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Culture & Society, Current Events, Featured, Health Policy, Medicine, Politics, What's New

America Out Loud PULSE: From Physician to Activist with Dr. Jane Hughes

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From my America Out Loud Pulse podcast with Dr. Jane Hughes – https://www.americaoutloud.news/from-physician-to-activist-meet-jane-hughes-md/

There was a time when patients sought medical care from a physician, not a “healthcare system.” Now there’s over-priced health insurance that falls short when you actually need it; Medicare Advantage plans that trap you like a roach motel and then don’t provide care when you actually get sick.

Rather than going after flash mob thieves, the government eyeballing parents who have the audacity to actually go to PTA meetings. Schools are supporting so-called gender affirmation without parental notification or consent. Physicians are acquiescing to government, corporate, and political pressures rather than individualized patient care. What’s a person to do?

Almost 50 years ago, an iconic speech in a critically acclaimed film written by Paddy Chayesfsky expressed it better than I ever could: (Peter Finch as Howard Beale, Network, 1976.)

I don’t have to tell you things are bad. Everybody knows things are bad. It’s a depression. Everybody’s out of work or scared of losing their job. The dollar buys a nickel’s worth; banks are going bust; shopkeepers keep a gun under the counter; punks are running wild in the street, and there’s nobody anywhere who seems to know what to do, and there’s no end to it.

We know the air is unfit to breathe and our food is unfit to eat. And we sit watching our TVs while some local newscaster tells us that today we had fifteen homicides and sixty-three violent crimes, as if that’s the way it’s supposed to be!

We all know things are bad — worse than bad — they’re crazy.

It’s like everything everywhere is going crazy, so we don’t go out any more. We sit in the house, and slowly the world we’re living in is getting smaller, and all we say is, “Please, at least leave us alone in our living rooms. Let me have my toaster and my TV and my steel-belted radials, and I won’t say anything. Just leave us alone.”

Well, I’m not going to leave you alone.

I want you to get mad!

I don’t want you to protest. I don’t want you to riot. I don’t want you to write to your Congressman, because I wouldn’t know what to tell you to write. I don’t know what to do about the depression and the inflation and the Russians and the crime in the street.

All I know is that first, you’ve got to get mad.

You’ve got to say, “I’m a human being, goddammit! My life has value!”

So, I want you to get up now. I want all of you to get up out of your chairs. I want you to get up right now and go to the window, open it, and stick your head out and yell:

“I’m as mad as hell, and I’m not going to take this anymore!!”

I recently heard someone say that there are three kinds of people in this world: those who make things happen, those who watch things happen, and those who wonder what happened. We must be the people who makes things happen. No act is too small. As Sir Edmund Burke said 200 years ago, “Nobody made a greater mistake than he who did nothing because he could only do a little.”

My guest, Dr. Jane Hughes has put the act in activism and will share her thoughts about medicine, our health care “system,” and the government’s role in our lives.

Bio

Dr. Jane Hughes is the current president of the Association of American Physicians and Surgeons. She is a board-certified ophthalmologist and a fellow of the American College of Surgeons. She received her medical degree from the University of Texas Health Science Center in San Antonio where she also completed her residency. Dr. Hughes is co-founder of American Doctors for Truth and serves on Congressman Chip Roy’s Physician Advisory Council for Healthcare Policy.

Culture & Society, Doctors, Featured, Guest Column, Medicine, What's New

Navigating the Medical Maze: Strategies for Avoiding Burnout

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Guest column by Virginia Cooper.

In the relentless and demanding field of healthcare, it’s all too easy to fall into the trap of burnout. As a medical professional, you are familiar with the high-stress environment and the toll it takes. Yet, there’s hope. By adopting specific strategies, you can preserve your well-being and continue to provide the best care to your patients.

Embrace Wellness Rituals

Your health is as critical as that of your patients. Integrating wellness rituals into your daily routine is not a luxury but a necessity. Think about activities that bring you joy and relaxation. Maybe it’s a morning jog, an evening of painting, or simply reading a book. Exercise not only keeps you physically fit but also serves as a mental escape from the pressures of work. Regularly engaging in hobbies can rejuvenate your spirit, making you more resilient in your professional role.

Be Conscious About Alcohol Intake

In the high-pressure world of medicine, turning to alcohol might seem like a quick fix for stress. However, moderation is key. Excessive drinking can lead to health issues and impact your ability to perform at work. If you find yourself struggling, consider seeking help. There are various treatment options in the area, with many rehab centers accepting major health insurance providers. Research facilities focusing on factors like treatment methods, location, and patient reviews to find the best fit for your needs.

Improve Decision-Making Under Stress

High-stress situations are part and parcel of medical work. Developing a strategy for making sound decisions under pressure is crucial. Before reacting, take a moment to assess the situation mindfully. This pause allows you to respond thoughtfully rather than reactively. Envision the broader implications of your decisions and trust your well-honed instincts, using the information at hand.

Building a Support Network

The path of a healthcare professional need not be a solitary journey. Building connections with peers can offer a much-needed sense of understanding and support. These relationships provide a safe space to share experiences, challenges, and advice. Engaging in conversations with colleagues who understand the unique pressures of the medical field can be both comforting and enlightening.

Consider Taking a Sabbatical

Sometimes, the best way to recharge is to step away temporarily. A sabbatical, or an extended break from work, can be a transformative experience. It offers an opportunity to rest, pursue personal interests, or engage in professional development activities without the daily pressures of patient care. This time away can provide a fresh perspective and renewed energy, ultimately benefiting both you and your patients.

Reflecting on Your Career Path

In the dynamic world of healthcare, it’s important to periodically reassess your career goals. Are you where you want to be? Is your current role fulfilling? Sometimes, a change within the medical field can reignite your passion for healthcare. Whether it’s specializing in a new area, shifting to a different facility, or even transitioning to a teaching role, these changes can provide new challenges and renewed motivation.

Mastering the Art of Saying “No”

One of the hardest but most essential skills to learn in any demanding career is the ability to say “no.” Setting boundaries is crucial for maintaining your mental and physical health. It’s okay to decline extra shifts or additional responsibilities when you’re already stretched thin. Remember, taking on too much can compromise the quality of care you provide to your patients.

Prioritizing Your Mental Health

The psychological toll of working in medicine can be significant. Regularly check in with yourself. Are you feeling overwhelmed, anxious, or depressed? Seeking professional help through counseling or therapy is a sign of strength, not weakness. Mental health professionals can provide coping strategies and support, helping you navigate the complexities of your role with resilience and clarity.

In the fast-paced, high-stakes field of healthcare, taking care of yourself is not just a personal priority—it is a professional necessity. From managing stress to seeking treatment for an alcohol issue and evaluating your career path, each step is crucial in avoiding burnout. Remember, making good decisions under stress is a skill that can be honed with practice and mindfulness. By prioritizing your well-being, you ensure that you can continue to provide the best care for your patients, day in and day out.

Virginia Cooper is a retired community college instructor. She always encouraged her students to see the real-world value in their education, and now, she wants to spread that message as wide as possible. Her hope is that Learn a Living (learnaliving.co) will be a go-to resource for adult learners embarking on starting, continuing, or finishing their education.

Image: Freepick

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. 

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

Giving Medicare for All a Facelift: the Ugly Is Still There

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By Marilyn M. Singleton, MD, JD

Medicare for All (M4A) retained its prominent place on the stage at the latest Democratic debate. In its purest Bernie Sanders form, concurrent with abolishing private health insurance, U.S. residents would be enrolled in “Medicare.” The program would pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health and substance abuse treatment, vision, dental, and hearing services, and long-term care with no out-of-pocket costs. Some supporters were scared off by the $32 trillion over 10 years price tag. Not to be outdone, Elizabeth Warren’s “I’m with Bernie” plan comes with a $52 trillion over 10 years price tag including up to $34 trillion in new government spending. Our country’s entire yearly budget is a mere $3.5 trillion. For perspective, if your salary is $40,000 per year it would take 25 million years to earn 1 trillion dollars. As M4A’s dark side emerged, the candidates distanced themselves from Bernie-care.

Elimination of private insurance? Whoa, Nellie! Over 156 million Americans —half the country—are covered by employer-sponsored health insurance plans and another 23 million have private individual policies. And most of these folks like that arrangement. Then there was pushback from some unions who had excellent health insurance policies for which they had bargained and given up other perks.

In the June debate the candidates raised their hands indicating they would abolish private health insurance. Now Mayor Buttigieg wants to “unify the American people around, creating a version of Medicare, making it available to anybody who wants it, but without the divisive step of ordering people onto it whether they want to or not.” Vice president Biden, noting his desire to keep patient choice stated, “we should build on Obamacare … adding a Medicare option in that plan, and not make people choose.” Of course, Obamacare caused a rise in premiums, a decrease in choice of insurance coverage, and like any large government-run program was prone to mismanagement and waste.

Possible financing mechanisms were screaming for a deep dive. One analysis concluded that most Americans would suffer financially if M4A were implemented as proposed. An analysis by a bipartisan think tank estimated a 32 per cent increase in payroll taxes would be needed to fund M4A. Everyone—even the working poor—would have more payroll taxes extracted from their paycheck. The analysis concluded that most households would pay more in new taxes than they would save by eliminating their current spending on private health insurance and out-of-pocket medical expenses.

Senator Warren tries to hide the ugly truth by railing about the evil rich who would be taxed down to their underwear. Take the deceptively worded “2-cent” annual tax for households with more than $50 million in assets. If you have $51 million in assets, most probably tied up in your business, you’d have to cough up (.02)($1,000,000) or $20,000, not 2 cents. The devil’s spawn, aka our 535 billionaires, would be subject to a 6 percent annual tax on their assets. Who will be the next target when the government has driven the assets to a sunny island in the Caribbean? Finally, raising the corporate income tax back up to 35 percent likely would result in businesses paying lower wages to current employees or cutting back on hiring to compensate for the increased tax burden.

During the latest debate, Senator Warren retreated from her “all-in” approach, asserting she would first provide Medicare at no cost to “everybody under the age of 18, everybody who has a family of four income less than $50,000”—about 135 million people. Second, she would lower the Medicare age to 50 and expand Medicare coverage to include vision, dental, and long-term care. In the third year, “when people have had a chance to feel it and taste it and live with it, we’re going to vote and we’re going to want Medicare for all.”

Senator Sanders owns that payroll taxes would be doubled or tripled and proposes a 4 percent surtax on families earning more than $29,000. So if you earn $60,000, you’d have to pay (.04)($31,000) or $1,240, enough for a whole year’s membership in a private Direct Primary Care plan. Senator Sanders, staying true to his principles, is sticking with unadulterated Medicare for All with its financial warts.

Even those who are numb to government over-spending can see the broader problem of inviting Uncle Sam into their lives in exchange for a Medicare card in their wallet. Any remaining privacy is erased. Our medical records would be furnished to the Department of Health and Human Services and the National Coordinator for Health Information Technology. Physicians and patients would be robbed of their autonomy and choice by medical care policies set by the government monopoly. Lack of competition leads to lower quality and fewer services. Coverage becomes an illusion.

Medicare for All’s beauty is only skin deep and its ugly goes to the bone.

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. 

Doctors, Health Policy, Healthcare Reform, Medicare, Medicine, Politics

Don’t Buy What They Are Selling

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By Marilyn M. Singleton, MD, JD

Buying and selling is in the news lately with President “at some point you’ve made enough money,” “climate change is urgent and growing” Obama’s well-publicized imminent purchase of a 7,000 square foot, $14.85 million estate in Edgartown, Martha’s Vineyard, the playground of the rich and famous, guaranteed to survive the rising seas. Our current politicians are also on the hunt for buyers.  

Sales Pitch Number One: A medical care crisis is afoot and only the government can save you. Yes, there is a crisis of rising prices and premiums after the government started meddling in the medical care market. Once health insurance became popular, by 1963 906 insurance companies wrote health and accident insurance, with 42 offering exclusively health insurance. Now we have five companies that have cornered the health insurance market. Additionally, politically powerful hospitals continue to merge and gobble up physicians’ practices leading to up to 70 percent higher prices in geographic areas with minimal competition.

Premiums and out-of-pocket costs steeply rose after the passage of the Affordable Care Act and show no sign of going back down. In 2018, according to eHealth, the average cost of health insurance premiums was $440 for individuals and $1,168 for families – almost double the cost in 2014. The deductibles (the amount of money that you have to pay out-of-pocket before health insurance starts paying for your covered benefits) similarly rose to $4,328 for individuals and $8,352 for families.

Sales Pitch Number Two: The government-to-the rescue plan is fair and free. Now that we have had debates and the Iowa State Fair, we’ve heard enough to know that Medicare-for-All is neither free nor fair. There is a good political reason the House and Senate Medicare-for-All bills fail to provide a financing mechanism. We would have a collective national heart attack after seeing the price tag.

In 2016, the federal government spent more than $1.2 trillion on Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Total national health expenditures by all government levels and private entities were $3.3 trillion. A 2018 Mercatus Center analysis concluded that Medicare-for-All conservatively would add $32.6 to $38.8 trillion to federal expenditures during its first 10 years. The government predicts that in 2026 the Medicare Hospital Insurance Trust fund will be depleted and total national health expenditures will be $5.7 trillion. The federal government collected about $100 billion in Medicare premiums and a total of $3.32 trillion in taxes last year. Given the projected expenditures and no cost-sharing or premiums, new ways to perform mass wallet biopsies on the populace will emerge. The simplest tool, as Senator Sanders has suggested, is to raise payroll taxes on everyone.

Moreover, with the elimination of private insurance, when the money runs out and care is rationed, only the wealthy will be able to pay for care outside of the government system. Is that fair?

Upping the ante, Senator Sanders wants to pay off some Americans’ current medical debt by taxing Americans with no medical debt. Under his proposal, only people unable to pay their medical debt would be granted relief. Those keeping up with their payments would have to continue to pay. What does “unable” mean? If they are living below the poverty level, they have Medicaid. Is it the working poor? Or is it people who failed to prioritize their medical bills over Starbucks and take-out food? Hardly fair.

Sales Pitch Number Three: If you like your doctor you can keep your doctor, Politifact’s lie of the year. Essentially, the promise was that government would not interfere in the practice of medicine. But both state and federal government wants the final say-so in our medical care. For example, the California assembly passed a bill requiring the state Department of Public Health to review and potentially reject medical vaccine exemptions written by doctors who have granted five or more in a year. No exceptions for doctors specializing in neurological or immunological diseases. In order for Medicare to pay claims, physicians will be required to complete a computerized algorithm and certify that they have done so before ordering certain imaging like MRIs and CT scans. A computer will now determine whether the order is “appropriate.” Medical care by government robots will supplant individualized care – the heart of the patient-physician relationship. Who cares if the patient has a missed or delayed diagnosis?

As the government tries to trap physicians and patients in its restrictive bubble, independent physicians are pursuing avenues for increased choice in medical care and insurance products. Above all, we will never put the needs of the state ahead of the needs of the patient.

Bio: Dr. Singleton is a board-certified anesthesiologist. She is a 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. 

Culture & Society, Health Policy, Medicine

Create Your Own Healthcare “System”

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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.

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

The Expendables: There’s More to Life than Death

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

April 16th begins a week of National Healthcare Decisions Day. Hopefully this week will encourage honest discussions not only about a so-called “good death” but the value of an individual’s life. I am not optimistic, given the trend toward consciously or unconsciously steering patients toward “death with dignity” rather than focusing on the dignity of life. Indeed, a recent documentary video of an Oregon couple’s dual physician-assisted suicide received positive reactions.

One Affordable Care Act program to promote “quality care” through financial incentives for attaining high performance scores (and penalties for low scores) contains a metric that is fraught with moral hazard. Hospitals with higher numbers of pneumonia, heart failure, or heart attack patients who die within 30 days of discharge receive a lower score. But if patients are designated for hospice (palliative) care during the first 24 hours of their hospital stay, and then die within 30 days of discharge, they are not counted against the hospital’s score. In order to improve its quality-of-care score, one Veterans Administration hospital disclosed that it used an “inappropriate admissions system” where sicker patients were turned away against the physicians’ recommendations.

As the Affordable Care Act continues its painful death, many are seduced by the promises of government-sponsored single payer healthcare. Given the federal government’s 2017 healthcare expenditures of $1.14 trillion, politicians and policymakers ponder how to pay for such a massive program. Patients wonder whether they will pay with their pocketbooks (taxes) or their lives (rationing).

The fallback solution of raising everyone’s taxes is unpalatable to most. Aware that providing fewer services saves money but fearing public outrage, politicians have shunned efforts to explicitly ration health. Thus, policymakers promote programs that reduce waste and inefficiency. For example, frugality is encouraged by reimbursing a set dollar amount for a course of treatment that includes all inpatient and outpatient care and physician fees (“bundling”). But once the waste and inefficiency are successfully addressed, what is the next step to rein in “overuse” of services?

The British National Health Service’s National Institute for Health and Care Excellence (NICE) supports the use of “quality-adjusted life years” (QALY) to measure the quality and quantity of life added due to a particular medical treatment. One QALY is one year of perfect health. Zero QALY is death. If the cost per QALY gained exceeds a predetermined amount, the government denies payment for that treatment. Touted as more ethical, the “Complete Lives System”—the brainchild of ObamaCare physician architect Ezekiel Emanuel—includes worrisome determinants of who should receive care. The system prioritizes adolescents and persons with “instrumental value,” i.e., individuals with “future usefulness.”

These rationing systems devalue the benefits the disabled, elderly, or others with a lower life expectancy could receive from a given treatment. A study of individuals with late-in-life disabilities found that overall quality-of-life assessments were often positive even as participants described things that made their lives uncomfortable or difficult. Dignity and a sense of control were most closely tied to overall quality of life.

Importantly, health care professionals are not immune to personal bias in presenting the treatment options to patients. And physicians sometimes forget that their notion of quality is not the same as the patient’s.

A nationwide multi-medical center study revealed the inadequacy of written living wills or the generic check-the-box Physician Orders for Life-Sustaining Treatment (POLST). Based solely on these documents, physicians reached a consensus (95 percent agreement) on code status and resuscitation decisions in only two out of nine clinical scenarios. Viewing a patient’s video statement produced statistically significant improvement in physician agreement in interpreting the patients’ wishes in seven scenarios. Moreover, in five of the seven scenarios, physicians were more likely to choose full aggressive treatment.

It seems the best way to be your own best advocate is jump into the 21st century and make a video. Ensure that in a critical moment you are seen as not merely a medical condition but a person. If you want no medical intervention, say so in your own unambiguous words. If you want the full court press, be clear and explicit. Tell your doctors to treat you as aggressively as 92 year-old Jimmy Carter was treated for his metastatic malignant melanoma. And NO, a former president is not more important than you are.

And to my fellow physicians: ask yourself what you would recommend to the parents of a 19 month old deaf and blind toddler who needed extensive intensive care. Helen Keller’s parents have the answer.

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

Patients and Physicians Unite: You Have Nothing to Lose but Your Chains

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

In an entertainment venue called the “Escape Room,” participants are locked inside a themed adventure room, and they must figure out how to escape. Themes include prisons, KGB interrogation, and hostage situations. Perhaps a new theme could be ObamaCare.

Despite a large majority of Americans reporting healthcare as their number one concern, Congress does not have the political appetite for a serious assessment of the Affordable Care Act. It’s time for Congress to say, “ACA and its ‘fixes’ are not working; cut our losses and move in a different direction.” New proposals should focus on reducing the cost of pharmaceuticals and medical services rather than shifting costs from one entity to another via mandated insurance benefits and government subsidies.

Dear Congress, please act on a few simple reforms that will help everyone and hurt no one—except the drug lobbies and middlemen.

First, seniors must demand to be treated like thinking adults—and save the federal government money in the process. Under current law, anyone age 65 and over who is entitled to Social Security benefits is automatically entitled to “free” Medicare Part A (hospital coverage). But if a senior wants to decline Part A and seek or keep other medical care options he must forfeit his Social Security benefits. As Judge Rosemary Collyer noted in a legal challenge to this rule, “plaintiffs are trapped in a government program intended for their benefit. . . They disagree and wish to escape.” Alas, the 1993 regulation was interpreted to confirm the draconian punishment for wanting to break free of the government control. To right this wrong, will one brave congressperson or senator revive the Retirement Freedom Act and support the Medicare Patient Empowerment Act that makes it easier for patients and physicians to opt out of Medicare?

Second, seven of ten Americans use prescription drugs, and they overpay for these 23 percent of the time. Patients often aren’t told they could pay less by not using insurance. If the insurance co-pay is higher than the actual cost of the drug, the middlemen (pharmacy benefit managers) keep the difference.

Legislative remedies exist. The bipartisan Patient Right to Know Drug Prices Act prohibits health insurance issuers and group health plans from restricting or penalizing pharmacies who tell enrollees the differential between a drug’s cash price and the insurance plan’s cost. The bipartisan Know the Lowest Price Act of 2018 prohibits health plans and pharmacy benefit managers in the Medicare Advantage program from restricting pharmacies from informing individuals regarding the prices for certain drugs. The bipartisan Transparent Health Pricing Act requires entities that furnish health-related products or services to the public to disclose the wholesale, retail, and discounted prices for those products and services at the point of purchase and on the Internet.

And when the price of brand name drugs has increased 10 times more than inflation, dear Congresspersons, consider supporting the Competitive DRUGS Act prohibiting name brand drug companies from compensating generic drug companies to delay a generic drug’s entry into the market.

With regard to medical services, the Direct Primary Care (DPC) model is burgeoning as patients yearn for quality time with their doctor at an affordable price. Here, all primary care services and access to basic commonly used drugs at wholesale prices are included in a fixed transparent price. Congress should support the Primary Care Enhancement Act, a one-page bill that allows Health Savings Accounts (HSAs) to be used to pay enrollment fees for DPC practices. Many Medicare beneficiaries prefer this model as they remember the era when patients actually knew their doctors.

Moreover, the DPC model saves federal dollars. Prescription drugs accounted for $110 billion in Medicare spending in 2015, 17% of all Medicare spending. With DPC dispensing, the cost of pharmaceuticals can be as much as 15 times lower than pharmacy prices. And Medicare spent $17 billion on potentially avoidable hospital readmissions. DPC’s better coordination of chronic care decreases hospital admissions.

Numerous bills designed to give patients more control over their medical care include provisions that: increase the maximum HSA contribution; allow Medicare eligible individuals to contribute to HSAs; allow members of healthcare sharing ministries to participate in HSAs; and allow individuals who participate in DPC practice, or who receive care from an employer’s onsite medical clinic to participate in HSAs.

Physicians want freedom to do the best for their patients and patients want good care at affordable prices. Will Congress act or continue to let such liberating legislative opportunities wither away?

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, Doctors, Medical Ethics, Medicine, Op-eds

Making Lemons from Lemonade: Squeezing the Joy Out of Medicine

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

Scandal upon scandal has dominated the airwaves and the web. Other than those involved, we have no way of knowing the truth or misremembering of the allegations. But we do know it is beyond sad that our congressional representatives who have the privilege and honor to serve their country have used the public purse to whitewash their misdeeds. These critters certainly know how to drag a noble calling into the gutter.

In the case of medicine, it is not the few well-publicized bad apples, but government and corporations injecting themselves into clinical practice that is driving the down trajectory of patient care. The days of physician as independent member of the community are fast waning—thanks to those paragons who run our country.

According to an American Medical Association survey, by 2016 only 47.1 percent of practicing physicians owned their own practice. Another report noted that hospitals acquired 31,000 physician practices, a 50 percent increase, from 2012 to 2015.

Now UnitedHealth Group plans to purchase the physician group from DaVita, a chain of dialysis centers, adding to their urgent care and surgery centers. Insurers owning (enslaving?) physicians is hoped to contain costs. While innovation in improving delivery of medical care is laudable, it is not without risks. Patients likely will have fewer choices of physicians or be told whom to see. As far as insurance pricing, economists agree that more competition benefits consumers.

We must be wary: as these behemoths consume and control medical care, sins are mounting. A few transgressions include Northern California’s Sutter Health that intentionally destroyed 192 boxes of documents that employers and labor unions were seeking in a lawsuit that accuses Sutter of abusing its market power and charging inflated prices. Anthem, the second largest health insurer in the U.S., was fined $5 million by California’s Department of Managed Health Care for “flouting the law” in dealing with consumer complaints. In 2016, insurance company denials were overturned in nearly 70 percent of medical review cases. California had already fined Anthem more than $6 million collectively for grievance-system violations since 2002.

And the federal government has stacked the deck in its new Quality Payment Program that “adjusts” physicians’ government payments if they don’t comply with the complex metrics. First, electronic medical records are a must. On the clinical front, anesthesiologists are scored on the percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure. Is the anesthesiologist supposed to send a proctor home with the patient? How is patient compliance grafted on to a physician whom the patient just met—no matter how convincing the anti-smoking pitch?

And then for internists there are “Additional improvements in access as a result of QIN/QIO TA” [Quality Improvement Network/Quality Improvement Organization technical assistance]. Or participation in a QCDR that promotes use of patient engagement tools. And what is a QCDR? A qualified clinical data registry. “A QCDR is a CMS-approved entity (such as a registry, certification board, collaborative, etc.) that collects medical and/or clinical data…”

The new medicine is forcing the remaining independent physicians to devolve from trusted confidants to automatons in order to survive in medicine’s brave new world. And it is not so pleasant for the patients: the algorithms, electronic computer screens, and hospitalists taking over care often with no consultation with the primary care physician.

Call me old-fashioned, but I come from a line of private practitioners who provided “population health” by being an integral part of the community. The Bradfield Community Association of Lima, Ohio, was formed in 1938 and named after my grandfather, Joseph C. Bradfield, M.D., a World War I veteran and beloved physician. The San Diego Board of Supervisors adjourned in memory of the death of my father, E.B. Singleton, M.D., a Tuskegee flight surgeon and primary care physician who charged people what they could afford and accepted tamales as payment. He didn’t need to take classes on dealing with denied insurance claims or filling our government forms.

Dr. Benjamin Rush, a signatory of the Declaration of Independence said, “Without virtue there can be no liberty and liberty is the object and life of all republican governments.” Liberty is also the cornerstone of good medical care.

Ask yourself do government bureaucrats and nameless faceless insurers have the moral authority to tell us what is just in delivering medical care to our populace? If the current happenings do not convince you that you and your private physician are your best advocates, then nothing will.

I wish you love, peace, and joy in this blessed season.

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

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

Be Careful about Replacing ObamaCare

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

Since the day the Affordable Care Act was enacted, we have been subjected to the “repeal and replace” mantra. Replacement offerings are basically slimmed down versions of the ACA. A few brave souls have proposed a straightforward repeal. Of course, such bills were merely making political hay since Obama would never sign away his namesake law.

Several GOP presidential candidates have doubled down on the misguided “repeal and replace” promise, including the yet-to-be-elucidated “Donaldcare.” But the real question is whether the ACA should be replaced at all.

Any healthcare “system” – new or old – is subject to the long arm of the federal government. Central control does not have a good track record for creative solutions, security, fraud control, administrative efficiency, or the ability to change personal habits.

The federal government has yet to figure out a way to comply with HIPAA’s twenty-year-old mandate to remove Social Security numbers from health insurance cards. Consequently, the mere possession of a Medicare card poses the risk of identity theft in our most vulnerable population.

And speaking of identity security, a core tool of the healthcare system is the electronic health record. Health “providers” seeing Medicare or Medicaid patients must have “meaningful use” of electronic records in their offices or face monetary penalties. However use of wireless networks for sensitive information requires sophisticated security measures most physician offices do not have. Moreover, even with the highest-level resources at its disposal, the federal government has failed to secure its own records.

The Health and Human Services (HHS) Office for Civil Rights reported 32 health data hacking incidents in 2015. Millions of people now have their medical information, Social Security numbers, and other personal identifying data compromised. According to a House Energy and Commerce Committee investigation, the HHS Inspector General reported that over the last seven years, HHS had “pervasive and persistent deficiencies across HHS and its operating divisions’ information security programs.”

Fraud and administrative errors plague the Medicare program. According to the federal Office of Management and Budget, its fiscal year 2014, “high-error” programs produced approximately $125 billion in “improper” payments, i.e., those that violated guidelines or rules in some way. Medicare Fee-for-Service alone had $45 billion in improper payments or 12.7 percent of the total. Fraud, lack of documentation, and medical necessity authentication issues are the main culprits.

Even as the Department of Justice touts its improved record of Medicare fraud convictions, the ACA’s federal Health Insurance Marketplace represented an epic failure on the fraud front. To assess the enrollment controls of the Marketplace, the Government Accountability Office (GAO) performed 18 undercover tests. During these tests, the Marketplace approved subsidized ACA coverage for 11 of the 12 fictitious GAO telephone or online applicants for 2014.

The Veterans Administration clinics debacle is a prime example of federal administrative inefficiency. The Office of Inspector General concluded “enrollment program data were generally unreliable for monitoring, reporting on the status of health care enrollments, and making decisions regarding overall processing timeliness.” The report confirmed that as of September 30, 2014 the system had some 867,000 pending records, 307,000 of which were for individuals reported as deceased by the Social Security Administration.

Finally, government attempts to mandate healthy behavior don’t work. For example, a 2015 scientific study analyzed the “Los Angeles Fast-Food Ban”, a 2008 zoning regulation restricting opening/remodeling of standalone fast-food restaurants in South Los Angeles. Data showed that consumption of fast food and obesity increased in all geographic areas from 2007 to 2012, and the increase was significantly greater in the regulated area.

Politicians need a “system” to expand central control. Central control breeds mediocrity. Government programs play to the lowest common denominator. One size fits all quickly becomes one size fits none. Call me crazy, but I want the second opinion about my treatment to come from physician, not a government bureaucrat evaluating me from his cubicle.

As Malcolm Gladwell of Tipping Point fame opined, rather than expanding insurance we should keep insurance in its proper role for “unexpected, big-ticket things.” And “the bottom end of healthcare should be a market-driven cash economy.”

Competition brings out the best in us. For example, Theranos, a company started by a Stanford freshman provides 14 accurate basic kidney/liver function tests from one drop of blood for $7.27 at Walgreens. By contrast, my insurance co-pay for lab tests is $40.

Politicians can’t fix our medical care access problems. That’s up to us. As a start, consider enlisting direct pay physicians (here, here, and here) who give personal care at reasonable prices and replace the ACA with your own healthcare system.

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.

Despite being told, “they don’t take Negroes at Stanford”, she graduated from Stanford and earned her MD at UCSF Medical School.

Dr. Marilyn Singleton then completed two years of surgery residency at UCSF, followed by an anesthesia residency at Harvard’s Beth Israel Hospital.

Dr. Marilyn Singleton was first an instructor, then Assistant Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins Hospital in Baltimore, Maryland before she returned to private practice in California.

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.

Dr. Marilyn Singleton has conducted make-shift medical clinics in two rural villages in El Salvador.

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. (Audio version of the speech to AAPS doctors by Dr. Marilyn Singleton.)

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

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