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.

I spoke with Harvard Medical School professor Dr. Bertha Madras about tangible steps our nation can take to curb the opioid crisis.

The Mayo Clinic Approach to Healing Healthcare

The power of volunteerism and compassion among healthcare workers is evident right now more than ever before. Healthcare workers are showing us the heart of America, and after this COVID-19 crisis resolves, we as a nation will stand taller. The Mayo Clinic, one of the most revered health systems in the world, is working at the front lines of this pandemic through extensive research efforts and preparing their hospitals to accommodate a surge in patients. But Mayo Clinic’s preparedness in this situation is the result of an over 150-year history of building a culture ingrained in employees. So, what makes the Mayo Clinic a symbol of hope to the 1.2 million patients who are treated at their hospitals and clinics each year? I spoke with Dr. Leonard Berry, a distinguished professor of Marketing at Texas A&M and co-author of Management Lessons from Mayo Clinic, to learn more. Dr. Berry’s book, coauthored with Kent Seltman who served as Mayo Clinic’s first marketing director, has sold more than half a million copies worldwide, and the book has been described as “a landmark” in the healthcare field by former Administrator of the Centers for Medicare and Medicaid Services Dr. Donald Berwick. Out of the innumerable positive qualities Mayo Clinic possesses, I want to discuss three that I believe are key to their success: Mayo Clinic’s high-quality doctors, its culture of medical teamwork, and its welcoming environment.

Healthcare is not a want-service, it is a need-service. We all need healthcare, and as Dr. Berry says, “the most important consumer decision you will ever make is choosing your doctor.” Only in the medical field does a patient need to trust their healthcare provider with their most personal and intimate information. From his study of the Mayo Clinic, Dr. Berry identified characteristics of Mayo doctors that help instill such a high level of physician-trust within each of their patients. Dr. Berry found that the ideal physician embraces the following qualities:

  • Confidence — the physician’s assured manner generates trust
  • Empathy — the physician is able to genuinely understand what a patient is feeling both physically and emotionally and is able to communicate this empathy
  • Humane — the physician has a deep level of care for the patient and is not rushed
  • Personal — the physician treats the patient as an individual rather than as “just another patient”
  • Forthright — the physician clearly explains the situation with a patient without beating around the bush
  • Respectful — the physician listens to the patient’s wishes intently 
  • Thorough — the physician explains everything and follows up with a patient’s health

Dr. Berry explains how many Mayo physicians possess most, if not all, of these qualities as do outstanding doctors elsewhere. At Mayo Clinic, doctors hold each other accountable. He says, “the currency at Mayo Clinic is clinical excellence, and employees set a very high standard for one another.” 

Mayo Clinic is guided by the principle of “the needs of the patient come first,” and this is clear in its compensation structure. Mayo doctors are paid by salary. While most doctors around the country are financially incentivized to perform more medical care, this is not the case at Mayo. At Mayo, a physician never has a financial incentive to do an unneeded test or procedure—or a financial disincentive to lend a helping hand to another physician. At Mayo, medicine is a cooperative science, and multiple doctors pool their knowledge and work together to treat a single patient. Dr. Berry explains how more care is not necessarily better care, and can harm the patient while resulting in waste. Dr. Berry summarizes this by saying that “those who need to bask in the starlight of personal recognition or wealth are not a good fit at Mayo and need to work elsewhere.”

I asked Dr. Berry what gives Mayo its competitive advantage among the 6,000+ hospitals in the US, and he discussed how all their medical services are provided “under one umbrella.” Mayo Clinic houses virtually every specialty in medicine, and this is fruitful for both patients and physicians. Often, if a patient has three medical issues, they have to visit four different doctors at four different facilities. At Mayo, patients receive a highly connected, coordinated care plan.

No one wants to be at the hospital, and Mayo Clinic knows this, which is why they have created a hospital environment in which the healing begins as soon as you walk in. Their buildings emphasize natural light, mute noise, and minimize the impression of crowding, just to name a few. Keeping the noise level to a minimum is a top priority, as noise is a significant patient stressor. Dr. Berry says many may not realize that moving a portable x-ray machine near a patient room creates the same level of noise as driving a motorcycle right outside the room. For kids, Mayo has embedded animal tracks in the carpet, guiding their young patients to their rooms. They even have water fountains as low as 18 inches so that not even toddlers feel left out! As Dr. Berry says, “Mayo Clinic is really good at majoring in minors… because the little things add up.” 

Whether there is a public health crisis that shakes the world or a personal health crisis that shakes your world, the Mayo Clinic will always be a symbol of hope. The compassionate culture ingrained in Mayo has created a hospital where employees want to finish the job rather than look at the clock. Stories of exceptional gentleness by Mayo employees are numerous, and each one shows us what is possible when the needs of the patient always come first. To conclude this article, I would like to share one story Dr. Berry includes in his book, describing a 91-year-old woman’s visit to the emergency room after suffering a fall. The elder woman came into the ER with her daughter, a Mayo employee, and they were seen by Dr. Luis Haro. As Dr. Haro examined her, he asked if the woman could stand up and take a few steps. As she took a few steps, she bumped into Dr. Haro. With her wit, she said, “Well, I suppose we could waltz.” To which Dr. Haro replied with “Yes, we could” before taking her into his arms and waltzing a few steps. In her letter to Mayo describing the story, the patient’s daughter says, “My mother was absolutely enchanted as she loves to dance, and I started to cry. The sight of this tiny fragile old woman being waltzed around the room by this most handsome young man was just too much… this is the caliber of doctor we have here, someone whose medical expertise is a given but whose compassion and kindness are extraordinary.” 

I spoke with Dr. Leonard Berry, co-author of Management Lessons from Mayo Clinic, about what makes Mayo Clinic a phenomenal health system.

Paying for Health, not Healthcare

As healthcare spending nears $4 trillion annually, political and economic questions regarding what should be done have consumed the 2020 democratic candidates. Some candidates such as Elizabeth Warren and Bernie Sanders have called for a complete dissolution of private insurance companies in exchange for a government-run Medicare-for-all plan. I spoke with Dr. Patrick Conway, the former CEO of Blue Cross Blue Shield of North Carolina and former Chief Medical Officer for the US Centers for Medicare and Medicaid Services, about ways that we can keep our current system while reducing overall healthcare costs. Conway’s work as the Chief Medical Officer included overseeing a $1.5 billion-dollar annual budget, and after becoming the CEO of Blue Cross Blue Shield of North Carolina, he oversaw healthcare delivery for 4 million Americans. It is incredibly challenging to find the “right answer” when it comes to healthcare, and I believe it’s important to seek out numerous perspectives in an attempt to determine our options. Insurance companies are often the center of the debate around healthcare, which is why I sought to speak with Dr. Conway; however, my goal is to present more than just one perspective, all of which share the common goal of reducing healthcare costs in America.

Throughout our conversation, Dr. Conway stressed the importance of “buying health, not just healthcare services,” meaning that, too often, we utilize unnecessary healthcare services that do not actually improve health. This is supported by numerous studies, which have said that unnecessary healthcare services account for over $200 billion dollars. Conway also cites the fact that US drug prices have increased at a faster rate than other developed nations, due in part, in his opinion, to the fact that many other developed nations utilize value-based drug pricing. Value-based drug pricing allows for drugs to be priced based on patient health outcomes after using a particular drug, and agreements between manufacturers and purchasers can even include providing refunds for adverse health outcomes caused by a drug. The current US system does not embrace a value-based system; instead, Medicare reimburses hospitals for drugs based on the Average Sales Price of a drug on the market plus 4.3%. Some say that this encourages drug companies to drive prices up as they know Medicare will continue paying for whatever the average price is, regardless of the drug’s efficacy.

Conway also discussed a fundamental issue with our healthcare system, which is the need for greater investment in preventative medicine. The CDC actually estimates that 75% of all healthcare spending could be avoided through preventative care, which is why patients should not only have access to free preventative care (a stipulation under the Affordable Care Act), but they should be encouraged and possibly incentivized to utilize this care. Greater preventative care for chronic diseases would not only directly reduce overall healthcare costs, but it would also prevent the estimated economic output loss of $260 billion due to patients being unable to work because of their disease.

As the director of the Center for Clinical Standards and Quality, Dr. Conway worked to implement MACRA (Medicare Access and CHIP Reauthorization Act of 2015), which is beginning to fundamentally change the way doctors are paid for treating patients with Medicare. Under MACRA, alternative payment models have been created in order to link payment for a provider to the quality of the care provided. Right now, approximately 90% of providers are paid for on a fee-for-service basis, meaning that medical services are paid for without regard to whether the service actually helped the patient or not. This means that providers are paid based on the quantity of care provided rather than quality. Alternative payment models aim to move away from fee-for-service by rewarding providers for performing procedures that improve the health of patients and penalizing those who conduct procedures that do not improve patient outcomes. Payment models are classified into different categories, with fee-for-service being category 1. The category 2 model makes the first step towards tying quality to compensation by incentivizing hospitals to report their data on quality of care. Providers can also receive benefits for more positive overall statistics, such as a reduction in number of hospital-acquired infections.

Dr. Conway believes that categories 3 and 4 create the biggest impact on patient care. Under the guidelines of these categories, payments involve two-sided risk, meaning that based on certain quality measures and patient outcomes, a provider’s pay may be increased or decreased. For example, providers in a hospital may receive bonuses for reducing hemoglobin A1c levels in their diabetic patients over a certain period of time. In theory, this incentivizes hospitals to do whatever they can to improve quality of care. Category 4 also includes bundled payment, which is a single payment for a particular episode of service. For example, when you go to a surgeon for a knee replacement, the final bill will state that the fee for the surgery itself is separate from the fee for the anesthesia used, even though the anesthesia is necessary for the surgery to take place. In a bundled payment model, all services needed for a specific operation are “bundled” into one price. In theory, this model reduces unnecessary care by encouraging providers to utilize resources efficiently and effectively because their compensation stays the same for a particular procedure, regardless of what additional resources are used. Conway believes that moving hospitals away from categories 1 and 2 into categories 3 and 4 will help in reducing costs of care and improving quality.

I also asked Dr. Conway about the plans proposed by some of the democratic presidential candidates. In terms of Medicare-for-all, Conway believes that a traditional Medicare-for-all plan would not necessarily work. Right now, when a doctor bills Medicare for a procedure, Medicare pays for it with little regard to whether or not the procedure was actually necessary. As Conway says, “People will get care, but from a cost-control standpoint, traditional Medicare-for-all is not a high-functioning system,” which is why the system is actually set to go bankrupt in 2026. Conway believes that private insurance companies are important here because they are able to actually manage appropriate care and control costs. A more legitimate policy conversation, in his opinion, involves Medicare Advantage, which is a public-private partnership system in which the public pays for the system, but private insurance companies manage the care provided.

From a bird’s-eye view, value-based care and bundled payments appear to be part of the “answer” to our nation’s rising healthcare costs. However, as we dive down into these issues, the answer is not so clear. Last year, researchers at Harvard Medical School found that the value-based care system implemented by the government has not only failed to improve quality of care, but instead may have increased healthcare disparities. This may be due to doctors being less encouraged to see sicker patients who are likely to bring down quality scores, which will ultimately increase physician compensation. Refusing to see sicker patients or even refusing to try out a treatment that may not result in greater compensation can lead to increased health disparities, exactly how the Harvard researchers described. In terms of bundled payments, researchers from the Agency for Healthcare Research and Quality looked at 58 studies on bundled payments and concluded that there is very weak evidence showing that bundled care actually reduces costs. It is critical to note how many of the policies described earlier work very well in theory; however, in a practical sense, they may cause physicians to play, what some call, “quality games,” in order to avoid reductions in their compensation. What is agreed upon, however, by researchers, policy-makers, and providers is that preventative medicine must be furthered. Additionally, we must continue to test out different models of care delivery so that we can create a cost-efficient, high-quality healthcare system for the American people.

I spoke with Dr. Patrick Conway, the former CEO of Blue Cross Blue Shield NC, about how we can reduce healthcare spending in the US

Sources:

How Preventive Healthcare Services Reduce Spending for Payers. (2017, August 29). Retrieved from https://healthpayerintelligence.com/news/how-preventive-healthcare-services-reduce-spending-for-payers.

Hussey, P. S., Mulcahy, A. W., Schnyer, C., & Schneider, E. C. (2012, August). Closing the quality gap: revisiting the state of the science (vol. 1: bundled payment: effects on health care spending and quality). Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24422914.

Lyu, H., Xu, T., Brotman, D., Mayer-Blackwell, B., Cooper, M., Daniel, M., … Makary, M. A. (2017). Overtreatment in the United States. PloS one12(9), e0181970. doi:10.1371/journal.pone.0181970

McNair, P. D., Bates, D. W., Singh, H., Cutler, D. M., Sahni, N. R., Harris, B. D., … Kurtzman, E. T. (n.d.). Medicare’s Policy Not To Pay For Treating Hospital-Acquired Conditions: The Impact. Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.28.5.1485.

Medicare will become insolvent in 2026, U.S. government says. (2018, June 5). Retrieved from https://www.latimes.com/nation/nationnow/la-na-pol-medicare-finances-20180605-story.html.

Pearl, R. (2017, September 25). Healthcare’s Dangerous Fee-For-Service Addiction. Retrieved from https://www.forbes.com/sites/robertpearl/2017/09/25/fee-for-service-addiction/#2a47c016c8ad.

Preventive care benefits for adults. (n.d.). Retrieved from https://www.healthcare.gov/preventive-care-adults/.

Roberts, E. T., Zaslavsky, A. M., & McWilliams, J. M. (2018, February 20). The Value-Based Payment Modifier: Program Outcomes and Implications for Disparities. Retrieved from https://annals.org/aim/article-abstract/2664654/value-based-payment-modifier-program-outcomes-implications-disparities.

Sarnak, D. O. (2017, October 5). Prescription Drug Spending Why Is the U.S. an Outlier? Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2017/oct/paying-prescription-drugs-around-world-why-us-outlier.

Congress’s Overdue Baby is Named ‘Paid Family Leave’

Republicans and Democrats have found every way to disagree when it comes to health policy, and this has caused us to lag behind on enacting legislation that will move our country forward. One of those policies is paid family leave following childbirth. There are not many similarities between the United States and Papua New Guinea, but surprisingly our great nation and New Guinea are two of very few nations that do not provide paid family leave after childbirth. But, we are at the perfect time for change. While the Family and Medical Leave Act, which provides up to 12 weeks of unpaid and job-protected leave, was passed under Clinton, President Trump has been a leader in the Republican party by being the first Republican president to endorse paid family leave for mothers and fathers after a newborn or an adopted child.

The first months of life are the most critical for a child. Poor upbringing can negatively impact a child’s entire life, and right now, only 17% of private industry workers have access to paid family leave. In our fiercely capitalistic society, almost 80% of Americans live paycheck to paycheck, and this makes taking time off to care for a newborn more challenging than ever before, which is why 25% of mothers must return to work within 10 days of giving birth. Researchers using data from the U.S. National Survey of Family Growth found that mothers who have access to paid leave are more likely to begin breastfeeding their newborn and are twice as likely to continue breastfeeding at 6 months compared to mothers who do not have access to paid family leave. Without breastfeeding or adequate time for bonding, a child’s full potential may be hindered. Unfortunately, there are no long term studies on the effects of paid family leave; however, it could be argued that the severity of future issues for a child and the likelihood of the child to utilize social welfare during adulthood is reduced if proper care during infancy is provided. This system overwhelmingly negatively affects the poor, who are often kept in cycles of substandard academic performance, but legislation on the floor of Congress could break that cycle.

Women who receive paid family leave have a higher likelihood of returning to their job, which benefits the entire system involved—the employer benefits from not having to spend additional money on training a new employee and the US economy benefits from a higher and more dedicated labor force. However, the largest challenge to the enactment of paid family leave is the possibility that some employers will choose not to hire women who are likely to have a child. This notion is substantiated by empirical data from New Jersey, which implemented statewide paid family leave in 2009. A 2016 study in New Jersey found that employment rates for women aged 22 to 34 fell about 8%. However, data is limited and states such as California have found that 90% of employers felt positively or neutral about paid leave after it was enacted statewide in 2004.

Now, with all this said, what are the plans currently being debated on the floor of Congress? As with the majority of our politics today, all the paid family leave proposals in Congress can be represented by two main plans: a fiscally conservative plan, led by senators Marco Rubio and Mitt Romney, as well as a liberal plan, led by senator and democratic candidate Kirsten Gillibrand. The two significant plans are briefly described below, and the best path of action is highly debated… where do you stand?

Gillibrand’s FAMILY Act: A working parent can receive 12 weeks of paid leave at 66% of normal wage with a maximum benefit of $4000/month. This plan would be paid for with a 0.2-0.4% payroll tax on all working American employees and employers, depending on your employment status. This is how the system is paid for by states like New Jersey that have already implemented statewide paid parental leave. One of the main concerns with this plan is that it adds a new tax. Despite a great federal deficit, our current administration and Congress voted on and passed a significant tax cut in 2017. Because of this, it is very unlikely that a plan proposing to add a new tax to working Americans will be well received by Republican congressmen.

Rubio and Romney’s New Parents Act of 2019: Working employees and employers contribute to social security, and this bill allows parents to tap into their future social security benefits to finance their leave, which can be up to 12 weeks. You are essentially paying for your own leave with money you were going to receive. In exchange for using this money earlier, a parent may work for 3-6 months past retirement age and continue contributing to their social security during this time, or they may receive small reductions in their social security benefits upon retirement. Similar to the FAMILY Act, parents will receive about 66% of their normal wage until a maximum benefit is reached. Overall, this mitigates the cost burden on employers, employees, and companies as a whole.

A significant issue is that there is bipartisan agreement that something needs to be done; however, neither side has been willing to accept the other’s way of acting, and this has blocked the enactment of any substantial federal bill regarding this issue. Right now, Democrats may need to accept that a full-benefit bill (FAMILY act) may not pass because of the added new tax stipulation that is highly unfavored among Republicans, who currently control the Senate and the Presidency. It may be important to start slowly with a more moderate bill like the New Parents Act proposed by Republicans, which is a more practical and feasible solution in our current state of no federal mandate for paid family leave.

Sources:

Burtle, A., & Bezruchka, S. (2016, June 01). Population Health and Paid Parental Leave: What the United States Can Learn from Two Decades of Research.

Jou, J., Kozhimannil, K. B., Abraham, J. M., Blewett, L. A., & McGovern, P. M. (2017, November 02). Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

May, A. (2017, May 18). Paid family leave is an elite benefit in the U.S.

Mirkovic, K. R., Perrine, C. G., & Scanlon, K. S. (2016, March 17). Paid Maternity Leave and Breastfeeding Outcomes – Mirkovic – 2016 – Birth – Wiley Online Library.

O’Dea, C. (2019, February 11). Lawmakers Move to Improve Paid Family Leave Program in New Jersey.

Vesoulis, A. (2019, May 16). Americans Could Finally Get Paid Family Leave. But Who Pays?

Warner-Richter, M. (2017, October 27). Paid parental leave is rare, but good for kids.

Congressional Research Service: Paid Family Leave in the United States

National Partnership for Women & Families: The Family And Medical Insurance Leave (FAMILY) Act

S.463 – FAMILY Act 116th Congress (2019-2020)

S.920 – New Parents Act of 2019 116th Congress (2019-2020)

America is Bleeding, and Congress is Trying to Stop It

With 16 physicians in Congress, America has taken great steps toward putting healthcare providers in a position to address our nation’s most pressing healthcare issues. We have all heard about the most prevalent causes of death in America such as heart disease and cancer, but trauma is actually the leading cause of death for Americans aged 1-44. Whether it’s a car accident, a fall, or even gun violence, trauma kills over 200,000 people per year in the US alone. The figures abroad are in the millions. Every year, trauma-related injuries cost the US almost $700 million. Many of these deaths are caused by massive blood loss, and around 20% could be prevented. With millions of dollars and thousands of lives to be saved, Congressman and physician Dr. Brad Wenstrup (R-OH) and Congressman Alcee Hastings (D-FL) have introduced bipartisan legislation, the Prevent Blood Loss with Emergency Equipment Devices Act of 2019 (H.R.2550), also known as the Prevent BLEEDing Act, which would require blood loss equipment such as tourniquets (a device tightly wrapped around an arm or a leg to stop bleeding) and clotting bandages in public spaces like libraries, schools, and malls.

I sat down with the Chairman of National Stop the Bleed Month Andrew D. Fisher, a fellow Aggie, to talk about this bill and other ways we can improve trauma care in the United States. As a Major in the US Army, Andrew Fisher’s military and civilian experience is extensive. He has completed over 500 missions with a total of 30 months deployment in Iraq and Afghanistan as a physician assistant, and he is a recipient of the Purple Heart. Fisher’s military prowess led him to be named the 2018 U.S. Army Hero of Military Medicine. Now, at the age of 46, Fisher has over 40 publications in peer-reviewed medical journals and is in his last year of medical school at Texas A&M College of Medicine.

Many Americans know how to perform CPR, but Fisher points out that after receiving CPR, only around 10% of patients survive to the time of discharge. However, Fisher says that in the case of massive blood loss, the application of a tourniquet yields a higher survival rate. His previous unit in the US Army brought prehospital mortality from blood loss down to zero after proper blood loss training was given. So far, tens of thousands of people have been trained in bleeding control through National Stop the Bleed Month, and all the training has been completed for free and supported by the American College of Surgeons. Furthermore, traditional CPR/AED courses should add basics about bleeding control. A Texas study found that the mortality rate after a severe vascular injury to the arms or legs was 8% without the application of a tourniquet immediately after injury. However, the mortality rate drops down to 3% for patients who receive a tourniquet. Learning how to use a tourniquet could be vital in a deadly situation.

My own uncle passed away six years ago in a bus accident, and his life could have been saved through the use of a tourniquet. His arm was severely injured in the accident, and he was bleeding out. In a perfect situation, a tourniquet would have been available on the public bus. In this case, a bystander would have wrapped his arm above the site of bleeding, and the tourniquet could have stopped blood from leaving the major artery in his arm. Even where a tourniquet is not available, any type of band, scarf, or long piece of fabric can be used to tightly wrap the arm or leg above the site of bleeding.

When I asked Andrew Fisher about the Prevent BLEEDing Act, he said that he appreciates Congress’s efforts, but noted that the federal government is “a little late to the game.” Fisher pointed out that a few states, such as Georgia, have taken matters into their own hands by equipping every Georgia public school with bleeding control kits. Actions by the slow-footed federal government may not be the most desirable; however, the ratification of this bill would greatly advance bleeding-control education, provide a federal mandate for the availability of blood loss supplies in public spaces, and situate blood-loss prevention as a nationally recognized issue.

Mass shootings in public spaces, such as the Las Vegas Shooting in which 58 people were killed and 851 were injured, have become more common. Bullets can cause major bleeding in an extremity, and death can occur in minutes, which is why time is essential. After the horrific shooting at Sandy Hook Elementary School in which 20 children and 6 adults were killed, the Hartford Consensus was created to improve the response to mass casualty and active shooter events. The Hartford Consensus calls for bleeding control bags to be present in places such as schools. And although it’s debated whether or not teachers should be armed, there are no apparent downsides to having teachers learn basic bleeding control techniques in the case of an emergency.

Fisher emphasizes that one is unlikely to be a victim of a terrorist attack or a school shooting; however, the chance of being in a car accident is much greater. This is where the vitality of emergency medical technicians (EMTs)  and paramedics comes into play. These emergency responders are the first experts to the scene, and their actions frequently determine the life and death of a patient. One of the most common injuries from a major car accident is internal bleeding, which cannot be stopped through the basic application of a tourniquet. However, a procedure called REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) can be done by inflating a balloon in the aorta to temporarily stop blood loss. Currently, only trauma-related physicians are able to perform this procedure. However, Fisher along with countless others in the field of pre-hospital medicine, are calling for the training of paramedics to perform the procedure in a life or death situation. Fisher, a former paramedic, says that it is a challenging skill, but it may save more lives after traumatic injury. In addition to REBOA, Fisher believes that all paramedics should be trained on the administration of ketamine as a pain-reliever. Trauma related injuries can cause excruciating pain that warrants care, which is why first responders must be trained to administer safe pain-relievers to severely injured patients. Only half of paramedics report learning about ketamine during their training; however, ketamine has been vetted through research and has been shown to be a powerful and safe tool for pain relief in the pre-hospital setting. Fisher also believes that EMT standards should drastically increase to broaden their understanding of anatomy and pathophysiology, noting that professional hairdressers have to complete over 1000 hours for their program while based on national averages, EMTs only have to complete a total of 120-160 hours. Overall, furthering the knowledge and clinical skills of our medical responders has the potential to better stabilize patients before they reach the hospital and ultimately save lives.

Thousands of bills flow through our legislative bodies, and the majority of the bills signed into law are sponsored by Republicans and Democrats. The Prevent BLEEDing Act, which would appropriate $10 million to making blood loss supplies more accessible in public spaces, has already gained bipartisan support, and this bill along with other improvements in emergency medicine would have a positive impact on trauma care in the United States.

Major Fisher and I met to talk about trauma care and prehospital medicine

Sources:

Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehospital and Disaster Medicine. 2017;33(1):23-28. doi:10.1017/s1049023x17007142.

Civilian Prehospital Tourniquet Use is Associated with Improved Survival in Patients with Peripheral Vascular Injury. Teixeira, Pedro G.R.Vu, Megan et al.Journal of the American College of Surgeons, Volume 226, Issue 5, 769 – 776.e1

DiMaggio C, Ayoung-Chee P, Shinseki M, et al. Traumatic injury in the United States: In-patient epidemiology 2000-2011. Injury. 2016;47(7):1393–1403. doi:10.1016/j.injury.2016.04.002

Hastings and Wenstrup Introduce the Bipartisan Prevent BLEEDing Act of 2019. U.S. Congressman Alcee L. Hastings. https://alceehastings.house.gov

Hax SD, Davis K, Stone B, Bledsoe B, Hodnick R. Ketamine’s Versatility Makes it a Powerful Tool for EMS. Journal of Emergency Medical Services. https://www.jems.com/articles/print/volume-42/issue-2/features/ketamine-s-versatility-makes-it-a-powerful-tool-for-ems.html. Published February 1, 2017.

Stop the Bleed – Georgia – Georgia Trauma Foundation.

Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390332/

https://firstcareprovider.org/blog/tk-how-to

Giving Life Twice

Most mothers only give life to one child at a time, but about 800,000 women worldwide give life to two… and I’m not talking about twins. I’m talking about the donation of their umbilical cord blood, the blood that remains in the umbilical cord after childbirth. Most commonly, the umbilical cord and the placenta are thrown away after birth, but these organs contain precious stem cells that have the capacity to save lives… to give a second life to someone else.

Harvesting umbilical cord blood and utilizing it for treatment is a relatively new scientific advancement that started in the late 1980’s. Scientists and doctors have realized that umbilical cord blood is rich in stem cells, specifically multipotent hematopoietic stem cells. These are big words to describe a simple yet incredible cell. Multipotent hematopoietic stem cells are cells that can give rise to all the blood cells, which is why these cells are invaluable to someone suffering from a blood disease. So, how does all this work and what does it treat? Well, first of all, the procedure is painless for both the mother and the child, and it takes 2-5 minutes. To collect the umbilical cord blood after a baby is born, the physician first cuts the umbilical cord then simply puts a needle into the blood vessels of the umbilical cord before drawing out the blood. This blood is then stored and frozen at -196°C. Mothers who have donated this blood have described it by saying that they did not even know it was being collected until after the doctor told them that they were done. After this blood is tested and stored, it can be matched with a blessed patient somewhere around the world who needs a blood transplant. Umbilical cord blood can be used to treat patients with various types of common blood cancers and diseases, such as leukemia, lymphoma, as well as sickle cell anemia.

Numerous advantages exist for umbilical cord blood, including the following:

  • No/very little risk to donor
  • Easily stored
  • Cells collected are immunologically immature and have a high growth potential
  • Low incidence of Graft vs Host Disease, which is a disease where the grafted stem cells detect the normal cells as foreign, resulting in the stem cells attacking the healthy body cells
  • Blood type matching is easier with stem cells harvested from cord blood compared to the conventional stem cells harvested from bone marrow

Now, you may be wondering where all this blood is stored, and this is where the debate comes in. There are two options you can choose from for where your cord blood goes: public banks or private banks. Public banks are completely free, and this is where your cord blood goes into a world registry where a matching donor can be found and treated. However, private umbilical cord blood banks make up a several hundred-million-dollar industry. When the private bank option is chosen, the blood is collected and stored for the sole use of that family. These blood banks say that their service is “biological insurance” for your kid if anything goes wrong in the future, and this is simply misleading. Numerous marketing techniques are used on pregnant mothers to sell them a cord-blood bank plan, but the chance of the child ever actually using this cord blood is trivial. Some studies show the rate of private bank blood used being 0.09% while other studies show that public bank blood is 30 times more likely to be used than private. Furthermore, numerous studies have shown that the quality of cells and the number of stem cells are lower when kept by private cord banks versus public. As one study published in the journal Transfusion said, “Quality parameters of privately banked umbilical cord blood are inferior to those stored in public banks.”

Very few blood diseases can be treated with one’s own umbilical cord blood because if the disease is genetic, then the stored blood has the same genetic abnormality, thereby rendering it useless for the kid. Almost 90% of transplants are between unrelated people with the remaining 10% being between family members, which is another powerful benefit of umbilical cord blood. For example, if you have a kid who has been diagnosed with leukemia, and you also have another kid on the way, then the umbilical cord blood for the second child can be harvested and used for the baby’s brother. This can be done through public bank systems at little to no costs. I keep talking about how public banks do not cost you anything because of the striking difference between public and private banks. Private banks are very expensive! For example, let me tell you about one of the several well-known private cord blood banking companies. According to the company’s website, to store your cord blood, the company charges $1,575 for the collection of the blood and an annual storage fee of $175. That already sounds like a lot, but a greater opportunity cost exists here. At the time of your child’s birth, if you put $1,575 dollars into a mutual fund that grows at a conservative rate of 8%, and you contribute just $175 to that fund every year, here’s how much your kid will have after….

20 years: $15,000

40 years: $80,000

65 years (retirement): $560,000

Many people never attain more than half a million dollars in their entire life, and now your kid can have it just for them at the time of retirement. The sad reality is that while 800,000 women have publicly banked their blood, 5 million have used private banks. Umbilical cord blood is much better off in the hands of a public bank, and this notion is supported by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and many more. As Dr. Paul Harker-Murray at UT Southwestern said, “Umbilical cord blood is an underutilized medical resource with immediate life-saving clinical applications,” which is why it is so important for pregnant women to strongly consider donating their umbilical cord blood to a public bank.

Sources:

Ballen KK, Verter F, Kurtzberg J. Umbilical cord blood donation: public or private? Bone Marrow Transplantation. 2015;50(10):1271-1278. doi:10.1038/bmt.2015.124.

Kurtzberg J. (2017). A History of Cord Blood Banking and Transplantation. Stem cells translational medicine6(5), 1309–1311. doi:10.1002/sctm.17-0075

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