Volume 73, no. 7 July 2017
In the Vietnam War era, the body count meant actual corpses with a clear cause of death: gunfire, explosion, fire, etc. Each one had a name and could be buried with appropriate military honors.
These days, body counts are in huge round numbers and have no identifiable, countable corpses. They are hypothetical calculations. “Air pollution deaths,” for example, might have an autopsy diagnosis of respiratory disease, myocardial infarction, or stroke, but since they occurred on a day when the particulates in the air were higher than usual (instead of a week later), they are attributed, through sophisticated statistical modeling, to pollution (http://tinyurl.com/j8k2cjd). Regulators then claim that a rule to reduce pollution will prevent those premature deaths.
Similarly, there is no ICD-10 code for death from lack of health coverage. Nevertheless, repeal of the Affordable Care Act (ACA or ObamaCare) will “kill” hundreds of thousands of people, according to Nancy Pelosi’s estimate, who are projected to “lose” (or forgo) their ACA plan. Media personality Montel Williams told CNN that the Republicans would “send 140 million to death with their health plan” (http://tinyurl.com/yc6esa6j).
Calculations for “loss” of coverage are like calculations of “cuts” in funding. First, you assume that 19 million more people would have enrolled, and choosing not to do so is a loss of coverage. And if Medicaid’s growth rate is slowed, the program is said to have been “slashed.” Under ACA, Medicaid spending is projected to soar to $8.2 trillion in the next decade, compared with $4 trillion in the last 10 years. Under the Senate plan, it would grow to only $7.7 trillion (David Stockman’s Contra Corner, Jun 29).
The next step is to calculate the number of premature deaths that would be prevented by coverage, or caused by loss of coverage. The claim that “Health Insurance Expansion under ACA May Be Linked to Lower Rate of Sudden Cardiac Arrest Outside of Hospital” is featured in AMA Morning Rounds on Jun 29. A person of age 45–64 had a statistically significant 17% reduction (P = .013!) in sudden death after Medicaid expansion (2014–2015) compared with pre-expansion years (2011–2012). It was then calculated by extrapolation that passage of the Senate Better Care Reconciliation Act (BCRA) could cause an additional 3,740 sudden cardiac deaths annually (http://tinyurl.com/y8v6xn3o).
Reviewing the study in J Am Heart Assoc (http://tinyurl.com/sxavxed) shows that the actual reduction was from 0.100% to 0.085%, a difference of 0.015%. In the population age 65 or older, the reduction was only from 0.275% to 0.269%, which was not significant. In the single urban county studied, the percentage of uninsured dropped from 18.3% to 7.7%, and Medicaid enrollment increased from 6.7% to 13.3%. How did having a Medicaid card prevent sudden death? There is no information on what care was actually given, or on all-cause mortality.
For the first time since 1993, all-cause mortality increased in 2015. In the 26 Medicaid expansion states and Washington, D.C., mortality rose more than 50% faster than in the 24 non-expansion states. Using the same flawed method as ACA advocates, one could argue that rejecting ACA would have saved 80,000 lives in 2015 alone, or alternately that ACA killed 80,000 people that year (http://tinyurl.com/zx938sl).
The cost of shifting resources from some other use into Medicaid is seldom evaluated. Yet states with a higher ratio of social to health spending have significantly better health outcomes (Health Aff 2016;35:760-768). Consider, for example, that a Nevada man lost his feet to frostbite because he had no dry place to sleep, while Medicaid paid somebody $563/month to keep him on the rolls. Last year, Nevada Medicaid paid as much as $213 million to managed-care companies for more than 30,000 people who received no care at all (http://tinyurl.com/ydehz5sx).
Also ignored is the 20th century death toll of “progressive” policies (socialism, Communism, Marxism): about 120 million.
In civilized, industrialized countries where healthcare is said to be a right, this right continues to expand to include medically hastened death. The Netherlands is considering the “Completed Life Bill,” which would allow perfectly healthy persons over age 75 to receive euthanasia on request. One 57-year-old felt the bill was too restrictive. He did not want to have to wait 18 years: “I want it now.” But some doctors feel the country has already gone too far. There were 6,091 reported cases of euthanasia in 2016: 141 in patients with dementia (up from 12 in 2009), and 60 in patients with chronic psychiatric illness (up from 0). Diminished quality of life due to “financial gutting of the health care sector” is blamed (http://tinyurl.com/svcfp89).
Countries with state medicine can also deny patients the right to try privately funded treatment. The European Court of Human Rights denied the final appeal of his parents to take their son Charlie Gard, who suffers mitochondrial depletion syndrome, a rare genetic condition, to the U.S. for experimental treatment. The British National Health Service will turn off his life support, to prevent exposing him to alleged “continued pain, suffering and distress” (http://tinyurl.com/y7b3hrux).
Timely death, “with dignity,” is becoming part of “population health.” Ontario has set up a “death hotline” to coordinate requests for medically assisted death, but doctors still have a duty to perform or refer (http://tinyurl.com/ybd95xur). Organ donation may become an option in Belgium (JAMA 4/11/17).
Flashback: “A Failed Health Reform”
The Kennedy-Kassebaum Health Insurance Reform Act—which turned into HIPAA—relied on “reforms that have already been tried at the state level—where they failed.” Guaranteed issue and community rating, enacted in New York in 1993, led to premium increases of 132%, versus 9% in the nation as a whole. These changes led 500,000 people to drop their coverage. Some thought it was worth it, to get the Health Savings Accounts also in the bill. And Ted Kennedy thought increased costs would make it easier to justify government-run health care (IBD 8/5/96).
“Copy and Paste”
Republicans’ month-long retreat behind closed doors did not result in a “repeal and replace,” but instead a reprise of most of the five core elements of ObamaCare, writes Daniel Horowitz. These are: actuarially insolvent insurance regulations; open-ended subsidies; Medicaid expansion; individual and employer mandates; and tax increases. The Republican version adds new Medicaid enrollees through 2020 and phases down the expansion subsidy through 2024. Block grants don’t come, if ever, before 2025. ACA subsidies are replaced with more subsidies, and Obama’s illegal cost-sharing subsidies are codified. Tax funding will be replaced with deficit financing (http://tinyurl.com/yaszx5mc).
AMA Opposes GOP’s ACA Reforms
At the AMA’s annual House of Delegates meeting, Richard Deem, senior vice president of advocacy, spoke for continuing the insurance “market reforms” [the ones that guarantee insolvency], opposed the $830 billion “Medicaid cut,” reiterated CBO’s projection that 23 million would “lose” their insurance, and opposed the ban on Planned Parenthood funding as a violation of physician freedom of practice principles (http://tinyurl.com/ybr2cb9n).
OPM (Other People’s Money) Addiction
- Federal Poverty Relief: More than 100 million Americans—nearly one in three—now receive assistance from at least one of the 79 federal poverty programs, not including Social Security and Medicare: up 32% since 2008 (http://tinyurl.com/ydyy95p9).
- Medicaid Expansion: More than 60% of new enrollment represents crowd-out of private insurance. The perverse work incentive results in 24 to 103 people losing their job out of every 1,000 expansion enrollees (http://tinyurl.com/uqny5rg).
- Financing: Relief is paid for by taxpayers and creditors. To keep the credit flowing, the Federal Reserve has engaged in “deep, unrelenting and systemic falsification of financial prices.” All mechanisms for financial discipline having been destroyed, the financial markets have become “unhinged casinos” (David Stockman’s Contra Corner 6/13/17).
“The lessons of history…show conclusively that continued dependence on relief induces a spiritual and moral disintegration fundamentally destructive to the national fiber. To dole out relief in this way is to administer a narcotic, a subtle destroyer of the human spirit. It is inimical to the dictates of sound policy. It is in violation of the traditions of America.”
Franklin Delano Roosevelt, 1935
ACTION OF THE MONTH
Sign up now for 74th annual meeting in Tucson, at www.aapsonline.org. Invite or sponsor a medical student or resident to attend on scholarship.
Resolutions must be received by Aug 5 to be considered at the annual meeting (send to [email protected]).
The Nominating Committee submits the following slate:
President-elect: Marilyn Singleton, M.D., J.D., Redondo Beach, CA
Secretary: Charles McDowell, M.D., Johns Creek, GA
Treasurer: W. Daniel Jordan, M.D., Atlanta, GA
Directors: Kenneth Christman, M.D., Dayton, OH; James Coy, M.D., Fruitland Park, FL; Paul Kempen, M.D., Weirton, WV; Jenny Powell, M.D., Lebanon, MO; and James Vernier, M.D., Hampshire, TN.
Public trust in science is threatened by exaggeration of marginal findings, states David Spiegelhalter, president of the Royal Statistical Society. A common problem is misuse of “p-values,” a tool designed to show whether a blip in the data is real or random variation. In one survey, about a quarter of scientists admitted to manipulating data to get a significant p-value (Guardian 6/28/17, http://tinyurl.com/y8s2kdz6).
Spiegelhalter said he was not concerned with “lies, utter falseness or fabrications.” But Americans are concerned about those too, e.g. with respect to the Environmental Protection Agency’s rules on particulate matter. Either the agency is lying to Congress “on the basis of flawed epidemiologic studies, unwarranted extrapolations, and contrived estimates of benefits,” write John Dale Dunn, M.D., J.D., and Steve Milloy, J.D., in the winter 2012 issue of J Am Phys Surg, or it is conducting unethical human experiments in an attempt to demonstrate harm. Researchers such as James Enstrom, whose findings contradict agency policy, are persecuted (J Am Phys Surg, spring 2014). Threats to scientific integrity, such as censorship and phony evidence, with talks by Dunn, Milloy, Enstrom, and others, are featured at the Aug 12-13 meeting of Doctors for Disaster Preparedness in New Orleans (www.ddponline.org).
Studies that find statistically significant correlations, associations, or links—say between out-of-hospital cardiac arrests and Medicaid expansion, have likely involved extensive data-dredging that also “found” many non-correlations. But it is rare to see a publication that mentions the number of negative results and applies a correction such as the Bonferroni method to determine significance. Bland and Altman discuss this in the context of studies that make multiple comparisons of subgroups, say in testing treatments for coronary artery disease (BMJ 1/21/95, http://tinyurl.com/yavnv6n3).
At our 74th annual meeting, Barbara Duck will discuss the misuse of Big Data by the Medical Industrial Complex.
Oct 5-7. 74th annual meeting, Tucson, AZ.
Oct. 3-6, 2018. 75th annual meeting, Indianapolis, IN.
Illinois Law Overrides Conscience
Although it pretends to protect conscience, Public Act 099-0690 provides that although doctors may decline to perform or refer for procedures that violate their conscience, they must counsel patients about the benefits of all legal procedures, or help the patient find a doctor who will. This includes abortion and sex-reassignment surgery, and would include assisted suicide if legalized (http://tinyurl.com/s6fjytu). Illinois obstetrician Robert Lawler, M.D., is fighting the law (http://tinyurl.com/s6lm3oo).
Conscientious objection is under attack (AAPS News, May 2017). To allow a witness that being legal does not make a medical act right is “intolerable to those who want to weaponize medicine to impose secular individualistic and utilitarian values on all of society” (Wesley Smith, Christian HealthCare Newsletter, July 2017).
Osteopaths’ Antitrust Case Proceeds to Discovery
A case brought by four osteopathic physicians challenging the American Osteopathic Association’s requirement to pay its dues or lose certification can proceed to discovery in the federal District of New Jersey. Judge Noel Hillman denied AOA’s motion to dismiss and its motion to change venue to the Northern District of Illinois near AOA headquarters (http://tinyurl.com/rt5l5av).
Physicians Remove MOC in Houston Hospital
At a Jun 27 medical staff meeting, physicians at Memorial Hermann Hospital Southeast voted unanimously to have the maintenance-of-certification (MOC) requirement removed from bylaws system-wide. Just-passed Texas SB 1148, which takes effect Jan 1, 2018, bars hospitals and health plans, except for medical schools and federally recognized cancer centers, from requiring MOC for credentialing or contracts. A hospital may require MOC only with an affirmative vote of the medical staff; the law prohibits the hospital administration from overriding the medical staff.
The Texas chapter of AAPS (www.texasaaps.org), led by Sheila Page, D.O., worked tirelessly to achieve passage of this bill, which was championed by Sen. Dawn Buckingham.
An updated compilation of MOC-related state legislation is posted at https://goo.gl/fnS22T.
Tip of the Month: Some physicians have received “cease and desist” letters concerning their use of hyperbaric chambers. But those are based merely on an application for a patent, which anyone can submit, not a patent that has actually been granted. Receiving a patent for a method related to the practice of medicine should be very rare. No lawsuit can be filed to enforce a patent that has not been granted. AAPS will monitor developments on this emerging issue and provide updates accordingly.
eClinicalWorks to Pay $155 Million for Fraud
The nation’s second-largest electronic health record (EHR) vendor settled a whistleblower suit alleging that it fraudulently obtained its certification for meeting meaningful-use requirements, agreeing to pay $155 million. Providers who used that system will not be required to return their incentive payments—assuming they are innocent (MPCA, July 2017).
Court Orders Illinois to Pay Medicaid MCOs
A court ruling in Memisovski v. Wright, 92-cv-01982, U.S. District Court, Northern District of Illinois, orders the state to pay $2 billion toward its $3 billion in past obligations to Medicaid providers, starting Jul 1 and ending Jun 30, 2018. Payments will go to safety net hospitals, managed care organizations such as The Meridian MCO and Aetna Better Health, and other providers. Judge Joan Lefkow said that the backlog was “dramatically reducing the Medicaid recipients’ access to health care.”
The state does not have funds to cover any of its $15 billion in unpaid bills. Services to the homeless, disabled, and poor are shuttered; universities’ accreditation is at risk; and state payroll and pension funds are in jeopardy (http://tinyurl.com/y9nrgjo9).
Vaccine Liability Standard Relaxed in Europe
The Court of Justice of the European Union (ECJ) ruled that the EU directive on product liability should be interpreted to allow national evidentiary rules permitting trial courts to consider “serious, specific and consistent evidence,” notwithstanding the absence of relevant medical research, that would support the conclusion that there is a defect in the vaccine and that there is a causal link between that defect and that disease. The instant case concerned the onset of multiple sclerosis after receipt of hepatitis b vaccine. It will go back to the trial court, as the EU court rules only on questions of law, not facts of individual cases (http://tinyurl.com/y7mqvykk). While some news reports said that the ECJ “threw science out the window,” Nature described the decision as “balanced and in line with long-standing legal traditions” (http://tinyurl.com/ycqebjb2).
Opioid Manufacturers Sued
Oklahoma is the fourth state to sue opioid manufacturers over their marketing practices, claiming that they fueled the state’s epidemic of opioid addiction. Drug overdose deaths increased eightfold from 1999 to 2012, surpassing car crash deaths in 2009. Teva Pharmaceuticals recently agreed to pay $1.6 million for substance abuse treatment to settle a lawsuit brought by two California counties (http://tinyurl.com/yaj3gd3v).
A retired Border Patrol agent noted that the broad governmental solutions to the opioid epidemic are focused on the pharmaceutical companies, pharmacists, and doctors, and never even mention the transnational criminal element bringing killer heroin and fentanyl to the illegal market in the U.S. through sanctuary cities and cartel hub cities. “Could it be that the trial lawyers association figured out they can’t litigate the transnational criminals?”
Mexican poppy fields cover an area larger than the District of Columbia (http://tinyurl.com/yckqgnyt).
EHR-Related Malpractice Landmines
According to The Doctors Company, EHRs are so far involved in only 1.3% of malpractice claims. However, more than 80% of such cases involve moderate or serious patient harm. Beware of the copy-and-paste function, of clicking the wrong box in a drop-down menu, or overlooking an item in structured information (http://tinyurl.com/yd7tskzc).
Advance Care Planning. Hospitals are sending out brochures offering free private consultations on ACP, a “new service program” that is part of quality measures. “ACP allows individuals to receive medical care that is consistent with their wishes and reduce the burden on family members.” It is wise to appoint a Health Care Proxy to make decisions for you if you are incapacitated, rather than leaving this to a socialist-minded doctor. You can stipulate that withdrawal of treatment, in a setting in which your survival is unlikely, does not include withdrawal of nutrition and hydration.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Imposed Death. Although some deny that hospice staff are intentionally killing patients, there is evidence of undeclared euthanasia as by deliberate drug overdose, even in lucid patients who attempted to refuse the medications (http://tinyurl.com/ybl2cbv7). This has also happened to patients with no terminal illness who were in a rehabilitation facility for a fracture (http://tinyurl.com/yd7542o8).
Ron Panzer, Hospice Patients Alliance
Political Reality. A Wall Street Journal editorial was spot-on in saying that the Ryan Plan was the best we could hope to achieve politically, and that failure to enact it would lead to something worse than ObamaCare. It gives me acid reflux to say this, but since medical care/insurance became half socialized a half century ago, by means of Medicare and Medicaid, the industry will remain half socialized, no matter what reforms we put in place for the other half. The other hard, cold reality is that half of Americans lack enough savings to last more than a week.
Craig Cantoni, Tucson, AZ
Why Not Now? Why did Republicans vote to repeal ObamaCare 60 times? It was safe then, and donors (such as insurers and hospital systems) didn’t care because Obama would veto it. And it won them some points with their base at election time. Maybe we’ll have ObamaCare forever. We didn’t need an act of Congress to launch the Wedge of Freedom, but a repeal of the ACA prohibition of catastrophic coverage would be very helpful. We’re now at 200 practices (www.JointheWedge.com).
Twila Brase, R.N., Citizens’ Council for Health Freedom
Grading on the Curve. Even if 95% of physicians are performing extremely well on MIPS quality measures, 50% will be below average and suffer a financial penalty.
Albert Fisher, M.D., Oshkosh, WI
What Is Health Care? At the 2017 AMA House of Delegates meeting, Resolution 007, “Health Care as a Human Right” was considered and tabled for further discussion. I proposed an alternate resolution for AMA to “vigorously educate the public to the fact that health care is first and foremost an individual’s responsibility.” This includes maintaining good health habits and seeking professional consultation in a timely manner. The “further resolved” is for the AMA to “vigorously oppose the flawed notion that healthcare is a right.” If necessities like food and medicine were rights, it would be the obligation of everyone to provide them for everyone else. The ramifications are absurd.
Ralph Kristeller, M.D., Hanover, NJ
The Only Answer. We need free-market competition to drive up quality and drive down prices. Neither ACA nor the Republican substitutes can work because insurance can’t have guaranteed issue, community rating, or cookie-cutter benefits, and be affordable. We must get patients and physicians unentangled from insurance companies, employers, and the federal government.
Craig M. Wax, D.O., Mullica Hill, NJ
The Business Model. Before 1965, patients and physicians were at the center of medical care. As the government poured money in, the secondary stakeholders began to devise ways to take government money off the top. The patient-physician relationship was destroyed. ACA gave the secondary stakeholders even more power. It reminds me of Microsoft’s patching upgrades on top of the DOS operating system of the 1980s instead of changing the operating system. Without a critical change in the model that returns control to patients, the system must collapse. Spending could increase to 100% of GDP in 20 years.
Stanley Feld, M.D., Dallas, TX
Why Republicans Want to Preserve ACA. Health insurer, hospital, and pharmaceutical stocks went up when Sen. McConnell introduced the non-repeal bill. Certain corporate entities benefit dramatically because of ACA’s forced transfer of wealth from the middle class and taxpayers to their balance sheets. Republicans do not want to tell their donors that their gravy train is about to stop. ACA also allows many businesses to transfer large portions of their employee health insurance expenses to the taxpayer. The Republicans’ conservative base was outright deceived. There was never any real intention to repeal ObamaCare. The discussions have been insufferable. Many politicians have accepted the premise that coverage of pre-existing conditions must be maintained. Their inability or refusal to explain basic economics is shameful.
Joseph Guarino, M.D., Reidsville, NC