LBJ and Nixon brought us the insatiable Medicare/Medicaid entitlement and the predatory managed-care monster that feeds off these cash cows (AAPS News, July 2018). They and their successor also set us up for the impending Baby Boom/Welfare State fiscal tsunami, as David Stockman describes it (tinyurl.com/yab4vh4u). Nixon’s 1972 Social Security amendments indexed earnings for wage inflation; and Jimmy Carter’s so-called reform package made the benefit amount calculation steeply progressive.
The benefits structure assumes that the strong productivity and real wage growth of the 1950s and 1960s (1.73%/annum) would continue forever. Now the growth rate of 0.8% shows no prospect of improving. We have a part-time, low-wage, gig-driven labor economy rather than a breadwinner economy, complicated by crushing debt and growing deficits. Official trustees’ reports simply assume these problems away. The political odds against entitlement reform appear insuperable with more than 100 million voters retired or approaching retirement, Stockman writes.
Also, since 1973, some 60 million potential American wage-earners have been aborted. Will low-skilled workers from the Third World be able—or motivated—to work hard to support retirees, with 15% or more of their earnings lost to payroll taxes?
Is this the LBJ et al. fiscal suicide pathway?
Reducing Liabilities
As managed care continues its takeover of Medicare and Medicaid—since the Affordable Care Act (ACA) passed Medicare Advantage (MA) enrollment has increased 71% and is expected to include more than 40% of all Medicare enrollees by 2027—end-of-life care has improved, according to Ezekiel Emanuel, M.D., Ph.D. More MA patients are placed in hospice, and fewer are admitted to hospital or intensive care units during the last 30 to 60 days of life. Plans are capitated, and physicians and hospitals are financially at risk. The focus of end-of-life care might be lengthened. Emanuel suggests a trial of capitating or bundling payments for patients expected to die within 12 months (JAMA 7/17/18).
Medical facilities, possibly supported by state law, may deny care designated as “futile”—although it sustains life. “Passive involuntary euthanasia” is the correct term for withdrawing life-sustaining treatment over the objections of a valid surrogate or competent patient, writes Michael Nair-Collins of the Florida State University College of Medicine (Perspect Biol Med 2017;60:415-422). He objects to terms like “potentially inappropriate” and “not medically indicated” as euphemisms for “medical futility.” Instead, distributive justice is the proper rationale, he writes.
The concept of medical futility came of age in 1998 with the Texas Advance Directives Act (TADA), which uses the term “medically inappropriate.” To date, TADA is the only legal safe harbor for physicians engaged in futility disputes, writes Robert L. Fine of Baylor University Medical Center. The law provides for no data collection, and few reports of outcome are available. The most important feature of the law is the “sentinel effect,” he writes: Hospitals are not Alice’s Restaurant, where “you can have anything you want” (Perspect Biol Med 2017;60:358-366).
As chronicled by AAPS, the end-of-life train has been building up steam over the last two decades. “End” is being used as a verb, in a setting of relativistic, collectivist morality (AAPS News, January 1999, tinyurl.com/y9o4o8w6). The Dutch started asking about when is it permissible to continue treatment (AAPS News, July 2005, tinyurl.com/y9arcfyy). The Robert Wood Johnson Foundation and George Soros’s Open Society Foundation are advocates of the Third Path to Death, which transforms “healthcare” into “managed death care” (AAPS News, April 2016, tinyurl.com/ycpsnypp). Hospitals are developing standards for withdrawing care deemed not to be of “significant benefit to the patient,” writes AAPS president-elect Marilyn Singleton, M.D., J.D. (tinyurl.com/y9xg6ar7).
At its 2018 House of Delegates meeting, the AMA, after extensive debate, decided to “study” its long-standing opposition to physician-assisted suicide (PAS)—which some like to refer to by the euphemism “Medical Aid in Dying” (MAiD). This issue was pulled from the agenda at the Arizona Medical Association House of Delegates meeting; the Medical Ethics Committee voted 8 to 8 on a proposal to change ArMA’s position to “neutral”—often a prelude to state passage of laws permitting PAS.
ArMA denies basing ethical positions on opinion polls—while it surveys opinions and notes the evolution of physicians’ views. Proponents of “neutrality” state that there are reasonable positions on both sides, and that PAS is not the same as euthanasia. The progression in other nations was deemed irrelevant by ArMA leaders, and experience in Oregon was claimed to demonstrate the adequacy of safeguards in the law.
Oregon destroys all records used to compile its annual reports on the law, and has no funding or authority to investigate abuse. A patient can become eligible for PAS by converting his chronic disease into a terminal one, say by stopping his insulin (Wesley Smith, https://tinyurl.com/y7bxw4e7).
Medical futility cases have names. Infant Charlie Gard was effectively imprisoned in a British National Health Service hospital to prevent his parents’ seeking care for his mitochondrial disease elsewhere. Death was determined to be in his best interest (see p 3). Alfie Evans, age 2, met a similar fate—lest the infallibility of the NHS be challenged (https://tinyurl.com/yajbo4la).
Death Watch
- In Oregon, Mentally Impaired Patients May Be Starved: Taking effect this June, Oregon H.B. 4135 changes the law concerning advance directives, allowing caregivers to starve or dehydrate patients even if they had not been given this authority before the patient became impaired (https://tinyurl.com/y6u5jl5l).
- ePOLST a MACRA quality measure: HEMR owns the first Qualified Clinical Data Registry (QCDR) certified by CMS to report electronic submissions of Physician’s Orders for Life-Sustaining Treatment (POLST) into the Medcordance ePOLST Registry under MACRA’s MIPS (tinyurl.com/y8l3ofbp). [POLST may give permission to starve and dehydrate you.]
- Second Death: Jahi McMath, who was declared brain dead at age 13 after a surgical complication, has actually died 4 years later. In California, doctors refused to do any procedures, saying it was unethical to treat a corpse. Her parents managed to move her to New Jersey, where she received loving supportive care, went through puberty, and displayed minimal responsiveness.
- No Stopping Point: About 7,000 people were euthanized in the Netherlands in 2017, up from 4,188 five years ago. A few criminal investigations have been opened. One doctor was cleared after reportedly forcing a lethal injection on a dementia patient who actively resisted (https://tinyurl.com/y7d5owfb).
- Teen Suicide: After accidents, suicide is the second leading cause of death in U.S. teens, increasing from 8.0 to 8.7/100,000 between 1999 and 2014. In 2017, nearly 1 in 10 teens between the ages of 15 and 19 attempted suicide (MedScape 12/1/17).
- Irretrievable Debt: Many states have accumulated unpayable debt. California, Illinois, New Jersey, and New York are unable to make pension payments to retired government workers, with debts of $428 billion, $30 billion, $104 billion, and $356 billion, respectively. A pension reset may be suggested, but in some states pensions may be constitutionally protected (https://tinyurl.com/ybbtmrgn). [What about pensioners’ lives? While dead people may vote, they do not eat.]
Total Transformation
In 2015, the Medical College Admission Test (MCAT), which all aspiring U.S. medical students must pass, underwent its first revision in 25 years. It was expanded from 5 to 8 hours and now includes “situational judgment tests.”
The president of the entity that makes the test, Darrell Kirch of the Association of American Medical Colleges (AAMC), intends to redefine what makes a good doctor. “I believe it is critical to our future to transform health care. I am not talking about tweaking it. I am talking about true transformation.”
The curriculum must now have social justice as a “core tenet of medical ethics,” teach about “unconscious racism,” and include 30 core competencies for caring for LGBT patients.
Medical schools may be imposing a moral and political litmus test to exclude students holding Biblical values, warns Mark Blocher, CEO of Christian Healthcare Centers (Samaritan Ministries, Christian Health Care Newsletter, July 2018).
“ Call it single-payer, Medicare for all or any other euphemism, socialized medicine is death.”
Daniel Greenfield, https://tinyurl.com/y8xtradk
ACTION OF THE MONTH
Contact your Senators to discuss needed changes to Sect. 3 of H.R. 6199, a bill to allow use of HSAs for Direct Primary Care.
Details at https://aapsonline.org/dpc
ACP Reaffirms Opposition to PAS
In September 2017, the American College of Physicians reaffirmed its opposition to the legalization of physician-assisted suicide and published an updated position paper in the Annals of Internal Medicine (tinyurl.com/ybdjdwxj). ACP concludes that PAS “alters the physician’s role as healer and comforter and the medical profession’s role in society, and it affects trust in the patient-physician relationship and the profession.” It finds that there is a “critical distinction between refusal of life-sustaining treatment and physician-assisted suicide,” and that “requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided” (https://tinyurl.com/ybyryzd4).
Government Spending Data: 55% Wrong
The Senate Permanent Subcommittee on Investigations, chaired by Rob Portman (R., Ohio), reported that nearly every agency is failing to accurately report its spending as required by the Digital Accountability and Transparency Act (DATA) of 2014. Data from Treasury, the agency in charge of USAspending.gov is 96% inaccurate (https://tinyurl.com/ybudb2gw).
Data Chasm
Medicare Advantage and Value-Based Purchasing rely exclusively on data coded by the International Statistical Classification of Diseases and Related Health Problems. In late 2015, the government transitioned from ICD-9, which was supported by decades of work validating accuracy of the codes, to ICD-10, of unclear reliability. Only 5% of ICD-9 codes can be linked 1-to-1 to ICD-10 codes. Hospitalizations with a diagnosis of opioid use disorder showed an abrupt 14% increase across the transition. A Veterans Affairs system study showed that ICD-10 was twice as likely to identify Alzheimer disease and half as likely to accurately identify HIV/AIDS or alcohol or tobacco dependence as ICD-9. Clinical studies spanning the transition will have to treat data as coming from two distinct epochs (JAMA 7/10/18, tinyurl.com/y9dvp9df).
Nominating Committee Report
The Nominating Committee submits the following slate:
President-elect: Kristin Held, M.D., San Antonio, TX
Secretary: Charles McDowell, M.D., Johns Creek, GA
Treasurer: W. Daniel Jordan, M.D., Atlanta, GA
Directors: Janis Chester, M.D., Dover, DE; Kenneth Jago, M.D., Canton, GA; Erika LeBaron, M.D., Manassas, VA; Michael J. A. Robb, M.D., Phoenix, AZ; and George Smith, M.D., Covington, GA.
AAPS Calendar
Oct. 3-6. 75th annual meeting, Indianapolis, IN.
Sep 18-21, 2019. 76th Annual Meeting. Torrance, CA
Beware of Guardianship Fraud
Ron Panzer of Hospice Patients Alliance writes: “We are receiving more and more complaints about people wrongly placed into guardianship in order to seize their estates, and the healthcare system (and especially hospice) wielded to end their lives after unsuccessful attempts by loving family members to get them out of the guardianship prison (or simple legal/medical POA[power-of-attorney] misuse against the individual’s wishes).” Professional guardianship abuse is accomplished under “color of law,” and corrupt judges often misuse an Order of Contempt against friends and family members (https://tinyurl.com/yd5ompj7). “Once judged incompetent and placed under a conservatorship [or guardianship], a citizen becomes a nonperson, with fewer rights than a convicted felon in a penitentiary,” writes Robert Case, editor of Bloomberg Wealth Manager.
Timely Access to Death Is a Right in Canada
The Canadian Supreme Court decriminalized medical assistance in dying (MAiD) on Feb 6, 2016, and parliament passed a bill specifying the circumstances under which it could be provided on Jun 17, 2016. Medical institutions and physicians are “obliged to implement MAiD, ensuring timely access and balancing the rights of patients and health care providers” (NEJM 5/25/17). Between Jun 17, 2016, and Jun 30, 2017, death service was provided to 1,982 patients (https://tinyurl.com/ya5m2w4x).
Patients who do not at first qualify for MAiD can purposely make their death foreseeable as by voluntarily stopping eating and drinking (VSED) long enough, and doctors may palliate the symptoms of starvation and dehydration (tinyurl.com/ybdengm8).
Some ask whether the right to MAiD should be expanded to those who are simply “tired of life,” writes Franklin Miller of Weill Cornell Medical College (Perspect Biol Med 2016;59:351-363).
While most provinces accommodate dissenting doctors, Ontario does not. When a group of physicians sued to be exempted, the reviewing court acknowledged that while forced referral does indeed “infringe the rights of religious freedom . . . guaranteed under the Charter,” this enumerated right must nonetheless take a back seat to the court-invented right of “equitable access to such medical services as are legally available in Ontario.” Objecting doctors would need to change the nature of their practice—say an oncologist becoming a podiatrist—if they wished to continue to practice medicine in Ontario (https://tinyurl.com/y9mltls9).
Ezekiel Emanuel has been just as blunt:
Health care professionals who are unwilling to accept these limits [on their rights of conscience] have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession” (NEJM 4/6/17).
Death Factories in Belgium
In a new book, Euthanasia and Assisted Suicide: Lessons from Belgium, Benoit Beuselink, Professor of Oncology at the Catholic University at Leuven, reports that nurses are leaving their jobs to avoid having to kill people. Palliative care units are becoming dumping grounds for patients, including those with dementia or psychiatric illness, who want to be killed.
The “Best Interest” Standard
The 1989 UN Convention on the Rights of the Child (CRC) establishes the “best interest of the child” standard for pediatric bioethics. In the U.S., this is used as a guidance standard, and state intervention is limited to cases of abuse or neglect or other special circumstances. However, in a CRC framework, this also an intervention standard, with physicians or the state standing as arbiters of whether parents are making the “best choice” for their child.
In Charlie Gard’s case, the parents wanted to bring their son to the U.S. for experimental treatment, and had raised private funds to pay for it. However, the child’s health-care team decided that was not in the child’s best interest, and courts concurred, applying an “objective” standard. Both UK sand European courts rejected the parents’ proposal that “significant harm” should be the intervention standard (Perspect Biol Med 2017;60:186-197).
The Illusion of Safeguards in PAS
In all jurisdictions that have legalized PAS, laws and safeguards were put in place to prevent abuse. However, there is evidence that these safeguards are regularly ignored and transgressed in all the jurisdictions and that transgressions are not prosecuted. About 900 people annually are administered lethal substances without having given explicit consent, and in one jurisdiction, almost 50% of cases of euthanasia are not reported.
Thirty years ago, euthanasia in the Netherlands was for patients with terminal illness. Now, denial of euthanasia is considered a form of discrimination against persons with chronic illness, whether physical or psychological. Moreover, nonvoluntary euthanasia is being justified by appealing to the social duty of citizens. No longer a last resort, euthanasia is a form of early intervention, writes José Pereira of the Univ. of Ottawa (tinyurl.com/m5d39zp).
Organ Harvesting in China
Transplant tourists can get an organ within two to four weeks in Communist China, from prisoners executed on demand. Some 65,000 Falun Gong practitioners were killed for their organs between 2000 and 2008 (persecutionoffalungong.com, about 7:28). Many petty and nonviolent criminals are also available. Although officials promised to cease the practice after 2015, at that time death-row prisoners were described as citizens with the “right” to donate organs. They are now re-classified as “voluntary deceased donors” like in other nations where family members consent to donate after accidental death (https://tinyurl.com/y829vxcd).
Courts Continue to Legislate
In just one week, progressives won more culture, fiscal, and security battles in randomly shopped courts than they could hope to win in 50 years of legislation, writes Daniel Horowitz. The 7th Circuit ruled that requiring an ultrasound within 18 hours of an abortion was an “undue burden.” Previously blocked Indiana laws required reporting of abortion complication; banned abortions solely because of race, sex, or Down syndrome; and defunded Planned Parenthood. In Oregon, it’s a civil right to shower with the opposite sex in public school, and in Wisconsin, Medicaid must cover “sex-change” surgery (tinyurl.com/ycpeey5c).
Correspondence
Hospital Imposes Rules Unilaterally. In its answer brief in the case of Anil Desai, M.D., v. Lawnwood Medical Center in the Florida Supreme Court, the hospital basically argues that it has the right to unilaterally impose rules, regulations, and policies on the medical staff, with no need for medical staff approval. It would seem that the Florida Supreme Court decision in Lawnwood Med. Ctr. v. Seeger should apply to prevent this. Medical staff bylaws and hospital rules are part of the “contract” between the hospital board and physicians on medical staff, so it would seem to be impermissible for one party to the contract to unilaterally create a rule that the other party does not specifically agree to. In another case at this same hospital, a hospital official testified under oath at a deposition that he “changed the wording” in official meeting minutes to state that the doctor said that she was “not competent,” as opposed to what she actually said, which was she was “not comfortable” treating trauma cases, which, as a surgical specialist, she had not treated since residency. That “altered wording” led to a sham peer review and the termination of the physician’s privileges, and she has been unable to work as a physician since.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
There’s No Such Thing as… “health care.” There’s health (actually medical) insurance—which does not include Medicare, Medicaid, or ObamaCare—and there’s medical treatment. All of the above, plus private insurance, are often joined together under “health care,” advancing the single-payer system philosophy. Also, there is no such thing as a “provider.” There are physicians, nurses, etc. The melding of terms aligns with the socialized medicine principle that all providers are equal and interchangeable.
Twila Brase, R.N., cchfreedom.org
The Source of Illegal Opioids. On Jun 14, the U.S. House passed a bill to help the U.S. Postal Service block international shipments with illegal opioids (https://tinyurl.com/y8xnygzh). It addresses part of the supply side for opioids at the street level. If it is successful, we can expect increased activity at our international borders to smuggle drugs into the U.S. Unless the infrastructure and business model of drug smuggling across our borders is addressed, there likely will be little disruption of supply at the street level. The illegal drug problem is a border security issue, not a prescription drug problem: Sanctuary Cities + Illegal Aliens = Transnational Crime. The real upside of this legislation is at least tacit acknowledgement by Congress that illegal opioids are not distributed by doctors and pharmacists.
Zack Taylor, NAFBPO.org
Remember 100 Million Victims. As the world celebrates the 200th anniversary of Karl Marx (born May 5, 1818), let us remember the cruelty of communism and the inhumane treatment that millions of innocent people were subjected to by tyrants and their failed ideology, an ideology concocted by Karl Marx whose theories ultimately imprisoned free men, destroyed their spirit, and killed more than 100 million worldwide in the name of collectivism, equality, and social justice. A living monument is the Memorial to the Victims of Communism and of the Resistance at Sighet, Romania, in the former Sighet Prison.
Ileana Johnson, https://tinyurl.com/ybsonk54
Statistics Are Now Hate Facts. Hate facts are true statements about reality that our elites demand remain occult and unuttered. The new field of “QuantCrit” is a portmanteau for “quantitative analysis” and “critical race theory.” It states that “quantitative data is often gathered and analyzed in ways that reflect the interests, assumptions, and perceptions of White elites.” This is a play for power. If statistics undercut and disprove the elites’ theses of equality and diversity, such “hate facts” must be banned.
William M. Briggs, Ph.D., http://wmbriggs.com/post/24651/
GIGO Study. The American Board of Internal Medicine (ABIM) paid big dollars to fund its own study of Maintenance of Certification (tinyurl.com/y6u6crke) and came up short (tinyurl.com/y73edbjg). This will not stop ABIM from providing the necessary spin to try to convince doctors, administrators, and politicians to continue to demand MOC, based on “evidence” that “MOC matters.” It only matters to those taking the money home! We have such tremendous waste in medicine that this $400 million dollar a year MOCkery seems trivial, until you add on the ancillary costs of time off, study, and lost patient contact hours, which multiplies the waste times ten at the minimum.
Paul Martin Kempen, M.D., Ph.D., Weirton, WV
AMA v. Private Medicine? A recent survey of graduating residents found that only 1% desired to go into solo private practice. A remarkable 41% indicated that they preferred hospital employment to any other option. Could it be that medical schools are poisoning the well by teaching that private practice is dying a slow death? Since 2016, many medical schools have been using a new textbook, Health Systems Science, created with the AMA, about the “third pillar of medical education” (tinyurl.com/y7vgl6cm). Perhaps the AMA no longer represents physicians, but rather coding systems. Medical educators need to re-read the Oath of Maimonides and the Oath of Hippocrates.
Howard Mandel, M.D., Los Angeles, CA
