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The Vitals - July 2015
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Determining When Physicians Are Too Old to Practice
CHICAGO – When is it time for physicians to hang up the white coats for good and trade it all in for more free time? The nation’s largest organization of doctors wants to help make that decision.
Rejecting the concept of a mandatory retirement age for physicians, the American Medical Association will create competency guidelines for determining whether aging physicians still are capable of providing safe and effective care for patients.
Part of the impetus for the plan is that one out of four doctors in the United States is over 65. Unlike some other professions where mistakes can be deadly, physicians have no mandatory retirement age, although they must meet requirements set by state licensing boards, on some occasions, hospitals.
In June, delegates approved the report from the AMA's Council on Medical Education, which states, "physicians should be allowed to remain in practice as long as patient safety is not endangered."
The report doesn’t specify how the testing would be done or who would do it, although it suggests that evaluations of physical, mental health and how patients are treated. Authors argue it could “head off a call for mandatory retirement ages or imposition of guidelines by others.”
As for when the review should take place, "Unfortunate outcomes may trigger an evaluation at any age, but perhaps periodic reevaluation after a certain age such as 70, when incidence of declines is known to increase, may be appropriate," the report notes.
The panel points out that aging can affect hearing, vision, memory and motor skills but adds that evidence is lacking on precisely how those changes affect physicians' competence and patient outcomes. The report also emphasizes that, while they may think otherwise, physicians don’t always have good judgment on when they need to retire.
The number of U.S. physicians aged 65 and older has quadrupled since 1975, reaching about 240,000, according to the AMA.
How Low Should Diabetes Patients Go in Lowering Blood Sugar
LEICESTER, ENGLAND – The sometimes singular focus on lowering blood sugar in type 2 diabetes patients might be too much of a good thing and lead to significant health risks.
That’s according to a new British study, published recently in the journal PLOS ONE, which finds that hypoglycemia is especially prevalent among patients using insulin but also occurs surprisingly often in those using other treatment regimens.
Researchers from the University of Leicester and Leicester's Hospitals in England looked at both mild cases, which are resolved without outside help, or severe cases, where either emergency medical care or assistance are required.
The review included 532,542 participants – nearly half of whom had experienced mild hypoglycemia and 6% who had experienced severe hypoglycemia. On average, the study subjects had 19 mild episodes per year and just less than one severe episode per year.
Hypoglycemia was found to be especially common among insulin users with prevalence of mild/moderate episodes at 50%, averaging 23 events per person-year, and prevalence of severe episodes of 21%, with an average of one a year.
For treatment regimens including a sulphonylurea, mild/moderate prevalence was 30% and incidence of two events per person-year, and severe event prevalence was 5% and an incidence of 0.01 events per person-year. A similar prevalence of 5% of severe events was found for treatment regimens that did not include sulphonylureas.
"Our results highlight an urgent need for raising awareness amongst patients and healthcare professionals about hypoglycemia,” said lead author Chloe Louise Eldridge, a postgraduate researcher. “This study particularly highlights the need for patient education to raise awareness of hypoglycemia and the consideration of a patient's hypoglycemia risk by healthcare professionals when prescribing diabetes treatments.”
Study authors point out that hypoglycemia significantly affects patient quality of life, employment, social interactions, and driving.
“In addition to the direct effects of hypoglycemia, there may be a substantial indirect impact on serious long-term health consequences from medication non-adherence and purposeful hyperglycemia, due to fear and avoidance of hypoglycemia,” they add.
The authors note that previous reviews often have focused on clinical trial data, not real- world settings:
Understanding Why Patients Refuse to Get Flu Vaccines
ATHENS, GA –No matter how compelling they may seem, public service announcements about getting a flu vaccine fall on deaf ears if the message is not in line with personal experience, according to a new review.
A qualitative meta-analysis published recently in the journal Vaccine and presented recently at the National Adult and Influenza Immunization Summit, sought to determine why more Americans don’t get annual flu vaccines.
The CDC reports that 29.6% of adults ages 18 to 49 receive the flu vaccination in 2013. The percentages are higher for older Americans –46.5% for adults ages 50 to 64 and 67.9% for adults older than 68.
"One of the most important findings was that personal experiences mattered a lot, both for people who got an annual flu shot on a regular basis and for those who didn't," said Glen Nowak, PhD, the director of the Center for Health and Risk Communication at the University of Georgia’s Grady College of Journalism and Mass Communication. "I think that is an important reminder that it is really hard to overcome personal experience with persuasive communications. A lot of time communicators think they can just educate someone or just persuade them to take action, but that isn't always the case. It may take a better product or a new and different personal experience."
To find an answer to the question, Nowak and Kelli Bursey at the Oak Ridge Institute for Science and Education analyzed 29 flu vaccine-related communication research reports sponsored by the CDC's National Center for Immunization and Respiratory Diseases between 2000 and 2013.
Seven reasons were identified as reasons leading people to get annual flu vaccinations, including:
- They believe they are susceptible to getting the flu.
- They believe the vaccine matters and works.
- They are older or have a chronic health conditions.
- They have received a recommendation from a doctor, which makes a positive difference.
- They have experienced a bad flu or flu-like illness.
- They have been on the receiving end of active vaccination promotion, which makes a positive difference.
- They have convenient and easy access to the flu vaccine.
The six primary reasons people didn't get the flu vaccination are:
- They believe, often as a result of personal experience, that flu is a "manageable illness."
- They don't believe the flu vaccination recommendation applies to them.
- They do not believe flu vaccines are effective.
- They have a concern about getting the flu from the vaccine.
- They believe other measures are more effective.
- They have a negative personal experience with the vaccine.
"Overall, these studies consistently found that people need to see flu as real and serious health threat –either through personal experience or communication messages and materials –in order to get vaccinated," Nowak said. "They also consistently found that misperceptions, such as believing the vaccine causes the flu, remain and are sometimes held by healthcare providers."
Interestingly, the study found some surprising misconceptions among healthcare workers who were included in the studies.
"Some healthcare workers are aware they can contract the flu, but they didn't acknowledge they can transmit the flu," Nowak said. "They saw patients as the threat and not themselves, which created a barrier for them to get vaccinated."
Fraud Alert to Physicians: Tread Carefully with Compensation Arrangements
WASHINGTON, DC – Physicians be warned: A compensation arrangement may violate the anti-kickback statute if even one purpose of the arrangement is to compensate a physician for past or future referrals of federal healthcare program business.
That’s according to a fraud alert issued by the Department of Health and Human Service’s Office of Inspector General, which states, “Physicians who enter into compensation arrangements such as medical directorships must ensure that those arrangements reflect fair market value for bona fide services the physicians actually provide.”
In a brief comment on the alert, the law firm King & Spalding notes that, “Although the OIG’s enforcement of physician compensation arrangements, including medical director agreements, under the Anti-Kickback Statute (AKS) is not new, OIG’s clear emphasis in the Fraud Alert on its prosecution of physicians who enter into such problematic arrangements is notable.”
In an item appearing on the JDSupra website, the law firm points out that, while AKS criminalizes the conduct of both parties to an arrangement, “OIG’s enforcement of physician compensation arrangements has traditionally focused on the party contracting with the physician.”
The HHS alert recounts how the OIG recently reached settlements with 12 physicians who entered into questionable medical directorship and office staff arrangements.
Why did the OIG allege that compensation received by the physicians was improper under the anti-kickback statute? Federal investigators took that position because:
- the payments took into account the physicians’ volume or value of referrals
- the payments did not reflect fair market value for the services to be performed, and
- the physicians did not actually provide the services called for under the agreements.
Another issue was that, under the arrangements with some of the physicians, an affiliated health care entity paid the salaries of their front office staff. OIG alleged that the salaries paid under these arrangements constituted improper remuneration to the physicians because they relieved the physicians of a financial burden they otherwise would have incurred.
Because the inspector general’s office determined that the physicians were an integral part of the scheme, they became subject to liability under the Civil Monetary Penalties Law.
“Those who commit fraud involving federal healthcare programs are subject to possible criminal, civil, and administrative sanctions,” the HHS alert warns.
King & Spalding suggests the Fraud Alert “could signal the beginning of a new enforcement trend focused on physician culpability under the AKS. Physician practices, both large and small, should certainly heed OIG’s message and take this opportunity to examine their compensation arrangements and carefully consider all new arrangements before they fall under government scrutiny.”
A blog post from the law firm Fitzpatrick, Lentz & Bubba, meanwhile, describes a “safe harbor” available for medical directorships, including that the “aggregate compensation paid to the physician must be set in advance and be consistent with fair market value and arm’s length transactions, and not be take into account the volume or value of referrals or business generated between the parties.”
“Problematic arrangements under this requirement include medical director agreements which compensate the physician based on a percentage of facility revenues,” the firm adds.