Volume 75, no. 4
At first, the great transition looked academic and boring.
In the late 1970s, protocols for the evaluation and management of the most common presenting complaints at the Tucson Veterans Administration Medical Center’s walk-in clinic were branched-chain algorithms in little spiral-bound books, meant for nurse practitioners. Each of the 12 had its own checklist in microprint for the chart note. During the study, the practitioners got a paper “error statement” if they didn’t follow the algorithm. Some results of the study—decreased costs because of ordering fewer diagnostic tests—were reported (Medical Care 1983;XXI:157-167). The main result was not mentioned—the algorithms and checklists were thrown in the trash as soon as the study was done.
Now we have far more sophisticated computers, with dropdown menus, which don’t allow one to proceed if key items are missing, and the ordering of many diagnostic tests is blocked by a need for prior authorization. All “providers” are equally constrained by the electronic medical record (EMR), and the consequences of not meeting “quality” metrics involve pay cuts and exclusion from networks, not just “educational” messages. The whole billion-dollar computer system might be trashed—only to be replaced by another.
Are we now doing better with the diagnosis and treatment of headache, back pain, dizziness, chest pain, abdominal pain, cough, or even sore throat? There is no reason to think so. Yet physicians are being replaced by “midlevel” practitioners. The doctor’s main function may be to assume the liability for tragic results of errors.
In Whom Do You Trust?
Because of the upheaval in American medicine, the American Board of Internal Medicine Foundation focused on “trust in health care” at its 2018 retreat, and a JAMA series of Viewpoints is emerging. The first, by Thomas H. Lee, M.D., of Press Ganey, concerns a “framework for increasing trust between patients and the organizations that care for them” [emphasis added]. Trust is at risk and must be re-built. Patient-physician relationships are not enough; patients must trust the “overall team,” and provide feedback on “coordination of their care” (JAMA 2/12/19).
In a case extensively discussed on Sermo, the supervising physician was named in a $6 million lawsuit, but not the nurse practitioner who misdiagnosed a fatal pulmonary embolus.
In the absence of a lawsuit, the doctor is likely anonymous. A member of a Medicare Advantage plan refers to her nurse practitioner gatekeeper, whom she does not like but cannot change, as her “doctor,” and does not know who the supervising physician is. She just sees many specialists to whom the nurse refers her.
A physician consulted by the desperate mother of a man declared brain dead was unable to help and was thrown out of the patient’s room, in a Catholic hospital in Arizona, for praying. As the patient was dehydrated and starved for 15 days, with no advance directive and against the wishes of the next-of-kin, it was not possible to speak to the attending physician or request a second opinion on the diagnosis.
A physician, who was concerned about her mother’s nutritional and other needs in a hospital where she was apparently captive in Florida, was unable to speak to the attending physician. “They play musical doctors,” she said.
Who’s the Patient?
Under the new medical ethics, population health and “equity” are the desired outcomes—not the optimal care of the sick. The Good Samaritan, according to bioethics pioneer Albert Jonsen, Ph.D., former S.J., must be concerned about an infinite line of suffering people outside the doors of clinics all over the world (The New Medicine and the Old Ethics, 1990). Quality metrics are mainly risk-factor metrics: blood pressure, Hgb A1C, BMI, smoking, lipid levels, and vaccination status. Ultimately, government agencies are determining the standards, and both noncompliant doctors and patients are targeted. Sugar taxes, tobacco taxes and restrictions, and limits on care to obese persons or smokers, are increasingly implemented or proposed.
The Leading Edge of Coercion
Remember what was said about AIDS: “It’s the virus” [not the high-risk behavior that spread it]. But with vaccine-preventable diseases, outbreaks are the fault of “vaccine refusers.” It may be all right to risk catching a disease yourself, but it is unacceptable to risk subjecting vulnerable people to catching a disease from you if you ever get exposed and infected. Thus, unvaccinated children and their parents are stigmatized—and worse.
In Arizona, police in tactical gear, pointing assault rifles, kicked down the door of a home, seized three children, and placed them with strangers. Details like “concrete floors” and “clothing piles” were duly noted. After a costly, lengthy, highly intrusive process, parents might regain custody of their children. The mother had taken her unvaccinated two-year-old to a doctor because of fever, but failed to go to the ER as advised because his fever broke. To check for vaccine-preventable meningitis, police used a battering ram and guns.
Is your doctor now the government? And if you become ill and consult a physician, will she be an agent of government, who will call in “protective” services if you are noncompliant?
Notes on MMR Vaccine
While the outbreak of concern is of measles, the mandated vaccine is measles-mumps-rubella—because that is what Merck makes available. One reason for religious objection is that MMR, like varicella, Pentacel, and all hepatitis A-containing vaccines, is manufactured using human fetal cell lines. Since the abortion occurred long ago, the Roman Catholic Church does not object to use of the vaccine, although some individuals apparently apply the “fruit of the poison tree” concept. Morality aside, the vaccine contains “unacceptably high levels of fetal DNA fragment contaminants” (Issues Law Med, Spring 2015). According to Theresa Deisher, Ph.D., human fetal DNA is “a very strong proinflammatory trigger.” She notes that “strong change-point correlation exists between rising autism rates and the US vaccine manufacturing switch from animal-derived cell lines for rubella vaccine to human aborted cell lines in the late 70s.” She advocates returning to animal cell line derived rubella vaccine, and splitting MMR into three individually offered options, as done in Japan.
The flawed Danish MMR study cited last month, based on the stated confidence intervals, did not have the statistical power to rule out a risk of vaccine-induced autism of 1 in 3,000, or in some subgroups as high as 1 in 130.
A person twice vaccinated with MMR contracted measles and transmitted it to four other patients, who were also fully vaccinated or had presumptive evidence of immunity, during a 2011 outbreak in New York City.
Death by 1,000 Clicks
According to a Mar 18 article in Fortune, the “virtual magic bullet” of the EMR is, 10 years and $36 billion later, an “unholy mess.”
Physician Time: Physicians spend more time with the EMR than interacting with patients.
Data Sharing: More than 700 vendors don’t communicate with each other. Doctors still send data by FAX or CD. Even vice President Joe Biden could not get his son’s records when he was dying of a glioblastoma. Clinicians write critical information on a paper towel and leave it on a colleague’s keyboard.
Cost: EMRs, initially optimized for billing, not patient care, facilitate upcoding or bill inflation.
Safety: Quantos has logged 18,000 safety events from 2007-2018, 3% of which resulted in patient harm, including seven deaths; Quantos calls the figure “drastically underreported.”
Drug Orders: EMRs failed to flag 39% of harmful medication orders in a simulation; 13% could have been fatal.
Whose Record: In some institutions, matching the EMR to the correct patient was accurate only 50% of the time.
Alert Fatigue: Overload may cause ignoring the occasional meaningful alert: 101 of a reported 170 resulted in a patient death.
“All our social problems arise out of doing the wrong thing righter. The more efficient you are at doing the wrong thing, the wronger you become. It is much better to do the right thing wronger than the wrong thing righter! If you do the right thing wronger and correct it, you get better.”
S. Stearn, Financial Times 11/10/03
ACTION OF THE MONTH
Spread the word about the AAPS 76th annual meeting scholarship essay contest for medical students and residents: top prize $500. See http://aapsonline.org/essaycontest.
Affordable Care Act (ACA): Wrong Way
ACOs: The percentage of physicians participating in ACA Accountable Care Organizations has fallen from 36% in 2017 to 28% in 2019. According to Medscape, physician participation in other payment models is: insurance, 81%; fee-for-service, 44%; direct primary care, 11%; cash-only practice, 6%; concierge practice, 2% (Becker’s ASC Review 4/12/19).
Care Restrictions: In 2010, a committee to establish restrictions to care under the “Healthy Living” initiative was set up by an Obama Executive Order as an important part of ACA. It targeted cancer survivors and patients with chronic pain, arthritis, type 2 diabetes, and “post-traumatic disabling conditions.” It promotes “self care” or meditation rather than medication. According to the Chronic Illness Advocacy & Awareness Group (CIAAG), discriminatory policies have caused “unspeakable pain and even suicide.” Patients with mobility issues are denied physician care and told to exercise more or see a psychologist. “Patients are being studied without their knowledge or consent, and without regard for their health and well-being.”
Broken Promises: Plans cancelled in 1st year, 4.7 million; average individual market premiums, up >100% 2013-2017; federal exchange premiums up $2,600 2016-2017; subsidies, $50 billion; enrollment up 3 million (https://tinyurl.com/yxb2xt43).
Flashback: Book by Leading Geneticist
H.J. Muller, who developed the dubious linear no-threshold (LNT) theory of carcinogenesis, which is now entrenched dogma, wrote the book Out of the Night: A Biologist’s View of the Future in 1936 while living in the Soviet Union. At the time he left the U.S., he was being investigated by the FBI for allegedly being a Communist. From a JAMA book review:
The title of the book suggests that humanity is emerging from the darkness of ignorance as to the mechanics of human evolution and is now in a position to direct the course of its own future evolution. Muller…regards mere negative eugenics (segregation or sterilization of the unfit) as unlikely…to advance the status of the human race. The only real advance…would result from breeding extensively from the best human types…. Selection should be based on social sense (comradeliness) and intelligence…. “How many women in an enlightened community…would be eager and proud to bear and rear a child of Lenin or of Darwin!” …[T]he book is an excellent exposition of the extreme hereditarian doctrine as held by most modern geneticists (JAMA 7/4/1936).
AAPS Calendar
May 4. Missouri chapter meeting, Kansas City, MO.
Sep 18-21, 2019. 76th Annual Meeting, Redondo Beach, CA.
Sep 30-Oct 3, 2020. 77th Annual Meeting, San Antonio, TX
AMA Supports ACA Constitutionality
Joined by some 18 other medical organizations, AMA has filed a brief amicus curiae on the side of intervenors-appellants, the State of California et al., in the case of Texas v. United States. Federal district Judge Reed O’Connor struck down ACA in its entirety (AAPS News, January 2019).
AMA president Barbara McAneny, M.D., states that overturning ACA would “wreak havoc on the entire health care system.” AMA claims that it would “adversely impact every single American.” The amicus states that Congress intended ACA to remain in effect even without the individual mandate. Among the provisions the AMA considers “fundamental to the delivery of high-quality, affordable care in this country” are: payments to states for voluntary expansion of their Medicare programs; required coverage of “essential health benefits” and preventive services, and required coverage of people with preexisting conditions. All of these things contribute to the post-ACA spike in premiums.
AAPS sent a letter to President Trump, thanking him for his decision not to defend ACA in the Fifth Circuit Court of Appeals: “AAPS opposes central planning and favors freedom. We applaud your efforts to expand options available to Americans even under ACA, which the previous Administration foreclosed. If the federal government’s interference in the states’ authority to regulate insurance and the practice of medicine ended, innovative and economical alternatives could arise rapidly in a competitive free market, based on voluntary decisions by Americans instead of special-interest stakeholders and bureaucrats.” AAPS will file an amicus brief supporting appellees.
Trump Sued over Planned Parenthood Defunding
A new rule from the Dept. of Health and Human Services would cut Title X Family Planning funding to facilities that are not physically and financially separate from abortion facilities, or that refer patients for abortion. This could cut about $60 million from the more than $500 million Planned Parenthood, the number-one abortion provider in the U.S., receives from taxpayers.
Planned Parenthood, the AMA, the state of California, and 21 states led by Oregon have filed lawsuits. “This blatant violation of patients’ rights under the Code of Medical Ethics is untenable,” stated AMA president Dr. Barbara McAneny. “The new rule imposes a government gag rule on what information physicians can provide to their patients.”
“Imagine if the Trump administration prevented doctors from talking to our patients with diabetes about insulin…. Reproductive health care should be no different,” said Dr. Leana Wen, president of the Planned Parenthood Federation of America.
Clinics will be able to talk to patients about abortion, but not where they can get one (NY Times 2/22/19).
The rule also removes the requirement that clinics must discuss all options, including abortion, so that pro-life clinics would be eligible to receive Title X funds.
Planned Parenthood claims that the rule will deny necessary health care to millions of women. In fact, fewer than 500 of 4,000 Title X service sites are Planned Parenthood facilities. The group’s “core mission” is “protecting and expanding access to abortion,” according to Dr. Wen.
NY Criminalizes MMR Refusal; Mothers Sue
Going even further than the Rockland County ban on unvaccinated minors entering public spaces during the measles outbreak, which was temporarily halted in court, New York City mayor Bill DeBlasio declared a state of emergency, requiring all persons, adults as well as children, living or working in four ZIP codes in Brooklyn, to receive MMR vaccine or prove immunity (NY Times 4/9/19). Violators may be fined $1,000 each; the law (§3.05 of the New York City Health Code) also provides for 6 months in prison. Five mothers have filed suit (C.F. v. NYC Health Commissioner) against DeBlasio’s overriding the religious exemption claimed by some Orthodox Jews.
The complaint notes that the city has failed to use less restrictive means such as isolation and quarantine. Stating that unvaccinated persons “shall be vaccinated” introduces the specter of forced vaccination, contravening the principle of informed consent, even though the MMR vaccine “indisputably carries the risk of severe injury and death to some individuals.” The city has “failed to disclose the number of cases that have been caused by MMR vaccination, i.e., vaccine-strain measles cases that occur because of viral transmission from those recently vaccinated.”
Petitioners state they are being stigmatized as a “public nuisance” though they do not have and cannot transmit measles.
According to a German news report, Holocaust survivor Vera Sharav stated in a sworn declaration that dictators always appeal to the greater good of society as they trample on individual rights. One mother complained of anti-Semitic witch hunts in Brooklyn neighborhoods. Former FDA associate commissioner Peter Pitts said he thought the penalties should be harsher: anti-vaccination parents should be imprisoned. A Jewish nurse said the solution was to build trust.
Tip of the Month: The travesty of maintenance of certification hits a new high, pun intended, by sneaking in a board certification requirement for physicians to prescribe marijuana in some states. In Oklahoma, for example, only a physician who is board-certified in his specialty may prescribe marijuana. Regardless of one’s view of medical marijuana, what possible justification is there for requiring maintenance of certification to prescribe it? No justification, but this is another gotcha to compel physicians to maintain certification. This bad smoke spread from Colorado, which also includes some board-certification requirements for medical marijuana there.
Anti-Kickback Statute and Value-Based Pay
The Stark Anti-Kickback Statute (AKS) was intended to curb self-referral in a fee-for-service system. Now the HHS Office of Inspector General (OIG) is considering revisions as part of its “regulatory sprint to coordinated care.” The merit-based incentive payment system (MIPS) by its nature contemplates “care coordination.” The AKS criminalized what would be considered innocuous business practices (e.g. referral) in other sectors of the economy. Physicians were dragged into a discriminatory system of justice when they opted into a socialized system, writes Alphonse Crespo, M.D. Safe harbors may protect some “value-based” compensation arrangements, but it’s likely impossible to be sure (DecisionHealth, April 2019).
Correspondence
Drinking Sewer Water, Not Kool-Aid. The true face of socialism is on view in Venezuela, where people lined up to get water from a sewer drain pipe during a six-day electricity outage that shut down water pumping stations (WSJ 3/12/19, tinyurl.com/y49oqf9q). The epic blackout may have been caused by lack of maintenance. The Maduro regime blamed the U.S. and arrested journalist Luis Carlos Diaz, accusing him of being part of a plot to plunge the country into darkness.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Doctors Deny Care. More Dallas pediatricians are refusing to see children who do not strictly adhere to CDC vaccination schedule. This policy gained acceptance from the American Academy of Pediatrics several years ago. Dallas-area pediatricians reportedly say “they’ve found that more and more parents want to be certain their children won’t be in a waiting room with children who haven’t had their shots, especially in light of recent measles outbreaks around Texas” (Dallas Morning News 3/10/19). There have been 0 cases of measles in Dallas, and only 11 around the state. Personally, I suspect there might be money involved. The majority of kids seen by pediatricians are on Medicaid, and the doctors can’t afford a pay cut, say for not meeting quality benchmarks.
[The Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP, contains dozens of items related to receiving vaccines within the window determined by CDC—Ed.]
Ray Page, D.O., Ph.D., Fort Worth, TX
The Network’s the Problem in “Surprise” Bills. Unexpected (“surprise”) medical bills come from out-of-network doctors and facilities. In real health insurance, the indemnity kind, there are no networks. Patients have been forced into networks because Congress imposed health plans for all Americans through the ACA. Those health plans use networks to ration care. Even though an insured patient may go to a network hospital, the emergency room doctor, radiologist, or specialist may not be part of the health plan’s network. Patients then may face a separate out-of-network deductible, which may be higher than their in-network deductible. Congress and various states are trying to impose price controls on all out-of-network doctors, essentially turning them into in-network doctors even though they have no contract with the health plan. If this happens, we expect many doctors to stop practicing altogether, reducing access to care.
Twila Brase, R.N., Citizens’ Council for Health Freedom
The Politics of EMRs. The electronic medical records project that President Obama forced on the medical profession in 2009 was predicted by a RAND study to save the country $350 billion in inpatient care and $150 billion dollars in outpatient care over 15 years. However, data from three other studies, a cardiology group, a Harvard group, and a Canadian group, showed there is no cost difference between paper records and electronic records. The EMR was also supposed to contain costs, reduce errors, improve quality, and simplify administration. This was called an “elegant exercise in wishful thinking” by the WSJ. Measures in all four areas have gotten worse. The RAND Corporation study was paid for by all the stakeholders with vested interests except physicians and patients. Epic Systems, Allscripts Healthcare Solutions, and the Cerner Corporation are the major EMR software companies who paid for the study. General Electric and health insurers were also major funders. The study sounded good to President Obama because he thought EMRs would enable the federal government to control medical practices. If EMRs hobbled the system, the population would beg the government to completely take over. The EMR project places secondary stakeholders in the position to judge physicians’ behavior and penalize them if they do not comply with government regulations.
Stanley Feld, M.D., Dallas, TX
Socialism, by Any Other Name… Some Democrats worry that their party is becoming more openly identified with socialism. For decades, its advocacy of socialism had been effectively veiled as “social justice,” as it attempted to socialize 15-20% of the economy. The Green New Deal would socialize the energy sector. Modern Democrats are authoritarians who seek to strip people of free speech rights, religious liberty, and gun rights, and to erase history they dislike. Note the Wikipedia definition: “Democratic socialism can be supportive of either revolutionary or reformist politics as a means to establish socialism.”
Joseph Guarino, M.D., Reidsville, NC
Building Socialism. In Dostoevsky’s The Brothers Karamazov, Ivan poses the question: “Imagine that you are creating a fabric of human destiny with the object of making men happy in the end, giving them peace and rest at last, but that it was essential and inevitable to torture to death only one tiny creature—that baby beating its breast with its fist, for instance—and to found that edifice on its unavenged tears, would you consent to be the architect on those conditions?” And softly, his brother Alyosha answers: No. Today’s Democratic Party says: Yes. See Gov. Ralph Northam’s remarks justifying infanticide.
Ben Domenech, The Transom