More Doctors “Fire” Vaccine Refusers
When this MCNTalk blogger was pregnant and interviewing a pediatrician, she told me that she couldn’t take our child on if we didn’t have our child vaccinated on the routine schedule. Though I didn’t necessarily disagree with her, this took me by surprise; I had thought we were doing the interviewing, after all. As it turns out, my pediatrician’s standard is not so unusual. Per this Wall Street Journal article, more and more pediatricians are choosing not to treat children whose parents don’t allow them to receive standard immunizations on a standard schedule.
Some interesting points:
- In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason.
- For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven’t yet been fully vaccinated.
- Pediatricians disagree about what their duty is to these families. “The bottom line is you should try to do whatever you can to maintain the family in the best care,” said Michael Brady, chair of the pediatrics department at Nationwide Children’s Hospital in Columbus, Ohio, and a member of the AAP’s immunization committee. “If they leave your practice, they’re probably going to gravitate toward another practice with unhealthy practices.”
- Other physicians say they rarely have had luck persuading vaccine opponents to change their minds.
Health Care Payers Push Back Against Costs
The opacity surrounding prices and the practice of charging different buyers different prices for identical goods or services contribute mightily to the cost of health care, but at the least the former may be on the way out, an economist writes in this New York Times “Business Day” post.
The DSM and categories of suffering
This article in The New York Times importantly describes some of the many problems with the DSM in particular, and medical diagnoses in general. When diagnoses gain power to drive resources and funds, create obligations on the part of others, excuse or justify shortcomings in behaviors and habits, demand more time on tests, and generate billions in drug sales – mischief and misuse follows.
The DSM is a worthwhile effort and useful for psychiatrists in treating patients. But in the hands of the greater society it has become wildly distorted. The power of diagnoses are profound. But psychiatric diagnoses in particular are highly reductionist. They are a cookbook that apply if a patient falls into particular boxes. They do nothing to explain the “why” of the human condition, nor does a particular diagnosis remove the unique humanity that makes each of us different. Pills may address particular symptoms and provide some relief. But they will never alter fundamental personality configurations, eliminate personal choice and accountability, or substitute for self-examination and introspection.
Medical Consultants Network Welcomes New Executive Vice President
Seattle, WA (January 30, 2012): Medical Consultants Network is pleased to announce the appointment of Richard Leonardo as Executive Vice President. Mr. Leonardo is charged with leading MCN’s sales and marketing team nationwide.
“I am ecstatic to join the preeminent player in the medical judgment space. Not only does MCN have an industry leading product, but I am blessed to join a leadership team that has attracted the right people, built the scalable systems, and implemented the processes to ensure we can consistently meet client’s current and ever-evolving needs,” notes Mr. Leonardo.
Mr. Leonardo brings to MCN more than twenty-five years of leadership experience and marketing and sales expertise in the workers’ compensation industry. Most recently he served as Vice President, Sales and Account Management, with Express Scripts, the nation’s largest pharmacy benefit management firm.
Mr. Leonardo joins MCN at a point of strong growth for the company; during 2011 MCN experienced its highest earnings while achieving a strong rate of growth. Dr. Brian Grant, MCN’s Chair & Associate Medical Director, notes, “We welcome Rich Leonardo with enthusiasm, and look forward to continued strong growth in the coming months and years.”
Paul Mayer, MCN President and CEO, states, “We are pleased to have Rich joining the team—his recent experience will be valuable in further developing products that address pharmacy utilization in the property casualty and group health markets. He will be a valuable asset to the executive team.”
The Money Traps in U.S. Health Care
I am continuously baffled when I experience the disconnect between the data and facts presented in this article, and the hue and cry by those many who defend our current health care system. Case in point: the data cited in this New York Times article. Make sure you click on the graphics and absorb the data. And if there are salient points missing that would reveal flaws in the article or this comment, please add a comment.
As a consumer, provider and employer – it is obvious that the return on investment in our health care system pales relative to our friends in Canada, France, Germany and Britain. Only the latter of these four to my knowledge has a system of government-employed physicians. The others have systems of government pricing controls for the private sector providers.
The annual inflation that we experience in health care is unsustainable and puts the US at a competitive disadvantage internationally. It is a major drag on employment as many employers focus in part on rising benefits cost as a reason to not hire more positions. And it is obvious that money that might go in the pockets of employees in the form of raises, or consumers in the form of lower costs, are going into the rising costs of health care premiums for employers.
That many who defend the current system are one pink slip away from no employer coverage, and that few could afford to pay the cost of a private policy, seems to escape the minds or vision of many.
So merrily we march forward, with persistent demonization of those who would dare point out that this problem is not going away.
There are many fine examples of systems that fundamentally work in terms of care delivery, quality of care, health outcomes, and cost of care. Adopting any will entail trade-offs in terms of quantity and access, but on balance would be a marked improvement over our very sick system. Read more…
The Generosity of MCNtalk Readers
Thanks to you, our MCNtalk readers, MCN has made year end donations to three non-profit organizations you’ve chosen. We recently sponsored a contest wherein new subscribers could select a non-profit organization of their choice to receive a $100 donation. We’ve listed the organizations below and provided a bit of information about them. All are medically related and two of the three benefit seriously ill and impoverished children, one nationally, one internationally.
At MCNtalk we frequently write about the issues we face in today’s world: the rising cost of medical care, the number of uninsured Americas and attempts to widen coverage, medical challenges faced by everyone. When viewed as a whole, the magnitude of the situation is daunting, perhaps overwhelming, so it is good to have the opportunity to provide some support. As an organization, MCN and our employees are privileged to provide financial support to both the thriving arts community in Seattle as well as umbrella social services organizations such as The United Way. Thank you to everyone who participated in the recent contest by subscribing to MCNtalk, and thank you to the contest winners for their choices.
- Smile Train, Ruth McClurg: Providing free cleft surgery to hundreds of thousands of poor children in developing countries while training doctors and other medical professionals in over 80 countries.
- The American Chronic Pain Association, Steven D. Feinberg, MD: facilitating peer support and education for individuals with chronic pain and their families so that these individuals may live more fully in spite of their pain.
- The Thon Foundation, fighting pediatric cancer, Tom Shaffer: the largest student-run philanthropy in the world, benefiting pediatric cancer in conjunction with the Four Diamonds Fund at Penn State Hersey Children’s Hospital.
Some Good News in the Struggle with Obesity
Per this New York Times SchoolBook article, the rate of obesity dropped in New York City to 207 children per 1,000 in the 2010-11 school year, down from 219 five years earlier.
This means that 20.7 percent were still considered obese, but overall this is good news considering that, as the city’s health commissioner Dr. Thomas A. Farley, notes: “This comes after decades of relentless increases…What’s impressive is the fact that it’s [the obesity rate] falling at all.”
Across the country, recent studies have shown childhood obesity rates remaining flat or slightly increasing. Los Angeles County, which has also conducted a campaign against sugary drinks, had a decline of 2.5 percent during the same period, according to a study by the U.C.L.A. Center for Health Policy Research and the California Center for Public Health Advocacy.
The study was cautious in its language, warning, “A causal relationship cannot be inferred between the fitness interventions implemented by New York City in schools and the decrease in prevalence of child obesity described in this report.” But it said the decreases in obesity “might” indicate that changes in the school or home environment were important.
MCNtalk has talked about obesity rates, particularly among school children, extensively in the past year (Apple juice can pose a health risk; What is in the best interest of the child; Understanding the causes of obesity; Who’s really to blame for childhood obesity?), in general because it’s a serious problem for our nation’s health and in particular because of obesity’s impact upon the workforce, workers’ compensation, and disability problems. But then again maybe we blog about it a lot because it’s what people talk about a lot, especially through the holiday season with holiday meals and treats everywhere…and, oh yes, New Year’s resolutions.
The good news is that there are 6500 fewer obese children in the New York City school district now than there were five years ago. That’s a very, very important step for their lifelong health. The bad news is that while we may know how to talk about the problem all too well, we still have 20% of the NYC youth obese, not to mention those who are “just overweight.” Read more…
MCN Promotes Industry-Wide Examination Standards
We at MCN speak about quality in examination and review services and hear similar speech from others including competitors. The term “quality” is but a homily or empty rhetoric unless it is defined and clarified. We also believe that some may have been led astray when they allow quality to be defined along standards that lose sight of the inherent values of the medical profession. We believe that adherence to quality standards is neither negotiable nor fluid or subject to market forces. From time to time we observe within our company or learn from other quarters certain practices that we can’t endorse and ought not be endorsed or practiced by others. By raising the matter publicly we call attention to standards that should be expected by clients who order review services, by doctors who perform them, and by companies that facilitate them.
The below memo was sent to MCN consultants. We share them with you and invite you to pass them on. Or if readers have additional standards or take issue with any we have raised, we would enjoy hearing from you:
December 6, 2011
To: MCN Consultants
From: Mark Doyne MD and Brian Grant MD, Medical Directors
Regarding: Examination conduct, standards and physician demeanor
As medical directors for MCN, we review complaints that periodically arrive from claimants regarding their examinations. Every one of these is reviewed individually and each physician is given the opportunity to respond. We are passionate about the integrity of MCN examinations and expect that all MCN consultants share our values and practice accordingly. Given the nature of our work, a complaint should be reviewed in the context of the nature of the issues raised, including the possibility of there being other motivations for a given complaint among other factors. We do not take complaints at face value at all times. We review the specifics and may conclude that a complaint may lack merit. Sometimes we may choose to investigate with a call to the claimant and review the consultant’s response to the complaint. Other times we have chosen to briefly survey other claimants who have been evaluated by the consultant via phone calls to them and an audit of the corresponding reports.
Certain types of problems, when representing a pattern, will and have resulted in termination of a consulting relationship with the company for specific consultants. We believe that adherence to appropriate standards should be inherent in the profession and are obvious requirements to perform quality reports. As such, they may be beyond the scope of MCN or others to teach, and when basic standards are not adhered to, this is a serious matter.
We expect consultants performing medical reviews, whether for MCN or others, clients requesting such examinations, and competing companies to adhere to basic standards of conduct and practice.
Some of the points below have been conveyed in past memos. We are restating them as a reminder, and for the benefit of new consultants. We call upon the industry, including clients, physician consultants and MCN’s competitors, to enforce adherence to these standards, embracing them in intent and practice. We also welcome your comments and additional ideas.
Our standards (as expected of all who perform medical reviews) include but are not limited to the following:
Sufficient Time Must Be Spent with Claimants. We expect that the consultant devote sufficient time for a thorough review of records, history and physical or mental status assessment of the claimant. It is NOT appropriate to book exams in increments of less than thirty minutes. We have heard stories of companies in certain regions of the country where four to six or more exams scheduled per hour are not uncommon. Some consultants find it of benefit to review the records in the presence of the claimant. If time has been spent away from the claimant reviewing the records, however, it might be a good idea to share this fact and show those records to the claimant. Actual face time with claimants should be sufficient to perform an appropriate history and examination without creating a perception by the claimant of being rushed. It is impossible to perform a thorough history and physical of a typical injury claim in less than thirty minutes and often more time is required.
Reports Must Be of Sufficient Length. A report should be several pages or more in length, have sufficient depth to answer the questions of the client, and reflect a thoughtful, individual review of the specific case. There should be documentation of what has been reviewed. We remind you that it is not necessary to extensively quote records that have been reviewed. Some consultants issue reviews that are unnecessarily long. It should generally suffice to state the nature of the record, date, person who generated it, and a brief reference to the conclusions. The goal is to be certain that you have reviewed the document and considered it in your conclusions. If need be, one can refer to the original document at a later date.
Each Case Must Be Evaluated on Its Individual Merit with Every Examination a Unique Event. Other than a preliminary disclosure paragraph used at times, MCN does not employ any standard language in reports. We expect that consultants likewise will individualize each report in their own words. Held to the light, no two reports should ever appear the same or close to the same. Clinical boilerplate is not permitted for MCN examinations. Normal findings, if conveyed numerically, should reflect normal range and not a standard value.
Report Findings Must Be Objective and Evidence-Based. Our clients want quality, objective reports, regardless of claim impact. They want reports that are based upon data, not merely a claimant’s self-report. They use IMEs and medical reviews because they want incisive and critical medical thinking. If they wanted a report to repeat the claims of the claimant in the absence of data, they would have no need to spend the time and resources to ask for an IME and would merely accept what the claimant says. The reader of the report (more often than not a non-clinical individual) should be able to understand the reasoning behind the conclusions.
Consultants Must “Stay in the Box.” This means answering each question you are asked, not answering questions you are not asked, and staying within your area of clinical expertise. These are simple concepts, but too often not honored.
Reports Must Be Issued in a Timely Manner. A good examination ceases to be good if the consultant is late on initial report submission, signatures, clarifications, and other actions that delay report issuance. Our clients are often working under time constraints. Delays rarely add value and quality may be diminished with the passage of time as specific details can fade. We rely upon consultants being timely to meet our mutual commitments.
Claimants Must Be Shown Respect During all Interactions. Remember that some claimants are nervous, apprehensive, and often unsophisticated when they report for an examination. They deserve a response to questions and an explanation of procedures as well as appropriate respect for modesty and personal boundaries. Curtness, over-familiarity, and criticism of the claimant or their treating physicians are all to be avoided. Demonstrate respect for claimants as you would want your own friends or family members to be shown respect if they were to be sent for an examination. And write a report that you would respect if issued by a colleague.
Treatment Is Never Offered During an Independent Medical Evaluation. Never offer treatment or comment on current or past treating doctors: Please remember that your credibility depends on being regarded as neutral, objective, and not vested clinically. From time to time a claimant may request that a reviewing doctor assume treatment, and there have been situations when a reviewing doctor has offered his/her own services or even issued a prescription. Offering any sort of treatment, however, should never occur. If there is an urgent medical matter observed during an evaluation, stabilization and referral to an appropriate physician or emergency facility should be undertaken.
Testing Should Only Be Performed as Necessary. Additional diagnostic testing should be only performed when necessary to answer questions posed to the examiner. In many cases testing must be authorized by MCN or the client. In our experience the need for additional testing is relatively infrequent because numerous diagnostic tests have typically been performed prior to the IME, with the results readily available in the medical records.
We are proud of our work at MCN. We have been in the business of performing medical judgment services for almost twenty-seven years and strongly believe in the value of our services to society and the integrity of the company and our consultants. We call upon all involved in requesting and providing such services to adapt and enforce standards that reflect the best of medicine and respect for the dignity of claimants.
Thank you for your support and quality consultations. If you have any questions or comments, feel free to contact Brian Grant at bgrant@mcn.com or 206.447.3449. Mark Doyne may be reached at mdoyne@mcn.com or by phone at 214.762.0784.
OxyContin: the strange saga of Purdue and its $3 billion drug
“Their chemical composition is such that the U.S. is just a few carbon molecules from being a nation of heroin addicts.”
That’s a pretty harsh quote from this recent article from CNN. And it’s just the start in this latest entry about the U. S. and our dependence on prescription pain killers. Some facts to back up this assertion:
- 254 million prescriptions for opioids were filled in the U.S. in 2010, according to Wall Street analysts Cowen & Co.
- Enough painkillers were prescribed in 2010 to “medicate every American adult around the clock for a month,” the federal Centers for Disease Control reported on Nov. 1.
- It estimated that “non-medical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.”
- Opioids generated $11 billion in revenues for pharmaceutical companies, says market research firm Frost & Sullivan.
- 15,000 Americans died of opioid overdoses in 2008
- Two decades ago opioid sales were a small fraction of today’s figures, as such drugs were reserved for the worst cancer pain.
Why this recent spate of attention on Purdue Pharma, the makers of OxyContin? Last year they began selling a reformulated version that should help reduce the worst form of abuse. The original drug had a time-release mechanism that could be defeated by crushing the pill and snorting it, smoking it, or adding water to the powder and injecting it for a heroin-like high. By contrast, the new version breaks into chunks rather than a powder; if water is added, the result is a gelatinous goop. But at the same time, taking that step lifts a stigma from the drug and may make doctors more comfortable prescribing it, an outcome Purdue is hoping for. The result could be an even greater number of invisible addicts. Read more…
To encourage direct subscriptions to MCNTalk, and support great causes, we are conducting a drawing to support a non-profit of the winners’ choice. $100.00 will be donated to 3 eligible organizations selected by 3 winners.
All you need to do is subscribe directly to the blog. This is as easy as adding your email address on the upper right of our homepage under the “SUBSCRIBE TO MCNTALK.” All subscribers as of the drawing date are automatically entered.
Feel free to refer others in your organizations or friends directly to MCNTalk if you believe that they may be interested in the topics we cover.
The fine print:
- 3 random numbers will be generated from the number of emails directly subscribed to MCNTalk by December 9 and applied to a download of these emails to select the winners.
- The winners must respond to an email sent to them by MCN on or about the 9th by December 13, and select a non-profit by the 15th. In the event of a non-response, alternates will be selected.
- The winners must consent to being identified. To decline participation, a non-response is sufficient, or an email response indicating a wish for us to choose an alternate.
- Eligible organizations must be US based and recognized as a 501C-3 organization by the IRS.
- MCN employee and their family members are not eligible.
- We will announce the winners, their affiliations and their organizational choice by December 23.
