Volume 74, no. 9 September 2018
A photograph of carriers of professionally made “I Am a Health Care Voter” signs heads a Forbes article about the most important mid-term elections “in our lifetime” or even “our country’s history” (https://tinyurl.com/y8xl6s75). There are also T-shirts and a Twitter hashtag. The HCVs appear to be mostly young, aggrieved, and angry. If they get their way, they will be a permanent feature of the political landscape. Socialism is a zero-sum game, so everyone must constantly fight for a “fair share” of the politically allocated take.
On Twitter, #HealthCareVoter posts warn that the confirmation of Brett Kavanaugh to the U.S. Supreme Court would “rip health care away from people with pre-existing conditions.” The [Un]Affordable Care Act (ACA) must be preserved—with no affordable options for low-risk people who have to pay their own premiums—until we get to universal care.
A “Medicare for All” Act has been introduced in every Congress since 2003 and has never gotten out of committee, even when Democrats have been in control. This time H.R. 676 has accumulated 123 cosponsors, with Rep. Keith Ellison (D-Minn.) replacing the disgraced John Conyers as first sponsor. The very short bill is a list of aspirations, lacking specifics.
The scariest part, writes AAPS president-elect Marilyn Singleton, M.D., J.D., is that, like in Canada, there could be no competing private insurance—only insurance that does not duplicate coverage. It would cover all individuals residing in the U.S. and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.
Funding would include (1) existing sources of government revenues for health care (Medicare, Medicaid, and the Children’s Health Insurance Program would be transferred in); (2) increasing personal income taxes on the top 5% of income earners; (3) a progressive excise tax on payroll and self-employment income; (4) a new tax on unearned income; and (5) a tax on stock and bond transactions (https://tinyurl.com/ybutloqu).
The program would be required to give employment transition benefits and first priority in retraining and job placement to individuals whose jobs are eliminated due to reduced clerical and administrative work under this bill.
A National Board of Universal Quality and Access would provide advice on quality, access, and affordability.
Counting the Cost
The Bernie Sanders version of single payer has been estimated to add more than $32.6 trillion to federal spending over its first decade. “Even if Congress were to double what it collects in individual and corporate income taxes, there still wouldn’t be enough money added to the federal coffers to finance the costs of this plan,” writes Charles Blahous of the Mercatus Center (WSJ 8/21/18, https://tinyurl.com/ycd5tnl4).
The idea is to somehow transfer all health-care dollars from the private sector to the federal government. A total $2 trillion could purportedly be cut from total health spending, despite all the increased utilization—by cutting at least 40% from payments that physicians, hospitals, and other “providers” were receiving from private insurance. For many, this would mean cutting payment below the cost of providing services. Nearly half of all hospitals would have negative facility margins by 2040, according to the CMS Office of the Actuary (https://tinyurl.com/yafjznux).
Hospitals in California defeated a law that would have set prices at Medicare rates, claiming that 175,000 jobs would be lost.
Note, $2 trillion is only 6% of $33 trillion. If such a drastic cut to those who do the work of patient care saves so little, where is all the money going?
Public View of Single Payer: It Depends
Between 1998 and 2017, there has been a modest increase in support for single payer (40% for, 53% opposed vs. 53% for, 43% opposed). However, the percentage opposed rises to 62% if people hear that opponents say the plan would give the government too much control over medical care, and to 60% if it would require Americans to pay more in taxes. While a national health plan may have broad support in the abstract, only about 12% say it is the single most important factor in 2018, according to the Kaiser Family Foundation (https://tinyurl.com/ychbdcfr).
Direct Patient Care
Both doctors and patients are voting with their feet for non-third-party-based models including Direct Primary Care (DPC), a membership model requiring a monthly retainer fee. Despite DPC’s improving the experience of care and reducing costs, two parts of the reformers’ Triple Aim, it’s not the answer, write Eli Adashi, Ryan Clodfelter, and Paul George of Brown University School of Medicine (JAMA 8/21/18). What about improving population health? DPC potentially “exacerbates racial, ethnic, and socioeconomic disparities” and might be too costly for some low-income patients. Reformers demand a system with cross subsidies, data reporting, oversight, “equitable” access, and required participation in “alternative payment models designed specifically to promote high-quality, cost-efficient care” [defined by them].
The last vote that counts is the one to give up freedom.
Not Single Payer
Other countries that have “universal access” systems, which cost the same as or less than Canada’s, do not follow the Canadian model. Private, for-profit hospitals comprise 39% of hospitals in Australia and 43% in Germany, but just 1% in Canada. Germany, the Netherlands, and Switzerland have primary private insurance, and all except Canada have private secondary insurance. All except Canada and the UK have cost-sharing by patients. Canada relies on a prospective global budget, in which patients are a cost. Others are increasingly moving to payment based on activity (Fraser Forum, summer 2018). U.S. proponents of “single payer” are generally pushing for the Canadian-style monopsony.
Savings on Insurance Could Buy a House
A comparison of the projected 2019 cost of short-term, limited-duration insurance (STLDI) with an ACA Exchange silver plan shows that to lower the out-of-pocket maximum by $813 costs $515/month or $6,180/year (tinyurl.com/yc3e7eoy).
A 10-year projection for a family of four shows that a traditional PPO costs about $260,000 more than a DPC membership plus a non-ACA $10,000-deductible plan (ibid.).
The Exchange plans are a terrible deal. What kind of forces would want to keep people trapped in ACA!
Volume to “Value”—or to Control?
“There is near-universal agreement that…we must move from fee-for-service reimbursement to paying for the value of care received,” write former Congressional Budget Office director Doug Holtz-Eakin and former HHS deputy assistant secretary Ken E. Thorpe (https://tinyurl.com/yaxyv43q). MACRA (Medicare Access and CHIP Reauthorization Act) “is not enough because it relies on voluntary participation.” One obstacle is the Stark and anti-kickback laws, which impede “care coordination,” or “directing the patient to particular doctors, hospitals, and care.”
The University of Illinois at Chicago states that “almost $750 billion of health care dollars are wasted.” The four main types of “value-based” structure are: shared risk, bundles, global capitation, and shared savings (https://tinyurl.com/yb4jcr3v).
1,000 Pharmacies Closing
More than 16 percent of the independently owned rural pharmacies in the United States shut down between March 2003 and March 2018, leaving their communities with few options for obtaining medications. Many blame pharmacy benefits managers, who set rates that do not cover costs. Unlike the big chains, these pharmacies do not have a huge retail business to offset losses. Additionally, more seniors are obtaining their drugs through Medicare Part D, which also may set prices below cost (Wash Post 8/23/18, https://tinyurl.com/y8lllumg).
“ The left only cares about pitting us against each other to keep control and keeping people dependent on them….. [W]atching people think for themselves and recognize the deceitful practices of the left and the manipulation of minorities has been like an awakening.”
Posted to Facebook by Rebecca Mali, #WalkAway
ACTION OF THE MONTH
Ask congressional incumbents or candidates to end the safe harbor to supply chain kickbacks driving up the cost of drugs and supplies. See a template letter at http://bit.ly/nokickback.
Short Takes on GPO/PBM Safe Harbor
To help explain the role of middlemen in price increases, pass along these short videos: https://www.youtube.com/watch?v=P21Zb_OySIg (by the Kaiser Family Foundation); http://www.ncpanet.org/advocacy/the-tools/pbm-resources/pbm-storybook (by the National Community Pharmacists Assn.), and http://nomiddlemen.org. (For precise details on the law alluded to in the last video, see AAPS News, April 2018, and www.jpands.org/vol23no2/singleton.pdf). Dr. Singleton’s “elevator speech” is here: tinyurl.com/ycbamb9x.
How Government Planners Protect Us
- Earthquakes: In Seattle, San Francisco, and Los Angeles, city planners still approve construction along faults known for decades, with no warnings to consumers.
- Floods: Despite Hurricane Katrina, construction in flood plains continues across the U.S.
- Man-made Hazards: Sacramento city planners allowed an ice- cream parlor to be placed at the end of an airport runway. An F-86 jet fighter failed to lift off, killing 22.
- Bio-weapons: A high-level biological warfare facility, housing Ebola and hundreds of deadly diseases, opened in 2008 close to homes, schools, and hospitals in Galveston, Texas. The site was swept away by a hurricane and storm surge in 1900 (Richard Maybury’s Early Warning Report, June 2018).
Report on Guidelines
Clinical practice guidelines are supposed to define the standard of care and protect doctors who follow them, but many problems are surfacing. In 2003, 1,402 guidelines were indexed on the National Guideline Clearinghouse (NGC). By 2013, the number had increased to 2,619. This number was cut in half by 2018 as older guidelines failed to meet a 2011 requirement for systematic review. On July 16, free access to the NGC was terminated for lack of funding. The NGC is supposed to help identify trustworthy guidelines. Different organizations’ guidelines may disagree. Financial conflicts of interest in organizations and experts preparing guidelines are “highly prevalent, can…be quite large, are often unreported or reported inaccurately, are subject to inadequate or nonexistent policies on disclosure,” writes Paul Shekelle, M.D., Ph.D. (JAMA 8/28/18). In his novel Assume the Physician, John Hunt, M.D., suggests that the main customer to be persuaded at upscale pharmaceutical dinners might be the speaker rather than the doctors, as he might be on a guidelines committee.
Oct. 3-6. 75th annual meeting, Indianapolis, IN.
Sep 18-21, 2019. 76th Annual Meeting, Redondo Beach, CA
Protect Whistleblowers from Retaliation, AAPS Urges
After Robert van Boven, M.D., reported 20 cases of patient harm, including avoidable death, Lakeway Regional Medical Center launched a career-destroying retaliation. It claims the doctor cannot receive damages because of allegedly violating a gag provision in a settlement agreement. An AAPS amicus brief (https://tinyurl.com/y9z53hnw) makes the following arguments:
(1) The possibility of being subjected to retaliation for reporting harm to patients has a chilling effect on all of medical practice. (2) There must be full legal accountability for the hospital’s misuse of law enforcement to take improper action against the doctor. (3) Hospitals, by virtue of their receipt of public money, have a duty to serve the public good. But unlike public schools and other government-funded institutions, hospitals typically lack meaningful oversight or external accountability. (4) Independent medical practitioners provide the only check and balance against runaway self-enrichment by hospital administrators. (5) Settlement provisions that purport to prevent a doctor from speaking out for patients and against hospital misconduct should be void and unenforceable as a matter of public policy.
AAPS Fights Warrantless Searches
The Texas Medical Board (TMB) is seeking immunity for conducting another warrantless search in violation of the Fourth Amendment, this time of the offices of family physician Courtney Morgan. The Fifth Circuit Court of Appeals recently held, in Zadeh v. Robinson, No. 17-50518, 2018 U.S. App. LEXIS 24914 (5th Cir. Aug. 31, 2018), that qualified immunity protected TMB officials from accountability even though the panel of judges unanimously agreed that the Fourth Amendment rights of Dr. Zadeh and his patients had been violated. In an amicus brief, AAPS argues that the violation in Courtney Morgan v. Mary Chapman; John Kopacz (Case No. 18-40491) is still more egregious.
Full Fourth Amendment safeguards for medical records are essential to the practice of good medicine…. When a search of a physician’s office is justified, then a valid search warrant can and should be obtained. But in the absence of that essential procedure of pre-compliance judicial review, physicians can no longer be confident that their medical advice, notes and personalized data…will be kept private, and patients are deprived of confidentiality in their intimate disclosures….
The Fourth Amendment is not a “vague, second-class right,” states AAPS general counsel Andrew Schlafly. It also protects other rights. For example, medical guidelines and societies are compelling physicians to place information about gun ownership in medical records, leaving only the Fourth Amendment as a protection against this “persistent back-door attempt at gun control.”
TMB already has powerful tools to address real threats to public safety, such as prescription drug abuse, AAPS notes, without violating the Fourth Amendment, such as suspending the physician’s ability to write prescriptions for controlled substances—though these “may be less exciting than conducting a surprise raid on a patient-filled physician’s office without a warrant.” These also allow the search to be restricted to controlled-substance prescriptions, without exposing the patient’s whole record to review by strangers without patient consent (tinyurl.com/ycpnbpbx).
!Tip of the Month: Beware the warrantless search: The Texas Medical Board has engaged in multiple warrantless searches of physicians’ offices, based on a mere administrative subpoena. There it is called a “subpoena instanter,” which means that the search occurs instantly based on a mere subpoena. But this violates the Fourth Amendment because it denies the opportunity to contest it beforehand in court, and physicians can sue if they or their staff clearly objected at the outset of the search. For a warrant to be valid, it must contain three things: approval by a disinterested magistrate, based on a showing of probable cause, and itemization of the things specifically to be searched. The more that you can document your objection to a warrantless search, and even video it on a cell phone, the stronger your case will be in court for damages. Be sure to obtain the names and positions of the perpetrators, and a copy of the subpoena.
CMS Requiring Shared Decision Making
Implanting a cardioverter defibrillator is the third procedure for which the Centers for Medicare and Medicaid Services requires patient participation in a shared decision making (SDM) process as a condition of coverage. The others are lung cancer screening with low-dose computed tomography and left atrial appendage closure (LAAC) for stroke prophylaxis in atrial fibrillation. The Commonwealth Fund estimated that requiring SDM for “high-cost, preference sensitive” procedures could save Medicare up to $1 billion annually. Physicians must document compliance. As yet, “no evidence-based [SDM] tool on LAAC has been published” (JAMA 8/21/18).
ACA Threatened in States’ Lawsuit
As early as this month, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas could overturn ACA in Texas v. United States (see AAPS News, July 2018). If he issued an injunction against the whole law as early as January 2019, pending final outcome, it would end ACA’s Medicaid expansion and stop funding for accountable care organizations, among other things, as well as ending mandates on guaranteed issue/community rating. In Medscape, Leigh Page asks, “Will the New ACA Lawsuit Wreak Havoc on Healthcare?”
The loss of protections on “pre-existings” would affect only the 7% of Americans in the individual insurance market; many of them would get much lower rates. The loss of the standardized rate-setting would make it impossible for the government to calculate subsidies for the 83% of Exchange plan purchasers who receive them. It might have to reprogram its software—if subsidies continue (https://tinyurl.com/yc4o54dd).
The bill introduced by Congressional Republicans would forbid insurers to deny coverage or charge more to people with pre-existings, but would not prevent them from excluding coverage. The effect is hard to estimate—perhaps $12,000/month for treatment of lung cancer diagnosed before buying a policy would not be paid by “insurance” [i.e. other subscribers] (https://tinyurl.com/y9veowdg). Note that pre-ACA, insurers by contract could generally not drop an already insured patient or stop paying for treatment. ACA created the incentive to skip buying insurance until an illness was diagnosed, knowing coverage could not be denied, supposedly countered by the individual mandate.
VA Fires Doctor for Shared Decision-Making. Although it touts shared decision-making in its advertising (https://tinyurl.com/y8xxnwa2), the Veterans Administration cited a doctor’s using it as a justification for patients to refuse “standard treatment” as a cause for terminating him. Apparently, patients are not supposed to exercise shared decision-making if the decision they make is to refuse a treatment. Enough did so to make the doctor a “market outlier.” Exactly what is that? Is it someone who falls between 5% or 10% on either end of a bell-shaped curve? Is staying in the middle of the bell-shaped curve equal to quality care? Does the VA have some sort of deal with manufacturers of a profitable class of drugs such that they expect a certain percentage of patients to be on them?
People are focused on clinical practice guidelines as the gospel of “quality care.” But, many, if not most, are significantly flawed. A recent study found that 60% of organizations that produce the CPGs found on the National Guideline Clearinghouse website received funds from a biomedical company, and 38% of guideline committee members had individual financial relationships (tinyurl.com/y7moh3dl).
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
SDM: a Nebulous Idea: In less than a decade, “shared decision-making” (SDM) has emerged as the uncontested principle that must inform patient-physician relationships everywhere. Government is now threatening to penalize doctors who do not participate in SDM prior to providing certain treatments, even if the legal process of informed consent has been fulfilled—and even if the treatment is widely considered to be clinically justified.
SDM was the solution conceived by ethicists to avoid the traditional medical disregard for patient autonomy on the one hand, and also the consumerist trend that a Presidential Commission somehow found objectionable. It is based on the shaky conceptual foundation of a “multitude of different realities”—with highly problematic implications (tinyurl.com/yc25bo8d).
Michel Accad, M.D., alertandoriented.com
Is There a Solution to Medicaid HMO Fraud? The proposed Medicaid Family Medical Accounts (FMAs) in Minnesota would give enrollees, rather than HMO barons, money for outpatient care on a debit card. If the enrollees do not spend the money, they can keep it. Note that if HMO barons don’t spend the money, they keep it. Which is better? Also, on-site payment simplicity would cut administrative costs.
Robert W. Geist, M.D., North Oaks, MN
Home Invasions. Insurance companies are hiring third-party companies to conduct “Personal Health Visits” on patients identified from claims data as “clinically complex.” Patients are notified by phone; doctors by snail mail. A mid-level practitioner “gathers healthcare data” and sends a report to the doctor. If an acute problem such as very high blood pressure is found, no action is taken. The motive is to collect Medicare money; and insurers can use the data to reduce their risks. Patients should refuse to allow insurer representatives to conduct a home visit; sometimes phone agents badger them into accepting.
Craig M. Wax, D.O., Mullica Hill, NJ
Free Care in Communist Romania. In egalitarian Romania, where healthcare was a “right,” sick people might have to stand all day in an overcrowded clinic (sitting on the floor was forbidden) to get a perfunctory exam by an overworked doctor. It was “first come, first served”—take a number like at the post office. The prized antibiotic prescription could only be filled on the black market, at great risk, because pharmacy shelves were empty. The pharmacist would simply shrug, and continue to earn his state income for doing nothing. American millennials, the majority of whom still seem to believe in the ideology that has failed elsewhere, have no clue about the bitter pill, literal and figurative, that people living under a socialist regime are forced to swallow.
Ileana Johnson, https://tinyurl.com/ybtpc3sv
Why We Need Physicians, Not Technicians. In a well-flowing corporate practice, value equals output divided by costs, and providers such as certified registered nurse anesthetists are simple technicians. But are anesthesiologists outdated, and is pre-op medical evaluation irrelevant, as has been suggested (Anesthesiology News 2018;44:21)? After 30 years in academic practice, I have worked for 5 years in a community hospital. I have personally diagnosed more aortic stenosis, atrial fibrillation, murmurs, severe anemia, and myocardial ischemia in one year than in my prior three decades of academic practice, where problems were addressed prior to scheduling the surgery. Millions of surgical patients face the realities of post–ACA medicine in the heartland!
Paul Martin Kempen, M.D., Ph.D., Weirton, WV
Where to Find Solutions? The greatest obstacle to free-market reform may be ourselves. We have been programmed to look to outside leaders and to government for solutions. It is hard to acknowledge that we have been duped. Ours must be a ground-up movement. We must not allow those who would like to be protected from innovation to stop us.
Keith Smith, M.D., Oklahoma City, OK