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Health Care

What’s Next for Hospitals

By Spiros Hatiras

The year is 2020, in the midst of an unprecedented pandemic, and the subject is the U.S. healthcare system — more specifically, the average U.S. hospital. Is it alive and well, or is it ailing?

I will argue that all is not well with our healthcare system, and that the average U.S. hospital is facing tremendous challenges now and for the foreseeable future.

It is important to establish that, while the healthcare-delivery model has been shifting to less hospital-centric models, the acute-care hospital remains solidly in the center of our delivery system and, in my opinion, will continue to do so. Any notion of a more decentralized model with less emphasis on hospitals has been pushed many years into the future, in part as a result of the COVID-19 pandemic. Despite the accelerated growth of telemedicine during the pandemic, the need for hospital bed capacity, specialized equipment, and personnel — including the ability to ‘surge’ when needed — has all but ensured that the trend toward a smaller hospital footprint will slow down if not entirely reverse.

Shouldn’t that be good news for the future of hospitals? Well, not quite. While we may have a new appreciation for the need of readily available inpatient hospital care, we have also not solved any of the problems that hospitals have been facing for many years. In fact, the pandemic laid bare one of the most fundamental problems facing the industry, especially for smaller community hospitals. At the very onset of the pandemic, it was immediately clear that many hospitals, suffering from years of underfunding, faced immediate financial threat and would not be able to survive without a financial bailout, while private insurance companies reported record profits.

“I will argue that all is not well with our healthcare system, and that the average U.S. hospital is facing tremendous challenges now and for the foreseeable future.”

Why is this the case in a country where healthcare demands the highest per-capita expenditure of all developed countries? According to a study published in January 2019 by the Johns Hopkins Bloomberg School of Public Health, the U.S. topped the ranking of healthcare spending among developed countries in 2016 at $9,982 per capita per year, a figure that is more than double the median of $4,033.

The reason for this disconnect is that most of that money is spent not on actual care, but on administrative costs. A recent study by the Center for Medicare and Medicaid Services found that, of the $3.5 trillion spent on healthcare in 2017, 33%, or $1.1 trillion, was paid to hospitals. Unfortunately, a significant portion of that money covered unnecessary costs to process bills and get paid by insurance companies, meaning the total spent on actual hospital care was far less. The same is also true for doctors’ offices.

In a study published in 2017 in Annals of Internal Medicine, Steffie Woolhandler and David Himmelstiein noted that the administrative cost of our healthcare system was estimated to be $1.1 trillion, of which the vast majority is excess and unnecessary spending. We are spending vast sums of money on a deliberately confusing and complex insurance system.

Trying to navigate the onerous billing requirements, denied-claims management, pre-authorization requirements, and a host of other administrative hurdles unique to the U.S. healthcare system is wasteful and frustrating to hospitals, doctors, and patients alike. We spend more money administering the system than we spend on care. This should alarm each and every one of us and prompt us to look a little more carefully at proposals for a single-payer system.

It is time to ignore private insurers who portray a single-payer system as the boogeyman, or the end of healthcare as we know it, and recognize their argument for what it really is: a reluctance to part with huge profits being made from a broken system at the expense of our health.

 

Spiros Hatiras is president and CEO of Holyoke Medical Center.

Health Care

What’s Next in Health Education

By Marie Meckel, Kathleen Menard, Susan McDiarmid, and Theresa Riethle

Despite the complexities that COVID-19 has brought to healthcare education, the trajectory from traditional models to hybrid or virtual experiences was inevitable. Today’s technology allows healthcare educators to transcend geography, which widens access to health education in all segments of the population despite location, economic status, and race. The pandemic also revealed the vulnerabilities of underrepresented minorities.

These challenges caused many educators to pause to re-evaluate and readapt to how we teach and develop medical curriculum. Incorporating technology through virtual learning experiences while focusing on how social determinants of health impact patient care and outcomes are two areas of focus in the future of healthcare education.

Health programs can integrate in-person and remote simulation experiences; these include the traditional simulation lab consisting of realistic mannequins where learners can develop clinical skills in a safe setting without patient harm. Additional virtual experiences include a wide array of interactive patient-encounter portals where learners can conduct histories, perform physical examinations, order and interpret diagnostic tests, develop assessments and treatment plans, all while documenting patient records and receiving coaching and feedback every step of the way.

“By incorporating technology into healthcare education, medical learners will be better prepared for clinical practice.”

Live rounding with certified medical providers has also enabled learners to experience traditional hospital rounding from wherever they are in an interactive manner. Even surgical experiences can be supplemented with high-definition surgical videos and medical lectures from subject-matter experts.

While none of these experiences will replace the need for traditional hands-on learning, they can provide learners with unique education experiences that directly correlate to what is seen in clinical practice. With the increase in telehealth visits, medical learners are now equipped to adapt to these visits, delivering care in a better and more effective manner.

Technology is intertwined into healthcare today as seen with diagnostic imaging, robotic surgery, and electronic health records. By incorporating technology into healthcare education, medical learners will be better prepared for clinical practice. The virtual experiences will also develop independent and critical thinking, thus making it easier to adapt to innovations and changing patterns of illness and health systems.

In order to provide equitable, high-quality healthcare to all patients, we must include social determinants of health in the curriculum. These include socioeconomic status, education, neighborhood and physical environment, employment, and social-support networks, as well as access to healthcare.

This charge became more evident with the pandemic, as we have seen its profound impact on underrepresented minorities. It would be a disservice to future providers to ignore the current healthcare disparities in these populations. Addressing these determinants is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.

Healthcare providers of the future will not necessarily be those who have a traditional classroom education, but will be those who know how to use, implement, and apply technology in healthcare systems and provide high-quality healthcare to all patients.

 

Marie Meckel, MS, MPH, MMSc, PA-C; Kathleen Menard, MS, PA-C; Susan McDiarmid, MS, PA-C; and Theresa Riethle, MS, PA-C are physician assistant faculty members at Bay Path University.

Health Care

What’s Next in Cancer Care

By John Sheldon, M.D.

Cancer is the second-leading cause of death in the U.S., but we continue to make significant advances in reducing its toll.

John Sheldon

John Sheldon

Key developments have included targeted drug therapies resulting from genomic profiling of tumor samples, which determines the molecular ‘fingerprint’ of the tumor; immunotherapy, which allows the body’s own natural immune system to better attack tumors; more sophisticated radiation-delivery technologies, which allow for more precise targeting of tumors and better sparing of adjacent normal tissues from radiation dose; and newer combination or ‘multi-modality’ treatment regimens, taking advantage of a combination benefit effect of different ways of attacking and killing tumor cells.

In lung-cancer treatment, for example, we now have drugs to target a variety of specific mutations that may be present, such as EGFR, ALK, ROS1, MET, RET, BRAF, or NTRK. Immunotherapy has been shown to provide a survival improvement in both stage-3 and stage-4 lung cancer. For earlier and smaller lung cancers, highly targeted radiation treatment can be delivered in a short regimen of just three to five sessions, as an alternative to surgery for patients who are not good surgical candidates. And for other patients, combination regimens of radiotherapy and chemotherapy followed by immunotherapy may be the preferred approach.

Even newer types of drugs are now available called antibody-drug conjugates, or ADCs, which target with high affinity a particular protein expressed on the surface of tumor cells, attach to the target, and then deliver a toxic payload to kill those particular tumor cells. This type of treatment was just approved by the FDA in April for metastatic ‘triple-negative’ breast cancer (a more aggressive type of breast cancer), and another drug in this category was approved last December for locally advanced or metastatic bladder cancer.

Molecularly targeted radiation delivery is another category of treatment that is advancing. Also known as peptide-receptor radiotherapy (PRRT), it consists of a radioactive particle, or radionuclide, linked to a protein, and this protein seeks out and targets its intended receptor, which is overexpressed on certain tumor cells. Once the protein-receptor binding takes place, the radionuclide is internalized into the tumor cell — and destroys the tumor cell. This treatment is currently being utilized for neuroendocrine tumors of the abdomen (the type of cancer that afflicted both Steve Jobs and Aretha Franklin), and it is being investigated for the treatment of metastatic prostate cancer.

Quality of life is an ongoing focus of cancer care, and while we always aim to increase survival, we simultaneously aim to optimize quality of life for patients under our care. In the realm of radiation treatment, shorter course regimens are more frequently being used (supported by evidence from clinical trials) in order to increase convenience for patients. Such regimens are now commonly used in the treatment of breast cancer, for early-stage lung cancer (as mentioned above), for some brain-tumor patients, and for some patients with prostate cancer. For the latter, radioactive seed implants into the prostate gland may be an option for a one-visit outpatient treatment.

In short, we continue to push forward strongly in the treatment of a broad range of cancers.

 

Dr. John Sheldon is medical director, Radiation Oncology at the Mass General Cancer Center at Cooley Dickinson Hospital.

Health Care

What’s Next in Behavioral Health

By Barry Sarvet, M.D.

As a science-fiction fan, I would love to be able to travel in time to see into the future of psychiatry. But, of course, the future isn’t really knowable and depends in large part on the choices we make. A more useful and realistic approach is for us to envision a possible future based on our awareness of the most urgent needs in the field, and to assume linear progress from the current state of our scientific knowledge and discovery.

Barry Sarvet

Barry Sarvet

In my opinion, the two most compelling needs within the field of psychiatry are the need for more effective, safe, and reliable treatments for the subset of psychiatric patients who don’t respond optimally to current treatments, and the need to make psychiatric care more accessible and equitable for everyone who suffers from mental-health conditions.

Depression is one of the most common psychiatric illnesses, affecting 7.1% of all adults and 13.3% of adolescents in the U.S. Severe depression is a potentially deadly illness, and suicide is a leading cause of death in this country. Although we already have a host of effective treatments for depression, between 10% and 30% of patients do not respond favorably to treatment. However, ongoing advances in our understanding of the neurobiology of mental illnesses in recent years have led to a number of novel biological treatments for treatment-resistant depression and other psychiatric conditions.

One recently developed treatment that has shown great promise with treatment-resistant depression is repetitive transcranial magnetic stimulation (rTMS). Available at Baystate, rTMS is a non-invasive procedure in which focused pulses of electromagnetic energy are applied to specific regions of the brain resulting in increases in blood flow and metabolic activity. rTMS belongs to a branch of psychiatric treatment referred to as psychiatric neuromodulation. We expect to see further development of this branch in coming years, particularly because of the encouraging observations of clinical effectiveness and safety of this type of treatment for patients whose conditions have not responded to conventional medications.

Other biological psychiatry advancements on the horizon include the development of medications targeting receptors for neurotransmitter systems (such as glutamate and NMDA) which have recently been implicated in the pathophysiology of depression and other psychiatric illnesses. We are also seeing a renaissance of research activity studying the use of so-called psychedelic drugs in combination with talk therapy to induce states of consciousness in which patients may find it easier to change well-worn patterns of thinking associated with psychiatric illnesses such as PTSD, anxiety, and depression.

Lastly, on the biological front, advances in the understanding of genetic variability in metabolism and responsiveness of the nervous system to psychiatric medications promise to usher in an era of personalized medicine in psychiatry, allowing psychiatric clinicians to select effective and tolerable medication treatments for patients without having to go through a trial-and-error process.

Even more important than advances in biological psychiatry is the need for progress in making psychiatric treatment more accessible to everyone who needs it. Currently, a majority of patients with mental illness do not receive any treatment at all, and for many more, treatment is delayed. In fact, many patients with untreated mental illness, disproportionately persons of color, end up in the criminal-justice system because of a lack of access to care.

In recent years, we have seen steady reduction in stigma surrounding mental illness and increased acknowledgment of the importance of mental health across society. Baystate’s recently announced plan for the development of a new, state-of-the-art psychiatric hospital facility for our region reflects the growing recognition of the importance of improving access to behavioral healthcare.

This new facility is just one component of a comprehensive strategy which needs to be executed in partnership with the whole community to improve access to all levels of mental healthcare and address persistent racial and socioeconomic disparities in access to care. Some of the components of this strategy includes work we have been doing at Baystate to embed mental-health services into our primary-care services. In addition, our development of new training programs for psychiatrists and child and adolescent psychiatrists have established a pipeline for enhancing the psychiatric workforce in our region.

We also will see continued use and improvement in telehealth models of psychiatric practice, which, of course, have dramatically grown in response to the pandemic, and have proven to be an important tool in reducing geographic barriers to access to care.

 

Dr. Barry Sarvet chairs the Department of Psychiatry at Baystate Health.

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