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".)

Quality Is In The Eye Of The Beholder

Dr. Saurabh Jha has penned a great essay, "Who is the better radiologist? Hint, it’s not that easy."

A couple of comments:

1) "Quality" is in the eye of the beholder.  And as the federal government starts setting more payment rules to govern "quality", that beholder will increasingly be the government.  Which won't necessarily be what patients would regard as "quality".

2) This is one of the best discussions of ROC and the trade-off between sensitivity-vs-specificity, without the jargon.

Dr. Brian Forrest on How To Start a Direct Primary Care Practice

Dr. Brian Forrest recently gave an interview with Concierge Medicine Radio on "How You Can Start a Direct Primary Care Practice for less than $10k".

Some of the topics he discussed include:

• The shockingly simple math behind how reducing overhead and eliminating collections allows primary care physicians to spend more time providing better care while improving their take home pay. 
• How Brian kept his total operating expenses to $50k in the first year and how you can too. 
• The rule of thumb Brian uses to make all his purchasing decisions. 
• The two most effective forms of advertising for Brian’s direct pay practices. 
• How to choose your billing software and Brian’s recommendations. 

For more details, listen here.  Here's more information about his particular practice, Access Healthcare.

Online Medical Shopping

The American Interest Blog discusses MediBid: "Online Shopping Finally Comes to Health Care".

More information from Kaiser Health News: "Patients Seeking Cheaper Care Are Soliciting Bids From Doctors Online."

(Via Debby Witt.)

Doug McGuff on Government Controls In Emergency Medicine

On Thursday's episode of Philosophy in Action Radio, Diana Hsieh interviewed emergency medicine physician Dr. Doug McGuff about "Government Controls in Emergency Medicine." The podcast of that episode is now available for streaming or downloading. You'll find it on the episode's archive page, as well as below. You can automatically download podcasts of Philosophy in Action Radio by subscribing to Philosophy in Action's Podcast RSS Feed:

• Enhanced M4A Feed: Subscribe via iTunes or another podcast player
• Standard MP3 Feed: Subscribe via iTunes or another podcast player

Podcast: Dr. Doug McGuff about "Government Controls in Emergency Medicine" The practice of emergency medicine is heavily regulated by the government. What is EMTALA? What are its effects? What have the effects of ObamaCare been so far? How do these laws compromise patient care and make the practice of medicine more difficult? How could emergency medicine be made more free? Dr. Doug McGuff is an emergency medicine doctor practicing in South Carolina. He graduated from the University of Texas Medical School at San Antonio in 1989, and then trained in Emergency Medicine at the University of Arkansas, where he served as Chief Resident. From there, Dr. McGuff served as Faculty in the Wright State University Emergency Medicine Residency and was a staff Emergency Physician at Wright-Patterson AFB Hospital. Today, Dr. McGuff is a partner with Blue Ridge Emergency Physicians. Diana interviewed Dr. Doug McGuff about fitness, weightlifting, and high-intensity exercise in December 2012 and about avoiding the emergency room in May 2013. Listen or Download:

• Duration: 1:11:49
• Download: Standard MP3 File (24.7 MB)
• Tags: Business, Free Society, Government, Health, Laws, Medicine, Politics

Topics:

• Emergency Medicine
• EMTALA and the history of government controls in medicine
• ObamaCare and its Accountable Care Organizations
• Practicing under ObamaCare
• Quality measures
• Government versus private insurance

Links:

• The Objective Standard: Moral Health Care vs. "Universal Health Care" by Lin Zinser and Paul Hsieh
• Western Canada Waiting List Investigators
• Surgery Center of Oklahoma
• First Choice Emergency Room
• KevinMD: ACOs and the modern day leper

About Philosophy in Action Radio

Philosophy in Action Radio applies rational principles to the challenges of real life in live internet radio shows on Sunday mornings and Thursday evenings. For information on upcoming shows, visit the Episodes on Tap. For podcasts of past shows, visit the Show Archives.

Concierge Medicine Article in Med Monthly

The medical professional magazine Med Monthly has reprinted (with permission) one of my Forbes pieces in their August 2014 issue: "Is Concierge Medicine The Correct Choice For You?"

Thank you, Med Monthly and creative director Tom Hibbard, for the wider circulation!

(Original Forbes link.)

Unintended Consequences of FDA Regulations

Eye surgeon Dr. Brian C. Joondeph described a crazy "unintended consequence" of FDA rules designed to "protect" patients.

Here's an extended excerpt from his blog post:

In my medical specialty of retina surgery, compounded and off-label Avastin is used in the treatment of macular degeneration, diabetic retinopathy, and other retinal conditions. At a cost of 40 times less than the FDA approved options, using compounded Avastin instead of the on-label expensive alternatives could save Medicare $3 billion per year. Studies have shown the lower cost Avastin is equivalent to the much more expensive Lucentis in treating macular degeneration. Many physicians will try Avastin as the first line of treatment in their patients and continue using it if it is working well.

As Avastin is being used “off-label” in a much smaller dose than used for its approved use in cancer treatment, it must be divided into extremely small doses suitable for injection into an eye. This is done by a compounding pharmacy. Most patients receive injections every four to six weeks for many years, with many physicians deciding at the time of the eye exam whether or not to give an injection. Most patients are elderly and/or visually impaired, meaning that a friend or family member brings them to their eye appointment.

Back to the FDA, which recently issued guidance in response to the new, compounding law. Specifically they “will require a patient-specific prescription for all drugs compounded.” While this may allow easier tracking of the rare cases when drugs are contaminated, it won’t alter the actual compounding process and won’t reduce the chance of contamination.

But once the retina surgeon examines the patient and determines that they need an injection, instead of using a preordered syringe from their inventory, they will instead have to send a prescription to the compounding pharmacy and have the patient return on a separate day for their injection. For a patient receiving monthly injections, this translates to 24 office visits rather than 12 each year. Depending on insurance, there may be a copayment for each visit. Not to mention the friend or family member doubling their driving duties and the physician further loading their already busy patient schedules. Imagine going to the family doctor for a flu shot and after a quick exam, having to return a week later for the shot after the doctor writes a prescription for it rather than simply pulling a vial of flu vaccine from the refrigerator and giving the injection.

The simple alternative for the surgeon is to abandon any intention of being a good steward of societal and patient monies by simply using the FDA approved, but far more expensive, drugs. This avoids the hassle of writing several hundred injection prescriptions each month and making patients return a week later for each injection. Good financial stewardship of government money loses appeal when the government complicates the physician’s business processes by such mandates. And when the government threatens physicians with a 30% cut in reimbursement via the SGR cuts, why should physicians jump through hoops to save Medicare a few dollars?

These FDA rules increase the "hassle factor" for patients and doctors. And cost more money in the long run.

Hsieh Forbes Column: "No, Gun Violence Is Not a 'Public Health' Issue"

My latest Forbes piece is now up: "No, Gun Violence Is Not a 'Public Health' Issue".

I discuss 4 reasons we shouldn't frame "gun violence" as a "public health" issue, including:

1) Gun violence is not an “epidemic”, except in a metaphorical sense.

2) If “public health” includes “gun violence”, then intellectual fairness demands that we consider pro-gun arguments as well as anti-gun arguments.

3) Expanding “public health” to include “gun violence” diverts us from genuine public health threats.

4) Guns are not the doctor’s “natural enemy.”

Although I think gun crime should not be shoehorned into the category "public health", I recognize that others may disagree. In that case, lives saved by allowing concealed carry should be just as much of the “public health” discussion as lives lost to gun violence.

For more details on each of the four points above, see the full text of "No, Gun Violence Is Not a 'Public Health' Issue".

Hiding Wrongdoing Behind "Privacy"

NPR has a good report on "When Federal Privacy Laws Protect Hospitals Instead Of Patients".

From the article:

In the name of patient privacy, a security guard at a hospital in Springfield, Mo., threatened a mother with jail for trying to take a photograph of her own son.

In the name of patient privacy, a Daytona Beach, Fla., nursing home said it couldn't cooperate with police investigating allegations of a possible rape against one of its residents.

In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.

When the federal passed in 1996, its laudable provisions included preventing patients' medical information from being shared without their consent and other important privacy assurances.

But as a litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation — and sometimes provides cover for health institutions that are protecting their own interests, not patients'...

Another issue is that patients are often being told they can't get a copy of their own medical records, in the name of "privacy"(!)

Armstrong on Halbig

Ari Armstrong takes a deeper look at the Halbig ruling in his latest post for The Objective Standard, "ObamaCare, Nonobjective Law, and Brothers' Keepers".

Money quote:

That ObamaCare pervasively violates the rights of individuals to control their own wealth and to freely negotiate terms of health insurance and health care on a free market is bad enough; that ObamaCare does so via ambiguous, nonobjective statutes is even worse. Not only through its ambiguous wording but through its deliberate deference to the whims of bureaucrats, ObamaCare substantially empowers the executive branch and hordes of bureaucrats to create whatever health policies they wish.

The basic problem is not that the Supreme Court will substantially decide how ObamaCare is interpreted. On the legal front, the basic problem is that Congress breached its Constitutional authority by ignoring its legally enumerated powers. On the moral front, the basic problem is that many American politicians—along with the Americans who voted for them—accepted the premise that, in health care, “we are our brothers’ keepers,” which now means, in practice, that elected officials, appointed judges, and unaccountable bureaucrats are to a substantial degree the keepers of each of us when it comes to health care. If Americans don’t want their health care controlled by bureaucrats, they must reject the premise that we are our brothers’ keepers and vote accordingly in the future.

Catron Vs. Roy On Halbig Rulig

Here are a few more responses to the recent federal court ruling on ObamaCare.

David Catron: "Obamacare Slowly Succumbs to Its Birth Defects" (PJ Media, 7/23/2014)

Avik Roy: "Halbig Court Opinion: A Victory For The Rule Of Law, But Merely A Speed Bump For Obamacare" (Forbes, 7/23/2014)

At this time, I think reports of ObamaCare's demise are premature.  But it's not a slam-dunk that it will survive intact either.

Halbig Ruling

Big legal news on ObamaCare. Here's a good description from Jonathan Adler, "D.C. Circuit strikes down tax credits in federal exchanges":

This morning the U.S. Court of Appeals for the D.C. Circuit released its much awaited opinion in Halbig v. Burwell.  In a 2-1 opinion, the Court held that the Internal Revenue Service regulation authorizing tax credits in federal exchanges was invalid.

Judge Griffith, writing for the court, concluded, “the ACA unambiguously restricts the section 36B subsidy to insurance purchased on Exchanges ‘established by the State.”  In other words, the court reaffirmed the principle that the law is what Congress enacts — the text of the statute itself — and not the unexpressed intentions or hopes of legislators or a bill’s proponents...

Although this decision is faithful to the text of the PPACA – that is, faithful to the text Congress actually enacted, as opposed to the health care reform some wanted or now wish they had gotten — it will provoke howls of outrage from ACA supporters.

On the other hand, William Jacobson notes: "4th Circuit upholds Obamacare federal exchange subsidy after D.C. Circuit rejects".  And related thoughts from Adler.

Given this split, the issue will almost certainly end up in the US Supreme Court.

(I also expect that many on the political Left to argue that this shows why the patchwork kludge of ObamaCare should be replaced by a simpler "single-payer" system.)

Bad Science, Bad Medicine

Forbes contributor Bill Frezza recently discussed the growth of bad science in his piece, "Bad Science Muckrakers Question the Big Science Status Quo".

In particular, he notes how a combination of publish-or-perish job pressures and the race for government grants produces an enormous amount of sloppy (and sometimes outright fradulent) science.

Fortunately, there are websites like RetractionWatch that keep on eye on scientific fraud and misconduct.

Another issue Frezza points out is the bias against privately-funded research.  One excerpt:

To make matters worse, private research dollars are being choked off by ill-conceived regulations, making researchers even more dependent on government grants, as Dr. Thomas Stossel at Harvard Medical School points out.

Stossel calls overly restrictive conflict of interest regulations “a damaging solution in search of a problem.” A self-described “typical academic socialist, totally living on grants for the first third of my career,” Stossel says his eyes were opened in 1987, when he was asked to serve on the scientific advisory board of Biogen (now Biogen IDEC), a fledgling biotech startup that went on to become a tremendous success. “I realized how fundamentally honest business people are compared to my academic colleagues, who’d run their grandmothers over for recognition.”

While working with Biogen, Stossel learned how difficult it was to translate academic research into products that actually help people. “It was during that time that conflict of interest mania emerged.” In 1988 Harvard Medical School instituted the first conflict of interest rules, largely as a result of an incident at the Mass Eye and Ear infirmary that was sensationalized by The Boston Globe.

Stossel characterizes this rationale as, “If I am paid by a corporation to do research, I am going to lie, cheat and steal.” Based on his experience at Biogen, he calls this a “total inversion of reality.” He notes that, “95 percent of the scientific papers retracted for falsification, fabrication, or plagiarism have no commercial connection.” And yet, conflict of interest rules continue to proliferate, choking off what could be a critical alternative to taxpayer funding...

In other words, "privately funded" is presumed to be corrupt whereas "government funded" is presumed noble and pure.

It's bad enough when taxpayers are obliged to fund sketchy science.  The problem gets worse when sketchy science is used to set "clinical guidelines" for physicians to follow -- guidelines that may be harmful to patients.

Dr. Robert McNutt and Dr. Nortin Hadler discuss this issue in more detail in, "How Clinical Guidelines Can Fail Both Doctors and Patients":

At best, these guidelines are recommendations based on scientific studies with results that pertain to the average among us. They do not adequately incorporate the personal differences and preferences of each of us as individuals. Furthermore, while these recommendations are based on clinical science, rarely is the science complete or incontrovertible.

Hence, the recommendations are consensus statements reflecting the perspectives of those charged with the production of the guideline. Of the thousands of clinical practice guidelines that have been produced, the majority is based on inadequate science and therefore reflects the conjecture of the “thought leaders” recruited to the task.

Unfortunately, under the new health law physician pay is going to be increasingly tied to various "quality measures" including adherence to clinical guidelines of dubious reliability. 

Do you want your physician to be rewarded for putting patients on anti-cholesterol drugs based on population guidelines that might not apply to you as an individual?  Or do you want your physician to be able to freely exercise his or her best individual discretion on your behalf? 

Physicians will be facing these sorts of questions in coming years.  You'd better hope your physician will stay loyal to you as a patient.

(National Institutes of Health; photo credit Wikipedia)

Hiding Misdeeds Behind Privacy Laws

Stewart Baker asks an interesting question in the Washington Post: "Who is protected by patient privacy laws? Hint: not patients."

He quoted from this recent Washington Post story, "VA uses patient privacy to go after whistleblowers, critics say":

Citing patient privacy, managers have threatened VA employees or retaliated against those who complain about agency misconduct, according to a key congressman and the union that represents most of the department’s employees.

“VA routinely uses HIPAA as an excuse to punish into submission employees who dare to speak out,” said Rep. Jeff Miller (R-Fla.), chairman of the House Committee on Veterans’ Affairs. He is leading a probe into the coverup of long wait times for VA patients.

David Borer, the American Federation of Government Employees’ top lawyer, listed a number of cases involving a VA claim of patient privacy used to stifle whistleblowers in a June letter to the department.

The Office of Special Counsel (OSC), which investigates whistleblower retaliation cases, is “very concerned about the misuse of HIPAA,” said Eric Bachman, an OSC deputy special counsel. “The potential chilling effect of even a small number of these HIPAA retaliation cases is a serious issue and one that should be addressed by the VA in short order.”…

Valerie Riviello is one VA employee who felt the lash of the department’s culture of retaliation.

A registered nurse at the Albany Stratton VA Medical Center in Upstate New York, Riviello said she was threatened with suspension and stripped of managerial duties after she complained last November about how a veteran was treated.

Riviello said the vet was unnecessarily restrained, with an arm and leg strapped to bedposts.

“They scared the hell out of me,” Riviello said with worry clear in her voice. “They sent me a letter saying I could go to jail.”

That threat came in the form of an e-mail to Riviello’s lawyer, Cheri L. Cannon, a partner with the Tully Rinckey law firm. The VA e-mail said that information Riviello provided Cannon “unlawfully includes medical records of a VA patient” and noted that violating HIPAA “is a felony offense subject to imprisonment and a fine of up to $250,000.”

If the government punishes whistleblowers, it's all the more remarkable that they are still willing to speak out.  Which is all the more reason to punish those covering-up misdeeds, not those doing the right thing.

Physician Autonomy Under Siege

Steve Jacob recently reported on how, "Physician Autonomy Is Under Siege".

One excerpt from a physician in the trenches:

Dr. Robert Monteiro, an internist in New Bern, N.C., said, "There is a huge amount of interference into the doctor-patient relationship, and that has a large impact on your professional satisfaction. You want to come to treatment decisions without someone telling you what to do and how to do it."

Monteiro said preauthorization for medications, imaging, and treatments requires increasing amounts of time. He said the uncompensated time required to complete paperwork associated with patient care limits patient access, because physicians run out of hours. He added that the constantly shifting insurance-plan changes and requirements can be overwhelming.

"It's as if you are playing a game and don't know the rules. Then rules constantly change and maybe you get penalized for new rules, even if you don’t know what they are. As doctors, we have no problem justifying how we take care of patients. But having to fill out a three-page form to get a generic blood thinner is ridiculous," he said.

He also linked to an article in JAMA (Journal of the American Medical Association) detailing the new pressures on physicians.

In particular, the JAMA article notes: "Clinicians increasingly are expected to substitute social and economic goals for the needs of a single patient."

Patients may want to start asking: Is my doctor really working for me?

(Link via Dr. Matthew Bowdish.)

Interview on 3 Languages of Politics

Philosopher (and my wife) Dr. Diana Hsieh recently interviewed me about "Understanding the Three Languages of Politics" 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:

How many times have you been in political discussions with friends where you find you're talking past one another? You'll make points they consider irrelevant, whereas they'll focus on issues you consider nonessential. Such problems can be overcome, at least in part, using Arnold Kling's concept of the "Three Languages of Politics."

Paul Hsieh will explain how freedom advocates (e.g., Objectivists and better libertarians), conservatives, and liberals tend to use three vastly different metaphors in political discussions, which can create unintentional misunderstandings and miscommunications. He will also discuss how to frame discussion points so they better resonate with those speaking the other "languages" without compromising on principles.

Listen or Download:

• Duration: [51:15]]
• Download: Standard MP3 File (17.6 MB)

Topics: Topics:

• About the "three languages of politics"
• The differences in the three languages
• The difference that the three languages make
• Examples of the three languages
• Conflict between camps
• Alliances between camps
• Political argument between camps
• The debates over the Hobby Lobby decision
• Using the three languages to become more persuasive
• Caveats and cautions
• Three take-home points

Links:

• The Three Languages of Politics by Arnold Kling
• EconTalk: Arnold Kling Interview

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

Volokh on Hobby Lobby

Of course the big news from yesterday was the SCOTUS ruling on the Hobby Lobby case. Here's a nice summary from UCLA law professor Eugene Volokh: "The Hobby Lobby majority, summarized in (relatively) plain English".

The decision was clearly a win for Hobby Lobby.  However, I don't know what wider ramifications (if any) it will have on the ObamaCare law.

And if you ever wondered how and why health insurance became coupled to employment in the US, here is an excerpt from a piece I wrote in November 2013, "The Only Obamacare Fix Is For Obama To Legalize Real Health Insurance":

The current system of employer-based health “insurance” is an artifact of federal tax rules from World War II. When the U.S. government imposed wartime wage and price controls, employers could no longer compete for workers by offering higher salaries. Instead, they competed by offering more generous fringe benefits such as health insurance. In 1943, the IRS ruled that employees did not have to pay taxes on health insurance paid for by employers; in 1954, the IRS made this rule permanent.

This law permanently distorted the health insurance market in favor of employer-based plans. If an employer pays $100 for health insurance with pre-tax dollars, the employee enjoys the full benefit. But if the employer pays that $100 as salary, the worker will only be able to purchase $50-70 of insurance after taxes. The law also created perverse incentives for insurers to shift as many services as possible into pre-tax plans. Gradually, they started covering not just major expenses but minor routine expenses such as immunizations and well-baby checks. (Think of what would happen to the market for car oil changes if they were offered as a tax-free benefit through your workplace.)

Over time, this tax disparity helped employer-based health insurance dominate the private insurance market. Hence, most workers don’t own their own health insurance in the same way that they own their auto or homeowners insurance. When workers change jobs, they almost always must also change health plans...

The battles over what benefits should be provided by employers would evaporate if we uncoupled health insurance from employment.  No one expects their employer to provide their car insurance or homeowner's insurance.

For some specific reform proposals, read the full text of "The Only Obamacare Fix Is For Obama To Legalize Real Health Insurance".

Why You Can't E-mail Your Doctor

From Slate: "Why you still can’t email your physicians with a simple question. (Hint: It's not their fault.)"

As an interesting contrast, many "direct pay" or "concierge" medical practices work hard to provide e-mail consultation services between patients and doctors.  These medical practices aren't bound by the same Medicare rules as many conventional practices.

Direct Pay Practice In Colorado Springs

MedPageToday recently featured a direct-pay practice by Dr. Mark Tomasulo based in Colorado Springs, CO: "Determined Doc Retrofits Family Medicine".

When the dust settles, the clinic, PeakMed, will house two conversation-oriented consultation rooms fitted with large, landscape-framing windows, and an in-house lab and pharmacy stocked with wholesale prescriptions.

"The point for me is to save you as much money as I possibly can. And provide a service to you that makes you want to come see me," he says.

Tomasulo is gearing up to treat patients in this all-in-one direct pay clinic of his own design, devoid of all third-party oversight. That also means he won't even bill insurance companies or Medicare...

Monthly subscription fees for patients will range from $25 per month for children up to 18 to $85 for adults 65 and older. Subscriptions will include unlimited office visits, 24-hour physician access, and nearly at-cost prescriptions and onsite lab work.

Tomasulo says he intends to encourage all of his patients to maintain a catastrophic policy for hospital coverage. "Our goal is to provide primary care, not all-encompassing care. It's imperative that someone has insurance. You would never want to go without insurance," he says.

I hope Dr. Tomasulo's practice thrives!

(Note: I have no commercial or other affiliation with his PeakMed practice.)

VA Scandal Whistleblower Speaks Out

CNN reported yesterday: "VA deaths covered up to make statistics look better, whistle-blower says".

One horrifying excerpt:

Beginning early last year, DeWenter said she was also instructed to hide the crisis at the Phoenix VA medical center by concealing new requests for treatment. This was at a time when the VA was paying bonuses to senior staff whose facilities met the goals of providing care in a timely manner for veterans, typically within 14 days.

New requests by veterans wanting treatment were actually stuffed into a drawer, to make the books look better, according to DeWenter.

Asked what happened to the new requests for appointments, DeWenter said: "They went into a desk drawer.... That would be the secret list."

There was "no doubt" it was, in fact, a secret list, she said.

Another excerpt:

But at least seven times since last October, records that showed that veterans died while waiting for care -- records which DeWenter personally handled and had entered in details of veterans' deaths -- were physically altered, or written over, by someone else, DeWenter said in an exclusive interview with CNN. The changes, or re-writes, listed the veterans as living, not deceased, essentially hiding their deaths.

The alterations had even occurred in recent weeks, she said, in a deliberate attempt to try to hide just how many veterans died while waiting for care, by trying to pretend dead veterans remain alive.

"Because by doing that, that placed (the veterans) back on the wait list," said DeWenter, explaining she believes that the purpose of "bringing them back to life" in the paperwork and putting the veterans back on the electronic waiting list was to hide the fact that veterans died waiting for care.

I applaud her and other brave whistleblowers for speaking out.  I hope those responsible for setting such apparently criminal policies are held fully accountable.

And a couple of other related stories;

The Denver Post has also picked up the story of Robert LeChevalier and Monica Hughes.

Anders Ingemarson offers "A Prescription For Curing VA Care".

Hsieh Forbes Column: 8 Star Trek Technologies Moving From Science Fiction To Science Fact

My latest Forbes piece is a change of pace from the usual health policy discussion. Instead, I decided to have a bit of fun and write about, "8 Star Trek Technologies Moving From Science Fiction To Science Fact".

Some of the 8+ technologies (or story elements) of Star Trek that I discuss include:

1) Warp Drive
2) Universal Translator
3) Handheld Computers
4) Medical Tricorder
5) Energy Weapons
6) Androids
7) Teleportation
8) Intelligent Aliens
9) Other Technologies

Although some Star Trek technologies are still clearly in the realm of science fiction (e.g., the warp drive), others like the medical tricorder are coming close to reality.  And some design elements (like the flip-style communicators of Star Trek: TOS) have already come and gone as consumer products in the real world.

For more details, read the full text of "8 Star Trek Technologies Moving From Science Fiction To Science Fact".

I had a lot of fun working on this latest Forbes piece.  I hope you enjoy reading it as much as I enjoyed writing it! 

(And I'd like to thank Ari Armstrong for his blog post on Microsoft and Skype Translator that inspired this article.)

2015 Crunch

Sarah Kliff at Vox.com reports, "States don't know how they'll pay for year two of Obamacare".

Here's the introduction:

More than a dozen states decided to build new health insurance marketplaces under Obamacare. Now, they need to figure out how to pay the costs of running those massive websites.

The Affordable Care Act provided federal grant funding for states to get their new web portals up and running. The Obama administration doled out $4.6 billion in grants to states launching their own marketplaces.

But Obamacare also requires state exchanges to become self-sustaining by the start of 2015. That means every state exchange that will operate next year now needs to figure out how to pay their bills. Every marketplace needs to be able to pay staff (which sometimes number in the hundreds), maintain office space and continue running outreach campaigns to increase the insurance rate.

"There won't be any big pot of federal money," says Elizabeth Carpenter, a director at health research firm Avalere...

Like the initial "free" sample of heroin, states are finding that the downstream costs of participating in ObamaCare are more than they like.

ObamaCare Costs Rise Due to Subsidies. Unexpectedly!

The Los Angeles Times reports, "Obamacare subsidies push cost of health law above projections".

From the article:

The large subsidies for health insurance that helped fuel the successful drive to sign up some 8 million Americans for coverage under the Affordable Care Act may push the cost of the law considerably above current projections, a new federal report indicates.

Nearly 9 in 10 Americans who bought health coverage on the federal government’s healthcare marketplaces received government assistance to offset their premiums...

Premiums that normally would have cost $346 a month on average instead cost consumers just $82, with the federal government picking up the balance of the bill.  While the generous subsidies helped consumers, they also risk inflating the new health law’s price tag in its first year.

In other words, the expanded "coverage" has come at the cost of a massive redistribution of wealth through the tax system.  Those who had insurance previously are thus paying for many others' health insurance as well as their own.

CBS Cites Me on Gun Violence

I recently learned that I was cited by CBS News in their 6/11/2014 story, "Is gun violence a public health issue?"

The article covers the growing desire by some to frame gun violence as a "public health" issue. 

I'm deeply opposed to attempts to "medicalize" issues that are more properly in the realm of law enforcement -- especially when many of those advocates appear to be attempting to leveraging the (real or perceived) prestige of the medical profession to push for more gun control laws.

The CBS story also noted the following debate within the medical community:

Earlier this week at the American Medical Association's annual meeting, a fierce debate erupted over whether the AMA's Continuing Medical Education program should offer a course on gun violence prevention. Some members support the idea of integrating medical professionals -- not only mental health workers -- into anti-violence efforts. But others worry that this may put physicians in a position of becoming social workers, which is not something there is time for in a busy emergency room or doctor's office.

Controversy has also flared around the idea of whether doctors should ask patients whether they keep guns in the home. Some doctors believe it's appropriate, just like asking about other factors, like smoking or alcohol use, that impact a patient's health.

Others consider it invasive or misguided. Dr. Paul Hsieh, co-founder of a group called Freedom and Individual Rights in Medicine, argued in Forbes that it could "compromise the integrity of the doctor-patient relationship."

A majority of -- 58 percent in an American College of Physicians study -- say they do not ask their patients about guns...

I'm glad that most physicians still choose not to ask patients about gun ownership.  For more on this, see my Forbes piece from January 2013, "Why Doctors Should Not Ask Their Patients About Guns".

And I very much appreciate the exposure from CBS News!

Doctor Waits Outside the VA

The Associated Press notes, "Outside the VA, waits for doctors can vary widely".

One excerpt:

Need routine primary care? The average wait to see a family physician for the first time ranged from 66 days in Boston to just five days in Dallas, according to a survey in 15 large cities by health care consulting firm Merritt Hawkins.

And doctors are bracing for new demand from millions of people newly insured through the federal health care law.

“To say it’s an easy solution to the VA problem — we’ll just have them get care in the community — overestimates the capacity the community has to absorb these folks,” said Dr. Yul Ejnes of the American College of Physicians.

It's interesting that the waits are so long on Boston.  As CNN reported last year, (10/2/2013) this is related to the Massachusetts "RomneyCare" plan:

When the Massachusetts law kicked in, wait times to get an appointment at primary care physicians' offices increased significantly, and they've remained high ever since, according to an annual survey from the Massachusetts Medical Society. And Massachusetts has the second highest physician-to-population ratio of any state.

When patients couldn't get doctor's appointments they once again turned to emergency rooms.

One unanswered questions is how bad waiting times will get in the rest of the country as ObamaCare kicks in, given that almost every other state has a far worse physician-to-population ratio than Massachusetts.

We'll find out soon enough.

VA Scandal Updates

Yesterday, the VA released details of its own internal audit of the waiting time scandal.

One important finding: "13 percent of VA schedulers have said they were told to falsify appointment-request dates to give the impression that wait times were shorter than they really were".

As an example of other problems, the Miami Herald reported:

"One year before he was appointed senior executive physician for the Miami VA Healthcare System in 2010, Vincent A. DeGennaro surrendered his medical license in New York, stemming from a disciplinary finding in a Florida case of a patient who died under his care at a Fort Lauderdale hospital."

As Twitter reader @seven2521 noted, Dr. DeGennaro is "Banned from practicing medicine in New York, but ok to practice medicine on Veterans."

Is The Employer Mandate Dead?

In his latest piece at the American Spectator, David Catron predicts that "The Employer Mandate Is a Goner".

In particular, he notes growing chorus from thoughtful people on the political Left (as well as the Right) arguing that it will cause serious economic harm. Whether this will translate into legislative action is a separate question, of course. But it's a good start in the right direction.

(For more details, read the full text of "The Employer Mandate Is a Goner".)

Licensed Dentist Attacked for Charging Too Little

The Institute for Justice has taken on a new case, "Licensed Dentist Attacked for Charging Too Little".

Here's the video and more details about the case:



From the IJ announcement:

When is it illegal for a licensed dentist in Arkansas to clean teeth? When he also happens to be a licensed orthodontist.

In 2013 Dr. Ben Burris ran afoul of Arkansas' law when he started offering low-cost teeth cleanings at his orthodontic offices. Ben's practice Braces By Burris has 11 offices around the state. In part because of his success Ben feels a strong need to give back to the community so he started offering simple teeth cleanings for $99 for adults and $69 for kids, a fraction of what other dentists charge for the same service. He saw the program as a great way to expand access to care for Arkansans.

Within weeks, Ben was told by the Arkansas State Board of Dental Examiners that he was breaking the law and that his license would be revoked if he continued offering the cleanings. Arkansas prohibits licensed dental specialists like orthodontists from doing work outside of their specialty even though they are qualified to practice general dentistry. These kinds of restrictions arbitrarily limit access to care and drive up prices for consumers.

Faced with the threat of seeing his practice ruined and his 100+ employees out of work, Ben suspended the program.

Now Ben and his colleague Dr. Elizabeth Gohl are fighting back. Together with the Institute for Justice they filed a federal lawsuit on May 27, 2014 to defend their right—as licensed dentists—to perform basic dental services. The 14th Amendment protects the right of professionals to offer services that they are perfectly qualified to perform. This case is about eliminating irrational protectionist laws and expanding access to affordable dental and medical care for Americans everywhere.

(Related: "How Medical Licensing Laws Harm Patients and Trap Doctors", Paul Hsieh, PJ Media, 10/1/2012)

Reynolds On VA Scandal and "Greed"

Glenn Reynolds (aka "Instapundit") has a good piece in USA Today: "VA scandal exposes greedy socialism".

One important point:

People sometimes think that government or "nonprofit" operations will be run more honestly than for-profit businesses because the businesses operate on the basis of "greed." But, in fact, greed is a human characteristic that is present in any organization made up of humans. It's all about incentives.

And, ironically, a for-profit medical system might actually offer employees less room for greed than a government system. That's because VA patients were stuck with the VA. If wait times were long, they just had to wait, or do without care. In a free-market system, a provider whose wait times were too long would lose business, and even if the employees faked up the wait-time numbers, that loss of business would show up on the bottom line. That would lead top managers to act, or lose their jobs.

In the VA system, however, the losses didn't show up on the bottom line because, well, there isn't one. Instead, the losses were diffused among the many patients who went without care -- visible to them, but not to the people who ran the agency, who relied on the cooked-books numbers from their bonus-seeking underlings.

(For more, read the full text of "VA scandal exposes greedy socialism".)

Hsieh Forbes Column: Three Factors That Corrupted VA Health Care

My second Forbes piece in two days again discusses the VA health scandal: "Three Factors That Corrupted VA Health Care And Threaten The Rest of American Medicine".

Here is the opening:

Veterans Affairs Secretary Eric Shinseki has resigned in the wake of the waiting times scandal. But the problems at the VA go much deeper than a single man. His eventual successor will have his hands full dealing with the toxic combination of problems that fueled the crisis: a shortage of doctors, perverse incentives, and a widespread culture of dishonesty. And these problems could affect the rest of America under ObamaCare...

The first two of the three factors are already in play under the Affordable Care Act (aka "ObamaCare") and there are troubling early indicators that the third may take root as well.  If this happens, Americans had better watch out.

Hsieh Forbes Column: VA Denies Coverage to USAF Veteran With Brain Tumor

My latest Forbes piece is now up: "VA Denies Coverage For US Air Force Veteran With Malignant Brain Tumor".

I discuss the bureaucratic hurdles that USAF veteran Robert LeChevalier had to endure when diagnosed with glioblastoma multiforme (a very malignant brain tumor).  Fortunately, he and his wife Monica Hughes have a lot of grit and tenacity.

I'm glad to publicize their open letter to the VA, and I hope it gets some attention!

Monica also posted this photo, which I used in the Forbes article with her permission:  "Here are the 58 claims denials, totaling $250,000 of emergency care, that we have received by the Veteran's Administration. Excuse? Robb was too healthy. He hadn't sought any care at the VA in the prior 5 months. Really."

Adalja on Sovaldi

Dr. Amesh Adalja has a new Forbes piece on the innovative new drug Sovaldi: "The Price is Right: New Hepatitis C Drug is Really a Priceless Breakthrough".

From his piece:

Hepatitis C is a scourge that is the leading cause for liver transplantation infecting close to 4 million Americans and over 180 million individuals globally. The historical treatments for this virus have been long, cumbersome, and laden with horrible side effects. The newest drug in our armamentarium, Sovaldi (sofosbuvir), offers the promise of substantially shortening treatment regimens while, at the same time, enhancing treatment response. In short, this is a wonder drug that we all should be grateful to scientists for developing and pharmaceutical companies for funding...

(Read the full text of "The Price is Right: New Hepatitis C Drug is Really a Priceless Breakthrough".)

Life Imitates The Onion On Physician Satisfaction Surveys

The Daily Beast just published an interesting article on, "You Can't Yelp Your Doctor" (5/21/2014).

One of their take-home points is that some of the country’s best doctors have the worst patient satisfaction scores (and vice versa).

From the article:

Armed with the idea that “patient is always right,” Washington figured that more customer satisfaction data “will improve quality of care and reduce costs.”

That turns out to have been a bad bet.

In fact, the most satisfied patients are 12 percent more likely to be hospitalized and 26 percent more likely to die, according to researchers at UC Davis. “Overtreatment is a silent killer,” wrote Dr. William Sonnenberg in his recent Medscape article, Patient Satisfaction is Overrated. “We can over-treat and over-prescribe. The patients will be happy, give us good ratings, yet be worse off.”

It’s Economics 101. If we ask drug-addicted patients to grade their physicians on how satisfied they are with the “service,” then a high score will likely indicate they got the opposite of good medical care. It doesn’t take a genius to figure out how putting addicts in charge of the patient encounter contributes to the $24 billion in excess medical costs caused by prescription opiate abuse.

Similarly,

[U]nnecessary antibiotic prescriptions are also on the rise, adding to the deadly menace of drug-resistant bacteria. A patient demanding unnecessary antibiotics is one of the things that doctors hate most, yet nearly half of physicians surveyed said they’ve had to “improperly [prescribe] antibiotics and narcotic pain medication in direct response to patient satisfaction surveys”...

“The mandate is simple,” wrote Dr. Sonnenberg. “Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” So instead of better care and cheaper care, satisfaction scoring is making patients sicker and driving up costs...

But when physicians don’t acquiesce, they pay a price. Last year, The Atlantic profiled a physician who quit due to the pressure to prescribe narcotics. In many cases, doctors can’t keep their jobs or make partner if their scores aren’t—not just good—but stellar. And many physicians claim that hospital administrators explicitly tell them to do whatever it takes to raise scores even if it means compromising their professional standards...

Of course, The Onion was able to make a very similar point more succinctly in their satirical piece, "Physician Shoots Off A Few Adderall Prescriptions To Improve Yelp Rating" (4/17/2014):

Noting that his practice’s rating on the business review website had dipped to just 3.5 stars, local primary care provider Dr. Frank Hawley reportedly dashed off several Adderall prescriptions Monday to give his Yelp average a needed boost.

“I keep a pretty close eye on my reviews, and whenever I see my number fall below four stars I just write out a few extra Adderall or Dexedrine scripts and it’s back up in no time,” said Hawley, adding that he usually ups the dosage to 30 milligrams and makes sure to prescribe two refills to ensure he stays near the top of the local general practice rankings. “Patients are always happy when I sign that prescription slip and hand it to them—it’s pretty much a guaranteed five-star rating. In a business that survives by word of mouth, good reviews are absolutely essential.”

In addition, Hawley confirmed he hasn’t advised a single patient to exercise regularly or maintain a healthy diet since 2011, saying he learned his lesson after receiving a devastating one-star review.

Dr. Hal Scherz on the VA Scandal

Dr. Hal Scherz of Docs4PatientCare has a powerful OpEd in the Wall Street Journal, "Doctors' War Stories From VA Hospitals".

The whole thing is worth reading, but here is an excerpt:

In my experience at VA hospitals in San Antonio and San Diego, patients were seen in clinics that were understaffed and overscheduled. Appointments for X-rays and other tests had to be scheduled months in advance, and longer for surgery. Hospital administrators limited operating time, making sure that work stopped by 3 p.m. Consequently, the physician in charge kept a list of patients who needed surgery and rationed the available slots to those with the most urgent problems.

Scott Barbour, an orthopedic surgeon and a friend, trained at the Miami VA hospital. In an attempt to get more patients onto the operating-room schedule, he enlisted fellow residents to clean the operating rooms between cases and transport patients from their rooms into the surgical suites. Instead of offering praise for their industriousness, the chief of surgery reprimanded the doctors and put a stop to their actions. From his perspective, they were not solving a problem but were making federal workers look bad, and creating more work for others, like nurses, who had to take care of more post-op patients.

At the VA hospital in St. Louis, urologist Michael Packer, a former partner of mine, had difficulty getting charts from the medical records department. He and another resident hunted them down themselves. It was easier for department workers to say that they couldn't find a chart than to go through the trouble of looking. Without these records, patients could not receive care, which was an unacceptable situation to these doctors. Not long after they began doing this, they were warned to stand down.

There are thousands of other stories just like these...

For more, read the full text of "Doctors' War Stories From VA Hospitals".

(Although the story is behind a subscriber paywall, the WSJ often allows readers to type "WSJ <article title>" into a Google search window to access their "Free Pass" version.  In other words, type "WSJ Doctors' War Stores from VA Hospitals" without the quotes.)

VA vs. Single Payer?

PJ Media has published my short blog post, "VA Scandal Has Nothing to Do with Single-Payer, Say Single-Payer Advocates".

Flawed Quality

At the KevinMD.com website, Dr. Karen Sibert explains, "Why the quality measures used in health care are deeply flawed".

Given the increasing reliance on government-backed "quality" measures to control costs, doctors will be increasingly pressured to follow measures that might not actually be best for patients.

(Via Dr. Art Fougner.)

RebelMD: "The Voice of Hippocratic Medicine in America"

I've been enjoying reading some of the health care commentary at a new site, RebelMD, which calls itself, "The Voice of Hippocratic Medicine in America".

Some of their recent posts include:

"The Doctor Rebels" (Dr. Meg Edison, 5/1/2014)

"Got Cancer? Dude, Get Over It" (Dr. Jane Huges, 5/8/2014)

"Patient-Surgeon, Rebel-Doctor" (Dr. Kris Held, 5/13/2014) 

If you like what you see, here's more about them:

This is where doctors from all specialities, all ages, from all over the country can speak truth.  We’ve reached a tipping point in American medicine, the ACA only adding to the crushing regulation and mandates we face. The docs who write here have drawn a line in the sand and said “Enough. My patients and my profession matter too much to sit quietly.”

Online Firms Bring Concierge Medicine to the Middle Class

Kaiser Health News and Wired recently published a story, "Online Firms Bring Concierge Medicine to the Middle Class".

From the article:

Grand Rounds is one of many healthcare startups bringing on-demand, concierge-like services once reserved for the ultra-rich to the middle class – similar to what tech outfits like Google, Amazon, Uber, and Lyft have done for personal shopping and transportation.

These budding companies offer basic access to medical advice, appointments and other assistance. Some operate regionally, others nationally. Their services and prices vary substantially—but all aim to fill gaps in the existing health care system, in part by using the Internet.

Often they charge monthly or annual subscriptions – say $50 a month or $149 a year for primary care services -- although physical exams, surgeries, and second opinions from specialists can cost more. At Grand Rounds, an online second opinion runs $7500 and an appointment with a specialist is $200.

To the extent that the free market is allowed to operate, these services help bring quality care to willing consumers at a reasonable price.

I'd love to see these services take off (just as I'd like to see companies like Uber thrive).

Here's the official website for Grand Rounds.

Sissel's Challenge To ObamaCare

Two recent commentaries about Matt Sissel's legal challenge to ObamaCare.

The first comes from David Catron, "Iraq Vet Continues Battle Against Obamacare" (American Spectator, 5/5/2014).

Catron explains the core issue as follows:

Sissel v. HHS is the only remaining lawsuit that has any chance of actually killing Obamacare. Neither the Hobby Lobby challenge to the egregious HHS contraception mandate nor the various lawsuits challenging the IRS decision to funnel tax credits and subsidies through ineligible federal insurance exchanges have this potential. Even if the government loses all of those cases, the much-despised “reform” law will continue to bedevil us. On the other hand, if Matt Sissel prevails against the administration’s lawyers, Obamacare is history.

Sissel’s challenge to Obamacare is based on the Constitution’s origination clause, which stipulates that all tax laws must be initiated by the House of Representatives. In June of 2012 the Supreme Court ruled that the health care law’s most conspicuous provision, the individual mandate, was a tax. Pursuant to the Court’s ruling, the Pacific Legal Foundation (PLF), which represents Sissel, filed a cause of action based on the well-documented fact that the “Affordable Care Act” originated not in the House but in the U.S. Senate.

This was accomplished by a devious series of unconstitutional procedural gimmicks concocted by Harry Reid, Nancy Pelosi, and the White House. The Democrat-controlled Senate took a piece of unrelated legislation passed by the House, the “Service Members Home Ownership Act of 2009,” removed every word from the bill, and filled the empty shell with the health care legislation that was eventually passed by Congress and which its authors endowed with the Orwellian title, the “Patient Protection and Affordable Care Act.”

Thus, the “reform” law signed by Obama—a law bursting with new taxes—contains not a syllable written in the only legislative body permitted by the Constitution to pass revenue bills. A variety of Constitutional scholars have weighed in on this skulduggery, of course, including Georgetown Law Professor Randy Barnett. Barnett writes, “If any act violates the Origination Clause, it would seem to be the Affordable Care Act. The Supreme Court has never approved the ‘strike-and-replace’ procedure the Congress employed here.”

George Will has a related piece, "ObamaCare's Doom" (Washington Post, 5/2/2014).

Will notes:

Case law establishes that the origination clause does not apply to two kinds of bills. One creates “a particular governmental program and . . . raises revenue to support only that program.” The second creates taxes that are “analogous to fines” in that they are designed to enforce compliance with a statute passed under one of the Constitution’s enumerated powers of Congress other than the taxing power. The ACA’s tax, which the Supreme Court repeatedly said is not an enforcement penalty, and hence is not analogous to a fine, fits neither exception to the origination clause.

The ACA’s defenders say its tax is somehow not quite a tax because it is not primarily for raising revenue but for encouraging certain behavior (buying insurance). But the origination clause, a judicially enforceable limit on the taxing power, would be effectively erased from the Constitution if any tax with any regulatory — behavior-changing — purpose or effect were exempt from the clause.

It's entirely possible that this case may end up in the Supreme Court.  Stay tuned...

Two Doctors In WSJ

The Wall Street Journal recently published two OpEds by physicians on ObamaCare.

Dr. Scott Atlas wrote about, "The Coming Two-Tier Health System" (4/30/2014)

Dr. Daniel Craviotto wrote, "A Doctor's Declaration of Independence" (4/28/2014).

(Ari Armstrong has this nice commentary on Craviotto's piece.)