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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. 

Culture & Society, Law, Medical Ethics, Medicine

The Soylent Green New Deal is Three Years Away

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

In an effort to cut carbon emissions from burials and cremations, the state of Washington, led by staunch environmentalist Governor Jay Inslee, became the first U.S. state to legalize human composting. To think, people can be criminally prosecuted for disrespecting a human corpse, a symbol of a once-living person. But the religion of Mother Earth now supersedes all cultural decency.

We’ve already cemented the contempt for life at the front end. I thought we had evolved since the ancient Greek elders determined that only the strong newborns survived and the weak were left to die. Virginia’s Governor Ralph Northam made it clear that infants were once again throwaways at will. In explaining the procedure of an “abortion” of a child who was born alive, he said “the infant would be resuscitated if that’s what the mother and the family desired, and then a discussion would ensue between the physicians and the mother.”

Now we must be acutely aware of what is happening at the other end of life’s spectrum. In the U.S., elders are all too often considered expendable by society at large and sadly, by their own families. Such disregard in some 10 million cases escalates to abuse in many forms. Government-certified entities make a significant contribution to this contemptible crime.

In many states court-appointed guardians cravenly plunder their wards’ assets with no repercussions. A U.S. Government Accountability Office (GAO) report identified hundreds of allegations of abuse, neglect, and exploitation by guardians in 45 states and the District of Columbia between 1990 and 2010. An investigation of a small sampling of the allegations found that court-appointed guardians had stolen or otherwise improperly obtained $5.4 million from 158 incapacitated victims, mostly older adults. Moreover, such crimes were frequently overlooked by judges.

Soon after coming into office, President Trump signed into law the Elder Abuse Prevention and Prosecution Act that provided for 90 prosecutors and “elder justice coordinators” nationally to prosecute those committing elder abuse, including guardianship cases. Currently, a sleepy little bill in the wings, the Stamp Out Elder Abuse Act, will direct the proceeds of a new postage stamp to enforcing laws against elder abuse.

These new laws may be for naught with the advent of more physician-assisted suicide laws. New Jersey is the latest, complete with a cute acronym: MAID – Medical Aid in Dying. All the calls for government-controlled medicine are terrifying to those of us who remember a dystopian film where in 2022, with rampant food shortages and homelessness, the only food available is a high-energy wafer purportedly made from plankton. Alas, we witness humans entering a processing center for a happy death and emerging as the main ingredient of Soylent Green.

I contend that the trend of placing older people into hospice before the ink is dry on the hospital admission papers is a new form of elder abuse. Hospice has become the new Medicare cash cow for unscrupulous facility owners who abuse and neglect patients. One study found that 8 percent of the hospices studied did not provide a single skilled visit—from a nurse, doctor, social worker, or therapist—to any patients who were receiving routine home care in the last two days of life in 2014.

Recall that President Obama robbed Medicare of $716 billion to fund the Affordable Care Act, including $56 billion from hospitals serving poor people. Recall that an ethics advisor for ObamaCare, Ezekiel Emanuel, MD, advocates for the “Complete Lives System” of medical care where resources are directed to those with “future usefulness.” Dr. Emanuel proudly claims he wants to die at 75 years of age. Tell that to the countless lives Mother Teresa transformed when she was her 80s. Tell that to John Glenn, who went back into space for 9 days at 77, and to the 20 million other over-75 disposables—or should I say, recyclables.

Quite coincidentally, eliminating the over-75 crowd from the insurance pool would help fund government-sponsored insurance for this country’s remaining uninsured. In other words, hurry up and die before the Medicare program goes bankrupt.

My gratitude goes to those congresspersons who recognize that our elders need protection. Given that the federal trust fund that finances much of the Medicare program is projected to run out in 2026, let’s hope these compassionate people realize that the first losers of Medicare for All are our elders.

Bio: Dr. Singleton is a board-certified anesthesiologist. She is 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, Medicine, Op-eds, Politics

Judge Kavanaugh’s Character Assassins Could Be Controlling Your Medical Care

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by Marilyn M. Singleton, MD, JD

Our legislators have been at their worst over the Supreme Court confirmation of Judge Brett Kavanaugh. What a shameful display: condescending, arrogant show-boating senators questioning him in a manner reminiscent of the Grand Inquisitor. The only things missing from this B-grade movie were the rubber hoses and interrogation lights. Some of us remember that you could count on one hand the “nay” votes for the confirmations of ACLU attorney Ruth Bader Ginsberg and known conservative Antonin Scalia.

This last-ditch effort to derail Judge Kavanaugh’s confirmation is more than mere political theater; the interrogators are immoral and beyond hypocritical. The “Lion of the Senate,” Ted Kennedy, killed a woman and former Senate majority leader Robert Byrd was an Exalted Cyclops in the Ku Klux Klan, and we all know about President Clinton. But that’s okay; their lapses in judgment were somehow worth our compassion and forgiveness.

Imagine if these political hacks were in charge of your medical care. Medicare-for-All as planned is the exclusive purveyor of medical “benefits.” If you want a medical service they do not want you to have, you are on your own.

The government is already shaping the way we use medical services. The Palliative Care and Hospice Education Training Act (PCHETA), S. 693 and the companion bill H.R. 1676 passed by the House and is now before the Senate Health, Education, Labor, and Pensions (HELP) Committee. This bill dedicates $100 million in additional taxpayer dollars to persuade patients to forgo treatment that might prolong life in exchange for a steady stream of increasing doses of narcotics. Perhaps knowing that many physicians still adhere to the Oath of Hippocrates, the legislators included multiple non-physicians and non-medical personnel as recipients of these funds.

Including outsiders in decision-making must be undertaken with caution. Hospice/palliative care has become the new growth industry in our “health system.” Compared to home health care, hospice had significant growth in 2017 – increasing 6.5 percent in one year. Further, according to the Medicare Payment Advisory Commission the “Increase in hospice is driven by for-profit providers” which made up two-thirds of the 4,400 hospices in 2016.

Why direct $100 million for a new medical specialty in relieving pain and suffering, a skill all physicians should embrace as part of a comprehensive treatment plan? The focus on palliative care may be one more bipartisan incremental under-the-radar step along the road to government control of our medical care. Subtly devaluing life softens us up and primes the pump for rationing – without having to pass a sweeping single payer bill that is bound to draw attention and criticism.

Ironically, within days of passing the Palliative Care bill, the Senate passed a huge package of some 70 bills designed to reduce opiate abuse. Unafraid to practice medicine without a license, the Senate legislated prescribing mandates and penalties for failure to comply. And the government is developing a “system of care” where all people will receive “appropriate” and “evidence-based” care for pain.

So now physicians may be under pressure to relinquish their patient to a palliative care specialist and prescribe medications according to government dictates. This is wrong. Our patients must never have any doubts that every treatment their physician administers is in their best interests.

We must not allow the whims of politicians to direct our medical care. Physicians must refuse to be tools of the government. Patients must decide whether they want their tax dollars spent on developing cures and life-saving treatment – or programs that steer them toward the least costly alternatives.

Can we trust our medical care to legislators who are willing to sacrifice their integrity on the altar of partisan politics — legislators who are willing to destroy a man’s life in their naked quest for power? Can we trust that doctors who oppose their agenda will not be treated like Judge Kavanaugh by medical boards, hospitals, and courts?

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, Healthcare Reform, Medical Ethics, Medicare, Medicine, Op-eds

You’re Old, You’re Sick, Get Over It

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

Senior citizens, don’t be fooled. The federal government asserts that Medicare sets a high bar for medical care and we are lucky to have it. Not so. It does, however, claim a virtual monopoly on health insurance coverage for all eligible persons.

All citizens who receive Social Security or Railroad Retirement Board benefits automatically receive a Medicare Part A card in the mail around their 65th birthday. Part A covers hospital, hospice, and limited skilled nursing services. This entitlement has very long strings attached. If retirees disenroll from Medicare Part A they lose future Social Security benefits and must return all past benefits. Even working seniors enrolled in Medicare or collecting Social Security cannot participate in Health Savings Accounts (HSA)/high deductible health plans.

Most new Medicare eligibles also automatically receive a Part B card (coverage for physician services and outpatient injectables, particularly cancer medications). Part B is voluntary and recipients are advised they can send the card back if they want to opt out. Medicare warns that a late enrollment penalty awaits the tardy: the monthly premium for Part B may go up 10% for each full 12-month period that they could have had Part B, but didn’t sign up for it—in perpetuity.

Bullying aside, it sounds pretty good. But Medicare, whose expenditures are 15 per cent of the federal budget, faces financial challenges, mainly due to our aging population. When Medicare started life expectancy was 70 years. Now it is 78.8 years. In 2012, per person personal health-related spending for the 65 and older population was more than 5 times higher than spending per child and 3 times the spending per working-age person. The Medicare Board of Trustees 2015 report estimates that under current law the Medicare trust fund will become insolvent in 2030.

Enter the Medicare hospice benefit in 1982. Policymakers believed this program would lower costs by reducing “aggressive” end-of-life treatments. With hospice care, Medicare pays a daily rate for services to persons with life expectancies of 6 months or less who choose to forgo life-saving or potentially curative treatment for the presumed terminal illness and related conditions.

But Medicare hospice expenditures are rising. Realistically, it isn’t easy to predict who will live and who will die and when. Not only has the number of Medicare hospice patients with not immediately terminal conditions such as heart failure and dementia dramatically increased, 19 percent of such patients receive services for much longer than 6 months.

The renewed focus on Medicare cost containment has produced various suggestions, including vouchers, tax credits, extending income-based premiums, increasing the eligibility age, and allowing contributions to HSAs in retirement.

Expanding HSAs presents the best opportunity to regain real choice and control over our medical care consistent with one’s personal values.

Instead, a culture of hastening death has gradually evolved, disguised as “death with dignity.” First, California, Colorado, Oregon, Washington, Montana, and Vermont have legal physician-assisted suicide, with 20 other states considering legalization. Second, when older folks fall ill, despite the uncertainty of medical prognosis, some families feel they are not merely offered hospice as a choice but are steered toward it. Third, disturbing news articles report hospice treatment plans for those who aren’t dying fast enough: “pain management” in terminal doses.

Finally, money talks. In the hospice program, if the patient goes to the hospital and the hospice “provider” (not one’s own physician) did not make the arrangements, the patient might be responsible for the entire cost of the hospital care. Additionally, the Affordable Care Act created a Patient-Centered Outcomes Research Institute. The Institute investigates the effectiveness of various medical interventions, but is prohibited from treating “the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.” However, the data may be used to determine coverage and payment rates. The patient can choose a federally determined “low-value” service, but the cost would be prohibitive. And the low physician payment rates will ensure that physicians’ practices will not be actively seeking such patients. It is an empty choice.

One day in the hospital costs Medicare about $708. One day in hospice costs $183. One hundred twenty morphine tablets cost $20.88 retail. Health Savings Account money in the bank creates real options. But if you leave the choice up to the government, with a roll of the dice you could figuratively be in Jail rather than passing GO and getting another turn at life, just like in the game of Monopoly.

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

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