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M4A as a Swing Issue

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BY MIKE MAGEE

“There’s common ground there—not the warm belonging of full creedal agreement, perhaps, but a place, even a welcoming place, where we can stand together.”    Ian Marcus Corbin, Research Fellow, Harvard Medical School

Most Americans would love to believe this statement. But political reality intervenes. A March, 2022 Pew Research Center analysis found our two major parties to be “farther apart ideologically today than at any time in the past 50 years.” 

Take, for example, Presidential hopefuls, Florida Gov. Ron DeSantis and Sen. Marco Rubio (R-Fla.). They see political pay dirt on the jagged peaks of America’s culture wars with the governor taking on Disney for defending LGBTQ employees by introducing the his “Stop W.O.K.E. Act“, while Rubio goes one step further with his “No Tax Breaks for Radical Corporate Activism Act”.

In academic circles, you increasingly find references to “what’s the matter with…debates.” The phrase derives from a 2004 book “What’s the Matter with Kansas?”  written by historian Thomas Frank, which spent 18 weeks on the New York Times Bestseller List. 

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Matthew’s health care tidbits: Texas is the present future of abortion care

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Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this edition’s tidbits, I have to return to the stunning impact of the Dobbs ruling. We know will happen because it is already happening in Texas where the 6 week law was already being enforced in contravention of Roe v Wade.

Taxpayer money is going to “pregnancy crisis centers” that flat out lie to vulnerable patients about the impact of abortions on their health. Doctors are questioning women who have miscarried–at a moment that is already terrible for them, and women who have miscarried are being denied basic D&Cs–which can kill them.

Don’t get me started on the absolute nonsense being talked–and passed into law –about ectopic pregnancies, of which there are over 130,000 each year in the US, being carried to term. How unlikely is it that an ectopic pregnancy makes it to term with no ill effects? Let me tell you a story. My dad was an OBGYN. He and his anesthetist saved the life of a woman and her baby who somehow had made it to term while being ectopic. During the surgery she needed 12 pints of blood (a normal woman has 7-8 pints in her body) and he considered it the greatest piece of surgery he did in his entire career. He thought that he and the patients were very lucky. So I demand that crazy legislation saying ectopic pregnancies have to be carried to term also mandates that my dad is around to do every single C-Section. Unlikely, as he’s dead, but no crazier than the legislation in Indiana.

Then there’s the impact on telehealth. Most abortions are done using drugs but more and more of the pandemic-era exemptions to prescribing drugs and seeing patients over telehealth across state lines are being withdrawn. Clearly the state-based licensing of doctors is itself ridiculous in an age of online commerce, but despite the DOJ statements the legality of prescribing abortifacients across state lines is very unclear and, as Deven McGraw explained in this harrowing piece on THCB Gang, HIPAA doesn’t protect patient privacy from local law enforcement. So what happens to someone in a state where abortion is banned if they have to go to hospital because of a complication from taking an abortifacient? Trump thinks they should go to jail.

What is clear is that bans on abortion don’t stop abortions. But they do endanger women. And if the pregnancy crisis center stops a woman from getting an abortion, do they help afterwards? Why yes, if you mean by “helping”, they have a celebratory dinner and light a fricking candle.

Mike Magee’s Advice to the AMA on Reversal of Roe vs. Wade

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BY MIKE MAGEE

Stable, civic societies are built upon human trust and confidence. If you were forced to rebuild a society, leveled by warfare and devastation, where would you begin? This is the question the U.S. Army faced at the close of WW II, specifically when it came to rebuilding Germany and Japan, hopefully into stable democracies. The Marshall Plan answered the question above, and its success in choosing health services as a starting point was well documented by many in the years to come, including the RAND Corporation. Their summary in 2007 said in part, “Nation-building efforts cannot be successful unless adequate attention is paid to the health of the population.” 

They began with services for women and children, the very location that a splinter of politicians and Supreme Court Justices has targeted, replacing entrusted doctors with partisan bureaucrats in an approach so obviously flawed that it forced a course correction a half-century ago in the form of Roe v. Wade.

The practice of Medicine is complex. Ideally it requires knowledge, skills, supportive infrastructure, proximity and presence. But most of all, it requires trust, especially in moments of urgency, with lives at stake, when an individual, and family, and community are all on high alert. When time is of the essence, and especially if one or more people are trying to make the right decision for two, rather than one life, decisions are impossibly personal and complex.

This was widely recognized by most physicians, including those most devout and conservative nationwide in the troubling years leading up to Roe v. Wade. As recently as 1968, the membership of the Christian Medical Society refused to endorse a proclamation that labeled abortion as sinful. In 1971, America’s leading conservative religious organization, the Southern Baptist Convention, went on record as encouraging its members “to work for legislation that would allow the possibility of abortion under such conditions as rape, incest, clear evidence of severe fetal deformity, and carefully ascertained evidence of the likelihood of damage to the emotional, mental, and physical health of the mother.” In 1973, both the Southern Baptist Convention and the Christian Medical Society chose not to actively oppose the Supreme Court ruling against a Texas law prohibiting abortion known as Roe v. Wade, and reaffirmed that position in 1974 and 1976.

What they recognized was that the nation’s social capital, its political stability and security, relied heavily on the compassion, understanding and partnership engendered in the patient-physician relationship. As most doctors saw it, what possible good could come from putting politicians in the middle of such complicated, emotion-ridden, and highly personal decisions?

The American Medical Association’s prepared reaction to the June 24, 2022, reversal to Roe v. Wade was direct and immediate. They labeled the decision “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship…” Their president, Jack Resneck Jr. M.D. went further to say, “…the AMA condemns the high court’s interpretation in this case. We will always have physicians’ backs and defend the practice of medicine, we will fight to protect the patient-physician relationship..” But what exactly does that mean?

Approaching 75, and a lifelong member of the American Medical Association, I expect I know the AMA, its history as well as its strengths and weaknesses, as well as anyone. Aside from having deep personal relationships with many of the Board of Trustees over the years (some of whom quietly continue to contact me for advice), I have studied the evolution of the patient-physician relationship in six countries over a span of forty years.

Those who know me well, and who have pushed back against my critique of the organization, know that my intentions are honorable and that the alarms that I sound reflect my belief that, for our profession to survive as noble, self-governing, and committed above all to the patients who allow us to care for them, we must have a national organization with reach into every American town and city, and official representation in every state, and every specialty.

My concern today, despite the strong messaging from Chicago, is that the AMA and its members have not fully absorbed that this is a “mission-critical” moment in the organization’s history. It is also an opportunity to purposefully flex its muscles, expand its membership, and reinforce its priorities. The strong words, without actions to back them up, I believe, will permanently seal the AMA’s fate, and challenge Medicine’s status as a “profession.”

Here are five actions that I believe the AMA should take immediately to make it clear that physicians stand united with our patients, in partnership with nurses and other health professionals, and that the actions of last week can not and will not stand.

  1. The AMA should pull all financial support for all Republican candidates through the 2022 elections.
  2. The AMA should actively encourage physician “civil disobedience” where appropriate to protect the health and well being of all women, regardless of age, race, sexual identity, religion, or economic status.
  3. The AMA should convene, under the auspices of its’ General Counsel, Andra K. Heller, a formal strategy meeting with the legal counsels of all state and specialty medical societies to formulate an aggressive legal approach to minimize the damage of the recent Supreme Court action.
  4. The AMA should actively promote AMA volunteers to help provide a full range of women’s health care services at federal institutions and on federal land, and stand up information sites that coordinate travel and expenses should inter-state travel be required for care access.
  5. The AMA should immediately make clear that any restriction of prescribing authority of medications in support of women’s health care, including contraceptive medications and devices, and Plan B treatments will result in a coordinated nationwide disruption of health services.

Mike Magee MD is a Medical Historian and the author of “CODE BLUE: Inside the Medical-Industrial Complex.”

Getting Sick and Going Broke – CVS, Credit Cards, and Crippling Medical Debt

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BY MIKE MAGEE

The Medical-Industrial Complex is swarming with grifters. This is to be expected when you build a purposefully complex system designed to advance profitability for small and large players alike. The $4T operation payrolling 1 in 5 American workers is, in large part, a hidden economy, one built by professional tricksters, designed by Fortune 100 firms with mountains of lobbyists, but reinforced as well by friendly doctors and hospitals engaged in petty and small scale swindling who justify their predatory actions as entrepreneurial, innovative, and purposeful means of necessary financial survival.

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Global Warming and Disease

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BY MIKE MAGEE

A study eight years ago, published in Nature, was titled “Study revives bird origin for 1918 flu pandemic.” The study, which analyzed more than 80,000 gene sequences from flu viruses from humans., birds, horses, pigs, and bats, concluded the 1918 pandemic disaster “probably sprang from North American domestic and wild birds, not from the mixing of human and swine viruses.”

The search for origin in pandemics is not simply an esoteric academic exercise. It is practical, pragmatic, and hopefully preventive. The origin of our very own pandemic, now in its third year and claiming more than 1 million American lives, remains up in the air. Whether occurring “naturally” from an animal reservoir, or the progeny of an experimental lab engaged in U.S. funded “gain-of-function” research, we may never know. What we do know is that viruses move at the speed of light, or more accurately, at the speed of birds.

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Hey, Old Guys!

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BY KIM BELLARD

OK, how many of you had on your women-in-power bingo cards that, in 2022, Sheryl Sandberg would be out at Facebook but Queen Elizabeth II would still be Queen?  It’s the Queen’s Platinum Jubilee, marking seventy years on the throne.  She’s getting a lot of love for that tenure, but it makes me think, geez, some people just don’t know when to step away.

Perhaps what sparked my cynicism about the Queen was an op-ed by Yuval Levin, Why Are We Still Governed by Baby Boomers and the Remarkably Old?  Dr. Levin is, of course, referring to the U.S., and he’s spot-on about our governance problem.  But I think the problem goes further: we have too many old people running our companies and major institutions as well.  

Whether it is, say, healthcare, education, or the military, we’re so busy protecting the past that we’re not really getting ready for the future.

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Virtual Care Regulatory Round-Up: Telehealth & Digital Care ‘State-of-Play’ by Nathaniel Lacktman

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BY JESS DaMASSA, WTF HEALTH

Just as HHS extends the Covid-19 public health emergency waivers until July, we kick-off a brand-new monthly interview series about the state-of-play for all things telehealth and digital care policy and reimbursement. Called the WTF Health Virtual Care Regulatory Round-up, we’re partnering with our friends at Wheel to feature health policy experts, lobbyists, health plan folks, and other virtual care experts and insiders who can keep us updated on the changing regulations and what they will mean to those health tech co’s whose businesses rely on virtual care.

Attorney-to-the-stars-of-telehealth, Nathaniel Lacktman, who chairs the Telemedicine & Digital Health Industry Team at Foley & Lardner and is a Board member of the American Telemedicine Association (ATA), kicks the series off for us with an update on those public health waivers and how he is coaching health tech businesses in preparing for the inevitable transition of care that will come when they come to an end.

What will happen to patients who live across state lines from their virtual care providers? What business decisions need to be made to avoid abandoning patients and maintaining continuity of care? Nate’s not bullish on a federal national license, but there are some cases where cross-state patient-provider relationships can continue to exist – they just might not work for everyone’s business model.

And, on the subject of telehealth business models, Nate gives us his take on where he thinks reimbursement will be headed, how policy around virtual prescribing will be impacted post-pandemic (particularly around controlled substances), and whether or not Medicare’s originating site requirement will be put back in place. We also get Nate’s perspective on which virtual care business models seem to be working best among health tech startups and what legal risk those more ‘reckless’ players might be creating for the rest of the field without even realizing it. Great education on virtual care and what’s happening in the space RIGHT NOW. Watch!

Special thanks to our series sponsor, Wheel – the health tech company powering the virtual care industry. Wheel provides companies with everything they need to launch and scale virtual care services — including the regulatory infrastructure to deliver high quality and compliant care. Learn more at wheel.com.

How About This Opportunity, Health Tech Investors? Promoting Contraception vs. Banning Abortion

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By MIKE MAGEE

Dr. Linda Rosenstock has an M.D. and M.P.H. from Johns Hopkins, and was a Robert Wood Johnson Clinical Scholar. She is currently Dean Emeritus and Professor of Health Policy and Management at UCLA’s Fielding School of Public Health, but also spent years in government, and was on President Obama’s Advisory Group on Prevention, Health Promotion and Integrative and Public Health.

In the wake of the release of Justice Alito’s memo trashing Roe v. Wade, she was asked to comment about the status of abortion in America. Here is what she said:

“The broader the access to proven family planning methods, the lower the unintended pregnancy rate and the lower the abortion rate. We can’t underestimate the role of educating and empowering women – and men – about these issues.”

These are not simply the opinions or insights of a single health expert. They are backed up by the following facts:

  1. Since 1981, abortion rates in U.S. women, age 15 to 44, have declined by nearly two thirds from 29.3 per 1000 to 11.4 per 1000.

2. Approximately half of all pregnancies in the U.S. are unintended.  Of those unintended, approximately 40% of the women chose to terminate the pregnancy by abortion – either procedural or chemically induced.

3.  The decline in the number of abortions has coincided with increased access to long-acting reversible contraception, including IUD’s and contraceptive implants. These options are now safe, increasingly covered by insurers, and more accessible to at-risk populations.

4. The increasing inclusion of sex education in middle school and high school curricula has been accompanied by a decline in high school sexual activity by 17% between 2009 and 2019.

5. There were 629,898 abortions recorded by the CDC in 2019. For every 1000 live births that year, there were 195 other women who chose to terminate their pregnancies. Almost half of the 1st trimester abortions are now chemically induced through Plan B-type pills.

What is clear from these figures is that knowledge and access to contraception is the best way to decrease the number of abortions in America.

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ONC Explainer: Micky Tripathi Deep-Dive on Info Blocking, API standardization & TEFCA

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By JESS DaMASSA, WTF HEALTH

Micky Tripathi the National Coordinator for Health Information Technology at HHS says this year will be a “transformative” year for Health IT as the decade-long, $40 billion dollar effort to lay an electronic foundation for healthcare delivery heads to the next level. Why is this year THE YEAR when it comes to the digital exchange of health information? Where is federal health IT strategy headed in order to provide the standards and policies health tech co’s need to be able to kick up the pace of innovation?

We get into a SWEEPING chat about the technology and business implications of all the work coming out of ONC, including implementation of those new information blocking regulations, goals for API standardization, and TEFCA (Trusted Exchange Framework & Common Agreement). Micky not only gives the background on the regulations and policies, but also provides some analysis on what they actually mean for those health technology companies trying to do business in-and-around a more digital healthcare ecosystem.

Healthcare Suffers from Patient Bias

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By KIM BELLARD

If you went to business school, or perhaps did graduate work in statistics, you may have heard of survivor bias (AKA, survivorship bias or survival bias).  To grossly simplify, we know about the things that we know about, the things that survived long enough for us to learn from.  Failures tend to be ignored — if we are even aware of them. 

This, of course, makes me think of healthcare.  Not so much about the patients who survive versus those who do not, but about the people who come to the healthcare system to be patients versus those who don’t. It has a “patient bias.”

Survivor bias has a great origin story, even if it may not be entirely true and probably gives too much credit to one person.  It goes back to World War II, to mathematician Abraham Wald, who was working in a high-powered classified program called the Statistical Research Group (SRG).

One of the hard questions SRG was asked was how best to armor airplanes.  It’s a trade-off: the more armor, the better the protection against anti-aircraft weapons, but the more armor, slower the plane and the fewer bombs it can carry. They had reams of data about bullet holes in returning airplanes, so they (thought they) knew which parts of the airplanes were the most vulnerable.

Dr. Wald’s great insight was, wait — what about all the planes that aren’t returning?  The ones whose data we’re looking at are the ones that survived long enough to make it back.  The real question was: where are the “missing holes”?  E.g., what was the data from the planes that did not return?

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