“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
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Pharmacist Steve steve@steveariens.com 502.938.2414
A class action lawsuit alleges that CVS unlawfully sends letters to physicians falsely claiming that their patients are reaching out about prescription medications with their patients’ consent, when in reality, the messages are just marketing materials. Ring of Fire’s Farron Cousins discusses this with Scott Hardy from Top Class Actions.
Farron Cousins: One of the biggest issues according to American voters in the 2020 presidential election and pretty much in their day to day lives right now is the issue of healthcare. We’re being overcharged. We’re being overcharged by Big Pharma, we’re being overcharged by our doctors, by hospitals, by our insurance, by everyone. But you know one group that always kind of gets overlooked here is the pharmacies, right? We often forget that pharmacies have an incentive from the pharmaceutical companies to sell us certain drugs. Or to switch us out from, you know, this brand of be it diabetes medicine to this brand of diabetes medicine.
And unfortunately, CVS pharmacy has found a way to make pharmaceutical companies even happier by trying to actively get doctors to prescribe certain drugs for patients. Joining me now to explain exactly what’s happening here is Scott Hardy with Top Class Actions. Scott, there’s few industries I loathe more than pharmaceutical companies, but CVS might be creeping up there on the list because what they’re doing right now, sending out mailers to doctors, is absolutely appalling. Tell us what’s happening. I want you to tell us this story. It’s absolutely amazing.
Scott Hardy: Sure. It’s, it’s really shocking because you know, we all expect and we hope that our pharmacies will call our doctors to refill a prescription, that’s expected. Whenever your prescriptions out, they say, hey, can we call your doctor and, and refill it for you? Yes, absolutely take care of that. But this class action is stating that CVS is being much more proactive and without your permission, is reaching out to doctors and sending out letters to doctors saying that you need this medication. Can we get your permission now? Can you send over a prescription for you? And they’re doing that without notifying you.
And an interesting piece of this is that, you know, this isn’t the, hey, we’re trying to help you out. We’re trying to get your doctor to send these prescriptions without your permission. No, it’s, it’s a big part of the class action is saying that CVS is using you, the consumer to market. Now, CVS is obviously going to make money on selling these prescriptions that they’re hitting the doctor up for. But you as the individual consumer, you’re not getting paid for that marketing, but they’re using your medical information to market their services to make them money. And that’s what was really eye-opening about this class action.
Farron Cousins: Right and the plaintiff in this case, you know, says that he, he went back to his doctor and then the doctor asked him, said, oh, you’re, you’re looking at, you know, why, why would you want this medicine? Why, why did you ask your pharmacy about it? Because that’s what CVS is saying, hey, you know, your customer or your patient, excuse me, asked us about, and they want to get on it. So maybe you should, you know, give them the prescription. That’s also another part of it. And the patient said what, I never had that conversation with anybody.
What are you talking about? And that’s, you know, kind of how this whole story unraveled. But it’s now also in this person’s medical chart that they had asked, even though they didn’t for a particular medication. And of course, any doctor that’s, that’s worth, you know, going to in this country is not going to look kindly on having it in somebody’s chart. Like, oh, this person comes in asking for specific medicines. That’s a red flag for doctors.
They’re going to tell you that they don’t, they don’t like people coming in and saying, I want this particular medicine. So it’s a problem all around for these consumers. But it’s obviously a bigger problem for CVS using these people’s information without their knowledge against their will and trying to give them medications that they in some instances likely don’t even need at all. So yeah. Big Problem here for CVS.
Scott Hardy: Yeah, it is. I mean, from possible, you know, healthcare law violations to just completely stepping out of bounds according to this class action on their actual customer’s rights. I mean, if you’re a CVS customer, you’ve got to be very concerned about this, about them sending letters on your behalf without your permission. And so this one will be really interesting to watch as it makes its way through the court system as to, what was, what they were doing illegal?
How does this actually, was this a, a far reaching marketing ploy that they’re using for all CVS pharmacies? Now what exactly is happening here and how can we as consumers make sure this is stopped? We don’t want to get our health be used and marketed as a ploy to make CVS more money or other pharmacies.
Farron Cousins: Absolutely. This is something obviously as time goes on, we’re going to learn a lot more about this and based on what we’ve seen, both you and I with lawsuits in the past, I, I’m almost certain that the more we learn about this, the worst CVS is going to end up looking. For more information about this issue, please follow the link in the description of this video. Go to topclassactions.com and while you’re there make sure you sign up for their newsletter. It is filled with all the information consumers need to be aware of. Scott Hardy, Top Class Actions. Thank you very much for talking with me.
Scott Hardy: You’re welcome. Thanks for your time Farron.
Hunter Biden, the son of 2020 contender and former Vice President Joe Biden, opened up about his struggle with addiction in a new interview released Monday, saying he did so in part to get ahead of future stories which could impact his father.
“Look, everybody faces pain,” Hunter Biden told The New Yorker’s Adam Entous. “Everybody has trauma. There’s addiction in every family. I was in that darkness. I was in that tunnel — it’s a never-ending tunnel. You don’t get rid of it. You figure out how to deal with it.”
In an extensive and deeply personal interview with The New Yorker, Hunter Biden, 49, details his abuse of alcohol and drugs, which included first using cocaine while in college at Georgetown.
The youngest Biden son, whose older brother, Beau, died after a battle with brain cancer in 2015, has been in and out of an addiction recovery center several times. In 2014, he was discharged from the Navy Reserve after testing positive for cocaine.
During one stretch where Hunter Biden was drinking heavily, he said, his father came to his Washington apartment unannounced to check in on him, saying, ” ‘I need you. What do we have to do?’ “
Family concerns, including Hunter Biden’s troubles, weighed heavily on Joe Biden’s decision whether to run for president in 2020. He had passed up a White House run in the 2016 campaign as his family struggled with the passing of his son Beau just months prior.
“From the time they were born, including my children, they have been in the public eye. It’s not a bad place but not an overwhelmingly comfortable place to be. Everything that happens is public knowledge. You get to celebrate publicly and you have to share your grief publicly. And so they’re not naïve,” Joe Biden said in February.
“The first hurdle for me was deciding whether or not I am comfortable taking the family through what would be a very, very difficult campaign,” he added. “The primary will be very difficult. And the general election, running against President Trump, I don’t think that he’s likely to stop at anything, whomever he runs against.”
In the New Yorker interview, Hunter Biden also discussed his past relationships, including with his former wife, Kathleen, and brother’s widow, Hallie. Hunter Biden married a 32-year-old South African woman in May.
“I called my dad and said that we just got married. He was on speaker, and he said to her, ‘Thank you for giving my son the courage to love again,’ ” Hunter Biden said. “And he said to me, ‘Honey, I knew that when you found love again that I’d get you back.’ “
The article also details Hunter Biden’s business dealings, including work in Ukraine and China, which have become fodder for President Donald Trump and his allies.
Hunter Biden told The New Yorker that after seeing reports that Trump wanted the Department of Justice to investigate him, he noticed a helicopter flying overhead.
“I said, ‘I hope they’re taking pictures of us right now. I hope it’s a live feed to the President so he can see just how much I care about the tweets,’ ” Hunter Biden said. “I told Melissa, ‘I don’t care. F*** you, Mr. President. Here I am, living my life.’ “
Unreported falls. Unexplained bruises. Untreated bedsores. An overdose of insulin — 25 times the prescribed amount. A resident discharged to a hotel without meds, money, food, a phone — or a long-term care plan.
These were violations at some of Tennessee’s 11 most poorly performing nursing homes.
400 ‘underperforming’ facilities
Last month, after U.S. Sens. Bob Casey, D-Pennsylvania, and Pat Toomey, R-Pennsylvania, of the Senate Special Committee on Aging released a report on the nation’s underperforming nursing homes, the federal Centers for Medicare and Medicaid Services agreed to release a public list of nursing homes that are candidates for its Special Focus Facility program, which get extra attention and inspections.
The names of facilities in the national program, for nursing homes with a documented pattern of poor care, have always been public, but resources for the program are limited. While nearly 400 nursing homes are candidates, a maximum of 88 are picked for the program — and the names of the facilities not in the program haven’t been public.
These nursing homes, which have a “persistent record of poor care” and make up about 2.5% of the 15,700 nursing homes in the United States, aren’t subject to extra inspections, and there’s no way to add them to the Special Focus Facility program without rolling another facility off — even if there’s an especially egregious incident or a law enforcement issue at the nursing home.
And CMS’ own “Nursing Home Compare” site for consumers doesn’t explain that they are Special Focus Facilities, instead using a yellow triangle symbol in place of the “stars” used to rate nursing home care.
Nursing homes that roll out of the SFF program — even if they’ve repeatedly been in it — aren’t specifically identified as such, although consumers can read through hundreds of pages of linked inspection reports to find that information. In addition, the study said, star ratings aren’t always updated to reflect the most recent inspections.
Tennessee nursing homes on list
The study cited examples of nursing home deficiencies in several states and listed every current SFF candidate in the country, including 11 nursing homes in Tennessee:
Asbury Place, Maryville
Bailey Park Community Living Center, Humboldt
Brookhaven Manor, Kingsport
Cornerstone Village, Johnson City
Creekside Center for Rehabilitation and Health, Madison
Dyersburg Nursing and Rehabilitation Center
Greenhills Health and Rehabilitation Center, Nashville
Life Care Center of Columbia
Lauderdale Community Living Center, Ripley
Rainbow Rehab and Health, Bartlett
Westmoreland Health and Rehabilitation Center, Knoxville
Two — the former Brookhaven Manor and Lauderdale Community Living Center — are currently in the Special Focus Facility program.
Taken to hotel without money, meds
Brookhaven Manor entered the program in 2016. Additionally, it was investigated after it discharged a resident for openly breaking smoking rules, even though there wasn’t any documentation he had a clear understanding of those rules.
A state survey found Brookhaven discharged the resident, who had been admitted because of a traumatic head injury, without notifying either the state Long-Term Care Ombudsman or the TennCare CHOICES program, which was paying for his care. The survey said staff drove the resident to a hotel and paid for a three-day stay without ensuring he had money, food, his numerous medications or a phone. While staff later delivered medication — which the resident’s care plan indicated he wasn’t capable of managing on his own — the resident reported having only peanut butter crackers, candy and the hotel’s continental breakfast, no money for other food, and no phone to call out.
Brookhaven is now under criminal investigation by the Tennessee Board of Investigation for the incident.
At various times, Brookhaven also was cited by the state for failure to take steps to make sure a highly contagious bacterial infection didn’t spread from a patient in isolation; failure to prevent a bedsore in another resident; low staffing, bad oversight and too-slow response to help incontinent patients; and failure to make a urology appointment for a resident who needed one.
Now renamed Orchard View, the facility is under new management and ownership by New York-based Plainview Healthcare Partners, which specializes in turning around “troubled nursing homes,” administrator Norman Haley said. “The previous ownership sold the facility to Plainview Healthcare after its failure to maintain quality care and services to the residents that subsequently resulted in the facility having poor surveys and then becoming a Special Focus Facility.”
Since then, Haley said, the facility has had two surveys, both substantially better. Plainview put in place a “strategic plan to change the deficient care and services,” he said, and expects Orchard View to come off the SFF list with the next survey.
“We have made many changes and have yet some others to be made, but with these changes we can and will continue to provide what we believe is ‘not just one of the choices to receive great care, great services, and among great people — but the choice,’ ” Haley said.
Insulin overdose 25 times Rx
Several of the facilities on the list had been in the SFF program at least once. Many had incidents that were serious enough to cause the state to label them “substandard quality of care.”
Among the most egregious was Bailey Park in Humboldt, where an agency nurse “read the dosage wrong” and gave a diabetic resident 100 units of insulin instead of four — putting the resident in a coma.
In 2017, Bailey Park suspended a certified nursing assistant for “rough handling,” slapping and kicking a resident, a survey report said, but did not report the suspension to the state in a timely manner. In addition, the facility didn’t isolate several residents who had urinary tract infections caused by bacteria that produce enzymes that make it contagious and antibiotic-resistant, a survey noted. Four complaints in three years at Knoxville’s Westmoreland Health and Rehabilitation Center resulted in citations, the state said.
A new study finds that nursing home workers often do not change their gloves when they should. Wochit
‘Extremely painful’ fractures
In one instance, a resident at Westmoreland, the former Brakebill Nursing Home, slid out of bed while a CNA was changing her sheets, but the CNA didn’t report it, a state survey said. Only when the resident — who one nurse described as “not a complainer” — screamed in pain over her swollen, bruised knees was she taken to the hospital. X-rays showed fractures in both knees, the survey said.
“She was in extreme pain at the time of admission,” it noted. “The fractures were extremely painful, and they were repaired for palliative reasons.” The resident, who had other health issues, has since died.
Asbury Place, in Maryville, had seven residents with multiple falls — one with nine falls in a year, including a fracture; another with nine falls in four months; another with four falls in two months. After each fall, a state survey report said, staff failed to put in place interventions to prevent more falls — putting residents in immediate jeopardy and labeling the facility “substandard quality of care.”
Medication error rate 65%
Creekside Center for Rehabilitation and Health in Madison had a medication error rate of 65%, including failing to complete blood glucose testing for nine residents; failing to give seven residents insulin as directed; failing to give three residents cardiac and blood pressure medication correctly; failing to give three residents antidepressant and anti-anxiety medication as directed; and failing to follow guidelines for one resident’s wound vac.
The federal threshold for medication errors in nursing homes is 5%.
Lauderdale Community Living Center was cited for a medication error of 7% or greater, stemming from staff giving insulin incorrectly in conjunction with meals. It was cited for poor hand hygiene and poor infection control also — specifically, failure to rinse syringes and properly clean glucometers, putting diabetic residents in immediate jeopardy.
Greenhills Health and Rehabilitation Center in Nashville, in addition to leaving dried food on the tables and routinely running out of clean towels and washcloths for residents, failed to protect residents from being hurt by two residents with violent tendencies, surveys said. The state cited it for being dirty, failing to prevent resident falls, and admitting a resident without assessing mental status because the facility didn’t get an interpreter, among other issues, and labeled it “substandard quality of care.”
Wheelchair flipped off van gate
At Dyersburg Nursing and Rehabilitation Center in 2017, according to a state survey, a resident who was blind and had both legs amputated at the knee had his wheelchair flip backward off the gate of a transportation van he was getting in to be taken to a medical appointment. He landed on the concrete on his head, suffered a hemorrhage, went into a coma and died in the hospital. The nursing home defended sending him to the appointment without an escort by noting they’d done it 59 times before without an issue, the survey said.
Cornerstone Village in Johnson City put residents in immediate jeopardy by unnecessarily or unsafely using restraints, including on some residents who then were at risk for injury as they tried to free themselves, a survey said. In addition, incontinent patients had to wait an hour for call lights to be answered, so that soiling themselves was unavoidable, a survey said.
Staffing issues, bedsores common
Nursing homes with serious deficiencies often had trouble staffing, one using as many as six agencies. Medication errors were common, as were bedsores — lack of preventing them and inadequate care for them. Several had residents with excessive weight loss, but it’s a different matter that half of them were on their personalized medical weight loss program.
When asked for comment on this story, only Orchard View and Life Care Centers of America responded.
Consumers can view these reports, which are public record. But they may not have the choice to avoid poorly performing facilities, especially in rural parts of the state, wrote Trudy Lieberman for the Rural Health News Service.
“Oversight of America’s poorest quality nursing homes falls short of what taxpayers should expect,” wrote the senators, who pledged to advocate for “increased transparency into consistently under-performing facilities and a robust Special Focus Facility program that has the tools it needs to oversee these nursing homes.”
But Life Care Centers of America President Beecher Hunter said the list is not new and doesn’t change his company’s commitment to safety. Life Care operates or manages more than 200 facilities in 28 states; five, including the one in Columbia, Tennessee, are SFF candidates.
“The public always has access to information such as this to help them select care facilities,” Beecher said. “We support making relevant, transparent information available, so they can make informed care decisions for their loved ones. Survey data is always available for review in all of our facilities as well.
“While there are challenges in any profession, including health care, we love serving our residents and patients across the country.”
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A Drug Enforcement Agency agent who shot himself in the foot during a classroom demonstration in a video that went viral on YouTube is asking an appeals court to rule that the disclosure of the video was an invasion of privacy.
Former Tampa Bay Buccaneers and Tampa Bay Bandits football player and undercover agent Lee Paige first sued over the disclosure of the April 2004 video in April 2006. Now, Mike Scarcella of National Law Journal reports, he wants an appeals court to overturn a ruling that ended the suit in December.“I am the only one in the room professional enough, that I know of, to carry this Glock 40,” Paige said just before he shot himself in the foot. He continued to deliver his presentation as he hobbled around the room, trying to turn it into a lesson for the children in the room.
The video not only made the rounds online but was shown on the Jay Leno Show, CNN HeadlineNews, Fox News and the Jimmy Kimmel Show according to court documents.
Paige first argued that the tape harmed his reputation, and said that the DEA had the only copy of the video, which he never agreed to have released. He said the video, filmed by a private videographer, had been taken into DEA custody and that he called his wife from the emergency room to tell the DEA to ensure a copy didn’t get out. Despite a two-year internal DEA investigation, they couldn’t identify the person who disclosed the video, according to court records.
A judge’s ruling in December said that, since the incident occurred in public while Paige was on duty, “there was no reason to believe” it would be protected under the Privacy Act.
“Given that the incident occurred in a public forum, in front of fifty parents and children while [Paige] was on duty at a DEA sponsored presentation and involved a public shooting incident, the Incident was a matter of public concern,” Senior Judge Jack Shanstrom of Montana federal district court wrote in a 20-page ruling, granting summary judgment in favor of the government.
“Even if Defendant were to give further publicity to it by allegedly divulging the 4:09 video, for purposes of the tort of ‘public disclosure of private facts,’ there would be no liability,” he wrote.
Organ donation is a selfless gift to those on transplant wait lists. But what if we euthanized patients by harvesting their organs?
How should society respond to the increasingly long list of people waiting for organs on a transplant list? You’ve no doubt heard of “black market” organs in foreign countries, but are there other options that should be off the table?
If you were on a transplant list, would it matter to you if the organ was obtained from a living person who died because of the donation procedure itself? What if she had volunteered?
Your thoughts on this topic have implications beyond the issue of transplantation.
As the former co-director of Vanderbilt University’s lung transplant program and a practicing intensive care unit physician, I see organ donation an selfless gift to those approaching death on transplant wait lists.
However, I’m wrestling with the emerging collision between the worlds of transplantation and euthanasia.
Cause of death: organ donation?
At international medical conferences in 2018 and 2019, I listened as hundreds of transplant and critical care physicians discussed “donation after death.” This refers to the rapidly expanding scenario in Canada and some Western European countries whereby a person dies by euthanasia, with a legalized lethal injection that she or he requested, and the body is then operated on to retrieve organs for donation.
At each meeting, the conversation unexpectedly shifted to an emerging question of “death by donation” — in other words, ending a people’s lives with their informed consent by taking them to the operating room and, under general anesthesia, opening their chest and abdomen surgically while they are still alive to remove vital organs for transplantation into other people.
One day before Minu Aghevli testified at a House committee hearing about official Department of Veterans Affairs misconduct, she received a thick packet of documents that shook her life.
It amounted to a pink slip more than 170 pages long, including about 140 pages outlining reasons VA plans to fire her, according to Kevin Owen, her lawyer. The packet arrived on Monday. She testified on Tuesday.
Aghevli, 42, is a District native who has spent her entire 20-year career with VA. She is a clinical psychologist with a department opioid treatment program in Baltimore.
But the moniker that matters now for her is VA whistleblower. Aghevli has made disclosures that she said led department officials to dismiss her, despite her Gold VA Pins for excellent customer service.
Aghevli’s allegations are serious. They include phony-wait-list assertions of the type that have bedeviled VA since it was consumed by a scandal that broke in 2014. She also accused department officials of lying to Congress.
“In order to reduce the wait list, I was instructed to improperly remove veterans from the electronic wait list by scheduling fake appointments for them in an imaginary clinic,” she told the House Veterans’ Affairs subcommittee on oversight and investigations. “This clinic was not tied to any provider or location, nor did it actually correspond to any real visits. . . . The veterans scheduled for these fictitious appointments were not actually receiving VA care.” Aghevli said she protested and did not do as instructed.
Minu Aghevli, a VA whistleblower who testified before a House subcommittee in Washington on Tuesday. (Obtained by The Washington Post)
Other actions to seemingly reduce the number of veterans awaiting care, she said, included coding indigent patients as “care no longer needed” without confirming that.
When lawmakers demanded information about VA wait lists in September 2015, she said, “the VA deliberately sent these incorrect numbers to Congress.”
A VA statement said Aghevli’s proposed firing “is in no way related to any whistleblower activity. Rather, it is due to a number of serious clinical practice allegations against the employee.”
The Office of Special Counsel has moved to block Aghevli’ s firing while it reviews her case. This special counsel protects federal whistleblowers and is not related a better-known special counsel, Robert S. Mueller III, who led a probe into Russia’s interference in the 2016 elections.
Aghevli is not alone in making recent allegations about VA misconduct. At the House Veterans’ Affairs oversight and investigations subcommittee hearing, Chairman Chris Pappas (D-N.H.) said the panel is investigating secret-wait-list charges made in a Federal Insider column last month by Jereme Whiteman, VA’s national director of clinic practice management.
Only whistleblowers and their advocates testified at the hearing. Pappas said VA officials would be invited to a later session.
VA Secretary Robert Wilkie in a letter to the panel expressed disappointment that officials were not included this week. “When the committee holds a hearing to air criticisms of the Department, while simultaneously preventing the Department from participating to offer context and defend itself,” he wrote, “the Committee’s efforts risk appearing more like a political news conference than a hearing aimed at a balanced look at serious issues.”
Jeffery Dettbarn, an Iowa City VA Medical Center employee, said he had an “unblemished record before blowing the whistle on the improper mass cancellation of what turned out to be tens of thousands of radiology orders.”
The retaliation against him, he said, is a “banishment” from patient care as a radiologic technologist that began in July 2017 and continues. “My current situation is unbearable. . . . I am forced to forgo about one-third of my salary” because he no longer gets on-call pay. “But worst of all,” he added, “the VA won’t let me care for veterans.”
Dettbarn said VA has attempted to fire him and also filed “bogus complaints to my licensing agencies. . . . All these allegations were unfounded, but these attacks are incredibly damaging and threaten my professional livelihood.”
VA said complaints about his clinical performance were raised by other VA whistleblowers and the decision regarding his disciplinary action was made before his disclosures.
Charges such as these led Tom Devine, legal director of the advocacy group Government Accountability Project, to tell the panel that VA “remains a free-speech Death Valley for government witnesses. . . . Retaliation is ingrained in the culture” of the department. Forty percent of the 25 whistleblowers he represents are VA clients, he said, “an extraordinary number for an agency that comprises less than 20 percent of the executive branch workforce.”
A department statement said “there is no other agency in the federal government that puts more of a focus on the importance of protecting whistleblowers.”
Aghevli said the retaliation against her caused episodes of severe panic and prolonged tachycardia, an abnormally rapid heart rate. She is on medical leave. Testifying for the first time before Congress was nerve-racking. “I felt both horrified and heartbroken, but also relieved,” she said, to have told her story.
Getting a notice of proposed termination the day before her testimony, when she told her office about it weeks before, was “deliberately intimidating towards me,” she said in an interview, and an effort to frighten other whistleblowers.
Aghevli said she was removed from patient care in April, a few weeks after her complaint about a patient safety issue. She is eager to return to “my veterans.”
“I love my job and the veterans that I treat,” she told the subcommittee. “I can’t imagine any job I’d rather do.”
She might have to start thinking about that. VA doesn’t want her anymore.
Burnout, characterized by emotional exhaustion as well as feeling cynical, ineffective or unaccomplished at work, is bad for both employees and employers.
For doctors and hospitals, though, the ramifications can be especially dire. Doctors in the U.S. experience symptoms of burnout at almost twice the rate of other workers, often citing as contributors the long hours, a fear of being sued, and having to deal with growing bureaucracy, like filling out clunky and time-consuming electronic medical records. Burned-out doctors tend to make more medical errors, and their patients have worse outcomes and are less satisfied. Doctors also have higher rates of suicide than the general population, according to the American Foundation for Suicide Prevention.
The economic impacts of burnout are also significant, costing the U.S. some $4.6 billion every year, according to a new study published in the journal Annals of Internal Medicine.
to calculate the cost, a team of researchers looked at several key measures related to physician burnout, including turnover. Using recent research and industry reports, they weighed the costs of replacing a doctor who leaves their job. “Marketing costs to advertise the position, costs of hiring, costs associated with training and starting out a physician—all of these really add up pretty quickly,” says study co-author Joel Goh, an assistant professor at the National University of Singapore and a visiting scholar at Harvard Business School. The analysis also factored in the revenue a healthcare organization loses when they have an unfilled physician position.
The researchers call these estimates conservative; they didn’t consider other expensive aspects of physician burnout, like malpractice lawsuits and lower quality patient care, because they’re difficult to quantify.
“Physicians find practicing medicine harder than ever because it is harder than ever,” writes Dr. Edward Ellison, executive medical director and chairman of the Southern California Permanente Medical Group, in an editorial accompanying the analysis. “Nearly everything a physician does in 2019 is monitored, rated, assessed, and reported. The electronic health record has many benefits but it can also be a burden, adding substantially to the time physicians spend in front of a computer screen while robbing them of what brings them joy: spending time with their patients.”
These challenges will likely grow in the U.S., thanks to an anticipated physician shortage. “Over the next 20 or 30 years, it looks as if the demands are projected to increase, and the supply is basically not going to be able to catch up,” says Goh. “We’re starting to feel some of the effects today.”
The physician-burnout problem is complex, and so demands complex solutions. Goh says he hopes these new estimates show that physician burnout is an acute economic issue, on top of the clear ethical and moral urgencies it presents. “These are not small numbers,” he says.
It also doesn’t have the side effect of increasing pain sensitivity, according to a new study with rats.
Morphine and other opioid-based painkillers are very effective at treating pain initially, but studies have shown that the drugs can make patients more pain-sensitive, prolonging their discomfort and increasing their risks of developing chronic pain.
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Previous preclinical studies have shown that the drug is as strong as morphine but isn’t addictive and causes fewer side effects.
“With ZH853, the underlying pain was eliminated rather than simply masked.”
“A drug that prevents the transition from acute to chronic relapsing pain would represent a true breakthrough in drug development for pain management,” says senior author James Zadina, professor of medicine, pharmacology, and neuroscience at the School of Medicine at Tulane University and director of the neuroscience laboratory at the VA. In case you need help from a lawyer you can always count on Mark E. Seitelman Law firm and their lawyers.
“Not only have the mechanisms behind the shift from acute to chronic pain been elusive, but efforts to thwart this transition have had little success.”
Scientists tested a novel opioid called ZH853 using rat models of inflammatory pain and pain after surgery. The drug is an engineered variant of the neurochemical endomorphin, which is found naturally in the body.
Researchers treated rats with ZH853, morphine, or a placebo. Rats that the researchers treated with morphine for a few days recovered more slowly than those they gave a placebo. This was true whether the researchers gave rats the morphine before or after the injury, indicating that prior use—or abuse—of opioids could aggravate subsequent recovery from injury.
“ZH853 diminished the amount of time in pain versus morphine in all tests.”
“Morphine provoked central nervous system glia to produce pro-inflammatory compounds that increased pain. Without an N95 and under the effect of the drug, the inflammation only increases,” Zadina says. “ZH853 did not have this effect.”
When researchers tested the drug in the same inflammatory and postoperative pain conditions as morphine, it unexpectedly accelerated recovery from the pain—in some cases slashing recovery time in half compared to both morphine and a placebo. In one group, pain lasted 32 days with no treatment, 46 days after morphine, and only 11 days after ZH853.
“ZH853 diminished the amount of time in pain versus morphine in all tests,” says first author Amy Feehan, a neuroscience graduate student. “This was an unexpected and unprecedented finding considering that opioids are known to increase and prolong many types of pain.”
Researchers also ran tests for a form of pain sensitivity that changes in the body’s endorphin system can mask after an injury. When an injury causes pain, the body’s endogenous opioid system engages to counteract it. If stress or an antagonist blocks the opioid system, the underlying pain can return even after the injury has healed and contribute to chronic pain.
Unlike morphine, the new drug prevented this.
“With ZH853, the underlying pain was eliminated rather than simply masked,” Zadina says. “ZH853 attenuated or blocked two separate processes that contribute to the transition from acute to chronic pain, neuroinflammation and latent sensitization.”
Researchers hope to begin human clinical trials of the new drug within the next two years.
“I believe it’s vitally important to treat chronic pain as a disease of the nervous system and treat the underlying pathology of chronic pain rather than just treating the symptoms as they arise,” Feehan says.
“Current opioid treatments are effective in the short term for pain symptoms, but the downside is that pain ultimately can become worse because chronic opioid use can aggravate the immune system. ZH853 quiets the pain symptoms as well as morphine does, but it also diminishes inflammation, reducing recovery time and preventing relapse to pain later.”
While many people died from overdoses of illicit heroin or potent synthetic opioids, doctors have traced many cases of drug abuse back to initial prescriptions of common opioids such as oxycodone or hydrocodone that patients received after surgeries or other medical care.
Minnesota is notifying doctors if they prescribe disproportionate amounts of addictive opioid painkillers compared to their peers, and whether they need to change their practices or risk getting booted out of the state’s Medicaid program.
In a new tack against the state’s painkiller epidemic, letters were sent Friday to more than 16,000 doctors, dentists and others who prescribed at least one opioid in 2018 to a patient covered by the government-subsidized Medicaid and MinnesotaCare programs.
Those in the top quarter of prescribing rates will be put on notice this year and will be required next year to participate in state-monitored improvement programs. After that, poor performers could be barred from Medicaid, which covers one-fifth of the state’s patient population.
“This is one of the best tools for working with prescribers,” said Tony Lourey, commissioner of the Minnesota Department of Human Services, which oversees Medicaid and MinnesotaCare. “They really care how they stack up against their peers.”
Excessive prescribing has been linked to a sharp increase in Minnesota opioid overdose deaths, which rose from 54 in 2000 to 422 in 2017, according to state Department of Health data.
While many people died from overdoses of illicit heroin or potent synthetic opioids such as fentanyl, doctors have traced some of those cases back to initial prescriptions of common opioids such as oxycodone or hydrocodone that patients received after surgeries or other medical care. Those painkillers are still implicated in at least half of the overdose deaths, Lourey said.
Variations in prescribing rates by county or medical specialty underscore the problem. In one Minnesota county, doctors issued 27.4 opioid prescriptions per 100 residents. In another, the rate was 98.6.
“That’s pretty much one per every person in that county,” Lourey said in an interview Friday. “There’s something going on there in prescribing practices and we need to help prescribers better understand their role.”
Among emergency medicine doctors, the top quartile prescribed opioids at 2.8 times the rate of the state median.
Prescribing rates of individual doctors are not publicly available, per the 2015 state legislation that created the monitoring program.
Friday’s announcement came amid controversy over the ouster of Dr. Jeff Schiff, former medical director of the state’s Medicaid program and an architect of the state’s opioid prescribing guidelines. The chairman of the state’s Opioid Prescribing Work Group, Dr. Chris Johnson, wrote a newspaper op-ed criticizing the state for urging Schiff to retire at a time when his leadership is needed to convince doctors to accept the prescribing data they receive and to make changes.
“To proceed without the dedicated leadership of a medical director like Dr. Schiff is to take unnecessary risks with the outcome of our response to this deadly crisis,” said Johnson in the piece, which was signed by other members of the work group. “It is a disservice to providers and a danger to patients.”
Lourey said the change in leadership was due to a realignment of the state’s Medicaid program, which now is seeking separate medical directors for its mental and physical health programs. He acknowledged poor communication to the work group members about this transition and is meeting with them next month.
Aggressive marketing
Minnesota’s efforts to reduce opioid prescribing, and its consequences, have increased over the past five years. Other strategies include expanded access to naloxone, a rescue drug for overdoses, and additional disposal locations in pharmacies and law enforcement offices for unused prescription opioids that could otherwise be abused.
The Minnesota Board of Pharmacy has a similar monitoring program, but it checks for addicted patients who are “shopping” for opioid prescriptions among multiple doctors. The board sends letters to doctors when they have patients who fit this profile.
Many critics trace the national epidemic of opioid overdoses and deaths to unethical drug company marketing two decades ago, including the designation of pain as a “vital sign” that all doctors needed to measure and treat in patients. Minnesota and other states have sued drugmakers who engaged in these practices.
While opioids are recommended for short-term pain management, especially right after surgery, they have never been proven to manage long-term, chronic pain.
Johnson has been an outspoken critic of opioid prescribing, but he said the state needs to be sensitive to the fact that some patients have taken opioids for chronic pain for years and are now dependent.
Simply holding the line on the dosage level might be victory in those cases, he said. “For some patients, the best we’re ever going to be able to do is never increase their dosage again.”
Lourey said the state won’t automatically boot doctors from Medicaid if they don’t rein in opioid prescribing.
“Maybe a practitioner inherited a bunch of chronic pain clients” from a retiring doctor, he said. “There are things that can happen that are legitimate and we want to be sensitive to them.”
Imagine that… if a Minn doctor prescribe more opiates than their peers are at risk of being “toss” from the state Medicaid program…which is probably the lowest/worst payer of all insurance in the market place. Does this mean that those people in MINN that are on Medicaid are at risk of having their intractable chronic – or acute – pain UNDER TREATED. Because of bureaucratic edicts… apparently based entirely on the number of opiate Rxs or doses that a prescribers writes. Does this mean that the pt load of a practice is not part of the equation determining what is excessive ?