Thursday, December 14, 2017

Never let a good crisis go to waste

Buried deep in proposed opioid regulations for Mississippi doctors is a little section that will drastically affect the practice of telemedicine in Mississippi.  Telemedicine is a subject that is near and dear to the Board's heart as its attempt to clamp down on the spread of telemedicine failed two years ago.  The Mississippi Board of Medical Licensure is trying to overhaul its regulations on prescribing opiods.  However, there is one section that appears to have nothing to do with prescribing narcotics and everything to do with limiting the practice of telemedicine.

Section 1.11 of the proposed "opioid amendments" to the Board's prescription regulations states:

Rule 1.11 Prescription Guidelines - All Medications. In addition to any other requirements set forth in these rules pertaining to the issuance of prescriptions of controlled substances, the following additional requirements apply to all prescriptions, whether or not said prescriptions are for controlled substances, legend drugs or any other medication:

A. Prescriptions may not be written outside of a valid licensee-patient relationship. The elements of this valid relationship are:
1. verify that the person requesting the medical treatment is in fact who they claim to be;
2. conducting an appropriate history and physical examination of the patient that meets the applicable standard of care;
3. establishing a diagnosis through the use of accepted medical practices, i.e., a patient history, mental status exam, physical exam and appropriate diagnostic and laboratory testing;
4. discussing with the patient the diagnosis, risks and benefits of various treatment options to obtain informed consent;
5. insuring the availability of appropriate follow-up care; and
6. maintaining a complete medical record available to the patient and other treating health care providers.

The amendment states that it shall apply to ALL prescriptions, not just controlled substances.  However, a brief history lesson is in order.

Telemedicine started appearing in Mississippi several years ago.   UMMC rolled out its own version of telemedicine to much acclaim.  However, competition began to appear as private companies provided telemedicine services as well.  The free market served up a diversity of telemedicine as some companies offer it directly to patients while others offer it through employers and their health insurance plans.  UMMC's is provided through doctors to other doctors.

A fight began over how telemedicine would be defined and regulated in Mississippi.   The entrenched doctors and their state medical association want to define it as the use of video conferencing in a doctor’s office to evaluate and treat the patient.  They see the technology as a supplement to the standard office visit where a physical exam must be made of the patient before any treatment can occur.   It is a doctor-to-doctor model.  However, the companies who dared to think they could offer health care to a state that suffers from a lack of access to health care, argued  that the use of the smartphone and modern technology can bring more health-care options directly to the patient, especially those who live in rural areas or the poor. The time of the day, the day of the week, or the location of the patient will mean little as he will be able to obtain a physician’s care almost immediately.   The horror.

Several companies offer telemedicine services in Mississippi to subscribers and employers. The physicians are licensed in Mississippi. No mistaking their voices for those one hears when using an AT&T call center. The patient can talk to a doctor through interactive audio or video conference. The patient can, gasp, use an app on a smartphone – a boon to those who live in rural areas and have poor broadband service or the poor who don’t have internet service at all.  Employers are able to lower their healthcare costs since medical care is delivered at the employer's site. No more losing  employee to an office visit for the rest of the day.  The patient can take a picture of a rash or other visual symptoms and send it to the doctor. The cost is approximately $40 per month or more, depending on the service.

 Keep in mind Mississippi suffers from a severe doctor shortage . However, the growth in telemedicine means government- and competitors- can’t wait to regulate it. It's an old story- regulators like to control and competitors like to use the government to drive competitors out of business.   The Board has been embroiled in a fight with telemedicine providers over the last few years. Smartphone app? Forget about using one if the Board has its way. The Board wants to limit telemedicine to using videoconferencing only at a doctor’s office. Stuck with the flu or a stomach bug at 3:00 AM? Sick baby on a Sunday evening and all the clinics are closed? Tough luck.  Go to the ER and whip out the credit card or ruin your credit if you have to go the indigent care route. Live an hour away from a doctor or hospital?   Oh well.  Should have moved closer to the city. 

The Board tried to amend its rules in March 2015 to cover telemedicine.   The proposed change would indeed force patients to use telemedicine only if they were in a doctor’s office.  The telemedicine doctor would also have to sign a contract with a local primary-care physician.  Got to give the local medical mafioso the vig.  Telemedicine would in effect be limited and transformed into a referral service for the Mississippi State Medical Association and its doctors. If the patient is in an area that is suffering from the doctor shortage, well that is just too bad.

 The board also said no economic impact statement was required as well since it was merely filing an amendment.  However,  government agencies can’t just make up rules and change policies on the fly while wreaking havoc on entire industries and companies. They have to follow a rule book for making rules. Protests erupted and the board was forced to hold a hearing in May 2015.  The Board took the hint and sent the amendments to a committee.  Committees are often a graveyard but not in this case.

The Board “clarified” its telemedicine regulations in October 2015. The "clarification" stated that the practice of telemedicine could not include interactive audio or use smart phone apps but instead must conform to the  proposed rules. So much for the rulebook for making rules. Why go through the hassle of hearing public comments and determining how a decision by some bureaucrats affects an industry when a "clarification" will do?

Indeed, a Board employee gave the game away in a private email (obtained through a public records request):

 if the examination of the patient provided the same information as if this examination were conducted face to face. Thus audio only or filling out a health inquiry is not acceptable for the practice of telemedicine in Mississippi.
Hmm..... that language sounds familiar.  It reads very similar to Section 1.11 of the Opioid Amendments.  The "clarification" failed as the Board was forced to draft an economic impact statement.  Such statements are required for all proposed regulations if they will have an economic impact.  The Board tried to say no such impact would take place but the companies who would be forced to quit doing business in Mississippi had other ideas.  The Board never submitted the economic impact statement. Thus the Board has been frustrated in its  attempts to limit the practice of telemedicine in Mississippi.

It should be noted that UMMC physician Dr. Claude Brunson is the chairman of the Board’s telemedicine committee. He and Dr. Randy Easterling also served on the Governor's Opioid task force.  Make no mistake, UMMC is a direct competitor of the telemedicine providers.  It invested heavily in its telemedicine program and obtained several grants for the program as well.  In other words, it has a vested interest in the outcome of this fight.  The Mississippi Medical Association publicly supports the Medical Board's past positions on telemedicine as well.  Dr. Easterling has made his opposition to most practices of telemedicine known. Read the "shameful" emails.

This new regulation will prevent telemedicine providers from issuing prescriptions for drugs unless their doctor conducts a physical exam in person.  Section 1.11 has nothing whatsoever to do with opioids. Make no mistake, someone drafted this little piece of regulation and buried it in fifty pages of proposed regulations on a completely different subject - opioid abuse.  The obvious intent is to force telemedicine companies to abandon Mississippi. 

Never let a crisis go to waste is an adage that is still true today.

Earlier posts on Medical Board and Opioid regs
Medical Board calls meeting yesterday to pass opioid regs tomorrow.  
 State health officer warns of "unintendend consequences"
Mississippi doctors on proposed opioid regs: "dangerous", "Ill-conceived", "idiots"  How much pain will proposed opioid regs create for doctors?  (Copy of proposed regs) Can medical weed fight opioids?   Opioids prescription: Mo' taxes, mo' spending, mo' jail (Governor's Task Force report)


Anonymous said...

Russia politics are alive and well at the Mississippi Board of Medical Licensure

Anonymous said...

"Easterling Special"

Anonymous said...

Fraud Brunson is on his game.

Anonymous said...

To rephrase what I said, in a post within the previous thread on this subject, the TRUE PURPOSE of all of this, is to reduce competition. The big, greedy guys with the big gunboats, are blowing all the little canoes out of the water.

This is hardly unique to the Medical Industry. Most auto regulations, in reality, are in existence because they're anti-competitive. In fact, a host of laws, regulating virtually every aspect of our existence, are there to help the big guys, and to hurt the little guy.

More regulations? More paperwork? More reporting? More complex taxes? In every case, the larger entities are more able to cope, while small-scale operations are crippled.

THIS is what the opioid regulations are REALLY about. The well-being of the public is not really a consideration, at all. The Road to Serfdom, is paved with ostensibly well-intended regulations.

Madison Doctor said...

You are going down a rabbit hole here. The Board is protecting our interest. That is what the Board is in place to do. I applaud Randy and Claude for carrying the water of the doctors.

Anonymous said...

This is going to hurt businesses in the state. Once again, Board of Med Licensure is out to hurt business.

Anonymous said...

This is a regulation without representation. So, especially at this point, what can we as laypeople do? I know what illicit drug use (any kind, every kind) is doing to this and every other state in the nation but I also know that this is a knee-jerk reaction to get some publicity (besides the underhanded things that are drivers)and will negatively affect a lot of good, seriously suffering people. Besides, I'm looking at another shoulder surgery in the near future and those things hurt like hell - 5 days of Tylenol ain't gonna kick it. So, back to the question - what can we do???

Anonymous said...

Heaven forbid anyone see a doctor 👨🏼‍⚕️ on that demon iPhone, iPad or computer 🖥. This is almost on the same level of stupid as requiring a script for medicine with real decongestant in it. It effected the meth trade for about a week. Yet honest tax paying citizens are left to live with a stupid law that’s sole purpose is to generate practice revenue either by call in fee or office visit. The real test comes if the GOP actually gets it together and McCain & Thad know who they are long enough to vote the tax cut in. How many people will pay what will amount to a 5% privilege tax to live here😳. Hands? Anyone who can is already looking at houses in Texas.

Anonymous said...

I'm still pissed off about having to see a doctor to be able to by OTC Sudafed. There still seems to be meth everywhere you look. Assholes.

Anonymous said...

Now my 5th grader has to be drug tested quarterly. Move over Obama, the control freaks in Mississippi want to go even farther than where you left off.

Anonymous said...

I thought as republicans we were for less government intrusion into people's live.

Ass Backward Republicans said...

We're all criminals and drug abusers and now we have to prove otherwise.

Anonymous said...

The hell with this mess, Blue Boy said he some black tar. It's easier to get and cheaper.

Anonymous said...

It's apparent that their freedums are not to be your freedums.

Anonymous said...

4:52, I agree. That stupid law has cost me a lot of time & money just to be able breathe out of my nose. Good grief!

Anonymous said...

This requires a physical exam for ANY prescription and is solely aimed at lining pockets.

Anonymous said...

The AMA is the single biggest labor union (yes really!) in the USA.

Their actions, while cowardly, are unsurprising. History is full of incumbents using underhanded methods to 'compete' rather than actual competition.

And history bears out that instead of competing and adapting, the incumbents utterly crumble when their short-sighted and greedy plans eventually fail.

Anonymous said...

Getting in a car so you can sit in a waiting room for two hours with 30 other sick people is the only reasonable solution.

Anonymous said...

Money and medicine do not mix.

We will break ourselves learning what the rest of the world already knows.

Such is life.

Unknown said...

Funny because the State health insurance is trying to encourage employees to use telecommunications for doctor visits such as colds, etc. to save the state money. When you recall the restrictions that went into effect to curb methamphetamine by requiring prescriptions and look at this it does appear the state is in fact making access more difficult.

Anonymous said...

Y’all are giving Claude Brunson way too much credit. That guy probably never even knew that telemedicine language was in the details. He most likely couldn’t tell you how it would even impact UMMC or anyone for that matter.

Anonymous said...

You're wrong. These regulations do NOT require a physical exam every time you get a prescription. It says the doctor must have established a doctor-patient relationship already, which includes a physical exam at some point in the past. It DOES appear though to prohibit a prescription from a doctor who you've never seen.

Kingfish said...

I posted the proposed amendment. The amendment states outside of a doctor-patient relationship and then defines the relationship. I didn't write it was required every time something was prescribed.

Anonymous said...

Does this physical exam mean a real one by a real doctor or one like the VA uses?
I once got a physical exam while walking down the hall at the VA.

picky nerd said...

Just let some Big Shot's kid die because the Nurse Practitioner on the other end of the video mistakes Rocky Mountain Spotted Fever for jock itch.

That'll be the end of telemedicine in Mississippi.

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