Google is universally well known as a search and advertising company. Now Google is tapping into the $3.5 trillion healthcare market. To compete with the Apple Watch, Google acquired FitBit, the wearable exercise, heart rate, and sleep tracking device. Data is king.
Voluntarily worn fitness tracking devices are one thing, but Google has entered the realm of the brave new world.A government inquiry has brought to light Google’s “Nightingale Project” that collected private medical data from Ascension Health’s 2,600 sites of care across 20 states and D.C., unbeknownst to the patients. Dozens of Google employees had access to the data which included lab results, physician diagnoses, hospitalization records, and health histories, complete with patient names and dates of birth. Google claims that the project complies with the Health Insurance Portability And Accountability Act (HIPAA) because it is a qualified business associate of Ascension Health. And unlike the ads for socks that appear on your computer a nanosecond after you purchased some tennis shoes, Google promises that the data won’t be combined with consumer data. Fat chance.
Amazon, which already knows our every thought, was not satisfied with merely creating software that can read medical records. Now they’ve created Transcribe Medical, a system that transcribes confidential patient-doctor conversations and uploads them directly into the electronic health record. Doctors would relinquish all control over “private” patient records. Google also has been working on its own automatic speech recognition “digital scribe” to upload multiple speaker conversations.
Not only is there a problem with inaccuracies that could lead to a patient receiving the wrong treatment, but we all know the ubiquitous problem of hacking—even in the Department of Defense and the federal Office of Personnel Management.
Disturbingly, certain circles oohed and aahed over the revelation that Google, using electronic health records (EHR), created an artificial intelligence program that could predict death better than doctors. Fortunately for humanity, many others found the thought of leaving doctors out of the equation horrifying. The cheerleaders crowed that it would decrease work for the doctors; they wouldn’t have to waste their time going through those pesky medical records to arrive at a conclusion. Using an artificial neural network to predict the death of a human being is a far cry from having a computer interpret an inanimate x-ray who is not a daughter, mother, sister, wife, or grandmother.
If you put it all together, it adds up to a death panel of one. Google’s software would decide that there is not a high likelihood of walking out of the hospital, no treatment would be given. We are becoming witness to the devolution of humanity.
Moreover, the government is incentivizing workforce development in palliative care through the Palliative Care and Hospice Education and Training Act. Perhaps this is why the hospice team seems to greet the patient at the hospital door. Of note, once a person has signed on to the Medicare hospice program, Medicare will not pay for any curative treatment or medications. Medicare will not pay for an emergency room visit unless the hospice team arranged it or someone decides it is not related to the hospice diagnosis.
The number of hospice agencies participating in the Medicare program nearly doubled between 2000 and 2016, for a total of some 4,382 providers. In 2000, about 30 percent of hospice agencies were for-profit, compared to about 67 percent in 2016. In that same period, Medicare payments grew from $3 billion to $16.8 billion.
Hospice care is lucrative. The minimum Medicare payment is $196 per day regardless of the quantity or quality of services provided on that day. A July 2019 report from the Office of Inspector General for the Department of Health and Human Services found that more than 80 percent of end-of-life facilities in the United States had at least one deficiency, and nearly 20 percent were poor performers with serious problems that jeopardized patient health and safety. It seems the compassionate medical service to care for suffering patients has turned into a heartless cash cow.
Is this what we want for our loved ones and eventually, ourselves? Medicare for All promises every type of medical care under the sun, including long-term care. Long-term care is expensive and if done properly, labor intensive. What better way to save money than to promote a computer program that convinces doctors that the patient is going to die no matter what they do. So the hospital tells the family that treatment or home care will drain their finances. For what? I’ll tell you for what. My parents died at home only after they were tired of doctors and ready to go. They strolled into heaven. They were not shoved in with a giant government backhoe.
Medicare for All (M4A) retained its prominent place on the stage at the latest Democratic debate. In its purest Bernie Sanders form, concurrent with abolishing private health insurance, U.S. residents would be enrolled in “Medicare.” The program would pay for unlimited “medically necessary” health expenses, including pharmaceuticals, mental health and substance abuse treatment, vision, dental, and hearing services, and long-term care with no out-of-pocket costs. Some supporters were scared off by the $32 trillion over 10 years price tag. Not to be outdone, Elizabeth Warren’s “I’m with Bernie” plan comes with a $52 trillion over 10 years price tag including up to $34 trillion in new government spending. Our country’s entire yearly budget is a mere $3.5 trillion. For perspective, if your salary is $40,000 per year it would take 25 million years to earn 1 trillion dollars. As M4A’s dark side emerged, the candidates distanced themselves from Bernie-care.
Elimination of private insurance? Whoa, Nellie! Over 156 million Americans —half the country—are covered by employer-sponsored health insurance plans and another 23 million have private individual policies. And most of these folks like that arrangement. Then there was pushback from some unions who had excellent health insurance policies for which they had bargained and given up other perks.
In the June debate the candidates raised their hands indicating they would abolish private health insurance. Now Mayor Buttigieg wants to “unify the American people around, creating a version of Medicare, making it available to anybody who wants it, but without the divisive step of ordering people onto it whether they want to or not.” Vice president Biden, noting his desire to keep patient choice stated, “we should build on Obamacare … adding a Medicare option in that plan, and not make people choose.” Of course, Obamacare caused a rise in premiums, a decrease in choice of insurance coverage, and like any large government-run program was prone to mismanagement and waste.
Possible financing mechanisms were screaming for a deep dive. One analysis concluded that most Americans would suffer financially if M4A were implemented as proposed. An analysis by a bipartisan think tank estimated a 32 per cent increase in payroll taxes would be needed to fund M4A. Everyone—even the working poor—would have more payroll taxes extracted from their paycheck. The analysis concluded that most households would pay more in new taxes than they would save by eliminating their current spending on private health insurance and out-of-pocket medical expenses.
Senator Warren tries to hide the ugly truth by railing about the evil rich who would be taxed down to their underwear. Take the deceptively worded “2-cent” annual tax for households with more than $50 million in assets. If you have $51 million in assets, most probably tied up in your business, you’d have to cough up (.02)($1,000,000) or $20,000, not 2 cents. The devil’s spawn, aka our 535 billionaires, would be subject to a 6 percent annual tax on their assets. Who will be the next target when the government has driven the assets to a sunny island in the Caribbean? Finally, raising the corporate income tax back up to 35 percent likely would result in businesses paying lower wages to current employees or cutting back on hiring to compensate for the increased tax burden.
During the latest debate, Senator Warren retreated from her “all-in” approach, asserting she would first provide Medicare at no cost to “everybody under the age of 18, everybody who has a family of four income less than $50,000”—about 135 million people. Second, she would lower the Medicare age to 50 and expand Medicare coverage to include vision, dental, and long-term care. In the third year, “when people have had a chance to feel it and taste it and live with it, we’re going to vote and we’re going to want Medicare for all.”
Senator Sanders owns that payroll taxes would be doubled or tripled and proposes a 4 percent surtax on families earning more than $29,000. So if you earn $60,000, you’d have to pay (.04)($31,000) or $1,240, enough for a whole year’s membership in a private Direct Primary Care plan. Senator Sanders, staying true to his principles, is sticking with unadulterated Medicare for All with its financial warts.
Even those who are numb to government over-spending can see the broader problem of inviting Uncle Sam into their lives in exchange for a Medicare card in their wallet. Any remaining privacy is erased. Our medical records would be furnished to the Department of Health and Human Services and the National Coordinator for Health Information Technology. Physicians and patients would be robbed of their autonomy and choice by medical care policies set by the government monopoly. Lack of competition leads to lower quality and fewer services. Coverage becomes an illusion.
Medicare for All’s beauty is only skin deep and its ugly goes to the bone.
Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). Her opinions are her own. This is an edited column that originally appeared at www.pennypressnv.com, reprinted with permission.
You finally get your dream and are selected to be a contestant on Wheel of Fortune. You get to see Pat Sajak and Vanna White! You win a vacation to some country that you don’t really want to see. You cannot get the cash equivalent. You have to take 10 days off of work to take the free vacation you did not want. You discover that you have to pay the tax on the free vacation.
Or you win a free car. You have a perfectly functioning 3-year-old car. The free car was not really the car you would have selected. You accepted it because it was free. Then you see that you have to pay tax on the list price of the free car. You also discover that the collision insurance and Department of Motor Vehicles registration for the free car are significantly higher than for the car you currently own.
These are examples of why nothing is “free.” This applies to medical care as well. You may have to see the “health care provider” the government program or private insurer makes available to you. You don’t particularly want to see a nurse, but that’s the way the cookie crumbles with free health care. Oh well, you convince yourself that it’s okay because, just like that car on the game show, it was free.
Here’s a new spin on “free.” Yes, your medical care should be free – free from the restraints of government control. Free from the government rules that have raised the price of insurance premiums. The Affordable Care Act mandated ten essential benefits that all insurance plans must include free of out-of-pocket charges to patients. Of course, this does not include the initial out-of-pocket charge: the insurance premium. Insurance premiums shot up over the post-ACA year because the insurance plan has to cover conditions that the insured persons may not even encounter in their own lives. A glaring example is obstetrics coverage in a menopausal female. Preventive and wellness visits are also labelled as free.
Moreover, a recent AMA study revealed that over the last four years the competition in the commercial insurance market has decreased. In over 50 percent of metropolitan areas, representing about 73 million persons, one insurer has half of the market. The more concentrated the market, the higher the premiums.
Remember that free car? We all know and readily accept that car insurance does not pay for the gas and basic maintenance. So why should maintenance medical care be covered by insurance? Car insurance would be unaffordable for most car owners if it paid for gas, oil changes, new mufflers, radios, and batteries. Most states require drivers to have car insurance. If people can’t afford the insurance, they lose the benefit of owning a car.
Similarly, if you lose your health due to long waits or delayed diagnosis because the CT scan was not authorized or poor medication response because you had to take the formulary drug that was not the doctor’s first drug choice for you, the care is not free, but very costly.
The underlying message of free “health care” is disempowering. The message is that we are incapable of taking care of ourselves. Empowerment is having control over our own lives. First, we take charge of our own health by thinking about the choices we make. We choose to not smoke, overindulge in food or drink, or engage in foolhardy behaviors. Second, we decide what is important for our own health. If you do not want insurance coverage for obstetrics or fertility treatment because you are 50 years old and do not want children, there should be a less expensive insurance product available to you. Third, we need to be free to choose our own doctor as well as the treatment the doctor—not the invisible third-party payer—recommends.
The promised free health care would increase the payroll taxes on all workers, even if that worker does not want that particular brand of free medical care. The next time you hear that medical care is free, just think about that “free” car that is the wrong color, is too small, has uncomfortable seats, inadequate headroom, and overall is not what you really want.
Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). Her opinions are her own. This is an edited column that originally appeared at www.pennypressnv.com, reprinted with permission.
At a graduation of a family friend, out of the blue, one in our group began lamenting that progressives tended to live in cities. She proposed that progressives should move to rural areas and “purge [such areas] of those awful conservatives.” Thus spoke the tolerant Left. I was stunned. Given the festive occasion, I kindly reminded her that this is America and we are lucky that we have all kinds of people. I wanted to ask her what we should do with the conservatives. Re-education camps? Death by a continuous loop of Bernie Sanders speeches?
It is unfortunate that such unreasonableness isn’t isolated within the D.C. swamp containment zone.
These pied pipers who offer free college, free food, free medical care, and free money for simply having a pulse freely admit they have no idea how to pay for it. Oh, yes: tax the “rich” and corporations who will pass the tax on to consumers and employees in the form of higher prices and lower wages. And eventually the heretofore untouchable middle class will be taxed directly. Let’s not forget that free food and housing are components of slavery.
These Einsteins are scientists when it comes to global warming and evolution but think it’s medically acceptable to permanently sterilize a 7-year old to avoid appearing like a “transgender” bigot. Science lesson: there are 2 genders. Every human has 23 pairs of chromosomes. The X chromosomes and Y chromosomes determine sex. With rare exceptions of random abnormalities, female is XX and male is XY.
These self-described health care experts try to debunk innovative medical care delivery methods like direct pay and direct primary care subscription practices by claiming these are reserved for the rich. Approximately, $1,500 per year ensures that you and your doctor, make your medical decisions—not the government. These “experts” are the same people who prop up the medical-insurance-government industrial complex at the expense of private physicians, writing laws that favor big-box retail clinics staffed by non-physicians. These swamp creatures equate physicians with “mid-level” practitioners with one fifth the training and education as physicians—but likely demand the chairman of the department when they themselves need medical services.
These compassionate legislators are keen on the government taking over the “social determinants of health,” including loneliness. I anxiously await an army of a government operatives coming to our homes and telling us to be happy or else. Most people just want to control their own lives, even if their life does not fit the government blueprint. If you want your life to be your own, and your body to be your own, then you cannot let the government’s foot in the door.
These forward thinkers decided it was good public policy to ban children’s fathers from the home in order for the family to receive government funds. It became normalized for the federal government to be the daddy.
These elitists castigate the middle class for not wanting homeless people sleeping and defecating in front of their houses for which they worked two jobs, saved, and sacrificed for years. Their remedy is a tent city in a middle-class neighborhood that is nowhere near theirs. These people do not want to admit that the disintegration of the family and the moral decay leading to drug use and detachment from society is the first problem that must be addressed.
And the biggest hobgoblins of them all are the peddlers of faux racism. Americans do not wake up every morning hating on each other. They ponder their family’s safety and keeping a decent job to pay their bills. Something is seriously wrong, indeed demented, when a former First Lady—unchallenged—claimed that white Americans are “still running” from minority communities when they move to another neighborhood. Perhaps they are getting away from homeless encampments (with mostly white people) or poorly run government schools in Democrat-controlled cities. Get over yourself.
Everything is not about race. Get out in the real world and sit at a local bar or café in central Mississippi and watch blacks and whites eating and laughing together. Who is the hatemonger?
America has had a few tragic well-publicized racially motivated incidents. Undaunted, we continue to strive for liberty for all—despite the calculated enmity and scab-picking by rich and famous black people who ran away from minorities to live on a $15 million estate on Martha’s Vineyard (and not in Oak Bluffs) and who expect us to swallow their vitriol-laced baloney.
This insanity is patently sick and sickening. It is about power at any cost and not what can help move America forward.
Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). Her opinions are her own. This column originally appeared on pennypress.com. Reprinted with permission.
What if purchasing medical products and services were like buying peanut butter? Grocery stores have several brands and varieties: smooth, chunky, old-fashioned, natural, organic, no added sugar, reduced fat, no-stir, and pre-mixed with jelly with clearly marked prices ranging from $1.75 for the store’s generic brand to $7 for the over-priced Yuppie brand. After carefully examining the labels, our shopper chose a 16-ounce, $5 jar of no-added-sugar peanut butter. She paid the cashier $5 for the peanut butter and went home.
If our shoppers were transported to the universe of medical billing with the $5 jar of peanut butter, the shopper with Medicare would pay $1.00 but her grandchild will be presented with a bill for $4. When the shopper with private health insurance attempts to pay, the cashier becomes unglued. The shopper cannot say whether she met her deductible or has a co-payment, and whether the brand of peanut butter is approved by the network. She really wants the peanut butter so she grabs the generic from the shelf and pays the $1.75. Our privately insured shopper was pleasantly surprised at the generic’s good taste and healthful ingredients, her wallet was happy for the cost savings, and she was glad not to have the middleman hassle.
Comparison shopping is one pillar of bringing sanity to the high cost of medical care, but the opacity of the pricing system for medical costs limits the value of posting list prices to encourage lower costs through shaming, competition, and choice. In addition to research and development, manufacturing, and distribution costs, drug costs are affected by additional layers of middlemen: pharmacy benefit managers (PBMs) and insurers. Using a “trade secret” process, PBMs negotiate discounts and rebates for private and government insurers. The money saved is supposed to go back to the government (taxpayers) or to insurers to lower premiums or otherwise benefit patients. PBMs typically are paid by a percentage of the rebate or discount off the list price. The higher the price, the bigger the rebate. Thus, the rebate system gives an incentive to raise list prices rather than placing the lowest-priced drug on the insurer’s formulary. (This same system is used by Group Purchasing Organizations (GPOs) for hospital product purchases.)
An analysis of the effect of California’s 2-year old drug price transparency law illustrates the complexity of pricing. Despite being compelled to post list prices, pharmaceutical companies raised the list price for wholesalers by a median of 25.8 percent but the data did not indicate the “price” that consumers actually paid. Moreover, with medical services and products the simple What the Market Will Bear (WTMWB) pricing method works because either the medication is essential (e.g., Epi-Pen®), has no alternative, is in short supply, or the medical consumer is not paying directly for the services.
Similarly, publishing hospital the charge description master (“chargemaster”). i.e., the standard industry price does not give consumers enough information to make a rational choice regarding elective medical services. The data necessary to make price comparisons depends on an individual’s circumstances. More relevant than the chargemaster price, a self-pay patient needs to know the lowest possible cash price. A patient with health insurance must know (1) whether the hospital is in the insurance network, (2) the price negotiated between the health care provider and insurer (including Medicare), (3) the amount and method of calculating cost-sharing, (4) the amount Medicare or other insurer will pay for services performed in a physician’s office in contrast to the hospital which tags on a “facility fee.”
Transparency is one tool for lowering costs through choice. As one of many studies on hospital consolidation noted, “The Sky’s the Limit” on prices where there is lack of competition. But the difficulties of achieving useful price transparency must not be a cue for the government to initiate bureaucratic band-aids. As we have seen with Obamacare, forcing insurers to pay more of the costs leads to higher premiums, deductibles, and/or co-pays.
Nor should the government impose price caps. President Nixon’s 1971 wage and price freeze brought product shortages—which we are already facing with certain drugs, including anesthetics and chemotherapy agents. If the government sticks to enforcing anti-trust laws, a competitive market will thrive. The court house door anti-trust settlement by Northern California’s Sutter Health sends a message to big hospital chains to stop using their market share to inflate prices or require insurers to join their networks on an all-or-nothing basis to prevent insurers from negotiating lower prices at individual hospitals.
If we can get to the point of direct exchange of money for goods and services and reserve health insurance for major expenses, we can see costs decrease just as we have seen with the Surgery Center of Oklahoma over the last 10 years.
Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). Her opinions, medical or otherwise, are her own. She is a guest columnist and this is an edited version of her article originally written for pennypress.com, reprinted with permission.
The high cost of medical care is on the lips of every politician and draining the pocketbooks of most Americans. After creating the Medicare/Medicaid monster, the government’s expanded intervention into the medical care marketplace with the inaptly named Affordable Care Act doubled the premiums and deductibles for both employer-sponsored and individual insurance. Piling on more laws, regulations, and agencies is not the answer.
Anonymity, complexity, and opacity invite shady behavior. Individuals, companies, and patients who defraud the massive federal “health system” would never dream of lifting money from their patients’ wallets or stealing from their doctors’ cash drawer.
The government’s track record does not bode well for imposing more bureaucracy to remedy a problem created by the layers of third-party payer bureaucracy. Waste, fraud, and abuse are so rampant that the government has a Medicare Strike Force to root out and recover lost federal funds. Medicare fraud—about $60 billion in 2016 alone—is about 10 percent of Medicare’s total payments. By contrast the typical private business loses 5 percent of its revenues to fraud. Unfortunately, since its inception in March 2007, the Medicare Strike Force has recouped less than $2 billion per year in misappropriated funds.
Medicare’s $16.7 billion per year hospice program is fertile ground for the unscrupulous. Hospices are paid a fixed daily sum for each patient enrolled “regardless of the services provided.” One amoral scheme recruits patients who unknowingly forgo curative treatment options by joining hospice. A recent Office of Inspector General (OIG) report revealed that in 2012 hospices billed Medicare more than $250 million for services to patients in long-term care or assisted-living residences who did not require hospice care, costing four times more than the appropriate level of care. Even worse, the OIG found that the quality of care suffered in 31 percent of programs. The bureaucratic morass allows the perpetrators to pocket the fixed fee and skimp on the services.
Further, the government cannot keep track of its program dollars. According to another OIG audit, in 2009, Medicare Prescription Drug program paid $33.6 million and hospice patients paid $3.8 million for medications that should have been included in the hospice daily fee. Even after discovering the snafu, the problem got exponentially worse. In 2016 the government paid $160.8 million for drugs that hospice organizations should have paid for from its fixed daily fee. Our tax dollars paid for the drugs twice.
Physicians know what patients want and are acting on it. Free from the restraints of government “healthcare” programs, the physician-led, price-transparent, direct-pay Surgery Center of Oklahoma performs some surgeries for less than the copays of some insurance policies. Direct Primary Care physicians provide 24/7 access and basic labs for as little as $50 per month with at-cost medications and low-priced x-rays.
The corporate private sector has learned a thing or two from innovative physicians. Care Accelerator is Sam’s Club’s version of “affordable [medical care] options with transparent pricing.” To offer relief from high out-of-pocket costs, $50 (individual) to $240 per year (families) buys access to lab screening for diabetes and heart disease, free generic drugs, telehealth, and up to a 30 percent discount on vision, dental, and other ancillary services. Additionally, Walmart is training its own employees for jobs in the health sector and ideally to staff Walmart’s own medical services. For their employees, Apple has “health care built around you” with its AC Wellness that offers office and home visits; Amazon launched its Amazon Care telemedicine services.
Given the outrageous price of drugs—largely due to the pharmacy benefit manager middlemen—Good Rx discount coupons are just what the doctor ordered. Good Rx is free to the consumer and makes money from advertisements on the website and referral fees. One typical victory is a Medicare patient whose neurologist prescribed a drug for his Parkinson’s disease symptoms. The government demanded testing that could not be done because of the patients debilitated condition. Despite a sympathetic ear and supporting research, the government arbiter could only parrot the party line: because the drug was not on the “list,” it was not covered by Medicare. In a fortunate twist of fate, with a Good Rx coupon the patient paid $34 per month cash instead of the drug’s $1,100 per month price with 20 percent patient co-pay that would have been charged through the Medicare Prescription Drug program.
Congress claims it plans a full-frontal attack on the high cost of medical care (with the same results as the war on poverty and drugs?). Frankly, we are better off with Congress engrossed in its impeachment clown show and keeping its nose out of our medical business.
Dr. Singleton is a guest columnist. Her opinions are her own. Dr. Singleton is a board-certified anesthesiologist. She is Immediate Past President of the Association of American Physicians and Surgeons (AAPS). She graduated from Stanford and earned her MD at UCSF Medical School. This is an edited version of her column that originally appeared on pennypress.com. Reprinted with permission.