Dr. Marc Siegel: The opioid crisis has a solution — Here it is

I recently attended a symposium examining how medical schools can prepare future doctors to deal with the continuing opioid crisis. I joined over 90 educators from 30 medical schools at the Warren Alpert Medical School of Brown University to discuss devising a curriculum based on a successful model that Brown has created.

The curriculum on opioids is designed to accomplish two objectives:

First, teaching medical students how to identify and properly treat pain. In the past, medical students have been notoriously undereducated when it comes to pain and pain management. They have over-prescribed opioids because of pressure from drug companies and patients. Now newly minted doctors will manage multidisciplinary teams to properly manage pain without opioids whenever possible.

Second, training medical students to qualify for waivers so that when they graduate they can prescribe treatments including buprenorphine to manage opioid use disorders.Buprenorphine is an opioid medication that produces less euphoria and physical dependence than other opioids and is used to treat opioid addiction.

At the groundbreaking symposium at Brown I joined former U.S. Surgeon General Dr. Vivek Murthy on stage to interview him and discuss key issues involving opioid addiction. Over lunch before the session, Murthy – who was surgeon general from December 2014 until April 2017 – and I discovered we have some things in common.

Both of us are internists and are married to doctors who serve as medical mentors. And both of us believe firmly that the primary responsibility for causing the opioid problem lies in the hands of over-prescribers.

“We are the ones who hold the prescribing pen,” I told Murthy. I told him that my wife, a neurophysiologist and back pain specialist, almost never prescribes opioids. Instead, she prescribes muscle relaxants, non-steroidal patches, heat and physical therapy for most back pain.

Doctors, beginning with medical students, must play an essential role in understanding and treating not just pain, but the addiction that arises from a community culture of drug abuse.

Murthy agreed with this approach. And I agreed with his view that opioids alone aren’t the problem, but are instead part of a cascade of widely used addictive substances. In addition to opioids (both prescribed and illicit), these substances include anti-anxiety medication, sleeping pills and alcohol.

In 2016 Murthy issued a report titled “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.” The report launched a community-based program to address the addiction epidemic in the U.S.

During my hour-long interview and discussion with Murthy attended by those at the symposium we talked about the need to better regulate and restrict opioid prescriptions with a federal monitoring program, along with the huge need for proper doctor education.

Proper pain identification and management, along with medically assisted therapy (including buprenorphine) has been shown to dramatically decrease the urge to use opioids.

In contrast, locking up addicts in jail and prisons instead of providing the treatment they desperately need is the wrong way to deal with the addiction epidemic, Murthy said. I wholeheartedly agree.

Everyone in the audience knew that Murthy and I come from opposite sides of the political aisle, with fundamental differences in terms of how we approach health policy. And yet, here we were, in a give-and-take discussion filled with agreement and common ground, with the ultimate shared goal of improving treatments for addicts to help them lead healthy and productive lives.

Murthy discussed the three main addiction centers of the brain, along with progress in research to create less addictive pain treatments.

U.S. Food and Drug Commissioner Dr. Scott Gottlieb told me in a recent interview for Fox News that new effective and less-addictive pain treatments are in the offing.

We can learn lessons about solving the opioid crisis in the world of public health.

Vaccines – the greatest public health advance of the 20th century – are most effective when everyone takes them, creating a herd immunity that protects society. Addiction should be viewed the same way.

There is a high recurrence rate for opioid addiction even after the most effective rehab program. Murthy talked about an addict’s essential loneliness, and about the need for the entire community to come together to help addicts overcome the stigma and embarrassment of their predicament.

The former surgeon general applauded the efforts that have been made by his successor – Surgeon General Dr. Jerome Adams – and others to provide much wider access to naloxone – a life-saving drug that rapidly reverses an opioid overdose by blocking the effects of other opioids. Naloxone can quickly restore normal breathing to someone whose breathing has slowed or stopped as the result of an opioid overdose.

Doctors, nurses, law enforcement officers, families and friends of addicts must all have access to naloxone and learn how to administer the drug. It is available as a prepackaged nasal spray and in a prefilled auto-injection device that make it easy to administer.

Murthy believes – as I do – that funding for wider distribution of naloxone at a low cost must be preserved and extended at the federal, state and local level.

And of vital importance, we must improve our understanding what works best to help addicts get off and stay off the substances they are addicted to.

We need to help addicts relearn a sense of their own usefulness and understand that addiction is more than a disease – it’s a form of emotional and physical paralysis.

Doctors, beginning with medical students, must play an essential role in understanding and treating not just pain, but the addiction that arises from a community culture of drug abuse. According to the National Survey on Drug Use and Health, an astounding 75 percent of opioid misuse begins with people taking medications that were intended for others. And close to 80 percent of heroin addicts begin with prescription painkillers.

The most effective place to address the opioid epidemic is not in the halls of Congress but in the doctor’s office. Doctors helped to cause this problem, and now we must help to cure it.

Source: Dr. Marc Siegel: The opioid crisis has a solution — Here it is | Fox News

Doctors prepare for medical issues surrounding legal pot

It’s a question that bore examining. What might happen when the recreational use of marijuana for adults over the age of 21 suddenly became legal on July 1? Would hospitals see an uptick in emergency room visits, as people could freely smoke and ingest what was previously considered an illegal substance for most users?

Dr. Gerald Beltran, chief or pre-hospital and disaster medical division for Baystate Medical Center told Reminder Publications he didn’t expect any big jump in emergency room visits right off the bat.

“We already saw the uptick when [marijuana use] became a civil penalty, not a criminal one,” Beltran said, adding he didn’t anticipate another noticeable bump until more cities and towns finalized their bylaws regarding cultivation and sale of marijuana.

But the slow acceptance of cannabis as a legitimate business doesn’t mean Betran and Dr. Louis Durkin MD FACEP, chief of Emergency Medicine at Mercy Medical Center, don’t have their concerns. From accidental pediatric exposure to potency issues to impaired driving, both men acknowledged there would be issues as marijuana became more widely accessible to the public.

“We do expect to see an overall increase of accidental and intentional overexposure and overdose, but it’s likely to increase on an individual basis, not 20 patients all at once,” Durkin said. “All the things that we’ve seen even though it was not legal, we’re going to see more frequently now that it is legal.”

Impaired driving and accidents
Beltran noted that a survey from one of the states where recreational marijuana use has been legal for some time found users felt comfortable driving an hour after smoking a joint.

“Studies show [marijuana’s effect] is still in the system three hours after smoking. People don’t realize they are impaired,” he said. “ Nobody wants to admit it, but studies have [also] been done on the number of accidents and fatalities, and there is an uptick in the number of deaths from operating under the influence [of marijuana.]

Durkin said driving accidents weren’t the only injury concerns with marijuana impairment.

“There’s going to be more slips and falls – [injuries] related to intoxication, similar to alcohol use, but it will be harder to measure” because there is currently no definitive test for marijuana intoxication, he said.

Pediatric exposure
Beltran noted that nationally, as marijuana legalization has spread from state to state, there’s been a steady, sometimes dramatic, increase in emergency room visits for children unintentionally exposed to marijuana.

For example, at a June 6 marijuana forum in Springfield addressing youth exposure concerns,  Captain Brian Keenan, Springfield Police Department Narcotics Division,  noted “pediatric exposure to marijuana is up 30 percent in Colorado.”

Durkin said this uptick is especially true when it comes to marijuana edibles. Though Jennifer Flanagan, a member of the Massachusetts Cannabis Control Commission who spoke at the Springfield event emphasized the Commission has gone to great lengths to discourage  any markings that would appeal to kids and tweens, and to and clearly label marijuana edibles as not for children, both doctors acknowledged accidents would happen.

“Like with Tide Pods, the same thing can happen with edible marijuana,” Beltran said. “I think it’s going to be very difficult to control as [they] become more available.”

Edible toxicity
Durkin said individuals unfamiliar with how marijuana works in an edible form are likely to run into trouble with the substance.

“The peak onset of effect is two to four hours after ingestion,” Durkin said. “You can get into the trap where you’re not feeling anything and you eat another brownie, and another brownie, and at four hours, you’re toxic.”

He said some individuals may feel some effects before the two hour mark, but the full intoxication doesn’t hit until the four hour mark and because “edibles take longer than inhalation to take effect, it takes longer [for the effects] to go away.”

Polysubstance problems
Both Beltran and Durkin said their biggest concern going forward would be polysubstance admissions involving marijuana, as it’s often used in conjunction with other substances.

“Marijuana and alcohol, marijuana and cocaine, marijuana and alcohol and cocaine, there are a lot of iterations” that might land an individual in the emergency room, Durkin noted.

Beltran agreed, noting marijuana is frequently a polysubstance drug.

“There are no tests for [marijuana]. If someone comes in completely altered – and we have seen people with marijuana and pcp – was it trauma from an accident or was it pcp or was it marijuana  –  it creates an interesting differentiation,” Beltran said.

Potency concerns
“Over the last 20 or 30 years, the level of THC [the psychedelic compound in marijuana] is much higher. People who smoke it now who have been away from it will [find] a more interesting effect that goes along with it,” Beltran noted.

At the June 6 seminar in Springfield, Lena Marceno, prevention specialist, Springfield Dept. of Health and Human Services, noted that the concentration of THC in street-level marijuana had increased from 3.7 percent in 1990 to 13.2 percent today.

Durkin said this potency inccrease is especially concerning when it comes to older former users.

“As all medications goes, it does depend on the sensitivity equation. If you’ve got a more susceptible older patient using a higher concentration [of THC], there’s a higher possibility of toxicity being achieved,” he said.

Seeking help
Durkin noted the following symptoms as indicating overexposure or toxicity when it comes to marijuana use:

“The most concerning symptom is  [that] you are unable to wake the person up. Seizure activity is another concern. And then there is intractable vomiting,” he said.

Beltran noted intractable vomiting is mostly associated with daily marijuana use, and the only cure is to stop using.

Source: Doctors prepare for medical issues surrounding legal pot

Shortage Of Pain Medication Hits US Hospitals

When you have an emergency, you probably don’t think twice about what you need to do next: you simply head to the hospital, where the trained medical staff can take care of you, right?

But what happens when the hospitals run out of medicine?

Unprecedented drug shortages

That scary scenario is actually happening now in hospitals across the United States. As of May 2018, 9 out of 10 emergency room physicians surveyed said that they did not have access to the “critical” drugs that they needed to treat patients.

As an example of just how dire the situation is, the New York Times reported that one hospital in Chicago has been out of morphine, a drug commonly used for pain, since March. That’s a staggering almost five months without a drug that is used every single day in most hospitals for even minor cases. Also on the list of drugs that have slowly gone missing without any hope for replacement are diltiazem, a drug used in cardiac care, and painkillers. The FDA’s website has a continually-updated list of drug shortages, which currently include everything from sodium chloride injections to combination heparin and dopamine mixtures. “We now have to drain off 900ml from a 1,000ml bag in order to mix infusions. 1,000 ml NS bags are the only solution we can currently get. This is a serious problem. “One more example of #drugshortages” tweeted Dr. Jeff Jarvis, an ER physician in Texas back in January. And while drug shortages are nothing new, the sheer volume of today’s scarcities are unprecedented.

Risky solutions

As a solution to the drug scarcity epidemic, doctors and medical care staff have been making do by either providing patients with alternative drugs, which may pose riskier side effects or cause unknown reactions or simply going without, unable to help when patients are in pain. One doctor described the scramble to figure out how to treat their patients without their long-relied upon medications as a “dancing” that occurs with every single patient and every single shift. And unfortunately, all of that dancing only leads to one thing — patients not getting the care that they need.

“This crisis is impacting patient care across the country,” said Academy of Ophthalmology President Keith Carter, M.D., FACS in a statement. “No region or demographic is spared from the harm these shortages cause.”

What’s driving the shortage?

Why are hospitals running out of critical medications that have historically been used almost every day? The answer is apparently pretty complex. For one, many of the drugs that the hospitals have come to rely on are both hard-to-make and cheaply sold, leading to low-profit margins for the drug manufacturers. With low profits, many of the drug companies simply stopped making them. Secondly, these types of drugs have long been made in older facilities which many companies have stopped investing in, leading to the factories to have problems and many to be shut down altogether. Drug manufacturing was particularly affected when Hurricane Maria hit Puerto Rico, home to a major center for pharmaceutical production and although the initial crisis has been resolved, the storm still brought the shortage to the forefront for America’s medical community.

Leading the way for much of the shortage is drug manufacturer giant Pfizer, which has been hit with warning after warning from the U.S. government. Pfizer is the nation’s single largest manufacturer of generic injectable drugs and essentially, with any slowdown in their production rate, the entire country is affected. Back in February of 2018, the FDA warned that one of the manufacturing processes at a facility in Houston was “out of control” when complaints of substances in IV solution bags turned out to be pieces of cardboard.

A call to action

The lack of medication has become so severe, in fact, that in June, the American College of Emergency Physicians (ACEP), the American Society of Anesthesiologists (ASA) and the American Academy of Ophthalmology (AAO) all issued a joint statement urging the FDA to work with federal departments in order to give recommendations to Congress on how to fix the drug shortage problem.

“These persistent shortages can last for months or longer and affect all types of medications used in a variety of settings – emergency departments, hospitals, ambulatory, surgical centers, among others,” related James Grant, MD, president of the ASA in the official statement. “These are essential products used every day, and for many, there are no suitable alternatives readily available. Critical shortages of injectable opioids and local anesthetics are affecting anesthesiology practices, public, private and academic throughout the country.”

The drug shortage is becoming a crisis in America, but unfortunately, patient care doesn’t stop while we wait for a solution. So as lawmakers and experts work to find a solution, we all have to do our part to advocate and support the nurses and other healthcare staff who are caring for patients directly each and every day — even without the medicine those patients need and deserve.

Source: Shortage Of Pain Medication Hits US Hospitals

Has marijuana caused emergency room visits to skyrocket? | PunditFact

Advocates against marijuana legalization frequently cite increased marijuana-related hospitalizations as proof the drug should not be sold commercially. But how much of a threat does cannabis actually present?

Since retiring from Congress in 2010, Patrick J. Kennedy has been speaking out about his struggles with drug addiction and mental health. Kennedy is the co-founder of Smart Approaches to Marijuana, a non-profit dedicated to combating cannabis legalization. The group refers to marijuana as “the next ‘Big Tobacco’” and advocates for increased research into cannabis as a potential medicinal source, rather than a recreational drug.

In Kennedy’s home state of Rhode Island, the push for recreational legalization continues. In February of 2018, the Rhode Island General Assembly resolved to create a working committee to study the effects of legalization. In May, Sen. Joshua Miller introduced a bill to the House to legalize for all people 21 and over. The day after the bill was introduced, the Providence Journal published an editorial by Kennedy.

In it, Kennedy draws connections between addiction and mental illness, and encourages readers to take control of their mental health through “healthy coping mechanisms and problem solving skills.” Especially for children, he writes, turning to drugs as a way of handling stress is a dangerous road to follow.

Good as that all sounds, one line in particular stood out to us: “These drugs (marijuana/THC), which masquerade as food, have caused emergency room visits to skyrocket,” Kennedy wrote.

Researchers have not been able to conclusively connect the drug with any serious long-term health problems. According to a 2003 study, the lethal dose of marijuana is 1,000 times more than an effective dosage (i.e. enough to feel the effects of the drug). No deaths caused by marijuana alone have even been recorded, according to a Drug Enforcement Administration fact sheet. But an increased number of high Americans might lead to an increased number of Americans doing risky things, and therefore higher numbers of emergency room visits.

We decided to look at the numbers and determine if marijuana really has caused emergency room visits to increase.

Colorado case study

When we contacted Kennedy about this claim, Kennedy’s spokeswoman directed us to two studies about marijuana usage in Colorado: one conducted by the Colorado Department of Public Health and Environment, and another compiled by Smart Against Marijuana.

Colorado was one of the first states to legalize marijuana for recreational use. Retail marijuana stores opened in early 2014, and medical marijuana had been legal since 2000. Colorado has also collected the most data on the consequences of marijuana legalization, serving as the template for other states considering the move.

Hospitalization and emergency department visit rates related to marijuana are studied based on patient records. When a patient arrives at the emergency department, they are assigned “billing codes,” which list their conditions. According to the American Health Information Management Association, the primary diagnoses should be listed first.

The 2015 report from the Colorado Department of Public Health shows that hospitalizations with marijuana-related billing codes have climbed steadily over the years. In 2011, 1,313 per 100,000 hospitalizations had marijuana-related billing codes, a figure which had risen to 3,025 by 2015.

However, hospitalizations and emergency department visits—the statistic that Kennedy claims to be citing—are slightly different. Emergency department visits refer to patients who come to the hospital and are treated without being admitted. According to Dr. Daniel Vigil, program manager of the Marijuana Health Monitoring and Research Program at the Colorado Department of Public Health, hospitalizations are more likely to include marijuana-related billing codes.

“The limitation that a marijuana code might be present even when it isn’t a causal factor in the visit may be more pronounced with hospitalizations, because there’s more opportunity for gathering and documenting substance use information,” Dr. Vigil told us in an email. “For this reason, I’m more likely to discuss the (emergency department) visit rates when asked about health impacts.”

So, although hospitalization rates are increasing in Colorado, emergency department rates are not. The emergency rate had increased from 2011 to 2014, peaking at 1,034 per 100,000 emergency visits, but then fell significantly in 2015 to only 754 per 100,000.

In both this dataset and the data for hospitalizations, researchers counted any patient with a marijuana-related billing code, even if that code was unrelated to the injury being treated. So, if a patient were to come in with a cut on their hand, but also had smoked a few hours prior, they would receive a billing code and count as a “marijuana-related hospitalization.”

What’s it all mean? In Colorado, there has been a significant increase in patients being hospitalized with marijuana in their system. In the last decade, the hospitalization rate has more than doubled.

However, it’s important to recognize that these numbers, while increasing, still make up a very small percentage of the total hospital visits. Three percent of hospitalizations in Colorado had a marijuana-related code in 2015, which could mean anything from “patient is currently high” to “patient smokes weed habitually.” Only 0.6% of Colorado hospitalizations list marijuana in the top 3 billing codes. And again, none of that means that people are in the hospital because of marijuana.

What About the Other States?

There are currently few studies which examine marijuana-related hospitalizations within individual states, even in areas where recreational cannabis has been legalized.

One nationwide study by Dr. He Zhu of Duke University Medical Center showed that across the United States, between 2004 and 2011, emergency department visits that involved the use of cannabis had increased from 51 to 73 per 100,000 patients between 2004 and 2011. Those that involved cannabis combined with other drugs had also increased from 63 to 100 per 100,000.

So again, definitely a trend upwards, but marijuana-related cases still encompassed less than 0.01% of total hospitalizations.

Similarly to the Colorado studies, the researchers relied on hospital records that could not identify cannabis as the cause of the visit, but rather just a contributing factor. Additionally, because the study only used data up until 2011, it could not accurately reflect the trends related to recreational sales.

Is it causal?

We cannot conclusively say that marijuana has caused an increase in visits to the emergency room. Rather, the data show that more people are arriving at the hospital having recently or habitually used cannabis, even if that is not their primary condition (or related at all to their primary condition). Through it seems plausible that impaired judgment or slowed reflexes may be a culprit, it is impossible to say how often that is true.

Dr. Jerome Avorn, a professor of medicine at Harvard Medical School, told us for a 2016 fact-check, “The main risk from marijuana is from the risky or stupid things people do after using it, such as driving, rather than from any toxic effects of the substance itself, which is remarkably safe.”

Our ruling

Kennedy wrote that marijuana and THC, “have caused emergency room visits to skyrocket.”

It is true that hospitalizations have increased over the last decade by people using marijuana, both in states like Colorado that have legalized recreational cannabis and nationwide.

However, due to the way hospitals keep patient records, it is impossible to say that marijuana is the cause of these visits. Rather, it is possible that the higher numbers of high patients are due simply to the fact that more people are using marijuana overall. To say that marijuana is causing emergency room visits to skyrocket is unfounded based on the limited data that has been collected.

We rate this claim Half True.

Source: Has marijuana caused emergency room visits to skyrocket? | PunditFact

Shut the back door to America’s opioid epidemic | TheHill

Opioid addiction is the greatest public health crisis we’ve faced in a generation. In 2015 alone, nearly 35,000 Americans died from prescription opioid overdoses. As a former U.S. Senator and attorney general for New Hampshire, I’ve witnessed first-hand the devastating impact of opioid addiction in our communities.

At pharmacies, opioid prescriptions are purchased one of two ways, using health insurance or with cash. Several initiatives by Pharmacy Benefit Managers (PBMs), the middlemen who administer pharmacy benefits for health insurance plans, have limited the supply of opioids that can be purchased by using health insurance.

These efforts include limiting to seven days the supply of opioids dispensed for certain acute prescriptions for patients who are new to therapy and limiting the daily dosage of opioids dispensed based on the strength of the opioid. While helpful, these steps are insufficient and leave a back door wide open for opioid abuse and so-called pill mills by providing little or no limits on cash purchases.

This is how the back door works. People pay cash for prescriptions because they lack insurance coverage or because they want to circumvent health insurance controls.  Cash prices for prescription drugs are set at artificially high markups, often as much as ten times more than the prices paid for the same drugs by health insurance plans.

To gain modest discounts to inflated cash prices, cash purchasers turn to prescription coupons known as “cash discount cards.” Even as PBMs limit access to opioids for patients using insurance, they issue cash discount cards that make opioid purchases easier to buy and more profitable for them. Prescription cash discount cards are heavily promoted in doctors’ waiting rooms, on television and on the Internet.

PBM cash discount cards are anonymous. With a cash discount card, it’s much easier to fill an opioid prescription at a pharmacy with no ID check, no drug history-check and with no health plan access limits. PBMs that issue cash discount cards do not monitor purchase behavior nor do they alert pharmacists or health insurance plans when cash discount cards are misused.

Predictably, PBM initiatives to control access to opioids purchased with health insurance may actually increase PBM profits. During my time as a senior advisor to Blink Health, a technology company focused on making prescriptions more affordable, I’ve learned that PBM profits are much higher for prescriptions paid for with cash discount cards than for prescriptions paid for with health insurance.

PBMs have led regulators and the public to believe they are fully invested in solving the opioid addiction crisis. Following the money tells a different story. By shifting opioid purchases to the cash pay back door, PBMs can increase their profits from our nation’s addiction epidemic.

I applaud the Senate Health, Education, Labor and Pensions Committee for its work on the Opioid Crisis Response Act of 2018 and the states’ attorneys general for their tireless efforts to stem this crisis.

Congress and the states should shine a light on the cash discount card back door by holding hearings with the largest PBMs that issue these cards for opioid sales, such as CVS/Caremark, Medimpact, Express Scripts, and Optum. PBMs issue cash discount cards 24×7 on the Internet and also in doctors’ offices. For example, you could look at www.insiderx.com operated by Express Scripts or www.wellrx.comoperated by MedImpact.

The American people are entitled to know how much the PBMs and national chain pharmacies profit from selling opioids and other controlled substances.

Our leaders should also implement common-sense solutions to close the opioid access back door including banning the use of anonymous PBM cash discount cards for filling opioid prescriptions and requiring digital ID verification at the time-of-purchase for all opioids and schedule II restricted pharmaceuticals.

These easy to implement measures will provide stronger and more genuine opioid prescription controls to better address this devastating health crisis.

Source: Shut the back door to America’s opioid epidemic | TheHill

Amazon is absolutely serious about disrupting healthcare

After months of speculation around how Amazon will enter the healthcare market, the home delivery giant announced the acquisition of pharma startup PillPack, causing more traditional pharmacies’ stock prices to fall.  

Amazon acquired an online pharmacy that offers pre-sorted doses of medication causing a small turbulence on the market, but firmly making another step into the pharma.

PillPack is an online pharmacy that provides patients in the US with their prescription in simple to use, pre-packaged doses. The company’s is currently licensed to ship prescriptions in 49 states. The company has also developed its own operational system — PharmacyOS — which organises patient and pharmaceutical data.

Jeff Wilke, CEO of worldwide consumers at Amazon, said: worldwide “PillPack’s visionary team has a combination of deep pharmacy experience and a focus on technology.”

“PillPack is meaningfully improving its customers’ lives, and we want to help them continue making it easy for people to save time, simplify their lives, and feel healthier. We’re excited to see what we can do together on behalf of customers over time.”

Following the acquisition announcement, stock prices for conventional pharmacies like Rite Aid, Walgreens, and CVS fell drastically, losing $11 billion market value, while Amazon shares gained over 2%.

These significant changes in the market values might be one of the first signals of potentially huge disruption in the US healthcare market Amazon has been promising for a while.

The terms of the deal haven’t been disclosed yet, but reports that surfaced online suggested that the acquisition went for just under $1 billion. In the recent statement, the companies said they expect to close the deal in the second half of 2018.

This acquisition is not the first, but another firm step for Amazon into the healthcare market.

At the beginning of the year, Amazon, Berkshire Hathaway, and JPMorgan Chase formed an independent healthcare company to “rethink healthcare for their own employees”.

Just last week, the trio announced respected surgeon, Atul Gawande to head the still unnamed company.

Source: Amazon is absolutely serious about disrupting healthcare – Pharmaphorum

By making strides in efficiency, Parkland is changing the landscape of health care | Commentary | Dallas News

Nestled in Parkland’s emergency department is a nondescript, cubicle-filled room. TVs displaying live video feed of the hospital entrances line the wall alongside what appears to be a giant spreadsheet of hospital names. Only the sight of an occasional medic grabbing Cheetos from a communal snack bowl hint the scene is in one of the country’s busiest hospital systems.

But then, a paramedic sitting at one of the cubicles is alerted by a sound from his headset, pulling him to his screen mid-sentence. The 20-year fire department veteran has just received the spiky mountain range of an EKG image, sent live from the back of an ambulance somewhere in Dallas County.

The image could indicate a heart attack, but he would need to pull in an emergency physician from across the hall to be sure. He murmurs a question to EMS over his headset before turning to the spreadsheet on one of the giant TVs to route the ambulance to a hospital listed in green, not the red or black fonts indicating an emergency room department is full.

On one end of that call, a patient in crisis and first responders struggling to save a life.

On the other, the full force of Parkland Memorial Hospital waiting to consult and coordinate.

Many of us are newly aware of Parkland for its gleaming (if boxy) new addition to Dallas’ skyline, but since its founding in 1872 the hospital has played a consistent supporting role in the community with a  focus on providing care for indigent patients. “Parkland” actually refers to a network of its main memorial hospital and its many partners and subsidiaries, and its services are still primarily targeted toward the approximately 1 million people in Dallas County who are uninsured or qualify for Medicaid.

But even those Dallas residents who have more comfortable, private medical options are part of  a health care system challenged by high uninsured rates and increasing utilization. Parkland’s sheer size, coupled with its inherent community focus, necessitate speed and efficiency in a way that is reshaping what all of us can expect from our health care system.

The hospital and its supporting health system have had challenges. Reports of patient abuse prompted regulatory scrutiny in 2011, and ongoing funding pressures continue to add levels of complexity to the already daunting task of providing quality care at low cost. But as patient safety improves and small funding respites offer space for limited growth, Parkland is continuing to turn its sights outward to serving its target population with evidence-based approaches.

Understanding the Parkland health system — and what makes it tick — is a crash course in health care’s changing landscape and the importance of working on the scalpel’s edge of health delivery.

Scaling efficiency

Medical emergencies can be a great equalizer — rich or poor, you call 911 when you have a heart attack. And as Dallas County’s largest public, taxpayer-funded hospital, Parkland is the natural home for the paramedics behind millions of emergency response calls. In this way, our county hospital serves everyone, regardless of whether you ever step

The BioTel office, with its TV monitors and Cheeto snack bowl, exemplifies Parkland’s leadership in meeting a community demand with the efficiencies of new technologies. When minutes matter, this pairing of scale and skill has immediate lifesaving implications.

Known as “the hidden heart of EMS,” BioTel is an emergency response group housed within Parkland, coordinating care for emergency patients. The work begins when paramedics somewhere in North Texas answer a 911 call, and ends when BioTel has found an available bed in one of the county’s more than a dozen hospital emergency rooms —  a home for that patient’s care.

The full-ime nurse and paramedics who staff BioTel draw from their own experience and knowledge to offer counsel or else use the resources of Parkland’s bustling emergency room right outside the BioTel door. Because BioTel works with 14 departments within Dallas County, more than a dozen cities in North Texas directly benefit from Parkland’s expertise.

A gunshot victim can bleed out in less than three minutes, and a heart attack victim’s chance of recovery ticks away with time, so this door-to-door coordination is a critical function. And if you find yourself in this situation, it’s a team working at Parkland that will answer the call.

This mission has improved as health fields integrate more technology into their care. Good information has always been a focus of BioTel — the term itself is short for “biomedical telemetry,” referring to the transmission of data over radio. But in recent years, tech innovations have driven this value to new heights, such as with the ability to transmit EKG images from the back of an ambulance and keep a real-time inventory of available emergency beds throughout the county.

In business, the term “throughput” refers to the amount of product or data moving through a machine or system. Though perhaps not the terminology we normally associate with compassionate care, high throughput creates a  positive domino effect in a hospital. When patient A’s path through the emergency room goes more quickly, patients B, C and D also benefit.

Emergency room wait times and inefficient use of limited public resources squeeze public hospitals. At one point, Parkland’s wait times averaged eight to 13 hours. But while building the “New Parkland” in 2015, Parkland CEO Dr. Fred Cerise pulled in another community partner to address the emergency room’s throughput problem.

That partner was Toyota. The automaker has a philanthropic arm that offers free expertise to nonprofits to improve efficiency in the model of “kaizen,” or continuous improvement. It’s a succinct motto for both an automaker and a hospital system. Parkland asked the local automaker famous for its logistics efficiency for help cutting down the time between a patient receiving discharge orders and actually leaving the hospital. Remember, if patient A is clogging the pipeline, B, C and D might be barred from lifesaving care.

Today, small purple, red and green lights outside a patient’s door helped communicate logistics, such as whether the patient needs to be seen, the room cleaned, a discharge order given. And it works. Typical discharge time dropped from 52 to 31 minutes.

Community care and community costs

Of course, Toyota was willing to help Parkland out precisely because it isn’t one of the private, luxury hospitals growing in prominence in the health landscape. Rapid hospital consolidation and a movement toward more profitable “concierge” care make public hospitals like Parkland an increasingly rare breed.

Parkland’s community-first ethos is more than a noble declaration — it’s a legal and funding reality. Parkland is a safety-net hospital, meaning it follows a legal mandate to accept all patients no matter their insurance status. Texas has the highest uninsured rate in the nation, almost twice the national average. It makes sense that an entire subsidiary of the hospital, Parkland Community Health Plan, focuses solely on linking communities to coverage.

Getting people insured puts Parkland on better financial footing and increases access to the preventative services that keep all of Dallas County happier and healthier.

Parkland faces pressures from within county lines as well, especially when it comes to mental health. When Timberlawn, formerly Dallas’s largest psychiatric hospital, closed earlier this year, Parkland wound up taking on a significant share of the acute cases that were previously diffused throughout the county, with the caseload almost doubling. You can see the need in the psychiatric emergency room, where cots sit ready to transform waiting areas to overflow rooms.

Ultimately, funding ties the Parkland system to every citizen of Dallas County, or at least their wallets. About a third of Parkland’s funding comes from Dallas County property taxes. This fact allows Parkland to experiment with innovative models of population health delivery and prevention for those who need it most, but it can also create an inherent conflict.

Uninsured and Medicaid  patients are drawn not just from the tax-paying Dallas County, but also from the suburbs. It’s a problem as old as the hospital itself. Surrounding counties’  lower property taxes and bare-minimum health coverage combine to push indigent patients toward Dallas, at the expense of Dallas residents. It’s not fair — to Dallas residents or to Parkland’s ER — but Parkland must still prepare to meet the needs of all patients.

Prevention is the best medicine

Of course, the ultimate goal of a health care system is to keep people out of hospitals in the first place. This may seem obvious, but it’s important to begin with this guiding principle to build systems that prevent illness, not just react to it. It’s also an efficient goal. Keeping one patient out of the hospital means you can treat another, and simultaneously lessens the burden on the taxpayers and government programs that fund care.

A hospital is a health care hub, but even one as big as Parkland cannot possibly oversee the vaccination schedules and yearly checkups of more than a million Dallas residents. So since 1989, Parkland has founded more than a dozen community clinics, responsible for broadening Parkland’s physical reach into communities and moving the most common primary care needs closer to patients.

As health care systems shift to prioritize prevention, community clinics are physically changing the county’s health care landscape, benefiting from Parkland’s scale and resources.

Plugged in takes a more literal meaning where Parkland uses technology. Virtual visits and e-consultations can get patients in quick contact with specialists, who in turn can see more patients. Electronic consultations, telehealth, predictive analytics: Technology and innovation give patients more choices while simultaneously eliminating pressures on Parkland.

For many Dallas residents, Parkland may come to mind only as an abstract public service paid for and forgotten. But its unique historical (and legal) obligation to the county’s medically indigent incentivize the kind of efficiency desperately needed in health care today. From an emergency response center to exams-by-phone, Dallas is setting the standards for how micro efficiencies can improve access to care on a macro scale.

As goes health care, so goes Parkland. And Dallas, all of Dallas, should pay attention.

Source: By making strides in efficiency, Parkland is changing the landscape of health care | Commentary | Dallas News

New bill could help Austin patients avoid surprise medical bills after visiting freestanding ERs

Over $800 in out-of-pocket expenses was not what area resident Lance Kubiak expected to pay after visiting a freestanding emergency department, or FSED, late one night last year.

Kubiak, who has employer-provided health insurance, visited the FSED after experiencing an extended period of nausea and vomiting.

The staff took his blood pressure, gave him medication and fluids non-intravenously and sent him home without further use of the facility. He said he then paid over $100 for a copay followed by a $300 bill and $500 bill over the next few months.

“In total I ended up paying over $800 to basically be given an over-the-counter nausea pill,” Kubiak said.

Kubiak’s experience is reflected in data from a statewide study on FSEDs and urgent care center use in Texas. The study was led by researchers from the UTHealth School of Public Health and Rice University and published in the “Annals of Emergency Medicine” in December 2017.

According to the researchers who analyzed Blue Cross Blue Shield of Texas insurance claims, in 2015 patients in Texas paid on average $763 in out-of-pocket costs at private FSEDs compared to $749 at hospital-based emergency departments and $63 at urgent care centers.

Although they have similar appearances, FSEDs, which were legalized in Texas in 2009, are different than urgent care centers because they are staffed by emergency room doctors and often have equipment such as X-ray machines, CT scanners and full laboratories on-site.

The researchers found the average cost per visit to treat the same ailment at an FSED is nearly 10 times higher than at an urgent care center.

David Huffstutler, CEO of St. David’s HealthCare, said opening FSEDs that are associated with St. David’s hospital network has helped expand accessibility to the emergency services available at hospitals, but they are more expensive to open than urgent care centers.

“Typically the freestanding ED’s are going to be more costly because the cost to operate them is much higher both in terms of capital [investment]and equipment.”

Use of FSEDs in Texas grew by 236 percent between 2012 and 2015, with significant overlap in the diagnoses and treatments administered at urgent care centers, according to the study. In Northwest Austin three FSEDs have opened since 2013.

Patients and lawmakers have expressed concern over a lack of transparency regarding insurance coverage at FSEDs and high out-of-pocket expenses.

A UTHealth health economics researcher from the study, Ellerie Weber, said a question raised after the study’s publication was what the FSED’s profits are.

“Certainly the people that work there think they are offering a service that the public needs and wants, and it’s justifiable,” Weber said. “Therefore the controversy is whether the prices are justifiable. We don’t know what their profits are and if that is a main driver for these things opening.”

In some communities where access to hospitals is limited due to geography or traffic congestion, FSEDs provide access to emergency medical care that was previously difficult to attain in a timely manner or outside of normal business hours.

Huffstutler said having St. David’s operate both FSEDs and urgent care centers that are associated with the hospital network has helped to increase availability of care in areas where traffic congestion or other issues make medical access difficult.

“With Austin’s growth and mobility challenges it’s very important that we bring varying levels of care out into the geography,” he said. “While patients out in these areas may need emergency care, it will never make sense to go into that area closer to their home and build another hospital, at least until there’s a lot more growth.”

Huffstutler said it is important for potential patients to understand the difference between FSEDs and urgent care centers. Going to an urgent care center for less time-sensitive ailments and injuries can save patients money.

“Urgent care centers are really intended to care for more minor illnesses but certainly in a convenient setting,” he said. “We’re talking about things like colds and flu strains, sprains, burns, lacerations, flu-like symptoms and those types of things.”

FSEDs, Huffstutler said, are designed to treat more traumatic injuries and illnesses. He also said patients should be aware of the difference between FSEDs that are associated with a hospital network and those that are not owned by hospital groups.

Huffstutler said nonhospital-affiliated FSEDs do not have to adhere to the same types of regulations that hospital-based FSEDs are subject to and also may not cover all insurance plans, which can lead to higher bills.

Each FSED may approach billing processes differently, said Lisa MaGruder, marketing director for an Austin-based FSED, Austin Emergency Center, which has a location at US 183 and Anderson Mill Road and one on Far West Boulevard. She said Austin Emergency Center has a patient advocate on call to handle billing disputes.

“That is something unique that we have that other freestanding EDs don’t. The patient advocate is a person that is 24/7 on call for billing problems and to answer questions,” MaGruder said.

In the wake of studies and complaints highlighting a lack of transparency in the billing process at FSEDs, state Rep. Tom Oliverson, R-Cypress, introduced and passed a bill during the 2017 Texas legislative session requiring that FSEDs make billing practices clear to patients.

The bill became effective in September and requires that FSEDs provide information about which insurance plans the facility is in-network with both on its website and in writing at the facilities.

Weber said that regardless of future policies or legislative changes patients should learn about the different types of medical facilities.

“The takeaway for patients is that you should educate yourself to the best extent possible,” Weber said. “[Patients should] really understand if this facility is going to be covered by your particular insurance and if this is something that can be treated elsewhere.”

Weber and her colleagues found that 15 out of the 20 most commonly treated diagnoses at FSEDs were also in the top 20 most commonly treated diagnoses at urgent care clinics.

Although Kubiak said he has gained a stronger understanding of the billing practices at FSEDs, he said he worries about the next time he needs medical attention without access to an urgent care clinic.

“Honestly after the last incident I’ll probably just wait it out, or if it gets really bad just call an ambulance,” Kubiak said. “If I am going to incur the same costs I would taking an ambulance to the ER, within reason, it’s not worth taking myself to a clinic and overpaying for a service.”

Source: New bill could help Austin patients avoid surprise medical bills after visiting freestanding ERs | Community Impact Newspaper

House passes comprehensive bill to combat growing opioid epidemic – ABC News

The House of Representatives passed a bipartisan, comprehensive bill Friday that aims at curbing the country’s growing opioid epidemic.

By a vote of 396-14, the House passed H.R. 6, the SUPPORT for Patients Communities Act, which is the collective product of the lower chamber’s extensive effort this year to combat the opioid crisis.

The bill contains several Medicaid, Medicare, and public health reforms, such as adding a review of current opioid prescriptions and screening for opioid use disorder as part of the Welcome to Medicare initial examination. It also aims at reducing the trafficking of Chinese fentanyl into the United States by giving law enforcement new tools to detect suspicious packages in the mail.

The measure was crafted by Energy and Commerce Chairman Rep. Greg Walden, who called it “the biggest effort” Congress has taken to address opioids.

During debate on the bill Friday morning, Majority Leader Kevin McCarthy spoke passionately about the issue – highlighting the story of his press secretary, Erin Perrine, whose brother Eamon Callanan died of a drug overdose two years ago.

“Erin was 24 days from her wedding when she learned she would never see her brother again—that he would not be there to celebrate with her on one of the happiest days of her life,” McCarthy, R-Calif., said. “Let that be a lesson to us all: There is no event so joyful, no place so safe, that it is untouched by the drug crisis. Even a wedding chapel. Even here, in the halls of power. Even in my office.”

The House had already passed a bevy of pieces of legislation that address opioid abuse, but this bill combines them into one measure that will operate as the legislative vehicle to send a package to the Senate.

In the Senate, all three committees of jurisdiction working on a companion package have reported their bills and leaders believe the package is ready for the full Senate to consider.

“The relevant chairmen and the Democrat ranking members and others are working on setting up an agreement for floor consideration,” Don Stewart, a spokesman for Senate Majority Leader Mitch McConnell, said. “All three of the committees reported their bills with wide bipartisan support. The Leader is obviously a strong supporter of the bills we’ve passed and the bills that are coming to the floor.”

White House press secretary Sarah Sanders applauded the House for passing the bill, and urged the Senate to follow suit.

“These necessary bills will help save American lives through prevention and education, treatment and recovery, and law enforcement and interdiction, Sanders stated. “We look forward to continuing our work with Congress on a problem that affects everyone and that should be solved by everyone. We urge the Senate to continue the bipartisan tradition of helping Americans who are affected by the crisis, to swiftly pass the legislation from the House, and to get these lifesaving bills to the President’s desk. Enacting this legislation will be another step in our long but worthwhile effort to ameliorating and then ending this crisis once and for all.”

Source: House passes comprehensive bill to combat growing opioid epidemic – ABC News

Cost of ER visits nearly doubled as fees are coded at highest level – Houston Chronicle

Even though the number of insured emergency room visits has stayed about the same in recent years, the cost to step inside the door has nearly doubled, according to new data released by a health care policy group.

In 2016, the average amount spent nationally by insurers and patients for emergency room visits was $247 per insured person. In 2009 it was $125, the Health Care Cost Institute research shows.

The reason for the spike appears to be a dramatic shift in how emergency visits are coded by facilities, with many more designated at the highest levels of severity and therefore billed at steeper prices, said John Hargraves, a researcher and co-author of the report.

The Washington, D.C.-based nonprofit group analyzed 40 million health-care claims for those with employer-sponsored plans between 2009 and 2016. The insurers included United HealthCare, Aetna and Humana.

“Since the population of insured people in emergency rooms is not changing, the only logical explanation is a change in how things are being coded,” Hargraves said.

When a patient arrives at an emergency room — either a traditional one attached to a hospital or a free-standing emergency center located in a retail center — the visit is assigned a procedure code ranging from 1 to 5 for purposes of billing. Level 1 is the least serious, Level 5 is the highest. The way such designations are determined can be tricky and in the eye of the beholder depending on patient history, age and complexity of treatment.

Hargraves said his research focused only on the so-called facility fees, meaning the price charged by a hospital or emergency room center for providing the treatment setting. It did not look at the cost of actual treatment.

He found that over the eight-year period, the facility prices rose for all procedure codes but climbed fastest for those designated as the highest severity. The price of the highest coded visit rose to $1,108, from $627 in 2009. This is particularly significant, Hargraves said, because during the same time his group found there were many more claims being designated as 4s and 5s while the use of lower severity codes actually decreased.

According to the group’s data, the number of emergency room visits was statistically the same in both 2009 and 2016.

Texas was among states that had the highest bump in the use of high severity codes, with the use of 4s and 5s rising to 61 percent, up from about 50 percent in 2009.

The cost of emergency room care has become a hot button issue recently. In Texas the state’s largest insurer, Blue Cross and Blue Shield of Texas, wanted to roll out a controversial new program this month to create a vigorous after-the-fact review system to determine if health maintenance organization (HMO), policy holders were using emergency rooms appropriately. If it was determined they could have reasonably received treatment in a less expensive setting the insurer would pay zero.

But late last week Blue Cross and Blue Shield officials announced its launch would be delayed until early August as the Texas Department of Insurance sought more information and assurances that patients would not be harmed by the new policy. Physician groups and some consumer advocates are also worried that the Blue Cross program would have a chilling effect as people become afraid to get the care they need.

Insurance executives have said the measure was designed to not only discourage inappropriate use of emergency rooms for non-emergency care but to also fight back against what it calls overtreatment and overbilling, including the practice of “up-coding” where the highest level of severity code is used for less serious patients.

Elsewhere in the country, Anthem, the insurance giant, has initiated a similar crack-down on emergency room claims in Kentucky, Missouri, Indiana, Ohio, New Hampshire and Connecticut.

Source: Cost of ER visits nearly doubled as fees are coded at highest level – Houston Chronicle

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