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Practice Management

Emergency Regulations for Granting Medical Exemptions from Immunizations

The New York State Department of Health recently issued emergency regulations to inform and assist physicians in granting medical exemptions under new state law which repealed non-medical exemptions for children attending school or daycare.
 
A series of Frequently Asked Questions (FAQ) on the new law was issued on August 16, 2019 by the NYSDOH and in collaboration with the Office of Children and Family Services and the State Education Department.
 
Physicians who issue medical exemptions are now required to complete the applicable medical exemption form approved by the New York State Department of Health or New York City Department of Education, which specifically outlines the medical reason(s) that prevent a child from being vaccinated. Additionally, the regulations require physicians to outline specific justifications for each required vaccine in order to be able to grant an exemption.  Physicians can no longer just submit a signed statement to schools without having to document on an approved form indicating why an immunization(s) may be detrimental to a child’s health.
For more information, please reference: New School Vaccination Requirements in New York State and Immunization Laws and Regulations

 


Opportunity to Provide Feedback on NYS PCMH and VBP is Right Around the Corner!

The NYS PCMH model is an integrated care delivery and payment model that ties together a service delivery model and reimbursement to promote improved health and health care outcomes that are financially sustainable.   The NYS PCMH model was designed to help primary care practices evolve to assure readiness to participate in the Value Based Payment (VBP) models being developed and implemented by both public and private payers.

NYACP, in collaboration with the NYSDOH and Health Research, Inc. (HRI), will be conducting two brief surveys in the next few weeks for (1) physicians that have achieved recognition through the NYS PCMH program; and (2) those that have chosen to not participate in NYS PCMH.  The purpose of the surveys will be to assess the effectiveness of the program and identify successes, barriers and concerns on sustainability and capability for value based payment.

Please keep an eye out for the survey and provide your feedback!

The project described was supported by Funding Opportunity Number CMS 1G1CMS331402 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services

Hot Topic:  Price Transparency
 

Price transparency is a hot topic in healthcare.  Patients are asking more questions related to the cost of their care.   Physicians are incorporating the topic into patient visits as part of whole-person care.  NYACP and ACP have supporting resources for addressing this topic.  The following are resources for the most common topics encountered in practice:

Getting the Conversation Started

Finding/Getting Better Insurance Coverage

Estimating and Planning Costs

  • What’s Covered – An App for Medicare patients that provides information about coverage by service. 
  • FAIR Health – A great place to get an idea of local pricing for services.  This is useful for uninsured patients and for dental estimates.
  • GoodRx – Compare medication costs at local pharmacies and find alternatives.  Use it for your pet’s prescriptions, too!
  • NYACP Donut Hole Handout – Help Medicare patients learn about and plan for their medication costs. 

Finding Assistance

  • NeedyMeds – Search $4 generic lists, get a listing of patient assistance programs for medications, transportation and supplies.
  • Community Health Advocates – Connect the patient with an organization that helps navigate insurance plans, surprise bills and find assistance programs. 

5.3.19: Measles Outbreak Throughout New York State: What Physicians Can Do

Recent outbreaks of measles in Rockland County, Orange County, and New York City have contributed to the largest measles outbreak in New York State since the elimination of measles in the US in the year 2000. Over 390 cases of measles outbreaks have been reported in Brooklyn and Queens alone.

Multiple studies have shown how impactful a state’s nonmedical vaccination exemption policies can be to the risk of an outbreak of a contagious disease. One recent publication in the journal of Academic Pediatrics found that “a state with easy nonmedical vaccine exemption policies is 140% and 190% more likely to experience a measles outbreak compared with states with medium or difficult policies, respectively.” The same report found that the magnitude of outbreaks decrease in half when there are fewer exemptions.

NYACP is supporting legislative efforts to address the measles outbreak, including support for NYS Bill S.2994 (Hoylman)/A.2371 (Dinowitz), which would eliminate non-medical vaccination exemptions for children. In addition, The Chapter has made available resources with the help of our members to help communicate with patients and physicians the importance of vaccinations. Here are a few:

From the DOH:

To read more, please view the Measles Page here.

*A special thanks to Rabbi Aaron Glatt, MD, FACP, for developing and producing this information to share.


5.3.19:Geriatric Spotlight: Deprescription, The New Fashion in Prescribing!

TS Dharmarajan MD, MACP, AGSF, FRCPE
Vice Chairman, Department of Medicine; Clinical Director, Geriatrics; Program Director, Geriatric Medicine Fellowship Program
Montefiore Medical Center (Wakefield Campus)
Professor of Medicine, Albert Einstein College of Medicine

Deprescription or Deprescribing is a relatively new term referring to the “appropriate and safe reduction in number or dosage of medications prescribed to an individual”; the process is intended to withdraw unwanted, ineffective medications.1 Deprescribing is not enforced, rather, is voluntary and carried out following discussions between provider and patient and/or caregiver, including acceptance by the latter. Following deprescribing the patient is followed for unexpected consequences that may warrant re-introduction of the medication.

An aging population with associated co-morbidity has resulted in the prescribing of numerous medications to older individuals. The redundant, excessive and inappropriate use of medications is termed “polypharmacy.” Definition of polypharmacy varies, ranging from three to five or more medications prescribed on a continued basis.2,3 Polypharmacy, in conjunction with over-the-counter medications and supplement use leads to adverse drug events (ADEs) and poor outcomes, including hospitalization. Examples of ADEs include falls, fractures, delirium, syncope, organ dysfunction and more. Sometimes, as exception, patients are appropriately on six or more essential medications, as with chronic kidney disease or heart failure. Seniors also visit multiple providers, each adding medications to the list; additionally, many elders also consume over-the-counter supplements.

Polypharmacy and associated ADEs result from drug-drug, drug-nutrient or drug-disease interactions. An ADE is “harm resulting from use of a drug, including all adverse drug reactions.”4 Failure to recognize an ADE leads to evaluation, additional prescribing and more poor outcomes. A new geriatric syndrome must be viewed as potentially drug related, prior to needless, expensive testing.

Who owns responsibility for addressing the burden of polypharmacy?  In large part, it is the primary provider or geriatrician, whose onus it is to coordinate care for patients who visit multiple providers of care. Medication reconciliation and opportunity for deprescribing exist at every patient encounter. Periodically, a patient feels overburdened by the number of medications and initiates a request for deprescribing. Unfortunately, there is no incentive for providers to engage patients into long-drawn discussions to assess and withdraw medications which may contribute to the reluctance for providers to attempt deprescribing!

At times, reduction in the dose or drug withdrawal results in negative consequences, as with beta blockers, benzodiazepines and antidepressants. In such cases the drug must be promptly re-introduced. Options always exist. Is a non-drug (life style) approach available? Is the patient on another medication that suffices? Is there any benefit at all from the drug, considering co-morbidity and life expectancy? Has harm resulted from the drug, e.g. renal dysfunction, a fall or hyperkalemia?  Several drug classes are always considerations for deprescribing: analgesics, anti-histamines, anti-psychotics, H2 blockers, proton pump inhibitors, vitamins, supplements and sedative hypnotics. In addition to improving outcomes, deprescribing reduces medication costs to patients and participating facilities.5

Ethical aspects may warrant consideration. One must factor comorbidity, life expectancy, quality of life and importantly, opinion of the patient with capacity (or that of caregiver should capacity be lacking). Properly utilized, safe deprescribing is a boon to older adults and results in better healthcare!

References

  1. Sivagnanam G. Deprescription: the prescription metabolism. J Pharmacol Pharmacother. 2016;7(3):133-37
  2. Rambhade S, Chakraborty A, Shrivastava A et al. A survey on polypharmacy and use of inappropriate medications. Toxicol Int. 2012;19(1): 68-73.
  3. Heuberger R. Polypharmacy and food-drug interactions among older persons: a review. J Nutr Gerontol Geriatr. 2012;31(4): 325-403.
  4. Nebeker JR, Barach P,Samore MH. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140:795-801.
  5. Page AT, Clifford RM, Potter K et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82(3): 583-623

updated 1.6.20

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