ON POINT…WITH POs: Certification Overload

By EWA MATUSZEWSKI
In last month’s column, I asked the question, “Why do physicians with a career history of providing high quality care have to continue to take board re-certification examinations every six years?” I guess the topic of certifications in general has me in a bit of a huff these days. Not physician certifications, necessarily; rather, the plethora of certifications that have sprouted in recent years for healthcare roles not directly related to personal, clinical care.

I recently came across a post on LinkedIn that noted 149 patient advocates were now certified through a board I won’t name, following the inaugural national certification exam for professionals working as patient advocates. I’m an advocate for advocacy in most forms, and certainly for patient advocates. Yet does an examination make them more qualified or effective than their non-certified patient advocate colleagues in the field? I use this only as an example, not to highlight the legitimacy of this particular board and/or certification.

In general, I believe there is mission creep when it comes to board certifications for professionals who work in the healthcare community yet are not providing direct clinical care. Is the goal of having an educated healthcare workforce being hijacked by non-profit or for-profit companies set up chiefly to create and promote new certifications? I’m as pro-business as the next person, but healthcare is a unique animal and the needs of the patient must always be front and center. I’m not convinced there’s a patient-first focus behind the proliferation of new certifications. Where is the evidence showing that certifications lead to better healthcare delivery and better outcomes?

Following this progression, the next likely certifications will be in telehealth. Certified in operating telehealth equipment?  (See “on” button.) Certified in understanding the psycho/social dynamics between patient and provider in a telehealth environment?  Okay, now I’m just getting silly, but you do see my point. Board certifications may be appropriate for some healthcare careers not directly involved in patient care, but they are likely the exception and should not be a substitute for the value of ongoing continuing medical education and interacting with peers and intra-disciplinary professionals as a way of gaining valuable knowledge that is job applicable.

What we seem to forget is that healthcare professionals require a state license to practice.  And this practice of licensing generally works well. In Michigan the Licensing Division, in conjunction with state licensing boards, regulates 25 health professions under the Michigan Public Health Code. That’s an impressive number, do we really need any more?

COMPLIANCE CORNER: Medicaid Work Requirements

By SARAH HILLEGONDS, ESQ
In June, a controversial bill that would impose work requirements on Medicaid recipients in the state’s expanded Healthy Michigan Plan made its way through the Legislature. It is expected that Gov. Rick Snyder will sign this bill into law, which could affect hundreds of thousands of individuals enrolled in the Healthy Michigan Plan. The House Fiscal Agency estimates that 540,000 of 670,000 individuals in the Healthy Michigan Plan would be subject to the new work requirements, and 5 percent to 10 percent of those individuals could lose coverage.

As background, the Healthy Michigan Plan was approved by the Legislature in 2013. It provides health coverage to individuals between ages 19 and 64 with income at or below 133 percent of the federal poverty line that do not qualify for Medicaid or Medicare.

Under the proposed bill, beginning in 2020, able-bodied adults ages 18 to 62 would have to show workforce engagement averaging 80 hours per month to be eligible for the Healthy Michigan Plan, unless an exemption applies. Qualifying work activities include employment or self-employment, education, job training, vocational training, internships, participation in substance abuse treatment, and community service. An individual is exempt from the workforce engagement requirements in the following circumstances:  pregnant; receiving disability benefits; full-time student; medically frail; the caretaker of a family member under six years old, of a dependent with a disability who needed full-time care, or of an incapacitated individual; a recipient who met a good cause temporary exemption; a recipient with a medical condition that resulted in a work limitation; a recipient who had been incarcerated within the last six months; a recipient of unemployment benefits; or a recipient under 21 years old who had previously been in foster care.

The bill proposes that the Michigan Department of Health and Human Services (MDHHS) implement and enforce the new work requirements. MDHHS will be required to notify able-bodied adults 90-days in advance of the implementation of the work requirements. An individual is permitted three months of noncompliance in a 12-month period. However, an individual found to have misrepresented his or her compliance will be ineligible for the Healthy Michigan Plan for one year.

Because the bill would change the eligibility requirements for the Healthy Michigan Plan, Michigan will be required to seek federal approval of the work requirements. If the federal government fails to approve the waiver within 12 months or denies it, the Healthy Michigan Plan will be terminated, leaving hundreds of thousands of people without health coverage.  However, denial of the waiver seems unlikely under the current federal administration, which has approved 20-hour per week work requirements in four states – Kentucky, Indiana, Arkansas, and New Hampshire.  Seven other states have submitted waivers that are pending approval.

Currently, there is a legal battle heating up in Kentucky over Medicaid work requirements. In January, Kentucky residents filed a class action lawsuit against the United States Department of Health and Human Services (“HHS”) claiming that HHS exceeded its authority under federal Medicaid law when it approved Kentucky’s work requirements and that these requirements reduce access to healthcare for low income people. That case will be heard by a federal court in Washington, D.C.  In February, Kentucky Governor Matthew Bevin filed a counter lawsuit in federal court in Kentucky seeking to uphold the waiver. If the two courts reach different decisions on the legality of the work requirements, it could delay implementation of the waiver requirements in Kentucky.

Therefore, even if Gov. Snyder signs the Medicaid work requirements bill into law, the future of these requirements is far from certain.  For additional information, contact Sarah Hillegonds, Esq., of Wachler & Associates, P.C., at (248) 544-0888.

LEGAL LEANINGS: When Hospital Systems Crash

By Tim Gary
Electronic medical records have become vital to both hospitals and physician’s practices. They are a secure, electronic version of a patients’ medical history and often include all of the clinical data relevant to a patient’s care, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EMR automates access to information and streamlines the healthcare provider’s workflow. When a hospital EMR crashes or is breached it can be catastrophic. There is a real risk of liability exposure if the clinical staff’s access to patient records is cut off and the clinician proceeds with treatment without having access to all of the relevant data. Having assisted a number of hospitals in acquiring, implementing and maintaining electronic healthcare record systems, I have witnessed some of the best and worst practices. Here are some guidelines on how to prepare for a crash, or loss of data, and what to do after it happens.

No Such Thing As A Failure-proof System
Normally there are several redundancies built into hospital computer systems and most Software as a Service (SAS) physician office EMRs in order to either prevent a crash or bring the system back up quickly. These include recovery programs and cloud-based storage systems to stop the loss of, or quick restoration of, access to critical information. If, however, ‘‘a perfect storm’’ occurs, and multiple, successive things go wrong, there could be a system shutdown. A smaller hospital may not have an effective crash-recovery system, and may have fewer resources it can dedicate to ensuring its systems aren’t vulnerable to a crash. For example, a larger facility may have two or more points of entry for their internet connection, while a smaller system may have only one, leaving it more vulnerable if that connection goes down. Crashes can and do happen.

Be Adaptable
Health-care providers are very dependent on electronic medical records that contain a patient’s treatment history, including what drugs a patient currently is taking and which ones may cause an adverse reaction. Losing access to that kind of information adds to the complexity of practicing medicine. Without this easy access to crucial information about patients, providers have to find other ways to access the data. This means doing it the ‘‘old-fashioned way.’’ Ensure your healthcare providers are practiced in asking patients and their families about their relevant medical histories and recording the information prior to making treatment decisions. Include imperative questions that must be asked of each patient at the beginning of the process.

Systems often include checklists for doctors and nurses and allow access to evidence-based tools that providers can use to make decisions about a patient’s care. Without those lists, they have to rely on their training and experience and think through the treatment process on their own. Before EMRs were in existence, most doctors did this as a matter of course. It was part of their muscle memory. Ensure that your doctors and nurses are adaptable and do not become overly reliant on technology to tell them ‘‘if A, then B.” Retain paper copies of the data, diagrams, and charts on the patient for documentation of the information gathering process when you decide to proceed with treatment.

Determining Liability
Just because the hospital’s system goes down, it does not mean that the provider is held liable for a less than optimal outcome. However, an adverse medical event that occurs during a period when a system is down will be examined under a microscope. Computer systems are facilitators of treatment. However, unlike the holographic physician on Star Trek Voyager, they don’t actually treat the patient. Clinicians are the care providers, so the question always will be whether the professional acted reasonably and in compliance with the standard of care, given the totality of the circumstances. Documenting what treatment was provided is not enough. The provider also needs to document the decision making process when an EMR system has failed. Remember, memories fade.

While crashes are unpredictable, it is important to have a plan in place to minimize disruption and data loss and maintain continuity of care. Training on these procedures should be a part of your compliance plan. For questions or comments, you may contact Timothy Gary at tgary@cruxstrategies.com.

LANSING LINES: Killing Legalized Pot

There are some high-rollers out there who are being asked to kick in some big bucks to bankroll what could be a $4-$5 million ad campaign to defeat legalized pot on the statewide ballot in November.

At an unannounced and closed door meeting during the week of June 11, the Senate Majority Leader asked the lobby shops in town that have a piece of this pot issue to meet to discuss the anti-pot strategy.

The unanswered question on the table was simple: Are these interests willing to shell out the money to run an effective vote no campaign?

No one around the table had the answer, but the pledge was made to make the contacts with the various entities to get an answer. Everyone agreed to meet in another week or so.

Recall that Senate Majority Leader Arlan Meekhof (R-Holland) was unable to pass the pot petition drive language with the hopes of regulating the smaller “microbrew”-type shops that come away with weakened state regulation under this proposal. He also wanted to address amounts and dosages, among other things.

Hence, when the lobbyists discuss this issue, a critical question will likely be why would these major donors wanted to fund the no vote campaign and toward what end?

If they were successful in killing the plan, theoretically they then could come back with their own legislation and try to push that through during lame duck.

Scott Greenlee, who is running one of the two coalitions against pot, is expected to kick in $1 million to $2 million to the no vote campaign in the fall following some research on which voting blocks should be targeted to defeat the pot plan.

The yet-to-be-answered question is, “Will that cash be it or will others decide to kick in another couple of million or so?” The lobbyists will report back with the answer to Meekhof soon.

Budget Signed; Planned Parenthood Language Unenforceable

The $39.9 billion piece of Michigan’s state budget was signed into law June 21, but Gov. Rick Snyder said a few pieces of the spending plan were found to be unenforceable, including a provision that would have stopped Planned Parenthood from receiving federal money for non-abortion services.

SB 0848 sinks $330 million more than expected into the roads, $60 million to upgrade Social Security and enough money to pad the state’s Budget Stabilization Fund to $1 billion. A second state prison is being shut down while prison food service is going back to being taken care of in-house.

Chronic wasting disease research and response efforts got $7.9 million for this year and next. Flint is receiving another $20 million to help with its water pipe replacement. The anti-bullying OK2Say program is up to $1.4 million in funding. The Secretary of State is getting $11.2 million in election security.

The School Aid Fund piece of the budget was slated to be signed in late June, the governor said.

Snyder signing the budget, however, was never in question. What was in question was whether the governor would find that the Legislature overstepped its authority when it banned Planned Parenthood from receiving as much as $4 million in federal money for the family planning services they provide 45,000 low-income women in about 10 counties, including Wayne and Macomb.

He did. If the Legislature wants to go down this road, they need to pass a law.

“We applaud Gov. Snyder for doing the right thing by standing with women and families,” said Dr. Anne Davis, consulting medical director at Physicians for Reproductive Health.

Snyder also found the following provisions unenforceable:

– Banning the interim state superintendent from promulgating new administrative rules until a permanent state superintendent is picked by the state Board of Education

– Banning the Department of Talent and Economic Development, the Michigan Strategic Fund and the Michigan State Housing Development Authority from issuing or refinancing any bonds for broadband-related projects

– Creating a two-year timeline by which the Department of Transportation submits a final cost-sharing bill to a county road commission, city or village as part of a joint construction agreement.

– A provision requiring able-bodied adults without dependents be subject to the time-limited food assistance and work requirements regardless of county or federal waiver status starting Oct. 1. However, the governor said the state “Is on track to comply with the spirit of that language.”

Judge Says No Guardian For Frozen Embryos

An Oakland County family division judge declined June 12 to appoint a guardian for frozen embryos, according to court records.

Meanwhile, Judge Lisa Langton heard arguments June 13 on whether the court has jurisdiction over the contract dispute between the parties. It was unclear from the court record if she also would consider a motion to dismiss the case.

Gloria Kato Karungi, of Farmington Hills, wants access to the embryos she made with her then partner, Ronald Lee Ejalu, so she can implant them.

She wants to bear a second, healthy child to use the stem cells from that child’s umbilical cord to treat the Ugandan emigres’ 7-year-old daughter who was diagnosed with sickle cell anemia in 2015.

Ejalu, of Novi, opposes implanting an embryo and he wants the case dismissed.

Dr. El Sayed Never Got MD License

Crain’s Detroit Business reported that Democratic gubernatorial candidate Abdul El-Sayed is telling campaign audiences he is a doctor, but the publication contends “El Sayed is not licensed to practice medicine in Michigan.” The article contends he leaves that information off his resume although he uses the term physician in his professional title and appears in white coat in campaign literature.

The candidate did graduate from Columbia University in 2014 with a Medical Doctorate degree. He also has a doctorate in public health from Oxford, where he was a Rhodes Scholar. Crain’s reported he worked as a “sub-intern” during med school at New York Presbyterian’s Allen Hospital near the Bronx and was a professor of public health at Columbia’s Mailman School of Public Health, having written a text book on the subject.

“My job was, in effect, to be the junior doctor who took care of patients,” he said.

However, the head of the Michigan Medical Society explained that as a student “you don’t do diagnosis . . . You can’t do patient management,” and Dr. Mohammed Arsiwala asserted, “If you are not practicing medicine, I don’t think you should call yourself one. If you don’t have a license, how are you going to call yourself a doctor?”

“I’m a doctor,” the candidate told Crain’s reporter Chad Livangood. “I’m a physician because I have an MD, but I’m also a physician because of the work that I’ve dedicated by career to.”

When he was hired by the city of Detroit as public health director, he was not a licensed physician, which is why the city hired one as its chief medical officer. The El-Sayed camp says the candidate has been forthcoming about having not done a residency and has done so “several times” in speeches, interviews and the like.

El-Sayed observed, “People are going to try and chip away, they always do. That’s the nature of politics.”

Dems Accuse Republicans Of Trying To Kill Chemotherapy Bill With Re-referral

Democrats accused Republicans of trying to kill a bill, that would require insurance companies to cover oral chemotherapy medication the same way they cover intravenous chemotherapy treatment, by sending it to a new committee.

“The majority Republicans, in an effort to kill the bill, have referred the bill to the Health Policy committee where it is very unlikely to see the light of day,” Rep. Tim Greimel (D-Auburn Hills) said after the vote in House Insurance Committee June 7.

Republicans say just the opposite is true.

“I support this bill. I want to get it passed,” said Rep. Beau LaFave (R-Iron Mountain), who voted to reassign the legislation. “If there is no pathway forward in one committee, let’s get it to another one.”

Health Policy Chair Hank Vaupel (R-Fowlerville), who also sits on Insurance, said he’ll “do a deep dive” into the bills this summer and intends to give them “a very, very fair assessment.”

“It certainly isn’t coming to my committee to be killed,” he said.

The difference of opinion led to a testy exchange as soon as Insurance Committee Chair Rep. Lana Theis (R-Brighton) called the meeting to order. Both Greimel and Rep. Gary Glenn (R-Williams Twp.) tried to make motions at the same time. Greimel moved that the bill be sent to the House floor. Glenn’s motion was to re-refer. Theis accepted Glenn’s motion and the committee voted 11-4 on party lines to send the bill over.

At issue is SB 0492, sponsored by Sen. Goeff Hansen (R-Hart). Health insurance policies tend to cover intravenous chemotherapy as a medical treatment and the oral alternatives as prescription drugs. As a result, the out-of-pocket costs for the oral treatments are higher than the costs for intravenous treatments. The Senate passed the bill 36-1 last October.

Rep. Daire Rendon (R-Lake City) has similar legislation, HB 5367, which was also sent to Health Policy in a party-line vote.

“This is a bill that would insure that oral chemotherapy is as affordable to patients as intravenous chemotherapy,” Greimel explained. “Oral chemotherapy is more effective in many instances for treating cancer, typically, and it has far fewer side effects than intravenous chemotherapy. So the bill makes a lot of sense and it is obvious that the Republicans and their insurance company allies want to kill this bill.”

“Lying and making shit up is basically a platform of the Democratic party the last couple weeks here,” LaFave countered, “so I’m not surprised.”

Theis said her committee members did not want a mandate for payment to result in runaway drug prices. She said Vaupel already has a bill in his committee requiring transparency for the pharmaceutical industry, so it makes sense for the bills to be considered together.

“There are concerns about the implications of mandated payment for unlimited profits that extend far beyond the insurance industry, as those who stand to profit from this bill are the drug manufacturing companies. These are some of the concerns I share, as we all should.  Drug costs and insurance premiums have been skyrocketing, and the legislature should not be adding to that problem,” Theis said.

House Speaker Tom Leonard (R-DeWitt) said he did not want to see a repeat of situations, like with the Epipen, in which mandates in other states led to a price spike.

“If we are going to put a government mandate on this particular issue, I would like there to be transparency. I believe the pharmaceuticals, they need to be fair. They need to open and transparent about what they are going to make off of this,” Leonard said.

“If we can work out something where there is transparency, certainly, I will support this,” he said.

Lansing Lines is a cooperative feature presented by MIRS, a Lansing-based news and information service and Healthcare Michigan.

Three Waterborne Outbreaks In Detroit

By GEORGE GAINES, MSW, MPH
The morbidity data from Michigan Community Health and the Detroit Department of Health show several disease outbreaks during the last two years. Here, I offer a description of the increases and a viewpoint on the causes involved.

A theory and hypothesis are derived from data from the study by Ford Hospital1 and the morbidity data from the City Health Department 2012 thru 2017. The supporting theory is the lack of household water will affect household sanitation increasing the risk for disease.

Given the fact of thousands of water-service shuts offs, sanitation is compromised increasing risk of disease. The hypothesis is outbreaks of waterborne disease in Detroit are caustically related to the massive number of shut offs in 2016-2017. The three waterborne diseases are proof of outbreaks: First, shigellosis an acute dysentery. Second, giardiasis is a protozoan infection. Third, campylobacter an acute enteric that attacks the intestines. Children are infected more by water contaminated water sources than adults. For shigellosis “most of the deaths, are in children under 10 years of age.”2

GI outbreaks annually averaged 10.2 from 2012 thru 2015 years. However, 2016 had 45 and 2017 had 87 out breaks of group clusters (individual cases are not required reportable).

Data are arranged in two sections: the usual number of waterborne cases for years 2012-2015 and, secondly, the two outbreak years 2016 and 2017, where the morbidity cases were compared to the previous usual annually number of cases. For example, shigellosis, the yearly rates were as follows: 2012 was (50), 2013 was (25), 2014 and 2015, (41) then in 2016 the rate jumped from an average rate of 35 from 2012 to 2015 to a rate of (93). Then in 2017 the rate increased again to (111).

An average for the four prior years that is the endemic rate as a mean was 35, that suggests there were three times more (cases) in 2017.

Campylobactar had a four-year average or mean of 43. The rate of disease in 2016 to 57 and in 2017 it went to 99. What is clear from the data here is an outbreak of epidemics that is, “more than the usual expected number of cases of a specific disease.”

Giardiasis, also fits the pattern of a low mean number of yearly infections, then a quantum jump in the years of massive water shut offs. This infection showed small annual rates: 14, 18, 12 but only one case in 2016 with an average of only 14 for the prior four years. In 2017, a increase to 21. Can it be concluded that the increases to outbreak rates is water shut offs?

No, not by the increases per se. However, when combined with findings of the Ford Hospital Study the case is made for a specific type of epidemic, one that has a “continuing source.” Water shut off city policy is ultimately setting up for compromised sanitation that feeds the disease agents. All named above require an environment with poor sanitation to thrive. Hypothesizing that water shut off has a causal relationship on disease requires connecting shut off with disease.

That connection was made in the Study “to measure whether City of Detroit government-imposed water offs shut had effect on illness experienced by a sample of Henry Ford Hospital patients,” Ford’s study found:

1. The overall ranking of a patient’s social vulnerability significantly increased the likelihood of being diagnosed with a water shut off as associated illness by 1.48 times.

2. Patients who came from blocks with water shut off were 1.55 times more likely to be diagnosed with a water associated illness. Also, if the patient had waterborne disease they more likely lived on a block with a shut off. Ford Study Examined (The impact of Geographical Water Shut Offs on Diagnosis of Potentially Waterborne illness, with the Role of Social Vulnerability.

3. The disease outbreaks (3) and possibly (4) coincide with the massive water service cancellations. Without running water to clean and to wash hands, the sanitation of a residency is set-up for disease existing and growing.

When water service is terminated in a residency, sanitation becomes an ongoing risk. A “Community Hygiene Glossary” from the Detroit Department of Health described sanitation as the process of effecting clean hygienic conditions the absence of dirt and agents of disease. Control of Communicable Diseases in Man discusses the “removal of infectious agents with hot water, especially those that may find as favorable; conditions for surviving or multiplying.”

Summary & Conclusion
There exists a positive causal relationship in shut off water and waterborne disease and the proposition is plausible. The case is based on three inter related facts: 1) Epidemic rates at the time of as many as 80,000 shut-offs, 2) A study that showed that a patient with waterborne disease ‘was 1.48 times more likely to be living on a block with water shut offs’ and 3) Without running wear to clean and to wash hands the sanitation of a residency is set-up for diseases existing and growing.
Recommendation:

Stop the water shut-offs.

1 Plum, Alexander, MPH < CHHES, Kyle Moxley, ABD, Marcus Zervos, MD. “The Impact of Geographical Water Shut-offs on the Diagnosis of Potentially Water Associated Illness, with the Role of Social Vulnerability Examined 8 Apr. 2017
2 Control of Communicable Disease in Man, APHA, Official Report Chart, Douglas & Karl Gaines

IndyCar Driver Kimball Races Past Diabetes

By PAUL NATINSKY
IndyCar driver Charlie Kimball says he is the first diabetic to start and finish the Indy 500. Legally, that is. Diabetic racer Howdy Wilcox II competed in the Indianapolis 500, finishing second in 1932, but he was disqualified before the 1933 race when diabetic symptoms revealed his secret.

Today’s racecar drivers travel much faster—in excess of 225 mph on oval tracks—than their compatriots of yesteryear. Consequently, the slowed reactions, vision issues and decision-making deficits characteristic of unmanaged diabetes are much more dangerous.

“Charlie needs to consistently keep track of before getting on the racetrack,” Michigan State University kinesiologist David Ferguson told MSU Today in 2017. “If his blood sugar is too low, it may take him too long to make the right decision. If his sugar is too high, his reaction time may be fine, but the likelihood of him making the wrong choice increases.” Ferguson works with Kimball to manage his diabetes and authored a study using data from his work with Kimball.

“Technically, since Charlie doesn’t have a functioning pancreas, all the other drivers have had an advantage over him,” Ferguson said. “We simply put him on a level playing field.”

Kimball, 33, thinks his heightened consciousness regarding his health and fitness gives him an edge. “Between my healthcare team, my training team and my race team, I feel like I’m probably a better athlete because of my diabetes rather than just leveling the playing field. I feel I understand my body as an athlete better than I ever would have without ever being diagnosed,” he said.

Kimball, who finished 23rd and 8th, respectively, in two Detroit Grand Prix races on Belle Isle June 2 and June 3, likens his disease management to the functioning of his IndyCar. “With good diabetes management, with good blood sugar control, there is no difference between someone who has a functioning pancreas and someone who has, as I like to call it, a manual transmission pancreas. I’ve always preferred driving a manual transmission car and my pancreas is just a manual instead of an automatic now.”

Kimball’s analogy extends to an actual symbiotic relationship with his race car. “My IndyCar is different than everyone else’s because my body is different. I wear a continuous glucose monitor, so I have a sensor on my body that transmits to a display that’s actually plugged into the car’s data system. On my electronic dash I have speed, lap time, oil pressure, blood sugar, water temperature—my car and my body data right there together.”

While the monitor keeps him alert to his blood glucose level, Kimball is not a candidate for an insulin pump to help him balance his glucose during races. Kimball uses insulin pens manufactured by Novo Nordisk—time-released Tresiba for long-term management and short-acting Fiasp for faster adjustments.

However, Kimball carries no insulin onboard his IndyCar, cockpit conditions and his fireproof suite are too warm for the drug to remain viable. But elevated blood glucose is not Kimball’s worry. The physical toll of racing without power steering or brakes at more than 200 mph tends to burn glucose, so Kimball is more likely to suffer from low blood sugar. He tries to start each race with slightly elevated blood sugar. So far, he has not had to use the toggle switch in his water bottle to deliver a glucose-fortified orange juice option.

This year’s Indy 500 tied the record for the hottest Indy 500 on record, said Kimball. He said he lost between eight and 10 pounds during the race. While that sort of speeding sauna might not be typical, extreme physical exertion is part of every race.

It is difficult for ordinary people to understand the physical demands of race car driving because they can’t go out and do it to get a feel for it, said Kimball. The closest they come is driving their road car to work or to the grocery store.

When Kimball details the grueling physical effects of driving his IndyCar he sounds like the techie kid he was more than a decade ago who had been accepted to Stanford University and pondered studying mechanical engineering. Kimball said his Indy car reaches speeds in excess of 225 mph, travels the length of football field every second and has enough downforce to hold two Indy cars on the ceiling. The car, with him in it, weighs 1,600 pounds, produces about 3,500 pounds of downforce, has no power steering, no power breaks and puts 700 horsepower under his right foot.

The numbers gleaned from Ferguson’s work with Kimball at MSU compare his physical conditioning favorably to that of a National Hockey League player—but there are some things hockey players and other elite athletes don’t face. “One of the unique things we see in the IndyCar series is the G-forces. My G-tolerance would have easily qualified me for the Apollo XI space program back in the day,” said Kimball.

A lot people in racing talk about their sponsors, said Kimball. But, for him, it’s been more of a partnership with drug maker Novo Nordisk. “Long before they knew who I was, I was on their insulin and their insulin delivery devices. I have been using Novo Nordisk insulin since the day I was diagnosed, back in 2007.

“When I talked to them about being involved in my race program, they saw some value and were excited. It started out really small and grew and grew and grew. This year is the 10th season of the Race with Insulin program with Novo Nordisk and myself sharing the message that diabetes shouldn’t stop you from living your dream; in my case racing at over 200 mph in the IndyCar series.”

Kimball said he and Novo Nordisk do a lot of community work, including talking to healthcare professionals to give them an anecdote they can share with newly diagnosed diabetic patients.

Kimball was born in England (his father, Gordon, who designs Formula 1 race cars, was on a job there), raised in Southern California and now makes his home in Indianapolis with his wife, Kathleen. They “love this city and how it comes alive for all four seasons,” but Kimball eyes an eventual return to California.
Gordon Kimball is an avocado farmer and Charlie envisions the more relaxed lifestyle “working on the ranch” might hold for him after his racing career is over.

“It’s a little different pace when in racing you are talking about tenths and hundredths and one-thousandths of a second and in avocado farming, you are talking about a fruit that takes 18 months to develop,” said Kimball.
But Kimball has no plans of driving a tractor soon. He has miles to go before he reaps.

His ultimate goals in racing include “being the first driver with diabetes to win the Indy 500 and being the first driver with diabetes to win the IndyCar championship; because the 500 is a body of work that is three weeks long and one of the most challenging races, if not the most challenging—and the largest one-day attended sporting event in the world—and the IndyCar championship is six months of work over 18 races. So those two are definitely on my list.”

Kimball, who raced in Europe at the beginning of his career, said he would consider other racing formats. “I’ve always said, ‘have helmet, will travel.’ I would love to drive anything, anywhere, anytime, but I still have a lot to accomplish in IndyCar. Here in the U.S., I think I can make a bigger impact within the diabetes community. That is something I take very seriously. The chance to give back to the diabetes community that gave me so much support after I was diagnosed is very important to me.”

So for now, Kimball will enjoy the rush of racing, Indianapolis’ four seasons and the remote starter in his Chevy Tahoe on those cold Midwestern nights.

OUR VIEW: An Attack On ACA Protections

Setting a building on fire and then “rescuing” its inhabitants does not make one a hero—quite the opposite.

Thwarting the intent of a law by refusing to enforce it and then using that action to further undermine the law does not make one a skilled policymaker representing the will of the people—quite the opposite.

But that is what the president and his attorney general have done in supporting a lawsuit that would eliminate the Affordable Care Act’s requirement to cover pre-existing medical conditions, leaving those who are sick and uninsured without coverage options. The suit was filed by several conservative states and the ACA is being defended against by a group of heavily Democratic states.

Actually, the administration is going much further, endorsing the declaration of the entire ACA as unconstitutional because the health insurance mandate (upheld famously by the Supreme Court in 2012) is so central to the law.

The conservative states’ lawsuit argues that if the there are no penalties connected to the mandate (a provision Republicans included in the recently passed tax bill), then there is no incentive for people to seek insurance until they are already sick—an unfair and expensive situation for insurers.

The lawsuit and the attorney general’s brief in support of it is the latest salvo from the Trump Administration and congressional leaders. It is also illustrative of the approach both of those entities have taken toward alleged healthcare reform.

To wit:
-After the passage of the ACA, Republican congressional leaders and most of the party’s rank-and-file passed straight-up repeal bills for seven years running, knowing they could make political hay amid repeated presidential vetoes.

-Donald Trump and most Republican candidates in 2016 campaigned on a “repeal and replace” position on the ACA and healthcare reform and—by-and-large—won.

-After gaining control of the presidency, majorities in both chambers of Congress, the Supreme Court, most state governorships and state legislative majorities, Republicans faced their most dreaded enemy—one another. With seven years to come up with a replacement plan, congressional leaders spent months tearing one another apart without coming up with a replacement for Obamacare.

-After failing at healthcare reform, congressional Republicans used a budget bill as a vehicle to strip enforcement of the financial penalties attached to the ACA’s mandate that all individuals buy health insurance.

That leads us to the most recent development, the lawsuit challenging the constitutionality of requiring insurers to cover pre-existing medical conditions. This move, as have past initiatives features no “replace,” only “repeal,” which leaves the United States with the most embarrassingly ineffective healthcare coverage environment in the free world and hurts the nation’s most vulnerable populations most.

This chain of events is most confounding because it occurs as public support for the ACA is rising and on the heels of Republican replacement plans that garnered widely reported support numbers of 17 percent.

Amid all of the smoke and debris, Republican leaders have consistently claimed that the main problem with the ACA and the current insurance environment is steadily rising premiums that put health insurance out of reach for middle-class people. Conservative policy wonk Sen. Ted Cruz in town hall meetings cited examples of small business people who could not afford to offer health insurance to their workers because of rising premiums that many who, while not wealthy, exceeded the income limits for federal premium subsidies.

Ironically, the lawsuit to end pre-existing condition coverage renders the affordability issue moot. Insurers can simply refuse to offer insurance to an individual—at any price. History suggests that is exactly what many will do.

It will be interesting to see how those who filed and those who support this lawsuit explain how creating more uninsured people and excluding the sickest among us from coverage is a good thing.

By the way, we’re still waiting for that replacement plan.

ON POINT…WITH POs: Alternatives To Board Exams

By EWA MATUSZEWSKI
Several DO and MD primary care physicians recently noted to me the grueling commitment of preparing for their respective medical boards. These exemplary practice leaders have been physicians for several decades—and plan to continue working for the foreseeable future. Each of the physicians I spoke with is a PCMH champion with an outstanding reputation for serving their patients and the surrounding Macomb, Oakland and Wayne County communities.

Why do physicians with a career history of providing high quality care have to continue to take board re-examinations every six years? I’m looking for a reasonable answer, but the response currently seems to be, “so they don’t get kicked out of a health plan.” At the same time, I can’t help but ponder the big business behind board certifications. Consider the cost of the board examinations and the prep programs including pre-tests, times the number of physicians taking them and it’s hard to deny the financial implications/advantages of keeping the status quo.

At a time when we aggressively aim to attract and retain primary care physicians, we need to remove barriers that prevent senior physicians in the field from staying. This problem is of notable concern in underserved areas where primary care physicians may be opting out of full-time physician status but want to stay engaged as a community physician resource. The financial and mental costs associated with the actual exam, pre-tests and preparation serve as further inducement for rural physicians to retire too soon, often to the detriment of the community.

Adding to the frustration (forgive the digression), is that Board exams for family practice physicians are peppered with questions a community-based physician striving to provide population-based care likely will never encounter. The fact is that board examinations as they currently stand are archaic in their continued focus on acute care. Where is the recognition of population health? That’s the future of primary care. How about the five social determinants of health? Today’s PCPs are trying very hard to be good stewards of care, especially in the era of Choosing Wisely and the Triple Aim. Board exams need to incorporate this mindset.

As a member of the Patient Centered Primary Care Collaborative (PCPCC), I see the number of PCPs leaving practice before their time—it’s not just a rural-area phenomenon. Easing rules on board-certified senior physicians could help reverse the trend. For example, a milestone combination of age 60 with 30-plus years of practice and currently practicing in a BCBSM-designated or NCQA-recognized patient centered medical home could qualify as an exemption from taking boards. Another option is to create a point system for PCPs in private practice using key criteria such as PCMH certification, CME hours and quality scores—or quality improvement programs that address population health.

Let’s be creative in addressing a new designation, such as board certified emeritus. Senior PCPs can retain the benefits and prestige that come with the designation and communities retain much needed primary care physicians.

‘Exposure’ & ‘Poisoning’ Toxic When It Comes To Lead

(Editor’s Note: The following is a statement issued by the Genesee County Medical Society, June 4)
The Genesee County Medical Society has reviewed the position taken by the Medical Staff of the Hurley Medical Center regarding the term “lead poisoned.” It’s very important to recognize there are no strict guidelines that would allow us to state that using the term “exposed” is different than using the term “poisoned” in regard to physiologic disruption caused by the toxic metal lead. It is vital to emphasize that there is no safe amount of lead when ingested by children, pregnant women, or any person daily for 15 months without any risk to health and/or development.

While there are still some who must see organ failure, seizures or altered consciousness to use the word poisoned, many medical and scientific experts along with the federal Centers for Disease Control have recognized the more subtle effects of lead poisoning and have repeatedly lowered the level of concern from 40 to 5 ug/ml starting in the 1970s. This has happened in part because the methods to measure blood levels have improved as well as the tools to evaluate brain function. Additionally, screening with blood lead levels does not measure the lead storage in other organs such as the brain, heart, kidneys, teeth, and bones. Perhaps more importantly, we have come to recognize that something being common does not make it acceptable.

Because the literature repeatedly states that there is no safe level of lead, we do not feel comfortable declaring a population safe unless all of its members are free of preventable exposure to this known neurotoxin. It is even more egregious that this neurotoxin is present in their tap water.

Our patients should not be exposed to any toxins when that exposure is preventable. As a clarifying analogy, we note that if a manufacturer knowingly produced a product containing lead for human consumption, they would be stopped from doing so. So too, for our government.

The use of averages, as has been cited in the Medical Staff position, does not take into consideration variations in exposure and susceptibility. It also does not consider the cumulative impact from other environmental insults and other longstanding health disparities. Finally, as an environmental justice issue, there is no acceptable reason why any one group of Michigan residents should tolerate a higher level of lead exposure and ingestion than others just because they live in a certain city or service area.

The statement issued from the most recent HMC Medical Staff meeting does not represent the opinion of the Genesee County Medical Society.

We stand by our position regarding water consumption in the City of Flint, a position also held by the Genesee County Health Department and the City of Flint.

Our communications have never used the term “lead poisoned.” We believe that physicians, and other health professionals who require the elimination of the term “lead poisoned” when referring to lead exposure resulting from the water crisis may in fact be doing harm. Despite the well-meaning intention of removing the possible stigma due to exposure and ingestion of tainted water, their statement may in fact increase stress levels, anger and distrust among the exposed populations. They may be perceived as denying or dismissing traumatic lived experience. We fear this may seriously damage the doctor-patient relationship, and the community’s trust in the medical community in general.

We are encouraged by some of the measures which have been taken to counteract the impact of lead such as avoidance, early childhood programs and the provision of nutritious foods. We believe that the resilience and strength of the people of Flint, in addition to a significant upgrade of the water infrastructure and other future needed measures will serve to help to reverse the effects of this toxic ingestion of lead and other contaminants in our water. Further, we hope that the problems and potential solutions will help to inform other communities that face similar contamination of a basic human need: Clean Drinking Water.

We look forward to future efforts to work with the people of Flint and physicians of Hurley Medical Center to improve communication to the public that best clarifies their risk in the wake of this environmental health crisis.

For questions or comments, you may contact Peter Levine at plevine@gcms.org.

COMPLIANCE CORNER: CMS Changes Home Health Policy

By KEVIN R. MISEREZ, ESQ.
Wachler & Associates, P.C.
On May 29, the Centers for Medicare & Medicaid Services published its 60-day notice to allow interested stakeholders the opportunity to comment on CMS’s proposed Review Choice Demonstration for Home Health Services (revised demonstration). The Review Choice Demonstration is a revised version of the CMS’s previous Pre-Claim Review Demonstration for Home Health Services, which was paused by CMS on April 1, 2017. According to CMS, the revised demonstration will “offer more flexibility and choice for providers.”

Under the revised demonstration, home health agency providers subject to the demonstration have the choice of participating in either a 100 percent pre-claim review or 100 percent post-payment review. These HHAs will remain under the chosen review method until the HHA reaches the target affirmation (for pre-claim reviews) or claim approval rate (for post-payment reviews). At this time, CMS has not provided any specific benchmarks with respect to the requisite “target affirmation” or “claim approval rate” HHAs will need to satisfy. However, once the target affirmation or claim approval rate has been met, HHAs may choose to be relieved from claim reviews with the exception of a “spot check” of their claims to ensure continued compliance.

Under the pre-claim-review option, CMS will review the medical documentation prior to payment to determine if the home health services meet all of the coverage requirements. The review request may be submitted at any time before the final claim is submitted and can occur after home health services have begun. According to CMS, the pre-claim review does not create new documentation requirements; rather, HHAs will submit the same information they are currently required to maintain for payment. Under the post-payment review option, the review by CMS will occur after the beneficiary has received the home health services and the HHA has received an Additional Documentation Request (ADR) for the particular claims under review.

In addition to the forgoing pre-claim and post-payment review options, CMS has also proposed a third option for those HHAs that do not wish to participate in either 100 percent claim review. Under this third option, HHAs may continue to furnish home health services and submit the associated claim for payment without such claims being reviewed, but those HHAs opting to do so will receive a 25 percent reduction in payment on all claims submitted. Moreover, CMS indicated in its notice that HHAs under the third option may still be eligible for review by Recovery Audit Contractors.

The precise start date for the revised demonstration has not currently been announced but will begin no earlier than Oct. 1, 2018 and will last for five years. Furthermore, the revised demonstration will initially only be in effect for HHAs located in five states, which will be implemented on a staggered basis beginning with the state of Illinois, followed by expanding to Ohio, North Carolina, Texas, and Florida, respectively. According to CMS, “These states include known areas of fraudulent behavior and had either a high home health improper payment rate or a high denial rate during the Home Health Probe and Educate reviews.”

While the revised demonstration is currently only proposed to be implemented in the five states above, CMS indicated in its public notice that it has the option to expand to other states if there is increased evidence of fraud, waste or abuse in these states during the demonstration period. Accordingly, it is unknown at this time whether any additional states and/or which additional states could eventually become subject to the revised demonstration program or similar type of claim review process down the road. For example, states that could be potential targets to such types of reviews in the future may be those with areas currently subject to CMS’s temporary HHA enrollment moratoria as these states, including Michigan, have previously been determined by CMS as having significant potential for fraud, waste, or abuse with respect to HHA services. Therefore, HHAs outside of the fives states currently being targeted should nevertheless ensure their claims and supporting medical documentation meet all of the Medicare coverage requirements for home health services.

CMS is seeking comments from the public regarding this proposed revised demonstration. Any home health stakeholders should ensure their comments are submitted by the July 30, 2018 deadline.