Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Reductions in nonfinancial barriers to care and improvements in social determinants of health are also necessary. This ACP position paper calls for ending discrimination based on personal characteristics; correcting workforce shortages, including the undersupply of primary care physicians; and understanding and ameliorating social determinants of health. The ACP calls for increased efforts to address urgent public health threats, including injuries and deaths from firearms; environmental hazards; climate change; maternal mortality; substance use disorders; and the health risks associated with nicotine, tobacco use, and electronic nicotine delivery systems in order to achieve ACP's vision for a better U.S. health care system.

The full position paper can be downloaded below.  

LIFE EXPERIENCES AND INCOME INEQUALITY IN THE UNITED STATES

Over the past five decades, income inequality has sharply increased between the highest income earners and middle- and lower-income earners in the U.S. This poll examines the implications of this growing inequality for the lives of U.S. adults across different income levels. This report, Life Experiences and Income Inequality in the United States, is based on a survey conducted for NPR, the Robert Wood Johnson Foundation, and the Harvard T.H. Chan School of Public Health. It explores how adults’ personal experiences, values, and views on income inequality, opportunity, and health in the U.S., differ among adults by household income. Surveyed adults are split into four income categories: those in the top 1% highest income households in the U.S. (earning at least $500,000/year), those in higher-income households (earning $100,000-$499,999/year), those in middle-income households (earning $35,000-$99,999/year), and those in lower-income households (earning less than $35,000/year). Due to the heterogeneity of incomes in the higher-income category, analyses in this report focus on differences between the top 1% highest income adults compared to middle- and lower-income adults, though results are included for all four income groups. It was conducted July 17 – August 18, 2019, among a nationally representative, probability-based telephone (cell and landline) sample of 1,885 adults ages 18 or older living in the United States.

The full report can be downloaded below.  

Requiring smartphone ownership for mHealth interventions: who could be left out?

Mobile health (mHealth) interventions have the potential to improve health through patient education and provider engagement while increasing efficiency and lowering costs. This raises the question of whether disparities in access to mobile technology could accentuate disparities in mHealth mediated care. This study addresses whether programs planning to implement mHealth interventions risk creating or perpetuating health disparities based on inequalities in smartphone ownership.

Video Directly Observed Therapy (VDOT) is an mHealth intervention for monitoring tuberculosis (TB) treatment adherence through videos sent by patients to their healthcare provider using smartphones. We conducted secondary analyses of data from a single-arm trial of VDOT for TB treatment monitoring by San Diego, San Francisco, and New York City health departments. Baseline and follow-up treatment interviews were used to assess participant smartphone ownership, sociodemographics and TB treatment perceptions. Univariate and multivariable logistic regression analyses were used to identify correlates of smartphone ownership.

Of the 151 participants enrolled, mean age was 41 years (range: 18–87 years) and 41.1% were female. Participants mostly identified as Asian (45.0%) or Hispanic/Latino (29.8%); 57.8% had at most a high school education. At baseline, 30.4% did not own a smartphone, which was similar across sites. Older participants (adjusted odds ratio [AOR] = 1.09 per year, 95% confidence interval [CI]: 1.05–1.12), males (AOR = 2.86, 95% CI: 1.04–7.86), participants having at most a high school education (AOR = 4.48, 95% CI: 1.57–12.80), and those with an annual income below $10,000 (AOR = 3.06, 95% CI: 1.19, 7.89) had higher odds of not owning a smartphone.

Approximately one-third of TB patients in three large United States of America (USA) cities lacked smartphones prior to the study. Patients who were older, male, less educated, or had lower annual income were less likely to own smartphones and could be denied access to mHealth interventions if personal smartphone ownership is required.

The full article can be downloaded below.  

Scaling Blockchains to Support Electronic Health Records for Hospital Systems

Electronic Health Records (EHRs) have improved many aspects of healthcare and allowed for easier patient management for medical providers. Blockchains have been proposed as a promising solution for supporting Electronic Health Records (EHRs), but have also been linked to scalability concerns about supporting real-world healthcare systems. This paper quantifies the scalability issues and bottlenecks related to current blockchains and puts into perspective the limitations blockchains have with supporting healthcare systems. Particularly we show that well known blockchains such as Bitcoin, Ethereum, and IOTA cannot support transactions of a large scale hospital system such as the University of Kentucky HealthCare system and leave over 7.5M unsealed transactions per day. We then discuss how bottlenecks of blockchains can be relieved with sidechains, enabling well-known blockchains to support even larger hospital systems of over 30M transactions per day. We then introduce the Patient-Healthchain architecture to provide future direction on how scaling blockchains for EHR systems with sidechains can be achieved.

The full article can be downloaded below.  

Why Aspiring Entrepreneurs Are Interested In Value-Based Medicine

Healthcare is a thriving market when it comes to business. Most people might think the industry is only for doctors and nurses, or other people with medical backgrounds, but this is not the case. The healthcare sector is an amazing opportunity for aspiring entrepreneurs from all walks of life and experience. It presents an incredible chance for someone to genuinely help people and make plenty of money at the same time.

The reason healthcare is attractive to aspiring entrepreneurs can be attributed in part to the recent government overhaul in the industry. The Centers for Medicaid Services (CMS) transitioned from fee-for-service to value-based care. It’s a game-changer not only for patients, but also for entrepreneurs who have a knack for customer service, are experts at efficiency and strive to provide quality.

The full Forbes article can be viewed at this link.  

The Real Epidemic: Not Burnout But 'Moral Injury' Of Doctors Unable To Do Right By Patients

During the course of my husband’s two months of outpatient care, and four days in the local ICU, I realized that the physicians were shockingly absent, and the nurses only a little less so. They had withdrawn into the recesses of the system, remote from patients and families, working at the top of their billing capacity, but walled off from those they were caring for by phone trees and receptionists playing a potentially deadly game of “operator.”

Blaming the medical staff in this situation would be easy, but misplaced. It is the system, designed and overseen largely by non-clinicians, that is to blame.

The full WBUR article can be viewed at this link.  

Why Pharmacies Are About To Be Hit Hard By Disruption

Pharmaceutical distribution vary from country to country, but all of them are subject factors that make genuine competition in the sale of prescription drugs a complex matter. The need to verify that the patient requesting a given medicine has obtained the corresponding prescription from a doctor, as well as other aspects related to how the medicine is acquired (totally or partially subsidized, by public or private bodies, etc.), along with other issues reflect a business fabric that can vary enormously from the large US drugstore chains to the traditional pharmacies in many European countries, owned by a qualified pharmacist, with their regulated margins, and which until a few years ago, sold only pharmaceutical or related products.

Recent moves by Amazon seem to presage disruption in the pharmaceutical sector. In June 2018, the e-commerce giant acquired PillPack for just under $1 billion, precipitating sharp falls in the share value of companies such as CVS, Walgreens, Boots or Rite Aid: PillPack, which also traded with Walmart and was simply a little-known startup as far as the general public was concerned, had obtained a license to sell prescription drugs in all US states, and furthermore, was a service designed from scratch to be digital, a situation very few of its competitors could contemplate.

The full Forbes article can be viewed at this link.  

How Telepsychiatry Is Improving Access to Mental Health Care

As an adolescent healthcare provider at Seattle Children’s Hospital, where she sees youths facing issues such as eating disorders and gender dysphoria, Evans has kept those concerns top of mind since joining the faculty in 2011.

“I knew that I wanted to try to serve more rural patients,” she says. “I understand the needs in these communities.”

Remote areas often lack specialists to provide counseling and intervention: A 2017 Merritt Hawkins report found 77 percent of U.S. counties reported a severe shortage of psychiatrists. The Association of American Medical Colleges notes that nearly two-thirds of practicing psychiatrists are 55 or older, setting the stage for a substantial retirement drain.

Meanwhile, 1 in 5 Americans will experience a mental illness in a given year, federal data shows.

It’s why Evans and some colleagues are using videoconferencing technology to reach patients outside a clinic’s walls. Seattle Children’s offers telepsychiatry services not only in Washington state but also in Alaska, Idaho, Montana and Wyoming.

The full HealthTech article can be viewed at this link.  

Patients can’t afford for doctors to misunderstand the healthcare business

Patients are often dismayed or surprised that their doctor cannot earnestly explain the cost-benefits of different treatments. A 2013 survey by the Journal of the American Medical Association found that 87% of graduating doctors felt uncomfortable with their knowledge of the business of medicine and 81% felt they lacked an understanding of healthcare legislation.  As surgeons, we have slowly let ourselves become exclusively technicians. Just like Aristotle and Plato said.

By turning our noses up at the business of medicine, we have lost ownership over our patients, and the agency to advocate for them. As Osler said, “The good physician treats the disease. The great physician treats the patient who has the disease.”

We as physicians and surgeons need to recover our identity and learn the business skills that our teachers have forgotten, but our forefathers stood up for.

The full Quartz article can be viewed at this link.  

The Complexities Of Emergency Medicine And Prolonged ER Wait Times

Some communities have already issued warnings of increased emergency room (ER) wait times in the upcoming months, a routine phenomenon during the height of the winter season. Congruently, one among many complaints that patients have nationally about the state of modern healthcare is ER wait-times. With nearly a 50% increase in the number of ER visits in the last 20 years, this is likely a plausible public perception. However, what may not be well known to the public are the complex algorithms and protocols that drive patient flow and care in the emergency room. It is these intricacies that ultimately determine the entire patient care experience, including wait times.

The full Forbes article can be viewed at this link.