Corporate Medicine in nursing homes, a new trend

As the United States' population ages it's a no-brainer that there is an increasing need for physicians willing, and able, to care for the elderly. This need is most acute and noticeable in nursing homes, yet nursing homes are becoming the first place where access to geriatricians is diminishing, thanks to recent corporate actions.

In an effort to squeeze more money out of payer sources, including Medicare, some corporate nursing homes are creating their own, corporate owned, physician practices. This is being sold to the state regulators as a way to "increase access" for nursing home patients, as most physicians are not interested in geriatrics.

The reality is quite the opposite, nursing home owned corporate medical practices use the nursing home referral power to eliminate existing independent geriatricians in favor of corporate employed physicians. In this monopoly, independent physicians are unable to compete on equal footing, and are left with two choices, leave the nursing home facility or join the corporate practice.

Here is a little background to illustrate the process and the conflict of interests generated by this new trend in corporate medicine:

Patients often arrive at nursing homes without the option of having their primary care doctor follow them at the nursing home, as most doctors chose not to follow patients in nursing homes. This common situation gives the nursing homes a unique referral power. The nursing homes are in a position to be a referral source to geriatricians or internal medicine/family medicine doctors who are interested in having a nursing home practice. When the nursing homes own a corporate physician practice, the right hand refers to the left hand, preferentially, and are free to exclude the independent physicians in their referral practices.

Another issue her is the position of "medical director" in a nursing home. Medical directors in nursing homes are traditionally independent contractors, which gives them an independent voice in promoting and advocating for best practices in nursing homes, regardless of financial considerations. With the creation of nursing home owned corporate practices, the first thing to go is the independent medical director, to be replaced by a corporate physician, owned by the nursing home. This, in effect, eliminates the independence of medical directorship, as corporate nursing homes start utilizing their own physicians to fill that position.

Under a corporate owned medical director, nursing homes are free to push through prolonged skilled rehabilitation stays and bill Medicare and other insurances for longer periods of stay, with no independent voice to keep them honest. They are also left free to create cookie-cutter operations that focus on cost saving at every turn, regardless of right or wrong when it comes to patient care.

Solution:

State "corporate medicine" legislation to address this emerging monopoly trend in nursing home health care.

This legislation would have to restrict the ability of nursing homes to acquire physician practices or hire physicians as employed corporate physicians, rather than independent contractors.

An exception can be made in rural areas, where access to physicians can not be secured in any other way, but even then, nursing homes should be required to not refer preferentially to their own physicians if community doctors become available to provide the same care. Patients should be given a clear choice of physician at the time of referral, and a disclosure of all conflicts of interests be made.

Link: examples of existing corporate medicine law in various states: http://www.dobbinslaw.com/cpmarticle.html

Feel free to send me your questions.

The pitfalls of the legislation allowing out of state health insurance

The recent legislation in Maine that allowed out-of-state insurance companies to sell insurance in Maine, has the admirable goal of increasing competition and reducing health insurance premiums.

As a small business owner, and a physician, in am personally interested in expanding coverage for the lower wage employees, who's yearly health insurance premiums currently cost businesses more than 25% of the yearly salaries. For example an employee earning $25,000 per year would cost the business an additional $6,000-$12,000 in health insurance premium. That's roughly 25-50% of added wage cost to a business.

I have learned in my profession to look for the unintended consequences in all actions. So what are the unintended consequences of this well intended legislation?

1. Out of state insurance would not have to adhere to state laws governing insurance practices such as exclusions of patients with pre-existing conditions, or other state checks and balances, put in place to protect the insured.
The new legislation could be considered as a way to bypass these existing state laws without having to change the laws.

2. As poorer patients will likely buy insurance primarily based on cost and not the generous or expansive health coverage, out-of-state insurance providers will have an advantage over in-state insurance providers, as they will be able to freely decrease coverage to make up for offering lower monthly premiums. In doing so, they would put in-state insurance providers out of business, or force them to move out of state to compete on equal footing and be out of reach of Maine laws.

So what's the solution?

I wish Maine law makers would sit down and review the existing Maine laws, with an open mind, and see if there are potentials for reform that would allow for more competition within the state to reduce premiums, and at the same time preserve basic safeguards for the insured.

Easier said than done, perhaps that's why we went through with this back door legislation we have now!


- Posted using BlogPress from my iPad
Jabbar Fazeli, MD

Location:Maine

Out of sight, out of mind! DEA actions affecting nursing home care

Many nursing home patients and their loved ones may not be aware that as of 2 years ago DEA actions have resulted in a mandatory delay in carrying out doctors orders to treat pain or seizures.

The DEA has no mandate to ensure timely delivery of care in nursing homes, but they do have a mandate to combat the abuse of controlled prescription drugs. To that end, 2 years ago, the DEA suddenly decided that the existing processes of carrying out doctors' orders in Nursing homes did not comply with the DEA regulations. Since then the nursing homes and pharmacies working with nursing homes have had to deal with a restrictive bureaucratic process that has led to significant delay in care for end of life patients and patients suffering seizures.

In order to understand this complex process I will try to review the process of carrying out doctors orders for controlled substances (substances designated by the DEA as subject to abuse, i.e. Seizure meds like valium, narcotics, some hypnotics, etc.).

A.
The old process of carrying out orders before 2009 DEA actions:

1. An order by the doctor is written in a nursing home patient's chart in person or by telephone order to the nurse.

2. The doctor's order is faxed to the nursing home pharmacy.

3. In case of an emergency, i.e. Seizure, or pain or respiratory distress, the nurses had the option of using the "emergency box" in the nursing home to dispense the medicine. Pharmacy staff would later replace the dispensed medicine and document it's use.

4. The pharmacy would supply the nursing home with the medicine ordered, and in case of narcotics orders, they would also send a duplicate order to the doctor to sign within 7 days.

5. Checks and balances were in place to ensure that the doctor's order is documented in the nursing home charts and the pharmacy files and that these two records matched. The pharmacists did routine monitoring and reported any discrepancy in records or discrepancy in number of pills to the DEA and the police. This was done to combat a known problem of drug diversion (stealing) in the nursing homes.

B.
New process imposed by the DEA since 2009:

1. Doctors' orders for controlled drugs in nursing home charts in person or by telephone orders are deemed inadequate and can not be carried out by nursing staff even if the doctor is on sight.

2. All orders for controlled substances have to be coupled with a hard presiciption from the doctor, that can't be filled unless it's faxed and processed by the pharmacist. For a patient in seizure or in end of life distress that adds a time element to process this added bureaucratic paperwork. Nurses can not follow orders even if the doctor has given the order and is at bedside, unless and until the pharmacist processes the paperwork.

3. The "emergency box" in the nursing home can no longer be used by the nurses to carry out doctors' orders unless a pharmacist confirms the orders with the doctor on the phone in a separate call, or receive a faxed hard copy of the prescription. The copy of the doctor's order is no longer adequate.

Many geriatricians, including myself, have been trying for two years to seek support from congress to remedy this problem that's out of sight and out of mind for many Americans. I am sorry to say that aside from meetings with aids to our senators and congressmen, we have not achieved much in Maine.
Senators Whitehouse from RI and Senator Kyl from AZ have championed this cause but so far they have not been able to presuade the DEA to change it's stance, or to introduce meaningful legislation that takes into account the need to allow timely treatment for seizures and end of life distress. They also failed to presuade the DEA to stop looking at the doctors to police drug abuse by nursing home staff.

What's the solution?

1. State Attorney generals could consider taking the DEA to court to ensure that their citizens in nursing homes are not denied timely care due to federal regulations by the DEA.

2. Congress could dictate to the DEA that they can not place law enforcement ahead of patient care in nursing homes and should allow doctors and nurses to do their job in providing end of life care and seizure treatments in a timely manner.

3. Congress could dictate to the DEA that they should enforce existing (pre-2009) checks and balances instead of creating new regulations to deal with the long standing drug diversion issue in nursing homes and assisted livings.

4. Congress could mandate that the DEA should apply above standards to assisted livings with contracted, in-house, pharmacies, as many elderly receive care in such facilities and have similar needs as nursing homes.

Thank you for reading this post. Feel free to send me questions or comments.
Please feel free to read the petition (and sign it if you agree) originally posted in nov 2009 on this issue.
http://www.gopetition.com/petition/32305.html

Jabbar Fazeli, MD
Geriatrician
Current president of Maine Medical Directors Association