Pain Clinics

Attached a great article from today's Miami Herald highlighting the issue of pain clinics and Buprenorphine use. The author points out that

"A Miami Herald review of 353 Suboxone-approved doctors in Miami-Dade, Broward and Palm Beach counties found at least 53 of them have been disciplined by state health officials or have been charged with a crime -- about one of every seven doctors."

This is a grave issue of concern!
Yours
Bernd

PS: Have a Happy New Year.




Posted on Tue, Dec. 29, 2009
South Florida pain-clinic doctors also treat drug addicts

BY SCOTT HIAASEN
shiaasen@MiamiHerald.com


CARL JUSTE / MIAMI HERALD STAFF
One of many pain clinics that have sprung up all over South Florida. In the past two years, the region has emerged as the pill-mill capitol of the United States.
State regulators stripped Dr. Michael I. Rose's power to write prescriptions two months ago, after health officials found that the pain-clinic doctor had prescribed enough painkillers to put one patient ``at risk of death from overdose.''
The health department findings are all the more alarming given the North Miami physician's other specialty: drug-addiction treatment.

Rose is one of at least 41 South Florida doctors who straddle the fence between two seemingly opposite disciplines: They treat drug addicts while at the same time giving pain patients addictive drugs that have been blamed for a spike in overdose deaths statewide. Rose declined to comment for this article.

Some of the same clinics offering addiction treatment are often targeted by out-of-state drug couriers seeking painkillers for an illicit black market stretching from South Florida to Appalachia and the northeastern United States.

Many of these doctors who serve as both pain and addiction specialists have been disciplined by state health officials for improper prescribing of drugs -- and some have been convicted of crimes, a Miami Herald review found.

Yet these doctors retain approval from the federal government to prescribe a narcotic called buprenorphine -- a drug used to help wean people addicted to opiates such as oxycodone.

Addiction experts say this mixing of two delicate medical fields has potentially dangerous consequences: Instead of receiving the therapy they need, addicts seeking to get off drugs may simply end up alongside users and drug peddlers who frequently skip from clinic to clinic seeking narcotics to be sold illegally.

`ADDED RISK'

``If you have an environment where you have drug access and availability, then you have an added risk,'' said Dr. Ihsan Salloum, an addiction psychiatrist with the University of Miami's Miller School of Medicine.

``Offering services of this kind is a slap in the face,'' said Dr. Bernd Wollschlaeger, an addiction specialist and past president of the Dade County Medical Association. He suspects many pain clinics are seeking not to help addicts but to boost profits by selling drugs used to curb dependency -- in addition to selling large amounts of potent painkillers.

``It's just a fig leaf to conceal their true nature,'' Wollschlaeger said. ``These pain clinics are pure and simple pill mills. Their goals are pushing huge volumes of prescription pills.''

Clinics offering both pain medications and addiction treatment can also present difficulties for police investigating pill trafficking. Under federal law, doctors approved to provide addiction drugs are afforded special protection from narcotics investigators. Agents need a court order from a federal judge before pursuing undercover investigations of these doctors.

Over the past two years, South Florida has emerged as the pill-mill capital of the United States, the chief supplier of black-market painkillers that spawned an epidemic of overdose deaths in Kentucky, Ohio, West Virginia, Tennessee and other states.

The pills have flowed by the millions through storefront pain clinics that open up almost daily from Miami to Palm Beach County. Broward County alone has at least 115 pain clinics, and is home to 33 of the 50 doctors who dispense the most oxycodone in the country, according to U.S. Drug Enforcement Administration data.

Dozens of clinics entice patients with blaring advertisements in alternative newspapers, offering coupons and discounts and not-too-subtle appeals to out-of-state clients.

In the same ads, many clinics also promote treatment for drug addicts with Suboxone, whose primary ingredient, buprenorphine, is designed to help blunt the affects of heroin, oxycodone or other opiates.

Suboxone and similar drugs are considered highly effective for treating dependency and addiction. It's also proven safer than methadone, once commonly used to treat heroin addicts.

To encourage more addicts to seek treatment, federal regulators in 2002 began allowing doctors to dispense Suboxone from their offices -- unlike methadone, which must be administered in hospital or clinic settings.

But a doctor does not need to be a board-certified addiction specialist to distribute Suboxone. A doctor can receive approval simply by completing an eight-hour online course. About 17,000 doctors nationwide are approved to administer Suboxone, including almost 1,200 in Florida.

TREATMENT METHODS

Addiction experts and federal health officials warn that Suboxone should be given to patients along with counseling and other treatment methods -- methods rarely employed at many pain clinics, where pills are often the only remedy, critics say.

``Use of the medication in and of itself is not a substitute for full addiction treatment,'' said Dr. Louis Baxter, president of the American Society of Addiction Medicine. ``Some of these people that are advertising their services may not be certified, and may not be experienced to do what they say they can do.''

But some doctors say it can be difficult to get many addicts to attend counseling or psychological therapy, which is often more costly than Suboxone treatment.

``The No. 1 reason for someone coming in to do detox is that they can't afford their addiction,'' said Dr. James Milne, who offers both pain management and addiction treatment as part of his general family practice in Fort Lauderdale.

Milne said he believes the need for addiction treatment has increased with the explosion of pain clinics in South Florida. As many as half of his new patients come to him first seeking painkillers -- and many end up as addiction patients, he said.

``Some of these people convert there on the spot. They burst into tears and beg for help,'' he said.

At the Fort Lauderdale Pain Relief Center, the staff emphasizes its detoxification program to its pain patients who may feel they are becoming dependent on pills, said clinic attorney Sandy Topkin.

``They want people to get off these medications more than they want them on them,'' Topkin said.

Though buprenorphine is less dangerous than methadone, a patient could overdose or die if it is mixed with other drugs, Baxter said. The drug is sometimes sold illegally on the street as well, although it doesn't produce the highs of other drugs.

``You want to have it prescribed in legitimate settings, and these pain clinics are not legitimate settings. There is a high probability that they are using this medication inappropriately,'' Wollschlaeger said.

Records show many of the doctors working for South Florida pain clinics have no special certification in either addiction or pain management. And many of the doctors offering both services have troubling professional records.

53 DISCIPLINED

A Miami Herald review of 353 Suboxone-approved doctors in Miami-Dade, Broward and Palm Beach counties found at least 53 of them have been disciplined by state health officials or have been charged with a crime -- about one of every seven doctors.

Among those allowed to dispense drug-treatment narcotics are doctors disciplined for recklessly prescribing addictive drugs, including:

• Dr. Rachael Gittens of Wilton Manors. She was suspended for 90 days and fined $10,000 earlier this year after investigators found 33 blank prescriptions given to patients without including their names or addresses. At the time, Gittens was working at a pain clinic identified by Kentucky investigators as a prime source of illegal pills in that state.

• Dr. Robert Lentz of Lake Worth. He was fined $30,000 and placed on two years' probation earlier this month for prescribing ``very high dosages'' of painkillers to a patient without documenting the medical need. The health department found that Lentz increased the dosage of oxycodone when the patient should have been sent to addiction counseling, records show.

• Dr. Ricardo Sabates of Delray Beach. State health officials suspended his medical license in October for over-prescribing painkillers and anti-anxiety drugs to 10 patients, records show.

Federal officials say the law allows any doctor to prescribe Suboxone, regardless of any disciplinary history, as long as the physician has completed an eight-hour training course, and the doctor has a valid medical license and approval from the DEA to prescribe medications.

``If the physician has a license to practice medicine, we don't have the right to prevent them from prescribing Suboxone,'' said Nick Reuter, a senior policy analyst with the Substance Abuse and Mental Health Services Administration, a branch of the U.S. Department of Health and Human Services that oversees the Suboxone certification program.

The American Society of Addiction Medicine has pushed for greater scrutiny for doctors prescribing medications to drug addicts, and for doctors offering narcotics for pain management, Baxter said. For example, he said, some states like New Jersey require doctors to be board certified in pain management before they can dispense painkillers. Florida has no such requirement.

``There are some renegade physicians that are doing the medication harm by doing unregulated and unorthodox pain and addiction treatment,'' Baxter said.

Pain Clinics: Immediate Action Required

Attached two recent articles from the Miami Herald and Sun Sentinel highlighting the continuous and growing problem with pain clinics in South Florida.
I also witnessed a new phenomenon: one pain clinic in my area was finally shut down but reopened several days later calling itself "MedClinic" offering ALL medical services INCLUDING pain management. That means they will restart the SAME activities with the SAME management!! Its really frustrating! We have to focus on promoting tough measures as outlined in the grand jury recommendations. Therefore, I ask FSAM to issue a press release supporting the following recommendations and to contact the legislators asking them for their support.

The grand jury recommended to the Legislature 18 new reforms to curb the pain-clinic problem, including closing several loopholes the new state law failed to address. They include:

• Preventing pain clinics from distributing drugs on site until the state database is up and running next year.


• Limiting prescriptions from pain clinics to no more than a three-day supply.


Looking forward to your comments.
Yours
Bernd


Bernd Wollschlager,MD,FAAFP,FASAM
Member of the PRESCRIPTION DRUG MONITORING PROGRAM IMPLEMENTATION AND OVERSIGHT TASK FORCE





Posted on Fri, Nov. 20, 2009
Broward grand jury recommends pain clinic reforms

BY SCOTT HIAASEN
shiaasen@MiamiHerald.com

A Broward County grand jury issued a damning report Thursday bemoaning the explosion of illegal painkillers sold through Broward pain clinics -- and warning that reforms passed by the Legislature may not be enough.
Echoing a Miami Herald investigation earlier this year, the report details how lax state laws spawned a cottage industry of storefront pain clinics across South Florida, which have become the primary source of illegal painkillers in the eastern United States.

In just the past two years, the number of pain clinics in Broward County grew from four to 115, the grand jury found. In one six-month span, Broward pain-clinic doctors dispensed more than 9 million tablets of oxycodone, one of the most powerful and dangerous painkillers on the market -- far more than any other part of the country.

Addicts and drug peddlers routinely hop from clinic to clinic using bogus medical records to pass off fake injuries and obtain prescriptions -- a practice known as ``doctor shopping,'' the grand jury found. The proliferation of clinics attracts carloads of illegal drug buyers from other states, notably Kentucky, Ohio, West Virginia and Tennessee.

While some pain clinics offer legitimate medical services, most are ``rogue clinics putting out pills for cash,'' the report found.

``By the time law enforcement initiates and completes a successful investigation leading to the arrest of a doctor, user or dealer, several new clinics have opened,'' the report said.

WEAKNESSES

In response to the growing problem, state lawmakers approved a new law this spring placing pain clinics under greater scrutiny, and creating a database of prescription drugs sold, so prescribing doctors can better detect ``doctor shopping'' patients.

But the grand jury highlighted weaknesses in the law -- most notably, that the database program has no dedicated source of funding. State officials plan to seek grants to pay for the $4 million program.

The grand jury also criticized a section of the law that allows doctors to record prescriptions in the database within 15 days of their distribution. The grand jurors said drug traffickers could have come and gone by the time their prescriptions are recorded.

CLOSING LOOPHOLES

The grand jury recommended to the Legislature 18 new reforms to curb the pain-clinic problem, including closing several loopholes the new state law failed to address. They include:

• Preventing pain clinics from distributing drugs on site until the state database is up and running next year.

Many clinics advertise that they both prescribe and sell pills on site to attract clients -- another practice the grand jury would ban.

• Limiting prescriptions from pain clinics to no more than a three-day supply.

Clients at pain clinics typically receive a 30-day supply of drugs -- 150 to 240 tablets of oxycodone, often coupled with the painkiller roxycodone and anti-anxiety drugs such as Xanax -- after only one doctor's visit.

CRIMINAL RECORDS

• Barring people with criminal records from owning pain clinics. The Miami Herald investigation found several examples of clinic owners with criminal records, including the owner of a Boca Raton pain clinic who once pleaded guilty to possession of steroids with intent to sell.

• Limiting the number of pain-relief patients to 100 per clinic, and placing limits on the number of out-of-state patients a clinic may have.

Narcotics investigators have said that some pain clinics have as many as 65 patients per day. One Coral Springs doctor indicted on trafficking charges last year had nearly 500 patients from Kentucky.


======================================================================================================================


sun-sentinel.com/news/broward/flgrand-jury-pill-mill-20091119,0,1892598.story

South Florida Sun-Sentinel.com

Grand jury recommends pill mill cleanup

In two years, number in Broward jumped from four to 115, panel finds

By Scott Hiaasen, The Miami Herald

November 19, 2009


A Broward County grand jury issued a damning report Thursday bemoaning the explosion of illegal painkillers sold through Broward pain clinics — and warning that reforms passed by the Legislature may not be enough.

Echoing a Miami Herald investigation earlier this year, the report details how lax state laws spawned a cottage industry of storefront pain clinics across South Florida, which have become the primary source of illegal painkillers in the eastern United States.

In just the past two years, the number of pain clinics in Broward County grew from four to 115, the grand jury found. In one six-month span, Broward pain-clinic doctors dispensed more than 9 million tablets of oxycodone, one of the most powerful and dangerous painkillers on the market — far more than any other part of the country.

Addicts and drug peddlers routinely hop from clinic to clinic using bogus medical records to pass off fake injuries and obtain prescriptions — a practice known as "doctor shopping," the grand jury found. The proliferation of clinics attracts carloads of illegal drug buyers from other states, notably Kentucky, Ohio, West Virginia and Tennessee.

While some pain clinics offer legitimate medical services, most are "rogue clinics putting out pills for cash," according to the report.

"By the time law enforcement initiates and completes a successful investigation leading to the arrest of a doctor, user or dealer, several new clinics have opened," the report said.

In response to the growing problem, state lawmakers approved a new law this spring placing pain clinics under greater state scrutiny, and creating a database of prescription drugs sold, so prescribing doctors can better detect "doctor shopping" patients.

But the grand jury highlighted weaknesses in the law — most notably, that the database program has no dedicated source of funding. State officials plan to seek grants to pay for the $4 million program.

The grand jury also criticized a section of the law that allows doctors to record prescriptions in the database within 15 days of their distribution. The grand jurors said drug traffickers could have come and gone by the time their prescriptions are recorded.

The grand jury recommended to the Legislature 18 new reforms to curb the pain-clinic problem, including closing several loopholes the new state law failed to address. They include:

Preventing pain clinics from distributing drugs on site until the state database is up and running next year. Many clinics advertise that they both prescribe and sell pills on site to attract clients — another practice the grand jury would ban.

Limiting prescriptions from pain clinics to no more than a three-day supply. Clients at pain clinics typically receive a 30-day supply of drugs — 150 to 240 tablets of oxycodone, often coupled with the painkiller roxycodone and anti-anxiety drugs such as Xanax — after only one doctor's visit.

Barring people with criminal records from owning pain clinics. The Miami Herald investigation found several examples of clinic owners with criminal records, including the owner of a Boca Raton pain clinic who once pleaded guilty to possession of steroids with intent to sell.

Limiting the number of pain-relief patients to 100 per clinic, and placing limits on the number of out-of-state patients a clinic may have. Narcotics investigators have said that some pain clinics have as many as 65 patients per day. One Coral Springs doctor indicted on trafficking charges last year had nearly 500 patients from Kentucky.

Governor Crist Appointment

Governor Crist appoints Past FSAM President to the Prescription Drug Monitoring Program Implementation and Oversight Taskforce.



http://www.flgov.com/release/11150

GOVERNOR CRIST APPOINTS NINE TO THE PRESCRIPTION DRUG MONITORING PROGRAM IMPLEMENTATION AND OVERSIGHT TASK FORCE

November 12, 2009

Contact:

GOVERNOR'S PRESS OFFICE
(850) 488-5394

TALLAHASSEE – Governor Charlie Crist today announced the following appointments:

Prescription Drug Monitoring Program Implementation and Oversight Task Force

· Andre Benson, 62, of Tampa, physician, Operation PAR Inc., appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Lora “Lorrie” Brown, 44, of St. Petersburg, pain physician, Coastal Orthopedics, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Kristen Cortes, 45, of Panama City, Florida Department of Law Enforcement agent, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· David Craig, 41, of Tampa, clinical pharmacist specialist, H. Lee Moffitt Cancer Center and Research Institute, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Joel Kaufman, 57, of Ft. Lauderdale, vice president, United Way of Broward County, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Nilesh Patel, 45, of Bradenton, interventional pain management physician, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Donnie Reynolds, 41, of Weston, chief operating officer, Automated Healthcare Solutions, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Paula “Pepper” Wakeland-Hewitt, 60, of Sarasota, pharmacy manager, Davidson Drugs, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

· Bernd Wollschlaeger, 51, of Miramar, self-employed primary care physician, appointed for a term beginning November 12, 2009, and ending July 1, 2012.

JCAHO and Screeing Issues

Attached an important e-mail and message from our ASAM Regional Director.
We must make every effort to submit our comments.
Yours
Bernd


=============================================================================
Richard Soper wrote:
>
>
>
>
> Richard Soper wrote:
>
> Chapter Presidents and colleagues;
>
> Last year, the Joint Commission on the Accreditation of Hospitals (JCAHO) called for comments on whether it should create standards for tobacco, alcohol and drug screening and referral for all hospitals. Many of us then wrote to the Joint Commission with our comments. Our efforts were successful. JCAHO has now published a set of proposed standardsfor tobacco, alcohol and drug screening, brief intervention, referral and treatment.
> In my view, publication and adoption of these standards is a fundamentally important recognition that alcohol, tobacco and other drug problems should be identified and treated in all hospital patients as a routine part of care. If adopted, the tobacco, alcohol and drug reporting standards would be among those that hospitals can select for monitoring their own quality and performance.
> Hospital administrators, boards and staff will know what they should be doing about tobacco, alcohol and drugs to help their patients get better.
>
> I am urging all of you to take personal action to achieve the final step in this long journey:
>
> Getting the draft standards adopted.
>
> Please do two important things now:
> 1. Submit Your Comments Online.The Commission has invited public comment until September 30, so you really need to do this NOW.
>
> You will find an online survey formthat asks whether you believe the proposed standards will improve patient care, are clear enough to be implemented, and meet other JCAHO goals for its hospital standards. Your answers will have an impact on whether the standards are adopted. There is a link to full text of the standards on the first page of the survey, and you can also read Join Together's recent feature story summarizing the proposal.
>
>
> 1. Send this Message To other ASAM members, a Colleague, friend. We need as many voices from the field as possible supporting SBI as the routine standard of care. Tell your colleagues about this major opportunity to affect the health care of millions of Americans.
> 2. WE can continue to make a difference and have impact of formation of policy with our combined efforts to guide this process.
>
> Onward,
>
> Rich Soper, JD, MD, FASAM

Updated Directory of Drug and Alcohol Abuse Treatment Programs Now Available

*FOR RELEASE:* *Contact: SAMHSA Press Office (240) 276-2130* August 6, 2009 http://www.samhsa.gov



*Updated Directory of Drug and Alcohol Abuse Treatment Programs Now Available*



A new, updated guide to finding local substance abuse treatment programs is now available from the Substance Abuse and Mental Health Services Administration (SAMHSA). *"National Directory of Drug and Alcohol Abuse Treatment Programs 2009"* provides information on thousands of alcohol and drug treatment programs located in all 50 states, the District of Columbia, Puerto Rico, and five U.S. territories.



The National Directory includes a nationwide inventory of public and private substance abuse and alcoholism treatment programs and facilities that are licensed, certified, or otherwise approved by substance abuse agencies in each state. The National Directory is organized in a state-by-state format for quick reference by health care providers, social workers, managed care organizations, and the general public and provides information on more than 11,000 community substance abuse treatment

programs.



The directory provides important information on levels of care and types of facilities, including those with programs for adolescents, persons with co-occurring substance abuse and mental disorders, individuals living with HIV/AIDS, and pregnant women. In addition, information is available on forms of payment accepted, special language services available with select providers, and whether methadone or buprenorphine therapy is offered.



The updated directory complements SAMHSA's internet-based *"Substance Abuse Treatment Facility Locator"* -- the online service, which is updated regularly and may contain more current information, provides searchable road maps to the nearest treatment facilities, complete addresses, phone numbers and specific information on services available. The electronic, searchable version of SAMHSA's updated *"National Directory of Drug and Alcohol Abuse Treatment Programs"* is available on the Web at

http://FindTreatment.samhsa.gov/



Hard copies of the National Directory may be obtained free of charge from SAMHSA's Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request inventory number

Controversial Treatment for Opioid Dependence

Attached an article which you probably have read already. Is anyone considering a response to the study? Its quite controversial and almost negating the current treatment approaches.
I found it especially troublesome that the authors claim that "It could be argued that another opioid-substitution medication, such as buprenorphine, might have been used as a comparison drug instead of methadone. The available evidence does not support this suggestion: a recent Cochrane review concluded that buprenorphine maintenance was significantly less effective than methadone maintenance.Thus, methadone maintenance remains the standard treatment and the proper comparison drug for an experimental substitution therapy."

Looking forward to your comments.

Bernd


Volume 361:777-786 August 20, 2009 Number 8

Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction

Eugenia Oviedo-Joekes, Ph.D., Suzanne Brissette, M.D., David C. Marsh, M.D., Pierre Lauzon, M.D., Daphne Guh, M.Sc., Aslam Anis, Ph.D., and Martin T. Schechter, M.D., Ph.D.


ABSTRACT

Background Studies in Europe have suggested that injectable diacetylmorphine, the active ingredient in heroin, can be an effective adjunctive treatment for chronic, relapsing opioid dependence.

Methods:
In an open-label, phase 3, randomized, controlled trial in Canada, we compared injectable diacetylmorphine with oral methadone maintenance therapy in patients with opioid dependence that was refractory to treatment. Long-term users of injectable heroin who had not benefited from at least two previous attempts at treatment for addiction (including at least one methadone treatment) were randomly assigned to receive methadone (111 patients) or diacetylmorphine (115 patients). The primary outcomes, assessed at 12 months, were retention in addiction treatment or drug-free status and a reduction in illicit-drug use or other illegal activity according to the European Addiction Severity Index.

Results:
The primary outcomes were determined in 95.2% of the participants. On the basis of an intention-to-treat analysis, the rate of retention in addiction treatment in the diacetylmorphine group was 87.8%, as compared with 54.1% in the methadone group (rate ratio for retention, 1.62; 95% confidence interval [CI], 1.35 to 1.95; P<0.001). The reduction in rates of illicit-drug use or other illegal activity was 67.0% in the diacetylmorphine group and 47.7% in the methadone group (rate ratio, 1.40; 95% CI, 1.11 to 1.77; P=0.004). The most common serious adverse events associated with diacetylmorphine injections were overdoses (in 10 patients) and seizures (in 6 patients).

Conclusions:

Injectable diacetylmorphine was more effective than oral methadone. Because of a risk of overdoses and seizures, diacetylmorphine maintenance therapy should be delivered in settings where prompt medical intervention is available. (ClinicalTrials.gov number, NCT00175357 [ClinicalTrials.gov] .)

DISCUSSION:

Discussion:

In this trial, patients assigned to receive injectable diacetylmorphine were more likely to stay in treatment and to reduce their use of illegal drugs and other illegal activities than patients assigned to receive oral methadone. These findings are consistent with the results of European studies that suggest greater effectiveness of diacetylmorphine than methadone as maintenance treatment for long-term, treatment-refractory opioid use.10,12,13 Two of these trials showed no differences between groups in the rate of retention in treatment for addiction. However, the fact that control patients were eligible to receive diacetylmorphine at the end of the study period may have introduced a bias in the observed retention rates. In addition, patients currently enrolled in methadone maintenance treatment were eligible for the European trials but not for the present study. Although the definitions of clinical response varied among the trials, all of them considered the same variables (drug use, illegal activities, health, and social adjustment) and showed greater effectiveness of diacetylmorphine than of methadone for maintenance treatment.

Secondary analyses showed that both groups had significant improvement in many of the variables that were evaluated. The diacetylmorphine group had greater improvements with respect to medical and psychiatric status, economic status, employment situation, and family and social relations. These results are particularly noteworthy in view of the nature of the population and the time frame. The fact that patients who received diacetylmorphine had significant improvement in these areas suggests a positive treatment effect beyond a reduction in illicit-drug use or other illegal activities.

Buprenorphine versus Methadone

Reading the Cochrane study I found some significant discrepancies in the representation of buprenorphine treatment.


Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.

Mattick RP, Kimber J, Breen C, Davoli M.

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia, 2052. r.mattick@unsw.edu.au

BACKGROUND: Buprenorphine has been reported as an alternative to methadone for maintenance treatment of opioid dependence, but differing results are reported concerning its relative effectiveness indicating the need for an integrative review. OBJECTIVES: To evaluate the effects of buprenorphine maintenance against placebo and methadone maintenance in retaining patients in treatment and in suppressing illicit drug use. SEARCH STRATEGY: We searched the following databases up to October 2006: Cochrane Drugs and Alcohol Review Group Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, Psychlit, CORK , Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress databases, reference lists of identified studies and reviews, authors were asked about any other published or unpublished relevant RCT. SELECTION CRITERIA: Randomised clinical trials of buprenorphine maintenance versus placebo or methadone maintenance. DATA COLLECTION AND ANALYSIS: Authors separately and independently evaluated the papers and extracted data for meta-analysis. MAIN RESULTS: Twenty four studies met the inclusion criteria (4497 participants), all were randomised clinical trials, all but six were double-blind. The method of allocation concealment was not clearly described in the majority (20) of the studies, but where it was reported the methodological quality was good.Buprenorphine was statistically significantly superior to placebo medication in retention of patients in treatment at low doses (RR=1.50; 95% CI: 1.19 - 1.88), medium (RR=1.74; 95% CI: 1.06 - 2.87), and high doses (RR=1.74; 95% CI: 1.02 - 2.96). The high statistical heterogeneity prevented the calculation of a cumulative estimate. However, only medium and high dose buprenorphine suppressed heroin use significantly above placebo.Buprenorphine given in flexible doses was statistically significantly less effective than methadone in retaining patients in treatment (RR= 0.80; 95% CI: 0.68 - 0.95), but no different in suppression of opioid use for those who remained in treatment.Low dose methadone is more likely to retain patients than low dose buprenorphine (RR= 0.67; 95% CI: 0.52 - 0.87). Medium dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for medium dose buprenorphine over medium dose methadone in retention (RR=0.79; 95% CI:0.64 - 0.99) and medium dose buprenorphine was inferior in suppression of heroin use. AUTHORS' CONCLUSIONS: Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is less effective than methadone delivered at adequate dosages.

Publication Types:

* Meta-Analysis
* Review


PMID: 18425880 [PubMed - indexed for MEDLINE]

Universal Health Insurance

Attached you find a summary of a bill (HR676)which so far has not been discussed during the current healthcare refom debate.It should be at least considered as an option and not discarded just because its politically difficult to promote.
Bernd Wollschlaeger,MD



H.R. 676, “The United States National Health Care Act,”
Or “Expanded & Improved Medicare For All”
Introduced by Rep. John Conyers, Jr.


Brief Summary of Legislation

The United States National Health Care Act (USNHC) establishes a unique American universal health insurance program with single payer financing. The bill would create a publicly financed, privately delivered health care system that improves and expands the already existing Medicare program to all U.S. residents, and all residents living in U.S. territories. The goal of the legislation is to ensure that all Americans will have access, guaranteed by law, to the highest quality and most cost effective health care services regardless of their employment, income or health care status. In short, health care becomes a human right. With 47 million uninsured Americans, and another 50 million who are underinsured, the time has come to change our inefficient and costly fragmented non-system of health care.

Who is Eligible

Every person living or visiting in the United States and the U.S. Territories would receive a United States National Health Insurance Card and ID number once they enroll at the appropriate location. Social Security numbers may not be used when assigning ID cards.

Health Care Services Covered

This program will cover all medically necessary services, including primary care, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, hearing services, long term care, palliative care, podiatric care, mental health services, dentistry, eye care, chiropractic, and substance abuse treatment. Patients have their choice of physicians, providers, hospitals, clinics, and practices. There no co-pays or deductibles under this act.

Conversion To A Non-Profit Health Care System

Doctors, hospitals, and clinics will continue to operate as privately entities. However, they will be unable to issue stock. Private health insurers shall be prohibited under this act from selling coverage that duplicates the benefits of the USNHC program. Exceptions to this rule include coverage for cosmetic surgery, and other medically unnecessary treatments. Those workers who are displaced as the result of the transition to a non-profit health care system will be the first to be hired and retrained under this act. Furthermore, workers would receive their same salary for up to two years, and would then be eligible for unemployment benefits. The conversion to a not-for- profit health care system will take place as soon as possible, but not to exceed a 15 year period, through the sale of U.S. treasury bonds.

Cost Containment Provisions/ Reimbursement

The USNHC program will negotiate reimbursement rates annually with physicians, allow for global budgets (monthly lump sums for operating expenses) for hospitals, and negotiate prices for prescription drugs, medical supplies and equipment. A “Medicare For All Trust Fund” will be established to ensure a dedicated stream of funding. An annual Congressional appropriation is also authorized to ensure optimal levels of funding for the program, in particular, to ensure the requisite number of physicians and nurses need in the health care delivery system.

H.R. 676 Would Reduce Overall Health Care Costs


Families Will Pay Less

Currently, the average family of four covered under an employee health plan spends a total of $4,225 on health care annually – $2,713 on premiums and another $1,522 on medical services, drugs and supplies (Employer Health Benefits 2006 Annual Survey, Kaiser Family Foundation and Health Research and Educational Trust; U.S. Department of Labor, Bureau of Labor Statistics, Consumer Expenditure Survey.) This figure does not include the additional 1.45% Medicare payroll tax levied on employees. A study by Dean Baker of the Center for Economic Research and Policy concluded that under H.R. 676, a family of four making the median family income of $56,200 per year would pay about $2,700 for all health care costs.

Business Will Pay Less

In 2006, health insurers charged employers an average of $11,500 for a health plan for a family of four. On average, the employer paid 74% of this premium, or $8,510 per year. This figure does not include the additional 1.45% payroll tax levied on employers for Medicare. Under H.R. 676, employers would pay a 4.75% payroll tax for all health care costs. For an employee making the median family income of $56,200 per year, the employer would pay about $2,700.


The Nation Will Pay About the Same, While Covering All Americans

Savings from reduced administration, bulk purchasing, and coordination among providers will allow coverage for all Americans while reducing health care inflation in the long term. Annual savings from enacting H.R. 676 are estimated at $387 billion (Baker).


Proposed Funding For USNHC Program

· Maintain current federal and state funding for existing health care programs
· Establish employer/employee payroll tax of 4.75% (includes present 1.45% Medicare tax)
· Establish a 5% health tax on the top 5% of income earners, 10% tax on top 1% of wage earners
· ¼ of 1% stock transaction tax
· Close corporate tax loopholes
· Repeal the Bush tax cuts for the highest income earners

Speak Up Against Propaganda

Sunday, August 23, 2009

Letter To The Editor:

RE: Recess Rally

Naturally, every American has the constitutional right to free speech but healthcare protesters are going too far by likening Obama to Hitler or claiming that government will control when people die. It especially puzzles me that the many of those protesters opposing meaningful and necessary healthcare reform are Medicare recipient benefiting from a government controlled, single-payer system! Would those same people be willing to turn in their Medicare cards in protest too? Would those people consider me a “death panelist” because I follow Florida Law and need to discuss advanced directives with them? According to their “logic” hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMOs), which are required to provide their patients with written information concerning health care advance directives, are part of the “death panels” too!
We have to tune down the hyperbolic and toxic rhetoric fueled by fearmongers and anti-government nut wings and return to a rational dialogue to resolve an urgent problem: how to provide healthcare for all Americans.

Bernd Wollschlaeger, MD,FAAFP,FASAM
Family Physician

Lets Get Real:

ver the last few months I witnessed the almost hyperbolic rhetoric used by my colleagues in organized medicine calling for a “battle for freedom” to protect the “sacrosanct patient-physician relationship” against the perceived intrusion by “big government.” They are now joining the chorus of fearmongers who paint the apocalyptic vision of a world dominated by government rationing of healthcare and imaginary death panels forcing seniors to sign living wills condemning them to die.
Meanwhile, those of us who call for a rational discussion about the issues are being marginalized.
The worst if still to come: in exchange for their support of health care reform health insurance companies are being handed the big price: to offer insurance to the uninsured without having to change their business practice. Fiercely defended by Republicans, ideologically motivated leaders in organized medicine and conservative Democrats the CEOs of health insurance companies can continue to reap fat profits by limiting and rationing healthcare for millions of policyholders who are clueless that their policies may not deliver the promised coverage. This win-win situation for insurance companies will result in a loose-loose situation for the average healthcare consumer because the basic principle of meaningful health care reform is missing: tight regulation of the health insurance market.
Uwe Reinhardt, a renowned economics professor at Princeton, got it right. In his recent blog entry “Who Needs The Public Option?” http://economix.blogs.nytimes.com/2009/08/21/who-needs-the-public-option/#more-27531 he states that “Citizens in the rest of the industrialized world have long had easy-to-understand, reliable, life-cycle health insurance. They do not wake up at night worrying that their health insurance might be rescinded over some willful or inadvertent omission on health status during the application for insurance. Nor do they worry that they and their families will lose their health insurance coverage when the family’s breadwinner loses a job or switches jobs or location of residence. It would be very rare, indeed, in those countries to see a middle-class family lose all of its savings and perhaps even its home over unpaid medical bills……….our health insurance system leaves most Americans basically “unsured”: Private, job-based health insurance purchased in the large-group market is stable and reliable only as long as an employee keeps that job. It is not permanent, nor portable. It leaves Americans exposed to considerable financial risk over their life cycle. It is not “insurance,” but “unsurance.”
Even though, I do not agree with his assertion that a public option is not a necessary condition for healthcare reform I wholeheartedly support his argument that we “must convince the public and the legislators who do not trust it that with the help of government – including a wide set of new government regulations – the industry can transform itself into a structure that can offer Americans the same permanent, reliable, easy-to-understand life-cycle financial security that citizens in other nations take for granted and Americans crave.”
The main challenge remains: either creating a purely private-sector model that will offer individuals reliable, life-cycle health insurance with relatively stable premiums, and at premiums that are defensible, or opting for a taxpayer funded single payer health care system (Medicare For All). As long as the typical employment-based health insurance premium for family coverage is $12,688 per year - and rising exponentially – I opt for the only logical solution: single payer healthcare for all Americans!
Bernd Wollschlaeger,MD,FAFP,FASAM

AMA Supports Reform

Kudos to Dr.Cecil Wilson, President Elect of the AMA, whose letter to the editor was published in todays Miami Herald.
He should be applauded for standing up for what we know is right: comprehensive healthcare reform benefiting all Americans.
Thank you Dr. Wilson for your commitment to our profession and the public health.

Bernd Wollschlaeger,MD,FAAFP,FASAM
AMA Member & Outreach Recruiter
============================================================================
AMA to Miami Herald: AMA Supports Reform

July 23, 2009 (published)

Miami Herald
Letter to the Editor

Floridians without health-insurance coverage are in dire straits (Report: 3,560 Floridians will lose health insurance every week, July 16). For their sake, we must achieve meaningful healthcare reform that provides all Americans with access to affordable, high-quality coverage.

The American Medical Association is committed to health reform this year that covers the uninsured, improves quality and ensures patients get the best value from healthcare spending. Important progress has been made with the House and Senate vigorously working on legislation. The AMA will stay actively engaged to make certain health reform that will improve the health of America's patients is accomplished.

The uninsured crisis playing out in Florida is one that can be seen all across America.

We must seize the opportunity this year to pass comprehensive health reform.

Cecil B. Wilson, MD
President-elect, American Medical Association

AMA and Healthcare Reform

Attached today's press release from the AMA regarding its support for H.R. 3200. Obviously, our AMA is supporting the legislation which DOES contain a stripped down version of the public health insurance option. I wonder why their press release omits this important fact? Maybe, to avoid stirring up discussion and potential opposition from the hardliners within our AMA? Nevertheless, the press release is also a small baby step into the right direction and I hope that its not followed by two steps backwards. We will see.For more information about the bill see http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BILLSUMMARY-071409.pdf .
Yours
Bernd


NEWS FROM THE AMA

FOR IMMEDIATE RELEASE

July 16, 2009



AMA SUPPORTS H.R. 3200, “America’s Affordable Health Choices Act of 2009”

House Bill Expands Access to High Quality, Affordable Health Care for Americans



WASHINGTON– Today, the American Medical Association sent a letter to House leaders supporting H.R. 3200, “America’s Affordable Health Choices Act of 2009.”



“This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform,” said J. James Rohack, M.D., AMA president. “We urge the House committees of jurisdiction to pass the bill for consideration by the full House.” H.R. 3200 includes provisions key to effective, comprehensive health reform, including:



* Coverage to all Americans through health insurance market reforms
* A choice of plans through a health insurance exchange
* An end to coverage denials based on pre-existing conditions
* Fundamental Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula
* Additional funding for primary care services, without reductions on specialty care
* Individual responsibility for health insurance, including premium assistance to those who need it
* Prevention and wellness initiatives to help keep Americans healthy
* Initiatives to address physician workforce concerns



“The status quo is unacceptable,” Dr. Rohack said. “We support passage of H.R. 3200, and we look forward to additional constructive dialogue as the long process of passing a health reform bill continues. This is an important step, but one of many steps in the process. The AMA is actively engaged with Congress and the administration to achieve health reform that best meets the needs of patients and physicians. We are committed to passing health reform this year consistent with principles of pluralism, freedom of choice, freedom of practice, and universal access for patients.”


# # #

Healthcare Reform Debate: Shall We Include Single-Payer In The Debate?

Dear Friends and Colleagues:

Attached an editorial from yesterdays Seattle Times written by Dr. John Geyman is professor emeritus of Family Medicine at the Universityof Washington, past president of Physicians for a National Health Program, and a member of the Institute of Medicine.
He argues that legislators are "only considering options that build on the present system."He adds that "after months of work, legislative committees in Congress have brought forth drafts of proposals that the Congressional Budget Office (CBO) is starting to score in terms of cost and effectiveness. As expected, the costs of these incremental proposals are high BECAUSE they are based on the CURRENT dataset of health care costs and on data provided by insurance company actuaries. "He is correct that legislators refuse to even consider a single-payer option and that the CBO has yet to score such an option and how it would compare to the models proposed during the current debate.
He ends the editorial with the following challenge: " President Obama has brought forward the concept of audacity of hope. Is it too audacious now to hope that the legislators we elect to Congress can see beyond their campaign contributions and the lobbying efforts by corporate stakeholders to require that single-payer be scored?"

Yours
Bernd



The Seattle Times July 6, 2009
A pay-go option for health-care reform

By John Geyman

As Congress recessed for the July Fourth holiday, the debate over
health-care reform was reaching a fever pitch. Now the top domestic issue
for the Obama administration, the biggest questions are how much a reform
bill will cost and how to pay for it, quite aside from how effective a
"reform package" will be.

Skyrocketing costs that are out of control are the hallmark of our present
system. Yet legislators have already acceded to pressures and dollars from
stakeholders in the present system (within which costs are revenue) and are
only considering options that "build on the present system."

After months of work, legislative committees in Congress have brought forth
drafts of proposals that the Congressional Budget Office (CBO) is starting
to score in terms of cost and effectiveness. As expected, the costs of these
incremental proposals are high. The first number of $1.6 trillion over 10
years (while still leaving 36 million Americans uninsured) sent these
committees back to the drawing board. At the moment, leading Senate
Democrats are hailing $1 trillion over 10 years as potentially doable.

After presiding over huge deficits during their eight years in power,
Republicans are now demanding "pay as you go" (pay-go) policies. Together
with Blue Dog Democrats, they are threatening to act as spoilers of any
health-care-reform bill on its price tag alone.

Given the dimensions of these difficult economic times including a $1.8
trillion deficit for 2009, $5 trillion in new federal debt over this year
and next, and rising unemployment, pay-go makes good sense. And the
president is making the case that his health-care plan must pay for itself.

Conventional "wisdom" (as generated by the mainstream corporate media) says
that any health-care reform will cost a lot, and that there is no pay-go
option. But there is.

Single-payer financing (public financing coupled with a private delivery
system, a reformed "Medicare for All"), as embodied in Rep. John Conyers'
bill (HR 676 in the House) with its 83 co-sponsors, will yield savings of
some $400 billion a year. That's enough to assure universal coverage for all
Americans while eliminating all co-pays and deductibles ? the ultimate
pay-go. Single-payer will give us far more efficient, affordable, effective
and reliable health care than our present multipayer system. Health insurers
have known for years that they can't compete on a level playing field with
single-payer, and have only been surviving by favorable tax policies and
other subsidies from the government.

This recent testimony before the U.S. Senate Committee on Commerce, Science
and Transportation by Wendell Potter, former head of corporate
communications at Cigna, says it all: "I know from personal experience that
members of Congress and the public have good reason to question the honesty
and trustworthiness of the insurance industry. Insurers make promises they
have no intention of keeping, they flout regulations designed to protect
consumers, and they make it nearly impossible to understand or even to
obtain information we need."

Many studies over the past two decades, including those by the CBO, the
Government Accountability Office (GAO) and the nonpartisan Economic Policy
Institute, have concluded that single-payer can assure universal coverage
and still save money. HR 676 needs to be brought out of the closet and put
on the table for CBO scoring against other options being considered in
Congress, all of which cost much more and fail to provide universal
coverage.

President Obama has brought forward the concept of audacity of hope. Is it
too audacious now to hope that the legislators we elect to Congress can see
beyond their campaign contributions and the lobbying efforts by corporate
stakeholders to require that single-payer be scored?

(Dr. John Geyman is professor emeritus of Family Medicine at the University
of Washington, past president of Physicians for a National Health Program,
and a member of the Institute of Medicine.)

http://seattletimes.nwsource.com/html/opinion/2009424809_guest07geyman.html

Insurance Mandate Gains Support

Attached a letter to President Obama supporting an employer mandate SUPPORTED by the President and CEO of Walmart and the Service Employees International Union (SEIU), the largest healthcare employees union in the US.
This serves as evidence that those of us who do support an insurance mandate DO NOT belong to the extreme left-wing fringes as claimed by our colleagues in organized medicine!
Yours
Bernd


"We are for shared responsibility. Not every business can make the same contribution, but everyone must
make some contribution."

June 30, 2009
President Barack Obama
The White House
1600 Pennsylvania Avenue, NW
Washington, DC 20500
Dear President Obama,
As the Congress considers legislation reforming our health care system, many difficult choices lie ahead.
During the debate, we must keep our eyes trained on one clear imperative: reforming health care is
necessary not just to improve the health of all Americans, but also to remove the burden that is crushing
America’s businesses and hampering our competitiveness in the global economy.
As the nation’s largest private employer, the nation’s largest union of health care workers with over one
million members, and a think tank that has been a leader on health care policy, we have worked closely in
support of health care reform since 2006, when we came together to help break the stalemate that had
defined the health care debate for too long. Now, to move the debate forward once again, we are coming
together to advance what we believe are important proposals that should be included in the current efforts
to reform our nation’s health care system.
We believe now is the time for action on this vital issue. We commend the leadership of elected officials
who are committed to enactment of reform, and we appreciate the commitment to inclusion and
transparency which has been present thus far.
We are entering a critical time during which all of us who will be asked to pay for health care reform will
have to make a choice on whether to support the legislation. This choice will require employers to
consider the trade off of agreeing to a coverage mandate and additional taxes versus the promise of
reduced health care cost increases.
Today, health care costs more because we don’t cover everyone – the average family premium costs an
additional $1,100 because our system fails to provide continuous coverage for all Americans. And losing
coverage pushes people already dealing with financial hardship to the verge of financial collapse. One
accident or unexpected illness can financially ruin them. In 2008, half of all people filing for home
foreclosure cited medical problems as a cause.
A large and growing uninsured population also cripples our broader economic growth. The higher taxes
and premiums needed to meet rising health care costs threaten to consume the benefits of nearly all
economic growth over the next four decades, according to research published in the journal Health
Affairs. And the U.S. economy is losing up to $244 billion every year in lost productivity due to the
uninsured according to a new analysis by the Center for American Progress.
From a business perspective, health reform could not be more critical. A majority of Americans—158
million—receive their coverage through their job or their spouse’s job, according to the Kaiser Family
Foundation. But few businesses will be able to keep up with the pace at which premiums are rising.
Premiums are expected to rise by 20 percent in less than four years, according to research by professors at
Harvard University -- costing 3.5 million workers their jobs, and cutting insured workers’ average annual
incomes by $1,700.
Fiscally, the growing cost of health care is poised to drive our federal budget over a cliff. A recent report
by the Senate Finance Committee found that by 2017, “health care expenditures are expected to consume
nearly 20 percent of the GDP.” In his former role as Director of the Congressional Budget Office (CBO),
current Office of Management and Budget Director Peter Orszag testified to Congress that, “the single
most important factor influencing the federal government’s long-term fiscal balance is the rate of growth
in health care costs.”
We believe payment reform and efficiency initiatives need to be at the center of healthcare reform. The
President and the Congress have put forward good ideas to improve the productivity of our health care
sector. These policies need to be strengthened and adopted because health care reform without controlling
costs is no reform at all.
We are for shared responsibility. Not every business can make the same contribution, but everyone must
make some contribution. We are for an employer mandate which is fair and broad in its coverage, but any
alternative to an employer mandate should not create barriers to hiring entry level employees. We look
forward to working with the Administration and Congress to develop a requirement that is both sensible
and equitable.
Support for a mandate also requires the strongest possible commitment to rein in health care costs.
Guaranteeing cost containment is essential. One way to ensure savings was recently advanced by former
Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole, “Implement pre-specified targets
for spending growth and enact a “trigger” mechanism that automatically enforces reductions,” (Crossing
Our Lines, Bipartisan Policy Center) President Obama suggested strengthening the role of Med Pac to
help enforce spending discipline.
With smart, targeted policies, we can create a financially-viable health care system that enables workers
to change jobs without losing their care, and allows businesses to become more nimble. Health care costs
will no longer stand in the way of their ability to retool for the 21st century. Focusing on health care cost
savings – and demonstrating a strong commitment to achieving these savings– would make this bill a win
/ win for employers, individuals and America’s competitiveness.

Respectfully,
John Podesta President & CEO Center for American Progress (CAP)
Andrew L. Stern President & CEO Service Employees International Union (SEIU)
Mike Duke President Wal-Mart Stores, Inc.

Prescription Drug Overdose

On June 23, 2009 Florida Gov. Charlie Crist has signed legislation aimed at curbing the growing black market of illegal prescription drugs flowing from South Florida pain clinics across the eastern United States. The new law, passed nearly unanimously in the Legislature, will require doctors and pharmacists to record patient prescriptions for most drugs in a state-controlled database.
Its about pain to reign in on the explosive growth of "pain clinics" in South Florida operated by unscrupulous owners, some associated with the criminal underworld and organized crime.
The number of overdose deaths are soaring, too!
Unfortunately, the prescription drug monitoring program cannot be implemented until the end of 2011 and so far funding is pending.
As physicians we must continue to push for the comprehensive implementation of such program because our patients and fellow citizens are being harmed by drug dealers in a white coat.
Lets not be complacent but proactive. We just won ONE battle but not the war against drugs.
Yours
Bernd
Posted on Tue, Jun. 30, 2009

Prescription drug overdose deaths soar in Florida

BY SCOTT HIAASEN
shiaasen@MiamiHerald.com

Florida continues to see a rapid rise in fatal overdoses caused by prescription-drug abuse -- a trend fueled by a cottage industry of cash-only pain clinics -- while deaths from illegal drugs wane, according to a report from the state's medical examiners released Tuesday.
Nearly 1,000 deaths were caused in 2008 by the potent painkiller oxycodone -- a 33 percent increase from 2007, the report says. Four years ago, only 340 deaths statewide were attributed to oxycodone, the most popular drug in the black-market pill trade supplied by pain clinics.

Conversely, deaths from cocaine overdoses declined by 23 percent, to 648 in 2008.

Overall, prescription drugs accounted for 75 percent of the drugs found in overdose victims last year, the report says.

''The magnitude and severity of prescription drug abuse calls for strong, coordinated action,'' said Bill Janes, the director of the state's Office of Drug Control, in a written statement.

Florida took a step in that direction when the Legislature passed a law creating a statewide database to monitor prescription sales and increasing oversight of pain clinics, which operate with little scrutiny.

The prescription database is designed to detect addicts and drug dealers buying pills from multiple doctors -- often by faking ailments or medical records -- a practice known as ``doctor shopping.''

''It's almost impossible to monitor different people shopping doctors,'' said Dr. Joshua Perper, Broward County's medical examiner. ``A person can get hundreds or thousands of pills.''

This can also lead to dangerous drug combinations. Perper said the most common overdoses involve mixing several drugs, with oxycodone and anti-anxiety drugs such as Xanax and Valium among the most common combinations.

Though the new prescription monitoring law takes effect Wednesday, the database is not expected to begin operating until late next year.

Broward has become the nation's capital of illegal prescription drug trafficking, police say, with nearly 100 storefront pain clinics feeding a black market in pain pills stretching through Kentucky, Ohio, Tennessee, West Virginia and Massachusetts. Florida leads the nation in oxycodone sales -- largely because of these clinics -- according to U.S. Drug Enforcement Administration data.

In 2008, Perper's office detected oxycodone in 171 Broward County overdose deaths -- more than twice the number found in 2005.

The highest number of oxycodone overdoses were reported in Pinellas and Pasco counties, where the drug was detected in 308 deaths last year.

The medical examiner in that district, Dr. Jon Thogmartin, attributes the unusually high number to advanced detection techniques employed by his lab.

''Prescription drugs have really begun, to a significant degree, to replace illicit drugs,'' Thogmartin said.

Thogmartin said many victims overdose on pills prescribed to them by licensed doctors.

To health advocates, this shows that doctors practicing as pain-management specialists need more training and more oversight from the state medical board.

''It's unacceptable to open up a practice and call yourself a pain management physician and start writing prescriptions,'' said Dr. Laura Brown, a Bradenton physician on the board of the American Society of Interventional Pain Physicians. ``That's not pain management.''

Medicare Fraud Continues!

Crackdown on Medicare fraud

On several occasions I reported on this blog http://floridadocs.blogspot.com/ about the audacious and callous Medicare fraud and abuse activity here in South Florida. During my tenure as DCMA President I met twice with representatives and senior executives of First Coast Service Options (FCSO) , the regional Medicare administrator, to discuss and understand why on one hand doctors in South Florida are being nickeled and dimed for legitimate services rendered but on the other hand billions of dollars are being paid out for obvious fraudulent claims. The most egregious example is the ongoing payment for HIV infusion “treatments” which, according to the court testimony of a leading HIV treatment expert, are obsolete, replaced for years by more effective oral antiretroviral drugs and not being utilized in clinical practice anymore. In most cases unscrupulous clinic owners, aided and abetted by medical doctors, set up such HIV Infusion clinics, recruited Medicare recipients suffering from HIV/AIDS and billed Medicare for services never rendered, In a series of award winning articles published in the Miami Herald Jay Weaver pointed out the continuous payment for those “services “ despite assurance made by First Coast Service Options that the payment were ceased. In a meeting with FCSO I personally received assurances that “ no such checks are being issued anymore.” Obviously, thats not the truth. I a recent article published on Saturday, June 27th 2009 http://www.miamiherald.com/news/front-page/v-print/story/1116390.html Experts estimate Medicare loses at least $60 billion to fraud every year, with Miami-Dade County at the center of the national crisis. I a recent crackdown agents broke up a Miami-based ring that allegedly schemed to defraud Medicare of $100 million by filing false claims for obsolete HIV therapy across five states. Two of the eight suspects have fled to Cuba.The organization, which was paid $30 million by the federal health insurance program, exported a fraudulent local business enterprise to Georgia, Louisiana, North Carolina and South Carolina by using empty storefronts and post office boxes, authorities said. What is being done to stop the bleeding of precious Medicare dollars? Well, I personally have written letters to the editors of local newspapers pointing out the obvious mismanagement of funds by FCSO. I have written to each and every member of the congressional delegation from Florida and only ONE responded advising me to contact the Officer of Inspector General to file a complaint! Thats it! Meanwhile, Medicare still considers such treatment "reasonable and necessary" and continues to pay hundreds of millions of dollars for fraudulent claims every year. FCSO refuses to consider the one and ONLY option: stop payment of ALL HIV infusion therapy claims in Florida/South Florida. The response: We can't because patients who actually need the treatment would be denied services -- a policy no-no at Medicare. But experts have testified that no one needs this treatments anymore!! If any patient would require such treatment it would be an exception and Medicare could consider payment on a case by case basis! Lets be clear: Medicare officials know the claims are fraudulent. Medicare says it has adopted technology to block false claims for HIV infusion treatment, yet the government program still misses hundreds of millions of dollars annually. To add insult to injury on September 12th, 2008 the Centers for Medicare & Medicaid Services (CMS) announced that First Coast Service Options, Inc. (FCSO) has been awarded a contract of up to five years for the combined administration of Part A and Part B Medicare claims payment in Florida, Puerto Rico, and U.S. Virgin Islands. This represents not only a contract renewal but EXPANSION! In a press release CMS emphasized that “ with this award, CMS continues its progress in reengineering the way in which the government contracts for claims administration for the largest part of the Medicare program. CMS is seeking the best value, from a cost and technical perspective for this critical function.” The “best value” they probably get from FCSO is the waste of Medicare dollars! But they do not stop here! FCSO will be financially awarded too! In the same press release CMS officials emphasized that “ the contract for FCSO includes a base period and four one-year options and will provide FCSO with an opportunity to earn award fees based on its ability to meet or exceed the performance requirements set by CMS.” So they can earn extra dollars on the fraudulent claims amount?

So what can be done:

1)Call, e-mail or write your representative and/or Senator to hold FCSO responsible for every dollar wasted.
2)Petition the Office of Inspector General of the US Department of Health & Human Services at HHSTips@oig.hhs.gov to investigate FCSO business activities.
3)Force FCSO to repay each and every dollar of fraudulent claims paid and hold company executives legally accountable for their actions (or inactions)

In times of financial crisis we all have to act in a cautious manner exercising our duties , obligations and responsibilities as citizens. The blatant abuse of the Medicare system has to stop!

Yours
Bernd

Does our AMA delegation represent our interests?

Copy of an E-mail to FMA AMA Delegates:

Dear Friends and Colleagues:
I regret that I was unable to stay until the end of the meeting and especially that I missed the opportunity to witness our President's speech.
But I had to return to Miami to attend to my ever increasing patient load at my my family medicine office and my voluntary teaching commitments at the University of Miami.
I shared my frustrations regarding our delegation with our Delegation Chair and Vice-Chair and now with you:
During my almost fifteen year of service for organized medicine I now witness an increasing intolerance towards open discussion, political extremism and radicalization within our delegation.
Fear mongering, political stereotyping and demagoguery is now prevailing in the so-called " discussions", whereas the attempt to introduce opinions based on rational thoughts, tolerance for the diversity of opinions and the ability to reach a consensus is being marginalized. As a consequence hardly anyone dares to introduce his/her ideas or thoughts. I observed that many carefully gauge the political thermometer and based on the prevailing mood introduce their thoughts.Voice volume has replaced the value of rational consideration.
Most of us are more concerned to fall into political lockstep because otherwise they may not get elected into desired position within the AMA or jeopardize their delegate status. As an AMA Top-Outreach -Recruiter I speak to many different people trying to convince them to join our organization. In the last year I have witnessed a steady drop in AMA membership numbers within Florida. This does not surprise me anymore, because our AMA Delegation has lost touch with the members they supposedly should represent. Delegates often articulate the MOST extreme political opinions and even question the legitimacy of BELONGING to the AMA! How shall I recruit members if members of our delegation are openly ridiculing our AMA policies and leadership? Unless our delegation changes its behavior I cannot serve as a delegate in its midst.
This is a painful realization after years of service for an organization I admire and respect. But I have lost hope that our AMA delegation can be the platform for pragmatic political action especially in those exciting and challenging times.
Our leadership alone has the opportunity and responsibility to change that!
Change has to include: 1) Open debate and sanctioning of incendiary language,2) Respect for diverse opinions, 3) Fully transparent resolution development process, 4) Candidate and Leadership development based on personal qualification and not years of service.
These are the minimum requirements needed to avoid the political implosion of or Delegation.
Many will disagree with me but I honestly do not care how many times I am going to be called Fascist, Communist or Socialist. Those using this language are demagogues and wannabe "thinkers."
I remain focused on growing our AMA as a professional organization and NOT as a trade association. I remain focused to motivate a diverse spectrum of practicing physicians to join and rejoin our AMA. If these goals are not OUR goals then I have to part with you.

Yours truly,


Bernd

President's Speech to AMA House of Delegates

President Obama Speech to AMA. June 15th 2009

From the moment I took office as President, the central challenge we have confronted as a nation has been the need to lift ourselves out of the worst recession since World War II. In recent months, we have taken a series of extraordinary steps, not just to repair the immediate damage to our economy, but to build a new foundation for lasting and sustained growth. We are creating new jobs. We are unfreezing our credit markets. And we are stemming the loss of homes and the decline of home values.
But even as we have made progress, we know that the road to prosperity remains long and difficult. We also know that one essential step on our journey is to control the spiraling cost of health care in America.
Today, we are spending over $2 trillion a year on health care – almost 50 percent more per person than the next most costly nation. And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren’t any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do.
Make no mistake: the cost of our health care is a threat to our economy. It is an escalating burden on our families and businesses. It is a ticking time-bomb for the federal budget. And it is unsustainable for the United States of America.
It is unsustainable for Americans like Laura Klitzka, a young mother I met in Wisconsin last week, who has learned that the breast cancer she thought she’d beaten had spread to her bones; who is now being forced to spend time worrying about how to cover the $50,000 in medical debts she has already accumulated, when all she wants to do is spend time with her two children and focus on getting well. These are not worries a woman like Laura should have to face in a nation as wealthy as ours.
Stories like Laura’s are being told by women and men all across this country – by families who have seen out-of-pocket costs soar, and premiums double over the last decade at a rate three times faster than wages. This is forcing Americans of all ages to go without the checkups or prescriptions they need. It’s creating a situation where a single illness can wipe out a lifetime of savings.
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.
Small business owners like Chris and Becky Link in Nashville are also struggling. They’ve always wanted to do right by the workers at their family-run marketing firm, but have recently had to do the unthinkable and lay off a number of employees – layoffs that could have been deferred, they say, if health care costs weren’t so high. Across the country, over one third of small businesses have reduced benefits in recent years and one third have dropped their workers’ coverage altogether since the early 90’s.
Our largest companies are suffering as well. A big part of what led General Motors and Chrysler into trouble in recent decades were the huge costs they racked up providing health care for their workers; costs that made them less profitable, and less competitive with automakers around the world. If we do not fix our health care system, America may go the way of GM; paying more, getting less, and going broke.
When it comes to the cost of our health care, then, the status quo is unsustainable. Reform is not a luxury, but a necessity. I know there has been much discussion about what reform would cost, and rightly so. This is a test of whether we – Democrats and Republicans alike – are serious about holding the line on new spending and restoring fiscal discipline.
But let there be no doubt – the cost of inaction is greater. If we fail to act, premiums will climb higher, benefits will erode further, and the rolls of uninsured will swell to include millions more Americans.
If we fail to act, one out of every five dollars we earn will be spent on health care within a decade. In thirty years, it will be about one out of every three – a trend that will mean lost jobs, lower take-home pay, shuttered businesses, and a lower standard of living for all Americans.
And if we fail to act, federal spending on Medicaid and Medicare will grow over the coming decades by an amount almost equal to the amount our government currently spends on our nation’s defense. In fact, it will eventually grow larger than what our government spends on anything else today. It’s a scenario that will swamp our federal and state budgets, and impose a vicious choice of either unprecedented tax hikes, overwhelming deficits, or drastic cuts in our federal and state budgets.
To say it as plainly as I can, health care reform is the single most important thing we can do for America’s long-term fiscal health. That is a fact.
And yet, as clear as it is that our system badly needs reform, reform is not inevitable. There’s a sense out there among some that, as bad as our current system may be, the devil we know is better than the devil we don’t. There is a fear of change – a worry that we may lose what works about our health care system while trying to fix what doesn’t.
I understand that fear. I understand that cynicism. They are scars left over from past efforts at reform. Presidents have called for health care reform for nearly a century. Teddy Roosevelt called for it. Harry Truman called for it. Richard Nixon called for it. Jimmy Carter called for it. Bill Clinton called for it. But while significant individual reforms have been made – such as Medicare, Medicaid, and the children’s health insurance program – efforts at comprehensive reform that covers everyone and brings down costs have largely failed.
Part of the reason is because the different groups involved – physicians, insurance companies, businesses, workers, and others – simply couldn’t agree on the need for reform or what shape it would take. And another part of the reason has been the fierce opposition fueled by some interest groups and lobbyists – opposition that has used fear tactics to paint any effort to achieve reform as an attempt to socialize medicine.
Despite this long history of failure, I am standing here today because I think we are in a different time. One sign that things are different is that just this past week, the Senate passed a bill that will protect children from the dangers of smoking – a reform the AMA has long championed – and one that went nowhere when it was proposed a decade ago. What makes this moment different is that this time – for the first time – key stakeholders are aligning not against, but in favor of reform. They are coming together out of a recognition that while reform will take everyone in our health care community doing their part, ultimately, everyone will benefit.
And I want to commend the AMA, in particular, for offering to do your part to curb costs and achieve reform. A few weeks ago, you joined together with hospitals, labor unions, insurers, medical device manufacturers and drug companies to do something that would’ve been unthinkable just a few years ago – you promised to work together to cut national health care spending by two trillion dollars over the next decade, relative to what it would otherwise have been. That will bring down costs, that will bring down premiums, and that’s exactly the kind of cooperation we need.
The question now is, how do we finish the job? How do we permanently bring down costs and make quality, affordable health care available to every American?
That’s what I’ve come to talk about today. We know the moment is right for health care reform. We know this is an historic opportunity we’ve never seen before and may not see again. But we also know that there are those who will try and scuttle this opportunity no matter what – who will use the same scare tactics and fear-mongering that’s worked in the past. They’ll give dire warnings about socialized medicine and government takeovers; long lines and rationed care; decisions made by bureaucrats and not doctors. We’ve heard it all before – and because these fear tactics have worked, things have kept getting worse.
So let me begin by saying this: I know that there are millions of Americans who are content with their health care coverage – they like their plan and they value their relationship with their doctor. And that means that no matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.
If we do that, we can build a health care system that allows you to be physicians instead of administrators and accountants; a system that gives Americans the best care at the lowest cost; a system that eases up the pressure on businesses and unleashes the promise of our economy, creating hundreds of thousands of jobs, making take-home wages thousands of dollars higher, and growing our economy by tens of billions more every year. That’s how we will stop spending tax dollars to prop up an unsustainable system, and start investing those dollars in innovations and advances that will make our health care system and our economy stronger.
That’s what we can do with this opportunity. That’s what we must do with this moment.
Now, the good news is that in some instances, there is already widespread agreement on the steps necessary to make our health care system work better.
First, we need to upgrade our medical records by switching from a paper to an electronic system of record keeping. And we have already begun to do this with an investment we made as part of our Recovery Act.
It simply doesn’t make sense that patients in the 21st century are still filling out forms with pens on papers that have to be stored away somewhere. As Newt Gingrich has rightly pointed out, we do a better job tracking a FedEx package in this country than we do tracking a patient’s health records. You shouldn’t have to tell every new doctor you see about your medical history, or what prescriptions you’re taking. You should not have to repeat costly tests. All of that information should be stored securely in a private medical record so that your information can be tracked from one doctor to another – even if you change jobs, even if you move, and even if you have to see a number of different specialists.
That will not only mean less paper pushing and lower administrative costs, saving taxpayers billions of dollars. It will also make it easier for physicians to do their jobs. It will tell you, the doctors, what drugs a patient is taking so you can avoid prescribing a medication that could cause a harmful interaction. It will help prevent the wrong dosages from going to a patient. And it will reduce medical errors that lead to 100,000 lives lost unnecessarily in our hospitals every year.
The second step that we can all agree on is to invest more in preventive care so that we can avoid illness and disease in the first place. That starts with each of us taking more responsibility for our health and the health of our children. It means quitting smoking, going in for that mammogram or colon cancer screening. It means going for a run or hitting the gym, and raising our children to step away from the video games and spend more time playing outside.
It also means cutting down on all the junk food that is fueling an epidemic of obesity, putting far too many Americans, young and old, at greater risk of costly, chronic conditions. That’s a lesson Michelle and I have tried to instill in our daughters with the White House vegetable garden that Michelle planted. And that’s a lesson that we should work with local school districts to incorporate into their school lunch programs.
Building a health care system that promotes prevention rather than just managing diseases will require all of us to do our part. It will take doctors telling us what risk factors we should avoid and what preventive measures we should pursue. And it will take employers following the example of places like Safeway that is rewarding workers for taking better care of their health while reducing health care costs in the process. If you’re one of the three quarters of Safeway workers enrolled in their "Healthy Measures" program, you can get screened for problems like high cholesterol or high blood pressure. And if you score well, you can pay lower premiums. It’s a program that has helped Safeway cut health care spending by 13 percent and workers save over 20 percent on their premiums. And we are open to doing more to help employers adopt and expand programs like this one.
Our federal government also has to step up its efforts to advance the cause of healthy living. Five of the costliest illnesses and conditions – cancer, cardiovascular disease, diabetes, lung disease, and strokes – can be prevented. And yet only a fraction of every health care dollar goes to prevention or public health. That is starting to change with an investment we are making in prevention and wellness programs that can help us avoid diseases that harm our health and the health of our economy.
But as important as they are, investments in electronic records and preventive care are just preliminary steps. They will only make a dent in the epidemic of rising costs in this country.
Despite what some have suggested, the reason we have these costs is not simply because we have an aging population. Demographics do account for part of rising costs because older, sicker societies pay more on health care than younger, healthier ones. But what accounts for the bulk of our costs is the nature of our health care system itself – a system where we spend vast amounts of money on things that aren’t making our people any healthier; a system that automatically equates more expensive care with better care.
A recent article in the New Yorker, for example, showed how McAllen, Texas is spending twice as much as El Paso County – not because people in McAllen are sicker and not because they are getting better care. They are simply using more treatments – treatments they don’t really need; treatments that, in some cases, can actually do people harm by raising the risk of infection or medical error. And the problem is, this pattern is repeating itself across America. One Dartmouth study showed that you’re no less likely to die from a heart attack and other ailments in a higher spending area than in a lower spending one.
There are two main reasons for this. The first is a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can’t spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it’s not truly necessary. It is a model that has taken the pursuit of medicine from a profession – a calling – to a business.
That is not why you became doctors. That is not why you put in all those hours in the Anatomy Suite or the O.R. That is not what brings you back to a patient’s bedside to check in or makes you call a loved one to say it’ll be fine. You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers – and that’s what our health care system should let you be.
That starts with reforming the way we compensate our doctors and hospitals. We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care.
And we need to rethink the cost of a medical education, and do more to reward medical students who choose a career as a primary care physicians and who choose to work in underserved areas instead of a more lucrative path. That’s why we are making a substantial investment in the National Health Service Corps that will make medical training more affordable for primary care doctors and nurse practitioners so they aren’t drowning in debt when they enter the workforce.
The second structural reform we need to make is to improve the quality of medical information making its way to doctors and patients. We have the best medical schools, the most sophisticated labs, and the most advanced training of any nation on the globe. Yet we are not doing a very good job harnessing our collective knowledge and experience on behalf of better medicine. Less than one percent of our health care spending goes to examining what treatments are most effective. And even when that information finds its way into journals, it can take up to 17 years to find its way to an exam room or operating table.
As a result, too many doctors and patients are making decisions without the benefit of the latest research. A recent study, for example, found that only half of all cardiac guidelines are based on scientific evidence. Half. That means doctors may be doing a bypass operation when placing a stent is equally effective, or placing a stent when adjusting a patient’s drugs and medical management is equally effective – driving up costs without improving a patient’s health.
So, one thing we need to do is figure out what works, and encourage rapid implementation of what works into your practices. That’s why we are making a major investment in research to identify the best treatments for a variety of ailments and conditions.
Let me be clear: identifying what works is not about dictating what kind of care should be provided. It’s about providing patients and doctors with the information they need to make the best medical decisions.
Still, even when we do know what works, we are often not making the most of it. That’s why we need to build on the examples of outstanding medicine at places like the Cincinnati Children’s Hospital, where the quality of care for cystic fibrosis patients shot up after the hospital began incorporating suggestions from parents. And places like Tallahassee Memorial Health Care, where deaths were dramatically reduced with rapid response teams that monitored patients’ conditions and "multidisciplinary rounds" with everyone from physicians to pharmacists. And places like the Geisinger Health system in rural Pennsylvania and the Intermountain Health in Salt Lake City, where high-quality care is being provided at a cost well below average. These are islands of excellence that we need to make the standard in our health care system.
Replicating best practices. Incentivizing excellence. Closing cost disparities. Any legislation sent to my desk that does not achieve these goals does not earn the title of reform. But my signature on a bill is not enough. I need your help, doctors. To most Americans, you are the health care system. Americans – me included – just do what you recommend. That is why I will listen to you and work with you to pursue reform that works for you. And together, if we take all these steps, we can bring spending down, bring quality up, and save hundreds of billions of dollars on health care costs while making our health care system work better for patients and doctors alike.
Now, I recognize that it will be hard to make some of these changes if doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue. And while I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed, I do think we need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine, and encourage broader use of evidence-based guidelines. That’s how we can scale back the excessive defensive medicine reinforcing our current system of more treatment rather than better care.
These changes need to go hand-in-hand with other reforms. Because our health care system is so complex and medicine is always evolving, we need a way to continually evaluate how we can eliminate waste, reduce costs, and improve quality. That is why I am open to expanding the role of a commission created by a Republican Congress called the Medicare Payment Advisory Commission – which happens to include a number of physicians. In recent years, this commission proposed roughly $200 billion in savings that never made it into law. These recommendations have now been incorporated into our broader reform agenda, but we need to fast-track their proposals in the future so that we don’t miss another opportunity to save billions of dollars, as we gain more information about what works and what doesn’t in our health care system.
As we seek to contain the cost of health care, we must also ensure that every American can get coverage they can afford. We must do so in part because it is in all of our economic interests. Each time an uninsured American steps foot into an emergency room with no way to reimburse the hospital for care, the cost is handed over to every American family as a bill of about $1,000 that is reflected in higher taxes, higher premiums, and higher health care costs; a hidden tax that will be cut as we insure all Americans. And as we insure every young and healthy American, it will spread out risk for insurance companies, further reducing costs for everyone.
But alongside these economic arguments, there is another, more powerful one. It is simply this: We are not a nation that accepts nearly 46 million uninsured men, women, and children. We are not a nation that lets hardworking families go without the coverage they deserve; or turns its back on those in need. We are a nation that cares for its citizens. We are a people who look out for one another. That is what makes this the United States of America.
So, we need to do a few things to provide affordable health insurance to every single American. The first thing we need to do is protect what’s working in our health care system. Let me repeat – if you like your health care, the only thing reform will mean is your health care will cost less. If anyone says otherwise, they are either trying to mislead you or don’t have their facts straight.
If you don’t like your health coverage or don’t have any insurance, you will have a chance to take part in what we’re calling a Health Insurance Exchange. This Exchange will allow you to one-stop shop for a health care plan, compare benefits and prices, and choose a plan that’s best for you and your family – just as federal employees can do, from a postal worker to a Member of Congress. You will have your choice of a number of plans that offer a few different packages, but every plan would offer an affordable, basic package. And one of these options needs to be a public option that will give people a broader range of choices and inject competition into the health care market so that force waste out of the system and keep the insurance companies honest.
Now, I know there’s some concern about a public option. In particular, I understand that you are concerned that today’s Medicare rates will be applied broadly in a way that means our cost savings are coming off your backs. These are legitimate concerns, but ones, I believe, that can be overcome. As I stated earlier, the reforms we propose are to reward best practices, focus on patient care, not the current piece-work reimbursement. What we seek is more stability and a health care system on a sound financial footing. And these reforms need to take place regardless of what happens with a public option. With reform, we will ensure that you are being reimbursed in a thoughtful way tied to patient outcomes instead of relying on yearly negotiations about the Sustainable Growth Rate formula that’s based on politics and the state of the federal budget in any given year. The alternative is a world where health care costs grow at an unsustainable rate, threatening your reimbursements and the stability of our health care system.
What are not legitimate concerns are those being put forward claiming a public option is somehow a Trojan horse for a single-payer system. I’ll be honest. There are countries where a single-payer system may be working. But I believe – and I’ve even taken some flak from members of my own party for this belief – that it is important for us to build on our traditions here in the United States. So, when you hear the naysayers claim that I’m trying to bring about government-run health care, know this – they are not telling the truth.
What I am trying to do – and what a public option will help do – is put affordable health care within reach for millions of Americans. And to help ensure that everyone can afford the cost of a health care option in our Exchange, we need to provide assistance to families who need it. That way, there will be no reason at all for anyone to remain uninsured.
Indeed, it is because I am confident in our ability to give people the ability to get insurance that I am open to a system where every American bears responsibility for owning health insurance, so long as we provide a hardship waiver for those who still can’t afford it. The same is true for employers. While I believe every business has a responsibility to provide health insurance for its workers, small businesses that cannot afford it should receive an exemption. And small business workers and their families will be able to seek coverage in the Exchange if their employer is not able to provide it.
Insurance companies have expressed support for the idea of covering the uninsured – and I welcome their willingness to engage constructively in the reform debate. But what I refuse to do is simply create a system where insurance companies have more customers on Uncle Sam’s dime, but still fail to meet their responsibilities. That is why we need to end the practice of denying coverage on the basis of preexisting conditions. The days of cherry-picking who to cover and who to deny – those days are over.
This is personal for me. I will never forget watching my own mother, as she fought cancer in her final days, worrying about whether her insurer would claim her illness was a preexisting condition so it could get out of providing coverage. Changing the current approach to preexisting conditions is the least we can do – for my mother and every other mother, father, son, and daughter, who has suffered under this practice. And it will put health care within reach for millions of Americans.
Now, even if we accept all of the economic and moral reasons for providing affordable coverage to all Americans, there is no denying that it will come at a cost – at least in the short run. But it is a cost that will not – I repeat, not – add to our deficits. Health care reform must be and will be deficit neutral in the next decade.
There are already voices saying the numbers don’t add up. They are wrong. Here’s why. Making health care affordable for all Americans will cost somewhere on the order of one trillion dollars over the next ten years. That sounds like a lot of money – and it is. But remember: it is less than we are projected to spend on the war in Iraq. And also remember: failing to reform our health care system in a way that genuinely reduces cost growth will cost us trillions of dollars more in lost economic growth and lower wages.
That said, let me explain how we will cover the price tag. First, as part of the budget that was passed a few months ago, we’ve put aside $635 billion over ten years in what we are calling a Health Reserve Fund. Over half of that amount – more than $300 billion – will come from raising revenue by doing things like modestly limiting the tax deductions the wealthiest Americans can take to the same level it was at the end of the Reagan years. Some are concerned this will dramatically reduce charitable giving, but statistics show that’s not true, and the best thing for our charities is the stronger economy that we will build with health care reform.
But we cannot just raise revenues. We also have to make spending cuts in part by examining inefficiencies in the Medicare program. There will be a robust debate about where these cuts should be made, and I welcome that debate. But here’s where I think these cuts should be made. First, we should end overpayments to Medicare Advantage. Today, we are paying Medicare Advantage plans much more than we pay for traditional Medicare services. That’s a good deal for insurance companies, but not the American people. That’s why we need to introduce competitive bidding into the Medicare Advantage program, a program under which private insurance companies offer Medicare coverage. That will save $177 billion over the next decade.
Second, we need to use Medicare reimbursements to reduce preventable hospital readmissions. Right now, almost 20 percent of Medicare patients discharged from hospitals are readmitted within a month, often because they are not getting the comprehensive care they need. This puts people at risk and drives up costs. By changing how Medicare reimburses hospitals, we can discourage them from acting in a way that boosts profits, but drives up costs for everyone else. That will save us $25 billion over the next decade.
Third, we need to introduce generic biologic drugs into the marketplace. These are drugs used to treat illnesses like anemia. But right now, there is no pathway at the FDA for approving generic versions of these drugs. Creating such a pathway will save us billions of dollars. And we can save another roughly $30 billion by getting a better deal for our poorer seniors while asking our well-off seniors to pay a little more for their drugs.
So, that’s the bulk of what’s in the Health Reserve Fund. I have also proposed saving another $313 billion in Medicare and Medicaid spending in several other ways. One way is by adjusting Medicare payments to reflect new advances and productivity gains in our economy. Right now, Medicare payments are rising each year by more than they should. These adjustments will create incentives for providers to deliver care more effectively, and save us roughly $109 billion in the process.
Another way we can achieve savings is by reducing payments to hospitals for treating uninsured people. I know hospitals rely on these payments now because of the large number of uninsured patients they treat. But as the number of uninsured people goes down with our reforms, the amount we pay hospitals to treat uninsured people should go down, as well. Reducing these payments gradually as more and more people have coverage will save us over $106 billion, and we’ll make sure the difference goes to the hospitals that most need it.
We can also save about $75 billion through more efficient purchasing of prescription drugs. And we can save about one billion more by rooting out waste, abuse, and fraud throughout our health care system so that no one is charging more for a service than it’s worth or charging a dime for a service they did not provide.
But let me be clear: I am committed to making these cuts in a way that protects our senior citizens. In fact, these proposals will actually extend the life of the Medicare Trust Fund by 7 years and reduce premiums for Medicare beneficiaries by roughly $43 billion over 10 years. And I’m working with AARP to uphold that commitment.
Altogether, these savings mean that we have put about $950 billion on the table – not counting some of the longer-term savings that will come about from reform – taking us almost all the way to covering the full cost of health care reform. In the weeks and months ahead, I look forward to working with Congress to make up the difference so that health care reform is fully paid for – in a real, accountable way. And let me add that this does not count some of the longer-term savings that will come about from health care reform. By insisting that reform be deficit neutral over the next decade and by making the reforms that will help slow the growth rate of health care costs over coming decades, we can look forward to faster economic growth, higher living standards, and falling, not rising, budget deficits.
I know people are cynical we can do this. I know there will be disagreements about how to proceed in the days ahead. But I also know that we cannot let this moment pass us by.
The other day, my friend, Congressman Earl Blumenauer, handed me a magazine with a special issue titled, "The Crisis in American Medicine." One article notes "soaring charges." Another warns about the "volume of utilization of services." And another asks if we can find a "better way [than fee-for-service] for paying for medical care." It speaks to many of the challenges we face today. The thing is, this special issue was published by Harper’s Magazine in October of 1960.
Members of the American Medical Association – my fellow Americans – I am here today because I do not want our children and their children to still be speaking of a crisis in American medicine fifty years from now. I do not want them to still be suffering from spiraling costs we did not stem, or sicknesses we did not cure. I do not want them to be burdened with massive deficits we did not curb or a worsening economy we did not rebuild.
I want them to benefit from a health care system that works for all of us; where families can open a doctor’s bill without dreading what’s inside; where parents are taking their kids to get regular checkups and testing themselves for preventable ailments; where parents are feeding their kids healthier food and kids are exercising more; where patients are spending more time with doctors and doctors can pull up on a computer all the medical information and latest research they’d ever want to meet that patient’s needs; where orthopedists and nephrologists and oncologists are all working together to treat a single human being; where what’s best about America’s health care system has become the hallmark of America’s health care system.
That is the health care system we can build. That is the future within our reach. And if we are willing to come together and bring about that future, then we will not only make Americans healthier and not only unleash America’s economic potential, but we will reaffirm the ideals that led you into this noble profession, and build a health care system that lets all Americans heal. Thank you.