Published 4/17/2017 


25 Years of POLST

By Bruce Smith, MD, MACP and Sharmon Figenshaw, RN, ARNP

This year marks a quarter century since the unique concept of POLST—a portable medical order form with treatment instructions—first became reality with its introduction in Oregon in 1992. (Washington’s POLST turns 16 this year, with the form seeing its first full year of use in 2001.)

POLST, or Physician Orders for Life-Sustaining Treatment, is a clinical tool for ensuring a patient’s wishes are honored when they, together with their physician or other designated provider, decide what kind of care they would like as they approach the end of life. The form allows the patient to choose among a range of treatment options, from “CPR/Attempt Resuscitation” (full code) and “Full Treatment” to “DNAR/Do Not Attempt Resuscitation” (allow natural death) and “Comfort Care Only.”

While POLST is particularly useful for those patients who wish to avoid certain types of treatment they may feel are non-beneficial or excessively burdensome, the form can also help patients approaching the end of life who prefer full treatment—a recent study in Oregon showed that patients documenting “Full Treatment” on their POLST were more likely to actually receive full treatment than those without the form1.

Early proponents of POLST in Washington saw a clear need for a medical order that could be honored by first responders in the field. Supported by the WSMA and the Department of Health, POLST was successfully piloted before being introduced statewide, with DOH establishing rules that would allow emergency medical personnel to honor the form. A task force sponsored by the WSMA regularly reviews the form to ensure the form keeps pace with current practice standards.

POLST works2. EMTs honor it, hospitals and facilities across the state honor it. The form provides a quick review of valuable information about a patient’s wishes for care if they cannot speak for themselves.

The key to ensuring the ongoing effectiveness of POLST is its proper use by clinicians: introducing POLST to the right patient at the right time. Please take a moment to review the “dos” and “don’ts” accompanying this article to ensure you are using the form as intended.

The introduction of POLST in Oregon in 1992 remains a watershed moment in the evolution of medical care that respects and honors the patient at the end of life. The WSMA and the POLST task force wish to thank you for using POLST to ensure that patients receive care that is beneficial and consistent with their values.

POLST Dos and Don'ts

Who should have a POLST? It is recommended that physicians and other clinicians ask themselves, “Would I be surprised if this patient died in the next 1-2 years?” Answering no to this question usually indicates that the patient has a serious chronic or acute illness nearing its end stages or likely to progress to a life-threatening state suddenly, and is an appropriate candidate for POLST.

DO remember to sign and date the form. Signatures of both clinician and patient (or surrogate) are required.

DON’T pre-sign forms for facility settings.

DO be aware that, while POLST can be signed by surrogates, it is best if the POLST agrees with the patient’s prior directives or if the patient signs the document themselves.

DON’T send the form home with patients for them to “fill out on their own.” If they want to show the form to their family or surrogate decisionmakers, DO set up an appointment to have them review it with you for final decisions and signatures.

DO make sure that the patient understands the treatment options at each level of care.

DO discuss the ‘non-emergent treatment’ section and indicate if the patient has preferences that would limit either use of antibiotics or artificial nutrition.

DO recognize that a patient wishing DNR for cardiopulmonary arrest might still want full treatment. This can be indicated by checking “DNAR” in Section A and “Full Treatment” in Section B. In general, “CPR” in Section A should always link with ‘Full Treatment” in Section B, since CPR frequently includes intubation and ICU care.

DO be aware that, while Medicare requires health care institutions to ask about advance care planning documents, it prohibits them from compelling or requiring patients have these forms.

For more POLST Dos and Don’ts, visit wsma.org/polst.

This article originally appeared in the April issue of WSMA Reports.

References

  1. Richardson DK, EK Fromme, D Zive, R Fu, and CD Newgard (2014). “Concordance of Out-of-Hospital and Emergency Department Cardiac Arrest Resuscitation with Documented End-of-Life Choices in Oregon.” Annals of Emergency Medicine 63(4):375-383. doi:10.1016/j.annemergmed.2013.09.004.
  2. EK Fromme, D Zive, T Schmidt, JNB Cook, and S Tolle (2014). “Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon.” Journal of the American Geriatrics Society. J Am Geriatr Soc 62:1246–1251, 2014

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Published on 4/17/2017

Published 4/4/2017 


Public health a threatened thread connecting all health care

By John H. Vassall, MD

Case 1

The patient was a 55-year-old man with HIV and moderate dementia living in a skilled nursing facility. He seemed lethargic and developed a severe cough and a low-grade fever. He was taken to the clinic where cough medication was prescribed, a chest X-ray was obtained and samples were sent to the health department for influenza testing even though he had been immunized for influenza A five days previously.

Two days later his temperature hit 101°F, he developed a persistent cough and refused to get out of bed. He was taken to the hospital emergency department where he was admitted with an elevated white count, deteriorating renal function and a left lower lobe infiltrate on chest Xray. The health department reported him as positive for influenza A. The nursing home refused to readmit him from the hospital, or to take any other new patients—essentially putting themselves on quarantine for influenza.

Case 2

The patient was a 28-year-old healthy, active vegan lab assistant at a local clinic where she had worked for four years. She avoided medications and had signed a declination refusing an influenza vaccination for the prior three years, saying immunization violated her deeply held personal beliefs.

She did not wear a mask as required by her employer at the time she drew blood from the 55-year-old nursing home patient above. She went on to develop influenza A, as did two clinic nurses, reducing the ability of the clinic to see patients during their busiest season and requiring them to divert some patients to the hospital emergency department for care.

Case 3

A 68-year-old man had suffered urinary urgency and frequency for a number of months. His internist diagnosed an enlarged prostate, prescribed a short course of antibiotics and a medication to reduce symptoms.

His symptoms were unchanged for another month, until he developed difficulty initiating a urinary stream and suffered small amounts of blood in the urine. He visited a hospital emergency department which was crowded and busy with long wait times.

He became increasingly uncomfortable during an epic eight-hour wait. By the time he was seen, he had a high fever and appeared to be septic. Treatment was started in the emergency department, but the hospital was above 100 percent capacity and several more hours passed before he was admitted.

Discussion

We are in the midst of an influenza epidemic which began earlier in the flu season and is shaping up as more severe and deadly than predicted. Most interesting to me is the domino effect of influenza on patients, health care professionals and the health care system as a whole. During a recent telephone conference involving the King County health department and representatives from hospitals along the Interstate 5 corridor, the collateral effects of the influenza outbreak were discussed, especially the fact that most hospitals had more patients to admit than available beds and nursing staff.

While the number of patients infected with influenza is still relatively small, their impact is great. As we see in Case 1, a single individual with active influenza A can affect an entire post-acute facility, making it more difficult for hospitals to discharge some patients for lack of a place to send them after acute care. As we saw in Case 2, a health care worker may also serve as a source of infection that can cripple the operations of an outpatient clinic, putting further pressure on hospital emergency departments.

As a result of that pressure, patients who might have been seen in lower acuity settings are sent to the emergency department, increasing congestion and potentially delaying care for more acutely and severely ill patients. We see the direct impact on the patient in Case 3 who could not be seen immediately. It’s likely that his minor urinary tract infection progressed and culminated in sepsis during the eight hours he went untreated, waiting in the emergency department.

What can you do?

Our public health colleagues render very important services to the community, including disease surveillance and establishing guidelines that if followed, could reduce the impact of epidemics and potentially prevent a public health catastrophe.

There seems to be controversy about immunizations—including influenza immunization—during those years when the disease is in decline; that controversy seems to subside when an epidemic is raging. We would do well to pay attention to our public health colleagues all of the time. And that includes ensuring health care workers should all be immunized against influenza A, not only to protect themselves but to protect their colleagues and patients as well.
This article originally appeared in the March issue of WSMA Reports.

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Published on 4/4/2017

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Published 3/20/2017 


A vision to guide us in challenging times

By Jennifer Hanscom, WSMA Executive Director/CEO

The vision of the Washington State Medical Association is to make Washington the best place to practice medicine and to receive care.

Folks are often incredulous when I mention I’ve been at the WSMA for 21 years. What’s kept me at the association for almost half my lifetime? Every day is different, and that’s certainly been more true than ever these past few weeks

Speculation about what’s next in health care, and in particular Medicaid expansion, came to a close last week when we were finally able to review a specific alternative to the Affordable Care Act: the American Health Care Act.

At their meeting last Thursday, the WSMA Executive Committee looked over a section-by-section analysis of the AHCA as compared to WSMA policy and our Principles of Health Care Reform. The committee voted not to support the bill at this time, releasing the following statement by WSMA President Dr. Shane Macaulay:</p><p>

“At the heart of the WSMA’s Principles of Health Care Reform is access to affordable health care for all Washingtonians. While the Congressional Budget Office analysis has yet to be released, as currently written, the AHCA puts our state’s Medicaid program at risk, reducing access to coverage for thousands of our most vulnerable patients. The act also shifts much of the Medicaid funding obligation onto Washington state. Sufficient funding of our state’s health care program is imperative to avoid damaging ripple effects throughout the entire health care system. Our state is already facing budgetary challenges, and is simply not able to fill the funding gap that would result from the policies proposed in this act.”

Since issuing our statement, the non-partisan yet oft criticized Congressional Budget Office released its analysis, and our state officials have shared their study regarding impacts on Washington state. Quick synopsis: Medicaid patients are most at risk of losing their coverage; our state budget will lose needed federal dollars; individuals won’t be required to have coverage; premiums will initially spike but eventually flatten out in 10 years and (hopefully) younger people will be incentivized to purchase coverage due to higher tax credits; yet older, low- to middle-income Washingtonians may struggle with accessing affordable and/or comprehensive coverage.

Other WSMA concerns about the AHCA in its current form:

  • With reduced Medicaid funding flowing into our state, will we be able to respond to changes in demand for services, including mental health and substance abuse treatment as a result of the ongoing crisis of opioid abuse and addiction? 
  • The repeal of the Prevention and Public Health Fund and its impact on needed patient services. 
  • Limits on services offered via Medicaid or in the nongroup market that eliminate the ability of patients to receive their care from qualified providers of their choice.

The WSMA has consistently opined that access to health insurance coverage does not equal access to health care, although having coverage certainly helps. One of the WSMA core principles guiding us through this debate is to ensure that all Washingtonians will have access to comprehensive, high quality, safe, affordable care through health care coverage options that are also designed to encourage participation of physicians and practices. But wishful thinking won’t ensure that will happen. Rather, we need to be involved in these discussions as the issues are debated. We need to lend our voice to shaping the health care delivery system in our state and work both sides of the political aisle so that we can achieve the quadruple aim in medicine: better outcomes, lower costs, improved patient experience and improved clinician experience.

As you read the WSMA principles for health care reform, you will see they are broad based and build upon what is working well in the current system: fewer uninsured people, essential market reforms and access to preventive services. These principles also point to core issues that need to be addressed with any future reforms: adequate funding for public programs, a strengthened health insurance market, reduction of regulatory and administrative burden, and solutions for achieving affordability of prescription drugs.

To that end, as noted at the conclusion of Dr. Macaulay’s statement:

“The WSMA is firmly committed to positive engagement on seeking solutions that bring better care for our patients. The physicians of Washington state stand on the frontlines of care. It is our goal to work toward positive health outcomes for all.”

The discussion taking place at the national level is far from over. We’ll continue to keep you abreast of any developments and will continue to make sure the profession’s voice is heard as future health care policy is shaped.

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Published on 3/20/2017

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Published 3/16/2017 


Legal Matters: Your LGBT patients and you

By Tierney Edwards, JD, WSMA associate director of legal and federal affairs

Increasingly, state and regulatory bodies are creating laws and rules specifically aimed at eliminating discrimination. Here in Washington, state law prohibits a physician from discriminating against a person based on, among other factors, race, color, creed, sex, disability, national origin or ancestry, and sexual orientation/gender identity, a combined category that includes lesbian, gay, bisexual and transgender (LGBT) individuals.

Recently, the U.S. Department of Health and Human Services released changes to federal regulations under Section 1557 of the Affordable Care Act, aligning the antidiscrimination protections already established by existing federal civil rights laws, and clarifying how HHS will apply Section 1557 and other laws to protect patients from discrimination based on their race, color, national origin, disability, age or sex (federal law includes sexual orientation within the category of sex). While it is unclear at the time of this writing what steps Congress will take to either repeal or modify the Affordable Care Act this year, for now the new changes broaden the definition of sex discrimination to include discrimination based on gender identity.

Those changes will apply to health care entities that receive federal funds. HHS has not provided an exhaustive list of which specific actions would or would not violate the anti-discrimination rules, but in guidance on its website, the agency states that it has tasked the Office of Civil Rights with evaluating “complaints that allege sex discrimination related to an individuals’ sexual orientation to determine if they involve the sorts of stereotyping that can be addressed under 1557. HHS supports prohibiting sexual orientation discrimination as a matter of policy and will continue to monitor legal developments on this issue.”

To help physicians offer high-quality, complete and welcoming care for all patients, and in response to Resolution B-14 “Health Care Access and Inequities in Persons Who Are Lesbian, Gay, Bisexual, and Transgender” adopted by the WSMA House of Delegates in 2014, WSMA’s legal staff has compiled resources for physicians to provide comprehensive and culturally competent care for LGBT patients. Resources include materials on terminology regarding these communities, their unique medical needs, cultural competency, LGBT-sensitive language for forms and paperwork, and suggestions for ways to make your waiting room more welcoming for all. These materials also aim to reduce disparities in health care faced by individuals who are, or may be, lesbian, gay, bisexual, and/or transgender. These resources can be found on the WSMA website in the Legal Resource Center under RegulatoryIssues.

The federal government’s summary of the rule can be accessed at federalregister.gov. If you need the regulation or summary in an alternative format, please call 800.368.1019 or 800.537.7697 (TDD) for assistance or email 1557@hhs.gov. For additional information, please contact Tierney Edwards, JD at tee@wsma.org.

This article originally appeared in the March issue of WSMA Reports.

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Published on 3/16/2017

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Published 2/15/2017 


Poison Control Center: An opioid epidemic ally for physicians

By Jeb Shepard, WSMA Associate Director of Policy and Regulatory Affairs

The opioid epidemic was finally thrust onto the national stage this year. While Washington state has been at the forefront of successfully implementing policies that have steadily reduced prescription opioid overdose deaths since 2008, much more needs to be done to alleviate the destruction caused by abuse of these drugs.

The WSMA is dedicated to identifying partnerships and resources that empower physicians to combat the opioid epidemic. The Washington Poison Center, a nonprofit staffed by registered pharmacists, nurses, physicians and other health care professionals, is one of those partnerships. All staff are supported around the clock by toxicologists, including Clinical Managing Director Alexander Garrard, PharmD, DABAT. Alexander and I discussed how the poison center can be an ally for physicians on the front lines of the opioid epidemic.

“The most important thing that physicians should know, especially newly minted physicians and those in rural areas, is that with a quick call to the Washington Poison Center, they have 24-hour access to a free consult in toxicology,” Garrard says.

These consults are extremely valuable, he says, because there are only seven toxicologists in the state that can consult on live patients, but 98 hospitals statewide. “People are often surprised to learn that 30 to 40 percent of calls come from health care facilities dealing with severe overdose cases in the emergency department,” Garrard says.

Staff can also provide knowledge and expertise concerning drug interactions, assistance with “clinical conundrums” (cases where patients are unconscious, and physicians cannot determine the cause, or causes, of an overdose), harm reduction guidance, antidote recommendations, even Hazmat protocols. While he acknowledges physicians are highly trained, “it’s impossible to know everything, and dangerous to believe that you do.”

This is especially true as the environment for substances on the street changes so frequently and so rapidly. “The illicit drug market is constantly changing,” Garrard says. “For example, fentanyl has recently exploded onto the scene—we’ve seen a marked increase in overdose from that very dangerous substance.” He adds: “The next wave will be synthetic analogs coming down from Canada, the W-series, that may not respond to current treatments. We’re the canary in the coal mine, so to speak, for many of these emerging drugs of abuse because we are collecting this information and sharing with physicians, public health officials and policy makers. It’s an important two-way flow of information.”

The Washington Poison Center is HIPAA compliant and should be viewed as a part of the continuum of care, Garrard says. “Once contacted, we follow up with the patient’s status until they are discharged from the hospital, making ‘toxicology rounds’ by phone twice a day. Just because a patient is stabilized, it doesn’t mean they’re out of the woods. We lend expertise that helps to get these patients out of the hospital and back into the community, at which point they are hopefully being connected with support services, such as counseling and treatment for addiction, if appropriate.”

At first blush, the Washington Poison Center might appear to be better geared to assisting emergency department doctors treating overdose patients. But Garrard encourages primary care physicians to become aware of what the poison center has to offer, not only for physicians, but also for their patients. “If a primary care physician has identified a patient at risk of an overdose,or is worried about children in the home finding their way into dangerous medicine, we urge them to provide information to the patient about the poison control center,” he says. “We distribute ‘poison prevention packages’ that physicians can keep on hand, and produce ‘toxic trend reports’ and seasonal health bulletins physicians can sign up for to prepare their practice for trends happening across the state. In addition, we visit health systems and practices to present information on harm reduction and how to better care for patients at risk of an overdose, free of charge—this is a community service.”

While the poison center is already an important resource for the state, they’re poised to play a more pivotal role, with the governor recently tapping the center as a critical vehicle for combating the epidemic in an executive order. The WSMA will work with the poison center in Olympia to address the problem. Meanwhile, any physician is welcome to call or visit and receive a tour of the poison center. “It’s an open invitation. We want to show you what we do and discuss how we can work together to address the opioid epidemic,” Garrard says.

This article originally appeared in the February 2017 issue of WSMA Reports.

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Published on 2/15/2017

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Published 2/14/2017 


The fresh faces of physicians practicing in underserved areas

By Elaine Porterfield, WSMA Reports senior editor

Like most pediatricians, Dr. Elaine Peterson’s days bring in waves of kids with ear infections, new babies for checkups and teenagers needing sports physicals. But she’s afforded a privilege few other pediatricians can claim— eating lunch at home.

“I see patients in the morning, I see patients in afternoon, and in between, I go home for lunch. I couldn’t do that in Seattle or San Francisco,” she says.

Peterson represents something special in short supply around Washington as well as the nation: a young, primary care physician practicing in an underserved or rural area. In this case, it means Moses Lake.

In a way, it’s perhaps not surprising Peterson sought a rural, primary care practice. She’s an osteopath, a branch of medicine with a heavy preventative, whole-person emphasis, and she graduated in the second class of the Pacific Northwest University of Health Sciences in Yakima. PNWU is an osteopathic medical school founded with a mission of educating and training health care profession als to practice in medically underserved communities around the Northwest.

It’s filling a huge gap because the need for primary care physicians is astonishing, here and across the country. The National Conference of State Legislatures says in a report the availability of primary care in rural America is a substantial concern, heightened by a demographic reality: “Physician supply in rural areas is already low, compared to non-rural areas of the country. Only about 11 percent of the nation’s physicians work in rural areas, despite nearly 20 percent of Americans living there.” 

The group says it’s a problem that will only worsen in the near future due to demographic shifts, such as an aging rural physician workforce, and growth in the rural elderly population as a result of baby boomers retiring to such areas at a time in life when they most need medical care.

A recent study found 30 percent of rural primary care physicians are at or nearing retirement age, while younger doctors under age 40 account for only 20 percent of the current workforce. In Washington, only 45.42 percent of our total primary care physician needs are met, according to the Kaiser Family Foundation, which closely tracks trends in health care.

The PNWU medical school is an outlier to such trends, according to the school:

  • Overall, 80 percent of its graduates matched to a generalist residency, including family and internal medicine, pediatrics, OB-GYN, psychiatry and general surgery.
  • About 78 percent of its students come from Washington, Oregon, Idaho, Montana and Alaska.
  • Around 36 percent of its graduate residency placement has been in the Northwest.
  • 82 percent of alumni come back to the Northwest to practice. Of that number, 67 percent return specifically to Washington.

Another young Moses Lake, PNWU-trained physician bucking demographic trends in favor of a rural, primary care career is family physician Dr. Lexie Zuver, 29, who graduated in the same class as Peterson. There never was any question where she’d practice, says Zuver, who grew up in Othello, Wash., just 30 minutes away.

“I was raised in a rural community, and we saw a traditional family practice doctor,” says Zuver, the mother of a fourmonth-old baby. “When I saw what a vital role he played in our community, I decided to pursue it. I like knowing my neighbors and the fact my kids will play on teams with my patients and my nursing staff. It gives me a different insight into the lives of my patients.”

Experts say a number of factors come into play regarding where young physicians choose to spend their careers. One is pressure to pick higher paying specialty practices, rather than primary care. That’s changing somewhat, with the University of Washington’s medical school ranked top in the nation in primary care by U.S. News and World Report. But projections show the country isn’t nearly on track to fill all the slots needed.

Though she’s Seattle born and raised, Peterson is exceptionally happy where she’s landed.

“I knew that a lot of primary care physicians were needed in the area,” she explains. “And my fiancé and I wanted a slower pace for our lives. That’s what pushed us to a rural area. I didn’t want to be at a hospital all day long.”

That’s not to say she doesn’t do some hospital work. “I do work in our local hospital doing on-call, intensivist work,” Peterson says. “I will admit my own patients, and I take care of newborns in the hospital.”

But much of her day is spent in-clinic, which has its own challenges—and rewards. “We don’t have all the resources we need, all the time,” she says. “We have to do care that isn’t immediately referred out, because we don’t have all the specialties here.”

But she enjoys the intellectual challenges that poses. She also enjoys what she says is a supportive professional community. Likewise, she benefits from another factor of working where she does: assistance with her medical school loan repayment from Samaritan Healthcare.

The lifestyle in Moses Lake suits her, as well. “I was looking for a position where I was needed, where I was supported, where I didn’t have to fight 45 minutes’ traffic to get to work,” Peterson says.

She loves the beauty of the region and its easy access to world-class outdoor recreation, such as hiking and water sports.

“We can have some kind of life outside of work,” Peterson says. “That’s factored into our decision to come here. Also, I love practicing in a place I can be a part of. You really feel like you’re more in a community. Living in a city, you might not know your neighbors for five years. It happens, of course, that I run into patients around the community. But it’s neat to be out and about and to see patients in the web of our community. It’s not intrusive—people are looking out for each other.”

And there’s another compensation, Peterson says: “The lifestyle here is a lot less expensive. Right now, we’re renting a place right on the lake. We could not afford that in Seattle.”

This article originally appeared in the February issue of WSMA's print publication, WSMA Reports.

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Published on 2/14/2017

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Published 2/9/2017 

Legal Matters: Physician-patient confidentiality threatened by state high court decision

By Denny Maher, MD, JD, WSMA General Cousel/Director of legal affairs

The Washington State Supreme Court recently issued a decision that promises far-reaching consequences for state physicians and other medical providers.

In a 6 to 3 December decision in the case Volk v. DeMeerleer, the court held it’s the duty of health care providers to warn all foreseeable victims of violence if a patient makes a specific threat during outpatient treatment. The WSMA was among the organizations filing an amicus curiae or “friend of the court” brief in the case advocating a narrower duty to warn and upholding doctor-patient confidentiality.

The case involved a man, Jan DeMeerleer, who had been treated by a psychiatrist, Howard Ashby, MD, for many years. At one point, DeMeerleer made threats to murder his ex-wife and her boyfriend, but never acted on them. Much later, DeMeerleer killed an ex-girlfriend, her 9-yearold son, stabbed another one of her sons, and then killed himself. DeMeerleer, however, had never made threats against the woman and her children.

The Superior Court judge granted summary judgment to Ashby. The Court of Appeals reversed the judgement, finding Ashby had a duty under Washington law to warn all foreseeable victims. The Court of Appeals wrote while existing state law creates a duty to warn others when a patient makes a threat against a reasonably identifiable victim, this narrower duty to warn applies only in the context of involuntary commitment—not anyone under outpatient treatment. The Supreme Court followed one of its earlier cases, Petersen v. State, holding there is a “special relationship” in the outpatient context between a psychiatrist (or presumably, any health care provider) and a patient establishing a duty to protect anyone who might foreseeably be injured if the patient threatens violence.

The majority appears to have opened a new path to sue physicians. Our state’s medical malpractice laws are set up so all malpractice claims against physicians must be brought under a certain set of laws. But the court now appears to distinguish medical malpractice cases (which relate to violations of care standards and a physician’s duty to a patient) and medical negligence cases (duties imposed on physicians). The WSMA is concerned this new interpretation might lead to an increased number of lawsuits brought against physicians by third parties who are not even patients of the physician.

In a dissent, three justices wrote this case should have been decided under existing medical malpractice laws, which would have led to dismissal of the case. Further, the dissenting justices disagreed with the majority about how Petersen v. State applies in the outpatient context. They felt the majority was at odds with existing law requiring there be a reasonably identifiable victim, triggering the duty to warn that potential victim. These justices wrote the majority decision will broaden liability of physicians and other mental health professionals. The dissent also says public policy doesn’t support such increased liability for the acts of others when the physician doesn’t have the ability to control the patient.

This case threatens to increase the risk of liability not only for psychiatrists, but for any health care provider treating a patient who makes threats while under their care. The difficulty now becomes determining who might be a “foreseeable victim” who must be warned—and how.

The WSMA is concerned this exception to confidentiality may have a negative effect on the patient-physician relationship, and lead to more involuntary commitments as physicians become reluctant to leave certain patients unsupervised. For these reasons, the WSMA and its partners are pursuing options both in the court and in the legislature. There may not be a quick fix to this significant problem, but we at the WSMA will work as hard as we can to correct this situation.

This article originally appeared in the February 2017 issue of WSMA Reports.

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Published on 2/09/2017

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Published 1/4/2017 

The opioid crisis continues, here and nationwide

By Marcia Frellick, WSMA Reports contributor

A 30-year-old patient named Troy had lifelong pain from a congenital hip malformation, only partially relieved by a hip replacement.

Like a growing number of chronic-pain patients, he had been self-medicating with heroin, then landed in a Washington hospital with a septic embolus to the prosthetic hip. There, a hospitalist provided partial relief with buprenorphine, prescribed for his opioid use disorder. Troy also received addiction counseling and help developing an employment plan.

However, he failed to follow up in clinic, reverted to using heroin and eventually ended up in prison.

Stories like Troy’s don’t have to end that way, says Lucina Grande, MD. Dr. Grande is a primary care physician at Pioneer Family Practice in Lacey, Washington, and about a third of her patients come to the clinic for help with chronic pain or addictions. She often prescribes buprenorphine.

Best known by the brand name Suboxone, buprenorphine is a powerful pain medicine and a safe version among opioids. It blocks neural receptors that lead to respiratory depression and overdose death. It also blocks euphoria and craving for opioids, so it effectively treats addiction.

“Buprenorphine frequently transforms lives and sometimes saves them,” she says. “It is thrilling for me to watch people go through this transformation and provide support as they rebuild their lives.”

Dr. Grande offers an alternative to the scenario above: The hospitalist offers Troy a six-month buprenorphine implant, approved in May by the U.S. Food and Drug Administration, prior to discharge. The steady drug level keeps him comfortable and helps him hold a job. “His heroin use, though not eliminated, is markedly reduced, along with his risk of incarceration, hospital readmission and overdose death,” Dr. Grande says.

This is just one of the stories that could have been different if physicians in all specialties knew more about pain management options and listened more intently and with more compassion to signs that a patient may be struggling with an opioid addiction, she said.

Fatal overdoses have quadrupled

The numbers struggling with addiction nationally are multiplying. In March of this year, amid growing concerns about a nationwide epidemic of painkiller addiction, the Centers for Disease Control and Prevention issued new guidelines for physicians on use of drugs like OxyContin and Vicodin.

Fatal overdoses from prescription opioids nationwide have quadrupled since 1999, according to the CDC. In the latest year available, 2013-14, rates of poisoning deaths increased 14 percent, from 7.9 per 100,000 to 9 per 100,000.

Washington state has been a leader in fighting opioid addiction, and new data from the state Department of Health show a significant drop in deaths from prescription narcotics, from 512 deaths in 2008 to 319 in 2014.

The WSMA has been partnering with others who are committed to attacking the problem—the governor’s office, members of the legislature, the Department of Health, many major health systems, the Washington State Hospital Association, the poison control center and others—and together, the efforts continue to make Washington a national example of what is working.

The WSMA continues to support the ER is for Emergencies program, which it launched in 2012, a program through which patients struggling with addiction or pain management problems may be identified.

The WSMA also strongly supports the state’s prescription drug monitoring program and encourages health care providers to use the program’s database to check a patient’s medical history for signs of potential opioid abuse.

Tools to treat addiction

The buprenorphine implant (called Probuphine) that Dr. Grande mentioned is one of the newest tools in treating opioid addiction. “Very few people know it exists,” she says. “Even for people who treat addiction, it’s been under the radar.”

She acknowledges it is costly. It was approved by the FDA for people already stable on the sublingual form of buprenorphine. However, it is expensive relative to the sublingual form ($5,000 for six months) and only makes sense for patients who would like protection from opioid craving but are at risk of inconsistent use or diversion if they were prescribed buprenorphine in individual doses, she says.

“The best candidates, I think, are people in a controlled situation—such as those hospitalized, incarcerated or in inpatient addiction treatment programs. They can initiate treatment on the sublingual formulation and then be offered the implant prior to discharge or release.”

Another change with great potential impact is for obstetricians to start prescribing buprenorphine for their patients with addictions, she says. They have a longitudinal relationship with patients, which is ideal for managing addiction, but currently, most physicians are referring their patients to outside sources and the patients aren’t following up.

Among the reasons physicians say they don’t want to prescribe buprenorphine is that it requires a waiver from the Drug Enforcement Agency, which entails a minimum eight hours of training (application for the waiver is available from the SAMHSA website). So far, only about 3 percent of primary care physicians have applied for the waiver. Some physicians who don’t want to treat opioid addictions have also said they don’t want to add patients they consider undesirable.

To the first, she says, the minimum eight hours of training can be accomplished on one weekend day. To the second, she says, “These people are already your patients. It’s just taking care of the ones you have with this problem.”

Pain centers close; demand surges

The problem in Washington is exacerbated by the closing of eight Seattle Pain Centers, which served about 25,000 patients. In July, Seattle physician Frank D. Li, medical director of the centers, was barred from practicing medicine and billing Medicaid after the state Medical Quality Assurance Commission charged that he failed to properly monitor prescription use of opiates.

Jeb Shepard, associate director of health policy and regulatory affairs at the WSMA said, “Eight thousand of those patients were actively being treated for chronic pain or other pain with opioids. They had the rug pulled out from underneath them."

They began to show up in primary care clinics for prescriptions, and primary care physicians were finding they didn’t have the resources or education to treat such complex patients, Shepard said.

The larger systems—University of Washington Medical Center, Virginia Mason and Swedish—were so inundated that they were turning people away. “These very large, very well resourced systems still can’t handle the number of patients coming from the fallout of the Seattle Pain Centers,” he said.

Shepard said in light of these developments and the worsening crisis, WSMA’s legislative efforts in 2017 will have a strong emphasis on addressing the opioid epidemic. Gov. Jay Inslee worked with the WSMA and WSHA and issued an executive order in October that outlined strategies for fighting the problem.

“This is a chance to change the momentum from opioids toward non-pharmacological treatments or other drugs such as buprenorphine or non-opioid alternatives,” Shepard said.

Ray C. Hsiao, MD, WSMA immediate past president and a child psychiatrist and addiction specialist at Seattle Children’s, said in a statement: “The governor’s executive order provides a path forward that brings together state agencies, health provider organizations, law enforcement and other partners in a coordinated and unprecedented effort to combat the opioid crisis in this state.”

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Published 12/22/2016 

Health equity spotlight: Treating opioid addiction in the native population

The following entry in our health equity spotlight is from WSMA member Sofia Infante, a first-year medical student at the University of Washington School of Medicine and co-chair of the WSMA Health Equity Task Force.

On the first day of working with my primary care preceptor at the Alaska Native Medical Center in Anchorage, Alaska, I started off the day in a pain management conference reviewing several complex pain management cases with an interdisciplinary team, then jumped into an afternoon of predominantly chronic pain visits. I spent the day listening to patients’ frustrations with chronic pain, and learning more about the burden of opioid addiction within Alaska Native communities.

Nationwide, American Indians and Alaska Natives are at least twice as likely as the general population to become addicted to drugs and alcohol and they have the highest rate of drug-induced death. An alarming 9.1 percent of American Indian youth reported using OxyContin by 12th grade, compared to 5.0 percent nationally2.

Washington’s rate of drug-induced deaths is above the national average. According to the Washington State Department of Health Drug Abuse and Overdose report, Washington was far from meeting the 2010 goal to reduce drug-induced deaths, and is not expected to meet the 2020 goal of reducing drug-induced death to below 11.3 per 100,000 (age-adjusted) if current trends continue3.

In Washington state, and nationally, there is a need for more treatment and prevention. American Indians and Alaska Natives are more likely than persons from other races to need illicit drug use treatment (6.5 percent vs. 3.1 percent)4. And while many tribes in the Northwest attempt to provide some level of addiction services, funding is limited for many.

This summer, President Obama signed into law the Comprehensive Addiction and Recovery Act, an overarching effort to address the opioid epidemic5. This December, Congress will be voting on funding for the act. Christopher Clifford, the American Medical Association Medical Student Section’s government relations advocacy fellow, and others are calling on medical students to advocate for increased funding for drug treatment and prevention programs to fight the opioid epidemic6.

Recently there have been monumental efforts to combat the impact of opioid addiction and some states have shown a decline in drug overdose mortality7. The current momentum on the opioid epidemic has been critiqued as a response to an epidemic that is increasingly affecting white communities.8 However, it’s important to consider that it continues to have a lasting impact on American Indian communities that have suffered from generational trauma. I was excited to learn about the programs the Alaska Native Medical Center is putting in place to combat this epidemic, including utilizing traditional healing practices in an interdisciplinary pain management team. With an unpredictable political climate, it is critical to continue advocating for access to evidence-based and culturally appropriate treatment programs, prevention and regulation on opioid prescriptions.

What are your experiences with addressing the opioid epidemic in Washington? And what can we do to improve the care for all communities affected by addiction? Share your thoughts in the comments below and continue this conversation with your local community and colleagues.

Sources:

  1. Whitesell NR, Beals J, Crow CB, Mitchell CM, Novins DK. Epidemiology and Etiology of Substance Use among American Indians and Alaska Natives: Risk, Protection, and Implications for Prevention. The American journal of drug and alcohol abuse. 2012;38(5):376-382.
  2. Stanley LR, Harness SD, Swaim RC, Beauvais F. Rates of Substance Use of American Indian Students in 8th, 10th, and 12th Grades Living on or Near Reservations: Update, 2009–2012. Public Health Reports. 2014;129(2):156-163.
  3. http://www.doh.wa.gov/Portals/1/Documents/5500/RPF-Drg2014.pdf
  4. SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2003 to 2005, 2006 to 2010 (revised March 2012), and 2011.
  5. http://www.cadca.org/comprehensive-addiction-and-recovery-act-cara
  6. https://wire.ama-assn.org/ama-news/medical-students-advocate-action-opioids-during-lame-duck-session
  7. http://www.cdc.gov/drugoverdose/policy/successes.html
  8. http://www.theatlantic.com/politics/archive/2015/08/crack-heroin-and-race/401015/
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Published 12/12/2016 


Turbulent times ahead for health care reform

By Jennifer Hanscom, WSMA Executive Director/CEO

At a Seattle press conference back in 2010, shortly after the Affordable Care Act passed, Christine Gregoire, then governor of Washington, said, “We’ve got four years to build a runway so the health care reform plane can land.”

Well, the plane landed here in Washington state, albeit with some turbulence. But with time, the bumpy ride smoothed out—our uninsured rate has dropped to approximately 6 percent with nearly 170,000 people participating in qualified health plans via our state’s insurance exchange and close to 600,000 individuals newly covered through Medicaid expansion.

If the last couple of years felt chaotic, prepare to buckle up. The new Trump administration appears poised to repeal the Affordable Care Act, and while the administration has clearly stated its intent to repeal and replace, it’s too soon to tell how any changes put forward by new agency heads and the administration will impact our state’s efforts.

The WSMA recognizes the ACA isn’t perfect. That’s why we stayed neutral on the original bills (there were two that made up the act). We supported several elements of the act—expansion of insurance coverage, insurance reforms that help consumers and pay-for-value, for example. With other elements, we questioned their effectiveness—a weak mandate that could fuel higher insurance premiums, a potential Medicaid cost shift to states, funding predicated on politically and economically challenging assumptions, and the fact that several key items were omitted, including meaningful tort reform.

Throughout the debate, the WSMA maintained that the health care system needed fundamental changes to the financing and delivery of services. In 2010, our state was already leading the way on several of the elements of the ACA, driven by federal and state budget constraints and the commercial market. That need remains unchanged.

A tremendous amount of thoughtful deliberation went into making the ACA effective here in Washington state. And, there is still some work to be done. But repealing the act—as is expected—could be enormously disruptive to our state’s expansion and reform efforts and has the potential to place an immense burden on our state’s health care system, depending on the steps the next administration takes.

At the moment, the focus is on Dr. Tom Price, President-elect Trump’s choice to lead the Department of Health and Human Services. Dr. Price is an orthopedic surgeon and congressman from Georgia, as well as a longtime member of the Medical Association of Georgia and the AMA.

Just as the ACA has its pros and cons, Dr. Price’s nomination brings good and troublesome news. In good news, he is a physician. He can view future policy and regulations through the lens of a physician treating patients, and he supports meaningful tort reform.

On the troublesome side: Dr. Price’s position on Medicaid expansion. In Congress, Dr. Price introduced H.R. 2300, which would fully repeal the Medicaid expansion and, as written, offers no replacement Medicaid coverage options for the newly eligible category of assistance. Individuals impacted by the repeal of the Medicaid expansion would likely be eligible for tax credits in the individual insurance market. However, in 2016, Congressman Price as chair of the House budget committee proposed changing Medicaid to a block grant program, referred to as “State Flexibility Funds.”

Details on how state flexibility funds work—and how much states get—are thin, particularly as they relate to a state like Washington that depends on federal Medicaid expansion dollars. If federal funds are eliminated, continuing to cover that population through state funding will prove to be prohibitive without a new source of funds (i.e. taxes).

The impact of ACA repeal on the insurance industry could be substantial, too. Some thoughts off the top:

  • If subsidies for purchasing insurance coverage through the state’s exchange are eliminated, the exchange would collapse almost overnight.
  • Only the sickest of the sick would purchase plans at full price and insurers’ will be unlikely to offer a plan to only full-price exchange enrollees. Here too, the state could try to bridge the gap, but it would likely be cost prohibitive.
  • If other coverage options are removed, the state’s high-risk pool (currently around 300 people) will likely need to be reopened to many thousands of lives. Paying for that will be difficult, but probably necessary. We’ve already heard one legislator say the existing pool is too expensive and physicians would need to accept cuts to keep it going.
  • The Ryan plan, which is the only GOP “replacement” health care plan we’ve seen, calls for tax credits, which are similar to the ACA’s exchange subsidies. Tax credits, however, won’t immediately help a current exchange enrollee who’s receiving a monthly subsidy for insurance coverage they couldn’t otherwise afford.

Alas, the runway is foggy with nearly zero visibility. Even so, we will continue to assess how best to maintain and strengthen access to care in Washington state. We will continue to advocate for the core of an effective and efficient health care delivery system: a strong, individual and personal relationship between patients and their doctors.

Most of the current transformation efforts involving increased care coordination and accountable care are intended to achieve this simple goal: a long-term, stable care relationship between patient and physician. We will continue our work to preserve and strengthen these relationships in these challenging times ahead.

And hopefully—by standing together—we’ll glide in for a smooth landing.

Back to WSMA Doc Talk

Published on 12/12/2016

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