Volume 75, no. 9
Dr. Robot is visiting patients in some places but could be displaced by Dr. Alexa, the virtual assistant in Amazon smart speakers, who is already able to perform certain health-related tasks. “She” can track blood glucose levels, describe symptoms, access post-surgical care instructions, monitor home prescription deliveries, and make appointments at an urgent care center.
Amazon has big ambitions. It thinks Alexa could help doctors diagnose mental illness, autism, concussions, and Parkinson disease. Alexa, the iPhone 5s, and the Samsung Galaxy S4 can correctly identify agonal breathing, an early warning sign in about half of all cardiac arrests, in 97% of instances, while registering a false positive only 0.2% of the time. The smart phone is constantly listening. Patented technology from the University of Washington differentiates coughs and sneezes from other background noises; Alexa could discern when someone is ill and suggest solutions.
Since Alexa won permission to use protected patient health records controlled under the Health Insurance Portability and Accountability Act (HIPAA), vast new opportunities are open. It could listen in on patient-physician interactions to take notes on visits, even suggesting possible treatments and writing up medical notes automatically.
Alexa could potentially combat loneliness. It is “learning” how to make conversation.
In 2018, private equity and venture capital firms have invested a record $10 billion in startups touting the benefits of virtual doctor visits and telemedicine. A startup called Kinetxx will provide patients with virtual physical therapy, along with messaging and exercise logging. And Maven Clinic, which is not actually a physical place, offers online medical guidance and personal advice focusing on women’s health needs.
Amazon now has a deal with the British National Health Service (NHS) to provide patient access to “reliable, world-leading N.H.S. advice from the comfort of their home,” freeing up more doctors’ appointments. An NHS spokesman said no patient data would be shared. Amazon insisted that it is not building health profiles, that no health information will be used to sell merchandise or make product recommendations, and that none of the information will be shared with third parties. But given past concerns about how Alexa-enabled devices handle their users’ information, social media users expressed caution or disdain. Big Brother Watch calls Amazon “one of the most aggressive corporate data guzzlers” and worries about people being profiled and targeted based on health concerns. The data “gives Amazon an opportunity to understand much more about people’s illnesses, behaviors and problems,” and could help it start a health-related business or a pharmacy.
“The physician-patient encounter is health care’s choke point,” write David Asch et al. from the University of Pennsylvania and Cornell University. “So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors.”
Authors cite automated teller machines, online travel booking, TurboTax and other do-it-yourself replacements for workers.
Common problems like hypertension, hyperlipidemia, diabetes, and anticoagulation “might be far more efficiently managed by a bot than by individual clinicians whose practices often deviate from guidelines,” they write. Information technology and value-based payment won’t enable transformation “until they move past facilitating care with a doctor and move toward facilitating care without one” (NEJM 5/10/19).
Big Tech giants such as Google are set to block all “alternative” medicine websites such as NaturalNews.com. They will not only be eliminated from search results, but within a year or so, the Google Chrome browser won’t even allow a user to visit a disapproved site—say one that is skeptical about vaccines, chemotherapy, or statin drugs—without changing the browser’s default settings. According to some reports, websites promoting conservatism, Christianity, or Donald Trump may also be blocked. Moreover, the Chrome browser may report back to Google on attempts to access banned sites, and add that to a social penalty score like that used in Communist China.
Geoffrey Fowler writes that “Google’s Web browser [Chrome] has become spy software” (Wash Post 6/21/19).
Doctors are under surveillance by the electronic health record (EHR). Newer versions of EPIC, for example, allow an auditor to see every keystroke and mouse movement, identify text that has been imported or copied and pasted, and tell how fast the transfer was done and whether that text has been edited. While presented as a “patient safety” measure, the tool can be used to “describe documentation practices by medical students, residents, and direct care hospitalists.” If anyone with proper password can see this information, so can compliance staff and payers. The information can be used not just for “mentoring,” but for corporate coercion and seeking evidence of fraud. Note that computers also have built-in microphones and cameras.
Alexa may be seeing you always—like the government “she” also serves, “a dangerous servant and a fearful master.”
Google et al. to Monitor Mental Health
The Trump Administration is reportedly considering a proposal to use Google, Amazon Echo, and Apple Watch to collect data on users who exhibit characteristics of mental illness that could lead to violent behavior. This is part of the initiative to create a Health Advanced Research Project Agency (HARPA), which got a renewed push after August shootings in El Paso and Dayton. HARPA would be modeled on the Defense Advanced Research Projects Agency (DARPA), the research arm for the Pentagon. HARPA would develop “breakthrough technologies with high specificity and sensitivity for early diagnosis of neuropsychiatric violence,” according to a copy of the proposal. “A multi-modality solution, along with real-time data analytics, is needed to achieve such an accurate diagnosis.”
The surveillance scheme, called “Safe Home” (Stopping Aberrant Fatal Events by Helping Overcome Mental Extremes), promises that privacy will be “safeguarded,” profiling “avoided,” and that data protection capabilities would be a “cornerstone of this effort.” Michelle Malkin reminds us, however, that “Google has already admitted to data mining children’s emails without consent and in violation of the Federal Educational Rights and Privacy Act.” Thousands, if not millions, of children are required to sign on to Google email and Chrome in order to access homework, schedules, and classroom discussions. They are forced to use laptops and tablets loaded with Google for Education, when paper and pencil would suffice. An app called E-Hallpass even keeps track of how much time is spent in the bathroom.
Mental health data mining is already happening, with students rated on how well they “cooperate and share ideas and materials in socially acceptable ways.” And who defines these terms? Malkin writes that we need to “de-platform Google and the other data-mining predators from public schools now.” And what about medical institutions?
Flashback: Tax Exemption Denied
In 1958, AAPS was denied a tax exemption for its campaign to teach schoolchildren about the Bill of Rights. Internal Revenue Service Commissioner Russell C. Harrington wrote: “Opposing Socialization of the medical or other sector of the economy or supporting the principles of individual liberty and freedom,…or support of the principles enunciated in the Constitution…are not, in our opinion, per se educational….” These are “preconceived conclusions.” To be “educational,” the program would have to offer a “fair and full presentation of all pertinent facts and information…whereby the public may make independent conclusions.”
AAPS noted that hundreds of organizations did enjoy the tax-exempt privilege, e.g. the Ford Found for the Republic, which was “openly committed to National and International Socialism” (Brownsville Herald 6/22/58).
“[Communism is] pervaded, in a pseudo-mystical way, with a certain false idea of justice, equality and fraternity,…inflaming the masses by enticing them with deceitful promises…. [It offers a false idea of redemption, a false religion without God,…a new gospel and…form of salvific redemption…. [The result is] the plundering of man’s liberty,…the overturning of human dignity…, [and] the removal of the authority of parents to educate their children.”
Pius XI, quoted by Vatican II
ACTION OF THE MONTH
AAPS will not report your CME to specialty boards as AMA will, but we fight MOC/MOL and defend your freedom. Can you spare $10/month? https://aapsonline.org/monthly
VA News Briefs: from the U.S. Single Payer
“Red Flags”: The Veterans Administration’s secretive database on “disgruntled” or “disruptive” veterans, reports Michelle Malkin, like an American version of China’s social credit system, red-flags vets without due process, transparency, or accountability, in the name of “safety.” Bureaucrats routinely deprive patients of medical treatment, based on arbitrary definitions of who and what constitutes a mental health menace.
Private Safety Net: The VA is preparing for “the biggest shift in the American health care system since the passage of [ACA].” Veterans facing a wait of more than 20 days for an appointment at their nearest VA can seek private care. There are now nearly 550,000 “providers” participating in its private network (NY Times 6/5/19).
Suicide: About 20 active duty service members, reservists, or veterans die by suicide every day. Veteran suicides increased by 26% between 2005 and 2016 (Wash Times 8/30/19).
No Socialist Miracle in Scandinavia
Democratic Socialist politicians such as Alexandria Ocasio Cortez and Bernie Sanders point to Scandinavian countries as their model—not Venezuela or the Soviet Union. Political scientist Daniel Schatz, born in Sweden, points out the “cold truth”:
The combined population of Nordic countries is comparable to metropolitan New York City, without the diversity. Social norms are based on a strong work ethic, social trust, and individual responsibility. Their success preceded the social welfare state. Sweden’s tax burden peaked at 52.3% in 1990 and had to be rolled back. Public monopolies had to be replaced (Commentary, Jul/Aug 2019).
‘1619’ Project: the U.S. Is Not a Democracy
The New York Times project commemorating the 400th anniversary of the beginning of American slavery aims to reframe American history. It begins with a serious error in the very first article entitled “America Wasn’t a Democracy, Until Black Americans Made It One” by Nikole Hannah-Jones, writes Walter Williams. The nation’s founders never intended for us to be a democracy and held that form of government in utter contempt. James Madison wrote in Federalist Paper No. 10, that in a pure democracy “there is nothing to check the inducement to sacrifice the weaker party or the obnoxious individual.” The U.S. Constitution is replete with anti-majority rule, undemocratic provisions, such as the Electoral College.
Williams notes that “black Americans have made the greatest gains, over some of the highest hurdles in the shortest span of time than any other racial group in mankind’s history.” This speaks to the greatness of our nation. “The challenge before us is how those gains can be extended to a large percentage of black people for whom they appear elusive.”
More than a quarter of the 365 people exonerated by the Innocence Project had confessed to their alleged crime. A confession can practically guarantee a guilty verdict, writes Douglas Starr. He reports on the experiments of Saul Kassin of John Jay College of Criminal Justice, who found that confessions that look real can actually be false even if corroborated by informants and forensic science. Interrogation tactics such as accusatory questioning or a “minimization” technique that lowers the barrier to confessing can provoke false as well as genuine confessions. Sometimes suspects, especially impressionable adolescents, worn down by hours of interrogation, may even go into a fugue state in which they begin to believe their own guilt. An American Psychological Association white paper suggests prohibiting lying by police, limiting interrogation time, and recording all interrogations from start to finish (Science 6/14/19).
Justice Thomas on Stare Decisis
Although concurring with the 7–2 majority in Gamble v. U.S., which upheld the doctrine of dual sovereignty under which two offenses are not the “same offence” for double-jeopardy purposes if prosecuted by separate (State and federal) sovereigns, Justice Clarence Thomas wrote that the stare decisis doctrine should not preclude overturning erroneous precedents:
I write separately to address the proper role of the doctrine of stare decisis. In my view, the Court’s typical formulation of the stare decisis standard does not comport with our judicial duty under Article III because it elevates demonstrably erroneous decisions—meaning decisions outside the realm of permissible interpretation—over the text of the Constitution and other duly enacted federal law.
The news site ThinkProgress, a project of the Center for American Progress Action Fund, accused Thomas of “judicial arson.” The precedent of greatest concern to the left is Roe v. Wade. Even the author of the majority opinion, Justice Harry Blackmun, doubted its ability to endure. He stated, “If this suggestion of personhood [for the unborn] is established, [the pro-abortion] case, of course, collapses, for the fetus’ right to life would then be guaranteed specifically by the [14th] Amendment.”
According to the Congressional Research Service, the justices have reversed themselves at least 141 times over their history, writing that “the court’s treatment of precedent implicates longstanding questions about how the court can maintain stability in the law by adhering to precedent under the doctrine of stare decisis, while correcting decisions that rest on faulty reasoning, unworkable standards, abandoned legal doctrines, or outdated factual assumptions.”
Tip of the Month: Promising to comply with HIPAA does not make a physician a covered entity. Standard contracts often contain language requiring HIPAA compliance. This can be puzzling to physicians who are non-covered entities under HIPAA and who want to stay that way. Signing such a contract does NOT make a physician a covered entity. A physician is a covered entity based on his actions of engaging in electronic transactions, such as electronic billing, not on promises.
Reportedly, nurses are required to ask all new patients admitted to the hospital whether they have received influenza and pneumococcal vaccines. If they have not, an electronic order can be entered without an individual provider’s order or prescription. Maine Medical Center was able to increase compliance with the Influenza and Pneumococcal Vaccination Performance Measures for the Centers for Medicare & Medicaid Services (CMS) Core Measure Pneumonia by 65%, from less than 20% to more than 75%. Since vaccines are biologics, patients may give consent by signing a form consenting to biogenics or biologics. Those who wish to opt out of vaccines must specifically state this on the consent form.
New Questions on Brain Death
Four hours after pigs were slaughtered and their brains removed from their skulls, researchers were able to restore certain structural and metabolic functions by using a perfusion system called BrainEx. This seems to contradict the belief that brain cells die when deprived of oxygen for just a few minutes. More patients might thus be candidates for brain resuscitation efforts. “There’s a potential conflict here between the interests of potential donors…and people who are waiting for organs,” said bioethicist Stuart Youngner of Case Western Reserve Univ. (Nature 4/18/19).
Some organ-recovery teams in the U.S. and Taiwan insert a thoracic aorta occlusion balloon when using extracorporeal membrane oxygenation (ECMO), to prevent perfusion of the brain. This is deemed a serious problem by an HHS panel because it raises questions about physician complicity in a patient’s death (Youngner S, Hyun I, Nature 4/18/19).
TMB Should Remove False NPDB Entry
In an amicus letter brief to the Third Court of Appeals in Austin, Texas, AAPS asks the Court to order the Texas Medical Board to “fully void all if its reports to the [National Practitioner] Data Bank” concerning Dr. Robert Van Boven. This physician has been completely exonerated of all wrongdoing, yet his opportunity to work is destroyed by the false and misleading report that TMB placed in the NPDB. AAPS writes: “There is no checking of the truthfulness of reports by anyone at the Data Bank,” and reporting agencies such as TMB must themselves take the initiative to remove erroneous or misleading entries.
“There is a Kafkaesque element implicit in the TMB’s actions and argument,” AAPS states. “The mere allegation of wrongdoing, with an administrative court finding after complete litigation that the allegation is unsubstantiated, is being used to blacklist a physician.”
“Restoring Morality” in China
China’s social credit system, not yet fully implemented, has blacklisted more than 13 million people. An embarrassing ring tone will warn others of the presence of an “untrustworthy” or “bad” person—as defined by the Communist Party chief—in their midst. The system has been exported to Venezuela.
Think about Surprises Outside the “Healthcare” Box. Suppose you are an independent ditchdigger. I have Acme Excavation Coverage, which advertises that “most providers accept their insurance.” You have decided not to become a provider because the fee is far too low, and sometimes Acme decides not to pay providers after the ditch is dug because it decides the ditch was “unnecessary.” I experience a break in a water line and need an emergency excavation. I call you, and you come immediately to fix my problem. Then I get a “surprise” bill for your sweat and toil, based on your fee of $250/hour. But the approved Acme “in-network” fee is $10/hour. Suppose Acme will pay only $10/hour or even nothing at all for this “unnecessary” or “unauthorized” service. So, who should have to pay? Nobody? Should you have to “negotiate” with Acme or submit to binding arbitration, which you will almost certainly lose? If you go out of business, who will do emergency excavations?
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
In Defense of Charles Ponzi. In the June article on the “Event Horizon for National Debt Death Spiral,” Charles Ponzi was disparaged. True, Mr. Ponzi was a liar, cheat, and crook, but he didn’t use the power and guns of the law to work his way to temporary riches. The perpetrators of the U.S. government’s national debt scheme are backed up by guns as well as tanks. Further, many of these perps become wealthy beyond my imaginings. In contrast, Ponzi was punished for his crimes and died a pauper.
Robert Cihak, M.D., Gilbert, AZ
From M.D. to N.P. In the early 2000s, I transitioned from being a nurse practitioner and became a physician. Now, people are going in the opposite direction! There are several programs, including one for international medical graduates (tinyurl.com/yxs6oh4a). After graduating medical school, new doctors may not be able to find a residency slot needed to obtain a license. After jumping through more hoops and acquiring more debt, they may at least be able to find employment that uses their skills, and begin to pay off their huge medical school debt. Perhaps better than waiting tables or driving for Uber, but what a waste! For the impending physician shortage, we need more residency slots, not more unsupervised midlevel “providers.”
Jaclyn Nadler, M.D., https://tinyurl.com/y43fbqq4
Reduce Seniors’ Costs. The way to lower costs is to reduce the role of third-party payers, including insurers and government. In the direct primary care membership model I use in my practice, I can offer a 90-day supply of losartan for $12.50, compared with the $150 that a Medicare patient paid out of pocket, and Plavix for $60 less than the patient’s Medicare copay. The complex drug supply chain is dominated by pharmacy benefits managers, who receive billions in kickbacks (“rebates”) for getting drugs on the formulary. The Trump Administration’s effort to eliminate these rebates is facing stiff opposition from AARP, which partners with UnitedHealth to offer supplementary Medicare coverage, earning more than twice as much in royalties as in membership dues. Federal programs prop up the health insurance oligopoly.
Raymond Kordonowy, M.D., Fort Myers, FL
The 0.05%. It has been said that “the cost of surprise bills is a small portion of all health care spending.” How small? From the CBO analysis of Sen. Lamar Alexander’s balance billing ban: “Effects on the Medical Tax Deduction: By eliminating surprise bills, title I of S. 1895 would reduce the number of people who qualify for and claim the itemized medical tax deduction. Under current law, CBO and JCT estimate that more than 4 million people will claim that deduction in 2019, thus reducing federal revenues by about $7 billion. The agencies anticipate that eliminating surprise bills could lower the amounts claimed by that population by about 0.05 percent, thus increasing federal revenues by roughly $71 million over 10 years [emphasis added].”
Jeremy Snavely, Tucson, AZ
What If They Win? A recent Gallup poll claimed that 4 in 10 Americans want socialism, the precursor to communism. If this poll is correct, then Nikita Khrushchev’s “conquest without war” may come to pass decades after his death. Those asked about their views on socialism generally have no ability to explain it, or why they desire it; they just think it’s a good idea, and they want “free stuff.” They have never opened a history book on socialism, nor have they studied the basic principles of economics. None understand that the European socialist welfare they admire is supported by the high taxes paid by strong capitalist corporations with shareholders and investors. They are unwitting tools of the few who are designing the one-party state. Will they become the apparatchiki, the bulldozing machine of control through fear, snitching on neighbors and relatives, jail, repressions, and purges? Under Stalin, apparatchiki also watched one another: “Socialist vigilance required the uncovering of deviations and deviationists, the unmasking of the class enemy who might have wormed his way into the Party.” Even the Marxist Trotsky was beaten and exiled. The Party allowed “democratic centralism,” within certain parameters—only until a decision was “adopted.”
Ileana Johnson, Ed.D., https://tinyurl.com/yxlu4msg