Sunday, May 12, 2013

"It's not our job."

Some people were criticizing me the other day when I suggested that CMS was wasting its time by publishing hospital chargemaster data while neglecting its real responsibilities.  "Why are you so hard on them?" was the typical comment.

Why?  Because the agency is neglecting important duties, tasks that could actually improve the quality and safety of patient care.

Well, just a few days later, Pro Publica makes the case so strongly that I will just quote excerpts from their report:

An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive. Federal officials have done little to detect or deter these hazardous prescribing patterns.

How does CMS respond?

"CMS's payments don't go to physicians, don't go to pharmacies. They go to plans, which is how our oversight framework has been established," Jonathan Blum, the agency's director of Medicare, said in an interview. The philosophy "really has been to defer to physicians" about whether a drug is medically necessary, he said.

Other disagree.

Asked repeatedly to cite which provision in the law limits their oversight of prescribers, CMS officials could not do so.

The Office of the Inspector General of the Department of Health and Human Services has repeatedly criticized CMS for its failure to police the program, known as Part D. In report after report, the inspector general has advised CMS officials to be more vigilant. Yet the agency has rejected several key recommendations as unnecessary or overreaching.

Other experts in prescription drug monitoring also said Medicare should use its data to identify troubling prescribing patterns and take steps to investigate or restrict unsafe practitioners. That's what state Medicaid programs for the poor routinely do.

"For Medicare to just turn a blind eye and refuse to look at data in front of them . . . it's just beyond comprehension," said John Eadie, director of the Prescription Drug Monitoring Program Center of Excellence at Brandeis University.

"They're putting their patients at risk."


RalfLippold said...

Thanks a lot Paul for bringing out this most relevant topic in times, when cash is scarce, and medication seems to be dropping into becoming a commodity (though without a clear and transparent price tag).

Seems like similar is happening here in Germany. Information about "real" healthcare costs are almost naturally hidden in the system. A normal patient (on a private healthcare insurance) has literally no way to gather exact knowledge on how expensive (financial flows towards the hospital or doctor has happened due his/her injury or intake).

A bit more than a year ago my girlfriend boiled herself, and needed treatment. Happened to be that a tetanus vaccination was necessary. As she is of Italian origin and back then was still covered by her Italian health insurance, it was only a paper exchange.

Now after one year, another vaccination shot was necessary. And here the "real" story starts (though a tiny one). Besides filling all personal information (which she did a year ago) again in paper (!) [in Italy to my surprise all of this is already in electronic form exchanged] she had to buy the vaccine shot across the street in a pharmacy. A nurse then gave the shot.

Here is the point when the ??? arise: she got a letter from the doctor's practice urging her to sign a form (that would be necessary to make the payment to the doctor possible).

In exchange with the healthcare insurance (on the German side) that in these cases act as the clearing point it was impossible to get information on what the amount of payment for this treatment (should be a rather standard one) to the doctor's practice would be, and whether there is a difference to getting the shot by the nurse or the doctor.

With full transparency of the financial flows, and the needed procedures it would certainly become clear which processes are overpaid, or not.

Wondering which stakeholders in the larger "game" have a reason for not going for transparency?

Best from Dresden,

PS.: In Germany there is a high stake in personal data and its confidential status, and it even grows stronger with more information technology in use.

Neville Sarkari MD, FACP said...


My guess is that CMS officials don't want to get branded by the "rationing" tag.

Remember, although certain prescribing might be suspect, there is a patient involved in every one of those prescriptions.

When you tell the physician he can't or shouldn't prescribe a therapy, you're also telling a patient they can't get that medication.

If someone believes the therapy helps, even if it does not, that is a powerful thing. People get very (irrationally) upset about these things.

I agree it is wasteful, sometimes harmful, but it's also very tough to stop.

Much easier for CMS to say "It's not our job, the plans need to monitor this."

Watch and see, the same thinking is behind the Accountable Care Organizations. CMS and Congress want to be far removed from decisions to disallow care, especially for financial reasons...

Dennis Byron said...

My problem with this article is that none of the findings or recommendations seem to have anything to do with Part D Medicare. Half of the little heart-wrenching sob stories in the article took place before Medicare Part D even went into effect in 2006. One of the most important little vignettes in the article (it comes up three times) says

"An Oklahoma psychiatrist regularly prescribes the Alzheimer's drug Namenda for autism patients as young as 12."

Sorry but it just intuitively seems unlikely that the prescribing of Alzheimer drugs to twelve year olds is a major Medicare Part D issue. I'm not saying this incident didn't happen. I'm just saying

"Huh? Out of a billion scripts filled, that's the best WaPo can do?"

And oh by the way, about that billion prescription statistic. You have to really follow the strained parsing of the authors to realize that they are talking about 30 million seniors getting an average of around three prescriptions each year. I get a very inexpensive and mild blood pressure med called lisinoprol prescribed once a year to be refilled 11 times. WaPo calls that 12 prescriptions.

David Joyce MD said...

CMS oversight, Oh wait, "I am with the government and I am here to help you." Ugh With EMR and E scripts, just put the price of the medication in the box and make the physician click it for the order to be processed. Then watch as the savings mount. Connect the concept of cost and prescribing when the prescribing actually occurs and keep CMS out of it, please.