First Opinion is STAT’s platform for attention-grabbing, illuminating, and provocative articles in regards to the life sciences writ giant, written by biotech insiders, well being care employees, researchers, and others.
To encourage strong, good-faith dialogue about points raised in First Opinion essays, STAT publishes chosen Letters to the Editor obtained in response to them. You possibly can submit a Letter to the Editor right here, or discover the submission type on the finish of any First Opinion essay.
The story
“I’m a medical pupil. RFK Jr. is true about medical faculty and preventive care,” by Lauren Rice
The response
I don’t suppose anybody is arguing vitamin and preventive care isn’t vital, and for medical college students who need to study extra, the assets are on the market, however is “lack of schooling” actually what we expect the issue is in prevention care? If we method well being and well-being with the concept dysfunction inside the particular person is solely the results of processes inner to the person (a virus replicates inside a cell, triggering immune response; an individual doesn’t eat sufficient fiber, inflicting weight and blood sugar points), then failure to progress in a specified method rests with that particular person, and higher schooling is the answer.
However well being and well-being aren’t siloed. The unique article supplies a nod towards that, with mentions of metabolic dysfunction, power irritation, and an obesogenic atmosphere, however involves the conclusion that discussing extra behavioral adjustments with sufferers will clear up these issues. However sufferers can not weight loss program and train their means out of poverty; they can’t weight loss program and train their means out of excessive cortisol related to lengthy work weeks, monetary pressure, and weathering; they usually actually can not weight loss program and train their means out of an more and more car-centric society and a meals provide riddled with chemical substances and sugars.
Past “root sources” of sickness, America has a elementary drawback with accessibility. Roughly half of U.S. adults say it’s troublesome to afford well being care and one-third keep away from well being care due to the associated fee, pushing aside care lengthy sufficient to set off these organ-specific penalties that require specialists.
And what of sufferers who danger dealing with racism, sexism, and queerphobia in well being care settings? What of sufferers whose first language isn’t English and who are inclined to obtain much less and worse well being care? If sufferers usually are not even making appointments, how can we offer them with preventive care?
All of the vitamin schooling on the planet won’t clear up the issue of the truth that Individuals can’t entry care within the first place. It’s unattainable to separate well being and sickness from the financial and political realities that sufferers face. If we genuinely need to enhance power sickness charges on this nation, then we have to tackle the social determinants of well being which are stopping so many individuals from being wholesome and accessing care. By all means, improve dietary schooling in medical faculty, however let’s not fake that telling a affected person to eat extra greens and train tri-weekly will overcome the fabric situations making individuals sick.
— Ellie Passmore
The response
I needed to supply a quick rebuttal for the writer to contemplate, given they raised many significant factors from their private medical faculty expertise, which many can respect, whereas additionally acknowledging the robust responses in both route. There’s a distinction in legitimizing an individual’s agenda versus discovering frequent floor. To say that Secretary Kennedy is “proper” about medical faculty and preventive care, when he has not attended medical faculty, engaged with medical faculty leaders relating to suggestions, or proven any willingness to interact in evidence-based preventive care corresponding to vaccination, is an argument that isn’t grounded in cheap supportive proof. The ache factors are well-taken. Many can agree, primarily based on their medical faculty expertise, that allopathic schooling relating to vitamin and preventive care (I can solely communicate from this expertise) is restricted, and in many faculties, these curricula might not exist.
However the writer and Kennedy are merely re-stating a reality, not outlining a reckoning of the medical faculty system. Whereas nobody is discounting this, it doesn’t make Kennedy “proper” about medical schooling wants, already overburdened by curricular calls for. It does create an invite to discover options in a nuanced, complete means. What’s the “proper” reply to a query rooted each in societal norms and standardized medical schooling follow? There could also be no single proper reply.
I’d encourage the author to contemplate that neither studying nor collaboration relating to advanced, nuanced challenges with our sufferers stops at medical faculty commencement. Maybe we will embrace our humility in not understanding every part and depend on our different colleagues who additionally spherical on our sufferers. Maybe a solution could possibly be to ask vitamin and preventive care consultants to the rooms the place these vital conversations happen to offer their experience. Maybe which means we advocate for our registered dietitians to obtain honest and cheap insurance coverage reimbursement for outpatient preventive care measures — their providers are needed for care, not ancillary. The physician doesn’t should be or do every part, when there’s a whole neighborhood of medical professionals with whom we will join, liaise, and construct partnerships to handle issues in tandem. That’s as a lot a tradition shift as it’s a coverage or academic adjustment.
— Marc Hem Lee
The story
“Uncovered and invisible in an ER hallway mattress,” by Jay Baruch
The response
This drawback engulfs ERs throughout the nation, but we nonetheless hold lowering and eliminating funding, rising the demand on the workers to do extra with much less and eliminating help assets. This recipe for catastrophic catastrophe goes to come back to a head. If we had a member of congress needing emergency care, we should always require them to attend in the identical strains, be left in the identical hallways, and allow them to really feel the delay of care that they so adamantly appear to be ignoring.
— Katie McNamara, Rhode Island Hospital
The response
Jay Baruch’s article “Uncovered and invisible in an ER hallway mattress” remarkably highlights the difficult realities of working within the emergency division and the actual harms to affected person and doctor morale that hallway care imposes.
Nonetheless, not all sufferers are at equal danger of bodily hurt from such a care — well being methods want to guard these most susceptible sufferers. As an emergency doctor in a busy New York Metropolis hospital, I admitted an 84-year-old man with pneumonia yesterday who was within the hallway. I returned at this time to seek out him nonetheless there, however newly confused and along with his oxygen cannula tangled round his face askew. Yesterday, this affected person was conscious of his environment. In the present day, he didn’t know the place he was attributable to delirium: an acute confusion that happens ceaselessly in older adults and is precipitated by acute sickness. Being in an unfamiliar place, getting poor sleep, and fixed stimuli from lights and noise all contribute to delirium. The emergency division is likely one of the worst locations for adults vulnerable to this, particularly if they’re in a hallway. The longer an older grownup boards within the ED, the extra probably they’re to turn out to be delirious and agitated. In truth, spending an in a single day within the ED moderately than the wards might improve the danger of loss of life. Our analysis exhibits that older adults with dementia could also be at particularly excessive danger of delirium and agitation in ED hallways. Moreover, chilling affected person quotes describe the expertise as feeling like a “prisoner” or “homeless.” Well being methods want to seek out methods to guard such sufferers who’re at highest danger of hurt, whether or not by means of improved bodily infrastructure, staffing fashions, or prioritization for these in danger to maneuver to upstairs rooms — until, in fact, they repair the whole inhumane follow of boarding.
— Sarah Perelman, M.D., and Shan Liu, M.D.
The story
“Congress should repair the No Surprises Act earlier than it bankrupts sufferers and employers,” by James Gelfand and Patricia Kelmar
The response
The op-ed on the No Surprises Act (NSA) misdiagnoses the issue. As head of human assets for TeamHealth, I share Gelfand’s duty to maintain well being care reasonably priced for workers. However I additionally see how insurers are making the most of this well-intentioned regulation.
The NSA rightfully protects sufferers from shock payments. I’m proud to work at an organization with a longstanding coverage in opposition to sending shock payments.
The NSA units out a transparent course of for insurers and clinicians to resolve cost disputes by means of an unbiased dispute decision course of.
Most clinicians need to be in-network with insurers — it’s higher for sufferers and supplies secure, predictable reimbursement for care. However insurers leverage the protections of the NSA to make presents which are financially unfeasible. Many presents are decrease than clinicians’ contracted charges in 2019. How many individuals would comply with take a pay reduce from their 2019 wage?
Insurers additionally generate billions in revenue from shared financial savings schemes so long as clinicians stay out-of-network. Insurers know the NSA protects their members from out-of-network payments, reducing their incentive to barter in-network contracts. This leaves the IDR course of as the one mechanism for clinicians to hunt honest reimbursement.
Clinicians aren’t abusing the IDR system. Knowledge self-reported by insurers present that solely 6.6% of eligible claims are even submitted to the IDR course of. Furthermore, clinicians are profitable greater than 70% of IDR disputes as a result of unbiased arbiters acknowledge that insurers are underpaying. Knowledge from Individuals for Truthful Well being Care backs this up. In additional than 60% of IDR disputes, insurer-reported benchmark funds — known as qualifying cost quantities — are beneath the median contracted quantity.
Because the sponsor of TeamHealth’s worker well being plan, I additionally see the IDR course of from the employer aspect. The NSA was designed to incentivize the dropping get together to hunt an in-network contract by requiring them to pay a considerable share of arbitration prices. That has not occurred. Insurers don’t have any “pores and skin within the sport,” passing these prices on to employer-sponsored plans, finally leading to greater premiums for workers.
In the meantime, insurers proceed to learn financially from the regulation. The seven largest well being insurers reported $71.3 billion in earnings in 2024 whereas sufferers face higher problem accessing care. A couple of-third of rural hospitals are prone to closing.
If insurers can leverage NSA protections for profiteering, the NSA will fail to facilitate in-network contracts as Congress supposed. IDR claims will solely proceed to rise.
— Eric Norman, chief human assets officer, TeamHealth
The story
“The AI push in well being care is deepening drugs’s belief disaster,” by Oni Blackstock
The response
Dr. Blackstock’s piece on AI and drugs’s belief disaster is vital and largely right. Institutional adoption of AI has exceeded the velocity during which we will add needed guardrails to AI implementation with a view to shield affected person privateness, guarantee equitable entry, and construct belief with our sufferers.
However the essay leaves a important use case unexamined: AI within the fingers of sufferers themselves. Final October, my mom developed acute-onset renal failure after restarting rifampin. She was wholesome and had no prior kidney illness. Inside a matter of days, she was within the ICU on dialysis. As a practising doctor, I used to be capable of translate lab values, urine output trajectories, and care plans from the medication and demanding care groups into phrases she may perceive. However I additionally watched my mom nod at explanations she didn’t totally perceive both as a result of she didn’t need to appear uncooperative or as a result of she lacked the medical vocabulary to ask the follow-up query that was forming in her thoughts. That’s not a failure of any clinician, however moderately it’s a structural drawback of data asymmetry between scientific experience and affected person understanding.
Throughout her hospitalization, I turned her well being advocate, and I used to be capable of due to my coaching. Most households can not. The communication hole between physicians and sufferers isn’t solely a minor inconvenience, it’s a outcomes concern. For sufferers with restricted well being literacy, estimated to be as much as 36% of U.S. adults, the hole is compounding. These sufferers are much less more likely to ask clarifying questions, extra more likely to misread discharge directions, and extra more likely to current later and sicker.
The usage of AI by sufferers themselves — not deployed by insurers and well being methods — presents a genuinely underexplored answer to bridging this hole and empowering sufferers with their very own well being. Instructing sufferers the best way to construct a symptom timeline, generate focused questions for his or her physicians, and determine purple flags earlier than an appointment won’t change our jobs as physicians, however increase our means to look after our sufferers.
Dr. Blackstock is totally proper that well being care should transfer on the velocity of belief. We will construct that belief by empowering sufferers to actively take part in their very own care, not really feel subjected to doctor’s prescriptions and plans. With extra oversight, we may give sufferers extra autonomy of their care.
— Nicolas Leighton, M.D.
The story
“How the insurance coverage system quietly undoes restoration from dependancy,” by John Fomeche
The response
The a part of this that basically stayed with me was it wasn’t about trauma or cravings — it was when the physician stated his affected person’s voice modified when she talked about her insurance coverage going up. I grew up watching my pals be handled like they didn’t matter as soon as dependancy entered the image. Like they misplaced their humanity. I keep in mind being a teen when OxyContin began being handed round on the events. I misplaced my greatest pals to this illness and I’ve been to extra funerals than I ought to have earlier than I even hit my 30s.
However I’ve additionally seen what restoration seems like when individuals are handled with dignity and given the proper help — and the way rapidly that stability might be shaken by one thing like an insurance coverage change. This isn’t a small coverage concern. It’s the distinction between stability and relapse for actual individuals. For my pals preventing every single day to remain sober. I needed to say thanks for bringing consideration to one thing that too many individuals don’t perceive till it’s too late.
— Angela Dion
The story
“There’s a successor to 340B lurking on the horizon,” by Sujith Ramachandran
The response
The federal government’s 340B drug buying program is straightforward: Purchase low, receives a commission excessive. The biggest customers of 340B — beginning with mega-consolidated hospital methods — buy medicine at giant reductions, typically 50% or higher. Then, they’re reimbursed properly above the discounted value. Research have documented that the reductions are sometimes not handed on to sufferers in want however are pocketed by the hospital. It’s, in impact, government-sanctioned arbitrage.
Some mistakenly consider that the Inflation Discount Act supplies the identical arbitrage alternative for personal follow physicians. I’ve heard this from some well being staffers on Capitol Hill and just lately learn the STAT First Opinion article drawing parallels between the IRA drug worth negotiation and 340B. It’s not simply fallacious — the IRA worth negotiation is a “reverse-340B.” 340B and the IRA drug worth negotiation function in diametrically reverse methods. With the IRA, Medicare creates a “most honest worth” (MFP) that can low cost Half B medicine. Doctor practices, corresponding to neighborhood oncology practices, shall be reimbursed on the decrease MFP however should purchase the drug at greater market charges.
Think about a easy instance: A $2,000 most cancers drug negotiated right down to an MFP of $1,400. The drug prices the follow $2,000, but is reimbursed off of the decrease MFP worth. The drug is straight away underwater — reimbursed beneath value. 340B flips this math on its head. The $2,000 drug prices the hospital $1,000 after reductions however then will get reimbursed by Medicare off of the $1,400 market worth. Though hospitals may even be uncovered to decrease MFP negotiated pricing, they will take in the influence as a result of all their Half B medicine are discounted by 340B, not simply these topic to IRA negotiations. And within the business market, giant 340B hospitals can mark up most cancers medicine a median of shut to 5 occasions.
The results of the reverse-340B shall be most cancers care migrating to the costlier hospital setting. 340B will proceed to develop — now near $150 billion in market {dollars} — costing sufferers and the federal government extra. The IRA reverse-340B is a risk to physicians — not the boon that 340B is to hospitals. Conflating the IRA with 340B is fallacious — 340B supplies hospitals with monumental drug margins, whereas the IRA does the reverse for unbiased physicians. It’s a dire risk and an accelerant to the consolidation in well being care that’s bankrupting Individuals.
— Ted Okon, Group Oncology Alliance