Cheryl Alkon

Medical marijuana allows Ajay Suman, MD’s cancer patients a safer alternative to opioids for chronic pain. It can be an effective treatment for his terminally ill patients, says Suman, a New York-based anesthesiologist and a professor of anesthesiology and pain medicine at Weill Cornell Medicine, who is qualified to evaluate patients in New York State who want to use marijuana for medical reasons.
	
	As of April 2018, medical marijuana was legal in 30 states as well as the District of Columbia, Guam, and Puerto Rico, according to the National Conference of State Legislators’ website.
	
	Meanwhile, medical associations such as the American Medical Association and the American College of Physicians are calling for more scientific research and trials regarding how medical marijuana actually benefits patients. Many also believe physicians and patients shouldn’t face federal penalties for its use in states where cannabis use is legal.
	
	For physicians who want to include medical marijuana in their practices, knowing their state laws is crucial. Federal law deems marijuana a Schedule 1 substance under the Controlled Substances Act, putting it in the same category as heroin, LSD, and Ecstasy for its potential for abuse and addiction. This makes it a federal offense to distribute marijuana.
	
	Marijuana is used to treat assorted medical conditions including chronic pain, side effects related to cancer, Alzheimer’s disease, and nausea, among others. Marijuana is not covered by medical insurance so patients pay out of pocket for products, which can include marijuana in different concentrations as well as different forms, including edibles, tinctures, and oils. 
	
	Here’s what doctors need to know if they want to prescribe marijuana to patients.


	
	Unlike a medical practice that offers ancillary services, generally a medical practice cannot partner with or incorporate an on-site marijuana dispensary due to marijuana’s federal classification as a Schedule I drug, says Michael F. Schaff, JD, an attorney with Woodbridge, N.J.-based law firm Wilentz, Goldman & Spitzer.
	
	“As of today, any medical practice relationship with a dispensary puts the physician in a position to risk losing their federal Drug Enforcement Agency (DEA) license,” he says.
	
	Angelo J. Cifaldi, JD, RPh, who co-chairs Wilentz, Goldman & Spitzer’s cannabis law group with Schaff, urges physicians to learn about their state’s marijuana laws, suggesting that physicians look at their state’s medical society and understand how to work with medical marijuana following state and federal laws.
	
	For example, notes Cifaldi, some states follow a corporate practice of medicine, which is a doctrine that may limit the practice of medicine to restrict non-licensed entities from practicing medicine; so a physician cannot be hired by a non-physician. A physician, therefore, needs to know state law if working for a dispensary as a medical director or is hired by a dispensary to train the staff, he says.
	
	Cifaldi also points out that physicians may not agree on making medical marijuana available to treat specific conditions, despite state laws identifying which diagnoses might benefit from its use.
	
	Physicians need to learn the proper terms used in their state. Because of marijuana’s status under federal law, physicians cannot write a prescription for a dose of medical marijuana. Instead, physicians write “recommendations” or “orders” (depending on state terminology, and comparable to writing a prescription while complying with state laws) for a medical marijuana card, which the patient then fills at a marijuana dispensary. “Clarify whether you are writing an order or a recommendation,” says Cifaldi. “If you use the wrong term on the wrong form, you may be violating the law.”
	
	Physicians can earn extra income for evaluating a patient’s eligibility for medical marijuana use by charging a fee for the visit, but “a medical practice should not just be charging for writing marijuana prescriptions to qualified patients,” says Schaff. He notes an evaluation should be conducted to determine a recommendation or order first versus simply for a visit to gain access to medical marijuana.
	
	Other ways physicians can earn income from medical marijuana, Schaff says, include working at a dispensary, if state laws permit it, or consulting with a dispensary or one of the growing number of marijuana-related companies. Physicians who evaluate patients for medical marijuana cards may see patient volume increase as new patients come into the office for evaluations.
	
	There are other things physicians must follow to maintain compliance with state laws. This can include things like checking with the landlord to determine if working with medical marijuana violates the terms of the practice’s lease or speaking to the practice’s medical partners to ensure that one physician’s views regarding marijuana are consistent with others in the same practice, because there may be limitations on the forms of treatment in company documents, says Schaff.
	 


	
	It can be tough for companies that work with medical marijuana to remain compliant with all the financial considerations by and between financial institutions, state licensing agencies, and licensees, particularly as they cross state lines. Since the law varies from state to state, banking options can be challenging, which physicians should keep in mind if they are considering working with marijuana as a way to increase business to an existing medical practice.
	
	Nathaniel Gurien, the founder and CEO of FINCANN, the Cannabis Banking Financial Network, helps businesses in the marijuana industry find banks that are comfortable providing checking accounts and/or MasterCard/Visa credit care processing to marijuana-related businesses.
	Often, Gurien says, banks refuse to open checking accounts or provide merchant processing for marijuana-related businesses because of marijuana’s stigmatized reputation. The few banks that do will charge relatively high fees to cover the additional risk and compliance-related costs of providing service to these customers, he says.
	
	Gurien notes, however, that there are more cannabis-friendly banks around the country today than in prior years and that access to such banks is improving as medical marijuana becomes more mainstream. A bank could potentially notice if a medical practice is now advertising medical marijuana evaluations through the practice’s website, and a bank’s representative may reach out to its physician customer and terminate the banking relationship if the bank has a problem with marijuana-related businesses.
	
	With any kind of marijuana business, even if it’s illegal, the federal government taxes it, says Eric Foster, director of strategy for the Banks & Company Cannabis Practice Group. “The federal government wants to minimize the tax write-offs of being in that business because cannabis is still a Schedule 1 drug.”
	
	As a result, those who grow, process, or sell marijuana products cannot deduct or write off many expenses related to the business, which reduces the potential return of running the business, says Foster. (Expenses related to the cost of cannabis can be written off, he notes.) However, this law doesn’t apply to physicians who are qualified to evaluate patients for medical marijuana cards, as they are an ancillary service for the industry, Foster notes. Physicians should still check with their practice’s tax advisor just to be sure, he adds.
	
	Ultimately, those who believe that medical marijuana is a valid form of treatment can decide how to best get involved with it. Some physicians may restrict their practice to patients with a specific condition. Others may decide to evaluate patients with any of the multiple diagnoses approved by state laws for medical marijuana treatment, despite its current federal legal status. And while some states have approved the use of medical marijuana, that might change in the future.
	
	“I’m prescribing medical marijuana to patients with terminal cancer,” says Suman. If new legislation makes medical marijuana illegal in New York State in the future, Suman says he isn’t worried about prosecution. “In three or four years, if my charts are audited, I have no question that I am covered. I don’t think people will come after someone prescribing it for terminal cancer patients.”

Articles

It is crucial for physicians to know how to legally handle what is still considered an illegal substance in some jurisdictions

Understanding the business of medical marijuana

For Sean McNeeley, MD, patient care was what drew him to medicine. But the challenges of running his own private practice, with its growing administrative burden, made it hard to stay there. So he decided to limit his work to urgent care.

“I loved being in private practice, but it was a challenge in family medicine to be able to do it all well and balance time with my family,” says McNeeley, the medical director of University Hospitals Urgent Care Network based in Cleveland. 

Board certified in both family and urgent care medicine, McNeeley ran his private practice from 1999-2004 while also working at an urgent care clinic for extra income. Ultimately, he closed his practice to work solely as an urgent care physician. Today he oversees healthcare providers at ten University Hospitals Urgent Care Network facilities, while still seeing patients every week.

“Working in urgent care gives physicians the ability to balance work and life, which has no on-call schedule, no nights, and limited weekends,” says McNeeley, who is also the president of the board of directors of the Urgent Care Association.

While urgent cares typically are open longer hours than practices, he notes that patients don’t expect to see a particular provider when they seek care at an urgent care clinic, so when a physician is off work, they are truly off. “I can feel good about what I’ve done during the day and I can go home and have some personal time,” McNeeley says.

Interest in, and demand for, urgent care clinics is growing rapidly. The number of clinics has ballooned from 6,946 in 2015 to 8,285 as of June 2018, according to Laurel Stoimenoff, CEO of the Urgent Care Association (UCA) and co-author of “The Essential Role of the Urgent Care Center in Population Health,” a 2018 association report. Behind those figures lies an $18 billion industry ex- perts predict will grow 5.8 percent this year.

Urgent care clinics handle about 89 million patient visits each year, or more than 29 percent of all primary care visits in the country, and nearly 15 percent of all outpatient physician visits, says Stoimenoff.

Urgent care isn’t booming only because of physicians seeking a better work-life balance. Other factors driving the industry’s growth include patient demand, convenience, and costs.

Patients seeking medical care don’t want to wait. Urgent care clinics, with their longer hours and walk-in appointments, fulfill that need in a way traditional physicians’ offices can’t always accomplish.

“This is the age of the patient as a consumer, where fast and convenient is never fast and convenient enough,” says Richard Park, MD, CEO and co-founder of CityMD, a group of urgent care clinics in New Jersey, New York, and Washington state, and president-elect of the UCA.

Urgent care clinics blend retail elements such as ground-floor locations that provide easier access, and the ability to schedule same-day appointments using an online calendar program. A customer-first approach, oriented to service and technology, is fueling growth, says Stoimenoff.

However, urgent care clinics could become victims of their own success, writes Len Schlesinger, DBA, Baker Foundation Professor at Harvard Business School, in a column for athenaInsight: “The tension that I see now is that as these urgent care clinics compete for patients, they might lose the focus that made them successful in the first place.”

Urgent care centers save money compared to emergency departments, where many patients go, even though they are not experiencing a true emergency.

A 2017 Annals of Emergency Medicine study compared the average price-per-visit for Texas-based urgent care clinics, free-standing emergency departments, and hospital-based emergency departments in 2012 and 2015. Researchers found that urgent care clinics charged $168 in 2015.

At hospital-based emergency department visits, the average price per visit in 2015 was $2,259 and $2,199 at a freestanding emergency care clinic. Most of the visits, regardless of facility, were for 20 of the most common diagnoses, and prices for patients with the same diagnosis were, on average, almost 10 times higher at freestanding and hospital-based EDs when compared to similar services received at urgent care centers, the study said.

McNeeley says the cost of an urgent care visit is typically similar to a primary care physician visit, and much less than an ED visit. In addition, urgent care clinics offer more services than most primary care offices. “We can do more, such as run IVs, splint a fracture, or sew wounds,” he says.

Millennials are considered relatively healthy and have only one or two episodic health emergencies a year, says Stoimenoff. This demographic makes up a quarter of all visits to urgent care clinics, according to a 2015 PNC Healthcare consumer survey. “I think it’s very appealing to that generation,” she says.

Other patient groups also report not always turning to a primary care physician for care. A UCA study of patients over age 65 found that 11 percent said they had no primary care physician. A Kaiser study from 2014-2016 reported that, on average, 17 percent of women in the United States didn’t use a primary care provider. For men it was 28 percent.

The growing number of older patients is also a factor, says Park, who oversees more than 100 CityMD clinics. An aging population is taking up the resources of primary care and emergency care departments, according to the same 2015 PNC Healthcare consumer survey. It found that 85 percent of seniors choose to see primary care physicians first. Only 11 percent of that population goes first to an urgent care center. This trend “is making other patients choose to go to urgent care clinics for faster, easier and cheaper service,” Park says.

Rural areas in particular are benefiting from the rise in urgent care clinics. A report by FAIR Health, a nonprofit that studies insurance claims, found that from 2007 to 2017 there was a 2,308 percent increase in insurance claims for procedures done in rural urgent care facilities compared to a 1,675 percent increase in urban areas.

And with more patients paying out-of-pocket for healthcare services, more are turning to urgent care because costs are lower, says Park.

“About 35 percent of employees are on high-deductible health insurance plans, and that number is growing,” he says. Many of those patients pay from $6,000 to $8,000 out-of-pocket before insurance pays anything. About 80 percent of them never meet their deductible, so they are essentially self-paying and want to pay the lowest fees.

“Urgent care is one service that checks both boxes,” says Park. “It is faster, better, and less expensive, and relative to primary care physicians, urgent care centers provide better access and an extended scope of practice.”

What’s behind the growth of urgent care clinics?

It’s a new concept and a buzzword cropping up in financial circles: blockchain. And it’s a technology that promises to disrupt the healthcare industry and how many physicians practice medicine.

Blockchain technology, in many ways, is like Google Docs, the online platform where a group of users can contribute to and edit a shared document to create a record of information-but perhaps a bit more sophisticated.

Blockchain, often associated with cryptocurrency and digital trading, is a cooperatively maintained repository for information. The technology enables multiple users to upload and share information to provide a single accurate collection of details using a blockchain database, according to Mike Jacobs, senior engineer of Optum, a business unit of UnitedHealth Group.

Physicians should be aware of the technology, because it could potentially improve healthcare delivery through sharing information. For example, blockchain can aggregate health records from other providers for more effective healthcare delivery that isn’t tripped up by, for example, health insurance claims getting denied due toinaccurate patient data.

Looking at it more closely, the blockchain users could be multiple companies, such as medical provider groups and health insurance companies, who want to access the same information so insurance claims can be processed and paid efficiently the first time. Some small bits of information can be stored on the blockchain itself, but the rest of the data is kept in existing user’s computer systems or “off-chain”-in other storage locations.

In this case, the blockchain stores information about transactions, such as the time stamp and where the data lives. To gain access to data, users must have a special password. “You want to have the two ends of the transaction have the same information for it to happen in a frictionless way,” says Jacobs.

So what’s the use of this new concept in medicine? Take the example of insurance claims. Currently, numerous problems often come up when processing claims, because details about provider contacts, provider information such as an in-network designation, and/or insurance rules regard- ing coverage can all result in data that don’t match up among companies’ databases.

“It results in islands of data that are intended to cover the same information but can fall out of sync,” Jacobs says. “It causes problems, phone calls and faxes ensue, and there are many questions about, ‘Why was this claim rejected?’” Blockchain can provide a single source of accurate information, thereby avoiding such problems, he says.

Blockchain is also known as distributed ledger technology. Just as a person keeps a ledger when paying bills, blockchain is the same-only in an electronic format, says Debbie Bucci, IT Architect with the Office of the National Coordinator for Health IT, a part of HHS.

“Multiple workers or participants are writing to it at one time, and they can craft different transactions one at a time and can’t erase it.” Writing to the blockchain means users can contribute to it at the same time while having access to the same accurate data at the same time.

While different parties add to the blockchain, the information itself remains in its original location whether that data is in an EHR or some other storage mechanism, notes Corinne Proctor Boudreau, senior solutions manager of physician experience of MEDITECH, an EHR vendor based in Westwood, Mass.

“Neither the blockchain or any particular entity takes a copy of and owns the data,” she says. “The distributive nature helps ensure data is stored where it originated from and in an unaltered state, thus providing a true historical record.”

Blockchain’s healthcare applications are still emerging. In April 2018, five large healthcare organizations-Humana, the MultiPlan PPO network, Quest Diagnostics, United- Health Group, and Optum-announced a blockchain project to incorporate provider data, such as name, address, specialty, and phone numbers, into one comprehensive database.

The goal is to run a pilot among the five companies through October, with results released in November and December, says Lidia Fonseca, MBA, MBI, chief information officer of Quest Diagnostics. Fonseca sees the alliance as a model of collaboration for quality improvement.

“It’s exciting and a great example of where companies are willing to cross company boundaries to bring benefits to the industry,” she says. The alliance hopes to help reduce some of the administrative burden for providers so that they can spend more time with patients and less on administrative tasks, Fonseca says, while also decreasing payment times.

Those tasks, which include time spent on phone calls and faxes to find out why claims are denied, added an estimated $2.1 billion across the healthcare system, according to statistics compiled in 2016 by the nonprofit Council for Affordable Quality Healthcare, which studies how to streamline the business of healthcare.

Opinions differ on whether blockchain can help healthcare. Some feel strongly that the concept can bring many benefits. Others think it’s too early to say whether blockchain can have an impact.

On the “benefits” side is Robert Chu, MEng, MCS, founder and CEO of Embleema, a Metuchen, N.J.-based healthcare blockchain network that launched a public beta release in mid-July. It allowspatients to share their medical histories with providers, and in future versions, with pharmaceutical companies seeking subjects for clinical trials and, potentially, with health insurers.

Embleema secures data so providers can see a complete medical history without the need for patients to fill out forms at every visit. Pharmaceutical companies seeking patients for new clinical trials will also be able to search Embleema’s database in the future to find candidates.

“All data on the blockchain is fully controlled by the patient and will show a complete trail of who accesses that data,” says Chu.

“At this point, nobody has actually proven that blockchain will work in healthcare,” Bucci says. “I don’t think anyone has clearly demonstrated what patients will see or get out of it, nor has the industry been successful, beyond proof of concepts or small target pilot demonstrations, to link multiple hospital systems. It looks like a potential solution to a security problem, but nobody has implemented it for that purpose, as of yet.”

Though blockchain may be difficult to understand, it is gaining momentum in healthcare and other industries such as finance. It’s a way to improve the accuracy of information shared among different users that can ultimately lead to better patient care and less time following up on inaccurate insurance claims, allowing physicians to spend more time with patients and less time on administrative tasks.

“Ultimately, it’s another tool in the box,” says Boudreau. “As with any tool, it is better suited to some uses than others.”

The technology has the potential to streamline healthcare delivery.

Author | Cheryl Alkon

Articles

Understanding the business of medical marijuana

What’s behind the growth of urgent care clinics?

How blockchain could make waves in healthcare