Health Policy Archives - Marilyn Singleton, MD JD

Culture & Society, Current Events, Health Policy, Healthcare Reform, Medicine, What's New

America Out Loud PULSE: The Superhighway of Medical Progress or the Road to Nowhere?

July 5, 2023 No Comments

From my America Out Loud Pulse podcast with Dr. Jane Orient -https://www.americaoutloud.com/the-superhighway-of-medical-progress-or-the-road-to-nowhere/

I used to enjoy watching medicine changing over the years. When I was an intern, we had to drill holes in the skull to diagnose a subdural hematoma. Now a quick CT scan without surgery gives a world of information. Ultrasound for pregnancy was a new thing. Surgery with the laparoscope (“belly button surgery”) was in its infancy. Now you are hard pressed to see a gallbladder removal done with a full abdominal incision.

I remember the days when humanity in medicine prevailed. You could get around the utilization reviewer’s bright green checkmarks that let you know that it was her opinion that the patient needed to be discharged from the hospital. We could exercise our empathy; the bean counters didn’t control us. I fondly remember letting an elderly patient stay a few extra days through Christmas because his only friend was also in the hospital.

The social changes in medicine are a far different story. It was a true step forward when all medical schools accepted not only women but students of all races. We saw all sorts of patients from many socioeconomic backgrounds, including patients on the prison and wards. We treated all of them to the best of our ability.

Now with schools latching on to this new twisted version of diversity and equality, I worry what happened to people merely treating one another like fellow human beings. What is motivating the rich and powerful to decide that we should be categorized in perpetuity by race instead of our individual characteristics? Divide and conquer comes to mind.

And what happened to the concept of not harming patients? What caused medicine to ignore science and like trained seals, agree that men can be women?

What caused educate persons to fall in line with grammatically incorrect and sometimes bizarre pronouns? Take for example, Dr. Jane Orient’s biography at Healthline.com: “Dr. Jane Orient, MD is an Internal Medicine Specialist in Tucson, AZ. “They” [emphasis added] specialize in Internal Medicine, has 47 years of experience, and is board certified in Internal Medicine.” I seriously doubt that wording was approved by Dr. Orient. Not only is she a she, ‘they’ is grammatically incorrect.

Bio

Dr. Jane Orient is the Executive Director of Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. She has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. Dr. Orient received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. Dr. Orient’s op-eds have been published in hundreds of local and national newspapers, magazines, internet, followed on major blogs and covered in the Wall Street Journal and New York Times as well as several novels and non-fiction books, including Sapira’s Art and Science of Bedside Diagnosis in its fourth printing.

Association of American Physicians and Surgeons site: https://aapsonline.org/

Dr. Orient’s nonfiction and fiction writings: https://www.janemorient.com

Culture & Society, Doctors, Health Policy, Medicine, What's New

America Out Loud PULSE: The ABCs of Drug Addiction and Treatment

June 24, 2023 No Comments

From my America Out Loud Pulse podcast with Dr. Molly Rutherford -https://www.americaoutloud.com/fentanyl-is-now-the-top-cause-of-death-among-u-s-adults-drug-addiction-treatment/

Fentanyl ushered in a new era of anesthesia making outpatient surgery safe and ultimately, commonplace. In contrast to morphine or meperidine (Demerol®), fentanyl is very short-acting, allowing patients to emerge from anesthesia faster. The downside for the safety profile is that fentanyl is 100 times more powerful than morphine. Of course, anesthesiologists (unlike the vast majority of drug users) are trained professionals and are constantly monitoring a patient’s oxygen, breathing, pulse, and blood pressure.

Now that fentanyl has become a street drug, it has become a quick path to death. According to the U.S. Centers for Disease Control and Prevention (CDC), fentanyl is now the top cause of death among U.S. adults (ages 18-45)—more than COVID-19, suicide and car accidents. Out of 2022’s 105,452 drug overdose deaths, 19 percent were due to fentanyl. According to the Drug Enforcement Administration (DEA), in 2021 fentanyl killed more Americans than guns and traffic crashes combined.

How did it become so popular? Seventy-five percent of overdose deaths are due to opioids. The legal prescriptions for hydrocodone, oxycodone, oxymorphone had been the main cause of overdose deaths. But after these medications came under scrutiny and became the subjects of multiple lawsuits, fentanyl hit the streets. Fentanyl is 50 times stronger than heroin. A lethal dose fits on the tip of a pencil. And fentanyl is synthetic—meaning it can be made in a lab from chemicals. (Heroin is made from poppies). But because fentanyl is so cheap, it is slipped into other illicitly-obtained prescription pills unbeknownst to the buyer of the drug.

Fentanyl and its ingredients are mainly smuggled into the U.S. from Mexico by drug cartels and is much cheaper ($4 or $5 per pill) than other opioids ($30 per pill). Fentanyl is a very versatile drug: it can be injected, snorted/sniffed, smoked, taken orally by pill or tablet, and spiked onto blotter paper. Teens have become a large portion of its victims as fentanyl has been sold via some social media outlets. Fentanyl was identified in more than 77 percent of fatal overdoses among adolescents in the first half of 2021.

I’m disturbed that all I am hearing about is naloxone, better known as Narcan®. This drug immediately reverses the effects of narcotics. An over-the-counter version of Narcan®, a nasal spray, was approved for purchase without a prescription by the FDA in March 2023. While this may save a life in the short term, it doesn’t stop drug use. I wonder whether it will make it worse if the user knows there is a reversal. Anecdotally, what I’ve seen after working in the ER, experiencing an overdose does not scare off an addict from using drugs again.

What’s wrong with Americans that’s they consume so many mind-altering drugs? Hopefully the $50 billion in settlements by drugmakers will go to prevention of addiction in the first place.

For information on newer trends in pain management: The Pain Management Best Practices Inter-Agency Task Force Report

https://www.hhs.gov/opioids/prevention/pain-management-options/index.html

Dr. Molly Rutherford is the founder, medical director, and physician at Bluegrass Family Wellness—a direct primary care clinic in Kentucky. She is board certified in Family Medicine and Addiction Medicine, and employs a holistic approach to her patients’ physical health. She has more than a decade of experience treating opioid addiction. She was chosen to be part of the federal Pain Management Best Practices Inter-Agency Task Force.

Culture & Society, Health Policy, Law, Medical Ethics, Medicine, Politics, What's New

America Out Loud PULSE: The Myth of Medical Privacy

June 18, 2023 No Comments

From my podcast with Twila Brase, RN, PHN - https://www.americaoutloud.com/the-myth-of-medical-privacy-with-twila-brase-rn/

Back in 2018, Amazon made a software application that can mine a patient’s medical data and convert it to a searchable database. Amazon could customize the database for pharmaceutical companies, insurers, hospitals, researchers, and clinicians. Amazon claims the application would comply with HIPAA, the Health Insurance Portability and Accountability Act of 1996. By the way, isn’t it interesting that the word “privacy” is not in the title of the law that everybody thinks is a law that protects privacy?

Worse, some electronic health records had an embedded app (developed by Xealth, Inc.) that prompted doctors to recommend health products to their patients that—surprise!—were sold on Amazon.

Amazon is being hailed as a “disruptor” in medical care with its online clinics. For a flat fee, you can get in touch with a clinician of some sort and describe your symptoms or needs. As one customer testimonial reads, “Amazon Clinic was incredibly easy and convenient to get my thyroid medical refilled. No hidden fees, no in person visit. Also for someone without health insurance the cost was the absolute best part.” But there is a giant “but.” Amazon’s health clinic requires patients to give Amazon the authority to redisclose their health information in the future.

Cost effective, yes; but Amazon clinic’s terms of use raise the question: How much is your medical privacy worth? I remember the attempt to discredit Daniel-Ellsberg who exposed damaging information regarding the Viet Nam War with the release of the “Pentagon Papers”. Operatives dispatched by the President broke into Ellsberg’s psychiatrist’s office looking for juicy tidbits. Imagine how easy that would be now. Hacking into electronic databases has become child’s play.

We’ll talk about this and so much more with my guest, a nationally recognized expert in the field of medical privacy.

Twila Brase, RN, PHN is President and Co-founder of Citizens’ Council for Health Freedom (CCHF), a national patient-centered, privacy-focused, free-market policy organization established 25 years ago in Minnesota to support health care choices, individualized patient care, and medical and genetic privacy. Her efforts led to a national law requiring parental consent for research using newborn DNA. Ms. Brase is author of the eight-time award-winning book Big Brother in the Exam Room: The Dangerous Truth About Electronic Health Records.

Ms. Brase’s “Health Freedom Minute” is heard weekdays by more than 5 million listeners across the United States. She provides testimony at state legislatures, meets with members of Congress and health care policymakers, and has been featured in major news outlets such as the Wall Street Journal and the Washington Post.

Health Policy, Law, Medical Ethics, Medicare, What's New

America Out Loud PULSE: Long Term Care

June 15, 2023 No Comments

From my America Out Loud Pulse Podcast with Stephen Moses - https://www.americaoutloud.com/the-ins-and-outs-of-long-term-care/

People are living longer and by 2030 about one in five Americans will be aged 65 years and older. Unfortunately, around 60 percent of adults suffer from at least one chronic condition, while 42 percent suffer from multiple conditions. Among those 60 or older, at least 80 percent have one chronic illness and 50 percent have two. Such conditions include heart disease, cancer, stroke, dementia, Parkinson’s, diabetes, kidney disease, debilitating hearing loss, blindness, and chronic lower respiratory disease (COPD, bronchitis, emphysema, asthma). Seventy percent of people who reach age 65 will eventually develop severe need, and 48 percent will receive paid care. The need for paid care spikes around age 85.

We hear interminable ads for life insurance with guaranteed acceptance and no physical exam that you can get in your 70s for under $10 a month! The unvarnished truth is that the death benefit is about $500 to $700—that amount would hardly pay cab fare to your funeral. We rarely hear ads for a type of insurance that we actually need and would improve our lives: long-term care insurance.

Ideally, our life’s medical trajectory would be good health for many years, then keel over one day and meet our Maker without going through a period of debilitation. I would venture to guess that most people cringe at the thought of spending their last years on this earth in a nursing home. Long term nursing care can be as high as $100,000 per year and many people look to the government to pay their nursing home bill.

But given the low reimbursement to facilities from the government and the low pay for workers in the long term care industry, it leads us to question the quality of care the residents receive.

My guest will discuss the ins and outs of long term care and what we should do to protect ourselves.

Bio

Steve Moses is president of the Center for Long-Term Care Reform. The center promotes universal access to top quality long-term care by encouraging private financing as an alternative to Medicaid dependency for most Americans. Previously, Mr. Moses was president of the Center for Long-Term Care Financing (1998-2005), Director of Research for LTC, Inc. (1989-98), a senior analyst for the Inspector General of the U.S. Department of Health and Human Services (1987-89), a Medicaid state representative for the Health Care Financing Administration (1978-87), an HHS departmental management intern (1975-78), and a Peace Corps volunteer in Venezuela (1968-1970). He is widely recognized as an experienced expert and innovator in the field of long term care. His recent monograph on the issue is Long-Term Care: The Problem.

Doctors, Health Policy, Medical Ethics, Medicine, What's New

America Out Loud PULSE: Ego Must Not Trump Patient Care

June 7, 2023 No Comments

From my America Out Loud Pulse podcast with Dr. Lawrence Huntoon -https://www.americaoutloud.com/ego-must-not-trump-patient-care/

When clinical practice guidelines were first introduced, they sounded like a good idea. Some experts in a certain field of medicine would get together and decide what is the best thing to do for patients. It didn’t take much time for the flaws in the guidelines concept to emerge. We saw that some of the recommendations were designed to save money rather than benefit patients. Some guidelines appeared to be influenced by the companies who would make money from their use—aka Big Pharma. We certainly learned during Covid-19 that the experts were not always right and were corrupted by influence from pharmaceutical companies.

Medicine traditionally is full of all sorts of information and differing opinions. After all, the human body and its reaction to medications and other treatments are not always predictable. Continually questioning the so-called settled science is how progress is made. It became clear to discerning physicians that these guidelines became a crutch, promoting “cookbook” medicine and as my guest puts it, “eliminates unproductive time spent taking the patient’s individual circumstances, conditions, and needs into consideration so as to provide optimal care.”

Worse yet, these guidelines have been used a weapon against good, innovative physicians, sometimes to crush a competitor or someone who refuses to sell his practice to a large group. The critics of innovative physicians conflate the guidelines with the “standard of care”—the standard of practice to which physicians are legally held. This is a legal definition of good medical practice in a community with the same resources as the physician at issue. What constitutes the standard of care will change from community to community as well as evolve over time. Guidelines may be considered as a factor, but they do not define the standard of care.

In the 1995 South Carolina malpractice case, McCourt v. Abernathy, the Court stated:

“The mere fact that the plaintiff’s expert may use a different approach is not considered a deviation from the recognized standard of medical care. Nor is the standard violated because the expert disagrees with a defendant as to what is the best or better approach in treating a patient. Medicine is an inexact science, and generally qualified physicians may differ as to what constitutes a preferable course of treatment. Such differences due to preference…do not amount to malpractice”.

My guest and I will discuss these issues and how needlessly attacking doctors harms patients.

Culture & Society, Current Events, Health Policy, Healthcare Reform, Politics, What's New

America Out Loud PULSE: Six Lessons in Healthcare Mythology

May 30, 2023 No Comments

From my America Out Loud Pulse podcast with Robert Graboyes, PhD - https://www.americaoutloud.com/six-lessons-in-healthcare-mythology/

The cost of medical care is a big topic in healthcare policy discussions – whether in Congress or in think tanks. Over the last few years costs for medical care have continued to rise. Until 2021 with the out-of-control inflation medical care prices have generally grown faster than overall consumer prices. From 2000 to 2022, the price of medical care, including services, insurance, drugs, and medical equipment, has increased by 115.1 percent, whereas prices for all consumer goods and services increased by 78.2 percent.

Hospitals “facility fees” are of particular concern. Facility fees are generally the price for using the hospital premises – the overhead charge in addition to professional charges. Some hospitals are charging such fees for telemedicine. Additionally, one large private insurance data analysis showed that the facility fees for emergency department use from 2004 to 2021 increased four times faster (531%) than professional fees (132%) for emergency department evaluation and management services. And until 2021 with the out-of-control inflation medical care prices have generally grown faster than overall consumer prices.

Healthcare policy isn’t just about saving money. Otherwise, we would simply ration care. Real human beings underlie the reason we provide medical care in the first place. Accordingly, we have to look at limitations on access for certain groups, the impact of cost-cutting on quality, the ethics of rationing, and many other factors affecting the individual patient.

My guest taught the economics and ethics of healthcare for 20 years and his overriding theme throughout those years was, “Always be skeptical.” He notes that “healthcare policy debates tend to be drenched through-and-through with myths, opinions, and politics—all masquerading about as scientific facts.”

America Out Loud PULSE: A Pediatrician Talks PBMs, Politics, and Porn

May 24, 2023 No Comments

From my America Out Lous Pulse podcast with Dr. Marion Mass -https://www.americaoutloud.com/a-pediatrician-talks-pbms-politics-porn/

There are a lot of pieces to the health care system pie. The insertion of third parties into the patient-physician relationship is at the core of many of such problems. Corruption and fraud are the last things we need. Accordingly, in 1972 Congress passed a law that that outlawed kickbacks for referrals for medical care and other contracts in the medical field. This was to be sure that referrals of patients to other medical care professionals were in the best interest of the patients. So far, so good.

But 25 years ago, the government made exceptions to this Anti-kickback law. This allowed some middlemen to do some fancy footwork when negotiating prices. In the world of prescription drugs, pharmacy benefits managers (PBMs) are the middlemen. Their price negotiation was supposed to save patients money. Now the system of pharmacy benefit managers has morphed into a big money-making scheme and patients are left holding the bag – or in most cases higher costs.

Congress has been talking about doing something about PBMs for years but the talk does not translate into action. Maria Cantwell and Charles Grassley introduced the Pharmacy Benefit Manager Transparency Act of 2023. This was also introduced in 2022. It seems to me the dithering around with the PBM legislation is an example of politics overriding actually doing something for the constituents. Perhaps the latest Senate hearings will yield some fruit.

There’s another even more important place where third parties inserting themselves into our family lives are being spurred on by the government—sometimes by statute. I’m talking about no parental notification for life-changing medical procedures, drag queen shows for children, distorted history lessons and teaching our children how different they are from one another rather than how much we have in common.

Remember this: the family is your first government. We have to get to a place where we can discuss these issues with respect for one another with the goal of putting parents back in charge of their children.

Current Events, Health Policy, Healthcare Reform, Medicine, Politics, What's New

America Out Loud PULSE: US Gov’t Impact on Policy, Consolidation & Challenges in Healthcare

May 16, 2023 No Comments

From my America Out Loud podcast with Grace-Marie Turner -https://www.americaoutloud.com/us-govt-impact-on-policy-consolidation-challenges-in-healthcare/

All the noise about culture wars has taken up the airwaves. Meanwhile things that affect all of us in our day to day lives get little press. We’ve heard about high insulin prices and pharmaceutical companies semi-voluntarily reducing the prices. (Drugmakers faced a penalty from Medicaid if they raised the price higher than inflation).

Let’s face it, most of us do not take insulin, but nearly 70 percent of Americans take at least one prescription drug. Should we seriously assess whether Americans take too many drugs in the first place? Should the government cap prices? If the government regulates prices, will the drug companies still make enough money to continue aggressive research and development?

Another real issue is the shortage of healthcare workers at all levels. According to Senator Bernie Sanders’ data, the nation faces a shortfall of about 450,000 nurses and 120,000 doctors in the coming years, and 100,000 dentists now.

Believe it or not, the government is in control of the number of physicians. Medicare funds expenses for residency slots but these have been capped for over 20 years. Typical of the large government bureaucracy, they didn’t notice that more primary care physicians would be needed as the population ages. These increased residency slots are particularly needed primary care, OB/Gyn, and in the rural areas ( where one out of four Medicare beneficiaries live).

Sadly, thanks in part to the Covid lockdowns and economic damage one in five adults have a mental health issue. According to the CDC, suicides increased in 2021, reaching their highest level since 2018. And as our country’s substance abuse problem snowballs, we will need more psychiatry residents and other health professionals in addiction medicine. Recently, HHS finalized a rule that will add 1,000 new Medicare-funded GME positions (capped at 200 new positions per fiscal year) to be distributed beginning in FY 2023.

And then we have all this consolidation of most segments of the health care chain of commerce. Insurance companies are integrated into pharmacies. Large health systems and private equity firms are buying medical practices and hospitals. The government claims it will look into these mergers that have drastically decreased competition and therefore raised prices. One study showed that among 578 physician practices acquired by private equity firms between 2016 and 2020, prices increased by 11 percent.

But is more federal intervention the answer?

My guest and I will discuss what’s going on in Washington DC. on the health care front.

Culture & Society, Current Events, Doctors, Featured, Health Policy, Law, Medical Ethics, Medicine, What's New

America Out Loud PULSE: What Do Roe, Doe, and Dobbs Really Mean?

April 26, 2023 No Comments

From my America Out Loud Pulse podcast with Brian Johnston - https://www.americaoutloud.com/what-do-roe-doe-and-dobbs-really-mean/

Ever since the Supreme Court opinion in Roe v Wade making privacy—which included abortion—a federal Constitutional right in 1973, the right to life debate has come and gone out of the public eye. At this point, most people who paid attention to the Roe opinion knew was not based on anything in the Constitution. It was more of a sociological and cultural decision than a legal one.

A couple of years ago, New York’s Catholic Democratic Governor had the World Trade Center in lights to celebrate its abortion-on-demand-until-the-day-of-birth law. This law was framed as empowering women through guaranteeing “reproductive health.” This and eight other similar state laws were largely ignored as merely codifying Roe v Wade. But the state of Virginia’s pediatrician former governor’s ghoulish advocacy for abortion until delivery of the infant was jaw-dropping as he explained that killing the infant after birth was allowed. Adding insult to injury, in California minors can obtain abortions without parental consent.

The normalization of the intentional killing of human beings weaved its way into our culture. Life was not only cheap for the unborn, but for other vulnerable or unwanted persons such as the elderly. Half the states have laws that charge a person for two murders if he or she kills a woman in any stage of pregnancy.

Fortunately for unborn children, the recent Supreme Court case, Dobbs v Jackson brought the abortion debate into the forefront. The pro Roe crowd went so far as to surround the homes of conservative Supreme Court justices. The media could not continue to ignore the large numbers of people participating in marches for life. More and more people publicly admitted that aborting a baby is not the solution for an unplanned pregnancy.

We can only hope that more and more physicians prefer to practice medicine in the mode of Dr. Mildred Jefferson, the first black woman accepted to Harvard Medical School: “I became a physician in order to help save lives. … I am not willing to stand aside and allow the concept of expendable human lives to turn this great land of ours into just another exclusive reservation where only the perfect, the privileged, and the planned have the right to live.”

Culture & Society, Doctors, Featured, Health Policy, Healthcare Reform, Medicine, Politics, What's New

America Out Loud PULSE: Medical Care Is About Patients, Not Politics

April 21, 2023 No Comments

From my America Out Loud Pulse podcast: Medical Care Is About Patients, Not Politics with Dr. Richard Amerling - https://www.americaoutloud.com/medical-care-is-about-patients-not-politics-w-dr-richard-amerling/

Several years ago the Association of American Physicians and Surgeons publish a Patient Bill of Rights. In this age of more government and corporate control of medical care, it’s time we remembered those rights.

“All patients should be guaranteed the following freedoms:

To seek consultation with the physician(s) of their choice;
To contract with their physician(s) on mutually agreeable terms;
To be treated confidentially, with access to their records limited to those involved in their care or designated by the patient;
To use their own resources to purchase the care of their choice;
To refuse medical treatment even if it is recommended by their physician(s);
To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party-imposed penalties for patients or physicians;
To receive full disclosure of their insurance plan in plain language, including:
- CONTRACTS: A copy of the contract between the physician and health care plan, and between the patient or employer and the plan
- INCENTIVES: Whether participating physicians are offered financial incentives to reduce treatment or ration care;
- COST: The full cost of the plan, including copayments, coinsurance, and deductibles;
- COVERAGE: Benefits covered and excluded, including availability and location of 24-hour emergency care;
- QUALIFICATIONS: A roster and qualifications of participating physicians;
- APPROVAL PROCEDURES: Authorization procedures for services, whether doctors need approval of a committee or any other individual, and who decides what is medically necessary;
- REFERRALS: Procedures for consulting a specialist, and who must authorize the referral;
- APPEALS: Grievance procedures for claim or treatment denials;
- GAG RULE: Whether physicians are subject to a gag rule, preventing criticism of the plan.”

1 2 3 … 9 Next »