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COVID-19, Current Events, Featured, Op-eds, Politics, What's New

Lowering the Barr

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The excoriation of Attorney General Barr at the congressional hearing was as low as politicians could go on the lack of humanity and civility scale. The Barr hearing was more like a Roman circus than a search for answers to important national issues. If this is what congress calls performing their duty under the Constitution, we are in for real trouble. Finger wagging, talking over, showboating, and developing soundbites for their reelections are not a search for truth.

It appears some congresspersons had been to a training session where they were told to call Attorney General Barr “Sir” as an expression of contempt, not respect. Chairman Nadler advised him that “our members expect sincere answers today and our country deserves no less.” However, unfriendly congresspersons continually asked questions in the form of statements and as Attorney General Barr began to respond, the congresspersons instantly interrupted him by “reclaiming their time.” To his credit, Attorney General Barr calmly responded, “but this is a hearing. I thought I was the one that was supposed to be heard.” Accusing someone of a crime and then gagging him officially crosses into Stalin’s henchman’s “show me the man and I’ll show you his crime” territory. 

Two moments sank to a new low. Referring to Attorney General Barr’s kind words about the recently departed John Lewis, Rep. Cedric Richmond obnoxiously declared, “you should [sic] really should keep the name of the honorable John Lewis out of the Department of Justice’s mouth.” Descending into the realm of subhumans, Chairman Nadler refused to grant Attorney General Barr a 5 minute break after hours of grilling. Refusing someone a (likely bathroom) break is a tactic straight out of enhanced interrogation techniques for dummies. 

The next day, during a congressional hearing on anti-competitive activities, the four “Big Tech” CEOs of Amazon, Apple, Facebook, and Alphabet (Google) were treated with kid gloves by all but a few congresspersons. Perhaps to protect a large source of campaign donations, denials of bias were allowed to go unchallenged despite evidence to the contrary.

 Concurrently, physicians trying to save their patients’ lives are being “cancelled.” YouTube removed as “misinformation” videos of the physicians who advocated for the use of hydroxychloroquine for early treatment of COVID-19, based on their extensive personal as well as international treatment successes. Hydroxychloroquine is an FDA-approved medication with a 65 year history of safety—not morning glory seeds. 

With all the garbage on Twitter, the removal of the physicians’ video based on the justification that it did not comport with World Health Organization (WHO) recommendations seems extreme. Recall that WHO also did not recommend wearing masks, the new Holy Grail of COVID-19 prevention. And are we to believe the same crowd who excoriated President Trump as racist for blocking travel from China at the end of January while they were encouraging people to frolic in crowded Chinatown in late February? 

Let’s look at a couple of examples of accepted medical tenets that were initially dismissed. Dr. Ignaz Semmelweis, a Hungarian physician, famously was ridiculed for advocating handwashing after performing autopsies before touching living patients. In less than 6 months after handwashing was instituted, post-partum (childbirth) fever mortality rates dropped 90 percent, from 18.3 percent to less than 2 percent. Despite the evidence, he was vilified and eventually was admitted against his will to an insane asylum where he died 2 weeks after being severely beaten. Now, failure to wash hands is unthinkable.

More recently, in the mid-1980s Dr. Barry Marshall was convinced that stomach ulcers were caused by bacteria, rather than the stress, acid, and spicy foods theory. Resistance was fierce: “Everyone was against me. But I knew I was right.” Finally, he drank a Petri dish with some thousand million bacteria, including cultured Helicobacter pylori and shortly developed documented stomach ulcers. Dr. Marshall received the 2005 Nobel Prize for this discovery.

Given that other prior coronaviruses, MERS (2012) and SARS (2003) still pop up, it is likely that the SARS-CoV-2 virus that causes COVID-19 will be with us for the foreseeable future. Accordingly, physicians want safe, affordable (less than $30 per full treatment), readily available COVID-19 treatments for their patients. Hydroxychloroquine—not a big Pharma moneymaker—is effective for many patients and physicians with experience simply want to educate others about another weapon in the fight against an ugly virus.

The vitriol and disregard for fact-finding on the part of congresspersons and the dissembling on the part of the social media giants leaves one wondering: Do the people who savaged Attorney General Barr and gave big tech a pass want people to live in fear of living life? Do they want people to be unemployed and dependent of the government for survival? Do they want children to stay home from school and regress from normal childhood development? Do they want the country’s economic boom to remain in the rear view mirror? Would they allow people to needlessly die in order to gain political power?

COVID-19, Culture & Society, Featured, Media & Press, Medical Ethics, Medicine, Op-eds, Politics, What's New

COVID-19 and the Universal Health Scare

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Politicians are a strange lot. Not content with merely being Speaker of the House, Nancy Pelosi is moonlighting as Surgeon General, opining on what medications the President should be taking. Service to the public is a distant memory. The new charge is to invent catchy phrases, like the “new normal,” to quietly coax us into obeying dictates, while ignoring facts and science.

It is not normal to base lifting the lockdowns on the trend in positive novel coronavirus (aka SARS-CoV-2) tests. Predictably, positive tests (with many folks never becoming symptomatic) will continue to increase as more tests are done. Given that the stated goal of lockdowns was to lessen the strain on hospital resources, using hospitalization trends makes more sense.

It is not normal for New York and Minnesota governors to insist that COVID-19 patients be admitted to nursing homes, even after it became clear that nursing homes were a hotspot for infections and up to 81% of COVID-19 deaths.

It is not normal for healthy people to walk around wearing masks—particularly when it is not recommended by the sainted World Health Organization.

It is not normal to never see your parents, children, or grandparents. Older folks suffer from loneliness in the best of times.

It is not normal for children to stay home from school indefinitely. When children do go back to school, it is not normal to tell them they have to wear masks and might not be able to play or eat with one another. Meanwhile, the CDC’s latest report tells us that the infection fatality rate for those aged 0-49 years is 0.05%. The CDC’s latest numbers are what Stanford researchers predicted in April.

It is not normal to have cellphone apps that track your movements. I suppose helicopter parents and stalkers would make good use of them.

It is not normal to propose “immunity passes” enabling the holders to move about society unimpeded. Immunity passes make no scientific sense given that the serology tests are unreliable, the length of immunity to SARS-CoV-2 is unknown, and invites social stigmatization.

The real “new normal” is politicians being blatant with their old games. It is normal for California’s Governor Newsom to make a secret $1 billion deal with BYD, a Chinese-based electric bus maker, to manufacture N95 masks at $3.30 a piece. Kudos to his fellow Democrat legislators for seeking transparency about his pandemic spending spree. To his credit, Los Angeles Mayor Eric Garcetti purchased 24 million “Made in America” masks from Honeywell at 79 cents a mask.

COVID-19 is a handy justification for Congress to promote a political ideology rather than propose targeted measures to assist those struggling with the consequences of the virus. The HEROES Act, the fourth stimulus bill, presents a path to universal basic income by paying some workers more to stay home than they would receive by returning to work. The CARES Act suspended student loan payments, but the HEROES Act paves the way for free college tuition for all by forgiving up to $10,000 of student loans for every borrower.

Moreover, the HEROES Act contains a multitude of other agenda-driven programs like access to financial services and the marketplace for minority-owned cannabis-related businesses, diversity in banking, a Post Office bail-out, $50 million to the Environmental Protection Agency for environmental justice grants, economic impact payments to illegal immigrants, permanent voting by mail, and the clearly relevant requirement that the President inform Congress of the reasons for not filling a vacancy for an Inspector General position.

The proposed Medicare Crisis Program Act of 2020 would provide health insurance for those who lost their health insurance due to the COVID-19 lockdown and its consequences. We want to help those who lost their jobs, but why use a newly-minted premium-free Medicare program as the vehicle? Is it to get people accustomed to Medicare covering all age groups?

The CONTACT initiative requires the CDC to work with states to implement a national system for testing, contact tracing, surveillance, containment and mitigation of COVID-19. (Have we done this for the infectious and deadly flu?). The CDC regulations, instruct authorities to use the “least restrictive means” in implementing public health measures. However, “when an individual is identified as a threat to the health and welfare of others, such as refusing medical treatment at a healthcare facility and refusing to self-quarantine, the government may take the individual into custody.”

The government has been known to abuse its power—whether through cultivating fear, regulatory force, or by individual miscreants. Frederick Douglass warned, “Find out just what any people will quietly submit to and you have the exact measure of the injustice and wrong which will be imposed on them.” We cannot let a declaration of a public health emergency become the new gauge of what it takes to break our spirit of liberty.

COVID-19, Culture & Society, Current Events, Medicine, Op-eds, What's New

Hoarding Toilet Paper is Not the New Normal

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By Marilyn M. Singleton, MD, JD

During my last visit to the grocery store, after directing me to the hermetically sealed conveyor belt, the clerk grinning proudly said, “welcome to the new normal.” No, thank you. These ad hoc restrictions on our liberties are not normal—at least in the United States of America.

In the name of public health, prisoners have been released from jail, physicians are being restricted in what drugs they can use to treat their COVID-19 patients, and cancer patients are having their treatments delayed as “elective.”

Every day 7,400 people die in the United States from many causes, including infectious diseases, but running totals are not broadcast on every medium. The unceasing barrage of news programs about the coronavirus/COVID-19 have become a means to whip us into submission.

The mayor of Los Angeles is perversely proud that 99 percent of “non-essential” businesses are closed and threatens to sue those who have not closed. A local town has issued 129 citations at $1,000 a pop for non-compliance. Riverside county plans to cite residents witnessed to have their faces uncovered.

Obamacare’s architect, Dr. Ezekiel Emmanuel, has suggested that the country stay on lockdown for one and a half years, or “until we find a vaccine or effective medications.” This is lunacy.

According to a Kaiser Family Foundation poll, 40 percent of women, 37 percent of men and nearly half of parents with a child younger than 18 years old report they have either lost their job, income, or had their hours reduced without pay. A classic 1979 study found that for every 10 percent increase in the unemployment rate, mortality increased by 1.2 percent, cardiovascular disease by 1.7 percent, cirrhosis of the liver by 1.3 percent, suicides by 1.7 percent, arrests by 4 percent, and reported assaults by 0.8 percent. Pre-pandemic, nearly 20 people per minute were physically abused by an intimate partner in the United States. Predictably, episodes of domestic violence and child abuse have now increased. Closed businesses have become easy targets for thieves.

There is a rational course of action without shutting down human contact and the economy. Sweden has no more deaths or symptomatic infections per capita than many other countries despite choosing to merely encourage its citizens to physically distance as much as possible.

We must allow physicians to treat their patients as they see fit with effective drugs. Multiple physicians around the world are reporting success with hydroxychloroquine: a new off-label use for this FDA-approved drug for a new virus. If this virus is akin to Armageddon, then all reasonable ideas should be welcomed. The erection of barriers to the use of this potentially life-saving drug by many governors and state medical boards is appalling and unforgiveable. Hydroxychloroquine was approved for medical use in the United States more than 60 years ago. It has been safely used for years for malaria prophylaxis, autoimmune disease, and porphyria, a blood disease affecting hemoglobin (that carries oxygen to our tissues). Hydroxychloroquine is on the World Health Organization’s List of Essential Medicines, the “most effective and safe” to meet the most important needs of a health system. Widespread use of this inexpensive drug could obviate the need for ICU beds and ventilators.

In addition to early treatment, we must have a rational policy for getting people back to work. All states are not affected equally. Let’s test every working person for antibodies to the SARS-CoV-2 virus that causes COVID-19. We may find that many have had an asymptomatic infection. These immune individuals will not pass the disease to others. At-risk individuals can choose to stay at home.

Ending the lockdown is not about Wall Street or disregard for people’s lives; it about saving lives. Advanced stages of non-COVID diseases, suicides, domestic violence, increase in substance abuse and mental health disorders, permanent poverty, and dissolution of the middle class are unacceptable. Our society must not be fractured into those who live in gated communities and those who live in the streets, trailer parks, and decaying homes that they can no longer afford to keep up.

We all want to do our part to attenuate the number of serious COVID infections in our communities. But we cannot hand our lives over to the government, particularly when the virus has become an opportunity for Congress to pass pork-filled legislation, for showboating governors to out-quarantine each other, and for politically connected tech companies to share cell phone tracking data with the government. I would hate to think some have a financial incentive for promoting a yet-to-be tested and approved vaccine in lieu of an effective, inexpensive and readily available treatment.

People are saying America will never be the same. Hopefully, this will not mean the statists have succeeded in using COVID as an excuse to enact laws that will permanently curtail our liberties and freedom to practice medicine in the best interest of our patients.

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, Law, Medical Ethics, Medicare, Medicine

The Medicare Bundlers and Bunglers Are Coming!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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