Hsieh Forbes Column: The New Congress Should Propose Free-Market Health Care Reforms

My latest Forbes piece is now up, "The New Congress Should Propose Free-Market Health Care Reforms".

Here is the opening:

As we prepare to ring in 2015, we will see a new Congress as well as a New Year. When the Republicans take over both houses of Congress, they’ll have an unprecedented opportunity to reshape the health care debate in a positive direction.

Ever since capturing the House in 2011, Republicans have voted more than 50 times to “repeal, dismantle, or defund” ObamaCare — to no avail. Opposing ObamaCare is not enough. Instead, The GOP should couple those efforts with their own positive free-market alternative to ObamaCare.

The good news is that there is no shortage of good alternatives to ObamaCare that Congress could rally behind...

In particular, I'm encouraged by the new media attention being given to alternative health care financing and delivery models such as "direct pay" primary care and "health care sharing ministries".

For more on positive free-market alternatives to ObamaCare and how Congress can promote them, see the full text of "The New Congress Should Propose Free-Market Health Care Reforms".

Consider Donating to the Benjamin Rush Institute

As 2014 draws to a close, many people are finalizing their year-end charitable deductions.

If you like to support good health policy work, consider donating to the Benjamin Rush Institute.

I've been impressed with their series of debates and panel discussions hosted at medical schools around the country, helping to expose tomorrow's doctors to a broad range of perspectives on important policy issues.

From their website:

BRI is an organization that unites medical students, residents, fellows, and doctors from across the political spectrum — as well as members of the general public — who believe that the medical profession calls its practitioners to serve their patients, rather than the government. We believe that the doctor-patient relationship is a voluntary and mutually beneficial one. Both parties have a right to enter it freely. The proper role of government is to protect this freedom, not to diminish it.

You can also see videos of talks and debates they've sponsored, including topics such as:

"Does healthcare require government intervention?"
"Sale of human organs?"
"Can the ACA be mended?"

Also, BRI is a a 501(c)3 non-profit organization, so your donations are tax deductible.

And for the month of December, all donations will be matched by an anonymous donor -- so you get twice the bang for your buck!

Here's how to donate.  I've already done so and I hope you consider doing so as well!

Podcast Interview Posted: Radiology In Practice

Philosopher Dr. Diana Hsieh recently interviewed me about "Radiology in Practice" on her live internet radio show, Philosophy in Action. You can listen to or download the podcast any time. You'll find the podcast on the episode's archive page, as well as below. About the Interview:

Most people have seen cool medical imaging devices such as CT and MRI scanners on TV shows. But what do those machines really do? Advanced medical imaging has revolutionized patient care in the past 25 years, allowing doctors to make diagnoses more accurately, quickly, and safely than ever before. Radiologist Dr. Paul Hsieh discussed the basics of modern radiology (x-rays, MRI, ultrasound, and nuclear medicine), how these different tests work, what they show about the human body, and how they help doctors take better care of patients.

Listen or Download:

• Duration: 1:17:28
• Download: Standard MP3 File (44.3 MB)

Topics: Topics:

• About radiology
• The different imaging modalities
• X-rays
• CAT Scans
• MRI Scans
• Ultrasound
• Nuclear Medicine
• PET Scans
• Interventional Radiology
• Radiation dangers
• Medical education
• Access to the radiologist
• Specialization in radiology
• Paul's work
• Paul's choice of radiology

Links:

• PowerPoint Slides
• New England Journal of Medicine: A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke
• New York Times: For First Time, Treatment Helps Patients With Worst Kind of Stroke
• Wall Street Journal: Stents Boost Stroke Recovery, Study Finds

For more about Philosophy in Action Radio, visit the Episodes on Tap and Podcast Archives.

Interview With Diana on "Radiology In Practice"

Announcement: On Thursday evening, philosopher Dr. Diana Hsieh will interview me about "Radiology in Practice" on her live internet radio show, Philosophy in Action. This episode of internet radio airs at 6 pm PT / 7 MT / 8 CT / 9 ET on Thursday, 18 December 2014, in the live studio.

If you miss that live broadcast, you can listen to the podcast later. Here's a bit more about the show:

Most people have seen cool medical imaging devices such as CT and MR scanners on TV shows. But what do those machines really do? Advanced medical imaging has revolutionized patient care in the past 25 years, allowing doctors to make diagnoses more accurately, quickly, and safely than ever before.

Radiologist Paul Hsieh will discuss the basics of modern radiology (x-rays, MRI, ultrasound, and nuclear medicine), how these different tests work, what they show about the human body, and how they help doctors take better care of patients.

To join the live broadcast and its chat, just point your browser to Philosophy in Action's Live Studio a few minutes before the show is scheduled to start. By listening live, you can share your thoughts with other listeners and ask follow-up questions in the text chat. The podcast of this episode will be available shortly after the live broadcast here: Radio Archive: 18 December 2014.

For more about Philosophy in Action Radio, visit the Episodes on Tap and Podcast Archives.

Michigan Can Assist In Real Health Care Reform

From the Detroit News: "Michigan can assist in the creative destruction of Obamacare".

An excerpt from the article:

Just like the smartphone pretty much eliminated the market for cell phones and calculators, enterprising doctors and other medical providers are starting to eliminate the demand for insurance companies and government bureaucrats to spend our health dollars for us. In Michigan, Lansing is poised to help this “destructive” process.

State Sen. Patrick Colbeck has introduced legislation to clear the way for direct primary care. For a fee, doctors deal directly with patients and bypass costly insurance or government regimes. Considering the traditional health insurance system adds about 40 percent to typical medical bills, charges to treat many common diagnoses are steeply discounted. For instance, treating an ingrown toenail costs $50 under a direct primary care doctor in Kansas. Under the traditional system, he’d have to charge $200.

This health care model is nothing new but is seeing a resurgence thanks, ironically, to a clause in the Affordable Care Act itself which Colbeck calls a “free market loophole” that he wants to drive a Mack Truck through.

The direct primary care model already has a reported half million people on board and is rapidly picking up steam with doctors, patients and even investors. It is really an offshoot of the higher priced “concierge care,” which is also gaining popularity.

From Colbeck's website:

[L]legislation sponsored by Senator Patrick Colbeck (R-Canton) to assert that Direct Primary Care Services should not treated as an insurance product was reported  out of the Senate Insurance Committee.  The purpose of the bill (SB 1033) is to assure physicians who convert their practice to a Direct Primary Care Service model that the administrative burden associated with insurance regulations will not interfere with their treatment of patients. 

Colbeck's position is absolutely right -- a "direct pay" practice should not be subjected to onerous insurance regulations.  

This approach will allow consumers and physicians to more easily contract to their mutual benefit -- saving money and lives in the process.

(Link via Dr. Megan Edison.  And if you haven't done so already, please feel free to check out her group blog on health care policy, RebelMD!)

Why Doctors' Waiting Rooms Have Such Crappy Magazines

A little change of pace from heavy health care policy: "Researchers Finally Figured out Why Doctors’ Waiting Rooms Have Such Crappy Magazines" (Slate, 12/13/2014).

From the Slate article:

Bruce Arroll, a doctor and professor at the University of Auckland in New Zealand (apparently this is a global problem) gathered up 87 new and old magazines (a number determined by "how many magazines the investigators could rustle up from family and friends") covering a variety of topics and placed them in the waiting room of his practice.

It turns out that if there are current magazines around, people steal them.

Jerks.

Here's the original British Medical Journal article: "An exploration of the basis for patient complaints about the oldness of magazines in practice waiting rooms: cohort study" (12/11/2014).

From the BMJ article:

"Figure 1. Survival probability for gossipy and non-gossipy magazines in waiting room"

Personal case example: When I went to take my father to a doctor's appointment in Los Angeles earlier this year, they had this 1987 (!) magazine in the waiting room.

I'm pretty sure this falls in the BMJ "non-gossipy" category.

Barnett on How to Finally Kill Obamacare

Georgetown University law professor Randy Barnett has a nice piece in the 12/5/2014 USA Today: "How to finally kill Obamacare".

He highlights the importance of having a positive alternative to offer to Americans.  Some of his suggestions include:

Restore the private insurance market using actuarially based insurance priced according to risk. For example, young people would pay much less than older people.

Restore consumer choice to buy true private insurance limited to the terms they want to pay for, including policies insuring only against the catastrophic health care costs, and medical savings accounts.

Increase competition by allowing state-regulated insurance to be sold across state lines so consumers can keep their policies when moving from one state to another.

Increase equity by extending the tax benefits now available only to employer-based insurance to all health insurance. Like car insurance, you shouldn't have to change health insurance policies when changing jobs.

These reforms would all be excellent steps moving us in the direction of a true free market in health care.  I hope Congress gives his ideas the consideration they deserve.

(Read the full text of "How to finally kill Obamacare".)

Alaska Doctors Overwhelmed By New Federal Rules

More consequences of various government mandates on physicians: "Alaska Doctors Overwhelmed By New Federal Rules".

From the article:

Dr. Oliver Korshin, a 71-year-old ophthalmologist in Anchorage, is not happy about the federal government’s plan to have all physicians use electronic medical records or face a Medicare penalty...

EHR,  ICD-10 and PQRS may sound like alphabet soup. But most doctors around the country know exactly what those acronyms stand for. They are programs championed by the federal government to improve quality and bring medicine into the electronic age. But in Alaska, where small medical practices and an aging physician workforce are common, the new requirements can be a heavy burden...

He says for his tiny practice, an electronic medical records system would cost too much to set up and to maintain.  “No possible business model would endorse that kind of implementation in a practice situated like mine, it’s crazy,” he says.

Korshin will lose another 1.5 percent of his Medicare payments next year for failing to enroll in PQRS, a federal program that requires doctors to report quality data.  And then there is ICD-10, a new coding system for medical bills — also set to take effect in the fall of 2015.

“This flurry of things one has to comply with,” Korshin says, “means that unless you work for a large organization like a hospital that can devote staff and time to dealing with these issues, there’s no economy of scale, I can’t share these expenses with anybody.”

The government is driving smaller independent physicians out of business, essentially forcing those who wish to practice to join large provider groups or to become hospital employees.

Why is this happening?  From an earlier piece I wrote for PJ Media on the rise of "Big Medicine":

Nor is this centralization of health care some “unintended consequence” of ObamaCare. Rather, it is an explicitly desired goal. In 2010, Obama health advisor Nancy-Ann DeParle wrote in the Annals of Internal Medicine that the health law will “accelerate physician employment by hospitals and aggregation into larger physician groups” and that “physicians will need to embrace rather than resist change.”

This consolidation of American medicine is merely a continuation of a much older strategy. In his book Liberal Fascism, Jonah Goldberg described how the Roosevelt administration sought similar consolidations of American agriculture and business during the New Deal:

[I]f you… want to use business to implement your social agenda, then you should want businesses themselves to be as big as possible. What’s easier, strapping five thousand cats to a wagon or a couple of giant oxen?

Similarly, it will be much easier for the federal government to regulate 1,000 large hospital groups and ACOs than 10,000 small private practices and independent hospitals. The New York Times notes that after physicians become hospital employees, they become much more accepting of government controls than their counterparts in private practice.

Unfortunately, physicians like Dr. Korshin and his patients will pay the price.

Hsieh PJM Column: Should You Have to Speak with Others in a Way the Government Can Understand?

My latest column at PJ Media is a change of pace from the usual health care writing. It is entitled, "Should You Have to Speak with Others in a Way the Government Can Understand?"

I discuss the demands by the federal government for "backdoor" access into your encrypted smartphone data and communications. Fortunately, Apple and Google are standing up to the government's demands.  I explain why they are right to do so.

Hsieh Forbes Column: How Mandatory Calorie Labeling Hurts Consumers

My pre-Thanksgiving Forbes column is up, "How Mandatory Calorie Labeling Hurts Consumers".

I discuss the strict new FDA rules mandating calorie counts on all manner of foods sold in restaurants, stores, etc.

These new rules will be unprecedented in scope, as the Washington Post describes:

Chain restaurants, vending machines, grocery stores, coffee shops and pizza joints will soon have to display detailed calorie information on their menus under long-awaited rules to be issued Tuesday by the Food and Drug Administration. The calorie-posting requirements extend to an array of foods that Americans consume in their daily lives: popcorn at the movie theater, muffins at a bakery, a deli sandwich, a milkshake at an ice cream shop, a drive-through cheeseburger, a hot dog at Costco or Target.

In particular, I discuss three problems with the new regulations:

1) It’s doubtful they will significantly change consumer behavior.
2) They create a significant economic burden on grocers.
3) They tilt the playing field away from fresher foods towards pre-packaged foods.

Given the federal government's poor track record in dispensing nutritional advice (e.g., promoting carbohydrates and demonizing fat), this merely reinforces a bad mindset towards food.

For more details, see the full text of "How Mandatory Calorie Labeling Hurts Consumers".

If the federal government wants a War On Bacon, I know what side I'm on.  And it's not the FDA's.

NYT: How Medical Care Is Being Corrupted

I was pleasantly surprised to see this OpEd in the 11/18/2014 New York Times by Hartzband and Groopman, "How Medical Care Is Being Corrupted".

In particular, they describe perverse incentives being imposed upon physicians to practice "cookbook medicine", often at the expense of actual patient care.

An excerpt:

Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.

For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients...

When a patient asks “Is this treatment right for me?” the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.

We fear this approach can dangerously lead to “moral licensing” — the physician is able to rationalize forcing or withholding treatment, regardless of clinical judgment or patient preference, as acceptable for the good of the population.

As always, a key principle is, "follow the money".  When the government (or insurers acting as proxies for the government) control the medical pursestrings, they'll also control medical care.  Which may or may not be the care that's right for you as a patient.

Quality Reporting Problems

Meeting "quality metrics" is not the same as providing actual quality medical care. From Dr. Arvid Cavale at Rebel MD: "The Physician Quality Reporting game hurts patients, physicians alike".

One money quote from Anders Gilberg of Medical Group Management Association (MGMA):

Medicare has lost focus with its physician quality reporting programs. Instead of providing timely, meaningful, and actionable information to help physicians treat patients, this has become a massive bureaucratic reporting exercise. Each program has its own set of arcane and duplicative rules which force physician practices to divert resources away from patient care .

In many ways, the various quality metrics are like the push for aggressive standardized testing in public schools.  The standardized tests may not reliably capture whether or not a school provides actual good education. And school districts can be tempted to "teach for the test" at the expense of doing what's best for their students.

Dr. Cavale's bottom line:

Medicine is a highly personal and individual profession, with incredible variation across specialities, regions and populations in our diverse country. All centrally planned and dictated methods, do not and cannot, provide evidence of quality of care. It is obvious to any observer that these attempts are simply methods to collect data, gain control over physicians and provide rationale for payment reductions...

Should Doctors Become Proxy Data Collectors For the Government?

The Institute of Medicine (a branch of the National Academy of Sciences) is recommending that doctors use electronic medical records "to capture patients' census tract information (to estimate their median income and for geo-coded mapping), as well as information about their financial resource strain and levels of physical activity and stress."

Furthermore, the IOM is recommending to the federal government that regulators and Medicare link such collection to financial incentives to physicians -- essentially turning them into proxy data collectors for the government:

The widespread capture of data in these eight categories, or “domains,” could be achieved by adding them to the requirements of the federal government's EHR incentive payment program, the IOM committee recommended.

The recommendations will be submitted to the CMS and the Office of the National Coordinator for Health Information Technology at HHS for their consideration as they develop requirements for Stage 3 of the EHR incentive program, according to Dr. William Stead, co-chairman of the 13-member IOM subcommittee that released the report. Stead is a professor of medicine and biomedical informatics at Vanderbilt University.

The CMS writes the rules on what providers must do to become “meaningful users” of EHRs, qualify for incentive payments and avoid Medicare penalties under the program created by the American Recovery and Reinvestment Act of 2009. The ONC sets the EHR testing and certification requirements vendors must meet so providers using their systems can meet their meaningful-use requirements.

Additional data that might be collected:

The IOM panel also recommended that EHRs and their users gather information about patients' educational status; whether they are experiencing depression; their social connections and sense of social isolation; and whether or not they're subjected to violence by a partner in an intimate relationship.

It's still unclear when and how such data might be released from patient medical records to which government agencies.

(Link via Dr. Kathleen Brown.)

AZ Approves "Right to Try"

I just learned of this bit of good election news, in the Washington Post (11/5/2014):"Voters in Arizona just overwhelmingly backed a 'Dallas Buyers Club' law":

Arizona voters on Tuesday became the latest state to approve a law providing terminally ill patients with greater access to unproven medical treatments, following in the footsteps of four states enacting similar measures this year.

Arizona's new law marks the first time a so-called "Right to Try" measure was approved by ballot initiative — and did so convincingly — after Colorado, Louisiana, Missouri and Michigan all passed laws in the past six months.

USA Today supported similar laws in its 8/17/2014 piece, "FDA vs. right to try: Our view".

For those who want to read an opposing view, see "USA TODAY flubs it big time over right-to-try laws".

WaPo On Gruber

Washington Post: "Obamacare consultant under fire for 'stupidity of the American voter' comment".

This issue has been making the rounds on social media, but finally hit the mainstream media yesterday.

The relevant quotes from ObamaCare advisor Jonathan Gruber include:

This bill was written in a tortured way to make sure CBO did not score the mandate as taxes... Lack of transparency is a huge political advantage. And basically, call it the 'stupidity of the American voter' or whatever, but basically that was really, really critical to getting the thing to pass...  In terms of risk-rated subsidies, if you had a law which explicitly said that healthy people pay in and sick people get money, it would not have passed...  You can't do it politically, you just literally cannot do it. It's not only transparent financing but also transparent spending.

Gruber subsequently apologized on MSNBC, saying that he "spoke inappropriately".

To me, it sounds an awful lot like, "I wish I hadn't said those things now that everyone knows I said them."

Armstrong on Direct Primary Care

Dr. Richard Armstrong has published a nice piece, "How Direct Primary Care Is Serving as a Health Care Solution".

An excerpt:

Combined with other straightforward alternatives to the Affordable Care Act, such as Health Savings Accounts and High-Deductible Health Insurance plans, Direct Primary Care practices could fill a glaring hole in America’s health care system by allowing patients direct access to their personal physicians for a fee comparable to what they pay for their cell phones each month.

But one potential barrier to the growth of Direct Primary Care is the question of whether these practices can be regulated as “insurers.” Direct Primary Care providers have been concerned they could be labeled by states as “risk-bearing entities” when they provide health care in exchange for a monthly fee, and thus be forced to be licensed and regulated as insurers...

Fortunately, some states (like Michigan) appear poised to recognize that these practices are not "insurance companies".  Let's hope other states (and the federal government) follow suit.

For more details on one promising alternative to ObamaCare, see the Docs4PatientCare Foundation "Physician's Prescription for Health Care Reform".

Medical IT Failures

A couple of quick links on the electronic medical records issues:

"Doctors, hospitals rethinking electronic medical records mandated by 2009 law" (10/10/2014).

The complaints focus on poorer quality care for patients and fewer medical reports while immense new financial burdens are imposed on medical providers. In addition, the new digitized system leaves millions of people vulnerable to hacker attacks.

Many of the responding physicians said they spend too much time looking at computer screens instead of the patients they are examining... [Dr. Kevin] Pho cited a study published earlier this year by the American Journal of Emergency Medicine that found doctors in community hospitals average spending 44 percent of their time in front of a computer and only 28 percent in direct patient care. 

"Why is medical IT so bad?" (11/1/2014)

Critical quote: "EMRs often hinder, not assist, the giving of medical care."

(First link via Dr. Matthew Bowdish.)

SCOTUS Updates From McArdle

Megan McArdle has a good summary of the Supreme Court's decision to review Halbig v. Burwell, which hinges on the availability of insurance subsidies on federally operated insurance exchanges.

From her piece, "Obamacare Courts Death Yet Again" (11/7/2014):

Sounds kind of boring, right?  Actually, this could severely damage, even potentially kill, Obama’s signature program...  [B]y granting cert, the Court is signaling that at least four judges are probably prepared to rule against the government.  Now, maybe they’ll change their minds later.  But I doubt it.

For more background, see her earlier piece, "Obamacare Takes a Body Blow" (7/22/2014):

This morning, a U.S. appeals court issued a ruling that could endanger, or even destroy, Obamacare. The case, Halbig v. Burwell, involved the availability of subsidies on federally operated insurance marketplaces. The language of the Affordable Care Act plainly says that subsidies are only available on exchanges established by states. The plaintiff argued this meant that, well, subsidies could only be available on exchanges established by states. Since he lives in a state with a federally operated exchange, his exchange was illegally handing out subsidies.

The government argued that this was ridiculous; when you consider the law in its totality, it said, the federal government obviously never meant to exclude federally operated exchanges from the subsidy pool, because that would gut the whole law. The appeals court disagreed with the government, 2-1. Somewhere in the neighborhood of 5 million people may lose their subsidies as a result.

This result isn’t entirely shocking. As Jonathan Adler, one of the architects of the legal strategy behind Halbig, noted today on a conference call, the government was unable to come up with any contemporaneous congressional statements that supported its view of congressional intent, and the statutory language is pretty clear. Members of Congress have subsequently stated that this wasn’t their intent, but my understanding is that courts are specifically barred from considering post-facto statements about intent...

For example, the core of the government’s case is that Congress cannot have meant to leave federal exchanges without subsidies, because without the subsidies, the insurance markets in states with federal exchanges would inevitably enter into a death spiral. And obviously Congress wouldn’t do that.

The problem, as the justices point out in their brief, is that the government has done just that...

And for what would happen if the Supreme Court rules against the government, see her piece "Questions for Obamacare Now" (7/23/2014):

In the states that don’t establish exchanges, the most likely outcome is a death spiral. For one thing, without the subsidies, fewer people would be subject to the mandate, because the cost of a policy would become “unaffordable” as the Internal Revenue Service defines it for the purposes of assessing mandate penalties. Even if that weren’t the case, without the subsidies, a lot of people would find it cheaper just to pull out and pay the penalties. The most likely people to do this? Healthy youngsters paying more in premiums than they get in health services. If they exit the exchanges, premiums will rise, and the markets will spiral downhill...

The most interesting question, I think, is what an adverse ruling would do to the insurance companies. A lot of big insurers mostly stayed out of the exchanges for the first year, waiting to see how they’d develop. Perhaps because the administration has sweetened the pot considerably for insurers over the last eight months, this year, they seem to be wading in deeper, albeit still cautiously.

But what if the pot of subsidy money starts shrinking, rather than growing? That was always going to be a problem, because the risk corridor program, through which the government has funneled many of its pot-sweeteners, ends in 2016, and starting in 2019, the law changes its indexing formula in a way that may require subsidized families to pay a higher share of their income toward premiums. This problem used to look comfortably far away, giving the exchanges some time to get their sea legs. An adverse ruling in Halbig might bring it right up close where we can see it.

If insurers start to pull out, or demand huge premium increases to stay, Obamacare’s future looks cloudier. As I’ve written before, Democrats and insurers are now locked in a sort of prisoner’s dilemma, where the benefits of staying together are probably high, but the temptation to defect may be even higher. Once one stampedes, both will head for the doors very quickly.

With new GOP control of the Senate (and the inevitable political calculations of leaders from both major political parties planning for the 2016 election), there's a lot more uncertainty now about the future of ObamaCare.

Hsieh Forbes Column: Who Hasn't Gotten Ebola

My latest post in Forbes discusses some important groups of people who have not contracted Ebola and now have the green light to resume their normal lives: "Who Hasn't Gotten Ebola".

Quick Links: Millenials, HCSMs, Quarantines

Huffington Post: "Millennials Openly Defy the Obamacare Mandate" (10/31/2014)

US News and World Report: "Can't Afford Obamacare? Consider a Health Care Sharing Ministry Instead" (10/24/2014)

AEI: "Why Ebola quarantines will grow larger — and more troubling" (10/30/2014)

Interpretation Only Genetic Services

Technology Review: "How a Wiki Is Keeping Direct-to-Consumer Genetics Alive".

The big question is whether regulators will attempt to shut them down:

Now a question is whether Promethease and sites like it could, or should, be the next target of regulators. Lennon believes his service is outside the FDA’s reach, because it doesn’t offer a spit kit or perform DNA tests itself but instead operates like a “literature retrieval service,” presenting a version of what’s in the science journals. Regulate us, says Lennon, and you’d have to shut down WebMD and Wikipedia, too.

Reached by MIT Technology Review, the FDA said it has authority to regulate software that interprets genomes, even if such services are given away free. The agency does not comment on specific companies.

Also important:

For now, consumers have to fend for themselves in a thicket of scientific information—and make their own decisions about risks.

Hsieh Forbes Column: Why You Should Be Concerned But Not Fearful About Ebola in NYC

My latest short post for Forbes discusses, "Why You Should Be Concerned But Not Fearful About Ebola in NYC".

This is obviously a rapidly-moving story.  But for now, NYC residents (and all Americans) should remain vigilant but not indulge in panic.

Quick Links: ACO Failures, Ebola Lessons

Wall Street Journal: "ObamaCare’s Failing Cost Control; The law’s ‘accountable care’ experiment is a bust so far."

Scientific American: "How Did Nigeria Quash Its Ebola Outbreak So Quickly?"

Health Care Cartels

Nice column in USA Today on how, "Health care cartels limit Americans' options".

The authors Thomas Stratmann (George Mason Univ) and Darpana M. Sheth (Institute for Justice) criticize the "Certificate of Need" (CON) laws that restrict health providers from installing new equipment without government approval.

I previously worked in a state that had CON laws  I was told that my radiology chief had clout with the CON regulators, our department could pretty much get first approval for any new technology.  But I felt bad for the other local doctors who wanted to offer such services (and their patients who might have benefitted), but who didn't have such clout.

Fortunately, my current state of CO doesn't have such CON laws.

D4PC Interviews Dr. Beth Haynes

Docs4PatientCare has a radio show, "The Doctor's Lounge".

Here's their 9/25/2014 interview with Dr. Beth Haynes of the Benjamin Rush Institute:

Join Dr. Scherz and his guest Dr. Beth Haynes, the executive director of the Benjamin Rush Institute. We discuss the need to give young doctors in medical schools the perspective regarding healthcare that they don't receive from their instructors regarding free market solutions to healthcare delivery. This is the mission of BRI and we tackle the challenges she has encountered trying to fulfill this mission.

You can listen at this link.

The Legality of Quarantines

Slate: "The rules and regulations on confining people who’ve been exposed to Ebola".

Quaranting people with serious contagious diseases is a legitimate function of government.

UK Health Strike

Labor unrest in the UK government-run health system: "Why we’re striking: NHS staff on their decision to walk out".

NHS staff in England will stage a strike on Monday in protest at a third year without a pay rise – their first over pay in more than three decades. More than 450,000 people, from cleaners and porters to ambulance drivers and occupational therapists, will be involved in a four-hour walkout.

Not Easy To Opt Out of ObamaCare Mandate

Politico reports that it will be, "A maze to opt out of Obamacare individual mandate":

Tens of millions of Americans can avoid the fee if they qualify for exemptions like hardship or living in poverty, but the convoluted process has some experts worried individuals will be tripped up by lost paperwork, the need to verify information with multiple sources and long delays that extend beyond tax season.

Some gory details:

The uninsured have two ways to opt out: The easiest way is fill out a new tax form for those exemptions that don’t require Obamacare marketplace approval. Some will be simple, including the exemption for being uninsured for under three months or those living below a certain income — about $10,150 for singles and $20,300 for married couples.

But many must be approved by the marketplace, including for people citing religious beliefs, like being Amish, or those who qualify for the dozen or so “hardships,” such as being evicted, experiencing domestic violence or having a health plan canceled because it doesn’t meet the law’s requirements.

There’s even one for being in jail, another for having medical debt and one for taking care of sick family members. An open-ended “hardship” exemption lets people try to explain situations not listed that stood in their way of coverage.

That’s where things get complicated. For marketplace approval, applicants must fill out an exemption application, gather proof of their situation, mail it off and wait a few weeks for approval.
Once they get the exemption certification number in the mail, they then fill out a newly drafted tax form to skirt the penalty.

Some math may be required: If the exemption covers only a few months of the year, the individual is responsible for calculating how much of the penalty he or she will owe...

So just think of all the "fun" you have every April 15 preparing your taxes.  And double that!

Firestone Success Vs. Ebola

NPR reports, "Firestone Did What Governments Have Not: Stopped Ebola In Its Tracks".

From the article:

Harbel is a company town not far from the capital city of Monrovia. It was named in 1926 after the founder of the Firestone Tire and Rubber Company, Harvey and his wife, Idabelle. Today, Firestone workers and their families make up a community of 80,000 people across the plantation.

Firestone detected its first Ebola case on March 30, when an employee's wife arrived from northern Liberia. She'd been caring for a disease-stricken woman and was herself diagnosed with the disease. Since then Firestone has done a remarkable job of keeping the virus at bay. It built its own treatment center and set up a comprehensive response that's managed to quickly stop transmission. Dr. Brendan Flannery, the head of the U.S. Centers for Disease Control and Prevention's team in Liberia, has hailed Firestone's efforts as resourceful, innovative and effective...

You can read more details (or listen to audio) at the link.

Hsieh Forbes Post: Did Bad EHR Lead to Ebola Patient Being Sent Home

My latest quick post for Forbes, "Did Bad EHR Software Lead to Ebola Patient Being Sent Home?"

Short answer: Maybe, maybe not.  The Dallas hospital first said "yes", then "no".

Thanks to Monica Hughes for allowing me to quote her and Dr. Matthew Bowdish for first bringing this story to my attention.

Related: "The Eyes of Big Medicine: Electronic Medical Records" (PJ Media, 8/18/2013) and "Can You Trust What's In Your Electronic Medical Record?" (Forbes, 2/24/2014)

Hsieh Forbes Column: Who Decides What Medical Care You Receive At End of Life?

My latest Forbes column was posted yesterday, "Who Decides What Medical Care You Receive At End of Life?"

I discuss how some patients in the socialized medical systems of Canada and the UK have been put on DNR ("do not resuscitate") status without their knowledge or consent and how that ties to the current debate over government-funded end-of-life counseling here in the US.

As I've said before: If you expect “somebody else” to pay for your health care, then “somebody else” will ultimately decide what care you may (or may not) receive.

I also discuss how free-market reforms for health insurance can protect patient choice in end-of-life medical decision-making.

And for some excellent practical advice on how patients can plan for such eventualities, check out this interview with Dr. William Dale by my wife Diana.

Who's Paying For Health Care?

Who's paying for health care?

According to Investor's Business Daily, the government is paying for 46% of our nation's health care, and that percentage will continue to grow.

Federal, state and local governments will spend a total of $1.4 trillion on health care this year, which will account for a record-high 46% of the nation's total health care tab, according to spending data released by the Centers for Medicare and Medicaid Services.

That's up from the government's 39% share just a decade ago, and the share is expected to hit 48% by 2023, as government programs continue to grow faster than the overall health care economy, the report found.

And of course, he who pays the piper calls the tune.

If you expect "somebody else" to pay for your health care, don't be surprised if "somebody else" decides what health care you will (or will not) receive.

Re-unite Consumer of Health Care with Payer of Health Care

Dr. Timothy Wingo explains that we should, "Re-unite the consumer of healthcare with the payer of healthcare".

He explains how in his Forbes piece, "Concierge Medicine For All: Direct Primary Care Is The Solution For Our Health Care System.

An excerpt:

However, starting several decades ago, we were sold on the idea that health insurance should cover everything including routine primary and preventive care; and once we paid our premiums, or they were paid on our behalf by taxpayers, we could expect extensive work-ups to be done with little thought of the costs.  If the additional cost to us was very little, why not?  We believed that more care was better care. Whether or not it was necessary rarely factored into our thoughts.  Doctors, needing to protect themselves from malpractice liability, and not having time to educate patients or argue, would oblige us as it also made them more money. The insurance companies, paying for all of this care, then started charging higher premiums, implementing higher deductibles, co-pays and co-insurances…and the cycle continued.

In large part because of this, doctors have faced increasing bureaucratic regulations from government and insurance companies in an attempt to control costs.  This has lead to doctors getting reimbursed very little for their time despite them spending 12-plus years in training and a few hundred-thousand dollars for that education....

This explains why doctors rush through appointments and spend very little time with patients.  In an attempt to not miss a diagnosis, not disappoint patients, and protect themselves from liability, they order multiple tests.  This makes hospital administrators all too happy. They really don’t expect to make a profit on their employed doctor’s time, they expect to make it off of the ancillary services he orders.  Some of these profit margins can exceed 10,000 percent!

So what is the solution?  Re-unite the consumer of healthcare with the payer of healthcare...

Contrasting Headlines

Here are a couple of contrasting headlines that came through my newsfeed recently.

"Peter Thiel: the billionaire tech entrepreneur on a mission to cheat death" (The Telegraph, 9/19/2014)

"Why I Hope to Die at 75" (Ezekiel Emanuel, The Atlantic, 9/17/2014)

Gunderman on How To Discourage a Doctor

Dr. Richard Gunderman describes the "playbook" of those who wish to control physicians for their own ends. His article was written about what physicians should expect from hospital executives, but it applies just as well to physican relationships with bureaucrats and others seeking to bring medical care under greater government control.

From his piece, "How To Discourage A Doctor":

Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are.

Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus...

Hence, those steps include:

• Make healthcare incomprehensible to physicians.
• Promote a sense of insecurity among the medical staff.
• Transform physicians from decision makers to decision implementers.  
• Subject physicians to escalating productivity expectations.
• Increase physicians’ responsibility while decreasing their authority.
• Above all, introduce barriers between physicians and their patients. 

He discusses each point in greater depth in the full article.

Given all this, one way for physicians and patients to best protect themselves is to allow patients to control their own medical spending. This allows doctors to treat the patient as "boss".  Various models such as Health Savings Accounts (for patients) and direct-pay practices (for physicians) work nicely together to protect that vital doctor-patient relationship. 

As Sun Tzu said, "Know Your Enemy".  His advice applies just as well today as it did in ancient China.

Venezuelan Breast Implant Shortage

The New York Post reports, "Venezuela has chronic shortage of breast implants":

Beauty-obsessed Venezuelans face a scarcity of brand-name breast implants, and women are so desperate that they and their doctors are turning to devices that are the wrong size or made in China, with less rigorous quality standards.

Venezuelans once had easy access to implants approved by the US Food and Drug Administration. But doctors say they are now all but impossible to find because restrictive currency controls have deprived local businesses of the cash to import foreign goods. It may not be the gravest shortfall facing the socialist South American country, but surgeons say the issue cuts to the psyche of the image-conscious Venezuelan woman...

As Dr. Megan Edison quipped online, "The problem with socialism is that eventually you run out of other people's breast implants."

Potential Perils of Personal Genetic Testing

Biologist "George Doe" (a pseudonym) described how: "With genetic testing, I gave my parents the gift of divorce".

I'm glad the 23andMe service allows people the option of learning about close relatives. But a couple of take home points:

1) If you get a 23andMe genetic test, make sure you really really want to know if you might have genetically close unknown relatives before you click through on that part of the results.

2) If you have a child you didn't tell your current family about, maybe you should come clean before you get your 23andMe test.

Related: "Genetic testing brings families together. And sometimes tears them apart".

Suspended Animation Update

From The Economist: "Doctors have begun human trials of suspended animation to buy more time for critically injured patients".

The article explains:

Dr Tisherman’s EPR process, developed with the help of $800,000 from the Department of Defence, is mostly about resurrection. The idea at this stage is to use equipment like the catheters and pumps that can be found in any trauma centre to suspend the life of critically injured people in order to buy more time for surgeons to try to save them.

EPR works by lowering the patient’s body temperature and replacing their blood with a cold saline solution. Hypothermia is already induced in patients to help reduce bleeding during some surgical procedures. But cooling the body down so that it goes into a suspended state has not been tried before. The idea came from observations that people have been resuscitated having stopped breathing for half an hour or more after falling into icy water.

I'm encouraged by this kind of medical advance.  One interesting quote from the article:

The Food and Drug Administration decided the procedure was exempt from informed consent, as patients would be too ill to give it themselves and might benefit because they were likely to die as no other treatment was available. For now, the patient has to be between 18 and 65 years old, have a penetrating wound, such as a knife, gunshot or similar injury, suffer a cardiac arrest within five minutes of arrival in the hospital and fail to respond to usual resuscitation efforts.

Given that these patients would like die anyways without the experimental treatment (and that they presumably want to live), one can make a much stronger case for waiving the usual informed consent in this kind of emergency than in the more-controversial UK experiment (which involves giving standard adrenaline therapy vs. placebo to cardiac arrest patients.)

For more on the latter topic, see my recent Forbes piece, "UK To Experiment on Cardiac Arrest Patients Without Their Consent".

Why Much of the Medical Literature Is Wrong

Medscape: "Why Much of the Medical Literature Is Wrong".

Topics discussed include:

1. Reverse Causality
2. The Play of Chance and the DICE Miracle
3. Bias: Coffee, Cellphones, and Chocolate
4. Confounding
5. Exaggerated Risk 

Some eye-opening examples:

Mistaking what came first in the order of causation is a form of protopathic bias.^[4] There are numerous examples in the literature. For example, an assumed association between breast feeding and stunted growth, ^[5] actually reflected the fact that sicker infants were preferentially breastfed for longer periods. Thus, stunted growth led to more breastfeeding, not the other way around...

One classic example of selection bias occurred in 1981 with a NEJM study showing an association between coffee consumption and pancreatic cancer.^[15] The selection bias occurred when the controls were recruited for the study. The control group had a high incidence of peptic ulcer disease, and so as not to worsen their symptoms, they drank little coffee. Thus, the association between coffee and cancer was artificially created because the control group was fundamentally different from the general population in terms of their coffee consumption. When the study was repeated with proper controls, no effect was seen...^[16]

[R]ecall bias, occurs when subjects with a disease are more likely to remember the exposure under investigation than controls. In the INTERPHONE study, which was designed to investigate the association between cell phones and brain tumors, a spot-check of mobile phone records for cases and controls showed that random recall errors were large for both groups with an overestimation among cases for more distant time periods.^[18] Such differential recall could induce an association between cell phones and brain tumors even if none actually exists...

A 1996 study sought to compare laparoscopic vs open appendectomy for appendicitis.^[29] The study worked well during the day, but at night the presence of the attending surgeon was required for the laparoscopic cases but not the open cases. Consequently, the on-call residents, who didn't like calling in their attendings, adopted a practice of holding the translucent study envelopes up to the light to see if the person was randomly assigned to open or laparoscopic surgery. When they found an envelope that allocated a patient to the open procedure (which would not require calling in the attending and would therefore save time), they opened that envelope and left the remaining laparoscopic envelopes for the following morning. Because cases operated on at night were presumably sicker than those that could wait until morning, the actions of the on-call team biased the results. Sicker cases preferentially got open surgery, making the outcomes of the open procedure look worse than they actually were.^[30] So, though randomized trials are often thought of as the solution to confounding, if randomization is not handled properly, confounding can still occur. In this case, an opaque envelope would have solved the problem...

The article (correctly) notes that these issues don't mean that medical knowledge is impossible -- but rather we must be diligent in looking for sources of potential error.

(Note: Reading the full text of the article requires free registration.)

Sibert Replies to Jauhar

Dr. Karen Sibert has penned a good reply to a recent Wall Street Journal OpEd by Dr. Sandeep Jauhar on the current problems with American health care.

Sibert's piece is entitled, "His diagnosis is right, but the treatment is all wrong". (Jauhar's original piece was, "Why Doctors Are Sick of Their Profession".)

Sibert discusses several important topics, including:

* The truth behind “quality” metrics
* The perils of patient satisfaction scores

She also observes:

Here is what I see as the downhill slide of 21st century medicine:

1.  The surge of uncritical belief in “evidence-based medicine” has led to rigid algorithms–cookbook recipes, really–for patient care. Experienced physicians know these algorithms are often a poor fit for patients with multiple medical problems, and must be ignored or subverted for the good of the patient.  At the same time, the physician may face criticism or sanctions for not following protocol.

2.  Bureaucrats and regulators seem convinced that if only we can produce enough care protocols, we can cut out physicians altogether and save money by having advanced practice nurses take care of everyone.  They encourage the devaluation of physician education and expertise. This seems to be the philosophy behind the proposed new VA rules which would eliminate physician supervision of veterans’ health care. (I’ll be curious to see if physician-free care will be considered good enough for the President and the Congress.)

And also:

Fee-for-service pay isn’t the chief culprit.  The best physicians stay busy because they have respect and referrals from their peers.  As they develop a base of satisfied patients and colleagues who recognize clinical excellence, they achieve financial success and have no wish to perform unnecessary procedures.  Price-fixing of physician services by third-party payers is the root cause of financial pressure to increase the number of services provided.

For more details on how our current problems and the right way to fix them, read the full text of, "His diagnosis is right, but the treatment is all wrong".

First Completely Functional Man-Made Organ

MedGadget: "Lab Created Thymus Gland is First Completely Functional Man-Made Organ"

More information from Professor Clare Blackburn:

Hsieh Forbes Column: UK To Experiment on Cardiac Arrest Patients Without Their Consent

My latest Forbes column is now up: "UK To Experiment on Cardiac Arrest Patients Without Their Consent".

Here is the opening:

Soon, thousands of UK cardiac arrest patients may find themselves enrolled in a major medical experiment, without their consent. This may be legal. But is it ethical?

As described by the Telegraph:

Paramedics will give patients whose heart has stopped a dummy drug as part of an ‘ethically questionable’ study into whether adrenalin works in resuscitation or not… Patients in cardiac arrest will receive either a shot of adrenalin, which is the current practice, or a salt water placebo but the patient, their relatives nor the paramedic administering it will know which. The trial is seen to be controversial because patients will not be able to consent to taking part and could receive a totally useless placebo injection…

First, I want to emphasize that this is a legitimate scientific question. Adrenaline (also known as epinephrine) has been a standard part of the resuscitation protocol for sudden cardiac arrest, along with chest compressions and electrical shocks. (Think of paramedics shouting “clear” on television medical dramas.) But more recent evidence suggests that adrenaline might cause more harm than good in this situation, helping start the heart but possibly also causing some neurological damage. There is a valid and important scientific question. My concern is not over the science behind the experiment, but rather the ethics...

(For more details and discussion, read the full text of "UK To Experiment on Cardiac Arrest Patients Without Their Consent".)

There are two parts of the study that disturb me the most: (1) The drug trial itself, and (2) the decision to not actively inform relatives that any patient who died had been an involuntary participant.  I cover both aspects in more detail in the piece.

Note: I'm not fully settled on what (if any) experimentation should be allowed on incapacitated patients in an emergency setting without informed consent.  But I do think this should be an issue of active discussion, especially for the people whose lives are on the line.

And for a discussion of prior US medical experiments that have been alleged to be unethical, non-consensual, or illegal, see this Wikipedia list.

More Benefits of Medical Marijuana?

An intriguing report: "In States With Medical Marijuana, Painkiller Deaths Drop by 25%".

In the study, published today August 25 in JAMA Internal Medicine, the researchers hypothesize that in states where medical marijuana can be prescribed, patients may use pot to treat pain, either instead of prescription opiates, or to supplement them—and may thus require a lower dosage that is less likely to lead to a fatal problem.

As with most findings involving marijuana and public policy, however, not everyone agrees on a single interpretation of the results...

Perhaps the science will become clearer as more states continue to legalize medical (and recreational) use.

Architecture and Hospital Rooms

The New York Times had a fascinating article on innovative thinking for hospital room architecture: "In Redesigned Room, Hospital Patients May Feel Better Already".

Some of the ideas seem simple ("same handedness", more natural light, and "double door lock boxes" for medications).  But in aggregate, they could reduce medical errors and improve patient outcomes.

I love reading about innovations in health care!

Edison on Narrow Networks

Pediatrician Dr. Megan Edison recently described what it's like to be on the receiving end of patients who lose their doctors because of ObamaCare: "Confessions of a Narrow Network Doctor".

She describes the problems patients faced by the loss of choice.  And she offers some solutions:

The solution seems so clear in my little corner of the world. I want my patients to have control over their own health care dollars regardless of employment status or political party in power. I want to work directly with my patients to help them choose how to best use those dollars in a price transparent healthcare environment. I want them to choose me. I want competition to push me to provide the best care at a good value, knowing that my patients always have a choice to see another doctor if I’m not doing a good job. In short, I’d love folks to own a high-deductible HSA for life, in a healthcare system that is transparent and competes for those dollars.

But that would give power directly to the patient and all the healthcare choices between the patient and the doctor. Turns out, there are more powerful players that want control over what happens in my office...

I recommend reading the full text of "Confessions of a Narrow Network Doctor".  If you like what you read, check out the rest of the RebelMD site!

Hughes On VA, FDA, and American Health Care

Monica Hughes recently gave an excellent talk on, "The Transformation of American Healthcare: Lessons from the Veterans Administration and Existing FDA Standards of Care" to Liberty On The Rocks at Flatirons.

Her talk is now available on YouTube (3 parts).

Part 1


Part 2


Part 3



Disclaimer and synopsis:

DISCLAIMER: The speaker is not a medical doctor or health care practitioner. The ideas in this video are not intended as a substitute for the advice of a trained health professional. All matters regarding your health require medical supervision. Consult your physician and/or health care professional before adopting any nutritional, exercise, or medical protocol, as well as about any condition that may require diagnosis or medical attention. In addition, statements regarding certain products and services represent the views of the speaker alone and do not constitute a recommendation or endorsement or any product or service.

Synopsis: In January 2014, Robb was diagnosed with glioblastoma multiforme (GBM), one of the deadliest brain cancers in existence. Nicknamed "The Terminator" the median survival time is around 11 months. Robb had brain surgery on January 16, which was performed by a team of surgeons while Robb was awake. The surgery was a success.

Monica's research into the post-surgery treatments that worked best for other survivors showed that they were not approved by the Food and Drug Administration, so they'd have to go to a cancer center that sprouted up in Tijuana, Mexico for treatment which included a 100 year-old immune system booster called Coley's Vaccine.

Bio: Monica Hughes has bachelor's, master's, and PhD degrees in biology and has taught college biology since 2006. Previously, Monica served as a medical writer for National Jewish Health, a premier research hospital for respiratory and immune disorders, and is now a patient advocate specializing in literature research.

Robb LeChevalier has served in the Air Force and has a bachelor's degree in electrical engineering. He designed his own home situated in the foothills outside of Denver, and currently develops high speed electronics for his own company, Astronix Research. He has been an Objectivist for 40 years.

More: Robb was given 2 months to live without surgery, a maximum of 6 months to live with surgery only, and an unspecified amount of time with additional therapy due to the unusually aggressive nature of his particular tumor. He and his wife Monica faced seemingly insurmountable hurdles by the Veterans Administration along the way, including timely care from the VA and a delay of emergency surgery that could have cost Robb his life had they not pushed for a special dispensation from a panel of VA doctors within the 48 hours leading up to his scheduled surgery. They are currently contesting 58 claims denials by the VA totaling nearly $250,000 in unpaid medical bills.

In the days following Robb's surgery, they discovered that immunotherapy held the best chance of long-term and quality survival for this cancer. Historical 3 year survival with FDA-approved standard of care for GBM is around 7%. 3-5 year survival for some GBM patients in clinical trials using cancer vaccines is between 20%-50%, depending on the vaccine. Yet they discovered that due to FDA regulations, it is impossible to enter these clinical trials without first or concurrently undergoing FDA-approved standard of care, and that such care would greatly reduce his likelihood of responding to immunotherapy, if he was lucky enough to meet the criteria for the study and be placed in the treatment arm of such a trial.

Given these poor odds, Robb chose to forego all standard of care therapy after surgery, and opted for an immunotherapy protocol abroad that, according to current MRI results, has left him without evidence of disease. As of June 10, 2014, their new low deductible PPO health insurance policy, purchased on the Obamacare exchange, has not paid out a single penny of reimbursement for Robb's cancer treatment.

(Note: I also discussed their case in my 5/28/2014 Forbes piece, "VA Denies Coverage For US Air Force Veteran With Malignant Brain Tumor".)