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Education and Political Action

Colorado's Bold New Healthcare Initiative


Frustrated with the suppressing effects of the Patient Protection and Affordable Care Act and the continued sky rocketing costs of health care, this Fall, Colorado will vote on Amendment 69, a petition induced amendment to the Constitution of the State of Colorado.

If passed, this single payer health insurance program will go into effect over an 18 month period. It's goal? To eliminate insurance premiums (about $8,000 to $12,000 per family annually), "un-affordable deductibles" (as much as $7,000 per family), and any out of pocket expenses like co-pays.

Understand, the only way to move away from the Affordable Care Act is for states to make a better and more affordable but fiscally solvent plan on their own. So again, Colorado spearheads a change in the law of the land, thumbing their noses at the Federal Government's inadequacies, and taking on the task themselves to protect Colorado's citizens.

It will start with a thirty-eight billion dollar budget through a state income tax increase of ten percent, and provide universal health coverage, choking off the profit seeking behaviors of national private insurers, and will save Colorado six billion dollars a year.

If passed, the first year of the plan will be directed by a 15 member interim Board of Trustees chosen by state legislative leadership and the Governor. This will be followed by an election of professionals and community members to the Board of Trustees to over-see and manage all "ColoradoCare" operations, with elections held annually thereafter. Amendment 69 outlines the length of the terms of the elected trustees, term limits, and procedures for filling vacancies. ColoradoCare Trustees are not subject to recall elections, but may be removed by a majority vote of the board.

Essentially, the State of Colorado will be carved into seven districts, with each district electing three board members each (total of 21). in the last year, It has been well known in professional medical and academic circles that VENTURE XVII supports this amendment. The B.E.A.M. Foundation will be funding the campaigns of two of it's members to run for ColoradoCare Board of Trustees positions. Yes, VENTURE XVII is actively involved, as three of the B.E.A.M. Foundation's positions are to alleviate poverty, create economic empowerment, and promote accessible healthcare to all. In addition, the B.E.A.M. Foundation supports Senator Bernie Sander's initiatives to make healthcare "a right of our citizens".

Unfortunately, the United States is the only first world economy where you can still be bankrupted by a medical condition. This is considered unconscionable by many, and Colorado feels compelled to act instead of talk (which has been going on now for over thirty years). Did you know that over sixty percent of bankruptcies are induced by medical expenses? Did you know that over forty percent of foreclosures are induced by medical problems?

The insurance companies keep getting richer, and our premiums and out of pocket costs keep going up and are crushing our citizens. When I see a patient for 15 minutes, I spend an hour on paperwork and coding or the insurance company will not compensate me for the visit, even if it's only for a Medicaid copay. Enough is enough! Colorado is fed up. Colorado not only has the resources, but the means to carry this through, and maintain it indefinitely.

Isn't it interesting that all of the media advertising opposing the amendment is backed by Blue Cross Blue Shield, United Health Care, Kaiser Permanente, The Travelers, other small cap insurance entities and those invested in the insurance industry. Why, you ask? Because if this passes, they will no longer write insurance in Colorado, and will lose market share of almost nine million insured lives. Do the math. 

Gaining health insurance is an important step in ensuring access to healthcare. Without insurance coverage, many patients would not be able to pay for the medical services they receive. But so far, no policy attempted in the United States, not even the Affordable Care Act, has been able to bring coverage to everyone or reign in costs. ColoradoCare attempts to solve that situation.

ColoradoCare would automatically cover everyone whose primary residence is in Colorado. The system would include people who currently can’t afford insurance, don’t want it, or don’t qualify for existing programs because they are immigrants who lack documentation.

Supporters say universal, publicly financed coverage would save money and time that is currently spent on insurance bureaucracy and paperwork, and allow patients to see any provider who agrees to contract with ColoradoCare.

Opponents (the insurance companies) argue the opposite, saying the proposed system would limit Coloradans’ choices about their health plans, restrain market competition and leave too many important details to be decided in the future. Typical corporate rhetoric.

The issue here is typical of all politics. There will be a tax increase. Everybody gets itchy when we talk about tax increases. But this initiative has a silver lining of beneficence: State of the Art Healthcare, but at no cost to the citizens of Colorado.

Here's an example of its impact on a family of four paying $1000 in state income tax per year. Now their income tax is $1100, but they didn't have to pay $12,000 in premiums in addition to if a family member was hospitalized, the $7,000 deductible they would most likely have to borrow.

Keep your eyes on Colorado. If this works well over the next three years, you will see other states take notice and use our system as a template for their own.

I understand when you read this, you can see that it is slanted to the "Yes Vote". But it's also about doing the right thing. We have the resources (remember all that money we're making from Weed?), We have some of the best medical and business minds in the nation right here. We can make a difference.

For an independent analysis, please go to: http://colorado69.org/



Keep reading, and Stay healthy.


Dr. Counce

















Maintenance of Certification: Doctors Strike Back


Doctors Strike Back

Underlying much of the controversy surrounding Maintenance of Certification (MOC), is the question of how much, or even whether, the process as currently structured actually improves physician performance and/or patient outcomes.
 
On February 3, 2015, many physicians received a surprising email from Richard Baron, MD, MACP, president and chief executive officer of the American Board of Internal Medicine (ABIM). Referring to the board’s controversial maintenance of certification (MOC) program, Baron wrote, “ABIM clearly got it wrong. We launched programs that weren’t ready and we didn’t deliver a MOC program that physicians found meaningful…We got it wrong and sincerely apologize. We are sorry. ”

Baron’s email— which went to the approximately 200,000 internists and practitioners of 20 sub-specialties who have obtained their board certifications from the ABIM—followed by a few weeks (and many believe was at least partially in response to) the announcement a new organization, the National Board of Physicians and Surgeons (NBPAS), with the announced goal of giving doctors “an alternative route for continued board certification.” It is led by Paul Teirstein, MD, chief of cardiology at the Scripps Clinic in La Jolla, California, and an outspoken MOC critic.

While the controversy surrounding MOC remains far from settled, it seems clear that critics of the process and of ABIM have scored some significant gains, by forcing ABIM to review or scrap some elements of MOC, and by possibly opening new paths to maintaining certification.

Evolution of MOC requirements

The creation of NBPAS and the ABIM’s apology are but the latest developments in a long-simmering dispute over how doctors should best keep their skills and knowledge up-to-date—and prove that they are doing so. The controversy dates to the 1990s, when the ABIM instituted a policy whereby, beginning in 2000, physicians who certified after 1990 would have to recertify every 10 years. (Until then certification had been life-long.) The change was subsequently adopted by the other 24 boards comprising the American Board of Medical Specialties (ABMS).

The 10-year maintenance requirement produced some grumbling among doctors, but no organized resistance. That changed at the start of 2014 when ABIM announced that doctors would need to earn accreditation points on a continual basis over the 10 years between taking the recertifying examination. Moreover, doctors who had board certified before 1990 would be listed as “certified, not meeting MOC requirements” on the ABIM’s web site.

For Teirstein and many of the physicians boarded by the ABIM, these latest changes were the final straw. They were further incensed by what they regarded as the excessive growth of the nonprofit ABIM—whose budget exceeded $59 million—and the nearly $29 million spent on salaries, benefits and “other expenses” during the ABIM’s 2014 fiscal year. A few months later Teirstein launched an online petition opposing the MOC requirements that to-date has garnered more than 23,000 signatures, he says.
In addition, he says, “I began getting comments like, ‘it’s great we have all these signatures, but what do we have to show for it? Have they [the ABIM] actually changed anything?’ And they had not.”
 
The NBPAS alternative

Teirstein’s response was to found the NBPAS, a nonprofit organization with what he describes as “a much less expensive, much simpler approach to life-long learning.” In the news release announcing its formation, the organization says it is “committed to providing certification that ensures physician compliance with national standards and promotes lifelong learning.” Among the requirements for continued certification are that a candidate be previously certified by an ABMS-member board and have completed 50 hours of CME in the past two years.
Teirstein describes NBPAS as a “grass- roots organization,” one that is funded entirely by its members. Membership fees are $85 per year or $169 for two years, and cover all specialties and sub-specialties covered by the ABMS. “Right now we’ve got about a thousand members and we’re making ends meet doing that,” he says. Teirstein is taking no salary.

As of mid-April none of the nation’s hospitals were accepting NBPAS certification as a basis for admitting privileges, but Teirstein notes that the process usually involves approval from numerous boards and committees and thus will take some time. “I’m of the firm belief that the as long as the medical community is willing to stand up and say this is what they want we’ll figure out a way to make it happen, but it won’t be overnight,” he says.

Teirstein and other NBPAS board members say they support the notion of physicians keeping their knowledge and skills up to date, but think CME offers the best method for accomplishing that. Teirstein notes that CME courses must be accredited by the American Council for Continuing Medical Education (ACCME) to count towards license renewal. “We’ve decided the best compromise is where you can have lifelong learning which doctors don’t consider onerous,” he says. “The doctors can choose which offerings to attend. They’re not going to pay and take time to go to something that’s not relevant.”

‘It’s not good learning’

Harry Sarles, MD, FACG, an NBPAS board member and past president of the American College of Gastroenterology objects to what he calls the “esoterica” on the certification examinations. “It’s not good learning. It’s learning for the test,” he says.

“ABIM should not be allowed to set the bar, make the rules, and then provide all the CME that can only be accepted to meet their rules,” he adds. “I’m answering to my hospital, my state, my patients, the health plans, in terms of my quality being measured and monitored. And now ABIM steps in and says you should be doing something for us too. I felt like I was in the middle of a shakedown.”

“When I took my certification I felt proud and driven to continuously improve myself,,” he says. “But everything ABIM has instituted since then, to my way of thinking, has really been about themselves and not what’s best for physicians.”

Sarles endorses the idea of physicians demonstrating quality and a commitment to ongoing education, but wants to see “multiple pathways” for doing so. “I’m all for competition, because it will make us all better,” he says. “If we only had one kind of car to buy it would probably be a crappy car. Whatever your criteria are, competition is very healthy and I believe in it.”
 
The ABIM response

ABIM’s February 3 statement, while not directly acknowledging NBPAS, did appear to address some of its complaints and those of others who have been critical of the MOC process. It said that the board will:

  • Suspend the practice assessment, patient voice and patient safety requirements of the MOC program for at least two years,
  • By August, 2015 change the language used to report a diplomate’s MOC status on the ABIM’s website from “meeting MOC requirements” to “participating in “MOC,”
  • Update the internal medicine exam so that it better reflects what practicing physicians are doing,
  • Keep MOC enrollment fees at or below 2014 levels through at least 2017, and
  • Allow internists to use most forms of ACCME-approved CME to demonstrate self-assessment of medical knowledge by the end of 2015.

In addition, according to the statement, “ABIM will work with medical societies and directly with diplomates to seek input regarding the MOC program” via meetings, webinars, forums, and other venues. “We are embarked on a whole new way of doing business and much more engagement with our community,” Baron said in a phone interview with Medical Economics.

As evidence, he cites implementation of “a sub-specialty board structure that involves depth in each of the disciplines in internal medicine,” and that includes physicians in community practice as well as patients and other public stakeholders.

“Those groups have been reaching out to colleagues and members of their societies,” Baron says. “And what we’re hearing is that lots of the activities we had either as board products or expectations maybe are being done by other people in the [healthcare] delivery system better than we’re doing them. And in that case we want to learn more about those and figure out how to give people credit for the work that they’re doing during their day jobs and avoid redundancy and wasting members’ time.”

Responding to the complaint that MOC tests doctors on knowledge and skills they don’t encounter in their practice, Baron says he took the exam a year ago and acknowledges that it included topics he’d not seen in his general internist/geriatrics practice. On the other hand, he says, “I think all of us in practice confront that there’s a difference between what we use every day and what we might need to use some time.”

Baron recalls joining the ABIM’s test-writing committee in the summer of 2001 and being surprised to find the test included a question on anthrax. But several months later it was a board-certified internist in Miami, Florida (Larry Bush, MD) who first identified anthrax as the mysterious substance being sent through the mail that was sickening—and in the case of Bush’s patient, killing—recipients was anthrax.

”That’s a doctor who had a piece of knowledge that he didn’t use every day, but fact that he had it made a huge difference for a patient,” Baron says. (Bush subsequently coauthored an article about the incident in The New England Journal of Medicine.)

Regarding the fees associated with MOC, Baron says, “Nobody likes to write checks, and when I was in practice there were a lot of things I wished I didn’t have to pay for. But I want to acknowledge that it’s really hard for doctors in practice now and every check is a painful check. We are looking at ways to reduce the cost.”
As evidence, he points to the February 3 announcement regarding enrollment fees. “We are taking time to listening to physician feedback about all aspects of our program before announcing any additional changes,” he says.
“We know that doctors need to experience more value in the program, and the areas we pulled back on were those that doctors were in effect saying, ‘I’m not getting much out of this,’” he says.
 
What do the data show?

Underlying much of the controversy surrounding MOC is the question of how much—or even whether—the process as currently structured actually improves physician performance and/or patient outcomes. A great many internists clearly believe it does not, according to a study published in the January 2015 issue of JAMA Internal Medicine.

The authors assembled a focus group consisting of 50 board-certified primary care and subspecialist internal medicine and family medicine physicians in an academic medical center and community sites. They found that “at present, MOC is perceived by physicians as an inefficient and logistically difficult activity for learning or assessment, often irrelevant to practice, and of little benefit to physicians, patients, or society.”

Data on the effectiveness of certification since the institution of time limitations is sparse, consisting largely of a handful of studies published over the past 15 years in Academic Medicine, the Journal of the American College of Cardiology and JAMA, among others. And while MOC supporters say the studies support MOC’s effectiveness, in a debate earlier this year with Baron and Lois M. Nora, president and chief executive officer of the ABMS, Teirstein maintained that the studies’ results are, at best, ambiguous.

He cited, for example, the results of a 2014 investigation published in JAMA comparing clinical outcomes among patients at four Veterans Administration hospitals treated by internists with time-limited and time-unlimited certifications (i.e. those who were grandfathered out of the ABIM’s 10-year certification requirements and those who were not.) The authors found “no significant differences” between the two groups on 10 primary care performance measures.

“If you say we have data that supports our MOC process, you’d better have the data,” Teirstein said in his interview with Medical Economics. “And if you look at the papers they cite, they’re very unconvincing.”
Baron acknowledges that the evidence in support of MOC “could be stronger,” but also notes “at least one of the studies he (Teirstein) criticized met rigorous methodological standards.”

“I don’t think it’s unusual to have good faith people arguing about whether the evidence shows ‘x’ or ‘y,” Baron says. “Every clinician operates all the time in an environment where the patient didn’t walk out of an article in a journal. You have to navigate between what you know you know and how close the patient before you gets to that.”
Teirstein says NBPAS has no plans to try and link ongoing education and training to quality and patient outcomes. “I just don’t think you can measure this adequately,” he says. “Would randomizing really work? A doctor might be more inspired to do a good job because he wants to prove you don’t have to do this [maintain certification.] It’s just not the kind of thing that lends itself to scientific study.”

Looking ahead, Teirstein envisions the NBPAS playing a watchdog role for the ABMS and its member boards, in addition to providing certification. “We’ll be keeping an eye on things and making sure everyone knows physicians are not just going to take whatever they’re given. We’re going to react and try to make our voices heard.”
 
 ABIM requirements

  • Possess a valid and unrestricted license to practice medicine and enroll in maintenance of certification (MOC)
  • Earn MOC points by completing some MOC activity every two years and earn 100 points every five years (at least 20 points in medical knowledge). Points earned every two years will also count toward your five-year requirement, and also count toward the milestones for the certifications you are maintaining. Points earned count toward all certifications being maintained.
  • If you are dual-boarded by one or more of the other American Board of Medical Specialties (ABMS) member Boards, your self-evaluation requirements will be waived.
  • Pass the MOC exam in your specialty(ies) every 10 years (first exam attempt in each certification area you maintain earns 20 MOC points).
  • Other requirements may apply depending on your specialty and situation. For complete requirements, visit: http://www.abim.org/maintenance-of-certification/requirements.aspx


Source: American Board of Internal Medicine


NBPAS requirements

  • Candidates must have been previously certified by an American Board of Medical Specialties (ABMS) member board.
  • Candidates must have a valid, unrestricted license to practice medicine in at least one US state. Candidates who only hold a license outside of the U.S. must provide evidence of an unrestricted license from a valid non-U.S. licensing body.
  • Candidates must have completed a minimum of 50 hours of continuing medical education (CME) within the past 24 months, provided by a recognized provider of the Accreditation Council for Continuing Medical Education (ACCME). CME must be related to one or more of the specialties in which the candidate is applying. Re-entry for physicians with lapsed certification requires 100 hours of CME with the past 24 months. Physicians in or within two years of training are exempt.
  • Other requirements may apply depending on your specialty and situation. For complete requirements, visit: https://nbpas.org/why-nbpas/


Source: National Board of Physicians and Surgeons








What Doctors Don't Know About The Drugs They Prescribe

A COMMENTARY ON THE PHARMACEUTICAL INDUSTRY

Introduction by Dr. C. M. Counce:

Many of my students have heard my lectures on "The Dark Side of Medicine". From grave robbing during the Renaissance to exposing African Americans to syphilis as a technique to study pathogenesis in the early twentieth century. Or how about Germany's Bayer Laboratories introducing Americans to Heroin as a so-called non addictive cough medicine in 1895. Let's not forget the current "dirty organ" trade?  And of course, need I remind you of all that was done by Nazi doctors for twelve years, and the data we gleaned and kept from the patients they tortured?

"Medicine" has a clear history of occasionally doing things the wrong way, fixing it, hiding it, then moving on and not letting on. Here is a commentary from Dr. Ben Goldacre, author of the books, "Bad Pharma", and "Bad Science", regarding the trillion dollar pharmaceutical industry and its hold on doctors, from The Huffington Post and TEDTalks.

TEDTalks can sometimes portray science in triumphalist tones, with fabulous innovations that are changing the world forever. But the real action in science is often around dirty, messy, angry problems, and my TEDTalk is about the dirtiest I've seen yet.

Doctors need the results of clinical trials to make informed choices, with their patients, about which treatment to use. But the best currently available evidence estimates that half of all clinical trials, for the treatments we use today, have never been published. This problem is the same for industry-sponsored trials and independent academic studies, across all fields of medicine from surgery to oncology, and it represents an enormous hidden hole for everything we do.
Doctors can't make informed decisions, when half the evidence is missing. 

Most people react to this situation with incredulity, because it's so obviously absurd. How can medics [physicians], academics, and legislators have permitted such a huge problem to persist? The answer is simple. This territory has been policed, and aggressively, by the pharmaceutical industry. They have worked hard to shut down public discussion on the topic for several decades with great success.

They say, for example, that the problem is modest, and that critics have cherry-picked the evidence: but this is a lie. The best evidence comes from the most current review of all the literature, published in 2010. It estimates that half of all completed trials are left unpublished, and that trials with negative results are about twice as likely to be buried.

Then they pretend that the problem is in the past, and that everything has been fixed. But in reality, none of these supposed fixes were subject to any kind of routine public audit, and all have now been well-documented as failures. What's more, they all shared one simple loophole: they only demanded information about new trials, and this is hopeless. Anything that only gets us the results of studies completed after 2008 does nothing to fix medicine today, because more than 80% of all treatments prescribed this year came to the market more than ten years ago. We need the results of clinical trials from 2007, 2003, 1999, and 1993, to make informed decisions about the medicines we use today. This isn't about catching companies for past misdemeanors, it's a simple practical matter of making medicine optimally safe and effective.


The arguments go on, with ever more red herrings: industry spokespeople pretend that information about trials, such as Clinical Study Reports, can't be released without breaching the confidentiality of individual patient participants. But in reality, the EU Ombudsman has already forced the European Medicines Agency (EMA) to release hundreds of these exact same documents. He stated clearly that the administrative burden of removing any individual patient information is minimal. Next, they claim the cost of sharing trial information is prohibitive: but both the EMA and GSK have committed to releasing all the Clinical Study Reports that they have, and the EMA has already shared millions of pages of documents, quite happily. Sometimes industry people even claim, in hugely patronizing tones, that it's better for only regulators to see trial results, behind closed doors, because the public would panic if exposed to dissenting views.

There's more. Sometimes they pretend that the academic journals are the bad guys, for rejecting papers with negative results, when the evidence shows this was barely ever an issue, and, in any case, there are now endless open access journals, specifically designed to accept negative results. Then there are the hole-pickers: people who pay lip service to the problem, with a brief claim that they are "on your side," then expend all their worldly effort trying to pour cold water on the problem, pretending that things aren't so bad after all.

Nassim Taleb, author of The Black Swan, once laughingly told me that every page of my book Bad Pharma was infused with paranoia: that he could tell I'd been made furious by having the same argument about missing data, over and again, with chancers; that I had resorted to obsessively covering every exit in the argument with snipers, to hem the enemy in, across hundreds of pages. I admit I am obsessed, and I hope you'll share those details: if not by reading the book, then at least by inhaling the eight page briefing we have produced for our campaign, at alltrials.net.

Because this is where I have to confront my inner grouch, and cave in to the optimism of TED. I have to tell you about the successful campaign for trials transparency that has grown since this talk first went up.

In the UK, last October, almost as soon as Bad Pharma was published, there were questions on withheld trial results in parliament, including a Prime Minister's Question (which David Cameron simply dodged). This led to widespread editorials, comment pieces, and news coverage in the London Times and elsewhere. A group of us, myself and some properly eminent UK medics, had a meeting with the Health Minister. The UK parliament's Health Select Committee called on the GMC, NICE, and the pharmaceutical industry to address the problem of missing trials; the Public Accounts Committee are looking at the withheld data on Tamiflu; and the Science and Technology Committee have now commenced a formal parliamentary inquiry into the problem of withheld results more widely.


In January, the science writer Simon Singh grew frustrated at my whining that things weren't moving fast enough, and gave a generous donation to the campaigning charity Sense About Science. This kickstarted some more traditional lobbying. We teamed up with the great and good journal editors, academics, and a knight -- to form the alltrials.net campaign.

AllTrials asks people to sign up to two simple things: firstly, recognize that this is an ongoing problem; and secondly, call for the release of basic information (including brief summary results, and the long "Clinical Study Report" where available) for all trials, on all treatments currently in use, whether past or future.

This has grown almost faster than we can. Over 40,000 individuals have signed up, and over 200 organizations. More than a hundred patient groups have committed their support, recognizing that it's their members who participate in trials, and take medicines based on their results. We are now supported by almost all medical and academic professional bodies in the UK -- the Royal Colleges, the Societies and Faculties -- not to mention the National Physicians Alliance from the U.S., and the European Public Health Association. The outsider position in the UK is now not supporting the AllTrials campaign.

In February, GlaxoSmithKline, one of the biggest drug companies in the world, signed up, and committed to publicly release all their Clinical Study Reports, going back to the beginning of the company. More companies are discussing signing, and if these promises are delivered, they could finally add an interesting new element to the game: for the first time ever, I believe there will be commercial incentives to transparency. Imagine that there are two treatments, both with apparently equal benefits. One is made by a company that shares all its results, but the other is made by a company that publicly mocks and derides the very notion that doctors and patients should dare to ask for such a thing. Which treatment do you want?


I think the answer is clear, but we need more than this. We need public engagement on the issue, and wider recognition among policy makers, to get on with concrete solutions. That's why I hope you'll sign up to alltrials.net, and if you're a member of a professional body anywhere in the world, then please get them to sign too. If you're from a company, then we are very happy to talk informally -- and confidentially -- about any anxieties you may have, but please, save your reputations, and sign.

The current state of affairs is absurd. We can spend tens of millions of dollars on just one trial, hoping to ensure it is free from bias, and trying to accurately detect tiny differences between one treatment and another. And yet we let all those biases right back in, by allowing people to bury half the data. Future generations will look back at our tolerating this bizarre situation in astonishment, the same way that we look back on medieval bloodletting. The time is now, to fix it forever, easily.

About the Author:

Dr. Ben Michael Goldacre is a British physician, academician, science writer, and author of the two well known industry books, "Bad Science", and "Bad Pharma". Dr. Goldacre is Wellcome Research Fellow in Epidemiology at the London School of Hygiene and Tropical Medicine.