What if lawyers weren’t allowed to own law firms or chefs weren’t allowed to own restaurants? Why not, you might ask? But doctors aren’t allowed to own hospitals.

This is the question posed by Senator James Lankford (R-Oklahoma) and Brian J. Miller (Professor of Medicine, Johns Hopkins University) in a recent Op-ed published in The Wall Street Journal. Most people don’t know that a tiny paragraph in the enormous Affordable Care Act (ObamaCare) prohibits physicians from building or owning hospitals. Any physician-owned hospital built before 2010 is grandfathered in, but is prohibited from growing beyond the size it was when the bill passed. What sense does that make?

This law limits competition, which always promotes quality and lower prices. Isn’t that a good thing? The law defies common sense and is surely contributing to higher prices for Medicare and reduced access to treatment for millions of Americans.

Recently, I discussed the financial problems of Medicare and some ideas to solve this problem (Solving Medicare/Medicaid Insolvency). Today, we are discussing yet another way to lower the costs of Medicare and solve the insolvency problem. According to the Medicare board of trustees, we have only about six years left to solve this problem. By 2030, Medicare and Medicaid will be the largest contributors to the national debt.

The authors say the current political debate has focused on the effects of monopoly power and consolidation across industries, including healthcare. The Biden administration’s executive order on competition specifically mentions hospital consolidation and subsequent rising costs. Yet political leaders overlook the most obvious way to increase healthcare options: letting doctor-owned and managed facilities grow as they did before 2010.

Naturally, the hospital industry opposes doctors owning hospitals. They don’t like the competition. They argue that physicians cherry-pick health patients and prefer those with private insurance as a rationale for supporting the ban on physician-owned hospitals. In response to these concerns, the Centers for Medicare and Medicaid Services (CMS) in 2007 added an adjustment to hospital payments for sicker patients. Other research shows that physician-owned hospitals had no difference in the number of Medicaid patients compared with hospitals not owned by physicians.

This is not a new issue; just one that needs reconsideration. I first wrote about this problem in a blog post 11/26/15 called Physician-Owned Hospitals Deliver Quality and Value. This post was later published in my recent book, Changing Healthcare. I said then that banning new or expanding existing physician-owned hospitals makes sense only if you want higher-cost, lower-quality healthcare.

Why does the ACA ban new construction of physician-owned hospitals?

The ACA was developed in close cooperation with the major stakeholders in the healthcare industry. That means hospitals, pharmaceutical companies, and healthcare insurers. The hospital associations are dominated by large non-profit general hospitals that must compete with smaller physician-owned hospitals (POHs). They successfully lobbied the Obama administration into punishing the POHs that violate the new construction ban by prohibiting their participation in Medicare and Medicaid. In other words, the ban is based on politics, not on lowering the costs of Medicare and Medicaid or providing access to healthcare.

At the time, the hospital industry claims that POHs provided higher cost, selective care went unchallenged. But since that time, research has shown a different story. Here are some revealing new statistics:

• Seven of the top 10 hospitals receiving quality bonuses in the Hospital Value-Based Purchasing Program in 2015 were POHs.
• The Centers for Medicare and Medicaid Services (CMS) released Star Ratings in 2015 based on consumer assessment survey. More than 40% of POHs received the top 5-star rating compared to only 5% of general hospitals.
• The Department of Health and Human Services (HHS) found that patients are 3 to 5 times more likely to experience complications at general hospitals than at physician-owned hospitals.

These statistics clearly establish that POHs are providing high-quality healthcare.

But what about the cost? How do the POHs compare to the non-profit hospitals?

An analysis by Avalon Health Economics said that POHs are saving Medicare $3.2 billion over 10 years. For that reason alone, you would expect the federal government to want more, not less, of these hospitals.

Furthermore, in contrast to claims by the general hospitals, POHs provide more charity care, not less. A CMS study found that POHs spend nearly 6% of their total revenue on community benefits compared to less than 1% for other hospitals. In addition, a major study was published in The British Medical Journal that found patients at POHs and non-POHs were equally likely to have Medicaid insurance and to be from racial or ethnic minority groups. The study concluded: “POHs also performed equally to non-POHs on a wide array of measures of quality of care, costs, and payments for care.”

With this much evidence to support POHs, including high-quality care and cost-lowering measures, what is standing in the way of reform? The answer is crony capitalism – government picking winners and losers based on political support. To reverse this bad decision will take political courage. Senator Lankford is introducing the Patient Access to Higher Quality Health Care Act to solve the problem. This legislation would put patient choice back into hospital markets by allowing doctors to build efficient businesses and better serve patients. Competition always raises quality and lowers costs – and we need that in healthcare if we’re going to solve the insolvency of Medicare and Medicaid.

We’re discussing a condition called “long Covid” and wondering if it is real or not. In Part I we talked about the opinion of a psychiatrist who believes this is not a real condition, but instead a misdiagnosis of those with anxiety and depression or physical conditions unrelated to Covid infection.

I also likened this situation to another vague condition, called fibromyalgia. Both are poorly understood conditions with little or no way to make a certain diagnosis. Fibromyalgia has long been diagnosed without any available accurate diagnostic tests, but recently there has been developed a blood test with possibly 70% correlation. In both conditions, there is a high incidence of anxiety and depression.

Unfortunately, getting to the truth is hampered by the social and political implications of each diagnosis. Fibromyalgia is often diagnosed rather than anxiety and depression because it is more socially acceptable. Long Covid may be diagnosed more often in those who wish to make political statements concerning pandemic treatments.

The evidence of this latter possibility is discussed in a recent article published in The Wall Street Journal by Allysia Finley. She is alarmed at the conclusions being touted by the Centers for Disease Control and Prevention (CDC) after a recent study that claims to find that nearly 36% of Covid cases among student, faculty and staff at George Washington University resulted in “long Covid.” The study suggests that young, healthy people face a high risk of chronic debilitating symptoms after infection despite being at low risk of getting severely ill with the virus.

The study also finds that the unvaccinated were at more than twice as high a risk of developing long Covid as those fully vaccinated who had gotten boosters. While this may seem logical, a closer inspection reveals there is little evidence to support those conclusions.

Like many colleges, GWU held classes online during the first year of the pandemic even as some students returned to campus. Those on campus were required to undergo weekly Covid testing. During the 2021-22 school year, classrooms reopened but students were required to be vaccinated and later boosted. The college recorded 4,800 Covid cases between August 2020 and February 2022. Those who tested positive were later asked to complete 15-to-20-minute surveys about their health and behavioral changes. Only one-third completed the surveys and those who did might have been more likely to report lingering health problems – a phenomenon in research known as nonresponse bias.

Finley says the study has two other major methodological problems. First, it doesn’t include a control group of students and faculty that weren’t infected. The finding that nearly 36% reported long Covid symptoms is meaningless without such a sample to determine how common such symptoms were among people who never had Covid.

Second, as I said earlier, “long Covid” is poorly defined, but the study defines it expansively to include problems common among college students – difficulty making decisions, fatigue, anxiety, sadness, trouble sleeping and the catch-all phrase “other symptoms.” If a student reported at least one physical or psychological problem, he was classified as having long Covid. (By this definition, I am surprised the incidence of “long Covid” wasn’t higher!)

A CDC survey in January 2021 reported that 57% of respondents between 18 and 29 had experienced anxiety or depression within the previous seven days. This survey included both those with and without Covid. The well-reported uptick in mental health problems among young people during the pandemic was in part caused by government lockdowns and virtual learning policies such as at colleges like GWU.

Finley says, “It’s impossible to determine from the study whether any GWU students actually developed long Covid, let alone whether vaccines and boosters reduce risk for the ill-defined syndrome.” (Remember, there is no definitive way to make this diagnosis.) Nonetheless, the study says its findings reinforce the need to “advocate and monitor for vaccine and booster adherence to published recommendation.” That sounds like a political, rather than a scientific, conclusion. This study is clearly being used by the CDC to justify their policies and recommendations.

None of this really answers the question of whether or not “long Covid” is real. A November 2021 study reported in the Journal of the American Medical Association (JAMA) found that many people with persistent physical symptoms that are commonly ascribed to long Covid didn’t actually test positive for antibodies! In other words, a belief that one had Covid was more strongly associated with physical symptoms than a lab-confirmed infection. Evidently, many people are simply looking for an excuse for their complaints which is socially, and perhaps politically, acceptable.

Lastly, Finley raises any interesting question – How did lockdowns and school shutdowns contribute to putative long Covid symptoms? A JAMA study last September found that depression, anxiety, perceived stress, loneliness and worry about Covid were tied to a 1.3 – 1.5 -fold increased risk of self-reported postviral symptoms as well as increased risk of daily life impairment. In other words, is the increased reporting of such symptoms a result of long Covid or the result of the mental stress of the pandemic itself?

She concludes with this concern: “By exaggerating the incidence of long Covid among young, healthy adults, the CDC deflects attention from mental-health problems caused by misconceived pandemic policies. It also fuels public distrust in the scientific enterprise, which may prove to be the pandemic’s most destructive long-term effect.”

For quite some time, since the onset of the Covid-19 pandemic in 2020, there has been a debate in the medical community and the media about post-Covid symptoms now referred to as “long Covid.” Is there really such a condition and, if so, how prevalent is it?

Nearly two years ago I published a post based upon an article written by Dr. Jeremy Devine, a psychiatry resident at McMaster University in Hamilton, Ontario, called Fake Science Behind Long Covid Symptoms. At that time there was very little known about this condition, but reports were becoming more frequent. Dr. Devine said there is no scientific basis for this condition. Yet, the National Institutes of Health announced then a $1.15 billion initiative to research the “prolonged health consequences” of Covid-19 infection.

Dr. Devine acknowledged that some elderly patients, with co-morbidities, do experience symptoms that outlast the coronavirus infection. But, as a psychiatrist, he notes that such symptoms can also be psychologically generated or caused by a physical illness unrelated to the prior infection. He says “long Covid” is largely an invention of vocal patient activist groups. Legitimizing it with generous funding risks worsening the symptoms the NIH is hoping to treat.

He based his opinions on shoddy research supported by NIH Director Francis Collins, who has ties to activist groups promoting this condition. Dr. Collins has since lost some of his credibility when it was revealed he and Dr. Anthony Fauci colluded to prevent any investigation of the origins of the Covid-19 pandemic that might look closer at the Wuhan, China laboratories, which received financial support from NIH.

Why would a scientific institution, such as NIH, support unscientific conclusions?

Dr. Devine opines that this subjugation of scientific rigor to preconceived belief reflects a common dynamic encountered in clinical practice. He says, “Patients who struggle with chronic and vague symptoms often vehemently reject a physician’s diagnosis that suggests an underlying mental health issue, in part because of the stigma around mental illness and the false belief that psychologically generated symptoms aren’t “real.”

The problem is there is no known way to positively identify “long Covid.” There is no laboratory test or imaging study that can confirm this diagnosis. The list of symptoms generally associated with “long Covid” include fatigue, “brain fog”, and other vague aches and pains. These same symptoms are also associated with chronic fatigue syndrome, fibromyalgia, anxiety and depression.

When I began medical school nearly 50 years ago, fibromyalgia was a new diagnosis. Very little was known about it then and very little more is known about it now. Like “long Covid”, there was no laboratory test or imaging study that could confirm the diagnosis. According to the National Institutes of Health, “Fibromyalgia is a chronic disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping.” Patients with fibromyalgia are considered hyper-sensitive to pain. There is a high correlation between patients diagnosed with fibromyalgia and those diagnosed with anxiety and depression.

Today, there is a laboratory blood test that can be used to determine if a patient has fibromyalgia. But the test has only about 70% accuracy according to the American College of Rheumatology. A patient must have pain in at least four of five regions; symptoms have to be present for at least three months, widespread pain index score must be >7 and symptom severity scale score is >5 or widespread pain index score is 4 to 6 and symptom severity score is >9.

Even if there really is a condition called fibromyalgia, there is great pressure on physicians to make this diagnosis instead of attributing their symptoms to anxiety and depression. The population most associated with fibromyalgia is middle-aged women (some studies say 90%) and the same population is also associated with a high incidence of anxiety and depression. Since fibromyalgia is a more culturally accepted diagnosis than anxiety and depression, many women prefer this diagnosis – and pressure their doctors to agree.

All of this brings me back to “long Covid.” Is it real, or is it a more acceptable diagnosis than anxiety and depression? At this point we don’t really know, but there is certainly pressure to make this diagnosis for many reasons.

(To learn more about this subject, stay tuned to my next post.”)