By Robert Nelson, MD
The 14th Amendment to the U.S. Constitution states, in part, that…
“No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.”
Every state has its own criteria for declaring a public health crisis. The the Model State Emergency Health Powers Act that was was floated following 9-11, proposed a model legislation designed to update protocols among the states to account for bio-weapons and infectious agents; and to standardize the approach among the States. There were many concerns about infringement on civil liberties and over-reach abuse from Governors. But even though it never became law, most states already had similar, albeit outdated, protocols allowing their executive branch to declare health emergencies. These states’ laws currently on the books give governors the authority to varying degrees to deprive people of use of property (business closures, etc…), prohibit peaceful assembly of groups (religious gatherings, weddings, family events, etc…) and even confine citizens to their homes during times of public health emergencies (enforceable with fines or imprisonment) all without due process of law, if certain thresholds are met; and by extension of logic, those emergency measures may continue if those same threshold criteria remain operational.
Even if we set aside the contradictions between the 14th Amendment and the power granted to States’ Governors under EHPA-like laws — given the substantial knowledge amassed about the risk of COVID-19 infections, we must question whether the criteria for sustaining a “public health emergency” still meets operational thresholds.
Based on definitions in the original model state Emergency Health Powers Act, the original cases of human-to-human COVID-19 infections certainly met the criteria for “new…infectious agent” and initial reports out of Europe and Asia justified viewing the threat as having high potential for “…a large number of deaths…” and “…widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of persons…”
There was reasonable agreement among many experts, and based on the death and devastation we saw in Italy, that COVID-19 cases could overwhelm the hospital systems’ ability to provide care for the sickest patients. This was a valid concern and represented an unacceptable risk if the calculus was accurate. Most agree, the initial reaction to temporarily shut down normal societal operations was justified.
But data coming mainly in March and April strongly suggested the initially justified fear was over-stated. And despite evidence that predictive models repeatedly over-estimated cases and fatalities, even with distancing measured factored in, many Governors have not taken their foot off the regulatory gas peddle or seriously thought of changing directions even though the evidence shows that most people are not at high risk.
So given the criteria required for declaring a public health emergency detailed above, and in light of drop in case load and data showing a much lower over-all fatality rate than originally estimated, are we still at risk for…”a high probability of a large number of deaths, a large number of serious or long-term disabilities, or widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of persons.”(?)
According to the facts, the answer is “NO.” Here’s a summary of supportive data:
Let’s summarize what we know.
There is no clear correlation to when various States went into lock-down and the time to peak or the magnitude of cases or deaths per 100,000. There is a similar non-correlation between countries across the same metrics.
Prevalence studies indicate number of infected people is MUCH higher than most realized suggesting COVID-19 is highly contagious yet very mild in vast majority of people. This also suggests restrictive lock-downs are minimally effective. A higher prevalence indicates a much lower case fatality rate than was originally published.
Herd immunity is vital to protecting the vulnerable. Prolonged distancing slows the herd immunity, which is likely to be the quickest and safest way to protect those most at risk.
Opening the economy gradually will be important to support the efforts of our communities to continue vigilant case monitoring and appropriate care for severe cases.
The goal of not overwhelming healthcare resources was successful. But many of those who had legitimate concerns which triggered an emergency declaration have failed to critically evaluate new data, and worse still, they have failed to fully come to grips with the consequences of keeping society and their economies locked-down.
The ability of millions of citizens to earn a living and provide for their families and keep businesses afloat (and the jobs that accompany those businesses) was/is severely compromised by overly aggressive, often coercive and sometimes punitive restrictions on basic freedoms. The negative fallout from the lock-down of 2020 will continue to pile up long after the risk from the virus has been forgotten. More people may end up being harmed by the disruptions in healthcare delivery and the loss of “non-essential” jobs, than were saved by trying to prevent the spread of a COVID-19. Ironically, the reaction to the threat of the virus could result in our self-inflicted death unless we learn to live with it.
by Robert Nelson, MD
It’s not an over-statement to assert that our strategy, thus far, for combating the novel coronavirus (COVID-19) has focused on preventing its spread through a variety of social distancing measures; such as shelter-at-home, work-from-home, closing large venues, prohibiting gatherings of 10 or more people, and numerous other variations of distancing. This is in addition to identifying and protecting the most vulnerable from falling prey to complications thereof. But the latter recommendations, although well known and often repeated, seem to have taken a back seat to a myriad of politically and socially controversial policies which have brought our collective economic and social engine to a grinding halt.
Here is the logic. By stopping the spread, then fewer contract the illness, then fewer get sick and fewer die. Who can argue with that? It all sounds perfectly reasonable. And even more reasonable if you’re fortunate enough to still be getting a pay check.
But what if containment strategies, relying on wide-spread comprehensive distancing protocols, simply delay the total number of cases and spread out the number of deaths? There is ample evidence (data-driven, empiric and observational) to suggest that social distancing is far from an ideal strategy.
Distancing, in any viral pandemic, would certainly slow the spread of the contagion; and distancing was the basis of our initial response plan, the goal of which was to “flatten-the-curve.” There was reasonable agreement among many experts, and based on the death and devastation we saw in Italy, that COVID cases could overwhelm the hospital systems’ ability to provide care for the sickest patients. This was a valid concern and represented an unacceptable risk if the calculus was accurate.
But the objective was never to halt the virus. This distinction is crucial since it appears we’ve conflated distancing to include an implicit bias that it will get rid of the virus and make us all safer. Neither is likely to be true.
The goal of not overwhelming healthcare resources was met. But the fear that transformed a targeted strategy into a mantra was too hard to resist for policy makers and politicians whose instinct (or what some would call mandate) is to DO SOMETHING even if doing less is a better choice. And that same fear was soon found to be overstated. And yet despite evidence that predictive models repeatedly over-estimated cases and fatalities even with distancing measured factored in, many have not taken their foot off the regulatory gas peddle or seriously thought of changing directions even though the evidence shows that most people are not at high risk.
This disconnect and failure to pivot, unfortunately, is more ideological than it is epistemological. You only have to look at the accusations and insults hurled by proponents of one strategy at the proponents of another; the lack of civil discourse and failure to acknowledgement that we all want the same good outcomes, shows us how easy it is to be pulled into our ideological corners. The data should drive the policy; not the other way around.
The implications that the real Case Fatality Rate (infection mortality rate) is likely to be much lower than we realized is vital information that should allow us to pivot very quickly. We have lost precious time arguing over the benefits of distancing and testing supplies and whether the President actually believes we should inject disinfectants. We should have been devising reverse lock-down strategies designed to actually prevent death; death from the virus and death from other causes including unemployment and all manner of social depravity and the illnesses that come with it.
So, can a strategy based primarily on distancing accomplish the goals we all want without unacceptable human collateral damage? And is that strategy even plausible based on the behavior of contagious respiratory viruses, and specifically based what we know about SARS-CoV-2 (COVID-19)? And furthermore, will it accomplish the goal of diminishing deaths?
To better answer those questions, let’s examine what we know about the behavior of this virus, much of it revealed fairly early in the lock-down and some of it we knew even before the lock-down began.
Sequencing and staging a return to work & life normalcy based on risk assessment, rather than waiting on achieving some arbitrary drop in cases or death rate (which is a function of current testing limitations) is a solution which can cut down on unnecessary deaths and avoid collateral human suffering across other important dimensions.
We can start by identifying the intersections of various Venn diagrams where low risk people can return to the most essential work; and likewise identify lower risk environments where less scrutiny about risk is needed.
Interventions such as N-95 or even regular surgical masks can be used in selected situations as needed. Staggering shifts and segregating open offices with cubicles or using room dividers can possibly minimize exposure in the workplace for those at risk.
Of course, the basics of hand-washing and proper respiratory “hygiene” are assumed to be at the forefront of any strategies.
These strategies should be done simultaneously with vigilant surveillance for new cases so appropriate measures (testing, observation, isolation or contact tracing) can be initiated.
And those at highest risk could work if they can do it safely; or they can work from home if they can for as long as possible.
Last, but certainly not least, -given that nursing home COVID cases have accounted for a disproportionate percentage of deaths- we need to segregate infected patients/residents from non-infected and have stringent protective measure for those caring for these at-risk people, just as if they were in a hospital.
If we want to get our world back, we have to get back in the world (paraphrased from David Katz, MD)
Welcome to Friday’s Philosophical Foray beyond Healthcare.
Exploring the Metaphysical & cognitive origins of Western thought: A unique viewpoint by Professor Jordan Peterson.
A Self-evident axiomatic principle of the intrinsic value of the individual >>> A proposition of Natural Rights >>> Emergence of social principles & Law based on individual sovereignty & Natural Rights >>> Moving beyond savage tribalism & divine rights >>> Unity based on collective belief in same axiomatic principles >>> Diverse elements find common ground >>> Societies more stable by way of respect for rights & sovereignty >>> Gives people tools to correct corruption & dysfunction in societal hierarchies to avoid deterioration into chaos.
By Robert Nelson, MD
Our health insurance-based third-party payer protocols have pernicious and nefarious economic consequences on the cost of medical care; and in many ways has diminished access due to regulatory complexities that accompany these interventions.
The undeniable result continues to be a rampant increase in healthcare prices, which is catalyzed by the economic distortions of the 3rd party payer effect and perpetuated by the price-obscuring distortions of the CPT billing cycle.
We have taken the concept of insurance, designed to pay out rare higher-priced claims on unpredictable events, and turned it into a product whose design promotes an incentive for everyone to use it as often as possible.
Insurance is sustainable only when the financial risks of individually rare events are spread over a large population. When it also becomes a funding source for anticipated and affordable events, combined with a perverse incentive to utilize it to the margin, the result is the creation of a perpetual payout fund.
The costs of sustaining this model are never satisfied, being squeezed by patients who are chasing the benefits and providers who chase the billing codes to achieve maximal reimbursement.
As evidence for the negative consequence of misusing insurance as a pass-through system for virtually every healthcare expense (accelerated by passage of the ACA), we can examine the employer-sponsored group market premiums.
From 2007 – 2017 the average premium for family coverage increased by 55% and employee contribution rate as a share of premium cost increased by 74% over the same 10-year period; while median household income went up by only 3%.
To add financial injury to insult, the percentage of employees with an out-of-pocket maximum of greater than $3,000 doubled, going from 30% to 60% of employees.
“Eighty-one percent of covered workers have a general annual deductible for single coverage that must be met before most services are paid for by the plan. Among covered workers with a general annual deductible, the average deductible amount for single coverage is $1,505.” ~KFF.org
Between 2012 – 2017, the percentage of covered workers with a general annual deductible of $1,000 or more for single coverage has grown substantially, increasing from 34% in 2012 to 51% in 2017. Thirty-seven percent of covered workers in small firms are in a plan with a deductible of at least $2,000, compared to 15% for covered workers in large firms.
In the ACA individual market insurance exchanges, single coverage premiums (unsubsidized) increased by 62% and family coverage premiums increased by 75% just since implementation of ObamaCare!
Our third-party payer system has created a dependency trap! The same financial tool we rely on to pay our healthcare providers also contributes to runaway costs; making us more dependent on it for access. This guarantees that Healthcare will cost significantly more than the sum of its individual parts, and will continue to escalate faster than our ability to pay for it.
The costs associated with health plan premiums (aka insurance) have become a surrogate for health-care costs.
Now let that sink in!
In what other market does the cost of an insurance product act as substitute for the aggregate cost of the product or services that it insures?
Now apply a similar scenario to the auto insurance market. It doesn’t take much imagination to extrapolate how that would play out. But if you want some help visualizing the scenario, here’s a brief vignette. https://lnkd.in/eUGeCKv
Self-insured employer health plans are in a unique position to break out of this dependency paradox.
By contracting with a Direct Primary Care practice and re-routing subsequent encounters away from the more expensive insurance-based protocols, Self-insured employers can utilize creative plan designs to cut costs and improve employee satisfaction.
Data from the Qliance experience, and supported by other self-insured employer’s experiences, utilization of efficient primary care via the DPC model reduces unnecessary downstream care by approximately 50%, with the resultant aggregate cost savings of nearly 20%.
The caveat being, as we double the number of primary care visits combined with longer visits to adequately address problems, the need for emergent visits, ER visits and specialty intervention drop significantly.
A similar level of savings for direct-pay lab tests was noted in data published in 2014 by CMT journal comparing lab fees charged to a Direct Pay practice by the lab vs. the CPT billed charges by the lab (assuming patient had no coverage or had not met their deductible). For five common blood tests the savings was 89% by not using insurance, with lab billed charges of approximately $782 compared to a direct pay cost of $80. Plum Health, a direct primary care practice in Detroit, shows similarly impressive lab test savings of 87% on six common blood tests; $811 vs $106.
Many Self-insured companies are beginning to discover the value and savings in this approach, while breaking free of the coverage trap and the myth that health insurance equates to health care; and the realization that so-called “access” to inflated pricing and the phony discounts used to fleece the buyer is no longer a conversation they are willing to have.
This whole issue of “surprise bills” is a symptom of a more pernicious economic disease which has been driving prices in healthcare for decades; that being, a lack on discoverable, actionable meaningful prices for bundled medical services.
Moreover, the lack of transparent/actionable pricing in healthcare is a derivative of the manner in which we have chosen to code, bill and get paid for medical services.
And most of the legislative and regulatory fixes proposed do NOT correct the core problem.
The corollary being, there are no surprise bills when we use real honest pricing strategies!
Case in point…you will never have a surprise bill from Surgery Center Of Oklahoma. They publish easily discoverable all-inclusive prices for their surgical procedures. And, they offer same price to any willing buyer, because they aren’t controlled by network contracts.
Price setting or caps is not the correct response to the problem of this form of price gouging. This knee jerk visceral reaction is shortsighted. Price setting ALWAYS distorts markets in negative ways which are not always apparent; shortages or supply chain inefficiencies/interruptions/gaps are inevitable.
It is NOT the cost of medical care & and pharma that is the problem…It is the simultaneous lack of both transparent & actionable prices, combined with using proprietary contractual formulary agreements as a substitute for honest pricing, which has brought us to this dangerous fiscal precipice. Hiding costs by shifting them or redistributing them is same economically illiterate strategy which brought us Obamacare.
We can do better.
You pull into a Gas Station and discover that there are no prices listed on the pump, just a slot to insert your auto insurance card…only to find out your State Farm policy is not part of the gas station’s network! You just want to fill up and you are willing to pay cash, so you ask the attendant how much it is per gallon.
The response: “We can’t be sure until we know what your out-of-network benefits are… so you’ll need to pay a $200 deposit until the claim cycles through. If the gasoline is less than $200 you’ll get a refund; if more, then you’ll get an additional bill.”
Or you sit down at a Restaurant, open the menu to discover there are NO prices listed…Not only that, but you have to agree to eat the food and pay whatever price your insurance company says you owe!!!
This, my friends, is the sorry state of healthcare economics and a big reason why Healthcare is so expensive…because it isn’t the cost of care that is the problem; it’s the price we are being charged for the privilege of using our insurance!!!
As we continue to examine the outcomes of socioeconomic initiatives throughout our history, it becomes apparent that society’s benefits are not necessarily derived from good policies as much as from the absence of bad ones.
– Robert Nelson
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