can direct patients to multiple resources where they can find assistance.
Biologics companies that offer patient assistance programs can sometimes offer medications for free, while others offer savings cards or copay cards, “which helps a lot,” Dr. Girnita said. She assists her patients by filing some of the paperwork necessary to qualify for these programs, and the patients submit the rest.
“For these companies to help the patient, they need the patient’s financial information,” she said. “But I do most of that work; I complete the forms and send to the company and justify need for the medication.”
What’s ahead for direct specialty care
While some patients have benefited, others have had to seek alternatives as their doctors transition to alternative models.
Not everyone can afford the concierge retainer fee, said Dr. Kazmers, who practices in a rural area of Michigan, where rheumatologists are scarce. Enrollment in her concierge practice filled months before the switchover from her traditional practice took place. There are 70 patients on a waiting list.
Patients who elect not to enroll in the concierge practice need to find another source of rheumatology care. This is a downside to the practice transition, she acknowledged. “The closest rheumatologist taking new patients is a 3- to 4-hour drive away, which simply reflects the shortage of medical school graduates choosing to go into rheumatology in the United States,” Dr. Kazmers added.
One physician caring for thousands of chronically ill, complicated patients within systems that don’t allow them the time to really care for their patients threatens to make the access problem worse, Dr. Ortiz said. The direct care/concierge model offers an alternative for the provider “and is a way to keep providers in the workforce, who may otherwise consider leaving.”
Direct care/concierge medicine isn’t for all doctors. But for Dr. Kazmers, it’s the best option for her at this point in her career. “I’ve been practicing for 45 years in various models, including academic positions and private practice employment. I have worked for years in settings accepting Medicaid. I understand that if every rheumatologist went concierge tomorrow, this would constrict access to needed specialty care. But in my case, it provided a viable alternative to closing the practice’s doors altogether.”
Ultimately, the U.S. medical system needs more rheumatologists and other specialists. “If you really want to increase the service, then Medicare or other sources should support opening more residency and fellowship spots for medical graduates to pursue,” Dr. Girnita said.
Other solutions call for more systemic and institutional changes, such as expanding rheumatology divisions and faculties at institutions that train fellows and addressing medical school debt, Dr. Ortiz said.
Some practices see themselves branching out from individual patient care and partnering with local businesses to provide care for employees. That’s the future for direct specialty care, said Dr. Girnita, who’s been in discussions with a few employers to make such arrangements.
The direct primary care community has already started to contract with employers. “Their employees get care they need for just a fraction of the cost. These discussions are arising more and more,” she said.
A version of this article first appeared on Medscape.com.
Elizabeth Ortiz, MD, knew she needed a change. Working at an academic county clinic, she was often worn down and pulled in different directions. “When I thought about what I really liked about my job, it was patient care and spending time with my patients, which I wasn’t able to do,” Dr. Ortiz said during the annual meeting of the American College of Rheumatology.
She’d heard of direct or concierge care but wasn’t sure if it was a good fit for her. COVID-19 offered a catalyst of sorts for a move to a new care model.
Ten weeks after she moved to Dallas, the pandemic hit full force. Seeing how telehealth was taking off, Dr. Ortiz began crafting a new model of care, a hybrid of telemedicine and house calls that offered multiple venues to connect with patients. The practice is just a year old, and “it’s working and it’s a constant experiment,” said Dr. Ortiz, who offers membership plans and prepaid appointments. She also does “a la carte” visits where established patients can see her at a one-off price. Her goal is to achieve 100% membership.
Although she operates through a direct pay and cash-only model, only recently has she become comfortable with the word “concierge.” There’s a preconceived notion of what that word means, she said.
Direct care: A definition
Following the trend of some primary care practices, more rheumatologists who are dissatisfied with the status quo are embracing these models of care.
Direct and concierge care are often mentioned in tandem, but there are nuanced differences. Direct specialty care removes third-party payers to protect the best interests of patients, according to Diana Girnita, MD, founder and CEO of Rheumatologist OnCall, a direct care practice. Her patient base hails from rural and urban areas in least 10 states. She also created a Facebook group for specialists in direct care and is the cofounder of the Direct Specialty Care Alliance.
Direct care offers a membership fee and additional fees for “as needed” services. “As the physician, I do not have to be contracted to an insurance company to see patients. I contract directly with patients. It is the patient’s choice to contract with an insurance and use the insurance for ancillary services and medication,” Dr. Girnita said. Patients with out-of-network benefits can claim the insurance to cover part of the consultation cost, she added.
In concierge or retainer medicine, a patient pays an annual or monthly fee or retainer to get access to the physician practice. In addition to this fee, the practice can bill the patient’s insurance for consultations or other services. “The concierge model does not eliminate the sub payer. You still contract with the patient’s insurance,” explained Dr. Girnita.
Physicians who establish these models sometimes do a hybrid of cash only and insurance. Micah Yu, MD, who practices rheumatology in Newport Beach, Calif., only takes Medicare. “Otherwise, patients are private pay. I am mainly fee for service, so patients are paying me for my time,” he said.
By tailoring their patient base and services, adopters find they have more time to spend with patients. “In my model, I spend 30 minutes for follow-up and 1 hour for new patients,” Dr. Yu said.
Limitations of traditional care
Carrying insurance doesn’t guarantee you the right care, Dr. Girnita said. Wait times to see a rheumatologist range from 4 to 6 months. For physicians who contract with insurance companies, reimbursement for services isn’t always paid promptly and decreases every year. A new cut in reimbursement is expected for rheumatology services in 2022.
Patients in direct care “pay a small amount for memberships that cover the cost of their visits and the time physicians spend in coordinating their additional care between the visits. The cost of the visits is always transparent,” Dr. Girnita said.
Irene Kazmers, MD, a solo private rheumatology practitioner in northern Michigan, was seeing 20-plus patients a day before she made the leap to a concierge model. “The paperwork and administrative burdens of practicing rheumatology as a solo [physician] have mushroomed in the last 10 years,” she said during the ACR meeting. She and staff were spending an inordinate amount of time on prior authorizations, step therapy requirements, electronic health record documentation, and other administrative burdens.
Reimbursements from payers have progressively declined as administrative challenges have necessitated more staff. “I was struggling to maintain an ample financial margin,” she said.
Improved communication, unlimited visits
Dr. Kazmers attests that the transition to the concierge model has enabled and fostered a higher level of communication and specialty care for her patients.
Patients who enroll in the practice pay an annual membership fee and get access to her personal cell phone number and email address. “If they need an urgent appointment, it is typically arranged the same or next day,” she said in an interview. “Visits are not as rushed as in the traditional model, conducive to incorporating beneficial integrative medicine modalities such as dietary, exercise, and mind-body approaches as appropriate, in addition to state-of-the-art treatment.”
She also has more time to coordinate care with her patients’ primary care providers and other care team professionals and to give patients feedback on lab and study results.
Dr. Girnita has ramped down from 28 to 15 patients a day. She’s able to spend 60 minutes for new patients and 30 minutes for follow-ups. Like Dr. Kazmers, she feels she has more time to address patient needs and listen to their concerns.
She’s kept her hospital affiliations but finds that she doesn’t have to go to the hospital as much as she used to. Direct care “reduces hospital visits because physicians significantly have much more time to spend with the patient and address the needs of the patient.” A patient with a gout flare, for example, may end up in the hospital under traditional care because there’s no room in the physician’s schedule to address the patient’s needs.
Dr. Girnita recalled when she assisted a patient who had developed inflammatory arthritis and was desperate to see a doctor. The patient had good insurance, but appointments in her area weren’t available for at least 6 months. “Her primary care physician called me. I saw her and provided her with the appropriate care. A couple of months later she is doing great.”
What insurance does and doesn’t cover
Many patients who seek out direct or concierge models retain their insurance. At least 90% of Dr. Girnita’s patients have insurance with high deductibles. The other 10% have other types of insurance or no insurance.
Ellen McKnight, MD, who has a hybrid rheumatology practice in Pensacola, Fla., still accepts commercial insurance, but has opted out of Medicare. Her patients mostly come from rural areas in Florida, and their insurance situations vary widely. “In my practice, I estimate that 65% have insurance and 35% do not. Most of my patients have commercial insurance, and a substantial portion, about 40%, are just paying cash. My cash pay patients have Medicare, HMOs, and others are uninsured,” she said in an interview.
Direct care practices may continue to bill traditional insurance for items like visits, injections, and ultrasound.
Dr. Girnita’s patients have the option of submitting a “superbill” or invoice to insurance companies for patients to be reimbursed by their insurance for the cost of the visit. It contains the CPT code for the visit along with the ICD-10 codes for diagnoses. “I use a company called Reimbursify to help patients submit their invoice to their insurance company,” Dr. Girnita said.
Dr. Ortiz takes a different approach, offering superbills for consults and individual appointments, but not for patients enrolled in her membership program.
Some in the payer industry contend that direct care arrangements increase costs and distort risk pools. If most direct care patients already have a comprehensive health insurance policy, it’s likely they’re being billed twice for services, said David Allen, spokesperson for America’s Health Insurance Plans.
“Duplicative payments inflate the cost of care at a convenience to the providers and increase the cost of insurance premiums when insurers receive bills for those same services from providers. In other words, patients are being double billed,” Mr. Allen said.
These providers are assuming risk without state insurance oversight or regulations to ensure patient protections and safeguards are in place, he continued. “If utilization of services outpaces capacity, the provider may ultimately be unable to provide the amount of care expected by the patient because their practice agreed to unlimited visits and services with little or no restrictions.”
Eliminating ‘surprise’ bills
Adopters of direct care/concierge services counter that it’s the insurance and pharmaceutical companies driving up costs. Patients – especially those who have high-deductible plans – save money through these models. “In the direct care model, doctors have worked out advocacy for patients that are unsurpassed. Insurance companies don’t do that,” Dr. McKnight said.
Consumers know up front what the price is for other services. When you go to a restaurant, you always look on the menu to see what the price is for a bottle of wine or steak, Dr. Girnita said. “Only in the medical field you don’t know anything. And you’re shocked about the price you must pay.” Not many practices list their prices on their website, although federal rules seek to further increase price transparency in hospitals and among insurers.
Patients will sometimes get a “surprise” bill for their visit, laboratory, or imaging tests. According to Dr. Girnita, “that doesn’t happen in my practice. I discuss all prices with them before they get to the lab or MRI. I don’t charge copayments or anything extra.” Without a copayment – usually $50-$75 for specialist services – or a surprise bill, patients are always paying less, she said.
Costs through insurance are oftentimes higher, she continued. For routine lab work, a patient in a direct care practice pays about $30-$40. If they request this work through a lab, they’re likely to pay $150. “Think about an MRI. Through a direct care practice like mine, you pay $450-$700. In a hospital setting, you pay at least $5,000.”
Patients with high-deductible insurance plans often pay thousands of dollars before meeting their deductible, Dr. Girnita and others noted. A patient with this type of plan may pay $250 for a vitamin D lab if they haven’t met their deductible, Dr. McKnight explained. “With direct care, you’ll be paying $12.50.”
Dr. Girnita said her members get excellent discounts for labs and imaging. In the direct care models, physicians can help with this by contracting directly with labs, imaging centers, and independent pharmacies, giving patients access to affordable and transparent prices for their medical care.
What patients pay for services
In direct and concierge care membership models, coverage for services and fees vary widely from practice to practice.
Dr. Girnita offers several membership options. One package, which is $199 a month, is for patients with stable symptoms that guarantee continuity of care. It includes four visits a year and immediate access to the practice in case of emergency (including two additional urgent visits). “This works for a lot of patients. They consider that affordable, and they have all the benefits of a concierge practice. They can have direct communication with me, and they have guaranteed continuity of care,” Dr. Girnita said.
The other model, which is $299 per month, is for patients who need monthly contact with the rheumatologist for visits, telephone and email communications, urgent appointments, integrative medicine consultations, and many other benefits. For 1-hour consultations, Dr. Girnita charges $399.
Dr. Ortiz, who offers a direct pay model, charges $899 for an initial consult, which covers 3.5 hours of her time. “We do an hour of telemedicine, and we do a house call, which is 1.5-2 hours.” She follows up with a telehealth visit. Labs and x-rays are not included and go through the patient’s insurance.
Once the consult takes place, she assesses what a patient needs and offers them either a 6- or 12-month membership, which includes unlimited visits.
Patients can also buy a prepaid, six-appointment package with a 12% discount. Dr. Ortiz prices her telehealth visits at $350 and house calls at $550.
Dr. McKnight’s cash-only model for established patients offers four visits a year, reducing the fee for each visit. For example, a patient will pay $95 for the first visit, then $90, $85, and $80 for subsequent visits.
Accessing medications through direct care
One challenge with this model is finding affordable medications for patients outside of insurance.
Insurance dictates what’s covered, leaving fewer options for patients, Dr. McKnight said. “You have to jump through hoops, and there’s prior authorizations.” For a condition like severe osteoporosis, treatment should start sequentially with the true bone builders first, then move on to a medication like alendronate (Fosamax).
“Insurers will make you go to Fosamax first and then fail it,” she said. This results in the patient potentially developing worsening bone loss or possibly even sustaining a fracture.
Prior authorization requirements demand excessive staff time and effort, Dr. Kazmers said. This can translate to more than $90,000 a year in human resource costs for rheumatologists, who often deal with many specialty drug authorizations. “Every practice needs to hire staff to handle prior authorizations. We receive no compensation for this from the pharmaceutical companies and middlemen who ultimately profit from this cumbersome process,” she added.
Among the two big classes for rheumatology patients, conventional synthetic disease-modifying antirheumatic drugs (DMARDs) are the most widely available. Pharmacies can offer DMARDs for cash, although some are limited in terms of where they can ship, Dr. Girnita said.
The other class, biologic DMARDs, are the most expensive medications rheumatologists use for conditions such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.
With biologics, it’s more difficult, as they’re very expensive, typically $6,000 a month or more, sources told this news organization.
“Unfortunately, we can’t partner at this time with pharmaceutical companies that produce biologics or independent pharmacies,” Dr. Girnita said. Physicians can’t control biologic prices either. “Insurance companies and pharmacy benefit managers have the control on these prices.”
Physicians can direct patients to multiple resources where they can find assistance.
Biologics companies that offer patient assistance programs can sometimes offer medications for free, while others offer savings cards or copay cards, “which helps a lot,” Dr. Girnita said. She assists her patients by filing some of the paperwork necessary to qualify for these programs, and the patients submit the rest.
“For these companies to help the patient, they need the patient’s financial information,” she said. “But I do most of that work; I complete the forms and send to the company and justify need for the medication.”
What’s ahead for direct specialty care
While some patients have benefited, others have had to seek alternatives as their doctors transition to alternative models.
Not everyone can afford the concierge retainer fee, said Dr. Kazmers, who practices in a rural area of Michigan, where rheumatologists are scarce. Enrollment in her concierge practice filled months before the switchover from her traditional practice took place. There are 70 patients on a waiting list.
Patients who elect not to enroll in the concierge practice need to find another source of rheumatology care. This is a downside to the practice transition, she acknowledged. “The closest rheumatologist taking new patients is a 3- to 4-hour drive away, which simply reflects the shortage of medical school graduates choosing to go into rheumatology in the United States,” Dr. Kazmers added.
One physician caring for thousands of chronically ill, complicated patients within systems that don’t allow them the time to really care for their patients threatens to make the access problem worse, Dr. Ortiz said. The direct care/concierge model offers an alternative for the provider “and is a way to keep providers in the workforce, who may otherwise consider leaving.”
Direct care/concierge medicine isn’t for all doctors. But for Dr. Kazmers, it’s the best option for her at this point in her career. “I’ve been practicing for 45 years in various models, including academic positions and private practice employment. I have worked for years in settings accepting Medicaid. I understand that if every rheumatologist went concierge tomorrow, this would constrict access to needed specialty care. But in my case, it provided a viable alternative to closing the practice’s doors altogether.”
Ultimately, the U.S. medical system needs more rheumatologists and other specialists. “If you really want to increase the service, then Medicare or other sources should support opening more residency and fellowship spots for medical graduates to pursue,” Dr. Girnita said.
Other solutions call for more systemic and institutional changes, such as expanding rheumatology divisions and faculties at institutions that train fellows and addressing medical school debt, Dr. Ortiz said.
Some practices see themselves branching out from individual patient care and partnering with local businesses to provide care for employees. That’s the future for direct specialty care, said Dr. Girnita, who’s been in discussions with a few employers to make such arrangements.
The direct primary care community has already started to contract with employers. “Their employees get care they need for just a fraction of the cost. These discussions are arising more and more,” she said.
A version of this article first appeared on Medscape.com.
Elizabeth Ortiz, MD, knew she needed a change. Working at an academic county clinic, she was often worn down and pulled in different directions. “When I thought about what I really liked about my job, it was patient care and spending time with my patients, which I wasn’t able to do,” Dr. Ortiz said during the annual meeting of the American College of Rheumatology.
She’d heard of direct or concierge care but wasn’t sure if it was a good fit for her. COVID-19 offered a catalyst of sorts for a move to a new care model.
Ten weeks after she moved to Dallas, the pandemic hit full force. Seeing how telehealth was taking off, Dr. Ortiz began crafting a new model of care, a hybrid of telemedicine and house calls that offered multiple venues to connect with patients. The practice is just a year old, and “it’s working and it’s a constant experiment,” said Dr. Ortiz, who offers membership plans and prepaid appointments. She also does “a la carte” visits where established patients can see her at a one-off price. Her goal is to achieve 100% membership.
Although she operates through a direct pay and cash-only model, only recently has she become comfortable with the word “concierge.” There’s a preconceived notion of what that word means, she said.
Direct care: A definition
Following the trend of some primary care practices, more rheumatologists who are dissatisfied with the status quo are embracing these models of care.
Direct and concierge care are often mentioned in tandem, but there are nuanced differences. Direct specialty care removes third-party payers to protect the best interests of patients, according to Diana Girnita, MD, founder and CEO of Rheumatologist OnCall, a direct care practice. Her patient base hails from rural and urban areas in least 10 states. She also created a Facebook group for specialists in direct care and is the cofounder of the Direct Specialty Care Alliance.
Direct care offers a membership fee and additional fees for “as needed” services. “As the physician, I do not have to be contracted to an insurance company to see patients. I contract directly with patients. It is the patient’s choice to contract with an insurance and use the insurance for ancillary services and medication,” Dr. Girnita said. Patients with out-of-network benefits can claim the insurance to cover part of the consultation cost, she added.
In concierge or retainer medicine, a patient pays an annual or monthly fee or retainer to get access to the physician practice. In addition to this fee, the practice can bill the patient’s insurance for consultations or other services. “The concierge model does not eliminate the sub payer. You still contract with the patient’s insurance,” explained Dr. Girnita.
Physicians who establish these models sometimes do a hybrid of cash only and insurance. Micah Yu, MD, who practices rheumatology in Newport Beach, Calif., only takes Medicare. “Otherwise, patients are private pay. I am mainly fee for service, so patients are paying me for my time,” he said.
By tailoring their patient base and services, adopters find they have more time to spend with patients. “In my model, I spend 30 minutes for follow-up and 1 hour for new patients,” Dr. Yu said.
Limitations of traditional care
Carrying insurance doesn’t guarantee you the right care, Dr. Girnita said. Wait times to see a rheumatologist range from 4 to 6 months. For physicians who contract with insurance companies, reimbursement for services isn’t always paid promptly and decreases every year. A new cut in reimbursement is expected for rheumatology services in 2022.
Patients in direct care “pay a small amount for memberships that cover the cost of their visits and the time physicians spend in coordinating their additional care between the visits. The cost of the visits is always transparent,” Dr. Girnita said.
Irene Kazmers, MD, a solo private rheumatology practitioner in northern Michigan, was seeing 20-plus patients a day before she made the leap to a concierge model. “The paperwork and administrative burdens of practicing rheumatology as a solo [physician] have mushroomed in the last 10 years,” she said during the ACR meeting. She and staff were spending an inordinate amount of time on prior authorizations, step therapy requirements, electronic health record documentation, and other administrative burdens.
Reimbursements from payers have progressively declined as administrative challenges have necessitated more staff. “I was struggling to maintain an ample financial margin,” she said.
Improved communication, unlimited visits
Dr. Kazmers attests that the transition to the concierge model has enabled and fostered a higher level of communication and specialty care for her patients.
Patients who enroll in the practice pay an annual membership fee and get access to her personal cell phone number and email address. “If they need an urgent appointment, it is typically arranged the same or next day,” she said in an interview. “Visits are not as rushed as in the traditional model, conducive to incorporating beneficial integrative medicine modalities such as dietary, exercise, and mind-body approaches as appropriate, in addition to state-of-the-art treatment.”
She also has more time to coordinate care with her patients’ primary care providers and other care team professionals and to give patients feedback on lab and study results.
Dr. Girnita has ramped down from 28 to 15 patients a day. She’s able to spend 60 minutes for new patients and 30 minutes for follow-ups. Like Dr. Kazmers, she feels she has more time to address patient needs and listen to their concerns.
She’s kept her hospital affiliations but finds that she doesn’t have to go to the hospital as much as she used to. Direct care “reduces hospital visits because physicians significantly have much more time to spend with the patient and address the needs of the patient.” A patient with a gout flare, for example, may end up in the hospital under traditional care because there’s no room in the physician’s schedule to address the patient’s needs.
Dr. Girnita recalled when she assisted a patient who had developed inflammatory arthritis and was desperate to see a doctor. The patient had good insurance, but appointments in her area weren’t available for at least 6 months. “Her primary care physician called me. I saw her and provided her with the appropriate care. A couple of months later she is doing great.”
What insurance does and doesn’t cover
Many patients who seek out direct or concierge models retain their insurance. At least 90% of Dr. Girnita’s patients have insurance with high deductibles. The other 10% have other types of insurance or no insurance.
Ellen McKnight, MD, who has a hybrid rheumatology practice in Pensacola, Fla., still accepts commercial insurance, but has opted out of Medicare. Her patients mostly come from rural areas in Florida, and their insurance situations vary widely. “In my practice, I estimate that 65% have insurance and 35% do not. Most of my patients have commercial insurance, and a substantial portion, about 40%, are just paying cash. My cash pay patients have Medicare, HMOs, and others are uninsured,” she said in an interview.
Direct care practices may continue to bill traditional insurance for items like visits, injections, and ultrasound.
Dr. Girnita’s patients have the option of submitting a “superbill” or invoice to insurance companies for patients to be reimbursed by their insurance for the cost of the visit. It contains the CPT code for the visit along with the ICD-10 codes for diagnoses. “I use a company called Reimbursify to help patients submit their invoice to their insurance company,” Dr. Girnita said.
Dr. Ortiz takes a different approach, offering superbills for consults and individual appointments, but not for patients enrolled in her membership program.
Some in the payer industry contend that direct care arrangements increase costs and distort risk pools. If most direct care patients already have a comprehensive health insurance policy, it’s likely they’re being billed twice for services, said David Allen, spokesperson for America’s Health Insurance Plans.
“Duplicative payments inflate the cost of care at a convenience to the providers and increase the cost of insurance premiums when insurers receive bills for those same services from providers. In other words, patients are being double billed,” Mr. Allen said.
These providers are assuming risk without state insurance oversight or regulations to ensure patient protections and safeguards are in place, he continued. “If utilization of services outpaces capacity, the provider may ultimately be unable to provide the amount of care expected by the patient because their practice agreed to unlimited visits and services with little or no restrictions.”
Eliminating ‘surprise’ bills
Adopters of direct care/concierge services counter that it’s the insurance and pharmaceutical companies driving up costs. Patients – especially those who have high-deductible plans – save money through these models. “In the direct care model, doctors have worked out advocacy for patients that are unsurpassed. Insurance companies don’t do that,” Dr. McKnight said.
Consumers know up front what the price is for other services. When you go to a restaurant, you always look on the menu to see what the price is for a bottle of wine or steak, Dr. Girnita said. “Only in the medical field you don’t know anything. And you’re shocked about the price you must pay.” Not many practices list their prices on their website, although federal rules seek to further increase price transparency in hospitals and among insurers.
Patients will sometimes get a “surprise” bill for their visit, laboratory, or imaging tests. According to Dr. Girnita, “that doesn’t happen in my practice. I discuss all prices with them before they get to the lab or MRI. I don’t charge copayments or anything extra.” Without a copayment – usually $50-$75 for specialist services – or a surprise bill, patients are always paying less, she said.
Costs through insurance are oftentimes higher, she continued. For routine lab work, a patient in a direct care practice pays about $30-$40. If they request this work through a lab, they’re likely to pay $150. “Think about an MRI. Through a direct care practice like mine, you pay $450-$700. In a hospital setting, you pay at least $5,000.”
Patients with high-deductible insurance plans often pay thousands of dollars before meeting their deductible, Dr. Girnita and others noted. A patient with this type of plan may pay $250 for a vitamin D lab if they haven’t met their deductible, Dr. McKnight explained. “With direct care, you’ll be paying $12.50.”
Dr. Girnita said her members get excellent discounts for labs and imaging. In the direct care models, physicians can help with this by contracting directly with labs, imaging centers, and independent pharmacies, giving patients access to affordable and transparent prices for their medical care.
What patients pay for services
In direct and concierge care membership models, coverage for services and fees vary widely from practice to practice.
Dr. Girnita offers several membership options. One package, which is $199 a month, is for patients with stable symptoms that guarantee continuity of care. It includes four visits a year and immediate access to the practice in case of emergency (including two additional urgent visits). “This works for a lot of patients. They consider that affordable, and they have all the benefits of a concierge practice. They can have direct communication with me, and they have guaranteed continuity of care,” Dr. Girnita said.
The other model, which is $299 per month, is for patients who need monthly contact with the rheumatologist for visits, telephone and email communications, urgent appointments, integrative medicine consultations, and many other benefits. For 1-hour consultations, Dr. Girnita charges $399.
Dr. Ortiz, who offers a direct pay model, charges $899 for an initial consult, which covers 3.5 hours of her time. “We do an hour of telemedicine, and we do a house call, which is 1.5-2 hours.” She follows up with a telehealth visit. Labs and x-rays are not included and go through the patient’s insurance.
Once the consult takes place, she assesses what a patient needs and offers them either a 6- or 12-month membership, which includes unlimited visits.
Patients can also buy a prepaid, six-appointment package with a 12% discount. Dr. Ortiz prices her telehealth visits at $350 and house calls at $550.
Dr. McKnight’s cash-only model for established patients offers four visits a year, reducing the fee for each visit. For example, a patient will pay $95 for the first visit, then $90, $85, and $80 for subsequent visits.
Accessing medications through direct care
One challenge with this model is finding affordable medications for patients outside of insurance.
Insurance dictates what’s covered, leaving fewer options for patients, Dr. McKnight said. “You have to jump through hoops, and there’s prior authorizations.” For a condition like severe osteoporosis, treatment should start sequentially with the true bone builders first, then move on to a medication like alendronate (Fosamax).
“Insurers will make you go to Fosamax first and then fail it,” she said. This results in the patient potentially developing worsening bone loss or possibly even sustaining a fracture.
Prior authorization requirements demand excessive staff time and effort, Dr. Kazmers said. This can translate to more than $90,000 a year in human resource costs for rheumatologists, who often deal with many specialty drug authorizations. “Every practice needs to hire staff to handle prior authorizations. We receive no compensation for this from the pharmaceutical companies and middlemen who ultimately profit from this cumbersome process,” she added.
Among the two big classes for rheumatology patients, conventional synthetic disease-modifying antirheumatic drugs (DMARDs) are the most widely available. Pharmacies can offer DMARDs for cash, although some are limited in terms of where they can ship, Dr. Girnita said.
The other class, biologic DMARDs, are the most expensive medications rheumatologists use for conditions such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis.
With biologics, it’s more difficult, as they’re very expensive, typically $6,000 a month or more, sources told this news organization.
“Unfortunately, we can’t partner at this time with pharmaceutical companies that produce biologics or independent pharmacies,” Dr. Girnita said. Physicians can’t control biologic prices either. “Insurance companies and pharmacy benefit managers have the control on these prices.”
Physicians can direct patients to multiple resources where they can find assistance.
Biologics companies that offer patient assistance programs can sometimes offer medications for free, while others offer savings cards or copay cards, “which helps a lot,” Dr. Girnita said. She assists her patients by filing some of the paperwork necessary to qualify for these programs, and the patients submit the rest.
“For these companies to help the patient, they need the patient’s financial information,” she said. “But I do most of that work; I complete the forms and send to the company and justify need for the medication.”
What’s ahead for direct specialty care
While some patients have benefited, others have had to seek alternatives as their doctors transition to alternative models.
Not everyone can afford the concierge retainer fee, said Dr. Kazmers, who practices in a rural area of Michigan, where rheumatologists are scarce. Enrollment in her concierge practice filled months before the switchover from her traditional practice took place. There are 70 patients on a waiting list.
Patients who elect not to enroll in the concierge practice need to find another source of rheumatology care. This is a downside to the practice transition, she acknowledged. “The closest rheumatologist taking new patients is a 3- to 4-hour drive away, which simply reflects the shortage of medical school graduates choosing to go into rheumatology in the United States,” Dr. Kazmers added.
One physician caring for thousands of chronically ill, complicated patients within systems that don’t allow them the time to really care for their patients threatens to make the access problem worse, Dr. Ortiz said. The direct care/concierge model offers an alternative for the provider “and is a way to keep providers in the workforce, who may otherwise consider leaving.”
Direct care/concierge medicine isn’t for all doctors. But for Dr. Kazmers, it’s the best option for her at this point in her career. “I’ve been practicing for 45 years in various models, including academic positions and private practice employment. I have worked for years in settings accepting Medicaid. I understand that if every rheumatologist went concierge tomorrow, this would constrict access to needed specialty care. But in my case, it provided a viable alternative to closing the practice’s doors altogether.”
Ultimately, the U.S. medical system needs more rheumatologists and other specialists. “If you really want to increase the service, then Medicare or other sources should support opening more residency and fellowship spots for medical graduates to pursue,” Dr. Girnita said.
Other solutions call for more systemic and institutional changes, such as expanding rheumatology divisions and faculties at institutions that train fellows and addressing medical school debt, Dr. Ortiz said.
Some practices see themselves branching out from individual patient care and partnering with local businesses to provide care for employees. That’s the future for direct specialty care, said Dr. Girnita, who’s been in discussions with a few employers to make such arrangements.
The direct primary care community has already started to contract with employers. “Their employees get care they need for just a fraction of the cost. These discussions are arising more and more,” she said.
A version of this article first appeared on Medscape.com.
12 state boards have disciplined docs for COVID misinformation
, according to a new survey from the Federation of State Medical Boards (FSMB).
The FSMB reports that in its 2021 annual survey two-thirds of its 71 member boards (which includes the United States, its territories, and Washington, DC) reported an increase in complaints about doctors spreading false or misleading information.
“The staggering number of state medical boards that have seen an increase in COVID-19 disinformation complaints is a sign of how widespread the issue has become,” said Humayun J. Chaudhry, DO, MACP, president and CEO of the FSMB, in a statement.
The FSMB board of directors warned physicians in July that they risked disciplinary action if they spread COVID-19 vaccine misinformation or disinformation.
The organization said 15 state boards have now adopted similar statements.
Dr. Chaudhry said the FSMB was “encouraged by the number of boards that have already taken action to combat COVID-19 disinformation by disciplining physicians who engage in that behavior and by reminding all physicians that their words and actions matter, and they should think twice before spreading disinformation that may harm patients.”
This news organization asked the FSMB for further comment on why more physicians have not been disciplined, but did not receive a response before publication.
Misinformation policies a new battleground
The FSMB and member board policies on COVID-19 around the country have become a new front in the war against mandates and restrictions.
The Tennessee Board of Medical Examiners voted just recently to remove its statement of policy against the spread of misinformation from its website after a Republican lawmaker allegedly threatened to dissolve the board.
The vote came just a few months after the board had approved the policy. The board did not rescind the policy, however, according to a report by the Associated Press.
In California, the president of the state’s medical board tweeted on December 8 about what she said was an incident of harassment by a group that has promoted “fake COVID-19 treatments.”Ms. Kristina Lawson said she observed four men sitting in front of her house in a truck. They flew a drone over her residence, and then followed her to work, parking nose-to-nose with her vehicle.
Ms. Lawson claimed that when she went to drive home the four men ambushed her in what was by then a dark parking garage. She said her “concern turned to terror” as they jumped out, cameras and recording equipment in hand.
The men told law enforcement called to the scene that they were just trying to interview her, according to a statement emailed by Ms. Lawson.
They had not made such a request to the California Medical Board.
Ms. Lawson tweeted that she would continue to volunteer for the board. “That means protecting Californians from bad doctors, and ensuring disinformation and misinformation do not detract from our work to protect patients and consumers,” she wrote.
The men who ambushed Ms. Larson allegedly identified themselves and were wearing clothing emblazoned with the logo of “America’s Frontline Doctors,” an organization that has trafficked in COVID-19 conspiracy theories and promoted unproven treatments like hydroxychloroquine and ivermectin, according to Time. It is led by Simone Gold, MD, who was arrested for breaching the U.S. Capitol on January 6.
Despite her activities, on November 30, the California Medical Board renewed Ms. Gold’s 2-year license to practice.
Who’s being disciplined, who’s not
Dr. Gold is not alone. An investigation by NPRin September found that 15 of 16 physicians who have spread false information in a high-profile manner have medical licenses in good standing.
Sherri Tenpenny, DO, who has claimed that COVID-19 vaccines magnetize people and “interface” with 5G cell phone towers, was able to renew her license with the Ohio State Medical Board on October 1, according to the Cincinnati Enquirer.
Some boards have acted. The Oregon Medical Board revoked the license of Steven LaTulippe, MD, and fined him $10,000 for spreading misinformation about masks and overprescribing opioids.
In August, Rhode Island’s Board of Medical Licensure suspended Mark Brody’s license for 5 years after finding that the doctor spread falsehoods about COVID-19 vaccines, according to board documents.
Maine physician Paul Gosselin, DO, is on temporary suspension until a February hearing, while the osteopathic board investigates his issuance of vaccine exemption letters and the promotion of unproven COVID-19 therapies.
The board found that Gosselin had “engaged in conduct that constitutes fraud or deceit,” according to official documents.
The Washington State Medical Board has opened an investigation into Ryan N. Cole, MD, a physician who has claimed that COVID vaccines are “fake,” and was appointed to a regional health board in Idaho in September, according to the Washington Post.
The Idaho Capital Sun reported that Dr. Cole claims he is licensed in 11 states, including Washington. The Idaho Medical Association has also filed a complaint about Dr. Cole with the Idaho Board of Medicine, according to the paper.
New FSMB guidance coming
The FSMB said it expects more disciplinary actions as investigations continue to unfold.
The organization is drafting a new policy document that will include further guidelines and recommendations for state medical boards “to help address the spread of disinformation,” it said. The final document would be released in April 2022.
In the meantime, some states, like Tennessee and others, are trying to find ways to counter the current policy — a development the FSMB called “troubling.”
“The FSMB strongly opposes any effort to restrict a board’s authority to evaluate the standard of care and assess risk for patient harm,” the organization said in its statement.
A version of this article was first published on Medscape.com.
, according to a new survey from the Federation of State Medical Boards (FSMB).
The FSMB reports that in its 2021 annual survey two-thirds of its 71 member boards (which includes the United States, its territories, and Washington, DC) reported an increase in complaints about doctors spreading false or misleading information.
“The staggering number of state medical boards that have seen an increase in COVID-19 disinformation complaints is a sign of how widespread the issue has become,” said Humayun J. Chaudhry, DO, MACP, president and CEO of the FSMB, in a statement.
The FSMB board of directors warned physicians in July that they risked disciplinary action if they spread COVID-19 vaccine misinformation or disinformation.
The organization said 15 state boards have now adopted similar statements.
Dr. Chaudhry said the FSMB was “encouraged by the number of boards that have already taken action to combat COVID-19 disinformation by disciplining physicians who engage in that behavior and by reminding all physicians that their words and actions matter, and they should think twice before spreading disinformation that may harm patients.”
This news organization asked the FSMB for further comment on why more physicians have not been disciplined, but did not receive a response before publication.
Misinformation policies a new battleground
The FSMB and member board policies on COVID-19 around the country have become a new front in the war against mandates and restrictions.
The Tennessee Board of Medical Examiners voted just recently to remove its statement of policy against the spread of misinformation from its website after a Republican lawmaker allegedly threatened to dissolve the board.
The vote came just a few months after the board had approved the policy. The board did not rescind the policy, however, according to a report by the Associated Press.
In California, the president of the state’s medical board tweeted on December 8 about what she said was an incident of harassment by a group that has promoted “fake COVID-19 treatments.”Ms. Kristina Lawson said she observed four men sitting in front of her house in a truck. They flew a drone over her residence, and then followed her to work, parking nose-to-nose with her vehicle.
Ms. Lawson claimed that when she went to drive home the four men ambushed her in what was by then a dark parking garage. She said her “concern turned to terror” as they jumped out, cameras and recording equipment in hand.
The men told law enforcement called to the scene that they were just trying to interview her, according to a statement emailed by Ms. Lawson.
They had not made such a request to the California Medical Board.
Ms. Lawson tweeted that she would continue to volunteer for the board. “That means protecting Californians from bad doctors, and ensuring disinformation and misinformation do not detract from our work to protect patients and consumers,” she wrote.
The men who ambushed Ms. Larson allegedly identified themselves and were wearing clothing emblazoned with the logo of “America’s Frontline Doctors,” an organization that has trafficked in COVID-19 conspiracy theories and promoted unproven treatments like hydroxychloroquine and ivermectin, according to Time. It is led by Simone Gold, MD, who was arrested for breaching the U.S. Capitol on January 6.
Despite her activities, on November 30, the California Medical Board renewed Ms. Gold’s 2-year license to practice.
Who’s being disciplined, who’s not
Dr. Gold is not alone. An investigation by NPRin September found that 15 of 16 physicians who have spread false information in a high-profile manner have medical licenses in good standing.
Sherri Tenpenny, DO, who has claimed that COVID-19 vaccines magnetize people and “interface” with 5G cell phone towers, was able to renew her license with the Ohio State Medical Board on October 1, according to the Cincinnati Enquirer.
Some boards have acted. The Oregon Medical Board revoked the license of Steven LaTulippe, MD, and fined him $10,000 for spreading misinformation about masks and overprescribing opioids.
In August, Rhode Island’s Board of Medical Licensure suspended Mark Brody’s license for 5 years after finding that the doctor spread falsehoods about COVID-19 vaccines, according to board documents.
Maine physician Paul Gosselin, DO, is on temporary suspension until a February hearing, while the osteopathic board investigates his issuance of vaccine exemption letters and the promotion of unproven COVID-19 therapies.
The board found that Gosselin had “engaged in conduct that constitutes fraud or deceit,” according to official documents.
The Washington State Medical Board has opened an investigation into Ryan N. Cole, MD, a physician who has claimed that COVID vaccines are “fake,” and was appointed to a regional health board in Idaho in September, according to the Washington Post.
The Idaho Capital Sun reported that Dr. Cole claims he is licensed in 11 states, including Washington. The Idaho Medical Association has also filed a complaint about Dr. Cole with the Idaho Board of Medicine, according to the paper.
New FSMB guidance coming
The FSMB said it expects more disciplinary actions as investigations continue to unfold.
The organization is drafting a new policy document that will include further guidelines and recommendations for state medical boards “to help address the spread of disinformation,” it said. The final document would be released in April 2022.
In the meantime, some states, like Tennessee and others, are trying to find ways to counter the current policy — a development the FSMB called “troubling.”
“The FSMB strongly opposes any effort to restrict a board’s authority to evaluate the standard of care and assess risk for patient harm,” the organization said in its statement.
A version of this article was first published on Medscape.com.
, according to a new survey from the Federation of State Medical Boards (FSMB).
The FSMB reports that in its 2021 annual survey two-thirds of its 71 member boards (which includes the United States, its territories, and Washington, DC) reported an increase in complaints about doctors spreading false or misleading information.
“The staggering number of state medical boards that have seen an increase in COVID-19 disinformation complaints is a sign of how widespread the issue has become,” said Humayun J. Chaudhry, DO, MACP, president and CEO of the FSMB, in a statement.
The FSMB board of directors warned physicians in July that they risked disciplinary action if they spread COVID-19 vaccine misinformation or disinformation.
The organization said 15 state boards have now adopted similar statements.
Dr. Chaudhry said the FSMB was “encouraged by the number of boards that have already taken action to combat COVID-19 disinformation by disciplining physicians who engage in that behavior and by reminding all physicians that their words and actions matter, and they should think twice before spreading disinformation that may harm patients.”
This news organization asked the FSMB for further comment on why more physicians have not been disciplined, but did not receive a response before publication.
Misinformation policies a new battleground
The FSMB and member board policies on COVID-19 around the country have become a new front in the war against mandates and restrictions.
The Tennessee Board of Medical Examiners voted just recently to remove its statement of policy against the spread of misinformation from its website after a Republican lawmaker allegedly threatened to dissolve the board.
The vote came just a few months after the board had approved the policy. The board did not rescind the policy, however, according to a report by the Associated Press.
In California, the president of the state’s medical board tweeted on December 8 about what she said was an incident of harassment by a group that has promoted “fake COVID-19 treatments.”Ms. Kristina Lawson said she observed four men sitting in front of her house in a truck. They flew a drone over her residence, and then followed her to work, parking nose-to-nose with her vehicle.
Ms. Lawson claimed that when she went to drive home the four men ambushed her in what was by then a dark parking garage. She said her “concern turned to terror” as they jumped out, cameras and recording equipment in hand.
The men told law enforcement called to the scene that they were just trying to interview her, according to a statement emailed by Ms. Lawson.
They had not made such a request to the California Medical Board.
Ms. Lawson tweeted that she would continue to volunteer for the board. “That means protecting Californians from bad doctors, and ensuring disinformation and misinformation do not detract from our work to protect patients and consumers,” she wrote.
The men who ambushed Ms. Larson allegedly identified themselves and were wearing clothing emblazoned with the logo of “America’s Frontline Doctors,” an organization that has trafficked in COVID-19 conspiracy theories and promoted unproven treatments like hydroxychloroquine and ivermectin, according to Time. It is led by Simone Gold, MD, who was arrested for breaching the U.S. Capitol on January 6.
Despite her activities, on November 30, the California Medical Board renewed Ms. Gold’s 2-year license to practice.
Who’s being disciplined, who’s not
Dr. Gold is not alone. An investigation by NPRin September found that 15 of 16 physicians who have spread false information in a high-profile manner have medical licenses in good standing.
Sherri Tenpenny, DO, who has claimed that COVID-19 vaccines magnetize people and “interface” with 5G cell phone towers, was able to renew her license with the Ohio State Medical Board on October 1, according to the Cincinnati Enquirer.
Some boards have acted. The Oregon Medical Board revoked the license of Steven LaTulippe, MD, and fined him $10,000 for spreading misinformation about masks and overprescribing opioids.
In August, Rhode Island’s Board of Medical Licensure suspended Mark Brody’s license for 5 years after finding that the doctor spread falsehoods about COVID-19 vaccines, according to board documents.
Maine physician Paul Gosselin, DO, is on temporary suspension until a February hearing, while the osteopathic board investigates his issuance of vaccine exemption letters and the promotion of unproven COVID-19 therapies.
The board found that Gosselin had “engaged in conduct that constitutes fraud or deceit,” according to official documents.
The Washington State Medical Board has opened an investigation into Ryan N. Cole, MD, a physician who has claimed that COVID vaccines are “fake,” and was appointed to a regional health board in Idaho in September, according to the Washington Post.
The Idaho Capital Sun reported that Dr. Cole claims he is licensed in 11 states, including Washington. The Idaho Medical Association has also filed a complaint about Dr. Cole with the Idaho Board of Medicine, according to the paper.
New FSMB guidance coming
The FSMB said it expects more disciplinary actions as investigations continue to unfold.
The organization is drafting a new policy document that will include further guidelines and recommendations for state medical boards “to help address the spread of disinformation,” it said. The final document would be released in April 2022.
In the meantime, some states, like Tennessee and others, are trying to find ways to counter the current policy — a development the FSMB called “troubling.”
“The FSMB strongly opposes any effort to restrict a board’s authority to evaluate the standard of care and assess risk for patient harm,” the organization said in its statement.
A version of this article was first published on Medscape.com.
Bullying a ‘persistent, important’ problem for cardiology trainees
A high rate of bullying towards U.K. cardiology trainees by their superiors has been revealed in a new survey. More than 10% of doctors training to be cardiologists in the United Kingdom say they have been bullied in the last 4 weeks, and one-third report having witnessed bullying on a cardiology rotation, the survey reports.
In addition, 33% of cardiology trainees said they had been on the receiving end of inappropriate behavior, including having their opinions and views ignored, being made to feel worthless/useless, and being shouted at or targeted with spontaneous anger.
Senior doctors (consultants) in cardiology were cited as the main perpetrators of such bullying and inappropriate behavior.
Women trainee cardiologists and those who attended medical school outside the United Kingdom were more likely to report having been bullied, suggesting a sexist and racist element.
“In this large and repeated survey of British cardiology trainees, we have shown a persistent and important problem with bullying,” the authors conclude.
Results of the survey from the British Junior Cardiologists’ Association, were published online in a paper in Heart on Dec. 6, 2021.
Examples of such bullying behavior by consultant cardiologists toward their trainees reported in the survey included being belittled in front of others, having their filing cabinet drawer thrown across the room, use of foul language toward trainees, and using previous mistakes as an excuse to humiliate and ridicule them, lead author of the survey, Christian Fielder Camm, MD, Keble College, Oxford (England) University, told this news organization.
Trainees also reported being made to feel inadequate when struggling to achieve unrealistic tasks and being pressured into not taking holidays and study leave.
Many respondents said they did not report such behavior for fear of repercussions and in some cases because the perpetrators were known for their bullying behavior, and previous attempts to intervene had not resulted in any change.
Dr. Camm, who is a cardiology trainee himself, says he has not personally been the victim of bullying, but as secretary of the BJCA he regularly receives reports about it happening.
“We wanted to look at this issue in our survey as we had been hearing anecdotal reports of bullying from cardiology trainees for a number of years,” Dr. Camm said. “We wanted to put it out there that this is not just an isolated issue and shine a light on the problem.”
Noting that the U.K. General Medical Council’s annual survey has found that bullying is seen across all disciplines in medicine, Dr. Camm said that cardiology has the highest reported rate of bullying among the medical specialties.
“This is not a new story – it has been played out throughout history, but things are not magically improving. Over the 4 years of our survey, rates of reported bullying have stayed the same,” he noted. “Our survey is asking more questions about bullying to find more detail on what is happening.”
The current data come from the BJCA annual survey from 2017 to 2020. As part of the survey, trainee cardiologists were asked about direct and indirect experiences of bullying and inappropriate language/behavior in cardiology departments in the preceding 4 weeks.
In all, 2,057 responses were received, 73% were from men, and the average age of respondents was 33 years. Over half (59%) were working in a specialist center for cardiology (tertiary referral center), and 94% had a national training number, which guarantees a continued place on a training program, subject to performance.
“This project has upset me to realize what my colleagues are experiencing. This is the working environment we are creating, and it is not good enough,” Dr. Camm said.
At present, the bullying behavior is not often reported. “Usually, the only person to report it to is the senior person in the department, who is frequently the cause of the problem, so most people just put up with it until they move on to their next training rotation. The working environment should not be so difficult,” he said.
The authors noted that bullying has been shown to significantly affect trainees, with those subject to bullying being 70% more likely to report serious or potentially serious medical errors, and more likely to take time off work and cease direct patient care.
They stressed that addressing bullying of trainees needs to be a priority both to ensure patient safety and to reduce trainee attrition in a time of unprecedented workforce pressures.
Dr. Camm believes a national plan needs to be put in place to deal with this issue and said the BJCA is keen to work with the British Cardiovascular Society to develop a zero-tolerance policy, with a clear strategy to address allegations of bullying.
“The world is changing. Hopefully this publication will be the start of some change,” he added.
Bullying culture is ‘endemic’
In an accompanying editorial, consultant cardiologist Resham Baruah, MBBS, PhD, of Chelsea and Westminster Healthcare NHS Trust, London, and independent professional coach Emma Sedgwick said the findings offer a “sobering insight into current practice” and indicate that “a bullying culture is endemic in many U.K. cardiology departments.”
“These trainee cardiologists are actually quite senior doctors with many years of experience. They work extremely hard. These surveys show that we are not valuing them enough,” Dr. Baruah said in an interview.
“Cardiology is a really competitive specialty. There is a lot of pressure. All the way through training the message is competitive,” she said. “Being collegiate and working as a team is not rewarded. We have to rethink this as we train the next generation.”
“We believe that publishing these data acknowledges bullying is not going unnoticed, although this alone is not enough,” the editorialists said.
Noting that labels matter, they propose a rejection of the term “juniors” and a return to the old system of calling colleagues senior house officers, registrars, and senior registrars.
They also proposed sanctions for institutions that ignore bullying, but stress that better working conditions for all staff are needed.
“Bullies are usually feeling defensive, overwhelmed, and stressed and take these feelings out on others,” Dr. Baruah commented. “I think what we are seeing in this paper is not just restricted to cardiology but happens all though the NHS and is related to workload, lack of autonomy, and burnout. Work culture is crucial to well-being and job satisfaction. Nobody wants to work in a toxic environment.”
She emphasized that bullying behaviors must not be accepted. “They can have catastrophic consequences for the trainees and for patient safety. While working in high-pressure specialties and emergency situations may foster such behavior, it is vitally important to arm trainees with the recognition of bullying and how to deal with it. They must feel empowered to speak up in an appropriate way.”
The editorialists noted that the Royal College of Obstetricians and Gynaecologists responded to high levels of bullying by creating behavior toolkits, workshops, and behavior champions. “This survey should act as a call to arms for cardiology to introduce similar initiatives,” they stated.
“While times are changing, the corporate environment has moved forward in encouraging positive workplace behavior faster than is happening in medicine,” Dr. Baruah said. “But there is an appetite for change. We have to have an environment where people can speak up.”
The study received no specific funding. The authors reported no competing interests.
A version of this article first appeared on Medscape.com.
A high rate of bullying towards U.K. cardiology trainees by their superiors has been revealed in a new survey. More than 10% of doctors training to be cardiologists in the United Kingdom say they have been bullied in the last 4 weeks, and one-third report having witnessed bullying on a cardiology rotation, the survey reports.
In addition, 33% of cardiology trainees said they had been on the receiving end of inappropriate behavior, including having their opinions and views ignored, being made to feel worthless/useless, and being shouted at or targeted with spontaneous anger.
Senior doctors (consultants) in cardiology were cited as the main perpetrators of such bullying and inappropriate behavior.
Women trainee cardiologists and those who attended medical school outside the United Kingdom were more likely to report having been bullied, suggesting a sexist and racist element.
“In this large and repeated survey of British cardiology trainees, we have shown a persistent and important problem with bullying,” the authors conclude.
Results of the survey from the British Junior Cardiologists’ Association, were published online in a paper in Heart on Dec. 6, 2021.
Examples of such bullying behavior by consultant cardiologists toward their trainees reported in the survey included being belittled in front of others, having their filing cabinet drawer thrown across the room, use of foul language toward trainees, and using previous mistakes as an excuse to humiliate and ridicule them, lead author of the survey, Christian Fielder Camm, MD, Keble College, Oxford (England) University, told this news organization.
Trainees also reported being made to feel inadequate when struggling to achieve unrealistic tasks and being pressured into not taking holidays and study leave.
Many respondents said they did not report such behavior for fear of repercussions and in some cases because the perpetrators were known for their bullying behavior, and previous attempts to intervene had not resulted in any change.
Dr. Camm, who is a cardiology trainee himself, says he has not personally been the victim of bullying, but as secretary of the BJCA he regularly receives reports about it happening.
“We wanted to look at this issue in our survey as we had been hearing anecdotal reports of bullying from cardiology trainees for a number of years,” Dr. Camm said. “We wanted to put it out there that this is not just an isolated issue and shine a light on the problem.”
Noting that the U.K. General Medical Council’s annual survey has found that bullying is seen across all disciplines in medicine, Dr. Camm said that cardiology has the highest reported rate of bullying among the medical specialties.
“This is not a new story – it has been played out throughout history, but things are not magically improving. Over the 4 years of our survey, rates of reported bullying have stayed the same,” he noted. “Our survey is asking more questions about bullying to find more detail on what is happening.”
The current data come from the BJCA annual survey from 2017 to 2020. As part of the survey, trainee cardiologists were asked about direct and indirect experiences of bullying and inappropriate language/behavior in cardiology departments in the preceding 4 weeks.
In all, 2,057 responses were received, 73% were from men, and the average age of respondents was 33 years. Over half (59%) were working in a specialist center for cardiology (tertiary referral center), and 94% had a national training number, which guarantees a continued place on a training program, subject to performance.
“This project has upset me to realize what my colleagues are experiencing. This is the working environment we are creating, and it is not good enough,” Dr. Camm said.
At present, the bullying behavior is not often reported. “Usually, the only person to report it to is the senior person in the department, who is frequently the cause of the problem, so most people just put up with it until they move on to their next training rotation. The working environment should not be so difficult,” he said.
The authors noted that bullying has been shown to significantly affect trainees, with those subject to bullying being 70% more likely to report serious or potentially serious medical errors, and more likely to take time off work and cease direct patient care.
They stressed that addressing bullying of trainees needs to be a priority both to ensure patient safety and to reduce trainee attrition in a time of unprecedented workforce pressures.
Dr. Camm believes a national plan needs to be put in place to deal with this issue and said the BJCA is keen to work with the British Cardiovascular Society to develop a zero-tolerance policy, with a clear strategy to address allegations of bullying.
“The world is changing. Hopefully this publication will be the start of some change,” he added.
Bullying culture is ‘endemic’
In an accompanying editorial, consultant cardiologist Resham Baruah, MBBS, PhD, of Chelsea and Westminster Healthcare NHS Trust, London, and independent professional coach Emma Sedgwick said the findings offer a “sobering insight into current practice” and indicate that “a bullying culture is endemic in many U.K. cardiology departments.”
“These trainee cardiologists are actually quite senior doctors with many years of experience. They work extremely hard. These surveys show that we are not valuing them enough,” Dr. Baruah said in an interview.
“Cardiology is a really competitive specialty. There is a lot of pressure. All the way through training the message is competitive,” she said. “Being collegiate and working as a team is not rewarded. We have to rethink this as we train the next generation.”
“We believe that publishing these data acknowledges bullying is not going unnoticed, although this alone is not enough,” the editorialists said.
Noting that labels matter, they propose a rejection of the term “juniors” and a return to the old system of calling colleagues senior house officers, registrars, and senior registrars.
They also proposed sanctions for institutions that ignore bullying, but stress that better working conditions for all staff are needed.
“Bullies are usually feeling defensive, overwhelmed, and stressed and take these feelings out on others,” Dr. Baruah commented. “I think what we are seeing in this paper is not just restricted to cardiology but happens all though the NHS and is related to workload, lack of autonomy, and burnout. Work culture is crucial to well-being and job satisfaction. Nobody wants to work in a toxic environment.”
She emphasized that bullying behaviors must not be accepted. “They can have catastrophic consequences for the trainees and for patient safety. While working in high-pressure specialties and emergency situations may foster such behavior, it is vitally important to arm trainees with the recognition of bullying and how to deal with it. They must feel empowered to speak up in an appropriate way.”
The editorialists noted that the Royal College of Obstetricians and Gynaecologists responded to high levels of bullying by creating behavior toolkits, workshops, and behavior champions. “This survey should act as a call to arms for cardiology to introduce similar initiatives,” they stated.
“While times are changing, the corporate environment has moved forward in encouraging positive workplace behavior faster than is happening in medicine,” Dr. Baruah said. “But there is an appetite for change. We have to have an environment where people can speak up.”
The study received no specific funding. The authors reported no competing interests.
A version of this article first appeared on Medscape.com.
A high rate of bullying towards U.K. cardiology trainees by their superiors has been revealed in a new survey. More than 10% of doctors training to be cardiologists in the United Kingdom say they have been bullied in the last 4 weeks, and one-third report having witnessed bullying on a cardiology rotation, the survey reports.
In addition, 33% of cardiology trainees said they had been on the receiving end of inappropriate behavior, including having their opinions and views ignored, being made to feel worthless/useless, and being shouted at or targeted with spontaneous anger.
Senior doctors (consultants) in cardiology were cited as the main perpetrators of such bullying and inappropriate behavior.
Women trainee cardiologists and those who attended medical school outside the United Kingdom were more likely to report having been bullied, suggesting a sexist and racist element.
“In this large and repeated survey of British cardiology trainees, we have shown a persistent and important problem with bullying,” the authors conclude.
Results of the survey from the British Junior Cardiologists’ Association, were published online in a paper in Heart on Dec. 6, 2021.
Examples of such bullying behavior by consultant cardiologists toward their trainees reported in the survey included being belittled in front of others, having their filing cabinet drawer thrown across the room, use of foul language toward trainees, and using previous mistakes as an excuse to humiliate and ridicule them, lead author of the survey, Christian Fielder Camm, MD, Keble College, Oxford (England) University, told this news organization.
Trainees also reported being made to feel inadequate when struggling to achieve unrealistic tasks and being pressured into not taking holidays and study leave.
Many respondents said they did not report such behavior for fear of repercussions and in some cases because the perpetrators were known for their bullying behavior, and previous attempts to intervene had not resulted in any change.
Dr. Camm, who is a cardiology trainee himself, says he has not personally been the victim of bullying, but as secretary of the BJCA he regularly receives reports about it happening.
“We wanted to look at this issue in our survey as we had been hearing anecdotal reports of bullying from cardiology trainees for a number of years,” Dr. Camm said. “We wanted to put it out there that this is not just an isolated issue and shine a light on the problem.”
Noting that the U.K. General Medical Council’s annual survey has found that bullying is seen across all disciplines in medicine, Dr. Camm said that cardiology has the highest reported rate of bullying among the medical specialties.
“This is not a new story – it has been played out throughout history, but things are not magically improving. Over the 4 years of our survey, rates of reported bullying have stayed the same,” he noted. “Our survey is asking more questions about bullying to find more detail on what is happening.”
The current data come from the BJCA annual survey from 2017 to 2020. As part of the survey, trainee cardiologists were asked about direct and indirect experiences of bullying and inappropriate language/behavior in cardiology departments in the preceding 4 weeks.
In all, 2,057 responses were received, 73% were from men, and the average age of respondents was 33 years. Over half (59%) were working in a specialist center for cardiology (tertiary referral center), and 94% had a national training number, which guarantees a continued place on a training program, subject to performance.
“This project has upset me to realize what my colleagues are experiencing. This is the working environment we are creating, and it is not good enough,” Dr. Camm said.
At present, the bullying behavior is not often reported. “Usually, the only person to report it to is the senior person in the department, who is frequently the cause of the problem, so most people just put up with it until they move on to their next training rotation. The working environment should not be so difficult,” he said.
The authors noted that bullying has been shown to significantly affect trainees, with those subject to bullying being 70% more likely to report serious or potentially serious medical errors, and more likely to take time off work and cease direct patient care.
They stressed that addressing bullying of trainees needs to be a priority both to ensure patient safety and to reduce trainee attrition in a time of unprecedented workforce pressures.
Dr. Camm believes a national plan needs to be put in place to deal with this issue and said the BJCA is keen to work with the British Cardiovascular Society to develop a zero-tolerance policy, with a clear strategy to address allegations of bullying.
“The world is changing. Hopefully this publication will be the start of some change,” he added.
Bullying culture is ‘endemic’
In an accompanying editorial, consultant cardiologist Resham Baruah, MBBS, PhD, of Chelsea and Westminster Healthcare NHS Trust, London, and independent professional coach Emma Sedgwick said the findings offer a “sobering insight into current practice” and indicate that “a bullying culture is endemic in many U.K. cardiology departments.”
“These trainee cardiologists are actually quite senior doctors with many years of experience. They work extremely hard. These surveys show that we are not valuing them enough,” Dr. Baruah said in an interview.
“Cardiology is a really competitive specialty. There is a lot of pressure. All the way through training the message is competitive,” she said. “Being collegiate and working as a team is not rewarded. We have to rethink this as we train the next generation.”
“We believe that publishing these data acknowledges bullying is not going unnoticed, although this alone is not enough,” the editorialists said.
Noting that labels matter, they propose a rejection of the term “juniors” and a return to the old system of calling colleagues senior house officers, registrars, and senior registrars.
They also proposed sanctions for institutions that ignore bullying, but stress that better working conditions for all staff are needed.
“Bullies are usually feeling defensive, overwhelmed, and stressed and take these feelings out on others,” Dr. Baruah commented. “I think what we are seeing in this paper is not just restricted to cardiology but happens all though the NHS and is related to workload, lack of autonomy, and burnout. Work culture is crucial to well-being and job satisfaction. Nobody wants to work in a toxic environment.”
She emphasized that bullying behaviors must not be accepted. “They can have catastrophic consequences for the trainees and for patient safety. While working in high-pressure specialties and emergency situations may foster such behavior, it is vitally important to arm trainees with the recognition of bullying and how to deal with it. They must feel empowered to speak up in an appropriate way.”
The editorialists noted that the Royal College of Obstetricians and Gynaecologists responded to high levels of bullying by creating behavior toolkits, workshops, and behavior champions. “This survey should act as a call to arms for cardiology to introduce similar initiatives,” they stated.
“While times are changing, the corporate environment has moved forward in encouraging positive workplace behavior faster than is happening in medicine,” Dr. Baruah said. “But there is an appetite for change. We have to have an environment where people can speak up.”
The study received no specific funding. The authors reported no competing interests.
A version of this article first appeared on Medscape.com.
FROM HEART
AMA, hospital group sue federal government over surprise billing law
which tilts toward using prevailing rates paid for services.
The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.
Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.
Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.
The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.
In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.
AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.
In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”
The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.
“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”
AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”
“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.
AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.
“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.
A version of this article first appeared on Medscape.com.
which tilts toward using prevailing rates paid for services.
The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.
Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.
Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.
The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.
In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.
AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.
In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”
The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.
“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”
AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”
“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.
AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.
“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.
A version of this article first appeared on Medscape.com.
which tilts toward using prevailing rates paid for services.
The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.
Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.
Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.
The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.
In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.
AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.
In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”
The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.
“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”
AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”
“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.
AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.
“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.
A version of this article first appeared on Medscape.com.
Underinsurance rises among U.S. children
The proportion of U.S. children who are underinsured for health care increased by 3.4% from 2016 to 2019, reflecting approximately 2.4 million underinsured children, based on data from the National Survey of Children’s Health.
Children with inconsistent or inadequate medical coverage are more likely to forgo medical care, including preventive well-child visits, and to have unmet medical needs such as prescription medications, Justin Yu, MD, of the Children’s Hospital of Pittsburgh, and colleagues wrote. Although the American Academy of Pediatrics and the Healthy People 2030 guidelines have endorsed increasing the proportion of children with adequate coverage, recent studies suggest that advances in insuring children in the wake of the Affordable Care Act have stalled, and trends in child insurance have not been well described, the researchers said.
In a study published in Pediatrics, the researchers reviewed data from the combined 2016-2019 datasets of the National Survey of Children’s Health, a survey funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration.
Adequate insurance was defined as a composite with three questions; whether the benefits “usually” or “always” meet the child’s needs; the benefits “usually” or “always” allow the child to see needed providers; and whether out-of-pocket expenses are either absent or “usually” or “always” reasonable.
Overall, the proportion of children with underinsurance increased from 30.6% in 2016 to 34.0% in 2019.
Underinsurance was significantly associated with increased health complexity and private insurance, with adjusted odds ratios of 1.9 and 3.5, respectively. In addition, underinsurance was significantly associated with child age of 6 years or older, non-Black racial identity, U.S. nonnative status, and a family income of at least 100% above the Federal Poverty Level. Notably, underinsurance grew significantly among White children living in “middle-income” families, the researchers said.
The increase in underinsurance was driven primarily by increased insurance inadequacy, which rose from 24.8% to 27.9% over the study period. The increase in insurance inadequacy was described primarily as unreasonable out-of-pocket medical expenses, according to the survey respondents.
The study findings were limited by several factors including the inability to show causality or to describe changes in outcomes for individual children, the researchers noted. Other limitations include the reliance on parent reports and the lack of a definitive definition of underinsurance.
However, the results highlight the ongoing problem of underinsurance in children, and the need to address the factors that contribute to inadequate insurance for children, the researchers said.
“Our data, demonstrating a shift from public to private insurance that is more likely to be inadequate, in conjunction with existing literature linking Medicaid/CHIP [Children’s Health Insurance Program] coverage with improved access to medical care as well as improved long-term outcomes in adulthood, should give policy makers and payers pause as they contemplate strategies to improve child health,” they concluded.
Nationwide action needed to fight underinsurance
The authors should be commended for highlighting the disturbing trend in underinsurance among children in the United States, Tim Joos, MD, a Seattle-based clinician with a combination internal medicine/pediatrics practice, said in an interview.
“With the passage of the Affordable Care Act, the population of uninsured and underinsured had shrunk quite a bit, but in the past few years, the numbers are growing again. This population has often been called the working poor; the vast majority are legal residents who make too much to qualify for Medicaid/CHIP programs, and whose employers don’t offer affordable robust health care coverage,” Dr. Joos said.
“These families have to make the risky decisions of how much of the family budget to spend on insurance plans, often to the detriment of their own and their children’s health,” he explained. “If you believe the old adage about ‘an ounce of prevention,’ then the money we spend on preserving the health of our children will more than pay for itself in benefits of increased productivity and health care savings in the 1-2 decades later when they reach adulthood. It is time for us as a nation to come up with a more comprehensive baseline coverage for all pediatric patients and take away any barriers for families to access basic health care for children.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Joos had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
The proportion of U.S. children who are underinsured for health care increased by 3.4% from 2016 to 2019, reflecting approximately 2.4 million underinsured children, based on data from the National Survey of Children’s Health.
Children with inconsistent or inadequate medical coverage are more likely to forgo medical care, including preventive well-child visits, and to have unmet medical needs such as prescription medications, Justin Yu, MD, of the Children’s Hospital of Pittsburgh, and colleagues wrote. Although the American Academy of Pediatrics and the Healthy People 2030 guidelines have endorsed increasing the proportion of children with adequate coverage, recent studies suggest that advances in insuring children in the wake of the Affordable Care Act have stalled, and trends in child insurance have not been well described, the researchers said.
In a study published in Pediatrics, the researchers reviewed data from the combined 2016-2019 datasets of the National Survey of Children’s Health, a survey funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration.
Adequate insurance was defined as a composite with three questions; whether the benefits “usually” or “always” meet the child’s needs; the benefits “usually” or “always” allow the child to see needed providers; and whether out-of-pocket expenses are either absent or “usually” or “always” reasonable.
Overall, the proportion of children with underinsurance increased from 30.6% in 2016 to 34.0% in 2019.
Underinsurance was significantly associated with increased health complexity and private insurance, with adjusted odds ratios of 1.9 and 3.5, respectively. In addition, underinsurance was significantly associated with child age of 6 years or older, non-Black racial identity, U.S. nonnative status, and a family income of at least 100% above the Federal Poverty Level. Notably, underinsurance grew significantly among White children living in “middle-income” families, the researchers said.
The increase in underinsurance was driven primarily by increased insurance inadequacy, which rose from 24.8% to 27.9% over the study period. The increase in insurance inadequacy was described primarily as unreasonable out-of-pocket medical expenses, according to the survey respondents.
The study findings were limited by several factors including the inability to show causality or to describe changes in outcomes for individual children, the researchers noted. Other limitations include the reliance on parent reports and the lack of a definitive definition of underinsurance.
However, the results highlight the ongoing problem of underinsurance in children, and the need to address the factors that contribute to inadequate insurance for children, the researchers said.
“Our data, demonstrating a shift from public to private insurance that is more likely to be inadequate, in conjunction with existing literature linking Medicaid/CHIP [Children’s Health Insurance Program] coverage with improved access to medical care as well as improved long-term outcomes in adulthood, should give policy makers and payers pause as they contemplate strategies to improve child health,” they concluded.
Nationwide action needed to fight underinsurance
The authors should be commended for highlighting the disturbing trend in underinsurance among children in the United States, Tim Joos, MD, a Seattle-based clinician with a combination internal medicine/pediatrics practice, said in an interview.
“With the passage of the Affordable Care Act, the population of uninsured and underinsured had shrunk quite a bit, but in the past few years, the numbers are growing again. This population has often been called the working poor; the vast majority are legal residents who make too much to qualify for Medicaid/CHIP programs, and whose employers don’t offer affordable robust health care coverage,” Dr. Joos said.
“These families have to make the risky decisions of how much of the family budget to spend on insurance plans, often to the detriment of their own and their children’s health,” he explained. “If you believe the old adage about ‘an ounce of prevention,’ then the money we spend on preserving the health of our children will more than pay for itself in benefits of increased productivity and health care savings in the 1-2 decades later when they reach adulthood. It is time for us as a nation to come up with a more comprehensive baseline coverage for all pediatric patients and take away any barriers for families to access basic health care for children.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Joos had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
The proportion of U.S. children who are underinsured for health care increased by 3.4% from 2016 to 2019, reflecting approximately 2.4 million underinsured children, based on data from the National Survey of Children’s Health.
Children with inconsistent or inadequate medical coverage are more likely to forgo medical care, including preventive well-child visits, and to have unmet medical needs such as prescription medications, Justin Yu, MD, of the Children’s Hospital of Pittsburgh, and colleagues wrote. Although the American Academy of Pediatrics and the Healthy People 2030 guidelines have endorsed increasing the proportion of children with adequate coverage, recent studies suggest that advances in insuring children in the wake of the Affordable Care Act have stalled, and trends in child insurance have not been well described, the researchers said.
In a study published in Pediatrics, the researchers reviewed data from the combined 2016-2019 datasets of the National Survey of Children’s Health, a survey funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration.
Adequate insurance was defined as a composite with three questions; whether the benefits “usually” or “always” meet the child’s needs; the benefits “usually” or “always” allow the child to see needed providers; and whether out-of-pocket expenses are either absent or “usually” or “always” reasonable.
Overall, the proportion of children with underinsurance increased from 30.6% in 2016 to 34.0% in 2019.
Underinsurance was significantly associated with increased health complexity and private insurance, with adjusted odds ratios of 1.9 and 3.5, respectively. In addition, underinsurance was significantly associated with child age of 6 years or older, non-Black racial identity, U.S. nonnative status, and a family income of at least 100% above the Federal Poverty Level. Notably, underinsurance grew significantly among White children living in “middle-income” families, the researchers said.
The increase in underinsurance was driven primarily by increased insurance inadequacy, which rose from 24.8% to 27.9% over the study period. The increase in insurance inadequacy was described primarily as unreasonable out-of-pocket medical expenses, according to the survey respondents.
The study findings were limited by several factors including the inability to show causality or to describe changes in outcomes for individual children, the researchers noted. Other limitations include the reliance on parent reports and the lack of a definitive definition of underinsurance.
However, the results highlight the ongoing problem of underinsurance in children, and the need to address the factors that contribute to inadequate insurance for children, the researchers said.
“Our data, demonstrating a shift from public to private insurance that is more likely to be inadequate, in conjunction with existing literature linking Medicaid/CHIP [Children’s Health Insurance Program] coverage with improved access to medical care as well as improved long-term outcomes in adulthood, should give policy makers and payers pause as they contemplate strategies to improve child health,” they concluded.
Nationwide action needed to fight underinsurance
The authors should be commended for highlighting the disturbing trend in underinsurance among children in the United States, Tim Joos, MD, a Seattle-based clinician with a combination internal medicine/pediatrics practice, said in an interview.
“With the passage of the Affordable Care Act, the population of uninsured and underinsured had shrunk quite a bit, but in the past few years, the numbers are growing again. This population has often been called the working poor; the vast majority are legal residents who make too much to qualify for Medicaid/CHIP programs, and whose employers don’t offer affordable robust health care coverage,” Dr. Joos said.
“These families have to make the risky decisions of how much of the family budget to spend on insurance plans, often to the detriment of their own and their children’s health,” he explained. “If you believe the old adage about ‘an ounce of prevention,’ then the money we spend on preserving the health of our children will more than pay for itself in benefits of increased productivity and health care savings in the 1-2 decades later when they reach adulthood. It is time for us as a nation to come up with a more comprehensive baseline coverage for all pediatric patients and take away any barriers for families to access basic health care for children.”
The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Joos had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.
FROM PEDIATRICS
Spam filter failure: Selling physician emails equals big $$
Despite the best efforts of my institution’s spam filter, I’ve realized that I spend at least 4 minutes every day of the week removing junk email from my in basket: EMR vendors, predatory journals trying to lure me into paying their outrageous publication fees, people who want to help me with my billing software (evidently that .edu extension hasn’t clicked for them yet), headhunters trying to fill specialty positions in other states, market researchers offering a gift card for 40 minutes filling out a survey.
If you do the math, 4 minutes daily is 1,460 minutes per year. That’s an entire day of my life lost each year to this useless nonsense, which I never agreed to receive in the first place. Now multiply that by the 22 million health care workers in the United States, or even just by the 985,000 licensed physicians in this country. Then factor in the $638 per hour in gross revenue generated by the average primary care physician, as a conservative, well-documented value.
By my reckoning, these bozos owe the United States alone over $15 billion in lost GDP each year.
So why don’t we shut it down!? The CAN-SPAM Act of 2003 attempted to at least mitigate the problem. It applies only to commercial entities (I know, I’d love to report some political groups, too). To avoid violating the law and risking fines of up to $16,000 per individual email, senders must:
- Not use misleading header info (including domain name and email address)
- Not use deceptive subject lines
- Clearly label the email as an ad
- Give an actual physical address of the sender
- Tell recipients how to opt out of future emails
- Honor opt-out requests within 10 business days
- Monitor the activities of any subcontractor sending email on their behalf
I can say with certainty that much of the trash in my inbox violates at least one of these. But that doesn’t matter if there is not an efficient way to report the violators and ensure that they’ll be tracked down. Hard enough if they live here, impossible if the email is routed from overseas, as much of it clearly is.
If you receive email in violation of the act, experts recommend that you write down the email address and the business name of the sender, fill out a complaint form on the Federal Trade Commission website, or send an email to spam@uce.gov, then send an email to your Internet service provider’s abuse desk. If you’re not working within a big institution like mine that has hot and cold running IT personnel that operate their own abuse prevention office, the address you’ll need is likely abuse@domain_name or postmaster@domain_name. Just hitting the spam button at the top of your browser/email software may do the trick. There’s more good advice at the FTC’s consumer spam page.
The answer came, ironically, to my email inbox in the form of one of those emails that did indeed violate the law.
I rolled my eyes and started into my reporting subroutine but then stopped cold. Just 1 second. If this person is selling lists of email addresses of conference attendees, somebody within the conference structure must be providing them. How is that legal? I have never agreed, in registering for a medical conference, to allow them to share my email address with anyone. To think that they are making money from that is extremely galling.
Vermont, at least, has enacted a law requiring companies that traffic in such email lists to register with the state. Although it has been in effect for 2 years, the jury is out regarding its efficacy. Our European counterparts are protected by the General Data Protection Regulation, which specifies that commercial email can be sent only to individuals who have explicitly opted into such mailings, and that purchased email lists are not compliant with the requirement.
Anybody have the inside scoop on this? Can we demand that our professional societies safeguard their attendee databases so this won’t happen? If they won’t, why am I paying big money to attend their conferences, only for them to make even more money at my expense?
Dr. Hitchcock is assistant professor, department of radiation oncology, at the University of Florida, Gainesville. She reported receiving research grant money from Merck. A version of this article first appeared on Medscape.com.
Despite the best efforts of my institution’s spam filter, I’ve realized that I spend at least 4 minutes every day of the week removing junk email from my in basket: EMR vendors, predatory journals trying to lure me into paying their outrageous publication fees, people who want to help me with my billing software (evidently that .edu extension hasn’t clicked for them yet), headhunters trying to fill specialty positions in other states, market researchers offering a gift card for 40 minutes filling out a survey.
If you do the math, 4 minutes daily is 1,460 minutes per year. That’s an entire day of my life lost each year to this useless nonsense, which I never agreed to receive in the first place. Now multiply that by the 22 million health care workers in the United States, or even just by the 985,000 licensed physicians in this country. Then factor in the $638 per hour in gross revenue generated by the average primary care physician, as a conservative, well-documented value.
By my reckoning, these bozos owe the United States alone over $15 billion in lost GDP each year.
So why don’t we shut it down!? The CAN-SPAM Act of 2003 attempted to at least mitigate the problem. It applies only to commercial entities (I know, I’d love to report some political groups, too). To avoid violating the law and risking fines of up to $16,000 per individual email, senders must:
- Not use misleading header info (including domain name and email address)
- Not use deceptive subject lines
- Clearly label the email as an ad
- Give an actual physical address of the sender
- Tell recipients how to opt out of future emails
- Honor opt-out requests within 10 business days
- Monitor the activities of any subcontractor sending email on their behalf
I can say with certainty that much of the trash in my inbox violates at least one of these. But that doesn’t matter if there is not an efficient way to report the violators and ensure that they’ll be tracked down. Hard enough if they live here, impossible if the email is routed from overseas, as much of it clearly is.
If you receive email in violation of the act, experts recommend that you write down the email address and the business name of the sender, fill out a complaint form on the Federal Trade Commission website, or send an email to spam@uce.gov, then send an email to your Internet service provider’s abuse desk. If you’re not working within a big institution like mine that has hot and cold running IT personnel that operate their own abuse prevention office, the address you’ll need is likely abuse@domain_name or postmaster@domain_name. Just hitting the spam button at the top of your browser/email software may do the trick. There’s more good advice at the FTC’s consumer spam page.
The answer came, ironically, to my email inbox in the form of one of those emails that did indeed violate the law.
I rolled my eyes and started into my reporting subroutine but then stopped cold. Just 1 second. If this person is selling lists of email addresses of conference attendees, somebody within the conference structure must be providing them. How is that legal? I have never agreed, in registering for a medical conference, to allow them to share my email address with anyone. To think that they are making money from that is extremely galling.
Vermont, at least, has enacted a law requiring companies that traffic in such email lists to register with the state. Although it has been in effect for 2 years, the jury is out regarding its efficacy. Our European counterparts are protected by the General Data Protection Regulation, which specifies that commercial email can be sent only to individuals who have explicitly opted into such mailings, and that purchased email lists are not compliant with the requirement.
Anybody have the inside scoop on this? Can we demand that our professional societies safeguard their attendee databases so this won’t happen? If they won’t, why am I paying big money to attend their conferences, only for them to make even more money at my expense?
Dr. Hitchcock is assistant professor, department of radiation oncology, at the University of Florida, Gainesville. She reported receiving research grant money from Merck. A version of this article first appeared on Medscape.com.
Despite the best efforts of my institution’s spam filter, I’ve realized that I spend at least 4 minutes every day of the week removing junk email from my in basket: EMR vendors, predatory journals trying to lure me into paying their outrageous publication fees, people who want to help me with my billing software (evidently that .edu extension hasn’t clicked for them yet), headhunters trying to fill specialty positions in other states, market researchers offering a gift card for 40 minutes filling out a survey.
If you do the math, 4 minutes daily is 1,460 minutes per year. That’s an entire day of my life lost each year to this useless nonsense, which I never agreed to receive in the first place. Now multiply that by the 22 million health care workers in the United States, or even just by the 985,000 licensed physicians in this country. Then factor in the $638 per hour in gross revenue generated by the average primary care physician, as a conservative, well-documented value.
By my reckoning, these bozos owe the United States alone over $15 billion in lost GDP each year.
So why don’t we shut it down!? The CAN-SPAM Act of 2003 attempted to at least mitigate the problem. It applies only to commercial entities (I know, I’d love to report some political groups, too). To avoid violating the law and risking fines of up to $16,000 per individual email, senders must:
- Not use misleading header info (including domain name and email address)
- Not use deceptive subject lines
- Clearly label the email as an ad
- Give an actual physical address of the sender
- Tell recipients how to opt out of future emails
- Honor opt-out requests within 10 business days
- Monitor the activities of any subcontractor sending email on their behalf
I can say with certainty that much of the trash in my inbox violates at least one of these. But that doesn’t matter if there is not an efficient way to report the violators and ensure that they’ll be tracked down. Hard enough if they live here, impossible if the email is routed from overseas, as much of it clearly is.
If you receive email in violation of the act, experts recommend that you write down the email address and the business name of the sender, fill out a complaint form on the Federal Trade Commission website, or send an email to spam@uce.gov, then send an email to your Internet service provider’s abuse desk. If you’re not working within a big institution like mine that has hot and cold running IT personnel that operate their own abuse prevention office, the address you’ll need is likely abuse@domain_name or postmaster@domain_name. Just hitting the spam button at the top of your browser/email software may do the trick. There’s more good advice at the FTC’s consumer spam page.
The answer came, ironically, to my email inbox in the form of one of those emails that did indeed violate the law.
I rolled my eyes and started into my reporting subroutine but then stopped cold. Just 1 second. If this person is selling lists of email addresses of conference attendees, somebody within the conference structure must be providing them. How is that legal? I have never agreed, in registering for a medical conference, to allow them to share my email address with anyone. To think that they are making money from that is extremely galling.
Vermont, at least, has enacted a law requiring companies that traffic in such email lists to register with the state. Although it has been in effect for 2 years, the jury is out regarding its efficacy. Our European counterparts are protected by the General Data Protection Regulation, which specifies that commercial email can be sent only to individuals who have explicitly opted into such mailings, and that purchased email lists are not compliant with the requirement.
Anybody have the inside scoop on this? Can we demand that our professional societies safeguard their attendee databases so this won’t happen? If they won’t, why am I paying big money to attend their conferences, only for them to make even more money at my expense?
Dr. Hitchcock is assistant professor, department of radiation oncology, at the University of Florida, Gainesville. She reported receiving research grant money from Merck. A version of this article first appeared on Medscape.com.
Closing your practice
“I might have to close my office,” a colleague wrote me recently. “I can’t find reliable medical assistants; no one good applies. Sad, but oh, well.”
A paucity of good employees is just one of many reasons given by physicians who have decided to close up shop. (See my recent column, “Finding Employees During a Pandemic”).
to address in order to ensure a smooth exit.
First, this cannot (and should not) be a hasty process. You will need at least a year to do it correctly, because there is a lot to do.
Once you have settled on a closing date, inform your attorney. If the firm you are using does not have experience in medical practice sales or closures, ask them to recommend one that does. You will need expert legal guidance during many of the steps that follow.
Next, review all of your contracts and leases. Most of them cannot be terminated at the drop of a hat. Facility and equipment leases may require a year’s notice, or even longer. Contracts with managed care, maintenance, cleaning, and hazardous waste disposal companies, and others such as answering services and website managers, should be reviewed to determine what sort of advance notice you will need to give.
Another step to take well in advance is to contact your malpractice insurance carrier. Most carriers have specific guidelines for when to notify your patients – and that notification will vary from carrier to carrier, state to state, and situation to situation. If you have a claims-made policy, you also need to inquire about the necessity of purchasing “tail” coverage, which will protect you in the event of a lawsuit after your practice has closed. Many carriers include tail coverage at no charge if you are retiring completely, but if you expect to do part-time, locum tenens, or volunteer medical work, you will need to pay for it.
Once you have the basics nailed down, notify your employees. You will want them to hear the news from you, not through the grapevine, and certainly not from your patients. You may be worried that some will quit, but keeping them in the dark will not prevent that, as they will find out soon enough. Besides, if you help them by assisting in finding them new employment, they will most likely help you by staying to the end.
At this point, you should also begin thinking about disposition of your patients’ records. You can’t just shred them, much as you might be tempted. Your attorney and malpractice carrier will guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer in yours. Unless you are selling part or all of your practice to another physician, you will have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.
Once that is arranged, you can notify your patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it. Some states also require that a notice be placed in the local newspaper or online, including the date of closure and how to request records.
This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.
As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Your state may have requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well. Check your state’s controlled substances reporting system and other applicable regulators. Once the office is closed, don’t forget to shred any blank prescription pads and dissolve your corporation, if you have one.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
“I might have to close my office,” a colleague wrote me recently. “I can’t find reliable medical assistants; no one good applies. Sad, but oh, well.”
A paucity of good employees is just one of many reasons given by physicians who have decided to close up shop. (See my recent column, “Finding Employees During a Pandemic”).
to address in order to ensure a smooth exit.
First, this cannot (and should not) be a hasty process. You will need at least a year to do it correctly, because there is a lot to do.
Once you have settled on a closing date, inform your attorney. If the firm you are using does not have experience in medical practice sales or closures, ask them to recommend one that does. You will need expert legal guidance during many of the steps that follow.
Next, review all of your contracts and leases. Most of them cannot be terminated at the drop of a hat. Facility and equipment leases may require a year’s notice, or even longer. Contracts with managed care, maintenance, cleaning, and hazardous waste disposal companies, and others such as answering services and website managers, should be reviewed to determine what sort of advance notice you will need to give.
Another step to take well in advance is to contact your malpractice insurance carrier. Most carriers have specific guidelines for when to notify your patients – and that notification will vary from carrier to carrier, state to state, and situation to situation. If you have a claims-made policy, you also need to inquire about the necessity of purchasing “tail” coverage, which will protect you in the event of a lawsuit after your practice has closed. Many carriers include tail coverage at no charge if you are retiring completely, but if you expect to do part-time, locum tenens, or volunteer medical work, you will need to pay for it.
Once you have the basics nailed down, notify your employees. You will want them to hear the news from you, not through the grapevine, and certainly not from your patients. You may be worried that some will quit, but keeping them in the dark will not prevent that, as they will find out soon enough. Besides, if you help them by assisting in finding them new employment, they will most likely help you by staying to the end.
At this point, you should also begin thinking about disposition of your patients’ records. You can’t just shred them, much as you might be tempted. Your attorney and malpractice carrier will guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer in yours. Unless you are selling part or all of your practice to another physician, you will have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.
Once that is arranged, you can notify your patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it. Some states also require that a notice be placed in the local newspaper or online, including the date of closure and how to request records.
This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.
As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Your state may have requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well. Check your state’s controlled substances reporting system and other applicable regulators. Once the office is closed, don’t forget to shred any blank prescription pads and dissolve your corporation, if you have one.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
“I might have to close my office,” a colleague wrote me recently. “I can’t find reliable medical assistants; no one good applies. Sad, but oh, well.”
A paucity of good employees is just one of many reasons given by physicians who have decided to close up shop. (See my recent column, “Finding Employees During a Pandemic”).
to address in order to ensure a smooth exit.
First, this cannot (and should not) be a hasty process. You will need at least a year to do it correctly, because there is a lot to do.
Once you have settled on a closing date, inform your attorney. If the firm you are using does not have experience in medical practice sales or closures, ask them to recommend one that does. You will need expert legal guidance during many of the steps that follow.
Next, review all of your contracts and leases. Most of them cannot be terminated at the drop of a hat. Facility and equipment leases may require a year’s notice, or even longer. Contracts with managed care, maintenance, cleaning, and hazardous waste disposal companies, and others such as answering services and website managers, should be reviewed to determine what sort of advance notice you will need to give.
Another step to take well in advance is to contact your malpractice insurance carrier. Most carriers have specific guidelines for when to notify your patients – and that notification will vary from carrier to carrier, state to state, and situation to situation. If you have a claims-made policy, you also need to inquire about the necessity of purchasing “tail” coverage, which will protect you in the event of a lawsuit after your practice has closed. Many carriers include tail coverage at no charge if you are retiring completely, but if you expect to do part-time, locum tenens, or volunteer medical work, you will need to pay for it.
Once you have the basics nailed down, notify your employees. You will want them to hear the news from you, not through the grapevine, and certainly not from your patients. You may be worried that some will quit, but keeping them in the dark will not prevent that, as they will find out soon enough. Besides, if you help them by assisting in finding them new employment, they will most likely help you by staying to the end.
At this point, you should also begin thinking about disposition of your patients’ records. You can’t just shred them, much as you might be tempted. Your attorney and malpractice carrier will guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer in yours. Unless you are selling part or all of your practice to another physician, you will have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.
Once that is arranged, you can notify your patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it. Some states also require that a notice be placed in the local newspaper or online, including the date of closure and how to request records.
This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.
As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Your state may have requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well. Check your state’s controlled substances reporting system and other applicable regulators. Once the office is closed, don’t forget to shred any blank prescription pads and dissolve your corporation, if you have one.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
