By DAVID INTROCASO PhD

In late January the Trump administration proposed a Department of Health and Human Services’ (DHHS) regulation that would legally protect any health care worker who refuses to provide care directly or indirectly to any individual by claiming a religious, moral or conscientious objection. While the federal government has for decades protected freedoms of conscience and religious exercise, the proposed would vastly expand these protections. No longer would these protections be applied to a very limited number of medical procedures. Think: abortion. Now, for example, a pediatrician could to provide care for a lesbian couple’s newborn or an emergency room nurse could refuse to provide a terminally ill patient palliative sedation.

Criticism of the proposed rule was immediate. Opponents contend if finalized the proposed would allow providers to ignore a patient’s medical needs including emergency needs that in some instances cause the patient further harm. It would undermine a healthcare entity’s effectiveness and patient safety responsibilities and would legally allow a provider to violate both their professional code of ethics and the patient’s civil and human rights. Critics argue the rule constitutes, in sum, an insidious form of bigotry. It would weaponize discrimination particularly against LGBTQs. It would, for example, roll back the Obama administration’s interpretation of the Affordable Care Act’s (ACA) anti-sex discrimination provision that protected gender identity. These, not insubstantial, criticisms aside there appears to have been little discussion of the proposed’s underlying rationale. What is the Christian theological basis, if any, for legally protecting religious exercise in denying health care?

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By BAILEY FITZGERALD, MD

“It’s a terrible way to die” The oncology fellow told me bluntly as we walked to the room. “There is nothing okay about this.”

Knocking on the open door, we entered his room. The blinds were raised to reveal a stunning view of the area surrounding the VA hospital, and light poured in.

Our patient reclined in bed, his eyes closed although he was not asleep. He opened his eyes at the sound of our entrance, and the eyes seemed to bulge, too large for his shrunken face with wasted muscles. A plastic tube, taped to the bridge of his nose, entered his nostril and disappeared. The other end of the tubing led to a canister filled with dark green liquid that had been suctioned from his gastrointestinal tract. Despite this invasion, his stomach remained distended, protuberant compared with his otherwise frail frame.

The man had an aggressive colon cancer. The tumor in his colon had grown so large that the hollow of his bowel had closed off, allowing no food to pass through. With nowhere else to go, the contents of his bowel backed up, puffing out his stomach and causing terrible nausea and vomiting. Even worse, the tumor invaded outwards too, anchoring tendrils into the surrounding tissue so that there was no longer any hope of removing the tumor surgically. “Palliative” chemotherapy to try to shrink the tumor would be offered, but it had no chance of curing his disease. The oncologist’s note summarized the situation: “Prognosis is extremely poor.”

It was a good learning case, a late presentation of a disease increasingly diagnosed at early stages by screening colonoscopies. This patient had not undergone screening, which might have diagnosed the cancer while there was still time for a cure. As an African American, this patient was more likely to develop this cancer than Caucasian patients his age.

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By MICHAEL J. ALKIRE

Pharmaceuticals play a major role in today’s population health era – they can prevent and cure disease, improve or maintain wellness and slow progression of existing conditions. Yet, their promise can also be a curse if high prices limit patient access and bankrupt the healthcare providers and insurers bearing significant financial risk for patient care.

The proactive new leadership at the FDA is promoting competitive markets by combatting the abuse of well-intentioned programs and market share monopolies. Commissioner Scott Gottlieb has ramped up the FDA’s efforts to prevent drug manufacturers from “gaming the system” in a number of ways.

Accelerating generic approvals and creating transparency to stimulate competition

For the first time, the FDA made publicly available a list of off-patent, off-exclusivity branded drugs without generic competition. Using the list, Premier immediately identified a number of critical drugs for patient care and has been working with manufacturers to participate in the FDA’s new expedited review process. Additionally, Congress recently enacted legislation creating an expedited review process for generic drug applications when there are fewer than three manufacturers in the market for a given drug product. We strongly support and helped to champion these efforts, and are hopeful that the FDA will use this new authority to foster competition and curb price spikes and shortages in generic drugs where only a few players dominate.

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By NIRAN AL AGBA, MD

Health Savings Accounts (HSAs) allow individuals to use pre-tax dollars to pay for high deductibles and other uncovered medical expenses. Currently, individuals are ineligible for tax-advantaged HSA contributions if they have “other” coverage in addition to a High Deductible Health Plan (HDHP.) Expanding HSAs to fund out-of-pocket expenses for routine healthcare places control directly in the hands of patients, a move that could bring down health expenditures. Large corporations are wrestling for control to direct where patients spend their hard-earned money.

A group of lawmakers recently introduced the “bipartisan” Health Savings Account Improvement Act of 2018 (H.R. 5138). This bill allegedly “expands” HSA coverage to allow use at “retail-based” (think CVS/Target) or “employer-owned” clinics (think Amazon) without losing eligibility to make tax-advantaged contributions to their HSAs. Increasing the flexibility of HSAs is a laudable goal yet, this legislation herds Americans like sheep into Minute Clinics for the benefit of corporate shareholders.

This bill should not become law. If HR 5138 passes, retail and employer-based clinics will become profit centers.   Alternative legislation, known as the Primary Care Enhancement Act (H.R. 365), amends the definition of “qualified medical expenses” to include fees paid to physicians as part of a “primary care service arrangement.” This common-sense legislation flounders in Congress every year.

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By STEPHEN BORSTELMANN, MD

Artificial Intelligence is at peak buzzword: it elicits either the euphoria of a technological paradise with anthropomorphic robots to tidy up after us, or fears of hostile machines breaking the human spirit in a world without hope. Both are fiction.

The Artificial Intelligences of our reality are those of Machine Learning and Deep Learning. Let’s make it simple: both are AI – but not the AI of fiction. Instead, these are limited intelligences capable of only the task they are created for: “weak” or “narrow” AI. Machine Learning is essentially applied Statistics, excellently explained in Hastie and Tibshirani’s Introduction to Statistical Learning. Machine Learning is a more mature field, with more practitioners, and a deeper body of evidence and experience.

Deep Learning is a different animal – a hybrid of Computer Science and Statistics, using networks defined in computer code. Deep Learning isn’t entirely new – Yann LeCun’s 1998 LeNet network was used for optically recognizing 10% of US checks.   But the compute power necessary for other image recognition tasks would require an additional decade. Sensationalism by overly optimistic press releases co-exists with establishment inertia and claims of “black box” opacity. For the non-practitioner, it is very difficult to know what to believe, with confusion the rule.

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