The biggest threats to medicine in the US

The state of American healthcare is concerning to many experts. According to a 2017 report by the Commonwealth Fund, the United States spends the most on healthcare but ranks last in performance among the following industrialized nations: Australia, Canada, the Netherlands, Germany, France, New Zealand, Norway, Switzerland, Sweden, and the United Kingdom. To make matters worse, several factors only serve to compound the status quo, including those listed below.

Read on to learn more about the seven most substantial threats to US healthcare:

Healthcare waste

Can you guess what the biggest impediment to universal healthcare is? You guessed it, healthcare waste. 

The United States spends 18% of its gross domestic product (GDP) on healthcare. Of this huge sum, about 30% may be wasted, or $760 billion to $935 billion, according to one recent JAMA review. On the other hand, measures to cut wasted resources in the United States resulted in $191 billion to $282 billion in savings.

Unfortunately, no quick fix exists for the problem of healthcare waste. Possible solutions include switching to generic drugs, shifting from inpatient to daycare for certain patients, and decreasing lengths of stay without risking readmission.

In the United States, per capita spending on prescription medications, for example, exceeds that of 19 other countries by more than double, tipping the scales at $858.

Here’s the conclusion of a separate review article in JAMA that sheds light on the issue:

“High drug prices are the result of the approach the United States has taken to granting government-protected monopolies to drug manufacturers, combined with coverage requirements imposed on government-funded drug benefits. The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policymakers about these choices.”

Burnout

The term “burnout” was first coined in 1974 by clinical psychologist Herbert Freudenberger, PhD, who noticed this phenomenon while working at a volunteer health clinic in New York City’s East Village. His colleagues were experiencing high levels of depletion and psychosomatic symptoms. He defined burnout as “excessive demands on energy, strength, or resources” experienced in the workplace leading to frustration, fatigue, malaise, inefficiency, and cynicism. Interestingly, Dr. Freudenberger took the term burnout from drug slang.

Burnout is a huge problem in the United States, and the repercussions trickle down to patients in the form of poor care. After controlling for covariates like age and sex, researchers have shown that more than half of American physicians experience burnout—more than double that of their peers in other occupations. Furthermore, according to some studies, burned-out surgeons commit more errors, and burned out physicians are more likely to quit their jobs—which exacerbates another major problem threatening healthcare: the physician shortage.

Causes of burnout include excessive work hours—with the average US physician working 51 hours a week. Excess bureaucracy demanded by the rigmarole of Medicare, Medicaid, and private insurance companies also contribute to burnout. Sadly, for every 1 hour a physician spends seeing a patient, there are 2 hours of associated “paperwork.”

Possible solutions to burnout include improved leadership that stresses self-care, alternative incentives such as time off, and greater flexibility in allowing physicians to schedule their own hours.

Physician shortage

If you haven’t already heard, there’s a physician shortage in the United States that’s only getting worse. The Association of American Medical Colleges projects a deficit of 46,100 to 90,400 physicians by 2025. Moreover, the US population is expected to grow to 347.3 million in 2025, compared with 316.5 million in 2013—a nearly 10% increase—with the elderly population expanding by 46%. To meet demand, medical schools have been educating more physicians. However, Medicare is capped in how many residency slots it can finance.

Aging physician population

The aging physician population is a hot-button topic best approached gingerly. Although some fear that physicians practicing in their twilight years could be dangerous, the prospect of a mandatory age for retirement scares many. Making physicians retire at a certain age could cull those who still have the skills needed to practice and hasten the physician shortage.

Ever since 1965, the number of practicing physicians age 65 years and older has almost quadrupled. In 2015, 23% of physicians were older than 65 years. Although cognitive decline is highly variable among individuals, people aged 40-75 years have cognitive declines that average greater than 20%.

Periodic age-based testing is not mandatory in medicine, but other professionals such as firefighters, air traffic controllers, and FBI agents are required to undergo such testing as measures of fitness for their jobs.

In a review article published in JAMA Surgery, researchers recommended the following:

“As physicians age, a required cognitive evaluation combined with a confidential, anonymous feedback evaluation by peers and coworkers regarding wellness and competence would be beneficial both to physicians and their patients. While it is unlikely that this will become a national standard soon, individual health care organizations could develop policies similar to those present at a few US institutions. In addition, large professional organizations should identify a range of acceptable policies to address the aging physician while leaving institutions flexibility to customize the approach.”

The authors warn that if professional organizations don’t take the lead in combatting the aging physician population, regulators and legislators may impose harsher standards.

Opioid crisis

To illustrate the scope of the opioid crisis, let’s trace out just one opioid death. One opioid death is linked to 20 substance-abuse admissions, 45 ER visits, 156 people with dependence, and 533 cases of abuse.

Overprescription and subsequent diversion are the roots of the opioid epidemic. Consequently, there are things that you, as a physician, can do to help stop the problem:

• Educate patients on the proper storage and disposal of opioids
• Prescribe naloxone to those at high-risk
• Screen patients for dependence or substance use disorder
• Proffer info on peer recovery support
• Draw up discharge planning for those with a history of overdose

Bacterial resistance

At least 23,000 of the more than 2 million Americans infected with antibiotic-resistant bacteria die each year.

The CDC breaks down resistant bacterial pathogens into three categories of threat: urgent, serious, and concerning.

Pathogens that pose urgent threats include:

• Clostridium difficile
• Carbapenem-resistant Enterobacteriaceae (CRE)
• Cephalosporin-resistant Neisseria gonorrhoeae

Some pathogens that pose a serious threat include:

• Drug-resistant Campylobacter
• Multidrug-resistant Acinetobacter
• Vancomycin-resistant Enterococcus
• Methicillin-resistant Staphylococcus aureus

Here are concerning threats:

• Vancomycin-resistant Staphylococcus aureus
• Clindamycin-resistant Streptococcus Group B
• Erythromycin-resistant Streptococcus Group A

Of note, threats that are deemed serious and urgent require more monitoring and prevention than do concerning threats.

The CDC recommends four strategies to curb antibiotic resistance:

• Preventing infections and decreasing the spread of resistance
• Tracking patterns of resistance
• Formulating novel antibiotic treatments and testing
• Optimizing antibiotic prescription patterns

Chronic disease

Heart disease, cancer, COPD, diabetes, and stroke account for 7 of 10 deaths among Americans each year. Furthermore, 45% of Americans face at least one chronic illness. Chronic illness results in hospitalization, decreased quality of life, disability, and death, as well as a huge chunk—75%—of healthcare spending. What makes chronic illnesses particularly sinister is that they co-occur; more than 50% of the elderly have three or more comorbidities. The aging population will only escalate the number of Americans with chronic illness.

Finally, you may be wondering why the United States ranks last in healthcare performance, compared with the top performers, Australia, the United Kingdom, and the Netherlands. These high-functioning healthcare systems all provide universal healthcare coverage and access in one iteration or another.

According to the authors of the Commonwealth Fund report, the key to improving US healthcare and mitigating potential threats involves “comparing countries’ health care system performance using standardized performance data [which] can offer benchmarks and other useful insights about how to improve care.” In other words, there are things we can learn from healthcare providers in other countries that may help us solve our own problems.