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

America Out Loud PULSE: Some Truths About Rural Healthcare with Dr. Edwin Leap

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From my America Out Loud Pulse podcast with  Dr. Edwin Leap – https://www.americaoutloud.com/dr-edwin-leap-some-truths-about-rural-healthcare/

Approximately 20 percent of the U.S. population is spread across 97 percent of the vast U.S. land area. Yet rural hospitals and patients have been largely neglected in articles about medical health and health care policy. We mainly hear about the disproportionate number of opioid problems in rural communities. But rural residents are about more than the opioid epidemic. These “flyover” citizens have families, jobs, heart disease, kidney problems, anxiety and depression – just like people who live in the cities. But what they often don’t have is access to medical care.

Between 2008 and 2018, an estimated 500 out of more than 4,500 rural nursing homes closed or merged. Consequently, some 10 percent of rural counties had no nursing homes. This is a significant loss given that 17.5 percent of the rural population was 65 years and older compared to 13.8 percent in urban areas.

According to the CDC, since 2010, more than 137 rural hospitals have closed, generally due to lack of money as many of the rural patients are uninsured or are on Medicare or Medicaid, resulting in less revenue than with commercial insurance. These closures force patients to travel as much as 2 or 3 hours for advanced medical care. During the peak of the COVID-19 pandemic and continuing today, many emergency departments needed to transfer the sicker patients but there were no beds at the larger, distant hospitals.

We hear about government programs “to apply a rural lens” to health policies but the patients in the countryside continue to lack care. What is going on? We will discuss lives how to tackle these issues with Dr. Edwin Leap who has worked in rural hospitals for over 20 years.

Featured, Health Policy, Healthcare Reform, What's New

America Out Loud PULSE: What Can a Truly Free Market Do for Medical Care?

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From my  America Out Loud Pulse podcast with Charles Sauer – https://www.americaoutloud.com/what-can-a-truly-free-market-do-for-medical-care/

Health Insurance is not the answer to health care costs. Ninety-one percent of Americans have health insurance but “the system” still presents problems to many. According to Kaiser Family Foundation data, about half of U.S. adults say they have difficulty affording health care costs. About 40 percent of U.S. adults say they have delayed or gone without medical care in the last year due to cost. About one-third of adults with health insurance worry about affording their monthly health insurance premium, and 44 percent worry about affording their deductible before health insurance kicks in.

Private equity firms have entered the health care arena, promising savings and efficiency but this trend may have added to the cost. For years, health policy experts have been warning about the dangers of private equityand consolidation in medical services. Five for-profit insurers now control 43 percent of the market, more than 60 percent of community hospitals belong to a health system. A large California study found that consolidation of the hospital, physician, and insurance markets increased prices of services as well as ACA premiums.

A new Congressional Budget Office report confirms that one factor keeping insurer costs high is that “markets have become more concentrated than they would be otherwise because of barriers to entry.”  What these barriers have in common is that they limit competition and patient access to care. Removing them would promote competition among providers and ultimately reduce costs.

My guest today will talk about some solutions to high medical costs that do not include government control of our medical care. Medicare, Medicaid, and the Affordable Care Act are strong evidence that government involvement does not save money overall.

Featured, Health Policy, Healthcare Reform, Medicare, What's New

America Out Loud PULSE: The Truth About Medicare and How to Improve It

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From my America Out Loud Pulse podcast with Steve Cohen, JD –  https://www.americaoutloud.com/the-truth-about-medicare-and-how-to-improve-it/

Medicare accounts for 20 percent of health care expenditures and is 13 percent of total federal spending. Medicare is the second largest program in the federal budget ($767 billion), second only to the Social Security program ($1.151 trillion).

In 2021, Medicare provided benefits to 19 percent of the population. By 2030, one in five Americans will be older than 65. The expenditures will most certainly rise due to increased enrollment, rising Medicare prices, increased use of care as people with chronic conditions live longer. Accordingly, it is imperative that policymakers arrive at viable changes to the program that do not sacrifice seniors at the altar of cost savings. (You all know I’m a fan of cash – but most people currently are not prepared to go that route. Health Savings Accounts take time to grow.)

Medicare is funded mainly from general revenues (43 percent), payroll taxes (36 percent), and beneficiary premiums (15 percent). And the well is running dry. We have gone from 41.9 workers per retiree to 2.8 workers paying into the fund. In 2020 Medicare’s trustees reported that the trust fund, which pays for hospital and other inpatient care (Part A), would start to run out of money in 2026.

People say we can’t agree on anything these days. They say we are too divided. (In my view, most of us want the same goals but have different ideas on how to achieve them.) One thing we all want is for seniors to not struggle in retirement after working hard for so many years. Another is that we don’t want to kill off our seniors with rationing of medical care. Treatment decisions regarding withdrawing or limiting medical care must be open and transparent and follow the patient’s wishes.

The rationing going on with seniors on Medicare is more subtle and behind the scenes. More and more seniors shifted to the Medicare Advantage managed care program with its fixed allotments to medical professionals and restricted prescription medications. Moreover, the Affordable Care Act decreased payments to this program by $156 billion. Will the program make up the difference by cutting services?

My guest today will discuss Medicare’s general rules, pitfalls for patients, and his ideas on how to improve it.

 

Doctors, Featured, Health Policy, Healthcare Reform, Medicine, What's New

America Out Loud PULSE: Is Cash King for Medical Care?

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From my America Out Loud Pulse podcast with Dr. Kathleen M. Brown –  https://www.americaoutloud.com/kathleen-m-brown-md-is-cash-king-for-medical-care/

Governments, doctors, and patients are looking for ways to improve health care quality and lower costs. Legislators have made attempts with the No Surprises Act and Health Care PRICE Transparency Act. But these laws do not get to the core of the perverse medical care pricing system. Insurers bargain for prices with various health systems and hospitals. The negotiated price can be up to double the price offered to “self-pay” patients, that is patients who offer to pay cash even if they have insurance.

Additionally, insured patients are on the hook for more costs mainly because many employers have shifted to high-deductible insurance plans to lower their costs. According to the Kaiser Family Foundation, annual deductibles in 2021 were as high as $2,378, an amount that steadily increased over the last 10 years. Moreover, the insureds must pay a copayment when they see the doctor. This can be a fixed amount (average $25 for primary care and $42 for specialty care) or a percentage (generally 20 percent) of the cost of the visit. And remember, this percentage is based on the insurance rate—which is higher than the cash rate.

What is a patient to do to save money while still getting good medical care? When patients choose to receive care from a physician or other health care professional who has a cash-based practice, the fees can be very low. Why? They have cut out the middleman—the insurer. That means no salary for an office worker to sit on the phone all day with an insurance company trying to extract payments. Dealing with a cash-based practice also leads patients to other areas with reduced fees: X-rays, CT scans, MRIs, laboratory tests, and pharmaceuticals.

I urge you to take a look at websites that list folks who publish cash prices, such as the Free Market Medical Association, Association of American Physicians and Surgeons and sites that offer discount coupons such as GoodRx and Blink Health. The savings are well worth the time. Consumer Reports secret shoppers found the cost of 5 commonly prescribed medications cost $66 at HealthWarehouse.com, $105 at CostCo and a shocking $900 at CVS and RiteAid.

And why should physicians be more like veterinarians? The vets love their patients and many have this sign like this in their offices: You are invited to discuss frankly with us any question regarding our services or fees. The best medical services are based on a friendly mutual understanding between the patient and doctor.

My guest today has operated a caring, compassionate cash based medical practice and we’ll discuss how she got there. And we’ll also touch on human behavior and politics and how they influence the practice of medicine.

Doctors, Featured, Health Policy, Healthcare Reform, Medicine, What's New

America Out Loud PULSE: Health Cost Sharing Ministries – An Alternative to Health Insurance

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From my America Out Loud Pulse podcast with Katy Talento –   https://www.americaoutloud.com/health-sharing-ministries-an-alternative-to-health-insurance/

Health insurance as we know it is a relatively new phenomenon. Accident insurance existed in the United States since the mid 1800s, becoming more prevalent as the industrial revolution brought more on the job injuries. Companies had onsite doctors who were paid by deductions from the employees’ pay checks.

In 1929 a group of teachers at Baylor University in Dallas formed the first modern group plan by contracting with a nearby hospital to receive care in return for a monthly fee. Under this “hospitalization policy” teachers would get two weeks of paid hospital care for 50 cents a month. This benefited both parties. The patients had relief from high hospital bills they were unable to pay and the hospital wouldn’t lose money on unpaid bills. With the onset of the Great Depression in the 1930s, many other hospitals followed the model of the Baylor Plan, and medical insurance became much more widespread. By 1963 more than 900 companies were offering health insurance products.

During World War II, the federal government imposed wage freezes. Consequently, employers were unable to attract workers through higher wages, health insurance was offered as an benefit and became linked with employment to this day. Over the years, the insurance products became more comprehensive and covered the cost of routine, preventive, and emergency health care procedures, and most prescription drugs. During the 1980s and 1990s, footing the bill for policies covering everything under the sun, along with diagnostic and treatment advances, the cost of health care rose rapidly. To save money, and the majority of employer-sponsored group insurance plans switched from “fee-for-service” plans to the cheaper managed care plans.

Even with the managed care model, according to Kaiser Family Foundation data, about half of U.S. adults say they have difficulty affording health care costs. About 40 percent of U.S. adults say they have delayed or gone without medical care in the last year due to cost. The Affordable Care Act so far has done nothing to contain medical costs or make health insurance more affordable for everyone.

Health sharing ministries have been an alternative to health insurance. Recently, more and more people are taking advantage of this option to pay for medical services. The concept of health sharing ministries is reminiscent of the early English-speaking American settlers who addressed social concerns through self-reliance and voluntarism.

My guest today will fill us in on the nuts and bolts of this type of medical cost sharing.

 

Doctors, Featured, Health Policy, Healthcare Reform, Medicine, What's New

America Out Loud PULSE: Direct Primary Care: Where Physicians Put Patients First

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From my  America Out Loud Pulse podcast with Dr. Kim Corba – https://www.americaoutloud.com/direct-primary-care-where-physicians-put-patients-first/

Many consider medical care in the United States as the best in the world. Potentates from multiple and disparate countries come here for treatment. On the other hand, efforts to create a “healthcare system” have been a failure. While necessary for major medical expenses, the health insurance industry has drained the life out of the patient-physician relationship and the pocketbooks of patients. Despite the promises of the ACA, many patients do not have access to good medical care and a stable relationship with their doctor.

Five for-profit insurers now control 43 percent of the market, more than 60 percent of community hospitals belong to a health system, and less than half of physicians own part of a private practice. Many of these former private practitioners became corporate employees and another cog in the hamster wheel of 7-minute patient visits.

Some physicians have taken another route. More and more are leaving their insurance-based private practice and taking the leap into a cash-based practice. One such model is called Direct Primary Care (DPC). The key word is “care.” With DPC physician’s office is dedicated to patients, not health insurers – where patients are a bean counter’s data points. Under the DPC model, physicians can maintain a small, independent practice with less time on paper (computer) work and more time with their patients. In addition to time and individual attention, patients can rest assured that their private medical information stays within the walls of the doctor’s office.

We can stop the corporate-government takeover of medicine. We can seek out private practices where you are treated as an individual human being, not an income generator.

My guest tonight will discuss her Direct Primary Care practice. And we will delve into the particular relevance of a strong, private patient-physician relationship as Covid lockdowns, masking, and economic issues take their toll on our mental health.

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

More Red Tape Does Not Provide Better Health Care

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The Affordable Care Act’s hundreds of pages of mandates and thousands of pages of regulations could not provide what we Americans want: more choice, lower costs, and better care. The premiums and deductibles continue to rise. Patients are finding fewer “in network” doctors, leading to surprise medical bills. 

While some were busy pontificating about how much they care about patients, the President was busy working to make our medical care great again. There was a time when there were hundreds of insurers offering a variety of individual health insurance plans tailored to an individual’s needs. Just as we do with the variety of products that we buy every day, we can use our purchasing power to compare costs and value. This includes using our tax-free health savings accounts to pay to day-to-day medical care out of pocket. 

Back in 2017, the President started the road to put patients in charge of their own money and medical care. After ensuring that the ACA’s mandate tax was repealed, his administration increased insurance options that cost up to 60 percent less that the lowest price ACA plans. The President launched a rule to broaden the availability of association health plans for small businesses which are projected to cover up to 400,000 previously uninsured individuals for on average 30 percent less cost. He expanded health reimbursement arrangements that allow consumers to use tax-free dollars to pay for some medical costs. 

The President signed a law banning “gag clauses” that prevented pharmacists from telling customers when it would cost less to directly purchase a medication, rather than through their health insurance. He continues to make rules to lower prescription drug prices in federal programs.

Speaking of caring about real patients, the President expanded choice to our veterans by allowing them to seek care from private physicians. And after many years of work by advocates, the President signed the Right to Try Act so critically ill patients could have access to life-saving treatment. The President’s latest executive order promises that he will not sign any law that does not cover patients with pre-existing conditions.

Medical care is one of the most personal aspects of our lives. A government bureaucracy by its very nature is one size fits all—or more realistically, one size fits none. The ACA has shown us that more government control is not the answer. It’s time for the President’s plan rooted in patient control. 

Culture & Society, Healthcare Reform, Medicare, Medicine, Op-eds, What's New

Obesity: America’s Self-inflicted Preexisting Condition

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Consuming too many potato latkes and Christmas cookies has left its mark on our waistlines. Unfortunately for Americans and their medical care, the seasonal overeating seems to last all year. Indeed, the American Medical Association has declared that obesity is a disease.

It may be more accurate to describe obesity as a contributor to certain diseases. Obesity raises the risk of premature death, heart disease, high blood pressure, stroke, type 2 diabetes, gallbladder disease, breathing problems, certain cancers, and osteoarthritis. Certainly, obesity can result from certain uncommon diseases and hereditary factors, but most people become obese simply because they eat too many unhealthy foods and do not exercise.

At its last count, the Centers for Disease Control and Prevention (CDC) estimated that 40 percent of U.S. adults age 20 and over, 21 percent of teens, and 14 percent of preschoolers are obese. A December 2019 study that analyzed 26 years of body mass index (BMI [the relation of weight to height]) data concluded that half of U.S. adults will be obese (BMI>25) by 2030. Some 25 percent will be severely obese (BMI>35). Moreover, less than 5 percent of adults get the recommended 30 minutes a day of physical activity. And even when people living in “food deserts” were presented with healthy options, only 10 percent changed their evil eating ways.

According to the CDC’s last comprehensive analysis, the annual medical cost of obesity in the United States to Medicare, Medicaid, and private insurers was $147 billion in 2008. And the medical costs for obese people were $1,429 higher than those of healthier weights.

The saddest development is the cultural normalization of obesity with lingerie models, singers, and television shows celebrating fatness. Do we high-five people with other lifestyle related conditions such as alcoholism, emphysema, or coronary artery disease? Of course not.

The obese are easy targets for drug company peddlers of quick fixes or “providers” who want to extract money from third-party payors. U.S. pharmaceutical companies spent $6.1 billion on direct-to-consumer prescription drug advertising in 2017. Many ads feature chunky type 2 diabetics happily frolicking about, thanks to the drug company’s magic pill. The ads might as well say, “pass the chocolate cupcakes with statin sprinkles drizzled with insulin.” We all know the prescription of eating less and exercising more is free of charge.

Alas, we are losing the battle of the bulge. A recent study found that participants failed to lose weight despite reporting that they were exercising and watching their diet. The authors concluded that “many of [the participants] might not have actually implemented weight loss strategies or applied a minimal level of effort, which yielded unsatisfactory results.”

While politicians debate the merits of spending trillions of dollars on government-sponsored medical care, a correctable source of high medical costs is hiding in plain sight. Irrespective of who pays for medical care, rational economic decisions must be made. The Affordable Care Act (ACA) waved a magic wand and removed preexisting conditions from the underwriting equation when calculating premiums. A sick person and a healthy person of the same age could purchase insurance at the same price. Consequently, the ACA doubled the costs for people who made the effort to take care of themselves.

The ACA did allow a “tobacco surcharge” of up to 50 percent more for premiums. Why not an obesity surcharge? This would provide an incentive for consumers to take obesity seriously. Additionally, health-conscious persons would not have to pay for the bad habits of others through taxes to fund government health insurance programs or through higher private insurance premiums.

Those who are stricken with illnesses through no fault of their own need a path to affordable medical care. A good start for lowering costs would be eliminating costly middlemen by encouraging consumers to pay directly for day-to-day medical expenses. Expanding contribution limits and eligible uses of Health Savings Accounts would help pay for the more reasonably priced direct-pay surgery and other alternatives to insurance like direct primary care.

With regard to insurance, we need a revival of competition in the insurance market with multiple products and carriers. Once again, single men could opt to decline pregnancy coverage. We need to restore the pre-ACA availability of low-cost catastrophic (major medical) insurance policies to all ages. Even before mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the large majority of insurers offered guaranteed renewable policies. Here, assuming timely payment of premiums, at the end of the policy period the insurer must renew coverage regardless of the health of the insured. Naturally, this valuable feature costs more but provides consumers with a strong incentive not let the insurance lapse.

Let’s confront the elephant in the room. Healthcare policy should promote personal responsibility, rather than encourage free riders. In America we are free to overeat and under-exercise but we have no right to make innocent bystanders pay for the consequences.

Culture & Society, Healthcare Reform, Medical Ethics, Medicare, Medicine, Op-eds

Data Mining, Artificial Intelligence, and Angels of Death

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By Marilyn M. Singleton, MD, JD

Google is universally well known as a search and advertising company. Now Google is tapping into the $3.5 trillion healthcare market. To compete with the Apple Watch, Google acquired FitBit, the wearable exercise, heart rate, and sleep tracking device. Data is king.

Voluntarily worn fitness tracking devices are one thing, but Google has entered the realm of the brave new world.A government inquiry has brought to light Google’s “Nightingale Project” that collected private medical data from Ascension Health’s 2,600 sites of care across 20 states and D.C., unbeknownst to the patients. Dozens of Google employees had access to the data which included lab results, physician diagnoses, hospitalization records, and health histories, complete with patient names and dates of birth. Google claims that the project complies with the Health Insurance Portability And Accountability Act (HIPAA) because it is a qualified business associate of Ascension Health. And unlike the ads for socks that appear on your computer a nanosecond after you purchased some tennis shoes, Google promises that the data won’t be combined with consumer data. Fat chance.

Amazon, which already knows our every thought, was not satisfied with merely creating software that can read medical records. Now they’ve created Transcribe Medical, a system that transcribes confidential patient-doctor conversations and uploads them directly into the electronic health record. Doctors would relinquish all control over “private” patient records. Google also has been working on its own automatic speech recognition “digital scribe” to upload multiple speaker conversations.

Not only is there a problem with inaccuracies that could lead to a patient receiving the wrong treatment, but we all know the ubiquitous problem of hacking—even in the Department of Defense and the federal Office of Personnel Management.

Disturbingly, certain circles oohed and aahed over the revelation that Google, using electronic health records (EHR), created an artificial intelligence program that could predict death better than doctors. Fortunately for humanity, many others found the thought of leaving doctors out of the equation horrifying. The cheerleaders crowed that it would decrease work for the doctors; they wouldn’t have to waste their time going through those pesky medical records to arrive at a conclusion. Using an artificial neural network to predict the death of a human being is a far cry from having a computer interpret an inanimate x-ray who is not a daughter, mother, sister, wife, or grandmother.

 If you put it all together, it adds up to a death panel of one. Google’s software would decide that there is not a high likelihood of walking out of the hospital, no treatment would be given. We are becoming witness to the devolution of humanity.

Moreover, the government is incentivizing workforce development in palliative care through the Palliative Care and Hospice Education and Training Act. Perhaps this is why the hospice team seems to greet the patient at the hospital door. Of note, once a person has signed on to the Medicare hospice program, Medicare will not pay for any curative treatment or medications. Medicare will not pay for an emergency room visit unless the hospice team arranged it or someone decides it is not related to the hospice diagnosis.

The number of hospice agencies participating in the Medicare program nearly doubled between 2000 and 2016, for a total of some 4,382 providers. In 2000, about 30 percent of hospice agencies were for-profit, compared to about 67 percent in 2016. In that same period, Medicare payments grew from $3 billion to $16.8 billion.

Hospice care is lucrative. The minimum Medicare payment is $196 per day regardless of the quantity or quality of services provided on that day. A July 2019 report from the Office of Inspector General for the Department of Health and Human Services found that more than 80 percent of end-of-life facilities in the United States had at least one deficiency, and nearly 20 percent were poor performers with serious problems that jeopardized patient health and safety. It seems the compassionate medical service to care for suffering patients has turned into a heartless cash cow.

Is this what we want for our loved ones and eventually, ourselves? Medicare for All promises every type of medical care under the sun, including long-term care. Long-term care is expensive and if done properly, labor intensive. What better way to save money than to promote a computer program that convinces doctors that the patient is going to die no matter what they do. So the hospital tells the family that treatment or home care will drain their finances. For what? I’ll tell you for what. My parents died at home only after they were tired of doctors and ready to go. They strolled into heaven. They were not shoved in with a giant government backhoe.

Bio: Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School.  Dr. Singleton completed 2 years of Surgery residency at UCSF, then her Anesthesia residency at Harvard’s Beth Israel Hospital. While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law.  She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers. 

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