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Health Policy, Healthcare Reform, Medicare, Medicine, Op-eds, Socialized Medicine

The High Cost of Free Care

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By Marilyn M. Singleton, MD, JD.,

When I signed in for my yearly mammogram the receptionist announced with a wry smile, “No co-pay this time, it’s free!” We both knew that it really wasn’t free.

To understand whether free means free, let’s look at Medicare as an example. Medicare has four parts. Part A (“hospital”) covers hospital admissions, post-hospitalization short-term skilled nursing, and hospice. Part B (“medical”) covers outpatient medical services such as physician visits, lab tests, and outpatient surgery. Parts A and B are called traditional Medicare. Part C (“Medicare Advantage”) is private HMOs. Part D is prescription drug coverage. Technically, all parts are optional.

Medicare is costly before and after we enroll. We pay for Part A through a 2.9 percent tax on earnings, half of which is paid by employers. Thus, an average worker earning $43,500 per year generates $105 every month for the promise of hospital insurance benefits beginning up to 45 years in the future.

Importantly, Part A is mandatory for those eligible for Medicare who receive Social Security payments. If beneficiaries want to opt out of Part A, they must forfeit all of their Social Security payments.

Those ineligible for premium-free Part A because they did not pay the Medicare tax during their working years may purchase it (at a cost of $426/month in 2014), but if they do not do so immediately, they are penalized. Their monthly premium can increase 10 percent and they must pay the higher premium for twice the number of years they could have had Part A, but did not enroll.

Just as with most private insurance, Medicare Part A has out-of-pocket expenses. The 2014 Medicare Part A inpatient hospital deductible is $1,216 per hospitalization and the co-pay for hospitalizations over 60 days is $304 per day.  There is no out-of-pocket limit.

General tax revenues finance 72 percent of Part B; beneficiary premiums finance the remainder. The government deducts a minimum of $104.90 for Medicare Part B from the monthly Social Security payments of everyone enrolled in either Part B or Medicare Advantage.

High-income earners (greater than $85,000/individuals, $170,000/couples yearly) pay progressively higher Part B premiums up to $335.70 per month. Part B has an annual deductible of $147.00 and co-pays of 20 percent, and a lifetime penalty for late enrollment. There is no out-of-pocket limit.

Part C Advantage plans, started in 1997 as “Medicare+Choice”, are sold by private insurance companies and have at least the same Part A and B coverage as traditional Medicare. Their advantage is that the monthly private insurance premium covers prescription drugs and more services than traditional Medicare (e.g., optometry, hearing tests, dental plan options), with low or no co-pays.

They also have limits on out-of-pocket expenses.  With traditional Medicare, to avoid unlimited out-of-pocket expenses, beneficiaries must purchase a private government-approved supplemental insurance (“Medi-gap”) policy with an estimated annual cost of $6,200.

Part D is largely (74 percent) financed through general revenues. Beneficiary premiums and state payments through Medicaid make up the remainder. High-earning beneficiaries pay a larger share of the cost of Part D coverage.

The Affordable Care Act cut $156 billion from Medicare Advantage. My 2014 Advantage plan’s out-of-pocket maximum rose from $3,400 to $5,900. Lab and X-ray costs rose from $30 to $45. Was this to pay for the “free” tests for traditional Medicare?

The next time someone rails about evil insurers and the health exchanges’ surprisingly high premiums and co-pays, concluding that “Medicare for all” is the solution, enlighten them with facts. Traditional Medicare covers only 64 percent of healthcare expenses for noninstitutionalized beneficiaries, according to the MedPAC Data Book, 2013.

Medicare pays hospitals an average of 10 percent below their costs of caring for patients, states the American Hospital Association in its Underpayment by Medicare and Medicaid Fact Sheet, December, 2010.

If a physician accepts out-of-pocket payment from Medicare patients who want to pay, for example, for extra time with their doctor during a Medicare-covered visit, the physician is forced from the Medicare program for two years. Explain that ObamaCare’s individual mandate-tax is trivial compared to the government’s holding Social Security benefits hostage to participation in socialized medicine.

Free is never free. Medicare is a transfer system from younger generations’ incomes to older generations’ healthcare. “Medicare for all” would force our youth into the same costly and bankrupt system that is already denying care.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Doctors, Health Policy, Healthcare Reform, Medicine, Op-eds, Socialized Medicine

ObamaCare: Sold to the Highest Bidder

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By Marilyn M. Singleton, MD, JD.,

The Affordable Care Act is like the television show Storage Wars, where unclaimed items in storage lockers are auctioned off after a quick peek through the door. People bid top dollar and hope for the best. Some find a goldmine, but the unseasoned bidders usually receive a Pandora’s Box.

Let’s look at some of the winners. The Center for Public Policy, a non-partisan public interest think tank in Washington D.C., estimated that $120 million was spent lobbying for health reform. Pharmaceutical Researchers and Manufacturers of America (PhRMA) alone spent $26 million lobbying for Obamacare in 2009. And PhRMA has spent well over $100 million on ad campaigns promoting healthcare reform legislation.

Upon passage of the bill, the stocks of some of the largest health insurers, including Cigna, UnitedHealth Group, WellPoint,and Aetna stocks climbed. Major makers of electronic health records (EHR) systems lobbied hard, locking out smaller competitors.

Chicago-based Allscripts Healthcare Solutions former CEO Glen Tullman, who had served as health technology adviser to Obama’s presidential campaign in 2008, made more than $200,000 in contributions to the campaign, and was frequent guest at the White House during 2009.

With some nudging from the Stimulus mandate for EHRs, annual sales of Allscripts more than doubled from $548 million in 2009 to $1.44 billion in 2012. Cerner, another software purveyor, spent $400,000 lobbying for EHR. During the same three-year period, sales rose 60 percent.

Of course, AARP’s CEO, Barry Rand, wrote that the ACA was “vital” for the nation’s seniors. This makes no sense when the ACA in fact cut a half a billion dollars from the popular Medicare Advantage program. It seems the ACA’s passage was vital to AARP’s insurance Medi-gap insurance products – which people with Medicare Advantage do not need.

The presumptive owners of the mystery storage locker – Congress – can change the contents at will. Congress, in a moment of bipartisan backbone or populist pandering, voted that their staff would be on the Exchange. Under the ACA, if an employee purchases a health plan through the Exchange, the employee will lose the employer contribution (if any) to any health plan.

When the chips were down as the moment of truth neared, Congress made a little adjustment: their staffers will keep their employer contributions of $5,000 to $11,000 – far and above those of ordinary Americans.

For example, a single person in Washington, D.C., earning $35,000 per year (an average staffer’s salary) can find a Silver plan unsubsidized annual premium of $2,166. This everyday American is not eligible to receive a government tax credit subsidy, and can have up to $6,350 in co-pays and deductibles (not including the premium).

So we the proletariat get containers of empty promises. We all remember, “if you like your current health plan, you can keep it.” But the CBO estimates that up to 8 million people will lose their employer-sponsored insurance.

We get corporatized medicine, more bureaucracy, less choice, more likelihood of seeing a mid-level practitioner rather than a physician, shorter office visits, markedly higher premiums for young men that pay for those “free” preventive services, no catastrophic/major medical plan option unless you are under 30 years old, more IRS snooping, work hours decreased to 29 hours a week to avoid the threshold requiring a business to provide health insurance, risk of exposure of private medical and financial information, unelected bureaucrats making unilateral decisions by non-medical personnel, unvetted government customer service navigators who are privy to our personal financial information, and predictions of increased emergency room use because of the increased number of Medicaid patients who historically use the ER more due to the shortage of primary care physicians.

Our esteemed public servants claim to be advancing good government but are instead engaging all the while in cronyism to our detriment. We are on a slow descent into tyranny and dependence on government. We still have our voices.

Insist that medical care be about you. Demand that medical care remain between you and your doctor – not the government’s highest bidder.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Culture & Society, Health Policy, Healthcare Reform, Medicine, Op-eds, Politics, Socialized Medicine

ObamaCare Is About Your Money, Not Your Health

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By Marilyn M. Singleton, M.D., J.D.,

“Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly, and applying all the wrong remedies.” Groucho Marx

The politics of selling the Affordable Care Act (ACA) focuses on promising health and wellness. Somehow, having “coverage” is supposed to get you to a primary care doctor, who will keep you healthy. And if he doesn’t, he will be held accountable by not being paid.

The fact is that “healthcare reform” is not going to cure America’s health problems.

Physicians, think tanks, and politicians are pointing out a myriad of problems with ACA. But most of them miss the main point, which starts with calling it “healthcare reform.” The term, and the conversation about it, conflates health care and medical care. But they are not the same thing. Individuals are in charge of their own health care. Physicians provide medical care to those who become sick.

Health reform begins with making it clear that individuals’ health is in their own hands. The relationship between personal behavior and health is clear. Almost all of the illnesses that we can prevent are related to smoking, over-eating, lack of exercise, alcohol or drug abuse, high-risk behavior, or too much sun exposure.

According to the CDC, 19 percent of all U.S. adults (43.8 million people) smoke tobacco. Almost one third of adults living below the poverty line smoke. Adverse effects include heart and vascular disease, stroke, emphysema, bronchitis, and cancer (lung, oral, esophageal, and likely bladder, kidney, and pancreas). Smoking tobacco is responsible for almost $200 billion in lost productivity and medical care expenditures per year.

Under ACA, doctors will check a box saying they asked about smoking and counseled people to quit. But the decision is up to the patient.

One third of American adults and 17 percent of children are obese. Consequences include fatty liver disease, type 2 diabetes, heart disease, high blood pressure, stroke, gallbladder disease, osteoarthritis, breathing problems, sleep apnea, pregnancy complications, and increased surgical risk. In 2011, the estimated annual medical care costs of obesity-related illness were nearly $200 billion, or 21 percent of annual medical spending in the United States.

Such costs are expected to rise if we allow today’s obese children to grow into obese adults. Obesity must not become the new normal. Indeed, a recent study concluded that since black women are more likely than white women to be satisfied with their weight and have less social pressure to lose weight, merely maintaining their current level of obesity was a success!

Prevention of obesity occurs at home: in the kitchen, at the dinner table, and while shopping. Not in the doctor’s office.

One-fourth of American adults don’t participate in any physical activities. Exercise can lower the risk of heart disease, stroke, dementia, colon cancer, breast cancer in post-menopausal women, and endometrial cancer.

More than half of all cancers related to lifestyle factors: 25-30 percent to tobacco, and 30-35 percent to obesity, physical inactivity, and poor nutrition. Certain cancers are related to sexually transmitted diseases such as hepatitis B, human papillomavirus infections (genital warts), or human immunodeficiency virus (HIV). Many skin cancers are caused by sun exposure.

We will have healthier people only if patients value their own health as much as good doctors do. And doctors must practice what they preach—who is going to listen to an obese doctor or nurse?

Some patients place a higher priority on enjoying risky behavior than on their health. ACA will not make them healthy. It only shields them somewhat from the consequences of their actions by forcing people who do take care of their health to share their costs.

Government cannot make us healthy, not even by trying to prohibit overindulgence or bad habits. Certainly, ACA’s massive new regulations, erosion of privacy, and higher taxes don’t bring health. But ACA’s subsidies compound our unhealthy reliance on government.

ACA redistributes the money flowing through the system. But your health care is still your responsibility. We can make others share the health plan premiums, but the pain and suffering are still the patients’ to endure.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Culture & Society, Health Policy, Healthcare Reform, Medicare, Medicine, Op-eds

Obama the Emperor Has No Clue

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The Emperor Has No Clue

By Marilyn M. Singleton, M.D., J.D.,

When President Obama hawks the wonders of the misnamed Patient Protection and Affordable Care Act, I’m reminded of those “As Seen on TV” products.

True believers ridiculed critics of the Independent Payment Advisory Board and its unchecked power to ration health care. They were impressed by the $575 billion cut to Medicare, although lower payments lead physicians to accept fewer Medicare patients. They cheered because 11 million Americans will be added to the Medicaid rolls over the next ten years.

While Medicaid looks like is a good deal with its low co-pays, provider payments are so low that only one-third of physicians accept new Medicaid patients.

True believers scoffed at claims of loss of privacy. After the NSA snooping revelations, a Pew survey revealed that 70 percent of Americans believe the government is using data for purposes other than fighting terrorism.

Not only could unethical employees misuse health and financial information, the health “Data Hub” can be shared among seven federal agencies for ill-defined “routine uses.” According to a former HHS general counsel, the federal government’s computer program for insurance exchanges lacks privacy safeguards and could expose applicants to identity theft.

President Obama has repeatedly promised that “if you like your health care plan, you can keep it.” Even his Praetorian Guard has now defected. The National Treasury Employees Union—which represents the IRS folks who are ultimately in charge of ObamaCare—does not want its members to be “pushed out” of the Federal Employees Health Benefits Program and into the insurance exchanges.

Candidate Obama promised: “If you already have health insurance, the only thing that will change for you under this plan is that you will spend less on premiums.” Au contraire. Insurance premiums have risen an average of 30 percent since ObamaCare’s enactment. In Orange County, California, premiums for a 25-year-old in good health will rise by 95 percent.

Insurance will cost less for the lucky 26 million Americans who are eligible for health insurance exchange subsidies that can pay more than half the cost of policies. Subsidies—paid directly to insurance companies—are available for those with incomes from 138% ($15,415 for individuals; $29,326 for a family of four) to 400% ($45,960 for individuals; $94,200 for a family of four) of the poverty level.

The ACA was to have employers report whether they were offering employees “affordable” care. Now with the employer mandate delayed, exchanges may accept applicants’ statements that they qualify for subsidies without further verification.

Another wrinkle in the program could limit access to care. If enrollees pay one month’s premium, exchanges must provide a grace period of three consecutive months during which coverage cannot be terminated. However, insurers are only required to pay claims during the first 30 days of the grace period.

Thus, patients with valid insurance cards in hand can seek treatment at a doctor’s office on day 31 through 90 of the grace period. When the physician in good faith submits a claim to the insurer, the claim can be denied. Although the physician can bill the patient, realistically, many patients simply will not pay.

Chalk up another win for the insurance industry, which has off-loaded two-thirds of the risk of nonpayment onto physicians.

ObamaCare ignores human nature. Despite the claimed efforts to have patients adopt behaviors that help control costs, two recent studies in the journal Health Affairs demonstrate that people do not change merely because you tell them to.

Uninsured and Medicaid patients reported that they preferred care in an emergency room to a doctor’s office. For Medicaid patients the financial cost of an ER visit and the physician’s office were similar, but the ER was more convenient. The uninsured reported the cost of office care was higher because of additional testing or specialist visits.

Another study revealed that a majority of patients didn’t want costs to enter into their medical decisions. Some participants even chose expensive care “out of spite” because of antagonism toward their insurance company.

Hucksterism cannot overcome reality. Government efforts at mass control are doomed.

Successful reform requires innovation, maximization of personal engagement with medical treatment, and minimization of third party involvement. ObamaCare does the opposite.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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

Physicians Victims of Body Snatcher Invasion

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Invasion of the Body Snatchers: Where Have All the Doctors Gone?

By author/contributor Marilyn M. Singleton, M.D., J.D.,

After a 20-hour encounter beginning at 9:30 p.m. in the emergency room at my health plan’s hospital, I honestly don’t know what it means to be a doctor any more. When my husband who had a history of bilateral pulmonary emboli developed chest pain, I thought it prudent to go to the emergency room.

We were triaged to the hallway, as there were no rooms. There was an empty room a few feet away, but it had dirty dressings on the floor from the last patient.

After seeing our admitting physician in our hallway “room,” I had high hopes. She had a smile and a white coat over her scrubs and had a note pad and pen. She listened to us.

When my husband offered that I was a physician, she asked what kind and asked what my concerns were. (The next day, she sent my husband an email thanking him for being a good patient, my input, and that she appreciated that we were doing our best to stay healthy.)

Then we were left to the nursing staff and two shifts of physicians who seemed to think they were very special, like stars on a television show called “ER.”

In the charting room, people in scrub attire or T-shirts entered data at more than 20 computer screens. This scene reminded me of a telemarketing sales boiler room. And this fit the level of caring of most of the staff.

I told the evening shift nurse that the pulse oximeter was not working. As an anesthesiologist, I am familiar with the machine. She said that it had been broken all day. My husband, an engineer, asked, smiling, “Then why did you put it on my finger?” She said they were supposed to put it on—and left it there.

Another nurse wanted to put my husband in the dirty room since it was “just for a x-ray.” I advised that there were dirty dressings on the floor and the last patient could have had an infection. He acquiesced and let us go to the cast room for the x-ray.

One of our day nurses kept his back to the bed during his questioning, focusing more on the computer than the patient. He wore a red T-shirt that said “emergency room” on it – the kind you get at a trade show.

He spoke in jargon and abbreviations, and my husband constantly had to ask what he meant. Are they in the new text-talk generation where URROFL (you are rolling on the floor, laughing), or are they showing how superior they are?

Are these the people to whom the authors of the Affordable Care Act want us to cede our profession?

My husband was to have a treadmill test at 9:45 a.m. By 6:00 a.m., after 9 hours without an IV or eating or drinking, I asked could he have anything to eat or drink—even water. The doctor said “no” without thinking.

I said it seemed counterintuitive to have a low blood sugar and dehydration while doing an exercise stress test. He handed us the treadmill instructions. I read aloud the instruction stating that the patient is to have a light meal up to three hours before the test.

Instead of owning that he misspoke, he tried to equate a treadmill test to a general anesthetic where patients should have an empty stomach. At the test my husband was offered water.

When discharge time mercifully arrived, my husband asked our discharging physician about co-pays and whether we needed to pay on our way out. He dismissively said he didn’t know—and didn’t need to say that he didn’t care. He gave the impression that he was content to do his shift and go off to Pilates class.

All but three of the 18 “health professionals” with whom we were in contact in the emergency room were unprofessional and resentful of questions. This appears to be the future of “healthcare reform.”

That is why physicians who still believe that medicine is a calling must resist. They must assert leadership, and not simply follow the flock of sheep.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Health Policy, Healthcare Reform, Law, Medical Ethics, Medicare, Medicine

The Medicare Bundlers and Bunglers Are Coming!

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Medicare: The Bundlers Are Coming! The Bunglers Are Coming!

Author/contributor:  Marilyn M. Singleton, M.D., J.D.

My long-time self-paying patient opined that the end of fee-for-service payments (payment for what you get) was imminent. I lightheartedly asked her how physicians would be paid. Would they be housed in military barracks and given vouchers for necessaries?

Perhaps she read section 3023 of the “Patient Protection and Affordable Care Act” (PPACA or “ObamaCare”), the National Pilot Program on Payment Bundling, which applies to certain Medicare beneficiaries.

The program’s stated goals are to improve access to care, quality, coordination, and efficiency (i.e., reduce costs) of services. Pilot programs, which started this year, will be conducted for 5 years, or longer if extension results in improved quality and reduced spending.

An earlier “pilot program” on payment by diagnosis (DRG or diagnosis related group), regardless of what the patient did or did not receive, simply became national practice in 1983 without looking at the results. Then there’s the HMO method of payment by the head (capitation), regardless of care or lack thereof. How will payment by the bundle be different?

A bundle or an episode of care includes the three days prior to admission to the hospital, the hospital stay, and 30 days (not 31 days) after discharge from the hospital. It comprises “applicable services”: acute inpatient services, all physicians’ services in and outside the hospital, outpatient and emergency room services, all post-acute care services (e.g., skilled nursing facility, rehab, home health), and other services the Secretary deems appropriate.

The amount of payment will depend partly on “quality” measures developed by the Secretary in consultation with the Agency for Healthcare Research and Quality. The measures include: functional status improvement, reducing rates of avoidable hospital readmissions, rates of discharge to the community, rates of admission to an emergency room after hospitalization, incidence of health care acquired infections, efficiency measures, measures of patient-centeredness of care, and measures of patient perception of care.

What do these things mean? Does “functional status” mean ability to perform ADLs (activities of daily living)? What if patient is so disabled that his ability to do ADLs can’t improve? What if he still needs a lift to get to the toilet, but can now beat his grandson at gin rummy? Does that count as an improvement?

What about the ultimate measure of functional status—being alive rather than dead? Might a hospital’s “efficiency” rating be better if the patient dies, instead of being readmitted or acquiring an infection?

The bundle will be characterized by a code from the soon-to-be-required U.S. ICD-10CM system. This International Classification of Diseases—Clinical Modification system is based on the 1992 World Health Organization ICD-10 codes. It increases the number of diagnostic codes in the current ICD-9 system from 17,000 to 68,000, including different codes for right or left side. Providers will have to be much more specific in their coding.

Even though providers will have to do much more work to code and do other documentation tasks, the bundled payments cannot be more than what would otherwise be paid for the beneficiary’s care. It is not clear who all will have to share the payment—perhaps the hospitalist, perhaps the patient’s own physician, along with all the team members needed to provide whatever the Secretary deems appropriate.

The changes in “payment methodology” may be seen as a power struggle. Rick Mayes wrote in 2007:

For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry.

Medicare’s new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it—a power that providers had successfully accumulated for more than half a century.

Some claim that bundling is a way to save Medicare, previous measures including the Sustainable Growth Rate (SGR) fee cuts having failed. In reality, it simply adds to the opportunity for bureaucratic bungling, while moving payment still further away from the value of care to real live patients.

Instead of more complex formulas, we need more transparency so that beneficiaries can make their own informed decisions about their individualized medical care, without interference from bureaucrats and the special interest groups that feed on the current muddled system.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Culture & Society, Healthcare Reform, Medical Ethics, Politics

A Black Physician Reflects on the 2013 Inaugural Address

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Author/contributor:  Marilyn M. Singleton, M.D., J.D. 

Despite the Martin Luther King, Jr., holiday, many of us were too busy seeing patients to hear President Obama’s second inaugural address. It was less painful to read the transcript.

“What binds this nation together is not the color of our skin or the tenets of our faith or the origins of our names,” he stated. Then let’s end the government’s obsession with African-Americans, Hispanic-Americans, and Asian-Americans (but never European-Americans). We are all Americans. I feel some moral authority and passion on this subject as a black American whose family moved here from England in the 1600s. I am a full-blooded American!

I can’t bear to hear one more person say, “I’m so glad we have an African-American President.” How ironic: Martin Luther King, Jr., urged that we judge people by the content of their character, not the color of their skin.

The head of the Congressional Black Caucus admitted that the CBC treats the President with a “deference” not accorded to a white President, and that the CBC is “hesitant” to criticize the current President. “With 14 percent unemployment [versus 6.9 percent for whites], if we had a white president, we’d be marching around the White House.”

This Administration and/or its tools use race as a crutch when facing legitimate criticism, for example Susan Rice’s willful or incompetent misleading of Americans about the Benghazi deaths. Rep. Jim Clyburn said calling Susan Rice “unqualified” to be Secretary of State was a racist “code word.”

Curiously, “unqualified” was not a “code word” when used against Clarence Thomas in his Supreme Court hearings. It was noted that he was particularly unqualified because he had served on the D.C. Circuit for only one year and four months. God forbid we should raise the same question about Elena Kagan or Thurgood Marshall (whom Thomas replaced), who were never judges at all.

And what about the other Rice? Who can forget how a former Secretary of State, Dr. Condoleezza Rice, was maliciously attacked as a “house slave” in the Bush Administration?

We next learned that the “patriots of 1776 did not fight to replace the tyranny of a king with the privileges of a few, or the rule of the mob.” I guess President Obama and Nancy Pelosi are not part of the Spirit of ’76 since the Patient Protection and Affordable Care Act (ACA or “ObamaCare”) was rammed through Congress with a five-vote margin, 34 Democrats and all 178 Republicans voting against it.

Obama only had one open discussion session, breaking his campaign promise to have open negotiations on C-SPAN. Instead, Democrats in the White House and Congress made private, multibillion-dollar deals with hospitals, pharmaceutical companies, other special interests—and each other.

Moreover, said Obama, “Together we discovered that a free market only thrives when there are rules to ensure competition and fair play.” Rules are fine when the President makes them up along the way. ACA waivers come to mind.

“We must make the hard choices to reduce the cost of health care.” Now that we are learning how “reform” will increase costs, it is clear that naming it the Affordable Care Act was a marketing tool. The most bothersome aspect is that we don’t yet know the identity of the “choosers” who will decide whose care to ration or whose bank account to raid. It is very telling that Obama did not proudly extol the virtues of his signature legislation.

“We understand that outworn programs are inadequate to the needs of our time.” Then, Mr. President, encourage Harry Reid to act on congressional legislation that attempts to restructure Medicare and Social Security instead of deriding these efforts as throwing Granny off a cliff.

Sadly, a thread woven throughout the speech was that Obama will liberate us from our autonomous, free, yet nonetheless pathetic, unhappy existence. He asserted several times that only a select few were making it in America, and he was going to do something about that!

We can only hope that Dr. Martin Luther King, Jr., was right: “A lie cannot live.”

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Culture & Society, Doctors, Health Policy, Healthcare Reform, Medicine, Op-eds

Medicine and the Twilight Zone 2013: To Serve Man

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Author/contributor:  Marilyn M. Singleton, M.D., J.D. 

During a discussion on the future of health care, a clinician-turned-healthcare-executive told me that the way we “deliver health care” (not the same as “practicing medicine”) will change. It will be a “process”—a more mechanized one.

She spoke enthusiastically about the advantages, such as electronic health records. These can improve fraud detection in government programs with computerized cross-checking of services delivered and payments made. This of course misses a larger point. If we didn’t have enormous government programs, fraud would not be so easy to perpetrate.

It’s pretty hard to double-bill a patient when there is no middleman. Patients generally remember whether they were in the doctor’s office last month. A patient who was not in a coma would immediately let the doctor know that she did not have that colonoscopy.

The executive was not concerned about the erosion of privacy. These days, she said, all of our information is in the ether anyway. If you are a random person, no one cares about your information. She did admit that the revelation of some conditions such as AIDS could lead to discrimination.

The prospect that electronic enthusiasts don’t seem to see is that someone who is a “nobody” today could aspire to become a “somebody”—if it weren’t for that pesky counseling that now has her labeled as a mental defective. Let’s not forget that the government will get that information it labels as “preventive medicine,” such as the question about whether there is a gun in the house.

What if your patient is the wife of a law enforcement officer and tells the truth? Has she just made her husband a target of disgruntled perpetrators?

What concerns me most is Americans’ quiet acquiescence to the intrusive nature of many health regulations. Putting the best construction on it, the continuing explosion of heath care regulations may be motivated by a sincere desire to improve the health of every American. But might they be used as the tools of another agenda: to make us feel secure enough to let down our guard as we become ever more dependent on the federal government?

Disturbed by this conversation and by the outcome of the fiscal cliff bullying, I was glad to try to escape reality by watching the Twilight Zone New Year’s marathon. But what I saw was the episode in which some philanthropic aliens came to earth and promised to eradicate famine and war. The aliens became the earthlings’ new best friends; they invited humans to visit their planet and enjoy a life without worries.

The scientists managed to translate the title of a book the aliens brought with them: To Serve Man. The earthlings were now fully convinced that the aliens had our best interests at heart. Just as the last previously doubting Thomas was boarding the spaceship, his assistant frantically tries to get him to turn back, screaming that To Serve Man is the title  of a cookbook!

Rod Serling’s voiceover cautioned that we had gone from being the rulers of the planet [i.e., our medical practice] to an ingredient in someone’s soup.

Does this sound familiar?

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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