When Your Hospital Doctor Doesn’t Work for the Hospital

Increasingly, for-profit companies are delivering clinical healthcare services, raising issues about goals, costs, and quality. Understanding the business decisions that ultimately affect patients is critical, and one major financial decision facing hospitals across the country is the decision to outsource clinical and non-clinical services. Outsourcing in healthcare is an issue I’ve been able to study and write about in “The High Stakes of Outsourcing in Healthcare” published in the November issue of Mayo Clinic Proceedings. To probe further beyond our paper, I interviewed a hospital CEO about his experience with outsourcing healthcare functions, asking him about when outsourcing is appropriate as well as its risks and benefits. Outsourcing in healthcare is a hot-button issue and such conversations can quickly spark controversy. To pave the way for total candor, the CEO and I agreed to keep his name anonymous. I’ll refer to him as “Chuck.”

Chuck has had significant experience in outsourcing hospital services, including cleaning, food, and physician services that include emergency medicine, radiology, and pathology. Our conversation began by discussing the outsourcing of patient-facing services, such as emergency room care. Most patients are unaware that half of ER doctors in the U.S. don’t actually work for the hospital, but rather they work for a contract management group that staffs the hospital’s emergency department. Chuck discussed how physician groups are often contracted for their expertise; however, patients don’t always benefit from these arrangements. Chuck said, “When you go to the ER, the hospital will charge you for your CT scan or your X-ray, but you’ll also get a bill from your ER doctor who works for a separate company. And, your scan was probably read by a radiologist, so you’ll get a radiology bill, too. Multiple groups billing the patient can lead to higher costs for the patient, particularly if one of the outside clinicians is out of the patient’s insurance network.” Hospitals tell physician group contractors to maintain insurance contracts with the hospital’s same group of insurers, but this doesn’t always happen, and resulting out-of-network bills contribute to the surprise medical billing we’ve seen across the country.

I asked Chuck about one of the findings in our research which was that although outsourcing companies may bring in “expertise,” they don’t always deliver on quality. He said that he hasn’t seen this as often with physician services as he does with non-patient facing services, such as hospital cleaning and food services. In our paper, my co-authors and I discuss a study showing that hospitals that outsource their cleaning services report significantly higher hospital acquired infection rates. When I asked for Chuck’s experience with outsourcing cleaning services, he echoed many of the findings in our research, saying, “When you talk about cleaning services, you have to ask: how does a third party profit off of this business when it’s not a business our hospital wants to be in? And that’s where you see inferior benefits for employees, you may see compression of wages… and with some of these service providers, I’ve seen relatively high turnover, in part because they may not have as rigorous pre-employee screening as we do. With all of this, you very well could be getting a lower-quality employee.”

Chuck’s discussion of the different outsourcing contract structures that hospitals enter into was fascinating. He explained the two most common, yet competing, outsourcing arrangements. The most commonly used contract is called a Profit & Loss Contract. That’s where the contractor says something like, “Let me sign a 5-year deal with your hospital to do all your housekeeping services. And I’m going to do that whole deal for $1 million.” Let’s say that $1 million contract breaks down as follows: $850,000 in wages, $50,000 in supplies, and $100,000 in management fees (profit). With such an agreement, Chuck says, “For the contractor to preserve its margin of $100,000, it will inevitably have to cut back on some other piece of the pie if costs are higher than expected (e.g. due to wage inflation over the 5-year period) or the contractor just wants to beef up their profit margin. And the way I’ve seen it most commonly play out is that as the contract progresses from year one to year five, you start to see suppression of the number of employees in order to cut back on wage spending. This is why at the beginning of the contract period, the contractor may provide 40 cleaning staff, but by the end of the contract period, there are only 32 staff. My hospital hasn’t changed in size over those 5 years, but now there are fewer cleaning staff… that’s where you start seeing quality issues. With Profit & Loss Contracts, there tends to be growing dissatisfaction with time.”

The second type of contract is the Management-Fee Contract (also known as a Cost-Plus Contract). In the same scenario, rather than signing a 5-year deal for a fixed amount of money, the contractor comes to the hospital and says, “I’m going to provide your hospital with 40 cleaning staff because that’s what I think it takes to provide high quality service. I’m going to take a management fee of $100,000, and I will bill your hospital for all the operating costs.” In this model, the supply and wage costs are passed down to the hospital. Chuck says that with this model, “as the contractor gives its staff wage increases, they don’t have to cut back on labor to preserve their profits because their profits are guaranteed and were made transparent through the stated management fee.” The hospital covers all of the costs of wages and other operating expenses. In this scenario, Chuck says that “the hospital may pay a little more each year compared to the Profit & Loss Contract, but the quality of service is maintained over time.” Chuck says that he likes the Management Fee structure, but it is the rarity and not the norm.

The decision to outsource hospital services is not one to be taken lightly, and when outsourcing is appropriate, hospitals should employ a contract arrangement that prioritizes patients over profit. Additionally, patients often don’t know of all the external financial relationships doctors have, and if you have to visit the ER, it may be worth asking if your work-up will involve doctors out of your network. Because the last thing we all want is a big bill and an unhappy surprise.

*I spoke with a hospital CEO about the risks of outsourcing in healthcare and how some patients can get an unaffordable, surprise bill from their hospital.*

When the Cards are Stacked Against You: A Conversation with Pediatrician, Professor, and Entrepreneur Dr. Michael Hole

Qualities of life that most of us take for granted—clean air and water, a safe environment, access to healthy foods, and others—are the same qualities that deeply affect the health of low-income Americans. And when you’re a kid, you have little control over the quality of air you get to breathe or the foods you are given to eat. But it’s this exact environment that can shape your future. For the 1 in 7 children born into poverty each year in America, the wealthiest nation on Earth, the cards are stacked against them at no fault of their own. I had the privilege of speaking with Dr. Michael Hole—a pediatrician, health policy professor at UT Austin, and entrepreneur—about the work he is doing to lift children and families out of poverty. In 2016, Dr. Hole was named in Forbes’ “30 under 30,” and in 2019, Presidents Bill Clinton and George W. Bush named Dr. Hole a Presidential Leadership Scholar.

If you’re in New York City, and you were to walk from the Upper East Side to East Harlem just a few blocks away, your short trip would cover a difference in life expectancy of 18 years. Same city, different world. The life expectancy across these two neighborhoods is not particularly unique. Similar and more drastic trends can be found in other major cities across the country, including Washington D.C., Chicago, and New Orleans. It’s a perfect example of how much your environment affects your health, and it’s these vulnerable populations that Dr. Hole treats. The families that Dr. Hole cares for are almost always without insurance, almost always experiencing poverty, and are often experiencing homelessness. When I asked Dr. Hole about social determinants of health, such as environment and income, he said, “Too many of my patients’ families face impossible decisions, like using their limited cash to fill a prescription or buy groceries. So much of my work is about connecting families to community resources and finding ways to get more money in their pockets so they can meet all their basic needs.” He included that although doctors have to know how to diagnose and treat diseases, “medical school curricula should include training in community engagement and how to form strategic partnerships with local service agencies tackling problems like hunger and homelessness. Only a fraction of people’s health is determined by the medical care they receive, so future physicians, regardless of specialty, must be equipped with the skills and networks they’ll need to address poverty and other social ills impacting their patients’ health.”

Dr. Hole has gone far beyond writing prescriptions to help his patients. He co-founded StreetCred, a national nonprofit helping low-income families file taxes, claim refunds, set up savings accounts, and build budgets, credit, and wealth while they wait in a trusted, frequent space: hospitals and clinics. Since its founding in 2016, StreetCred has put over $8.5 million in tax credits in the pockets of low-income families. Integrating tax-preparation with healthcare may appear opaque, but Dr. Hole shared how the two are interrelated, saying “When you have children, you come to the doctor’s office a lot, especially when they are little, even when they’re healthy. And the doctor’s office is a place you trust. Doctors ask about sensitive topics all the time: sex, drugs, mental health. So it’s a place to have hard conversations about finances, too—and to connect people with financial resources. Money matters to people’s health, and as such, I’m on a mission to make sure America’s health systems act like it.”

Dr. Hole discussed how important it is for low-income families to take advantage of the Earned Income Tax Credit (EITC). The EITC is the nation’s largest federal anti-poverty program, and it provides tax credits to low-income families based primarily on their income and the number of children they support. This money can be invaluable to low-income families, and as Dr. Hole says, “The program is well-studied. We know that when low-income families get this money, good things happen for their health, children’s education, and their future financial outcomes. For example, pregnant women who receive the EITC deliver babies with higher birth weights. Mothers who get the money have less stress, and children in families who receive the EITC graduate high school at higher rates. These are remarkably good things, but the EITC goes largely unclaimed. 20% of the families who are eligible for it do not take advantage of it every year.” StreetCred ensures more families get the money they need.

In talking about the impact of StreetCred, Dr. Hole shared that their very first ‘client’ was a “grandmother with a toddler who used the extra money to buy him a winter coat, which was a luxury in her mind.” Millions of children are lifted out of poverty every year thanks to the EITC, and it’s critical to ensure low-income families know the credit exists and know how to take advantage of it. Dr. Hole concluded by saying, “At the core of nearly any social problem—food insecurity, housing insecurity, etc.—is financial insecurity. As such, StreetCred is addressing social issues at their core. And that’s important because wealth is health.”

Like the earned income tax credit, the Supplemental Nutrition Assistance Program (SNAP) is a lifeline for low-income families and a critical program for lifting children out of poverty. SNAP provides money for food to low-income families, and the children impacted by SNAP are significantly more likely to graduate high school and experience far better health outcomes, including lower rates of obesity later in life. About 17% of children live in households that receive SNAP benefits. In the realm of food insecurity, I asked Dr. Hole about a service called Good Apple, for which he serves as the Founding Advisor. Good Apple is focused on fighting food insecurity, and the organization partners with farmers, food pantries, transportation companies, philanthropists, nonprofits, medical clinics, and universities to deliver healthy foods, such as fresh fruits and vegetables, directly to the doorsteps of families facing food insecurity. Dr. Hole told me that “Food shortage isn’t the problem. We have food banks, food pantries, government programs like SNAP, and a whole host of other food services available to people facing food insecurity. But that doesn’t mean people have easy access to those services and places. Transportation is a huge barrier, and it got even worse amid the COVID-19 pandemic when traveling in public meant increased risk of infection. What’s worse: federal programs don’t subsidize food delivery services. So, while you and I can order groceries online and have them delivered to our doorsteps—that’s a big privilege. Good Apple is working to close that gap.”

A kid’s health is impacted by where they live, what they are fed, how much income their parents earn, the color of their skin, and several other social factors. We know that multiple, compounding social problems early in life can lead to really poor health outcomes later in life. Many of the federal programs currently in place, such as SNAP, are contentious, and proposed government programs like universal basic income instantly create debate. Welfare legislation can look expensive upfront, but as Dr. Hole says, early investments in children’s health can “save our very expensive healthcare system a lot of money.” It’s important for us to dive deep into the best strategies to lift American children out of poverty because investing in our children’s health is investing in the future of America.

Kindness and Empathy in the Wake of Covid-19: A Conversation with Critical Care Physician Dr. Rana Awdish

Covid-19 has forced all of us to question what we often take for granted, and the pandemic will have a lasting impact on healthcare in America. While the pandemic is certainly not over, cases are declining while vaccinations are on the rise. Empathy has taken on a greater role in the wake of Covid, as hospitalized patients are left unaccompanied due to the fear of infecting family members and caregivers. I had the privilege of speaking with Dr. Rana Awdish about the role of kindness and empathy in the wake of the pandemic, and the lessons we can learn from caregivers on the frontlines. Dr. Awdish is a critical care physician, director of the Pulmonary Hypertension Program at the Henry Ford Hospital in Michigan, and author of the LA Times bestselling book In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.

Being in the hospital for any illness presents its own challenges, but Covid has complicated care even further. My conversation with Dr. Awdish began by asking her how these additional challenges materialized at the beginning of the pandemic. Dr. Awdish said, “Covid presented real challenges because we couldn’t be the kind of healers we wanted to be—healers who knew the patient as a person, knew the patient’s family, and understood their values. At first, we didn’t know how Covid spread, or if our masks would really protect us, so all of us limited our interactions with patients. What surprised everyone about this was how much that truly took away from our sense of purpose… We had come to really need that connection with our patients.”

Not only were the connections weakened between clinicians and patients, but caregivers also had to witness some of their patients’ last breaths. In a powerful piece published in Intima, Dr. Awdish writes about her staff’s reaction to their patients’ deaths: “We leaned forward and bowed our heads in order to redirect the flow of tears. We couldn’t risk touching our faces and we need them to fall onto our scrubs. We couldn’t ruin our masks.” When I asked Dr. Awdish how hospitals could show greater empathy towards healthcare workers on the frontlines, she said, “Organizations can show empathy to their staff by building an infrastructure of resilience into the system.” She explained how the current system for many hospitals stretches staff too thin during times of adversity. Healthcare is a high-emotion service, and staff must be able to take breaks when needed. But when there are not enough staff, there is not a buffer present when something like a pandemic strikes. Dr. Awdish compared this preparatory mindset to the way our own parents buy groceries and cook for us before we actually get hungry, saying, “If our parents waited to buy groceries until we were hungry, that system wouldn’t work very well. Similarly, hospitals have to have anticipatory love…They have to put the infrastructure into place before they need it.”

In the realm of kindness are the stories of true self-sacrifice demonstrated throughout the pandemic. Dr. Awdish shared a story of one patient who came into the hospital in respiratory distress at the peak of the pandemic in Detroit. When he was told he was going to have to be put on a ventilator, the patient very clearly said, “If someone needs the ventilator more than me, you need to give it to them… because I have lived my life and made my peace. Don’t prioritize me.” Dr. Awdish said that this “level of sacrifice is something we saw again and again,” and it drove home the point that “Individual health means nothing in the context of a community that is unwell.”

Throughout the pandemic, hospital visiting hours have been substantially limited and often nonexistent. But when PPE is available, Dr. Awdish strongly advocates for families to be allowed to visit patients in the hospital. When I asked Dr. Awdish to describe the impact she’s seen when families are given the chance to visit their loved ones, she said, “It has been a real awakening for all of us to see how much the family contributes to the care of ICU patients. There’s so much that they do – even just their presence and familiarity at the bedside helps to prevent delirium.” She made clear that “A family member’s role is not that of a visitor… and it is so reductive to think that they are anything but essential members of the care team. By separating patients’ families, we are doing a tremendous disservice to patients.”

Visiting rules also affected healthcare staff who had family members who were ill. Dr. Awdish shared a heartfelt story of her friend—an ICU nurse—who couldn’t visit her sister who was dying of Covid in a hospice. When Dr. Awdish asked the nurse how she was holding up with working in a unit full of Covid patients, the nurse said, “This is the easy part. Here, I can be there for the patient. Here, I can do the work of nursing, but my sister is dying, and I can’t be there… and that’s so hard for me.” Without a chance to be at her sister’s side in the hospice, the nurse clung to the glass of the hospice for 9 hours while her sister passed away… hoping that her sister could feel her presence. The powerful story teaches all of us a lesson on having humility about others’ experiences. Dr. Awdish says, “We think we can assume what is hard for someone when, in reality, the sharp edges of their life are totally hidden from us.”

Before finishing our conversation, I asked Dr. Awdish to share her thoughts on whether she thinks the pandemic has effectively motivated us to raise the wages of frontline essential workers who are often forgotten, such as hospital housekeeping staff. The average hospital housekeeper earns about $30,000 a year, which is right at the Federal Poverty Level for a 5-person household. These staff have been particularly stretched thin during the pandemic, as the focus on proper cleaning has intensified. Dr. Awdish said, “I certainly hope that we have begun to recognize that without grocery store workers, environmental services (hospital housekeepers), teachers, and others, we can’t survive. We are interdependent on each other, and I think society has done a terrible job at recognizing that work. We have undervalued so many people for so long.” Dr. Awdish continues to work on the frontlines of this pandemic, and she continues to show us how to value the humanistic element of patient care. Her story is one we can all learn from.

I had the privilege of speaking with LA Times bestselling author Dr. Rana Awdish about kindness and empathy in the wake of Covid-19.

When a Hospital Errs: A Conversation with ENT Surgeon Dr. Ron Kuppersmith

Imagine you’re in the hospital receiving treatment for an aneurysm, and the radiology team comes by to perform a routine procedure to ensure that your latest surgery was successful. Your family’s expectation is that the procedure you are having is routine and that you will be in the same condition after the procedure as you were before going to the radiology department. The radiology technician is tasked with obtaining the contrast dye needed for the procedure. In the procedure room, there are 3 identical containers all filled with colorless solutions. The technician knows that the contrast dye is colorless, so he draws up a syringe full of liquid from one of the containers to give to the radiologist to inject into you. Trusting the solution given to him, the radiologist administers the solution as usual. Soon after injection, your health rapidly deteriorates. It turns out that the colorless liquid given to you was not contrast dye… it was chlorhexidine, a toxic chemical used to disinfect the skin before surgery. The three containers with colorless liquids were not labeled, and they all had different solutions. The technician accidentally drew up the wrong liquid, as they all looked the same. It was a simple, yet fatal mistake.

While this story may appear to be hypothetical, it is unfortunately a true story from 2004 about a patient named Mary McClinton, who was receiving treatment for a brain aneurysm at the Virginia Mason Medical Center in Seattle, Washington. Worse, Mary McClinton is not alone. While the exact number of deaths attributed to medical errors is disputed, medical errors injure millions of Americans every year. I had the privilege of speaking with Dr. Ron Kuppersmith about how hospitals can rebuild trust after committing an unintentional medical error. Dr. Kuppersmith is a head and neck surgeon who has previously served as the President of the American Academy of Otolaryngology-Head and Neck Surgery. He is also a professor of surgery at the Texas A&M College of Medicine.

Medical errors are preventable adverse events, such as giving a patient the wrong medication, performing the wrong procedure, or providing an inaccurate diagnosis. These errors are devastating and, too often, deadly. However, Dr. Kuppersmith made clear that there is an important distinction between errors and complications. During any medical intervention, unexpected complications may occur that are not the fault of the physician or the patient. As Dr. Kuppersmith says, “Every patient’s anatomy and physiology is different, so while the steps of a procedure may be the same, no two surgeries are the exact same.” Dr. Kuppersmith added it is sometimes hard to determine whether an unexpected outcome was caused by an error, saying “Unless a hospital commits a sentinel event, which is a ‘never-ever event’ such as amputating the wrong leg, the complexity of a specific case may make it difficult to look at a sequence of events and determine if an error occurred that led to a negative consequence. Often times when looking at what happened in retrospect, the issues seem obvious. In real time and with limited information, the decision making can be much more complicated. For example, let’s say a patient has a life-threatening reaction to a medication that is prescribed, and the patient did not disclose to the treating team that they previously had a reaction to a related medication. Reviewing old medical records that were not available at the time of treatment reveal that the patient previously had been seen in the emergency room on several occasions for similar events. This was not disclosed by the patient as they were unaware of the type of medication that previously caused the problem, and they were not great at providing previous medical history. Additionally, the old medical records were not immediately available to the treating team because they were in a different computer system from a different hospital system. As seen in this case, cause and effect are often difficult to determine.”

Dr. Kuppersmith continued by saying that, on the front-end, patients may not fully understand all the risks of being treated in a hospital, saying “In our culture, surgery is often glorified on television…especially new technologies, cosmetic and elective surgery. But, everything we do is filled with risks. Physicians need to communicate with patients what they expect to happen while clearly acknowledging all the things that could happen, using language and explanations that patients can understand.”

And when an error does occur, what can the hospital do? First, Dr. Kuppersmith says, “you have to be transparent with the patient and the family.” Then, it’s important for physicians and hospitals to take steps to ensure that the error does not happen again. Dr. Kuppersmith says, “Physicians and hospitals have multiple mechanisms to review complications and errors that occurred over a period of time. This may occur through a peer review process or through departmental conferences to review morbidity and mortality events. There is a very long tradition in medicine of looking at errors and complications and learning from them.”

From a patient’s standpoint, these learnings and improvements may not be known, but that doesn’t have to be the case. While filing a malpractice lawsuit and/or hospital complaint are always available, hospitals can take the effort to ensure an affected patient’s story positively impacts others. Going back to the death of Mary McClinton, Virginia Mason took substantial measures to ensure that the situation never occurred again. The hospital profusely apologized and publicly took responsibility for their mistake. In addition to a legal settlement, the hospital “declared that, going forward, it would have a single goal: To ensure the safety of our patients through the elimination of avoidable death and injury.” As their Vice President of Quality and Compliance said after the incident, “if we cannot ensure safety of our patients, we shouldn’t be in business.” In Mary’s honor, Virginia Mason sets aside one day every year to reflect upon their safety improvements over the past year, and teams at the hospital annually compete for the Mary McClinton Patient Safety Award. Additionally, The Joint Commission, a nationally recognized hospital accreditation organization, began requiring hospitals to label all medications and medication containers. The steps taken at the hospital and national level made it clear to the McClinton family that Mary did not die in vain. In fact, her death has saved the lives of many others.

When errors occur, physicians and hospitals need to learn from the event and be willing to change policies and practices to ensure that the error does not occur again. Just as in Mary McClinton’s case, hospitals should tangibly show how a patient’s death was not taken lightly and show how the patient is leaving a legacy that will protect and save those who walk through the doors of the hospital in the future. Medical errors have affected the lives of far too many Americans, but if all hospitals choose to follow a strong mission of safety, regardless of costs, we can have trust in knowing that our healthcare won’t kill us.

I had the privilege of speaking with ENT surgeon Dr. Ron Kuppersmith about how hospitals can respond to medical errors.

With or Without a Robot’s Help: A Conversation with Emory Surgeon Dr. Manu Sancheti

If we went back in time and walked into a hospital in the mid-1800s, we would likely be shocked. Hospitals weren’t places of healing… hospitals were facilities where the poor would hopelessly visit as a last resort, often ending with their death. Fast forward to a little over 150 years later, and we see hospitals saturated with the latest and most expensive technology the world has to offer. Hospitals have the capability to take you from near death and restore you to nearly full life. Even the most complex surgeries are now being done with robots, utilized for their high dexterity and precision. The increasing prevalence of robotics in surgery has raised questions about the role that technology has played in rising healthcare costs. Several studies have shown that technological advancements, in fact, are the primary drivers of higher healthcare costs in America. I had the privilege of speaking with Dr. Manu Sancheti, director of robotic thoracic surgery at Emory, about the role of technology in rising healthcare costs. Dr. Sancheti practices thoracic surgery and teaches as an assistant professor of surgery at the Emory University School of Medicine.

The da Vinci is one of the most popular robotic surgical systems, with the robot having been used for over 6 million surgeries worldwide since its manufacturer Intuitive Surgical received FDA clearance for the machine in 2000. The robot itself costs $2 million with around $180,000 in maintenance fees each year, and these high costs raise questions about whether the da Vinci’s increased prevalence is worth it. This is particularly important to look into because using the da Vinci generally does not produce better outcomes compared to when surgeons utilize a laparoscopic or thoracoscopic technique, in which narrow tubes are inserted through small incisions to perform a surgery in the abdominal or thoracic cavity, respectively.

I started our conversation about robotics by asking Dr. Sancheti about the concept of “Supply Sensitive Care,” which states that the use of health services depends upon the availability or supply of that service. For example, evidence shows that if a hospital has an MRI scanner available to them in their facility, they are more likely to use it more frequently than necessary. The same is true for hospitals with lots of beds: the more beds a hospital has, the more likely a patient will be recommended to stay overnight for “monitoring.” When I asked Dr. Sancheti if he believed that the availability of the da Vinci in a hospital led to the robot being used more often than necessary, he said that “The difficulty lies in terms of how you get to the point where you are comfortable using the technology for its main advantages. I do a surgery to recreate the esophagus after removing it because of esophageal cancer, and it’s much easier for me to do the surgery with the robot compared to using thoracoscopic instruments. However, yes, the robot initially may need to be used in some ways that are not cost-effective in order to build up to the repetition level necessary to achieve cost-efficiency. There’s no question that robotic technology is more expensive than laparoscopic instruments, so we have to be smart about our utilization of the robots. However, those of us who do a lot of robotic thoracic surgeries feel that the da Vinci provides an advantage in complex cases, and we want to provide that advantage to the patient if we can.”

A key factor protecting robots from being potentially overused for financial gain is the fact that Medicare, the government insurance plan for Americans over 65, does not reimburse doctors or hospitals more when they use robots over a laparoscopic technique. When I asked Dr. Sancheti if he believed reimbursement rates should be greater for robotic-assisted surgeries, he said, “The robot is just an instrument used to assist in a minimally invasive operation, so I don’t think reimbursement rates should be different when using a robot vs. a laparoscopic technique.”

Our conversation then moved to what some call a “Medical Arms Race,” in which competition among hospitals leads to overconsumption of medical technology because after one hospital adopts a new, exciting piece of technology, other hospitals in the area follow suit in order to stay competitive. When I asked Dr. Sancheti if he has observed this phenomenon, he said, “Yes. Our health system is very business oriented, especially in a big city like Atlanta where there are hospitals everywhere. Patients are intelligent consumers, so they are going to go wherever they can get the best medical care for their situation. So to stay market competitive, the adoption of a new piece of technology at one hospital often leads to other hospitals getting it as well.”

Georgia is one of 35 states with a “Certificate of Need” program, which requires healthcare facilities to receive state approval before obtaining any piece of technology costing over $1 million. The National Conference of State Legislatures states that “the basic assumption underlying Certificate of Need regulation is that excess health care facility capacity results in health care price inflation.” Essentially, these programs are in place to theoretically stifle unnecessary care and higher prices by only allowing hospitals to purchase technologies that are needed to serve the community and not anything extra. When I asked Dr. Sancheti what he thought about Certificate of Need programs, which are highly debated in state legislatures, he said that “the concept sounds good.” However, it doesn’t work as well as it sounds. As Dr. Sancheti says, “You can imagine the bureaucracy that can be involved. Even when you genuinely need a new piece of technology, it’s hard to get it because of all the bureaucratic layers you have to go through ”

When I probed him further about the dynamic between hospital administrators, who are often businessmen, and physicians, he said, “All doctors have to deal with their hospitals’ administrators in different ways, and what we need as clinicians is for business leaders to bring their business acumen to the table, but listen to our clinical needs. I fortunately work in an environment where administrators and doctors work together really well.”

To close, I asked Dr. Sancheti about the future of robotics in medicine, and he said, “I think that all surgeries, at some point, will have some kind of computer assistance. Having some kind of guidance from a computer is just vital.” Dr. Sancheti discussed how “augmented visualization technology is being developed where tissue, such as blood vessels, can be seen on a screen while you’re doing a surgery even though you’re not actually able to see the vessels…almost like virtual reality. There is also research on marking tumors with fluorescent chemicals, then using fluorescence detectors on the surgical tools’ cameras to identify the location of cancer cells.” In all, Dr. Sancheti made clear that robotics had a valued and justifiable place in surgery, despite the additional expense to hospitals.

I had the privilege of speaking with Emory surgeon Dr. Manu Sancheti about the role of technology in rising healthcare costs.

Prescribing Smarter: A Conversation with Harvard Medical School Professor Dr. Jerry Avorn

President Trump made headlines recently after signing several executive orders aimed at lowering the costs of prescription drugs. The overarching goals of the executive orders are noble, but questions have risen regarding the actual impact these orders will have on the prices of life-saving medications. I had the privilege of speaking with Harvard Medical School professor Dr. Jerry Avorn about the impact the executive orders would have on drug prices as well as the work he is doing to reduce the costs and improve the quality of drugs prescribed by doctors. In addition to his role as a Professor of Medicine at Harvard, Dr. Avorn was the founding Chief of the Division of Pharmacoepidemiology at Brigham and Women’s Hospital and is the author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs.

On July 24th, the President signed four executive orders, which he says will “massively reduce the prices of prescription drugs, in many cases by more than 50%.” However, experts are not so sure that this wishful statement can become a reality. The Wall Street Journal quickly came out with an article titled “Expect Little from Trump’s Drug-Price Move,” and Dr. Avorn began our conversation by saying that “These executive orders are clearly an attempt for the President to say that he is doing something, but making a speech about a plan to issue executive orders is not the same as enacting good policy. The themes found in the executive orders have been around for years, yet the President has not implemented anything of consequence. There are administrative, legal, and policy reasons why I don’t expect much to come out of any of these executive orders.”

The issues outlined in the orders, however, are worth diving into. One of the orders is aimed at cutting profits for Pharmacy Benefit Managers, or PBMs, which are middlemen who administer prescription drug plans for over 270 million Americans. PBMs contract with pharmacies and health insurance companies to negotiate drug prices for employees’ health plans, and they claim to save money for consumers and reduce waste in the system. However, PBMs notoriously play games that reap massive profits. As Dr. Avorn says, “It is impossible for a patient or prescriber to know how much a drug actually costs, and this nicely suites the needs of PBMs because PBMs can say, ‘We are saving a lot of money for people… but we won’t tell you how much!’”

One of the other executive orders signed by the President involves a proposal to import drugs from Canada—where many drugs are much cheaper. Canada has not agreed to such a measure, and when I asked Dr. Avorn whether this plan would work, he said, “If we take a step back and look at the volume of medications used in the U.S. compared to the volume used in Canada, our country could rapidly deplete the supply of drugs in Canada. I know that Canadians are worried about this. So, while I don’t believe it should be illegal to import drugs from other countries, it is an incomplete method to deal with the problem.”

Our conversation then moved towards what Dr. Avorn is famous for inventing. In the early 1980s, Dr. Avorn invented the practice of Academic Detailing, which is an educational outreach program in which healthcare professionals, such as physicians, pharmacists, and nurses, are trained to provide prescribers with the latest research on the most cost-effective prescription drugs, rather than having physicians rely so heavily on receiving drug information from sales representatives who work for drug companies. Sharing the origins of academic detailing, Dr. Avorn said, “When I was in medical school, I noticed that there was a tremendous difference between the ability of academics to make a case for using a specific drug vs. the effectiveness of drug company representatives in influencing doctors to prescribe a medication. The problem with sales reps is that their job is to sell their product,” even if it’s not the most effective drug on the market. “Ideally, we don’t want doctors to learn what drugs to prescribe from sales reps who are trying to promote their company’s products. So, I thought: What if we take the sophisticated communications tools that drug companies deploy so effectively, but instead use them to give doctors the latest and best facts about drugs’ comparative efficacy, safety, and cost effectiveness?” He called the practice Academic Detailing.

To test the effects of an academic detailing program, Dr. Avorn said, “We conducted a randomized trial in four states in which we trained pharmacists to visit doctors and discuss certain drugs from a non-commercial, academic standpoint. We found that such a program could save $2 for every $1 it costs to run, and physicians really do improve their prescribing practices.” His initial studies were published in The New England Journal of Medicine.

After more randomized trials started coming out showing how successful academic detailing programs are in improving the prescribing practices of doctors, Dr. Avorn said that, “Countries, such as Australia, got in contact with me and said that they want to set up an academic detailing program across their continent. The Veteran’s Administration (VA) also set up a nationwide academic detailing program, so it really caught on in a gratifying way.” Much of that work is now conducted by a non-profit he helped found, and for which he serves as an unpaid clinical consultant. It’s called Alosa Health, named after the genus of fish that swim upstream, like salmon. When I asked Dr. Avorn what is holding back some parts of the country from embracing academic detailing services, he said that implementing the program is easiest in an integrated health system, such as the VA or the Kaiser system, compared to the fragmented system that dominates our nation. Dr. Avorn added that, “Until lawmakers actually solve the problem of unaffordable drugs, physicians can at least help each other understand what medications are the most effective. If there are several drugs that are comparable in efficacy, but one or two are far costlier than the others, we can help prescribers choose which drugs are the most cost-effective… all while the politicians are twiddling their thumbs trying to figure out what to do from a policy standpoint.”

When I asked Dr. Avorn about other ways in which we could reduce the costs of prescription drugs, he started by pointing to the patent laws that drug companies manipulate, saying that “We must not allow drug companies to use legal trickery to extend their patents well after they have expired.” Dr. Avorn also discussed how there is currently legislation that reduces the negotiation power of Medicare and Medicaid in choosing drugs and drug prices, adding that fixes to such issues are often blocked by pharmaceutical lobbying groups. Importantly, Dr. Avorn finished by noting that the persistence of these issues has not been caused by partisanship, saying that “It’s not just Republicans or Democrats… it’s both. In the Obama administration, we made very little progress on drug pricing, so it’s not about who’s in the White House. Rather, it’s about trying to get sound public policy to overcome what pharma lobbies want to happen.” President Trump has called the absurdly high prices of drugs “unfair,” and his administration has promised to “stop it fast.” It is unclear, however, whether the President is strong enough to battle Big Pharma’s loud voice in Washington.

I had the privilege of speaking with Harvard Medical School Professor Dr. Jerry Avorn about how we can reduce the costs of prescription drugs.

Is Medicaid Worth It? A Look into the Benefits and Drawbacks of One of the Most Expensive Health Insurance Programs in America

Over 40 million Americans have filed for unemployment benefits over the course of the Covid-19 pandemic, and the situation only appears to be worsening. Many of these workers are now turning to Medicaid to receive the health insurance coverage that they once received through their employer. Medicaid is a joint federal and state health insurance program that provides coverage to over 64 million low-income Americans. The program has proven to be the center of significant political debate ever since the Affordable Care Act (Obamacare) required states to expand Medicaid coverage, only for the Supreme Court to then give individual states the option to expand coverage or not two years after the ACA was passed. Thirteen states, most of which are Republican-leaning, have not adopted Medicaid expansion, and this has posed concerns for those living in those states who are currently trying to receive the health coverage they recently lost due to job losses related to Covid-19. Overall, however, Medicaid enrollment is already on the rise, with an estimated 5-18 million additional enrollees in the coming months. Once this pandemic ends, the number of Medicaid beneficiaries will likely remain significantly higher than pre-pandemic times. As the Medicaid program grows in our country, it is critical to evaluate how effective the program is at serving the American people. I had the privilege of corresponding with Dr. Katherine Baicker about her notable experiment, The Oregon Health Insurance Experiment, and the lessons we can gather on the efficacy of one of the largest health insurance programs in our country. Dr. Baicker currently serves as the Dean of the University of Chicago Harris School of Public Policy, and prior to this position, she was a professor of health economics at Harvard. She also worked in the White House as the senior economist on the Council of Economic Advisors under President George W. Bush.

Dr. Baicker famously led the 2008 Oregon Health Insurance Experiment, which was made possible as a result of Oregon deciding to expand Medicaid coverage to more low-income adults. Due to limited funds, Oregon could only provide Medicaid coverage to 10,000 of the nearly 90,000 citizens who signed up to receive health insurance. To decide who received coverage and who did not, Oregon employed a lottery system in which citizens were randomly chosen to receive Medicaid benefits. The use of a lottery system created a randomized control study, which Dr. Baicker says is “almost never available in public policy.” In this experiment, Dr. Baicker and her fellow investigators were able to study the benefits and drawbacks of the Medicaid program by tracking those who received Medicaid coverage (the experimental group) and those who did not receive coverage (the control group.)

While many politicians are quick to assert that the Medicaid program is an incredible success, it is important to note that we spend around $600 billion on the program, and some studies show that the program may go bankrupt in the near future. The Medicaid program is controversial because, as Dr. Baicker says, “Covering the uninsured never pays for itself. It would be nice to think that reductions in ER visits and more efficient use of preventative care would actually save us money in the long run. But if we are honest about it, bills proposing to cover the uninsured do not pay for themselves.”

The Oregon Health Insurance Experiment measured several outcomes, including blood pressure, cholesterol levels, glycated hemoglobin levels (which is high in patients with diabetes), healthcare utilization, out-of-pocket spending, depression levels, smoking habits, obesity, and even voter turnout. The study revealed that two years after the lottery system was put into place, those who had access to Medicaid experienced reduced financial strain caused by medical expenses, increased preventative care utilization, decreased rates of depression, and even increased voter turnout. However, the study also showed that access to Medicaid coverage, when compared to the control group, had no significant effect on patients’ blood pressure, cholesterol levels, glycated hemoglobin levels, smoking habits, or obesity, all of which are significant drivers of chronic and expensive health conditions. Dr. Baicker says, “We found some things that people viewed as supporting Medicaid expansion and some things that people viewed as arguing against expansion. We could eliminate the unduly optimistic view of Medicaid. Some people contended that expanding Medicaid would not only improve health for low-income populations, but also get people out of the Emergency department and back into the workforce and ultimately save money. It turns out that Medicaid doesn’t save money. When you expand health insurance, people use more healthcare, and that’s great for their health, but it doesn’t save money. At the same time, we could also eliminate the unduly pessimistic view of the Medicaid program. Some people contended that Medicaid cost a lot of money but didn’t provide real benefits to enrollees. But Medicaid enrollees had much better access to care, reduced financial strain, lower rates of depression, and better self-reported health.”

As the Medicaid program grows, it is important for policymakers to be wary of an overly optimistic or pessimistic view of expanding public health insurance. As Dr. Baicker says, “Policymakers face a real tradeoff: expanding Medicaid provides important benefits to those it covers, at a substantial cost to tax-payers. Policymakers and voters have to decide how much of a priority that coverage is.”

I had the privilege of corresponding with Dr. Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, about her famous health insurance study, the Oregon Health Insurance Experiment.

Healthcare as a Human Right: A Conversation with Obama-nominated CMS Administrator Dr. Donald Berwick

The Covid-19 pandemic has exposed several areas of improvement for our healthcare system, with many hospitalized patients confused and concerned about whether or not their health insurance plan covers their treatment. The pandemic has led many to reiterate their belief that our healthcare system is fundamentally broken. Because healthcare is not available to every citizen as a human right in our country, politicians have been quick to speak about how our largely-capitalistic healthcare system fails amid a crisis. I had the honor of speaking with Dr. Donald Berwick about our nation’s healthcare system, and why he firmly believes that healthcare is a human right. In 2005, Dr. Berwick was appointed “Honorary Knight Commander of the British Empire” by Queen Elizabeth II for his work with Britain’s healthcare system. Nominated by President Obama in 2010, Dr. Berwick served as the Administrator of the Centers for Medicare and Medicaid Services (CMS) where he managed an over $800 billion budget and managed health insurance for over 100 million Americans. Most recently, Dr. Berwick worked with Senator Elizabeth Warren in crafting her healthcare plan during her 2020 presidential campaign. Dr. Berwick is one of our nation’s leaders on healthcare, and he made clear that “no healthcare system will truly work in America until we make the promise to guarantee every citizen health coverage.”

The debate on healthcare as a human right is incredibly divisive, yet many may not be aware of what healthcare could look like if we made it available to all Americans. When I asked Dr. Berwick to share why he believes healthcare is a human right, he began by saying that “as a compassionate society, we all realize that there are some things that we need to do together in order to protect each other and ourselves. That’s why we have firefighters, publicly funded roads, and public education for children. It’s better when we have equal access to some things, and that’s partly because each one of us individually cannot produce the service or item ourselves. Take clean air as an example. We need a social contract that says we will together produce clean air. We will make it a right for people so that when we breathe, we can feel safe. The same is true for healthcare. Most of the time, illnesses that we contract are not a result of things we chose. We may have engaged in behaviors that increase the risk of certain illnesses, but we don’t know who is going to fall sick next, and we can’t assume that everyone will have the ability to fund their own care.” Dr. Berwick’s point on the financial capability of most Americans is true, with over half of Americans having less than $1,000 in savings. The economic hardship experienced by millions of American families explains why medical expenses are tied to over 65% of all personal bankruptcies: most families simply don’t have a comfortable financial safety net if a family member falls ill.

I asked Dr. Berwick about his thoughts on those who say that we all have a personal responsibility to manage our own situations, to which Dr. Berwick replied by saying “Even if you only care about your own economic situation, you would still want healthcare available to everyone as a right because other people’s illnesses affect you. We can see that very clearly right now during this pandemic, but it’s also true for circumstances outside of this emergency. When people’s health deteriorates, total costs for society go up. And if we make healthcare a right, we can offer people an opportunity to stay healthy and have their diseases treated earlier so that problems such as heart attacks don’t arise later. Then, total costs for society would go down.”

In every developed country, healthcare is a human right… except the United States. When I asked Dr. Berwick about how our current capitalistic system would compare to a single-payer system, in which the government finances all care, he said that “The system we have now is a crazy quilt of different financing systems—numerous private insurance companies, government insurers, and even some state programs—the complexity of billing, payments, and record-keeping drives administrative costs way up.” Administrative costs in the U.S. are indeed absurd, with over $300 billion in administrative waste spent each year. That’s right–$300 billion. And don’t be fooled about where this money comes from… Dr. Berwick says that “every single nickel we spend on healthcare is coming out of the pockets of workers— there is no other source. The money is coming out of workers’ wages-as companies put money towards healthcare premiums instead of their employees’ wages… it’s coming out of the taxes they pay… and it’s coming out of their out-of-pocket expenses, which are steadily rising.” He followed this up with saying, “So, whenever we say we spend $300 billion on administrative costs, remember that every nickel is coming from workers. Instead, if we take a single-payer approach, you can take all the money we spend on healthcare—through employer contributions, tax contributions, out-of-pocket expenses—and create a healthcare system that costs far less than the one we have today. It’s simpler, more responsible, less wasteful, more proactive… and that lowers costs.”

A traditional Medicare-for-all plan would essentially dissolve very powerful private insurance companies. In one of my previous articles, I spoke with the former CEO of Blue Cross Blue Shield of North Carolina, Dr. Patrick Conway, who spoke on the idea of having a “Medicare-Advantage-For-All” plan. Medicare Advantage is a public-private partnership in which Medicare pays for a healthcare plan, which is administered through private insurance companies. It is considered by some to be the “middle ground” between upholding private insurance and embracing a single-payer healthcare plan. When I asked Dr. Berwick about whether he believes a Medicare-Advantage-For-All program would work well, he said that from what we have seen of the program so far, “it’s a mixed bag.” He continued by saying, “It’s still private insurance, and remember, those private companies are taking profits—the government is not taking a profit—and that’s added costs. So to me, Medicare Advantage does not seem like the most favorable way to tackle the challenge of getting everyone covered.”

Dr. Berwick began working in Washington D.C. just 4 months after the Affordable Care Act (Obamacare) passed in March of 2010, so I took this opportunity to ask him about an interesting discrepancy within the Republican Party in which many Republican voters who obtain health coverage through Obamacare also chant alongside President Trump’s promise to “Repeal and Replace” Obamacare. Dr. Berwick responded by saying that “President Trump has not come up with any effective alternative to the Affordable Care Act. During Trump’s tenure thus far, millions of Americans have already lost their health insurance… If voters think that taking the Affordable Care Act away is a good thing, then they have to explain how over 20 million Americans are going to get the care they need. What happens to prevention benefits? Obamacare expanded prevention benefits to everyone—not just Medicare and Medicaid beneficiaries—so do you want to say goodbye to that? I think that as people became more familiar with the Affordable Care Act, they started to see the benefits. The bill is not perfect, but it is a big step forward for our country”

It’s important to note that about half of us already receive healthcare through government-financed or government-provided care, such as Medicaid (70 million), Medicare (44 million), Tricare (10 million), Veterans Health Administration (9 million), and the Indian Health Service (2 million). As Dr. Berwick says, “The government is already involved in your care in ways that you like. Do you really want Medicare to disappear? Don’t you want to offer our military veterans a promise of receiving healthcare? Be skeptical about this idea that the government is inept or can’t help you.” Despite its drawbacks, a government-funded healthcare system would likely be cheaper and more compassionate. For our extraordinary expenditure on healthcare, we must ask ourselves how much value we are really receiving in return. As the debate continues, however, Dr. Berwick reminded me that “we are one country… and we must make important decisions on how willing we are to be united as one country” on vital issues such as providing healthcare to all Americans.

I had the privilege of speaking with Dr. Donald Berwick, the former Administrator of the Centers for Medicare and Medicaid Services, about how he believes our nation can change healthcare for the better.

Should Congress Pass the Latest $3 Trillion Stimulus Package? Why One U.S. Congressman Voted No

With over 100,000 deaths and over 36 million jobs lost thus far, the United States is suffering from the Covid-19 crisis more than any other nation. While millions of Americans are still waiting on their first $1,200 stimulus check, the U.S. House of Representatives just voted on a bill that would provide another round of checks to over a hundred million Americans. This bill, called The HEROES Act, passed in the House by a slim majority with almost every Democrat voting in favor and every Republican, except one, voting against the bill. I had the privilege of speaking with U.S. Congressman Bill Flores about why he voted against the bill. Congressman Flores is in his fifth congressional term, serving as the United States representative for Texas’s 17th congressional district, which spans from Waco to College Station.

Before diving into my conversation with Congressman Flores, I want to provide a few highlights of the HEROES Act. The bill will add around $3 trillion to our national debt clock, which is already quickly ticking towards $30 trillion. So, what is the plan for using Americans’ hard-earned tax dollars? Here are a few of the highlights:

$1 trillion will go towards state and local governments to provide money to vital workers, such as healthcare workers
$75 billion for testing, tracing, and treatment
$175 billion for housing assistance for struggling families, renters, and homeowners
Another round of $1,200 stimulus checks, with a $6,000 max per household

Republicans and Democrats agree that the American people need more aid, and this bill would save more Americans and even states from declaring bankruptcy. So why did Congressman Flores and almost all the other Republicans vote Nay? Congressman Flores told me three main reasons he voted against the bill.

First, Flores discussed how many states are yet to use a lot of the money that Congress has already given them through bills such as the $2 trillion-dollar CARES Act that was signed by the President on March 27th. He says, “Congress has already passed about $3 trillion worth of support for the American economy, and the bulk of that money has not even gone through the processes needed to make an impact. For example, we provided over $700 billion to state and local governments, but 32 states are yet to move that money outside of the state treasury. So, I think that before we put another $3 trillion into fighting the problem, we ought to make sure that the first $3 trillion moves smoothly through the system.”

Second, Flores said that “there was very little in the bill that would have actually done anything to improve job creation.” A fundamental dispute between the parties in Congress involves the timeline to reopen our economy. While Republicans are generally focused on the economic impacts of this crisis, Democrats are focused on information from public health experts who suggest that reopening too soon could prove to be deadly. Congressman Flores strongly believes that Americans need to get back to work, saying “Giving everyone another $1,200 stimulus check is not what the American people want… they want paychecks. So, what’s best for a hardworking American family right now: a stimulus check or a paycheck? I think they would choose a paycheck all day long.”

Third, Flores discussed multiple parts of the bill that appear to be relatively irrelevant to the Covid-19 crisis, saying that the bill “had all this extraneous stuff in there, such as getting rid of Voter ID. And, the bill mentions ‘cannabis’ 68 times, which is more than the word ‘job’ is mentioned.” After looking through parts of the bill, I found it interesting that multiple paragraphs were dedicated to items not relevant to Covid-19, such as allowing businesses selling marijuana to have access to banking services. The bill also dedicates $20 million to the National Endowment for the Arts and Humanities. While this is important, critics cite that efforts by the slow-footed federal government often result in our tax dollars being caught up in bureaucratic red tape, not to mention that the HEROES Act is meant to be about Covid-19, not the arts and humanities.

While Congressman Flores’ decision to vote against this bill may appear to be quite conservative, he is quick to point out the mistakes that the Republican-led federal government made in our response to this crisis. When I asked him for a candid judgement on the government’s response, he said that “the government gets different grades in different areas of our response.” When it comes to Covid-19 testing, he gives the government “a solid F.” Flores explained how testing in this country has always been highly centralized, and the CDC was not built to produce 100 million tests in a short period of time, saying “we were woefully unprepared for something like what we are experiencing.” Beyond testing, however, Flores believes that we really excelled in our pharmaceutical development efforts, saying that “We have seen incredible public-private collaborations, such as the National Institutes of Health working with a variety of pharmaceutical companies and vaccine developers.”

Congressman Flores also expressed concerns over our healthcare supply chain, saying that “we totally got caught flat-footed, which was partly due to ignorance and partly due to poor cooperation among the private sector, states, and the federal government. For example, in terms of personal protective equipment (PPE), I don’t think we realized how much of the supply chain we let leak offshore to places like China.”

Now that the HEROES Act has passed in the House of Representatives, it faces trial in the Senate where it is all but guaranteed to die. However, Congressman Flores told me that he believes a different bill will likely be agreed upon in the near future, saying “My hope is that Speaker Nancy Pelosi moves past this and then sits down with us to pass something that can be bipartisan. This is not a Democrat issue or a Republican issue… This is a Covid-19 American issue.” We can all only hope that partisanship doesn’t get in the way of doing the right thing for the American people.

I had the privilege of speaking with U.S. Congressman Bill Flores about why he voted against the latest Covid-19 economic relief package, the HEROES Act.

America’s Pill-Popping Problem: A Conversation with the Former Deputy Drug Czar

Over 5,000 years ago, the Sumerians in Mesopotamia began cultivating what they called Hul Gil, or “the joy plant.” Fast forward to the 21st century, and we see that these leaves of “joy,” which was in fact opium, take 130 American lives every day, and opioid overdoses have been a leading cause of death for years. I had the privilege of speaking with McLean Hospital and Harvard Medical School professor Dr. Bertha Madras about tangible steps we can take to end this epidemic. Nominated by President George W. Bush in 2006 and unanimously confirmed by the Senate, Dr. Madras served as the White House Deputy “Drug Czar” where she oversaw the nation’s anti-drug efforts. In 2017, President Trump appointed Dr. Madras to a 6-member commission on combating drug addiction and the opioid crisis. Tackling the opioid epidemic is far from a simple task, and Dr. Madras made clear that we cannot just prevent, treat, or arrest our way out of this crisis—we must do all three.

More than 190 million opioid prescriptions were written in the US in 2017 alone. So how did the numbers get this high? When we look at the history of opioid prescriptions in America, we don’t have to look back too far to find a problem. In 1980, a five-sentence letter to the New England Journal of Medicine from Dr. Hershel Jick declared that “addiction is rare in patients treated with narcotics.” Cited affirmatively in hundreds of manuscripts, this fatally flawed letter was used by opioid advocates as evidence that opioids are innocuous in pain management. In the late 1990s, Purdue Pharma introduced OxyContin, a strong semi-synthetic opiate with an incredibly high addictive potential. In its first four years on the market, OxyContin sales grew from $48 million to $1.1 billion. And Purdue Pharma is not alone… well-known companies such as Johnson & Johnson have played a huge role in the production and prescription of several highly addictive opioids. These pharmaceutical companies were well aware of the high addictive potential of their drugs, yet they intentionally and vigorously marketed their drugs as highly effective drugs for non-cancer pain with a low addictive potential. Dr. Madras says that the “evidence for the safety of opioids was so thin and so weak, yet it was marketed to physicians in a way that they simply accepted the marketing without critical evaluation.” Dr. Madras stressed the importance of starting fewer patients on opioids because “the literature shows that the likelihood of an individual becoming a long-term opioid user is strongly correlated with the number of opioids prescribed to them for the first time.” This is especially important because non-steroidal anti-inflammatory drugs, such as Ibuprofen (Advil, Motrin), can be just as effective as opioids in treating the most common causes of pain, such as lower back pain, which is why Dr. Madras says that it is “critical to evaluate whether an alternative medication will suffice” in treating a patient’s pain.

So how do we get doctors to prescribe fewer opioids? First, Dr. Madras stresses that we need much better medical education when it comes to prescribing opioids. It is crucial to better train current and future physicians to know when opioids are appropriate for a patient. Second, we need to better incentivize patients and doctors to rely on non-opioid medications or other treatments. Dr. Madras notes that alternatives such as exercise are less reimbursable, saying that “healthcare insurers reimburse a doctor less for telling a patient to jog around a track or take over-the-counter anti-inflammatory medications.” But, physicians are well-reimbursed for writing an opioid prescription. While physical therapy is also an effective treatment option, Dr. Madras says that physical therapy is labor-intensive and more expensive for patients. Patients often demand immediate relief of their pain, which can be satisfied by the prescription of opioids. Because of the current physician reimbursement structure, “there’s a tremendous incentive to prescribe opioids—and a tremendous disincentive to look at alternatives for pain management, such as physical therapy.”

Dr. Madras also discussed patient satisfaction scores as another incentive for physicians to prescribe more opioids, as some research suggests that patients who receive more opioids report higher satisfaction scores compared to those who receive fewer opioids. To solve this problem, Dr. Madras and the other members of the President’s Commission recommend that pain survey questions are completely removed from patient satisfaction surveys. In this same vein, making pain a fifth vital sign has come into question in recent years. Vital signs are supposed to be limited to measurements that assess a patient’s vital functions, such as heart rate and temperature. However, some entities recognize pain as a fifth vital sign, which Dr. Madras calls “a disaster.” To exemplify why, she says, “Patients coming into the ER with a runny nose and sore throat are asked ‘Do you have any pain?’ and the patient thinks, ‘Well maybe I do’” Bringing pain up to the level of a vital sign is yet another route for heightened attention to pain and opioid prescribing.

Recent regulations have limited the number of opioids being prescribed by physicians. However, while physicians began to change their practices of high-volume opioid prescribing, fentanyl emerged as the primary driver of the opioid crisis. China and Mexico are the major sources of fentanyl and fentanyl-analogs, with U.S. Customs and Border Protection seizing over 2,500 pounds of fentanyl in 2019 alone. It’s important to note that fentanyl quantities as low as a few grains of salt are enough to kill you. In recent years, the United States government has strengthened its borders by using new technology that detects drugs passing through the US Postal Service, the primary mail carrier used by fentanyl-producing labs in China. The US has also attempted to improve relations with both Chinese and Mexican officials so that adequate cooperation is attained in shutting down fentanyl-producing laboratories, and Dr. Madras believes that talks with these two nations must continue.

As we look forward, it’s important to note that America is quite unique when it comes to opioids. No other country in the world prescribes even close to the number of opioids as we do for patients experiencing acute or chronic non-cancer pain. Western European countries prescribe four times fewer opioids than we do, despite chronic pain rates being similar. By cutting down on opioid prescriptions, financially incentivizing alternative treatment options, improving medical education, treating those with an addiction, and cutting the fentanyl supply, the United States can greatly reduce opioid overdose deaths, improve public health, and become an even greater nation.