Direct Pay Practices Archives - Marilyn Singleton, MD JD

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

Obesity: America’s Self-inflicted Preexisting Condition

January 7, 2020 No Comments

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.

Doctors, Medicare, Medicine, Op-eds

Medical Costs Transparency: As Clear as Peanut Butter

October 23, 2019 No Comments

By Marilyn M. Singleton, MD, JD

What if purchasing medical products and services were like buying peanut butter? Grocery stores have several brands and varieties: smooth, chunky, old-fashioned, natural, organic, no added sugar, reduced fat, no-stir, and pre-mixed with jelly with clearly marked prices ranging from $1.75 for the store’s generic brand to $7 for the over-priced Yuppie brand. After carefully examining the labels, our shopper chose a 16-ounce, $5 jar of no-added-sugar peanut butter. She paid the cashier $5 for the peanut butter and went home.

If our shoppers were transported to the universe of medical billing with the $5 jar of peanut butter, the shopper with Medicare would pay $1.00 but her grandchild will be presented with a bill for $4. When the shopper with private health insurance attempts to pay, the cashier becomes unglued. The shopper cannot say whether she met her deductible or has a co-payment, and whether the brand of peanut butter is approved by the network. She really wants the peanut butter so she grabs the generic from the shelf and pays the $1.75. Our privately insured shopper was pleasantly surprised at the generic’s good taste and healthful ingredients, her wallet was happy for the cost savings, and she was glad not to have the middleman hassle.

Comparison shopping is one pillar of bringing sanity to the high cost of medical care, but the opacity of the pricing system for medical costs limits the value of posting list prices to encourage lower costs through shaming, competition, and choice. In addition to research and development, manufacturing, and distribution costs, drug costs are affected by additional layers of middlemen: pharmacy benefit managers (PBMs) and insurers. Using a “trade secret” process, PBMs negotiate discounts and rebates for private and government insurers. The money saved is supposed to go back to the government (taxpayers) or to insurers to lower premiums or otherwise benefit patients. PBMs typically are paid by a percentage of the rebate or discount off the list price. The higher the price, the bigger the rebate. Thus, the rebate system gives an incentive to raise list prices rather than placing the lowest-priced drug on the insurer’s formulary. (This same system is used by Group Purchasing Organizations (GPOs) for hospital product purchases.)

An analysis of the effect of California’s 2-year old drug price transparency law illustrates the complexity of pricing. Despite being compelled to post list prices, pharmaceutical companies raised the list price for wholesalers by a median of 25.8 percent but the data did not indicate the “price” that consumers actually paid. Moreover, with medical services and products the simple What the Market Will Bear (WTMWB) pricing method works because either the medication is essential (e.g., Epi-Pen®), has no alternative, is in short supply, or the medical consumer is not paying directly for the services.

Similarly, publishing hospital the charge description master (“chargemaster”). i.e., the standard industry price does not give consumers enough information to make a rational choice regarding elective medical services. The data necessary to make price comparisons depends on an individual’s circumstances. More relevant than the chargemaster price, a self-pay patient needs to know the lowest possible cash price. A patient with health insurance must know (1) whether the hospital is in the insurance network, (2) the price negotiated between the health care provider and insurer (including Medicare), (3) the amount and method of calculating cost-sharing, (4) the amount Medicare or other insurer will pay for services performed in a physician’s office in contrast to the hospital which tags on a “facility fee.”

Transparency is one tool for lowering costs through choice. As one of many studies on hospital consolidation noted, “The Sky’s the Limit” on prices where there is lack of competition. But the difficulties of achieving useful price transparency must not be a cue for the government to initiate bureaucratic band-aids. As we have seen with Obamacare, forcing insurers to pay more of the costs leads to higher premiums, deductibles, and/or co-pays.

Nor should the government impose price caps. President Nixon’s 1971 wage and price freeze brought product shortages—which we are already facing with certain drugs, including anesthetics and chemotherapy agents. If the government sticks to enforcing anti-trust laws, a competitive market will thrive. The court house door anti-trust settlement by Northern California’s Sutter Health sends a message to big hospital chains to stop using their market share to inflate prices or require insurers to join their networks on an all-or-nothing basis to prevent insurers from negotiating lower prices at individual hospitals.

If we can get to the point of direct exchange of money for goods and services and reserve health insurance for major expenses, we can see costs decrease just as we have seen with the Surgery Center of Oklahoma over the last 10 years.

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.

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

Jumping Into Medicare For All With Eyes Wide Shut

February 27, 2019 No Comments

by Marilyn M. Singleton, MD, JD

The unveiling of the ballyhooed House of Representatives Medicare for All Act of 2019 bill will be met with chants of “equal healthcare for all!” While the country will be forced into a government-run program, the limousine liberals and champagne socialists will keep their array of medical care choices — whether on or off the record.

A key feature of the Medicare-for-All bills is the elimination of private health insurance that duplicates benefits offered by the government. Given the coercive nature of the existing Medicare program, we should be very concerned. Medicare Part A (hospital insurance) 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 — including paying back any Social Security benefits received up to the time Part A was declined. So a “beneficiary” is punished for saving federal dollars by declining to be on the government healthcare dole.

Enrollment in Medicare Part B (all physician and most outpatient services) is not mandatory but beneficiaries are financially coerced to enroll. The standard 2019 Part B premium amount is $135.50 per month, progressing to $460.50 based on income. But if a beneficiary doesn’t sign up for Part B when first eligible, he must pay a lifelong penalty of 10 percent for each full 12-month period that he could have had Part B. So if the beneficiary waited 3 years before signing up, he would pay a 30 percent higher premium throughout his lifetime.

Medicare Part D (prescription drugs) also imposes penalties on those who do not sign up when eligible unless they are in a Medicare Part C/Medicare Advantage HMO that covers drugs. The lifetime penalty is not trivial: one percent per month of the average monthly premium (currently about $33) for all the months they were not signed up.

Will we be somehow punished if we do not want to enroll in the new government program? Will there be an “individual mandate” penalty? Hopefully we’ll know before the bill is passed and we can find out what’s in it.

Another troubling aspect of a new government health program is the lack of an articulated budget or cost controls. According to the Medicare Board of Trustees 2018 Report, Medicare’s Part A trust fund will be depleted in 2026, three years earlier than the 2017 projection. Our 2017 healthcare costs were $3.5 trillion with $1.2 trillion attributed to Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Apparently, financing would depend on monies earmarked for existing federal health programs, heavily taxing “the rich” and an unspecified increase in everyone’s taxes.

In addition to notoriously underestimated cost projections, Medicare underpayments to hospitals must be addressed. Hospitals receive 88 cents on the dollar from Medicare and 90 cents on the dollar from Medicaid for their expenditures on these patients, translating to reimbursements of $41.6 billion and $16.2 billion, respectively, below actual costs. Currently, hospitals make up the shortfall with higher payments from private insurance — which will no longer exist. Slashing oft maligned CEO salaries would be a drop in the bucket. Hospital workers — unionized or otherwise would not accept pay cuts.

So how will the inevitable funding shortfall be addressed? Private practitioners may be enticed by the promise of a steady stream of patients and income or strong-armed into submitting to lower reimbursement or by new licensing requirements. Of course, many of us remember being paid with IOUs from the California Medicaid program.

The promise of completely “free” medical care of every sort imaginable gives one pause. What happens when the money runs out? Because Medicare defines what care is reimbursable as “medically necessary,” the simple answer is to decrease covered services. But by then, the private health insurance industry would be decimated and our options limited.

Proponents of government-sponsored healthcare say people want it. But a 2019 Kaiser Family Foundation survey found that enthusiasm wanes when folks are told they would (1) lose their private insurance, and/or (2) pay more taxes and/or (3) have longer waits.

Direct pay independent physicians may be the salvation. Many Medicare patients are paying for direct primary care where a modest monthly fee direct to the physician guarantees full access to a physician, inexpensive medications and lab tests. Some specialists treating various chronic conditions such as diabetes also use this model to provide patients with timely individualized quality care.

The same people who clamor for a woman’s reproductive choice are strangely silent about everyone else’s freedom to choose the type of medical care they want. Patients and physicians should be free to pay for services and accept payment for services without being subject to penalties.

Medicare for All could be one of those concepts that “seemed like a good idea at the time” – just like diving head first off a cliff into an inviting but shallow pool of water.

Dr. 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, Law, Medicare, Medicine, Op-eds, Socialized Medicine

The Healthcare Revolution: More Choices, Not More Taxes

December 20, 2018 No Comments

By Marilyn M. Singleton, MD, JD

Paris is in flames over a fuel tax increase that would pile 30 cents onto the $7.06 per gallon price paid by citizens whose average monthly salary is $2,753.This burdensome “carbon tax” on the middle class is intended to help meet Europe’s commitment to reduce carbon dioxide emissions and thereby halt global warming or climate change. It appears that the 21^st century French Revolution has begun. This time, Brussels is sending in tanks to protect the new elite and its agenda.

Back in the states, some well-heeled, presumably well-intentioned Medicare-for-All advocates from California, New York, and New Jersey are grousing about how “Trump took away my homeowners tax deduction!” The Tax Cuts and Jobs Act now caps the previously unlimited federal tax itemized deductions for the combined state, local and property taxes at $10,000. The portion of a mortgage on which interest can be deducted is limited to $750,000, down from the current limit of $1 million.

Folks with million-dollar homes who continue to vote for legislators who impose high state taxes to finance their pet social programs are less sympathetic than the French Yellow Vests—especially when these same elitists want to take away the “crumbs” from the 80 percent of taxpayers who are receiving some relief from the near doubling of the standard deduction.

But everyone will face still more taxes to fund Medicare-for-All. Bernie Sanders’s financing plan would “limit tax deductions for the wealthy,” defined as $250,000 per household. Sanders also proposes eliminating health savings accounts (HSAs), which allow patients to take charge of their own care. And it won’t stop there—or at the equivalent of 30 cents per gallon.

It’s not just the taxes: it’s the loss of the freedom to choose. The M4A bills prohibit virtually all private health insurance. M4A promises “free” access to “willing healthcare providers”—but robs us of choice. Even existing Medicare offers 11 supplemental insurance programs with options for different premium structures. Purchasers can decide to pay a little more now for a stable premium price as they age, or pay quite a bit less and anticipate the age-related increase over the years. But, you say there would be no premiums with M4A. Wrong. The “premiums” are increased taxes. And taxes are not optional. You must obey.

We should take a cue from the French (minus the fires and looting). We need a middle-class medical care revolt against the elitists and politicians who think more government through high taxes is The Answer while ignoring community solutions. For example, We Do Better, a humanitarian movement, seeks out solutions to social problems based not on a particular political ideology or lobbyist’s effort, but on what works. In Southern California eight Clinica Mi Pueblo (CMP) clinics accept only cash, have transparent pricing on their website, and their services cost less than half of the price set by third parties. Where the average charge for an X-ray is between $260 and $460, CMP charges only $80. Utah’s Maliheh Free Clinic (MFC) serves low income and uninsured residents who are ineligible for Medicare, Medicaid, or any government subsidized healthcare. The MFC provided free healthcare to more than 15,000 patients in 2016 at an average cost of only $56 per patient, and 95% of donations to MFC go to providing medical services. New Jersey’s Zarephath Health Center is a volunteer-run and funded facility for patients who cannot find care “in the system.” Here it costs $15 to see a patient, versus $160-$280 at the Federally Qualified Health Center down the street.

Another increasingly popular model is direct primary care (DPC). Here, patients pay a monthly subscription fee to the practice (between $40 and $100 depending on age and family size), which covers all primary care services, certain laboratory tests, and at-cost pharmaceuticals at as much as 15 times less than the price at the pharmacy. The personal relationship with a physician enhances the care to patients with chronic conditions, reducing costly hospitalizations. Catastrophic insurance can cover major medical expenses. St. Luke’s Family Practice in Modesto, California is a DPC non-profit organization. Here, “benefactors” pay the fees for the “recipients” – those who cannot afford the fees.

Then there are many health care sharing ministries where members engage in voluntary sharing of costs for its members’ health needs. One such model, the Christian Healthcare Ministries (CHM), has plans that cost half as much as ACA Marketplace plans. It has more than 279,000 members, and has covered more than $1 billion in medical bills since 1981.

Americans want authority over our own lives. Our innovative spirit and generosity have created and will continue to create ways to deliver medical care to the most people without sacrificing choice—and at a more affordable cost.

Dr. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and 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.

Culture & Society, Health Policy, Medicine

Create Your Own Healthcare “System”

June 19, 2018 No Comments

By Marilyn M. Singleton, MD, JD, @MSingletonMDJD

Kudos to the folks in D.C. who are advancing alternatives to the Affordable Care Act’s over-regulated and expensive health insurance policies. Small business association health plans and expanding health savings accounts (HSAs) are among several tools to increase health care choices. However, one element in the medical care cost analysis that is rarely addressed is personal responsibility for one’s health. Politicians are reluctant to “blame the victim” (patients) so they criticize the health care “system.” That misses the point: It is not the government’s job to keep us healthy.

Estimates of 2016 U.S. health care spending averages $10,345-per-person. Purchasing insurance makes up the bulk of the spending: $3,852 annual insurance premium, $4,358 to meet the deductible, for a total of $8,210. But most of the actual spending on medical care is for 5 percent of the population, mainly for chronic conditions.Eighty-six percent of the nation’s $2.7 trillion annual health care expenditures (2010) were for people with chronic and mental health conditions.

It takes more than good luck to maintain good health. Up to 40 percent of lost years of life from each of five leading U.S. causes (heart disease, cancer, chronic lower respiratory diseases, stroke, and unintentional injuries) are preventable according to the Centers for Disease Control and Prevention (CDC). Sadly, opiate use disorder jumped from 52nd on the list in 1990 to 15th in 2016.

Research suggests that behaviors, such as smoking, poor diet and over-eating, and lack of exercise are the most important determinants of premature death. Over the last 25 years the percentage of Americans with healthy lifestyles (exercise, good diet, “normal” body fat, non-smoking) has dropped from 6.8 percent to 3 percent. More than two-thirds of all adults and nearly one-third of all children and youth in the United States are either overweight or obese. The CDC reports that 9.3 percent of Americans have diabetes. Will this problem be solved by expanding government “healthcare” programs? No. In 1965 when Medicare and Medicaid were established, 1.2 percent of Americans had diabetes. This number had doubled by 1975, even with more sources for medical care, and continued to rise at the same rate despite the implementation of the ACA.

The American Diabetes Association estimates that in 2017, diabetes and its related complications accounted for $237 billion in direct medical costs — a 26 percent increase from 2012. The price of poor lifestyle choices is staggering. For the years 2009–2012, the costs for direct medical care due to smoking was at least $170 billion. Medical costs linked to obesity were estimated to be from $147 billion to nearly $210 billion per year.

Let’s face it. Many Americans have been duped into ignoring responsibility for their own health. With the drug companies’ relentless ads, prescription drugs have become the equivalent of “As Seen on TV” products. These ads send the unstated message that the latest diabetes or lung disease medication will take care of you so you do not have to take care of yourself and possibly avoid these diseases in the first place. It’s no surprise that 70 percent of Americans take at least one prescription medication.

And the same government geniuses that permit food stamps to be used at fast food outlets mandates over-priced insurance products that include “free” preventive care. But, of course the high-priced cholesterol medication will cancel that out, right?

No sane person would wish a chronic condition on anyone, or deny treatment for such patients. But preventive health begins at home. Changing behaviors requires someone who connects with patients, will take time to listen and help identify personal motivators for change. This requires a physician who will spend time with you—not a storefront doc-in-the-box. Direct pay practices (DPC) offer quality time, service, and chronic disease management. These physicians are not constrained by insurance companies’ and the government’s paint-by-the-numbers treatments.

Health insurance is necessary for big ticket items like hospitalizations. But there is no need to pay thousands for services that will never be used. Pre-ObamaCare high-deductible plans and their out-of-pocket costs were generally offset by lower premiums and employer contributions to health savings accounts.

Shifting all our personal responsibilities to the government has not improved our nation’s health. Imagine if the $1,000 spent on designer coffee or manicures were spent on foods and a non-sedentary activities that improved health.

Dr. 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.

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, Healthcare Reform, Medicare, Medicine, Socialized Medicine

Money, Media, and Medical Care

November 15, 2017 No Comments

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

More than 50 years ago Professor Marshall McLuhan posited that the medium is the message. Now it seems that money is the medium of the message.

This month Medical Marketing and Media magazine published its 2017 Health Influencer 50, a “list of professionals across the health care spectrum.” The magazine writes that these “influencers” made their impact by innovative thinking and “patient-centric” strategies. As expected, the ever-present Google, Facebook, Twitter, and several medical marketers were amply represented. Disturbingly, five of the top eleven influencers were pharmaceutical companies. The only physician on the list (#12) was Food and Drug Administration Commissioner Scott Gottlieb, M.D.

Only three of the named organizations were actually involved in the delivery of medical care: Dignity Health, the fifth largest health system in the nation; Ascension, the largest nonprofit health system in the U.S.; and the Cleveland Clinic.

One troublesome “patient-centric” strategy is the ubiquitous brazen direct-to-consumer pharmaceutical ad. One crafty example is an “informational” or public service-type announcement persuading the viewer to get vaccinated against pneumococcal pneumonia. Ummm. Was the ad sponsored by a health plan? Medicare? The American Academy of Family Physicians? No. The sponsor (credited in very small print) was Pfizer, the vaccine’s manufacturer.

Apparently, the influence of many of these entities extends to Congress. The 2017 lobbying expenses of Medical Marketing Magazine’s number one “influencer,” GlaxoSmithKline, totaled $3,070,000. The other influencers’ lobbying costs: Gilead Sciences (#2), $2,650,000; Allergan (#4), $2,380,000; Johnson & Johnson (#8), $3,160,000; Pfizer (#10), $8,510,000; and Bayer (#11), $7,050,000. Overall, the pharmaceutical manufacturing industry hired more than 800 lobbyists to the tune of $132,405,742.

The mega-health insurer Blue Cross/Blue Shield’s vice president of Strategic Communications made the list at number 39. If the criterion were lobbying, the Blue Cross/Blue Shield (BCBS) had a leg up with $14,173,960 in lobbying costs—more than triple that of the next health insurer that employs lobbyists.

Or perhaps BCBS was rewarded for navigating its way out of the financial depths of the Affordable Care Act’s essential benefit mandates. Of the 35 BCBS companies, 23 reported a collective $1.9 billion decline in earnings for the first nine months of 2015 and 16 reported net losses because the ACA’s “free” services resulted in claims paid exceeding premiums collected. But by 2017 BCBS along with the rest of the health insurance industry managed to regain its profits by increasing rates, restricting provider networks, and changing benefits packages.

At first glance, physicians appear to be playing hardball with the big boys. In 2017, the American Medical Association (AMA) spent $16,970,000 for lobbying. But the AMA might be called the American physicians’ version of AstroTurf. Only 15-18 percent of physicians are paying members and just 11 percent of physicians said AMA’s stance and actions reflect their beliefs regarding physician practice autonomy, tort reform, and intrusive government regulations. Moreover, the AMA benefits from the dominance of insurance market as it exclusively publishes the official CPT® billing codes necessary to file insurance claims.

The problems with the marketing penetration of drug companies and insurers go beyond simple unseemliness. At the patient care level, when insurance companies demand authorizations prior to agreeing to pay for treatment, they are dictating what care we receive. What good is health insurance if the treatments your physician recommends are not covered?

The current opioid problem is a distressing example. The New York Timesreported that few opioids require preauthorization and are readily covered by insurance plans. When it comes to less addictive but more expensive pharmaceutical alternatives or addiction treatment, the coverage is not guaranteed.

Don’t blame the insurers and drug companies. After all, although they are providing useful products and services, it is their job to make money. It is our congresspersons who are not doing their job.

Sadly, influence peddling has become the norm. But your health is too precious to be bought and sold. Your physician should be the top “influencer” for you. Our physicians, not peddlers, should be the source of the pros and cons of medications and recommendations of specific treatments for their patients.

If you are tired of our do-nothing Congress and big business running up the score, play some defense. Demand transparent prices. Cash prices can be several times lower than prices charged to patients with an insurance card. Demand expanded health savings accounts and universal availability of major medical insurance. Find a direct-pay medical practice (e.g., selfpaypatient.com) and discover how eliminating the middlemen results in reasonable prices.

You have the influence. Use it.

Dr. 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.

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