A Health Savings Account Could Save Your Life

Some pundits blamed algorithmic trading for the stock market’s recent wild ride. “Algo-trading” relies on computers programmed to follow defined instructions for placing trades. For example, the computer buys 50 shares of stock when its 50-day moving average goes above the 200-day moving average. Period. Algo-trading was popularized as a systematic approach that removes human emotion, intuition, or instinct from the transaction.

Advanced medical algorithms are becoming the next best thing. Their intended purpose is to improve and standardize decisions made in the delivery of medical care, enabling multiple levels of health care practitioners to use the same “thought” process.

A medical algorithm can be a list of risk factors for various conditions, such as heart disease, or a simple calculation such as BMI (body mass index) utilizing height and weight to determine ideal numbers. Many algorithms are flowcharts with a binary decision tree: if BMI is greater than 25, do this; if not, do that. Newer algorithms based on machine learning, a form of artificial intelligence that simulates how humans learn, can analyze and diagnose radiology images or pathology slides or predict the actual risk of developing certain conditions.

Some of these advances are extraordinary and will likely add to our medical armamentarium. But they do not exist in a vacuum. Concomitant with the flow chart revolution, patients complain that when barely a nanosecond has passed since the physician’s first “hello,” they are handed a DNR form.

Yes, it is a good thing for a physician to know about a patient’s desires at what could be the end of his life. But it is unsettling when the 35 year-old “provider” cheerfully encourages a patient to fill out the form, crowing that she signed her DNR form. The patient is thinking, “you’ll feel a lot different about it at 65 than you do now.” Unfortunately in today’s healthcare delivery factories, when illness strikes “your” doctor may be a previously unknown-to-your hospitalist whose sole knowledge about you, the human being, is lab tests, x-rays, findings on physical exam, and a form you signed 10 years ago. Your family relationships, religious views, and the like are not his purview. When death is actually walking down your street you want to know and trust those in charge of your life.

In a recent case, a toddler was declared brain dead by one hospital, but apparently showed signs of life. His mother sought but failed to stop the removal of her child from life support. After the plug was pulled, she challenged the constitutionality of California’s Determination of Death Act which effectively takes away life-and-death decisions from parents. The Act provides that a person is dead when, in accordance with accepted medical standards, either the body or the brain has irreversible cessation of all function. A federal court dismissed the case, reasoning that the State cannot be held responsible for its determination-of-death laws, because doctors have “broad and legitimate discretion” to end patients’ life support.

Less obvious but nonetheless devastating, is the power Medicare, Medicaid, and insurers exercise over life and death through pre-authorizations and denials of claims. In a lawsuit against Aetna for denial of benefits which the patient alleges “almost killed him,” Aetna’s medical director admitted under oath that he never looked at patients’ medical records when deciding whether to approve or deny care.

If physicians have the power over life and death, “if you like your doctor, you can keep your doctor” takes on added significance as more states adopt physician-assisted suicide laws. Even in Belgium where euthanasia is legal, its proponents are increasingly uncomfortable with the speedy approval of psychiatric patients’ requests to die. Discomfort turned to outrage when a dementia patient was euthanized when there was no evidence that the patient had asked to die.

As independent physicians we want to use the best advances to help our patients but we do not want medicine to devolve into paint-by-the-numbers. We dread the day when “algo-medicine” devoid of human emotion, intuition, or instinct will say Sell! (to the mortician) when the patient hits 70? Buy! if the baby has no problems discerned on prenatal ultrasound?

If you want to ensure that your doctor has your back, run – don’t walk to a direct primary care practice (DPC). Tell your congresspersons to add the 1-page Primary Care Enhancement Act (HR 365 / S 1358) to upcoming “must pass” legislation. This will allow patients to use Health Savings Accounts (HSAs) to pay for DPC. Your life could depend on it.

There’s More To Black History Than Slavery

Black History Month is a time to celebrate Americans whose accomplishments are sometimes overshadowed by the eye-catching negative news stories.

It was discomfiting to watch the State of the Union address while black congresspersons churlishly sat with their arms crossed even as President Trump announced that black unemployment was at its lowest recorded rate. This sort of behavior does nothing except promote the notion that rudeness and incivility is accepted congressional protocol. The employment news could have been a great segue into Black History Month. These “resisters” could have transformed a statistic into an opportunity to let their unquestionably loyal constituents know that ordinary black people can rise to the top.

Black leaders should help dispel the myth that the only money in the black community is in the hands of sports figures and entertainers. Maybe they should read “Why Should White Guys Have All the Fun?,” the autobiography of Reginald Lewis. Lewis attended college on a scholarship and Harvard Law School, worked his way up in the financial world of leverage buy-outs and in 1987 bought Beatrice International for $985 million. Renamed TLC Beatrice, this snack food, beverage and grocery store conglomerate was the largest black-owned and managed business in the U.S. Lewis’s philanthropy built the Museum of Maryland African American History and Culture. The first major facility at Harvard named in honor of an African-American was the Reginald F. Lewis International Law Center.

Instead of stirring the racial and gender identity victimization pot, black leaders should display the qualities that we would want to develop in our children.

Take persistence in achieving one’s aspirations, exemplified by Bessie Coleman. She was the daughter of sharecroppers who became the first black American female pilot and the first black American to have an international pilot license.

Denied admission to American flight schools because she was black and refused private training because she was a woman, Coleman was undeterred. She learned French and in 1921 went to a Paris flight school. She first appeared in an American air show in 1923 at an event honoring veterans of the all-black 369th Infantry Regiment of World War I. Before she could fulfill her dream of starting a flying school, she died in 1926 while practicing for an air show.

Lieutenant William J. Powell, a decorated World War I veteran, wrote, “Because of Bessie Coleman, we have over- come that which was worse than racial barriers. We have overcome the barriers within ourselves and dared to dream.”

Congresspersons, tell your constituents that prior to the Reconstruction there were black legislators, such as Matthias de Souza of the Colonial Maryland Legislature, 1641-1642 and Alexander Twilight of the Vermont Legislature, 1836-1837. And as early as 1783 an ex-slave, James Derham, could become a skilled and respected physician with a successful practice, treating both black and white patients.

None of these successes denies the reality of social and health issues affecting the poor and some ethnic minorities. Despite the Affordable Care Act (ACA), non-elderly black Americans, among others remain significantly more likely than whites to be uninsured. Disturbingly, a degree of fear and distrust of medical care exists in some black Americans. A public hospital focus-group study found several contributing factors, including an expectation of racism. In today’s climate where some black leaders imply that white Americans are racists, only personal experiences can slay that fire-breathing dragon.

Another determinant was fear of experimentation noting the infamous Tuskegee syphilis study. Only a deep, detailed discussion about treatment choices can allay such fears. This is impossible in a seven-minute visit.

Additionally, offices’ requests for insurance information made patients feel like money was the prime concern. This perception could be invalidated by instituting government policies that encourage medical care on a charitable basis— something physicians have happily done since the days of Hippocrates.

The key factor engendering distrust was poor “interpersonal competence,” with participants complaining, “physicians barely spoke to them, did not examine them, and immediately took out a prescription pad.” Sadly, this is becoming the norm for all patients—black and white. The way to rid the health system of disparities is not give everyone the same level of robotic treatment. We physicians can contribute our time and use every patient encounter to let patients know they will be treated with respect and dignity.

And as for our ornery congressional “resisters,” they should rent the film, “Remember the Titans,” take its message of receptivity and cooperation to heart, uncross their arms, roll up their sleeves, and join the winning team.

Dr. Marilyn M. Singleton is a board-certified anesthesiologist. She is also a Board-of-Directors member and President-elect of the Association of American Physicians and Surgeons (AAPS). While still working in the operating room, she attended UC Berkeley Law School, focusing on constitutional law and administrative law. She interned at the National Health Law Project and practiced insurance and health law. She teaches classes in the recognition of elder abuse and constitutional law for non-lawyers.