Health Insurance, What's a grad to do?

This article is a re-publish from May 17, 2017.  

Graduating students now have several options for insurance plans. The Affordable Care Act has introduced several options.

As graduation approaches for thousands of young adults this spring, sorting out your health insurance options may seem more daunting than any political economics problem you faced at school.

You may not think it’s a high priority, but remember: Even healthy young people wind up in the emergency room for all sorts of mishaps, and having health insurance will let you get preventive care, including contraceptives, without paying for it.

As graduation approaches for thousands of young adults this spring, sorting out your health insurance options may seem more daunting than any political economics problem you faced at school.

You may not think it’s a high priority, but remember: Even healthy young people wind up in the emergency room for all sorts of mishaps, and having health insurance will let you get preventive care, including contraceptives, without paying for it.

There are several items to consider when choosing.

Take A Look At Your Parents’ Health Insurance.

In 2015, 29 percent of 19- to 25-year-olds were covered as dependents on their parents’ job-based plan, according to a Commonwealth Fund analysis of data from the U.S. Census Bureau’s Current Population Survey. It was the most common type of coverage for this age group.

Employer-sponsored plans are often more generous than an individual plan on the marketplace, with more comprehensive benefits and lower premiums and out-of-pocket costs. And parents can pass these benefits on.

Compare Coverage Through Your Employer.

Seventeen percent of young adults were insured by their own employer in 2015.

Large employers often offer insurance plans, called PPOs, that let workers choose their own doctors and providers from the insurer’s network and often allow them to seek care outside the network if the patient pays a larger share of the cost. A typical PPO plan offered by an employer with at least 500 employees paid for 87 percent of enrollees’ health care costs on average, according to data from benefits consultant Mercer. Compare that with the most popular silver-level plans sold on the ACA’s online marketplaces, which pay 70 percent of costs.

One benefit of an employer’s plan over your parents’: Buying your own plan may improve the odds that you’ll find doctors and hospitals nearby that are in your health plan’s provider network, said Erin Hemlin, director of training and education at Young Invincibles, an advocacy group for young adults.

If Employer Coverage Isn’t An Option, Consider The State Marketplace.

Twenty-two percent of young adults under 26 had marketplace coverage in 2015.

Marketplace plans must provide comprehensive coverage, including hospitalization, drugs and doctor visits. In addition, if your income is between 100 and 400 percent of the federal poverty level (about $12,000 to $48,000 for an individual) you could qualify for tax credits that will help cover the cost of premiums.

If you have a college health plan that ends when you graduate, you may qualify for a special enrollment period to sign up for a marketplace plan. But if you’re uninsured or insured through your parents, you probably can’t buy a marketplace plan until the next open enrollment period in the fall.

A key consideration: If your parents claim you as a tax dependent, you can’t claim the premium tax credit yourself, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Unemployed? Uninsured? Consider Medicaid.

In 2015, 15 percent of people between ages 19 and 25 were on Medicaid.

To date, 31 states and the District of Columbia have expanded Medicaid coverage to adults with incomes of about $16,000 or less.

If you don’t have a job or earn very little and you live in one of these states, you may qualify for Medicaid, which provides comprehensive coverage, typically without a premium.

Unlike marketplace coverage, there’s no open enrollment period for Medicaid. You can apply anytime through your state Medicaid agency, healthcare.gov or your state marketplace.

A key consideration: If your parents claim you as a dependent on their taxes, it could also affect your eligibility.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

What' a Grad to do?

How Ketamine Infusion Will Transform the Way Depression is Treated

Dan Hancock, MD 

The newest method to treat depression is an anesthetic medication, ketamine.

People suffering from depression aren’t alone. In fact, depression is one of the most common mental health issues in the United States today, with nearly 15.7 million American adults suffering from these feelings of persistent sadness and irritability. More than 300 million people experience depression worldwide, according to the World Health Organization. Untreated, depression can become a chronic debilitating disease, leading to anxiety disorders, eating disorders, substance abuse issues, heart disease, and even suicide.

Fortunately, there’s new hope for healing severe depression and improving lives—and it’s called ketamine infusion therapy. Ketamine is an anesthetic medication that, in traditional doses, has been used for more than 50 years to sedate adults and children in emergency and operating rooms. In recent years, ketamine has emerged as a very safe, rapidly-acting, and effective alternative for treatment-resistant depression. In fact, ketamine has been touted as one of the most significant advancements in treating certain treatment-resistant chronic diseases including:

• Depression (including postpartum depression)
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Generalized anxiety disorder (GAD)
• Bipolar disorder (manic with refractory depression)
• Fibromyalgia
• Complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy (RSD)
• Neuropathic pain
• Migraine headaches/Persistent daily headaches

How ketamine infusion therapy works

Simply put, ketamine improves and rebuilds synaptic connections in the brain.  Traditional oral antidepressants can take weeks or even months to reach therapeutic levels, and only half of all patients get relief from their symptoms. As a NMDA receptor antagonist, ketamine has a positive effect on the neurotransmitter glutamate. Emerging evidence has linked depression with dysfunction in this neurotransmitter. Research has shown that subanesthetic doses of ketamine not only produces a rapid and robust antidepressant effect where it can lift depression in many patients within hours, but it also can put a quick end to suicidal thinking.

Ketamine is a very safe drug with few side effects. As anesthesiologists, we regularly administer this medication and are specifically trained to monitor and respond to its effects. With low doses of ketamine, side effects can include feelings of euphoria, confusion, dizziness, drowsiness, fuzzy vision, and nausea. These side effects clear up quickly, within approximately 10-15 minutes after completion of the infusion. There are no long-term reported side effects with ketamine infusions.

The majority of the patients see some mood elevation and symptomatic relief between the first and second infusion. If the infusions are effective, a series of four additional infusions are scheduled over the following 10 days. After that, maintenance “booster” infusions may be scheduled weeks/months later to maintain a positive response. Each patient is unique, so the dosage, frequency, and total length of treatment can vary and is customized to maximize the most effective sustained response.

Research shows it is changing lives for the better

A recent study, which was published May 3rd in Scientific Reports, reinforces ketamine’s reputation as an effective antidepressant both as a monotherapy and adjunctive therapy. Researchers at Skaggs School of Pharmacy and Pharmaceutical Sciences at University of California San Diego mined the FDA Adverse Effect Reporting System (FAERS) database for depression symptoms in patients taking ketamine for pain. They found that depression was reported half as often among the more than 41,000 patients who took ketamine, compared to patients who took any other drug or drug combination for pain. The team found that the incidence of symptoms of depression in patients who took ketamine in addition to other pain therapies dropped by 50% compared to patients who took any other drug or drug combination for pain.

Setting the record straight

There are some controversies surrounding the use of ketamine, which has been known to have a reputation as an illicit party drug (with a street name of “K” or “Special K”) due to its hallucinogenic effects at high doses. Like many drugs, if abused and misused, there can be harmful side effects with the potential to overdose. But current studies do not demonstrate an addictive potential for ketamine infusion therapy. We mitigate the risk of abuse by limiting access to the infusions and instead of sending patients home with oral medications, our trained health care providers are providing ketamine in a medically supervised clinical environment. This approach greatly minimizes the potential for addiction and misuse.

There is an additional concern with using ketamine infusion therapy because although the U.S. Food & Drug Administration (FDA) has only approved this medication for anesthetic purposes, it has not yet been approved for its use in treating chronic conditions such as depression. It is said that ketamine has never been tested for its safety and effectiveness in treating depression in a large-scale clinical trial due to financial reasons and the ethical controversy surrounding the misuse of it.

If more research can continue in this field, including large-scale clinical trials, ketamine infusion therapy may transform the way the public and other medical professionals think about treating depression, and it could open the door to even more effective forms of treatment.

Find the right, multi-faceted treatment

Not all people who suffer from the chronic diseases we’ve mentioned will respond to ketamine infusion therapy, and even those who are responders from this therapy may require a multi-faceted approach for a comprehensive treatment plan. Ketamine infusion therapy may not be a “silver bullet” treatment to heal depression. As caregivers, we need to address all aspects of a person’s disease, including social, environmental, biological, and psychological considerations. However, for some patients, ketamine infusion can be the long-awaited solution to return to a good quality of life.

Those who have one of the chronic diseases mentioned, and feel they’ve exhausted all treatment options, should talk to their primary care provider about whether ketamine infusion therapy may be the next step in their care.

How Ketamine Infusion Will Transform the Way Depression is Treated

Why are Nursing homes and extended life facilities so expensive.

Nursing Home vs. Cruise Ship

At first it appears to be comparing Apples and Oranges.  However when analyzing the cost of each service it turns out the cruise liner is cheaper and the service is outstanding.  There is no comparison to either facility, nor the customer service rendered.

CBO Reveals Winners, Losers In Senate Health Care Plan : Shots - Health News : NPR

What you should know about the House and Senate bills to repeal/amend the Affordable Care Act.  

CHART: CBO Weighs Who Wins, Who Loses With Senate Health Care Bill

The nonpartisan Congressional Budget Office weighed in on the Senate health care bill on Monday, saying that 22 million people would lose health coverage in the next 10 years under the Senate's plan. Of those, 15 million would lose Medicaid coverage. It's projected to lower the deficit by billions over 10 years, and also cut taxes on corporations and the wealthy.

Medicaid covers low-income people including children, pregnant women, older people in nursing homes and the disabled. Under the Affordable Care Act, the federal government offered subsidies to help states to cover more people, though 19 states chose not to accept the federal money.

For individuals who purchase health coverage on the exchanges, the CBO says prices will vary — some will see lower premiums, especially in states that opt out of some consumer protections, which will allow insurers to sell plans that offer fewer benefits. However, for people would like to purchase plans that cover the essential health benefits mandated by the Affordable Care Act, including mental health coverage, addiction treatment, maternity care and prescription drug coverage, costs could go way up.

Other provisions in the Senate proposal would reduce subsidies and cause out-of-pocket costs to rise, the CBO says. As a result, starting in 2020, "despite being eligible for premium tax credits, few low-income people would purchase any plan."

AFFORDABLE CARE ACT (OBAMACARE)

Can get insurance through a parent’s plan or buy independently.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Stays the same.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Stays the same.

Adults under 65

AFFORDABLE CARE ACT (OBAMACARE)

Can buy insurance on health exchanges, with tax credits and subsidies if they meet income requirements up to 400 percent of poverty level. Cost of insurance is based on tobacco use and age, with the people nearing 65 paying no more than three times what the youngest pay. Premiums can’t cost more than 9.5 percent of income. Those with very low or no income qualify for Medicaid.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Will see tax credits to pay premiums based on age, not income, and that max out at $4,000, much less than under the ACA. The oldest people under 65 can be charged five times more than the youngest, and maybe more depending on state rules. Medicaid cut after 2020.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

The CBO report says 22 million people would lose health insurance over the next 10 years, with people between 50-64 disproportionally impacted. The oldest people under 65 would pay five times more than younger people on the exchanges. Subsidies to help pay for insurance would be less and end at incomes of 350 percent of poverty level. Federal contributions to Medicaid start to decline in fiscal year 2020.

Low-income nursing home residents

AFFORDABLE CARE ACT (OBAMACARE)

Skilled nursing care covered by Medicare up to 100 days. Medicaid is available based on income.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Skilled nursing care covered by Medicare up to 100 days. Medicaid services could be cut as states see federal funding decline.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Skilled nursing care covered by Medicare up to 100 days per illness. Medicaid coverage for nursing home services could be cut as federal payments to states decline.

People with pre-existing medical conditions

AFFORDABLE CARE ACT (OBAMACARE)

Coverage cannot be denied or cost more.

HOUSE BILL: AMERICAN HEALTH CARE ACT

States can get permission to let insurers charge more for some pre-existing conditions and to exclude some people altogether. States would have access to federal money to help those with expensive policies or conditions.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Insurance companies would be required to accept all applicants regardless of health status. But the draft bill lets states ask permission to reduce required coverage, also called “essential health benefits,” which would give insurers some discretion over what they offer in their plans. That could result in “substantial increases” in costs for people who want those services, according to the CBO. Caps on annual and lifetime spending by patients would no longer apply if the benefit is no longer classified as essential.

People who go to Planned Parenthood

AFFORDABLE CARE ACT (OBAMACARE)

Federal programs reimburse for most Planned Parenthood services.

HOUSE BILL: AMERICAN HEALTH CARE ACT

A one-year block will be placed on federal reimbursements for care provided by Planned Parenthood.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

A one-year block will be placed on federal reimbursements for care provided by Planned Parenthood. The CBO estimates 15 percent of women would lose access to family planning care, increasing birth rates and Medicaid spending for childbirth and children’s insurance. But those increases would be offset by Planned Parenthood cuts.

People with disabilities

The majority of Medicaid dollars go to people with disabilities.

AFFORDABLE CARE ACT (OBAMACARE)

May qualify for Medicare and also Medicaid.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Services covered by Medicaid could be cut as federal funding to states declines over time.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

Services covered by Medicaid could be cut as federal funding to states declines over time. The CBO report suggests that by 2026, Medicaid enrollment would fall by more than 15 million people.

People who use mental health services

AFFORDABLE CARE ACT (OBAMACARE)

Covered by all plans under essential health benefits.

HOUSE BILL: AMERICAN HEALTH CARE ACT

Could lose coverage in states that get waivers from covering essential health benefits.

SENATE DRAFT: BETTER CARE RECONCILIATION ACT

States could request waivers to opt out of requiring essential health benefits. If a state opted out of coverage for mental health care, the CBO says insurance that includes mental health care coverage could become “extremely expensive.”

Either plan leads to reduced access to plans for patients. Medicaid plans would be impacted.

CBO Reveals Winners, Losers In Senate Health Care Plan : Shots - Health News : NPR

The U.S. Senate has drafted it's own version of the Affordable Care Act,   The Senate bill, called the Better Care Reconciliation Act (BCRA), also would reduce the federal deficit by $321 billion over the next 10 years, $202 billion more than what the House bill would save, the CBO said in a report released today. 

Senate Bill Replacing ACA Leaves 22M More Uninsured, CBO Says.

The House of Representative formulated it's own bill, The American Health Care Act.  U.S. President Donald Trump on Tuesday backed a draft Republican proposal to dismantle Obamacare that was unveiled Monday, saying the proposed healthcare legislation was "out for review and negotiation."

Trump, in a tweet on Tuesday morning, described the bill proposed by fellow Republicans in the House of Representatives as "Our wonderful new healthcare bill."

The plan, released late on Monday, would undo Democratic President Barack Obama's 2010 healthcare law, removing the penalty paid by Americans without insurance coverage and rolling back extra healthcare funding for the poor.

The plan was swiftly criticized by Democrats.

Although Obamacare has long been a common target of Republicans, the proposal also met with skepticism from some in the party who are concerned about the replacement plan's tax credits for buying health insurance and changes to coverage under Medicaid, the government health insurance program for the poor.

The plan must pass both the Republican-led House of Representatives as well as the Senate, where it faces a higher bar for passage, making its future uncertain.Both bills address cost saving as compared to the original affordable care act.  Neither addresses insuring the uninsurable or pre-existing clauses for denial of insurance coverage.

The BCRA has already been panned by major medical societies for reducing healthcare coverage, particularly in the Medicaid program. One of the most strongly worded criticisms from organized medicine came today from the American Medical Association (AMA). In a letter to the US Senate, AMA Executive Vice President and CEO James Madara, MD, said the BCRA in many ways violates the physician's imperative of "first, do no harm".

"We believe that Congress should be working to increase the number of Americans with access to quality, affordable health insurance instead of pursuing policies that have the opposite effect," Dr Madara wrote.

Neither House or Senate Bill prioritizes patient access or quality of care. It is more about budgetary requirements.  Patients seem to be a side issue.

Senate Bill Replacing ACA Leaves 22M More Uninsured, CBO Says

Fitbit eyes sleep apnea space for next digital innovation | MobiHealthNews

Sleep apnea is not a benign problem. People who are overweight, loud snorers and even normal people can be at high risk of sleep apnea.

Sleep apnea is correlated with higher risks of hypertension, stroke, and sudden death. Sleep apnea causes poor sleep, chronic fatigue by interrupting normal REM sleep.

Normally most patients are referred to specialty sleep labs for testing.  This entails an overnight stay where  blood oxygen saturation levels, movement, and respirations are measured.  The recordings are reviewed by a physician.

If sleep apnea is diagnosed a CPAP device may be recommended while sleeping.

Fitbit has made increasingly targeted moves to wedge itself deeper into the healthcare ecosystem. No longer able to rely on the consumer market alone to stay financially healthy, the company has continually upped the ante to prime itself as a digital health company in its own right.

There have been many efforts as of late, including developing more sophisticated wearables to enable tracking of more varied biometric data, participating in a large amount of clinical research, making itself a regular fixture in many corporate wellness programs and merging their digital health and enterprise health sectors into one. And now, as CNBC reports, the company is working to make itself a part of the booming “sleep tech” market by developing tools to help diagnose and monitor sleep apnea, a common condition that is marked by shallow breathing and pauses in respiration during sleep.  

While it isn’t yet known exactly what form that will take, Fitbit already has much of the technological capabilities to start building such a device. Conor Heneghan, the company’s lead research scientist told CNBC they are exploring the use of heart rate monitoring and optical technologies to track changes in oxygen levels. By shining a light into the skin, the technology can detect the difference between highly oxygenated red blood and that which is more blue due to less oxygen saturation. If the levels fluctuate during the night, it could indicate sleep apnea. 

"We'd perform a useful public service by alerting users to the fact that they have a problem," Heneghan told CNBC.

It’s obvious why Fitbit, which has suffered declines in sales and products shipped in the last few quarters, would want to get into sleep tech. The space has been heating up for the last year, and it was decreed the hottest topic at CES 2017. Even Apple is betting on it, with the acquisition of Beddit in May. The market for sleep apnea is expected to hit $6.7 billion in the next four years, and many digital health companies such as ResMed have enjoyed considerable success with their connected, medical-grade devices to diagnose and treat the condition.

It’s also unknown whether Fitbit would seek to develop a diagnostic device, one that works as a prompt to get people to seek medical attention. Additionally, they could be working on something that monitors treatment adherence and effectiveness, and any such device would require different regulatory pathways.  

Heneghan told CNBC Fitbit is currently working with sleep labs to learn how prototypes to detect sleep apnea are performing. If they can develop a device that stands up to accuracy standards of existing sleep apnea-detecting tests and devices (digital or otherwise), the company expects to bring a product to market within a year.  

It may be some time until this device is on the market. It will require FDA approval as a medical device.

Fitbit eyes sleep apnea space for next digital innovation | MobiHealthNews

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In the next several weeks we will be focused on health reform paying close attention to those who make decisions for us about our healthcare.  One post in particular will be discussed in an upcoming post later this week.  Mark your calendar for this event.

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The Real 13 Senators to Watch on Health Care

The Real 13 Senators to Watch on Health Care

How Data Mining Facebook Messages Can Reveal Substance Abusers -

Substance abuse changes people’s patterns of behavior, and this is detectable in their social media messages, say researchers.

• by Emerging Technology from the arXiv
 
• May 26, 2017

“A substance use disorder (SUD) is a condition in which recurrent use of substances such as alcohol, drugs and tobacco causes clinically and functionally significant impairment in an individual’s daily life.” So begin Warren Bickel from the Addition Recovery Research Center in Roanoke, Virginia, and a couple of pals, who study this condition.

Substance abuse is a serious concern. Around one in 10 Americans are sufferers. Which is why it costs the American economy more than $700 billion a year in lost productivity, crime, and health-care costs. So a better way to identify people suffering from the disorder, and those at risk of succumbing to it, would be hugely useful.

Bickel and co say they have developed just such a technique, which allows them to spot sufferers simply by looking at their social media messages such as Facebook posts. The technique even provides new insights into the way abuse of different substances influences people’s social media messages.

The new technique comes from the analysis of data collected between 2007 and 2012 as part of a project that ran on Facebook called myPersonality. Users who signed up were offered various psychometric tests and given feedback on their scores. Many also agreed to allow the data to be used for research purposes.

One of these tests asked over 13,000 users with an average age of 23 about the substances they used. In particular, it asked how often they used tobacco, alcohol, or other drugs, and assessed each participant’s level of use. The users were then divided into groups according to their level of substance abuse.

The results make for interesting reading. The team says its technique was hugely successful. “Our best models achieved 86%  for predicting tobacco use, 81% for alcohol use and 84% for drug use, all of which significantly outperformed existing methods,” say Bickel and co.

The technique also identified a wide range of keywords that people with substance abuse disorder are more likely to use in social media posts. “Swear words such as ‘fuck’ and ‘shit,’ sexual words such as ‘horny’ and ‘sex,’ words related to biological process such as ‘blood’ and ‘pain’ are positively correlated with all three types of substance use disorder,” say Bickel and co, referring to tobacco, alcohol and drug use. “In addition, female references such as ‘girl’ and ‘woman,’ prepositions, space reference words such as ‘up’ and ‘down’ are positively correlated with alcohol use, while words related to anger such as ‘hate’ and ‘kill,’ words related to health such as ‘clinic’ and ‘pill’ are positively correlated with drug use.”

That’s interesting work that immediately suggests a way to identify people who are at risk of substance use disorder—simply look at their Facebook posts and likes. “We believe social media is a promising platform for both studying SUD-related human behaviors as well as engaging the public for substance abuse prevention and screening,” say Bickel and co.


How Data Mining Facebook Messages Can Reveal Substance Abusers - MIT Technology Review

Washington's Princes of Paperwork Are Crushing Physicians and Bankrupting, If Not Killing, Patients

Totally neglected in the ACA and proposed AHCA is restricting the mounting paperwork burden placed on providers. This is a critical issue.  Each "improvement" which is proposed to increase quality of care, or reduce cost creates a paradoxical effect.  This is the reduction in patient care, increased non clinical paperwork and the addition of EHR and other HIT cost.

This issue must be addressed in any new health reform law.

Steve Hanke ,  

 CONTRIBUTOR

I cover economics and finance.  

Opinions expressed by Forbes Contributors are their own.

Thomas Eakins

The Agnew Clinic (1889).

In the rancorous to and fro over the repeal of ObamaCare and its possible replacement with the American Health Care Act, an elephant in the room has remained unnoticed. It’s that giant bundle of burdensome regulations that is crushing physicians, their staffs, and sending the costs of healthcare soaring.

A recent, detailed study published by the American Medical Association (AMA) sheds a common-sense light on what Washington chooses to ignore. For every hour physicians spent with patients, almost two additional hours are spent pushing papers. Even when face-to-face with patients, doctors spent 37% of their time filling out forms.

Burdened with the weight of regulatory paperwork, doctors are becoming increasingly unhappy – more paperwork, less time with patients. Indeed, in a typical day, during office hours, doctors spent only 27% of their time attending to patients face-to-face and 49.2% on electronic health records (EHR) and desk work. Even during after-hours work, doctors spent a whopping 59% of this time dealing with electronic health records.

The following table summarizes the AMA’s stunning findings. It tells the red-tape tale in horrifying detail.

Just why do regulators promulgate so many regulations and produce so much red tape? For one thing, it creates jobs for the boys (read: the Princes of Paperwork). There is no better bulletproofing for a bureau’s bloated budget than a complex maze of regulations that “must” be enforced to protect the public’s health and safety.

But, there is another, perhaps more important, reason why regulatory bureaus produce endless miles of red tape to wrap around doctors, medical staffs, and the U.S. healthcare system. Bureaucrats are conservative. They like to avoid risks, and decision making is an inherently risky activity. After all, decisions can prove to be wrong, unpopular, or both. So, to avoid the risks and responsibilities that come with discretion and decision making, regulators produce rigid rules and red tape – the more, the merrier. The regulators’ check-the-box mentality allows them to slip out from under any responsibility if something under their regulatory purview “goes wrong.” The regulators are protected, and the onus is placed on the doctors and their staffs who must check all those boxes – boxes that cover everything under the sun.

Washington's Princes of Paperwork Are Crushing Physicians and Bankrupting, If Not Killing, Patients