MedPod Today: Upcoding Concerns; COVID Vax Recs; Med School Credit for Parenting

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insight into the week’s biggest healthcare stories. I’m your host, Rachael Robertson.

To start off, we’re talking with Kristina Fiore about allegations of a toxic work environment at the University of Virginia and some leaked meeting audio of surgeons’ concerns there. Then, Jennifer Henderson will update us on new recommendations for additional COVID vaccines for older adults. Last up, Sophie Putka will tell us about how some medical schools are giving credit for parenting and caregiving.

In September, more than 100 doctors at the University of Virginia signed a letter of no-confidence in its health system CEO and its medical school dean. And now an audio recording from a meeting last year has surfaced, shedding more light on the doctors’ concerns. Kristina Fiore is here to tell us more.

Kristina, give us the backstory about what’s going on at UVA.

Kristina Fiore: Yeah, sure. So in September, 128 doctors anonymously signed a letter of no-confidence in UVA Health CEO Craig Kent and School of Medicine Dean Melina Kibbe, calling for their immediate removal. In that letter, these doctors alleged that patient safety was compromised, that there was a culture of fear and retaliation, that there was bullying and harassment of trainees, and they also decried excessive spending on C-suite executives. It was a wide variety of complaints, but the letter didn’t really get into specifics. But last week, a local paper in Charlottesville, Virginia, obtained an audio recording of a meeting that was held last November, so almost a year ago, where surgeons voiced some very, very specific concerns.

Robertson: What were some of those concerns?

Fiore: Surgeons said that they were pressured by leadership to upcode in an effort to bring in more money. I’m sure our listeners are very familiar with the concept of upcoding, but generally it’s when physicians or medical coders document a code that involved more time or more extensive care than what was actually provided. The U.S. Department of Justice has long come down hard on providers and hospitals for doing this, but apparently it still happens all the time. So according to this recording, a surgeon said that they were told to bill 99291 on more patients than they were comfortable with. This code brings in about $1,000 and 4.5 RVUs, or relative value units, as opposed to a similar code, 99232, that brings in only $200 and only about 1.39 RVUs. One of the surgeons reportedly said, “We’re the ones that will get fined and go to jail.”

Robertson: Are these doctors’ claims being investigated?

Fiore: Yes, a spokesperson for UVA Health confirmed that they’ve hired counsel to do an independent review of the allegations in the September letter. The doctors who anonymously wrote the letter aren’t happy that they’ve been asked to speak with UVA investigators without being provided their own counsel. They asked the state’s attorney general for support, but they told me that they haven’t heard back yet.

They do have the support of the UVA faculty senate, which includes Stephen Culp, MD, who has pushed back on the administration’s claims that the 120 signatories represent a small part of the 1,400 school of medicine faculty and the 30,000 UVA Health employees. Culp said that the letter likely has broader support, but many are fearful of retaliation.

Robertson: That makes sense to me. We’ll be sure to check back in if there’s updates on the situation. Thanks, Kristina.

Fiore: Thanks, Rachael.

Robertson: The CDC Advisory Committee on Immunization Practices, or ACIP, has weighed in on additional doses of COVID vaccine for older adults this season. Jennifer Henderson is here to tell us more about it.

Jennifer, what did ACIP recommend for older adults and other high risk groups, and how is it different from before?

Jennifer Henderson: So in an update to recommendations from June, ACIP recommended a second dose of the 2024-2025 COVID vaccine for adults ages 65 and older, as well as people ages 6 months to 64 years who are moderately or severely immunocompromised. The advisors also recommended additional, or three or more doses, for people ages 6 months and older who are moderately or severely immunocompromised under shared clinical decision making.

In June, ACIP recommended that people who are moderately or severely immunocompromised receive additional doses of the 2024-2025 COVID vaccine. However, they made no recommendation for additional doses for older adults at that time.

Robertson: Okay, what kind of evidence swayed ACIP to update these recommendations for older adults?

Henderson: Data presented by a COVID vaccines work group showed that during the 2023-2024 season, vaccine effectiveness against hospitalization for immunocompromised individuals waned to null by roughly 4 to 6 months after receipt. Vaccine effectiveness against emergency department and urgent care visits, as well as hospitalizations for adults ages 65 and older also waned to null during the same time. However, vaccine effectiveness against critical illness for older adults remained above 40% at 5 months. During ACIP’s meeting, voting member Jamie Loehr, MD, of Cayuga Family Medicine in Ithaca, New York, highlighted the incidence rate of COVID hospitalizations among older adults, specifically those ages 75 and older for the period of October 1, 2023 to September 28, 2024.

“When you look at 1,410 hospitalizations, you think that’s a number, but when I did the conversion, that’s 1 in 70 adults,” Loehr said. “And that is just stunning that so many people over 75 are going to be admitted to the hospital with COVID,” he added.

Robertson: Wow. Were there other vaccine recommendations?

Henderson: Yes. So ACIP also recommended lowering the age for adult pneumococcal vaccination from 65 to 50 years. The advisors also voted 14-to-1 to recommend a pneumococcal conjugate vaccine, or PCV, for all PCV-naive adults ages 50 and older. Future considerations should include indirect effects from new pediatric pneumococcal vaccines, duration of protection from adult vaccination, and impacts of new higher valency vaccines for adults, a pneumococcal work group noted.

Additionally, CDC advisors unanimously voted to include high-dose and adjuvanted inactivated influenza vaccines as options for solid organ transplant recipients who are receiving immunosuppressive medication under the Vaccines for Children program which makes coverage free for uninsured or underinsured children.

Robertson: Thanks for that update, Jennifer.

Henderson: Thank you, Rachael.

Robertson: Next we’re talking about parenting in medical school. We all know those years can be hard enough without having to care for another human, but one school has been offering an elective that allows new parents and caregivers in medical school to get credit for what they learn in the process. Here’s Sophie to tell us a little bit more.

Sophie, what is this elective, and how does it work?

Sophie Putka: Thanks, Rachael. So this new parent/caregiver elective is at the University of Minnesota’s medical school, and it actually started back during the pandemic. It recently came up in a post on X where a med student at another program gave it a shout out.

The way it works is students can use the elective as a rotation of sorts in their third or fourth year and get two to four credits for two to four weeks in the course, if they’re new parents or full-time caregivers for someone else, like a family member, and it can count toward their degree. What they have to do in return is write a short weekly reflection and meet with the course director once a week, and at the end, come up with a way to present something that they learned during their time caregiving that’s clinically relevant to the rest of the medical community.

Students have presented about everything from jaundice in infants, to breastfeeding, postpartum disorders, and sleep. Essentially, it’s a way for students to get some extra leave and put their real life experience to use in medicine.

Robertson: That’s very cool. How did this whole idea come about?

Putka: A little bit of background here. This isn’t actually a new idea, and these kinds of programs have been offered in a number of residencies for a while now, usually in specialties like pediatrics, family medicine, or internal medicine, where the experiences of parenting are very relevant to patient care that new doctors will be giving. But apart from this one at the University of Minnesota, only one other medical school, an osteopathic program, offers this to medical students. I spoke to the course director, Kristina Krohn, who said that a student brought it up with her in 2020. They asked why their school didn’t offer this, and Krohn thought they should, so she and the student teamed up to design it and got it approved by the school administrators.

Robertson: How has it gone so far?

Putka: So far, it sounds like it’s gone really well, and other schools are interested in adding their own electives that do the same thing. It’s often really difficult for new parents to take leave during their medical training, and this can give them some relief so that they can stay on track.

One student I spoke to, Emily Cunningham, said she would have had to restart her third year of medical school altogether if this hadn’t been an option for her. She was expecting her second child just a few weeks before starting a surgery rotation, and she was worried about how taking time off might hurt her career trajectory, or how hard getting back into an intense schedule too early would be.

Cunningham told me, “As a student, there’s not a lot of options, because you’re not making any money. The elective really was a fantastic option for myself and for my family to just make sure that I was still on track for graduation, but also be able to get credit for some of the work that I was already doing with childcare.”

She also said she’s used a lot of her parenting skills already in patient care, like with a little girl who wouldn’t let her examine an appendectomy incision site. Krohn, the director, said that the presentation students give at the end are often some of the best attended events at school. She told me, “There is no better way to see child development, especially in those early first weeks to months.”

Robertson: Thanks so much for this reporting, Sophie.

Putka: Thanks, Rachael.

Robertson: And that is it for today. If you liked what you heard, leave us a review wherever you listen to podcasts and hit subscribe if you haven’t already (Apple, Spotify). We’ll see you again soon.

This episode was hosted and produced by me, Rachael Robertson. Sound engineering by Greg Laub. Our guests were MedPage Today reporters Kristina Fiore, Jennifer Henderson, and Sophie Putka. Links to their stories are in the show notes.

MedPod Today is a production of MedPage Today. For more information about the show, check out medpagetoday.com/podcasts.