Homeless Americans have a life expectancy of only around 50, and often use the ER for primary care at a huge cost. The lack of follow-up care for their illnesses and the mental health or substance abuse disorders common in this population add up to an enormous health burden. Experts discuss how doctors on the street can improve health for the homeless and lower cost for society.
Dr. Jim Withers, Medical Director and Founder, Pittsburgh Mercy Health System Operation Safety Net and the Street Medicine Institute
Dr. Jim O’Connell, President, Boston Healthcare for the Homeless Program and author, Stories from the Shadows: Reflections of a Street Doctor
High prescription drug costs are a problem that most Americans deal with. In response to this, President Donald Trump announced last month that his administration is introducing a 50-point plan to cut drug prices. Dr. David Hyman, Professor of Law at Georgetown University Law Center and co-author of Overcharged: Why Americans Pay Too Much for Healthcare, talks through some of the major points of the plan and how effective they could truly be in the long run.
Two important parts of the plan are an attempt to ease the entry of generic drugs into the market and to make their prices more flexible. Eric Hargan, Deputy Secretary of the US Department of Health and Human Services, says branded drug companies must stop the “gamesmanship” that slows the creation of a competitive, free market for drugs. And, getting more drugs into “part D” allows Medicare to negotiate for lower prices through pharmaceutical benefit managers (PBMs).
But, the PBMs bring a problem of their own into the industry. President Trump says that these middlemen have been part of the problem by stopping the distribution of rebates and discounts to consumers and pocketing the money themselves, which also leads to artificially high list prices for drugs. Dr. Hyman says that PBMs are still important to the industry, because they structure the pharmaceutical market, but the plan will hopefully help to create a fairer market.
Another potentially influential part of the plan, announced by Alex Azar, Secretary of the US Department of Health and Human Services, will be to require drug companies to announce the list prices of drugs in their advertisements in the interest of transparency.
In his book, Dr. Hyman introduces several points that he believes would be beneficial in helping Americans pay less for drugs, although these points are not in President Trump’s recent plan. He suggests that allowing Americans to import generic drugs from foreign markets would help solve the generic drug price hikes. Dr. Hyman also stressed that high insurance costs are the biggest driver of high costs for prescription drugs.
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Dr. David Hyman, Professor of Law at Georgetown University Law Center and co-author of Overcharged: Why Americans Pay Too Much for Healthcare
Eric Hargan, Deputy Secretary of the US Department of Health and Human Services
With the opioid epidemic continuing to take many lives every year, people are concerned with how to stop it. In order to help counter this epidemic, Medicare has taken steps to implement limits on the prescriptions of opioids. However, the Medicare proposal has left doctors wondering if these new limits will do more harm than good for patients.
Currently, the United States is experiencing the second wave of the opioid epidemic. Dr. Anna Lembke, Associate Professor and Chief of Addiction Medicine at Stanford University School of Medicine, explains that opioid addiction arises from the prescription of these medications as a go-to for doctors even if the medical condition does not necessarily call for it. Furthermore, Dr. Sally Satel, an addiction psychiatrist and lecturer at Yale University School of Medicine and Resident Scholar at American Enterprise Institute, states that another issue is not just the prescribing of opioid medications, but the over-prescribing. In many cases, a doctor will prescribe a patient an unnecessary amount of opioids, but this often leads to leftover medication that tends to get into the hands of people who are likely to abuse it. So, one way that Medicare is working to counteract this is by regulating the quantity and overall dose of opioids that are allowed to be prescribed to a patient. Dr. Satel explains that by limiting the number of pills allowed when refilling a prescription, not only will it decrease the number of leftover pills, but it will also guarantee that those who benefit from opioids continue to take them appropriately. Along with this, Dr. Lembke states that this limit on the number allowed to be prescribed is important because doctors most likely would not limit their prescriptions enough to a point that would allow for a decrease in the epidemic. With this regulation, the number of leftover pills being circulated outside of who they were prescribed to will decrease which will allow for a drop in the number of people addicted to prescription opioids.
The proposed Medicare regulations also came with a second leg to it. This other guideline would cut-off any doctor from prescribing a high-dose of opioid medications. However, Dr. Satel explains that many pain physicians had problems with this regulation because it would make it extremely difficult for patients who do benefit from these prescriptions, and use them properly, to have access to them. So, when the final Medicare proposal was released, this second guideline was altered to allow physicians to prescribe high-doses of opioid medications, but it gave pharmacists the power to override a high-dose request that seemed unnecessary.
While these Medicare limits are a step in the right direction for managing the opioid epidemic, there is still much that can be done to improve it. For instance, other medical treatments should be made more accessible through Medicare, explains Dr. Lembke. It’s important to reduce the access to opioids. However, it is also important to facilitate the use of other medical treatments to help with pain. Improvements are being made in the healthcare system to stop the opioid epidemic, but those who benefit from opioid prescriptions should not have to suffer.
Dr. Anna Lembke, Associate Professor and Chief of Addiction Medicine at Stanford University School of Medicine
Dr. Sally Satel, addiction psychiatrist and lecturer at Yale University School of Medicine, and Resident Scholar at American Enterprise Institute
In some areas, it has become almost impossible to find independent physician practices. Many of these smaller practices have opted into being bought by hospitals and other large medical groups. So, what has prompted the increase of consolidation in the medical field? And what does this mean for patients?
The incentives of consolidation have been researched, but the results do not point to one reason. Dr. Laurence Baker, Professor of Health Research and Policy at Stanford University School of Medicine, explains that physicians running smaller practices might benefit from no longer having their own business. Another possibility, Dr. Christopher Ody, Research Assistant Professor at Kellogg School of Management at Northwestern University, explains, is that some hospitals may view consolidation as a way to improve the quality of healthcare and decrease the costs to help physicians and their patients. However, data has indicated that the factor with the largest role in consolidation has to do with increasing the amount that hospitals are getting paid, and decreasing the amount paid to pharmaceutical companies. Even though research has not provided an overarching incentive that drives consolidation, the data seems to point to increasing income for hospitals rather than providing patients with better care. Furthermore, hospital consolidation has not been shown to benefit the patient. Dr. Baker explains that data indicates that the cost of healthcare has not gone down for patients with consolidation. Since the cost of healthcare has increased for patients, many have started to wonder how consolidation has been able to continue and what is being done to control it.
In the medical field, it is important to maintain consistency in market concentration and ensure that the markets are still competitive. One way in which authorities in the medical field work to maintain market concentration is by regulating transactions that reach a price threshold. However, Dr. Ody explains that hospitals have been able to avoid these regulations by partaking in multiple smaller transactions that invest in a small number of physicians at a time in order to ensure that the cost is below the threshold for evaluation. By avoiding regulations, hospitals have been able to grow into much larger entities that generate a lot of power and income from smaller practices. Since consolidation has prompted increased healthcare costs, it currently appears to be detrimental to the medical field rather than helpful. Yet, it could be worth it if hospitals were able to determine a method of consolidation that decreases healthcare costs and improves the quality of care that is provided to patients.
Dr. Laurence Baker, Professor of Health Research and Policy at Stanford University School of Medicine
Dr. Christopher Ody, Research Assistant Professor at Kellogg School of Management, Northwestern University
We all know that doctors endure years and years of schooling and training in order to learn how to diagnose their patients and provide them with the best care. But, studies have shown that many doctors tend to miss details about other aspects of a patient’s life that can also have an affect on their wellbeing. Dr. Saul Jeremy Weiner, Professor of Medicine, Pediatrics & Medical Education at University of Illinois and co-author of Listening For What Matters: Avoiding Contextual Errors in Health Care, explains that patients will make important comments that do not necessarily pertain to their symptoms, but that this information is often overlooked despite being critical for a doctor to understand in order to provide the patient with an effective care plan. But, what is the overall impact of this on the patient? Dr. Weiner and Dr. Alan Schwartz, Michael Reese Endowed Professor of Medical Education at University of Illinois, Chicago, and co-author, Listening For What Matters: Avoiding Contextual Errors in Health Care, have done their own research that has shown the effects of doctor’s that are too focused on the biomedical details in providing care for patients. Dr. Schwartz explains that the results of their research showed that doctors who address the patient’s personal life were able to provide a much more successful care plan for the patient. Furthermore, the study also showed that the cost of healthcare for the patient increased when the doctor was too concerned with the science of the diagnosis. In order to have the most successful outcome without increasing the cost of healthcare, doctors must address more than just the patient’s biomedical symptoms.
So, how can doctors learn to listen to their patients more efficiently? Dr. Weiner suggests using an approach commonly used in other industries: mystery shoppers. In the medical field, a mystery shopper is an unannounced standardized patient that is trained to go into a physician’s office and provide data to help identify problems–a tool that many doctors have found to be helpful in improving their practice. Dr. Schwartz states that by investing in improving contextual care doctor’s will be able to provide better care for their patients and decrease the cost of healthcare, too. However, all patients and employees in the medical field must be willing to undertake these methods and procedures in regular practice in order to improve the overall experience for everybody.
Dr. Saul Jeremy Weiner, Professor of Medicine, Pediatrics & Medical Education at University of Illinois and co-author of Listening For What Matters: Avoiding Contextual Errors in Health Care
Dr. Alan Schwartz, Michael Reese Endowed Professor of Medical Education at University of Illinois, Chicago, and co-author of Listening For What Matters: Avoiding Contextual Errors in Health Care.
In the past, healthcare has spent thousands of dollars on treating the homeless, and often times the hospitals are never paid for these treatments. Homelessness affects an individuals health and severely decreases their life expectancy. Stephen Brown, Director of Preventive Emergency Medicine at University of Illinois Hospital and Health Sciences, Chicago, explains that homeless people are admitted to the hospital more than the average person and on a more consistent basis. Yet, following these treatments, the homeless are often sent back to the streets and forced to fend for themselves again.
However, some hospitals around the nation are beginning to acknowledge their role in helping homelessness. In light of this growing problem, bigger cities around the nation have started to provide housing to the homeless. But, they have replaced the traditional model that required people to be clean of their addiction before they were provided with housing with a much more efficient model that has already shown higher success rates. Shannon Nazworth, President and CEO of Ability Housing in Jacksonville, Florida, explains that the new “housing first” model takes people straight from the street and provides them with shelter, and then gives them access to resources that help them get back on their feet. She explains that they have the responsibility to pay rent, but the program helps the individuals access funds through benefits. The end goal of this program is to help the person work toward a financial position in which they are able to to move from program housing to different community housing.
Since “housing first” programs began, they have shown a significant increase in getting homeless individuals off the streets and keeping them off the streets. But, the programs have still faced backlash. Nazworth explains that due to stigmas associated with mental health and homelessness there have been misconceptions about the individuals that would be allowed in these programs. In order to change this, Nazworth states that the program allows people to come in and observe the housing to acquire more knowledge on it. By providing homeless individuals with the opportunity to receive housing and aid, many of them are capable of redeeming their health and eventually no longer rely on the programs for help anymore.
Stephen Brown, Director of Preventive Emergency Medicine at University of Illinois Hospital and Health Sciences, Chicago
Shannon Nazworth, President/CEO of Ability Housing, Jacksonville, Florida
Big data is changing almost every aspect of modern-day life. Healthcare is one of the most recent adopters of big data collection. Paddy Padmanabhan, a healthcare IT expert and CEO of Damo Consulting, says over the past ten years health records have been moved to digital files, but most of the time the advantages of doing so are not fully utilized. Most of the time, health providers do not share information with each other, so when you go to a new provider they have to start from scratch.
Padmanabhan, also the author of The Big Unlock: Harnessing Data and Growing Digital Health Businesses in a Value Based Healthcare Era, advocates for evidence-based healthcare, which entails providers are accountable for providing data which illustrates they are delivering acceptable care at an acceptable price. Consumers have more financial responsibility than ever for their healthcare cost. Previously, when insurers would pay providers directly and in far higher percentages, patients had almost no idea of the actual cost associated with their treatment. Providers had incentive to charge whatever they could get away with. Today, patients have more choices and providers are forced to offer more transparency. Big data is the next logical step if the goal is to improve accountability.
Eventually, so much healthcare data will be available that artificial intelligence will be needed to assist in diagnosis and recommend possible treatment options. There is such a vast range of potential applications for the data. For example, sequencing you genome can provide far more information that your medical history alone. There are, however, downsides to the collection of this data. There is potential for the data to fall into the wrong hands, primarily the possession of insurance companies who could use the data to predict complications extremely accurately. Eventually, insurers could refuse to cover certain individuals because they could predict the high cost of their treatment, so steps must be taken to protect valuable healthcare data.
Paddy Padmanabhan, CEO, Damo Consulting and author, The Big Unlock: Harnessing Data and Growing Digital Health Businesses in a Value Based Healthcare Era