Let’s Not Rush In Urgent Care Centers

Did you hear my heart go thud? As I write this, I just read of Beaumont’s plan to open 30 urgent care centers in Metro Detroit by the end of 2019 with an out-of-state urgent care clinic operator. It’s not a new concept, just more of the same; yet I fear the proliferation of urgent care clinics may lead to the demise of the Patient Centered Medical Home and its focus on patent-centric, whole person coordinated care.

We want everything fast: our information, our food, our relationships… but should we slow down just a bit here and think about the patient/physician bond that is formed through the years, through primary care physicians who sometimes take care of entire families, even multi-generations of families? What’s the likelihood of replicating the health benefits of a primary care physician/patient relationship in an urgent care setting? How about the multi-disciplinary team efforts offered by many PCP practices as an effective means of controlling and or preventing chronic conditions? That’s not on the urgent care menu. (Or should I say “Immediate Care?” I see signs, literally, that this segment of the industry is morphing into a drive-through type healthcare approach.)

Interoperability, one of my crusading initiatives, (Yes, I have many), will prove extremely difficult if not impossible in an urgent care setting, with patients the losers when their PCPs or specialists are not able to access EHR data from the urgent care provider. Another challenge is the ability for PCPs to maintain solid financial footing relative to their urgent care physician peers. PCPs can’t charge a facility fee—but many health system urgent care clinics can. Even when providing the same exact service. Not only isn’t it fair, it’s not the appropriate use of our precious health care dollars. Did Beaumont or other health systems ask local PCPs if they wanted to be part of an urgent care type network? That could be an innovative and prudent approach to what is apparently a pressing need for the type of services/hours/care rendered by urgent care clinics.

This is not to say that urgent care clinics don’t have a place in keeping us healthy, especially over the weekend when a trip to the Emergency Department seems unnecessary, (not to mention costly and time consuming) yet our strep throat, sliced finger, eye infection or flu-like symptoms do merit medical attention. But they are complementary to our existing medical relationships, not replacements. Their focus is on episodic care, not forging relationships with patients. I’ve been to urgent care clinics many times over the years for myself and immediate family members. I’ll be darned if I can remember the name of any of the treating physicians, as kind and capable as they may have been. Such encounters simply don’t tend to produce relationships, unlike the physician/patient relationships that develop in primary care. On that note, I want to redirect the conversation to a group of physicians that are trying to rescue primary care in Michigan: osteopathic physicians (DOs).

A September 2018 JAMA article highlights the impact that DOs play in driving primary care, noting that among the osteopathic physicians in residency training programs in 2017, 50 percent were training in internal medicine, family medicine, pediatrics and ob/gyn, compared to 40 percent of MDs, with an additional 25 percent of family medicine residency programs filled by osteopathic physicians. In my own experience, I repeatedly witnessed DOs in action, steeped in community, stepping up to participate in new primary care initiatives and reaching out to the disadvantaged. As a child, I recall my immigrant father turned away from Highland Park General on Christmas Eve when he had no insurance and little cash to treat the open wound on his foot. He hobbled in the snow to Detroit Osteopathic Hospital on Glendale Avenue, where he was not only treated but given cab fare by the emergency room physician to ensure his safe travels home. That’s primary care at its finest.

Risky Business For Health Plans

This summer featured continued disruption in aspects of the Affordable Care Act. This time, the vehicle was suspended risk adjustment payments to health plans. The payments have since resumed, but the methodology used to determine them has come under question.

So-called “risk adjustment” payments were established in the ACA to stabilize the health insurance market by transferring money to plans serving higher risk patients from those serving lower risk patients. The total in transfers for 2017 is $10.4 billion.

Two lawsuits, one in Massachusetts and one in New Mexico, declared the methodology used to determine payments respectively legal and then illegal. These lawsuits prompted CMS to issue a final rule in late July intended to address concern about the methodology used for the payments.

“The final rule will restore the operation of the risk adjustment program and mitigate some of the uncertainty caused by the New Mexico litigation,” CMS Administrator Seema Verma said in a statement. “Issuers that had expressed concern about having to withdraw from markets or becoming insolvent should be assured by our actions.”

And some issuers were glad to see the payments resume. “The risk adjustment program is an important tool that ultimately protects consumers and helps lower costs for members,” said Andy Hetzel, vice president corporate communications, Blue Cross Blue Shield of Michigan. “Overall, Michigan’s market is more competitive than other states, and has a lower statewide average premium. BCBSM is the largest insurer, with rates extremely competitive to other insurers.

But other issuers are not so sanguine. “We were disappointed that the states and CMS didn’t take this opportunity to rethink the payment formula equation, which is flawed. We thought it was a really great opportunity to crack open the model and the payment calculations to make sure what they had intended to protect against was actually occurring in the model,” said Marti Lolli, Chief Marketing Officer and Senior Vice President of Consumer and Government Markets for Priority Health, a Michigan health plan.

Lolli said the current formula bases risk adjustment payments on a state average premium, moving money from those with low premiums to those with higher premiums, ostensibly to cover the added risk of high-needs patients that tend to drive premiums up. But Lolli said administrative costs and profit margins are used to calculate a health plan’s average premium. She said the premiumsshould be calculated based on medical
costs alone, and health plans that have low administrative costs and use management strategies such as narrow provider networks (which Lolli
said save 18 to 20 percent) to drive down costs should not be penalized with high risk adjustment payments.

Lolli said larger plans with higher average premiums penalize other plans operating in the state by driving up risk adjustment payments.

In 2017, Lolli said Priority Health paid $57 million in adjustment
payments. Blue Cross and Blue Shield of Michigan received $105

“The statewide premium accomplishes the goal of the program, incentivizing insurers to set prices based on average risk, which creates a
more stable and less expensive risk pool,” said Hetzel.

“Frankly, the system would even better protect consumers if all carriers offered PPO plans. These plans have broader networks and typically attract people with more costly and complex health conditions. All other
carriers in Michigan have dropped this type of plan, leaving Blue Cross as the sole PPO option,” he added.

Lolli said there are a number of fixes that would make sense. In addition to removing administrative costs and profit margins from the state average
premium calculation, she said average premiums should be based on regions, rather than states to eliminate differences in costs between rural
and urban areas and to address market peculiarities within states.

Pursuing millennials and other young, healthy populations should not be penalized as enrolling healthy people who pay premiums was a major focus of the ACA, she said.

Another potential fix is limiting the exposure to risk payments for health plans that end up paying more in risk adjustment payments for their patients than they collect in premiums, a situation that affects about 20 percent of Priority Health’s enrollees, said Lolli.

“The risk of using a different formula, such as a calculation using a plan’s
own premium, is that the proposal would significantly increase volatility
in the market from year to year,” said Hetzel.

LETTER: Medicare For All Solves Many Problems


Read your paper for the first time (Sept., 2018 issue), picked it up at U of M hospital.
Interesting letter to the editor by Allan Dobzyniak, MD. Apparently, he needs to research exactly what Medicare for all means. If he seriously thinks that doctors and other providers won’t be paid, he is mistaken. He also claims that socialized medicine, as he refers to it does not work and is akin to slavery. Funny, I don’t see any ofthe countries that have socialized medicine taking steps to get rid of it. Socialized medicine is a term some like to use to scare people and whether we admit it or not, we already have some types of socialized medicine in the United States.

His letter to the editor was quite clear concerning his thoughts. He thinks doctors will be giving away care for free, “That someone would expect a service from another without payment seems much like the scourge of slavery that was belatedly banished from this country in the mid-19th century. There seems a hypocrisy here as the loud screams of the
virtue signalers for social justice are joined by equally loud screams for physician services on demand for “free.” Medicare for all in no way would force physicians to provide services for free. They would continue to be paid, just through a different venue.

Britain started its universal healthcare in 1948 and ranks above the United States in many areas when it comes to healthcare. Its citizens have a longer life expectancy and lower infant mortality. The country has more acute care hospital beds per capita and fewer deaths related to surgical or medical mishaps. Britain achieves these results while spending a lot less on health care than we do. When it comes to funding, universal healthcare in Britain it is funded through a national healthcare tax. Which is basically the same plan some are pushing for here. Taxes would be used to fund Medicare for all. For 2017 my premiums alone totaled nearly $7,000 and that figure does not include my deductible or co-pays. What difference does it make if I pay our government several thousand dollars for healthcare coverage, rather than a private entity? HMOs and
PPOs limit which doctors and providers you can use and they put limits on what care or drugs you can receive under their plans.

Medicare for all would level the field for all of us. We would all be able to access the same care, which isn’t the way it is today. One of my children (my youngest) was severely injured in an auto accident in 2001. Recently, my son was an inpatient at U of M for testing (for seizures). Due to a mix-up at the hospital they sought prior approval through his Medicaid plan, the request was denied and his appointment was on the verge of being
canceled. Luckily, I was able to connect with them and let them know he was covered by our auto coverage for the testing he needs. His appointment wasn’t canceled. This experience shows that not all patients are treated equally. They receive care based on the insurance coverage they have. If we had UHC then everybody would be treated the same.

For Dr. Dobzyniak to insinuate that doctors and providers won’t be paid is just ridiculous. My husband has Medicare, his providers are paid. I have BCBS and my providers are paid. My son has Medicaid for routine care, his providers are paid and he has auto insurance for auto related injuries and his providers are paid. Medicare and Medicaid are both government-run health insurance programs. Our auto insurance coverage, while
purchased through private insurers, could also be considered government coverage, since it is mandated by law. And, coverage for catastrophic injuries is for life (MCCA fund) and must cover any care that is deemed medically necessary for injuries received in auto related accidents. Under any of these types of insurance we have the ability to appeal,
should they deny any service’ or the payment for any service. One thing that would change is the fee scale. Doctors and providers would no longer be able to collect different fees from different entities.

Medicare for all in Michigan should help lower the cost of auto insurance premiums, since we would no longer need to purchase separate coverage for auto related injuries. There is a fight in this state currently to gut our no-fault auto insurance law and those that are trying to gut it claim that high premiums are due to medical providers gouging the auto insurance industry. When, in actuality, it is because there is not a fee schedule in
place like there is for every other form of healthcare insurance. Some may not like the idea of universal healthcare, but if we are going to get a handle on exploding healthcare costs we have to do something.

Cheryl Botbyl

COMPLIANCE CORNER: Suggestion For Medicare Providers

Erin Diesel Roumayah, Esq.
Wachler & Associates, P.C.

In June, the Office of Medicare Hearings and Appeals (OMHA) publicly implemented an expanded Settlement Conference Facilitation program. SCF is an alternative dispute resolution process which provides appellants and the Center for Medicare and Medicaid Services an opportunity to discuss a mutually agreeable resolution for claims appealed to the Administrative Law Judge (ALJ) or Medicare Appeals Council levels of appeal. This program applies mediation principles to resolve eligible Medicare appeals in an expedient and efficient manner. Through this program, an OMHA senior attorney or program analyst trained in mediation techniques acts as a neutral facilitator between the appellant and CMS in a one-day mediation, to negotiate a lump-sum settlement on eligible appeals.

OMHA has significantly modified the eligibility criteria for appellants and appeals under the expanded program. This program was first released in the summer of 2014 and was restricted to Medicare Part B providers and suppliers. Nearly two years later, given wide support and interest in the program, it was expanded to Medicare Part A providers. As of December 31, 2017, OMHA resolved 70,785 appeals through the various phases of the SCF program. Notably, this is the equivalent of almost an entire year’s disposition capacity for all of OMHA. Resolving nearly an entire year’s worth of appeals from the ALJ level of the appeals process frees up considerable resources for OMHA to adjudicate claims that are not eligible for SCF or other resolution processes, or claims that appellants preferred to try at hearing.

In the most recent SCF expansion, OMHA has significantly expanded the program’s eligibility criteria for appellants and appeals. For appellants, any Medicare Part A or Part B provider or supplier (with an assigned National Provider Identifier number) is eligible for participation, so long as that provider or supplier has not filed for bankruptcy or expects to file for bankruptcy in the future; does not have past or current False Claims Act litigation or investigations against them or other program integrity concerns such as civil, criminal or administrative investigations; and has either: (1) 25 or more eligible appeals pending at OMHA and the Council combined, or (2) less than 25 eligible appeals pending at OMHA or the Council and at least one appeal has more than $9,000 in billed charges.

Appeal eligibility criteria are as follows:
• Appeals must involve requests for ALJ hearing or Council review filed on or before November 3, 2017;
• The request(s) for ALJ hearing or Council review must arise from a Medicare Part A or Part B Qualified Independent Contractor (QIC) reconsideration decision;
• All jurisdictional requirements for OMHA or Council review must be met for the eligible appeals;
• All pending OMHA and Council appeals associated with a single NPI and corresponding Provider Transaction Access Number (PTAN) must be included in SCF;
• Appeals must not be scheduled for an ALJ hearing and an ALJ hearing must not have been conducted;
• The billed amount of each individual claim must be $1,000,000 or less. For the purposes of a statistical sample, the extrapolated overpayment amount stated in the initial demand notice must be $1,000,000 or less;
o Settlement agreements with individual claims, or extrapolated overpayments, of $100,000 or less will be fully executed when CMS and the appellant sign the settlement agreement.
o Settlement agreements with any individual claims, or extrapolated overpayments, in excess of $100,000 (and up to $1,000,000) will be subject to U.S. Department of Justice (DOJ) approval prior to full execution by CMS and the appellant.
• Appeals must not be involved in OMHA’s Statistical Sampling Initiative;
• Appeals must not be actively engaged in a CMS Medicare appeals initiative made available on or after November 3, 2017 (i.e. the Low Volume Appeals Settlement, the QIC Demonstration Project, or the CMS Serial Claims Initiative);
• The beneficiary must not have been found liable for the amount in controversy after the initial determination or participated in the reconsideration;
• Appeals must not involve items, services, drugs or biologicals billed under unlisted, unspecified, unclassified or miscellaneous healthcare codes;
• Appeals must not involve payment disputes (but appeals arising from down coding of claims can be eligible for SCF);
• Appeals must not arise from a QIC or ALJ dismissal order; and
• Appeals must not be beneficiary-initiated appeals of QIC reconsiderations or any appeals arising from Medicare Part C, Part D or appeals of Social Security Administration decisions regarding entitlement, Part B late enrollment penalties, and Part B and Part D income-related monthly adjustment amounts (IRMAA).

To initiate SCF under the expanded program, an appellant must submit a Request for SCF to OMHA. CMS will have 15 calendar days to accept or reject participation in the process. If CMS agrees to participate, OMHA will create a SCF Request Spreadsheet identifying all potentially eligible appeals for SCF resolution. OMHA will then send the spreadsheet to the appellant in a Preliminary Notification Package. An appellant will have 20 calendar days from receipt of the Preliminary Notification Package to accept or reject participation in the SCF process. Following OMHA’s receipt of the appellant’s Preliminary Notification Package the appellant will be issued an SCF Confirmation Notice.

In a significant departure from prior iterations of this program, certain eligible appellants may participate in a “fast track” resolution process. Specifically, appellants with appealed claims that have billed amounts of $100,000 or less or appeals of an extrapolated overpayment that is $100,000 or less are eligible to participate in the “fast track” process. These appellants will be offered an “SCF Express” settlement offer in the initial stages of the process. This offer is a non-negotiable settlement sum and OMHA clearly communicated that the SCF Express offer is not based on a medical review of an appellant’s eligible appeals. Appellants do not have the opportunity to submit initial information for CMS’ consideration as part of the SCF Express process. However, appellants should expect that the SCF Express settlement offer will be based on preliminary data available to CMS regarding the appellant and its claims, such as the appellant’s track record of favorable findings before ALJ hearing and the Council, or the number or scope of prior audits initiated by CMS regarding the appellant. If an appellant accepts the SCF Express settlement offer, the appellant and CMS will sign a settlement agreement memorializing the terms of the settlement and the covered claims will be dismissed from the Medicare appeals process.

If an appellant rejects the SCF Express settlement offer but wishes to proceed to the SCF conference, OMHA will coordinate a Pre-Settlement Conference between the appellant and CMS. At the Pre-Settlement Conference, the appellant, CMS and the OMHA facilitator will discuss the logistics for the settlement conference, schedule a date and time for the settlement conference, select sample claims for CMS’ and the appellant’s consideration, and schedule the timing of submission of supporting materials such as a position paper. At the day of the conference, if settlement is not reached, the appeals will return to the previous assigned adjudicator, if applicable, or to the OMHA and Council docket for future assignment in the order in which the request for review was received. If a settlement is reached, a settlement agreement is signed the day of the facilitation and the settled claims are dismissed from the Medicare appeals process.

There are recommended best practices and strategies for participation in SCF. For one, appellants should prepare a thorough evaluation of any sample claims identified during the Pre-Settlement Conference. The thorough evaluation should include a comprehensive position paper with supporting documentary evidence and testimonial support. Appellants should timely submit this information to CMS for CMS’ consideration in advance of the SCF conference. Appellants should also consider showcasing their major strengths, accolades and any unique considerations for CMS’ review. A thorough and strong posturing of the case prior to the conference can have a substantial impact on the success of the conference. Although at the conference there are no findings of fact or rulings of law, participants should be prepared to make an opening statement which highlights major issues and concepts for CMS’ consideration. Following opening statements, the SCF conference then proceeds through private sessions with the OMHA facilitator, who acts as a neutral intermediary in facilitating a resolution between the appellant and CMS.

The voluntary and expedited nature of the SCF process should be attractive to Medicare appellants seeking a cost-effective and efficient resolution of their pending appeals. If settlement is not reached, an appellant’s claims return to the ALJ appeals process in the order in which they were originally received. Although OMHA did not establish a firm time table for completion of the SCF process, a conservative estimate is that this process takes at least 10 weeks from the date an appellant receives OMHA’s spreadsheet identifying eligible claims until the date of the SCF conference. That is considerably faster than the Medicare traditional five-step appeals process that at recent estimates takes nearly 173 weeks at the ALJ level of appeal alone. As there currently is no deadline by which appellants must elect to participate in this program, providers and suppliers should review their potentially eligible claims and consider participation.

i . At a recent speech regarding the appeals process and new initiatives to combat the backlog and improve the appeals process, Chief Administrative Law Judge Nancy Griswold of OMHA estimated that in FY 2017 OMHA decided 84,729 appeals. “Latest Policy & Regulatory Changes to the Medicare Appeals Process,” American Health Lawyer’s Association Conference, March 21-23, 2018, presentation by Nancy J. Griswold, Chief Administrative Law Judge, OMHA and Erin Diesel Roumayah, Esq.

LEGAL LEANINGS: Mental Health Parity

Mental Health Parity Really Does Mean Equal Benefits
By Erica Morris, Gregory Moore and Russell Kolsrud

In Danny P. v. Catholic Health Initiatives, 891 F.3d 1155 (9th Cir. 2018), the Ninth Circuit clarified the full extent of the “parity” required in the federal mental health parity law1 which has been in place since 2008.

In Danny P., the Ninth Circuit held that a particular group health plan (the Catholic Health Initiatives Medical Plan—Blue Cross Blue Shield) was prohibited from denying the same or equivalent room and board coverage in behavioral health facilities that it provided in non-behavioral health facilities, overturning the district court’s decision in favor of the plan. Specifically, the Court held the plan could not be permitted to deny inpatient room and board costs at a behavioral health inpatient residential treatment facility while simultaneously allowing coverage for non-behavioral health (medical and surgical) inpatient room and board costs at a skilled nursing facility.

The plan at issue was a self-funded group health benefit plan covering Catholic Health Initiatives employees and their dependents, and provided for coverage of “mental health services,” bed, board, and general nursing care, ancillary services provided at skilled nursing facilities, and also provided coverage for residential treatment facilities (licensed facilities that deal with illnesses affecting mental health). The health insurance plan here was trying to limit payments for behavioral health residential services. Many plans attempt to limit residential behavioral health services because they are much more costly than the physical medicine corollary (e.g. a skilled nursing facility).

As stated in the opinion:

The Parity Act requires that benefits in a plan that provides for “both [ (a) ] medical and surgical benefits and [ (b) ] mental health or substance use disorder benefits,” must not impose more restrictions on the latter than it imposes on the former. 29 U.S.C. § 1185a(a)(3)(A). Specifically, the Parity Act states the following:

In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that—

(i) the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits; and

(ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.


See Danny P., 891 F.3d at 1157–58.

The Ninth Circuit explained that neither the Parity Act nor the regulations specifically address every situation, leaving room for interpretation but reasoned the regulations “did indicate that mental and medical/surgical benefits must be congruent, and that limiting the former while not placing a similar limitation on the latter would be improper.” Id. at 1159.

As the opinion’s mandate ripples outward from the Ninth Circuit and impacts other enforcement actions, the next area of advocacy for parity will likely focus on qualitative or nonquantitative treatment limitations, which will be harder to identify, but equally if not more important to the successful and comprehensive treatment of mental health and substance use disorders envisioned by the Parity Act.

1 Most health plans must include behavioral health benefits as the Patient Protection and Affordable Care Act mandates. As such, under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), plans containing behavioral health benefits must offer them on par with medical/surgical benefits. For more information, see https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html.


He’s Running As A Doctor But Can’t Practice . . . Does It Matter?
Matt Longjohn’s chief selling point in his Michigan 6th Congressional district run is that he’s a medical doctor. But he can’t practice medicine in Michigan because he isn’t professionally licensed in this state or in Illinois, where he formerly worked.

Longjohn, the Democrats’ nominee in the southwest Michigan district, has made a career on the administrative side of health care, most significantly as the first-ever National Health Officer for the 2,700 YMCAs in the United States when he worked in Chicago.

In campaign materials, he refers to himself as Dr. Matt Longjohn, MD, and uses the squiggly heartbeat signal to punctuate the point. But according to the Department of Licensing and Regulatory Affairs, he’s never been licensed as a health professional in Michigan.

And whether he’s allowed to describe himself as such under the Michigan Public Health Code is an open question in the legal community.

The Public Health Code (333.16261) reads “an individual who is not licensed or registered under this article shall not use an insignia, title or letter . . . to induce the belief that the person is licensed or registered in this state.” Asked if that means Longjohn is in violation of the code by presenting himself in a political campaign as a doctor when he is not licensed to practice, LARA spokesperson Pardeep Toor simply referred MIRS back to this section of law.

Four attorneys that specialize in healthcare that were contacted by MIRS were split on the question.

Mike Stevenson from the East Lansing firm of Willingham & Cote said this type of question about the use of the title “doctor” has come up before among his colleagues and there are “varying opinions” on it.

“In my opinion, it’s not untruthful. If he has a medical degree, he is telling the truth. As long as he’s not practicing,” Stevenson said he doesn’t see a problem.

A second attorney questioned by MIRS agreed that as long as Longjohn wasn’t advertising his services as a medical professional, he not sure there’s a problem.

However, practicing medicine in Michigan without being a licensed doctor is a felony and while what Longjohn is doing doesn’t rise to that level, attorney Ronald Chapman II, of Troy, isn’t comfortable with it. He viewed the usage of the terms as “problematic” in that it gives people the impression he can perform medical services when that is not the case.

“I would advise my client against using these titles, particularly using the combination of the ‘MD’ and the ‘Dr.’ It insinuates you are in the practice,” Chapman said. “I don’t think that’s appropriate.”

A fourth healthcare attorney for a major Michigan firm told MIRS MCL 333.17011(5) specifically limits those using “MD” to those “authorized to use the term” as they are written. The only people who can claim to be an “MD” are those allowed by the state to be doctors of medicine, this attorney said.

Longjohn may be able to use the term “doctor,” but that’s not clear under the law, either.

“Whether he can use ‘Dr.’ depends on several factors. Does he have any other degrees? Many professors and other professionals with doctorates use the title ‘Dr.’ Technically, I can call myself a ‘Dr.’ since I have a JD degree. Is he trying to induce the belief that he is licensed?” this attorney asked.

Longjohn said he earned his medical and public health degrees from Tulane and did his internal medicine internship at Northwestern University. During that time in 2001, he received a “temporary medical permit in Illinois,” according to the state of Illinois.

Since then, he’s been a teacher, a researcher, and a leader of non-profit organizations.

“My achievements as a health care innovator came as a result of work done outside of clinical settings, where my teams developed programs, policies, and coalitions to improve the health of millions of people’s lives,” he said. “I have never once said during this campaign that I am a currently practicing physician.”

Told of Longjohn’s resume, former U.S. Rep. Joe Schwarz, a physician by trade, said “it’s not unheard of” for the carrier of a medical license to not get licensed as a doctor in the state in which he or she is living, but “it is odd.”

“It raises the question to me, ‘Why do you not have a Michigan license?'” Schwarz asked. “To me, I can see where, if I were running against him, this would be duplicitous. He can call himself a doctor, but he can’t practice? I just find it odd.”

MRP Says Longjohn Playing Doctor On TV
The Michigan Republican Party believes Democratic 6th Congressional District nominee Matt Longjohn is “misrepresenting himself” as an “MD” in conflict with Michigan law, because he is calling himself a doctor when he isn’t licensed to practice in Michigan or seemingly anywhere else.

Longjohn is calling himself “Dr. Matt Longjohn MD” in his campaign materials, while using a heartbeat monitor line to his campaign material to stress his medical competence.

Longjohn did complete medical school at Tulane and held a temporary medical license in Illinois during his residency at Northwestern, but that expired in 2001, MIRS reported.

He’s since gone on the administrative track with his medical degree, working on issues such as diabetes and running health issues for the YMCA in Chicago. However, Michigan Republican Party Deputy Chief of Staff Sarah Anderson concurs with an attorney contacted by MIRS that Longjohn is running afoul with the Public Health Code by claiming to be a MD when he isn’t licensed to see any patients.

“Matt Longjohn may not be a doctor, but he plays one on TV,” Anderson said. “Matt Longjohn is lying about his experience to win votes on the critical issues of healthcare. Voters deserve better. If Longjohn is willing to misrepresent himself about this, where does he draw the line?”

But speaking on Michigan’s Big Show recently, Dr. Rob Davidson, the Democrats’ congressional candidate in the 2nd District, said he went to medical school with Longjohn and he doesn’t believe there is any false advertising in Longjohn using the titles “MD” or “Dr.”

“He’s a doctor. He’s chosen a path of post-training to promote policy in a bigger way,” Davidson said. “He was YMCA national health director. He did many things for diabetes, education, prevention, health eating. He worked with Michelle Obama.

“I know Matt. Matt and I went to college together. We lived down the hall from each other and it’s exciting to me that people who come at health care from many different angles are running for Congress.”

Groups Band Together To Create Health Plan For Small Businesses
Two of Michigan’s leading small business organizations announced the creation of a new health insurance program, known as an Association Health Plan (AHP), that they say could actually lower rates for small businesses.

Rob Fowler, president and CEO of the Small Business Association of Michigan (SBAM), predicted savings “with some confidence of 3 to 5 percent in the first year.”

In the longer term, we will be able to negotiate on behalf of a very large group—and the rates will be based on the experience of the group so it is experience-rated as a group, not each of the companies themselves but the group—so in the third and fourth years, if we have good experience … We have talked a lot about the trajectory of health care costs or bending the cost curve. I think we are actually going to bend it down, not just not going up so fast,” he said.

“Rates have been going up year over year for many years. We are talking about rates going down,” said Jennifer Kluge, president and CEO of the Michigan Business and Professional Association.

Under an executive order signed by the president in October 2017 reforming the Affordable Care Act and under new rules drafted by the U.S. Department of Labor to implement it, SBAM and MichBusiness joined together to form a nonprofit 501-c6 and create one of the first AHPs in the country, named TranscendAHP.

An AHP allows small businesses and their employees and self-employed workers to band together by geography or industry to obtain health care coverage as if they were a single large employer. The strength of an AHP is creating negotiating power by creating large risk pools with greater economies of scale.

Fowler said a key to getting rates as low possible is getting bigger numbers in the plan.

“Actuaries believe that about 40 percent of the marketplace would do better in an association health plan. Forty percent of Blue Cross’ small group market would be 90,000, that’s employees,” he said.

“Access to comprehensive health insurance programs continues to rank at the top of small business owners’ concerns. Combined with a tight labor market, our members need options that allow them to compete with much larger companies for the talent they need to be successful,” Kluge said.

Blue Cross Blue Shield of Michigan and the Blue Care Network was selected as the provider, which will give small businesses access to options that previously had only been available to larger companies.

TranscendAHP will be available to businesses of between one and 50 employees. There are membership requirements, but the new plan will be ready to start providing quotes this week to businesses interested in signing up for coverage beginning Jan. 1.

More information about the plan is available at the plans website at https://transcendmichigan.org/

“We are happy to say that we designed this to benefit the small business community, we also made it open to all independent insurance agents, so we are not competing. We are open to everyone. That’s the whole thing, we are open to everyone and we are not creating more competition. We really want to make this successful,” Kluge said.

Union-Backed Health Care Bus Rolls Into 6th, 8th CD
A pro-Affordable Care Act group fueled by organized labor money rolled its bus in front of the Capitol Oct. 3 as a backdrop to a general condemnation of U.S. Rep. Mike Bishop’s (R-Rochester) support of the U.S. House Republicans’ healthcare bill.

Protect Our Care is drawing attention to how congressional Republicans passed a re-work of the ACA earlier in the term, but the reforms never made it out of the U.S. Senate.

Former gubernatorial nominee Mark Schauer, Sen. Curtis Hertel Jr. (D-East Lansing) and House Minority Leader Sam Singh (D-East Lansing) stood with a pair of cancer survivors in arguing how Republicans “need to be held accountable” for wanting to dismantle the ACA.

The bus rolled on later in the day to Kalamazoo, where 6th District Congressional candidate Matt Longjohn held a press conference with state Senate candidate Sean McCann.

In Lansing, cancer survivor Amanda Itliong apologized for being delayed in getting to the press conference. Moments earlier, she was in a parking lot throwing up. It’s something that she’s had to get used to as she’s gone through treatment.

She proceeded to give emotional testimony about how the certainty of the ACA has helped her get through the challenges for her multiple bouts with cancer and the anxiety that comes with worrying about losing her health insurance. She fingered Bishop House Republicans for wanting to gut the law.

“Mike Bishop is my representative, but he doesn’t represent me,” Itliong said.

Laura Packard added that as a stage four cancer survivor, she’d be either bankrupt or dead if it weren’t for the ACA.

“President Trump may have blocked me on Twitter, but he can’t stop me and the American people from fighting to protect our care,” Packard said.

The Protect Our Care bus tour is rolling from late September to early November through 23 mostly swing states, such as Ohio, Florida, Wisconsin, Iowa, Arizona, Colorado, Missouri, Tennessee and Virginia.

Supremes Decline To Hear Appeal Requesting Flint Water Case Goes To COC
The Michigan Supreme Court declined Oct. 2 to hear an appeal of a lower court’s decision that transferred a Flint water case from the Court of Claims to Genesee County Circuit Court.

The Court of Appeals said COC Judge Christopher Murray “properly transferred” the case, Melissa Mays et. al v. Governor, State of Michigan, et. al.

The MSC also declined the plaintiffs’ motion to dismiss the defendants’ June 19 application to appeal and a motion to stay the lower court proceedings.

Justice Elizabeth Clement did not participate in the court’s decision due to her prior involvement as chief legal counsel for Gov. Rick Snyder, a named defendant.

Mays and 18 other named plaintiffs allege Snyder, State of Michigan and former treasurer Andy Dillon violated the Elliott-Larsen Civil Rights Act.

Flint switched its water source from Lake Huron to Flint River in April 2014 and the river was not properly treated, allowing lead to leach.

In related news, Mays was one of a number of Flint community leaders and residents speaking out against Attorney General Bill Schuette for allegedly “trying to brush off his record of failing and then ignoring” Flint residents’ complaints about the water in 2014 and 2015. The press conference was held this afternoon in Flint.

Meanwhile, the U.S. Supreme Court declined Tuesday to hear Michigan Department of Environmental Quality (DEQ) employees’ writ of certiorari in Nappier et. al v. Stephen Busch et. al, which also is related to the Flint water crisis.

Applicants Will Know Early If An Old Conviction Will Keep Them From License
License applicants will be able to learn early in the process if an old criminal conviction is going lead to denial, under three bills reported out of House Regulatory Reform Committee Oct. 2.

The bills, HB 6058, sponsored by Rep. Scott Vansingel (R-Grant); HB 6059, by Rep. Terry Sabo (D-Muskegon); and HB 6060, by Rep. Jim Lilly (R-Holland) allow the applicants to get a preliminary determination of eligibility from the state before they sign up for courses or put down money for testing fees.

“We don’t want people to spend the money for the licensure and then not being able to get it, taking the course work and not being able to get a license,” Committee Chair Rep. Brandt Iden (R-Kalamazoo) explained.

The bills were added into a four-bill package intended to remove barriers to licensure for people with old convictions.

Some 200 occupations and professions in Michigan require a license, equaling about 20 percent of available jobs.

“This is really an issue that so many folks, as I talk to them throughout the state, talk about. People that have got past criminal convictions that cannot get licensure because one issue that happened 20, 30 years ago. And if we want to talk about filling gaps in the workforce, which we hear from all of our employers in the state of Michigan, we need to make sure we are addressing that,” Iden said.

Iden’s HB 6110 would change the definition of “good moral character” to keep a conviction from being the sole reason for license rejection or a permanent ban. Licenses would still be reviewed by the department, most often the Department of Licensing and Regulatory Affairs.

Many licenses have a list of specific crimes which would result in denial. HB 6111, by Rep. Beth Griffin (R-Paw Paw), would address health occupations; HB 6112, Rep. Michele Hoitenga (R-Manton), skilled trades; HB 6113, by Rep. Joseph Bellino (R-Monroe), addresses eligibility requirements; and HB 6381, by Rep. Jeremy Moss (D-Southfield), would require an annual report on the denial of licenses based on lack of good moral character.

All bills were reported out in 15-0 votes.

Iden has a related bill, HB 5881, to ease the prohibition of employing casino workers and suppliers who have convictions, but the bill is being reworked to make general updates to the Gaming Control Act.

Supremes Decline To Stop Healthy Kids Contract
The Michigan Supreme Court denied a Florida insurance company’s request to halt implementation of the state’s Healthy Kids Dental Contract until the courts decide whether the state violated the statutory competitive bid mandate.

Scott Eldridge, attorney for the MCNA Insurance Company, said the company was disappointed in the MSC’s decision, but they will “continue to fight to shine a light on the dark corners of state government and provide much-needed transparency and accountability to a deeply flawed bidding process.”

“Michigan taxpayers deserve a full accounting of how their tax dollars are being spent and to know why a $659 million Healthy Kids Dental contract was awarded in a process fraught with illegalities and improprieties,” he said.

MCNA alleges the Department of Technology, Management and Budget (DTMB) showed “blatant favoritism” in awarding a $659 million contract for its Healthy Kids Dental Program to Blue Cross Blue Shield, whom the state acknowledged was allowed to change its bid.

Ingham County Circuit Court Judge Joyce Draganchuk ordered state officials and DTMB to submit an affidavit and testify under oath about the awarding of the dental contract.

The state appealed Draganchuk’s decision and it went to the MSC who remanded it to the Court of Appeals for “plenary” consideration on an “expedited basis.” The contract went into effect Oct. 1.

Lansing Lines is presented in cooperation with MIRS, a Lansing-based news and information service.

Drugmakers Play The Patent Game

David Herzberg was alarmed when he heard that Richard Sackler, former chairman of opioid giant Purdue Pharma, was listed as an inventor on a new patent for an opioid addiction treatment.

Patent No. 9861628 is for a fast-dissolving wafer containing buprenorphine, a generic drug that has been around since the 1970s. Herzberg, a historian who focuses on the opioid epidemic and the history of prescription drugs, said he fears the patent could keep prices high and make it more difficult for poor addicts to get treatment.

“It’s hard not to have that reaction of, like … these vultures,” said Herzberg, an associate professor at the University at Buffalo.
James Doyle, vice president and general counsel of Rhodes Pharmaceuticals, the Purdue subsidiary that holds the patent, said in an email statement that the company does not have a developed or approved product and “therefore no money has been made from this technology.”
“The invention behind the buprenorphine patent in question was developed more than a dozen years ago,” he wrote. “If a product is developed under this patent, it will not be commercialized for profit.”
Yet, the patenting of a small change in how an existing drug is made or taken by patients is part of a tried-and-true pharmaceutical industry strategy of enveloping products with a series of protective patents.
Drug companies typically have less than 10 years of exclusive rights once a drug hits the marketplace. They can extend their monopolies by layering in secondary patents, using tactics critics call “evergreening” or “product-hopping.”

Lisa Larrimore Ouellette, a patent law expert at Stanford University, said the pharmaceutical industry gets a greater financial return from its patent strategy than that of any other industry.

AztraZeneca in 2001 famously fended off generic versions of its blockbuster heartburn medicine Prilosec by patenting a tweaked version of the drug and calling it Nexium. When Abbott Laboratories faced multiple generic lawsuits over its big moneymaker Tricor, a decades-old cholesterol drug, it lowered the dosage and changed it from a tablet to a capsule to win a new patent.

And Forest Laboratories stopped selling its Alzheimer’s disease drug Namenda in 2014 after reformulating and patenting Namenda XR to be taken once a day instead of twice.

Another common strategy is to create what Food and Drug Administration Commissioner Scott Gottlieb calls “patent thickets,” claiming multiple patents for a single drug to build protection from competitors. AbbVie’s rheumatoid arthritis drug Humira has gained more than 100 patents, for example.

The U.S. Patent and Trademark Office awards patents when an innovation meets the minimum threshold of being new and non-obvious. Secondary patents are routinely granted to established drugs when an improvement is made, such as making it a once-a-day pill instead of twice a day, said Kristina Acri, an economist and international intellectual property expert at the Fraser Institute and Colorado College.

“Is there a better way? Maybe, but that’s not what we’re doing,” Acri said.

The controversial patent that Sackler and five co-inventors obtained is widely known as a “continuation patent.” (The original patent application for the wafer was filed in August 2007.)

Continuation patents do not necessarily extend the patent life of a drug, but they can have other uses. In 2016, Rhodes filed a lawsuit against Indivior alleging patent infringement.

Indivior, formerly part of Reckitt Benckiser, sells a film version of the popular addiction treatment drug Suboxone that is placed under the tongue — an oral medicine similar to what Rhodes has patented. Indivior’s comes in a lime flavor.
Indivior’s film, which federal regulators approved in 2010, dominates the market with a 54 percent average market share, according to the company’s most recent financial report. And the company has vigorously fought rivals, including filing lawsuits against firms such as Teva Pharmaceutical Industries, which sought approval to manufacture generic versions. Indivior declined to comment.

The Rhodes Pharmaceuticals version would be a wafer that melts quickly in the mouth. The inventors list potential flavors including mint, raspberry, licorice, orange and caramel, according to the patent.
For opioid historian Herzberg, the patent battles between companies like Rhodes and Indivior are “absolute madness.”

Decisions on what is available on the market to treat addicts should be based on what is the best way to treat the people who have the problem, he said.
Patent battles, Herzberg said, are “not how you want drug policy getting made.”

Attempts to change the patent system have intensified over the past decade as prices of prescription drugs continue to climb.

In 2011, President Barack Obama signed the America Invents Act, which included the creation of the Patent Trial and Appeal Board. The PTAB is an alternative to using the cumbersome U.S. court system to challenge weak patents. Generic drug manufacturers have used the board’s “inter partes review” process and overturned 43 percent of the patents they challenged, according to recent research.

Critics of the administrative process, including the pharmaceutical industry trade group PhRMA, said it creates “significant business uncertainty for biopharmaceutical companies.” Often companies have to defend their products twice — both in the courts as well as before the PTAB, said Nicole Longo, PhRMA’s director of public affairs.

Drug giant Allergan attempted to overcome the PTAB’s review process by arguing that the patent couldn’t be challenged at the review board because they sold the patent to the St. Regis Mohawk Tribe, which had sovereign immunity. A federal appeals court ruled this summer that Allergan could not shield its patents from the PTAB review this way.

This year, several members of Congress proposed bills that would unwind or limit changes made by the America Invents Act, though nothing is likely to happen before the midterm elections. The STRONGER Patents Act, introduced in both the House and Senate, would weaken the PTAB board by aligning its claims standards with what has been established by court rulings.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. http://www.kaiserhealthnews.com

Dems Call For Immediate PFAS Hearings; They Won’t Happen

House Democrats called on Republicans to hold hearings this week, specifically in the Natural Resources and Oversight committees, to have the Department of Environmental Quality present what it knows about PFAS contamination and how extensive the problem is in Michigan.

Eight Democrats, led by Minority Floor Leader Christine Greig (D-Farmington Hills), held a press conference Sept. 4 to demand the hearings and that lawmakers take immediate action to strengthen water quality standards for perfluoroalkyl and polyfluoroalkyl substances (PFAS), a diverse group of compounds resistant to heat, water and oil. Such chemicals have been used in hundreds of consumer products and industrial applications including carpeting, apparels, upholstery, food paper wrappings, fire-fighting foams and metal plating.

The chairs of those committees, Rep. Gary Howell (R-North Branch) and Rep. Joseph Graves (R-Linden), called the press conference “political” and said hearings won’t be happening in early September. Howell said he is committed to holding hearings, but will wait until after the election.

“It is a pattern of indifference. That’s why we need the public pressure right now to call for hearings, call for oversight, and get back to an empowered DEQ that understands the issue, listens to the scientific data, listens to the public health concerns, and actually takes action,” Greig said in the press conference.

“I think the big concern is we have very few session days left,” said Rep. Kevin Hertel (D-St. Clair Shores). “They have already cancelled a few weeks between now and the election and our concern is that we are here this week. There is no reason we cannot have hearings this week. The Oversight Committee meets at 9 a.m. on Thursdays and legislators will be here this Thursday. So, let’s bring the department in and ask them the important questions.”

Howell was not convinced.

“I don’t see, in the current atmosphere, it being a productive hearing. I’m not wanting to hear people demagogue this issue one way or the other. I want calm, clear testimony from scientifically qualified people to explain what the level should be going forward. And I just believe that we are not in the right atmosphere, at the moment, to have that kind of calm discussion and work out the best possible solution. But I am committed to doing hearings in November,” Howell said.

Graves noted the state legislature gave the DEQ $23 million a few months ago to study the problem.

“We want to give the DEQ an opportunity to do their job, conduct a study, take the proper empirical measurements, be analytical because this is a new animal . . . We need to know what this is. They are doing their testing. They are working with the feds. And we want to make sure they understand what’s a safe level and what’s an unsafe level,” he said.

Acceptable levels of PFAS in drinking water are a key issue. Rep. Winnie Brinks (D-Grand Rapids) noted that currently there are 30 communities in Michigan which have PFAS levels above the current advisory level of no more than 70 parts per trillion.

“Even more troubling is that that level is only an advisory. We still do not have an enforceable drink water standard established in law to protect our citizens from PFAS contamination,” Brinks said. She introduced legislation last year to set a much lower level for drinking water of 5 ppt. She said that is more in line with new recommendations from the Centers for Disease Control of no more than 7 to 11 ppt.

Brinks also said Democrats are proposing to increase the funding for PFAS response to $39 million. She noted Gov. Rick SNYDER originally asked for that amount in the budget. She said Republicans in the legislature cut the amount to $23 million.

And Democrats have called for the Legislature to provide communities with alternate water supplies in cases of contamination, instead of relying on impractical bottled water for washing, bathing and cooking.

Since the introduction of legislation in December, House Democrats say they have repeatedly called on the chairman of House Oversight to hold hearings on PFAS contamination, yet their calls for action have gone unanswered.

Both Howell and Graves said they had not been contacted by Democrats about the call for hearings the week of Sept. 4.
“We are finally back in session tomorrow,” Greig said. “The time for excuses is past. This administration and legislative Republicans have an opportunity to show that they can do more than the bidding of the wealthy corporate donors. As the Great Lake State, our water is part of our collective identity. Yet, even as we are surrounded by the most abundant freshwater source on Earth, we are unable to assure the water coming out of our taps is safe for us to drink or bathe in. Pure Michigan has to be more than a marketing slogan.”

This story presented in cooperation with MIRS, a Lansing-based news and information service.

Toxic Déjà Vu – PBBs And Now PFAS

Do you remember Polybrominated Biphenyls (PBBs) sowing fear and disease into the lives of Michigan citizens approximately 43 years ago? Those PBB’s entered the larger food chain through a single error made by a Gratiot County chemical company worker when a ton of Firemaster (a toxic fire retardant) was added to cattle feed. PBB’s were ingested by cattle throughout this area and spread throughout Michigan and the Midwest, producing one of the largest chemical poisonings in the Western world. Another much larger and more dangerous toxic chemical exposure has been discovered. This family of toxins, through ignorance, and poor oversight has been introduced to Michigan’s and U.S. citizens in multiple insidious ways. These chemicals are called Per- and Polyfluoroalkyl Substances (or PFAS and PFOS).

U.S. Rep. Dan Kildee said that “the seriousness of PFAS contamination cannot be overstated.” Frankly, like the PBB issue in the ‘70s the PFAS poisoning ushers in another era of ecologic crisis. These perfluorinated compounds are linked to cancer, liver damage, birth defects, infertility, thyroid and autoimmune disease, neurologic disorders and hypercholesterolemia. According to Kildee at a recent meeting with physicians, these compounds have been found in more than 30 sites throughout Michigan and are entering aquifers and the Great Lakes. Recently, large amounts have been measured in Lake St. Clair, near 1,000 parts per trillion. Because of this, there is a fish consumption advisory and concern among the cities supplied by water from this lake. All of the Great Lakes will eventually be affected.

The State of Michigan was warned back in 2012 by Superfund section specialist Bob Delaney, a Department of Environmental Quality employee. Not until five years later did Gov. Rick Snyder’s office set up a PFAS response team.

These chemicals have been used in military installations and businesses for a variety of purposes. Some of the most common are water repellant clothing, non-stick pans (Teflon), stain resistant fabrics including carpets, tanning products, cosmetics and fire-fighting foam. There are more than 3,000 of these man-made fluorinated organic chemicals. M-Live reported that it had been found in high concentrations in both Flint’s Gilkey Creek and the Coldwater Road landfill. The EPA has set the concentration for a lifetime consumption limit for humans at 70 ppt. Like with the Lead and Copper Rule used by the federal government, many feel these toxic exposure limits should be lower.

Should physicians desire further information regarding these chemicals for their patients, laboratory tests exist that will evaluate levels of these chemical families in the water and in the blood. Water testing can be done with Pace Analytical Lab, Watercheck and TapScore, to name a few. For testing blood samples there are at least two labs available, NMS and Vista Analytical Laboratory.

The Precautionary Principle was not applied to the PFAS family of chemicals. This is a rule that is used in other countries and Europe but not often in the United States. It is also part of an accepted resolution by the AMA produced by the Genesee County Medical Society. It states that prior to the release of a new chemical into an environment the chemical must be studied and its potential for harm thoroughly understood. In the United States, traditionally many chemicals are released first with little safety evaluation and if significant harm comes, then they are removed. Unfortunately, the fines are much less in many cases than the profits gained.

PFAS contamination was a disaster just waiting to happen. It was not adequately studied for disease-causing potential in people, animals or fish. The sad thing is that people will be injured and die because the Precautionary Principle had not been applied.

In both environmental disasters, PBBs and now PFAS chemicals, serious mistakes were made with their testing, handling and use. It is clear that an in-depth study of chemical safety prior to release into the environment of all chemicals are required. Following this, strict regulation of all discovered toxins needs to be enforced. Perhaps by doing so the ecosystem our children and grandchildren inherit will be healthier than the one that we now share.

This column comes to Healthcare Michigan courtesy of the Genesee County Medical Society. Natzke is GCMS President. The article was previously published in the Genesee County Medical Society Bulletin and appears here with permission.

I’m Voting For Healthcare Interoperability In November. How About You?

We know that “Fix the Damn Roads” is a critical imperative for one of Michigan’s gubernatorial candidates—and hopefully for both. But is “Fix the damn interoperability problem with electronic health records” another? The intersection of healthcare and politics is obviously not new. I would contend it’s more visible—and viscious—than ever. Still, the focus tends to be on access to care and delivery of care, and I understand that. Interoperability of EHR hardly pulls at the heartstrings or incites passionate conversation from either side of the aisle. Accordingly, it doesn’t garner much attention from the consumer media either. That is why it is important for healthcare decision makers to individually and collectively raise awareness of the issue, not just in the healthcare community, but with our elected officials.

To make sure we’re clear on the topic (and in case some politicians are reading this,) interoperability in this context refers to the ability to share and interpret patient data and information electronically across systems and devices among hospitals, insurers, clinics and private practice physicians.

I’ve said it before, and I’ll say it again: there ought to be a law. While I disdain the proliferation of excessive laws that seemingly aim to control our every move, legislation embraced by both parties to establish requirements for the interoperability of individual healthcare records is critical element of health reform. It empowers both patients and their providers to get sensible, timely care without excessive testing, over-testing and re-testing. It is patient-focused and cost conscious, while consistent with population health goals.

If I’m hospitalized and then transferred to another hospital, the assumption is that my records will be immediately available electronically to the receiving hospital. Let’s also touch on emergency room or urgent care activities. These “urgent” encounters become part of the patient’s permanent health record seamlessly. Right? Similarly, if I had an ultrasound done at hospital “X” last year, the ultrasound results should be available online, with my permission, at hospital “Y” this year, correct? The response to all these scenarios is, “Not necessarily.” Similarly, unless a physician practice uses a registry or an EHR that “speaks” to a data repository, health plans are also forced to send auditors to the provider to extract much needed HEDIS information, which can get needlessly complicated when the physician doesn’t use a registry at all. (Yes, some physician practices still rely on paper documentation.) Why is this lack of patient data transfer acceptable in 2018?

Surprising to many, interoperability also plays a role in chronic illness surveillance and treatment. Among our organization’s patient population, primary care physicians have dramatically increased compliance with diabetic patients for retinal eye exams, thanks to the affordability of a mobile eye scanning device that allows the scan to be taken in the PCPs office. The scans are then immediately sent electronically to a retinal specialist for interpretation; a referral to a local retinal specialist is provided when merited.

Despite multiple state-wide initiatives in recent years to make interoperability a reality, including those spearheaded by state agencies, none of our collective efforts have moved the needle far enough. Rather than getting all the players to the table to discuss interoperability, new silos are being created to mask communication inefficiencies. Maybe legislation would help us finally achieve the goal?