18 minute read
The 21st Century Healthcare Crisis
The Dichotomous Dilemma and War Between
Modern Medicine and
Friday, June 24, 2022
DCMS Central PA Medicine
Intragenomic EvolutionTheodore Miller Incoming MS1 at Penn State College of Medicine tjm7147@psu.edu
Bio
Theodore Joseph Miller (Joey Miller) is an incoming MS1 at the Penn State College of Medicine. He is interested in pursuing medicine with a focus on the social determinants of health and public health equity/policy for vulnerable populations. His clinical interests include medical genetics, pediatric hematology/oncology, emergency medicine, and medical education pedagogy. Theodore ' s future goal after training at the Penn State College of Medicine is to become a pediatric oncologist and research investigator that promotes equitable, holistic, and preventative healthcare practices for communities with unpredictable clinical and social needs.
By THEODORE MILLER, MS1 at Penn State College of Medicine
From the invention and discovery of penicillin to more specialized antibiotics like vancomycin and linezolid, human beings live in an unprecedented environment of personal health security and comfort that has never been previously seen or experienced. Maybe you got scraped by a rusty pipe on your walk home or you fell off your bike and broke both your arms; if you were unfortunate enough to grow up in the early 19th century, you would certainly be dissatisfied with the surrounding level of treatment and care. The tetanus vaccine was essentially nonexistent until the 1890s, and the repair process of any bone fracture would be limited by the sub-optimal antiseptic and pain-management applications available. We take our general well-being for granted due to the seemingly limitless supply of antibiotic and antiviral medications. We fail to acknowledge the impact of federal legislation and implementation of financially accessible healthcare policies and social/educational campaigns within our world, as well as the foundation these programs have laid in providing practical, relevant information that has equipped modern households with tools to fight against virulent pathogens. Modern medicine has provided the human race with unparalleled biological stability, yet we’ve become complacent in our victory over illness and disease and, without proper intervention, will fall back into historical patterns of death and reduced longevity.
The deadly superbug, the typical reference of any bacterium that has developed resistance against a multitude of antibiotics, has been given the perfect opportunity for growth in the 21st century. Despite the paradoxical nature of medical access across the globe, as evident in the comparison between first and third world countries, antibiotics are taken constantly and for some genuinely inappropriate reasons. This allows for bacterium with plasmid or chromosomal resistance to proliferate against their non-resistant counterparts, which in turn accelerates their growth because of the heavily reduced biological space that has now been freed for occupancy. It is important to note the relevance of adaptive and innate immunity, as any remaining bacteria are disposed of by the pairing of helper B-cells and cytotoxic T-cells (as well as other immunity components like neutrophils). However, if any resistant cells were to remain or “escape” detection, they would exponentially divide and pose a severe problem for that infected person. While the magnitude of virulence is significant for the individual, healthcare professionals can only throw so many antibiotic medications at a particular infection while maintaining an ethical, financial, and effective balance.
This issue is exacerbated further when someone with a minor cold takes antibiotics unnecessarily or its customary usage across the globe for livestock protection. That pounding headache, intense fever, and constant stomachache may make you jump to the most potent solution to resolve these symptoms, yet you are unknowingly increasing the likelihood of stimulating bacteria that carry resistant alleles against that antibiotic. The same idea applies for our cattle, pig, and chicken populations; substantial amounts of antibiotics, with varying degrees of strengths and targets, are given to these animals which enhance these superbug organisms. While generally beneficial for those animals that may be at risk for combating illness and allowing for that $1 fast food burger or Chick-fil-A spicy sandwich (YUM), they pass on these superbugs to humans that consume them. Both situations may seem inconsequential at first glance; humans have invented hundreds of antibiotics that, through proper combinations and allotted time periods, can eliminate these deadly foes. Yet, it is because of our creative spirit and intelligent advancements that have made the perfect platform for this issue to become catastrophic.
From air travel to densely populated cityscapes, our expansion as a species and our inherent social connectivity introduces the fundamental reason behind the gravity of the “superbug.” There are approximately 100,000 flights within any given day as of 2013, and, coupling that number to countries like India and Brazil with staggering populations, transmission of disease is an inevitable consequence of our manufactured luxuries. Even automobile transportation to and from work or our daily interactions with our friends and classmates exposes us to the potential of resistant-bacteria introduction. Any singular bacteria can also spread resistance to other non-resistant bacteria in numerous ways, including transduction, transformation, or conjugation. We have increased the velocity by which infection can proliferate and share this resistant-information with other cells, and we have even allowed for so-called superbug “incubation-centers,” or what we know today as the common hospital setting where this problem is of central concern due to excessive antibiotic use. It is this linked association we have built across the world that makes superbugs a real threat, but fortunately this is not a glass half-empty situation. As one side evolves, so does the other, and despite the evolutionary adaptive potential of bacteria cells for resistance, resistance can also be lost over time when its energy expenditure is no longer needed. We also cannot forget the resilience on our side as well, as new vaccines and antibiotics are being researched and discovered constantly; the fight may currently be in favor of our pathogenic neighbors, but the never-ending war will continue to rage on between humans and bacteria.
It may sound contradictory to state that we live in the most technologically and medically advanced and innovative time period in human history and that resistant bacterium should be a focal point for medical attention as a potential global pandemic, but it’s ingrained within human nature to avoid highlighting issues that do not appear to be of immediate priority. We have forgotten previous eras in human history where amputation and bloodletting were primary approaches against illness, and it is this willful ignorance that has given bacteria an opening in our co-evolved war that may just return us to an age of historical, heightened morbidity and mortality.
LEGISLATIVE UPDATES
PENNSYLVANIA MEDICAL SOCIETY
Summer Recess
For those engaged in the daily grind of the legislative process, summer has finally arrived with the passage of a $39.8B state budget. In the days leading up to the June 30 budget deadline—and a few days afterwards—we saw activity on an unusually large number of legislative proposals on which PAMED has been actively engaged. A number of them made it across the finish line and to the Governor’s desk, while a few could still see passage when the General Assembly returns in the fall.
Suffice it to say legislative activity has been somewhat contentious over the past few months as lawmakers positioned themselves politically for either the recent primary election or the upcoming election this fall. While PAMED’s government affairs staff is always sensitive to the “politics” that drives the development of public policy, we do our best to limit our focus on the impact legislation has on physicians and the patients they treat.
While the list below reflects the entirety of legislation that has been “active” since the current legislative session began in January of 2021, there are several items that deserve special recognition.
Prior authorization reform (SB 225) has been a priority issue for PAMED and our 40+ member coalition of physician organizations and patient advocacy groups for over six years. Earlier this session, Senator Kristin Phillips-Hill introduced SB 225, and has since been championing the effort to achieve senate passage before this year’s summer recess.
Over the past 6 months, various coalition partners met countless times with senate staff and representatives of the insurance industry to hammer out language that could pass the senate. These meetings were often contentious, as one might expect, with the industry pushing back on nearly every provision of the original bill. Again, PAMED remained focused on how prior auth impacts patient care. Happily, her efforts, along with the efforts of key staff and our coalition partners, resulted in the unanimous approval of SB 225 by the full senate on June 29th. The bill now moves to the House Insurance Committee for consideration.
In the past, legislative activity during fall sessions have been robust as lawmakers work to wrap up their business before the end of the year. This year may prove different as there are only twelve legislative session days currently scheduled with rumors that a few additional days may be cut. With that in mind, PAMED will be aggressively pushing for the House of Representatives to approve SB 225 before they break for the November election…which will ostensibly end the legislative session.
When it comes to legislation addressing scope of practice, PAMED has always viewed patient safety as our number one concern… not as competition against our non-physician colleagues. As a result of the COVID-19 waivers that granted pharmacists with expanded authority to provide COVID-19 vaccines, pharmacists began efforts in early January to further expand their role into the realm of childhood immunizations, seeking the authority to provide this service to their “customers” over the age of 5. Working in concert with the PA Academy of Family Physicians (PAFP) and the PA Chapter of the American College of Pediatrics (PA-ACP), that effort was stopped before it even became part of a legislative proposal.
Though the child vaccine issue was sidelined, PAMED along with PAFP and PAACP did agree to allow pharmacists to provide seasonal flu and COVID-19 vaccines to individuals aged 5 and above. This “compromise” should serve to keep the issue of child vaccines off the table for the foreseeable future.
Speaking of the future, PAMED was successful during the recent budget process in securing additional funding for the state’s Primary Care Loan Repayment Program. This program provides loan forgiveness, presently up to $80,000, for physicians who choose to practice in a rural or underserved community for two years. PAMED secured an additional $2.5M to bring the program’s total allocation to $7M. This is the first time in more than a decade that the legislature has increased this line item.
PAMED was also engaged in advocating for the passage of HB 2660, a legislative resolution that would have been the first step in potentially amending Pennsylvania’s constitution to place the question of judicial “venue” in the hands of the legislature instead of the state Supreme Court. Unfortunately, efforts by PAMED, the Hospital Association, and a number of business groups, all of which are members of the Pennsylvania Coalition for Civil Justice Reform (PCCJR), were unsuccessful. Though the bill only won committee approval in the House of Representatives, it was successful in getting the issue before the legislature. PAMED will continue to work within the framework of PCCJR to ensure that Pennsylvania’s legal climate is improved.
At this point, the state Supreme Court has not taken any formal action to change venue thresholds. However, we continue to keep
our ear to the ground in the event a potential change is once again made public.
PAMED encourages all physicians to engage in the legislative process by getting to know your individual representatives in Harrisburg. Nothing is more important than developing a trusting relationship with lawmakers so that your concerns are heard and respected.
The following are legislative initiatives that either made it to the Governor’s desk thus far this year or are still “in play” between now and the November General election.
SB 818
Amends the Health Care Facilities Act to allow ambulatory surgical facilities to perform certain permitted surgical procedures without seeking a waiver/exception from the Department of Health. The bill creates an updated waiver/exception process for surgical procedures not on the 2022 CMS ASC-CPL list or otherwise prohibited by state regulation.
Signed by the Governor as Act 87 of 2022 HB 1421
Provides additional funding for the Primary Care Loan Repayment Program. Raises funding from $4.5 million to $7 million.
Signed by the Governor as Act 54 of 2022
HB 1563
Amends the Pennsylvania Drug and Alcohol Abuse Control Act (DAACA). This legislation brings DAACA into alignment with HIPAA to create a consistent and easily understandable standard and revises outdated regulations. The bill also provides consistency between statutory and regulatory language. Signed by the Governor as Act 33 of 2022
HB 2419
Allows psychiatrists, and other mental health providers, to provide telehealth services.
Signed by the Governor as Act 76 of 2022 HB 2604
Allows name badges to have the health system a healthcare provider works for on the badge. Previously name badges had to be specific to the location where the provider was working, becoming an issue for providers who work in multiple locations. Signed by Governor as Act 79 of 2022
HB 2679
Amends the Pharmacy Act to allow pharmacists, and supervised pharmacy interns, to administer influenza and COVID-19 vaccines to children ages five and older. Signed by Governor as Act 80 of 2022
SB 106
A Joint Resolution proposing five separate and distinct amendments to the PA Constitution. • Establishes that the PA Constitution does not grant any right to abortion or taxpayer funding for an abortion. • Allows the General Assembly to disapprove regulations by its own vote with no signature by the Governor required. • Eliminates separate election for Lieutenant
Governor. Allows the gubernatorial candidate to select his own running mate. • Requires all voters, whether in person or not, to present a government-issued form of identification prior to voting. • Requires the General Assembly to provide by statute for the auditing of elections and election results. Current Status—Passed the General Assembly on July 8, 2022. Identical language must pass again next session and then the ballot questions can be presented to the voters at the next statewide election, possibly as early as the 2023 Primary Election.
SB 225
Amends the Insurance Company Law of 1921 to standardize and streamline the practices of prior authorization. Current Status—Unanimously passed the Senate on June 29, 2022. Referred to House Insurance Committee.
SB 317
Provides health care practitioners the authority to prescribe or personally furnish antibiotics to treat sexually transmitted infections, without having examined the individual for whom the drug is intended, in accordance with the Expedited Partner Therapy (EPT) in the Management of Sexually Transmitted Diseases guidance document issued by the United States Center for Disease Control (CDC). Current Status—Unanimously passed the Senate in April 2022. Reported out of House Health Committee on April 26 but no further movement.
HB 1280
Amends the Patient Test Results Information Act. Provides for certain exclusions, and definitions within the Patient Test Results Information Act. Current Status—Waiting consideration from the Senate Health and Human Services Committee.
HB 1393
Amends the Controlled Substance, Drug, Device and Cosmetic Act to legalize the use of drug testing products like fentanyl test strips for personal use. Current Status—Passed the House on June 20, 2022. Referred to Senate Judiciary Committee but no further movement.
HB 2660
Proposed Constitutional amendment that would put the current Venue Rule into the Pennsylvania Constitution. Current Status—Referred to House Rules.
Stay up to date on PAMED’s legislative priorities at www.pamedsoc.org/Advocacy
RESTAURANT REVIEW
ONE13 SOCIAL
By ROBERT ETTLINGER, MD
Notwithstanding the price of gasoline lately, a close drive to Carlisle can make for a special evening to relax. A short walk away from the Dickinson University campus, the neighborhood around High and Pitt Streets includes the Carlisle Theater (with talented and oft-times famous performers), Cafe Bruges (great Belgian food), and the
Hamilton Restaurant (if you’ve never had a Hotchee Dog, you are sorely missing out on one fabulous tube steak). Joining them since January, One13 Social brings a New American menu that’s upscale yet casual.
In remodeling the building with the help of Carlisle Design, the wood- and leather-accented, sound-proofed rooms feature both a main bar with patio seating for sunshiny days, and a Scotch bar. After spending many years at the Boiling Spring Tavern, owner
Kevin Rockwood and Chef Ross Graham took six months to work on the globally inspired menu. Small plates shared were Tuna Tartare Tostada, Korean BBQ Ribs (in a kimchi aioli that’s not too hot), and the popular One13 Fries (julienned Russets done in duck fat, with tasty shots of salsa verde and garlic-parmesan aioli). Our server also recommended the She Crab Bisque and the Oven-Roasted Oysters with chipotle-garlic butter.
Their reportedly best-selling entree is Salmon Au Poivre, in a peppercorn-cognac cream with sauteed spinach. Scampi Gnocchi, with a perfect bite, was done with gulf shrimp and saffron. Chicken Florentine was served with shiitakes and feta in a sherry cream. Notable among the four sandwich choices was the Chicken Torte, with moist thigh meat, queso fresco and Pico de Gallo on an excellent ciabatta from Talking Breads Bakery on Lisburn Road in Mechanicsburg. Argentinian Flank Steak with rosemary chimichurri and Pork Roulade in a mulled wine coulis looked good at a nearby table.
House cocktails are inventive, and the wine and beer lists are long but well organized. It was hard to choose, but you just don’t see Chimay Belgian on menus very often. Desserts are house-made and crafty...a dinner-mate described the Key Lime Pie as having “just the right pucker.”
If you live anywhere near the Capitol area, a ride to One13 Social is well worth the trip.
ONE13 SOCIAL
113 W. High Street | Carlisle, PA 17013 | 717-706-3514 open Tuesday-Saturday 11 am-10 pm
FRONTLINE GROUPS
The Dauphin County Medical Society thanks the following for their 100 percent membership commitment and their unified support of our efforts in advocating on behalf of physicians and the patients they serve.
Allergy Asthma & Immunology Brownstone Dermatology Associates Conestoga Eye-Hershey Cummings Associates PC Elena R Farrell DO Family Internal Medicine Family Practice Center PC-Millersburg Forti & Consevage PC Gastroenterology Associates of Central PA PC Harrisburg Gastroenterology Ltd Hershey Pediatric Ophthalmology Associates PC Hershey Psychiatric Associates Houcks Road Family Practice James R Harty MD Jatto Internal Medicine & Wellness Center PC John E Muscalus DO Morganstein De Falcis Rehabilitation
Institute-Harrisburg Patient First-Harrisburg PinnacleHealth Express PinnacleHealth Radiation Oncology Premier Eye Care Group Saye Gette & Diamond Dermatology Assoc PC Schein Ernst Mishra Eye Stratis Gayner Plastic Surgery Tan & Garcia Pediatrics PC Todd R Fisher MD Family Medicine UPMC Heart and Vascular Institute-LCV UPMC Pinnacle Colon & Rectal Surgery UPMC Pinnacle Harrisburg Transplant Services UPMC Pinnacle Harrisburg-Emergency Room UPMC Pinnacle PHCVI Cardiovascular &
Thoracic Surgery Woodward & Associates PC
Chance Benner, DO Connor Lee Appelman, MD Philip Kronfli Anthony, MD Morgan Engler, DO Jennifer Boles Scott, MD Zahir Sheikh, MD Aakash Sheth, MD Christian Park, DO Ariel Jones Hakim T. Uqdah, DO Sreeram Ravi, MD Ariel Herschel Kwart, MD Francois Philippe Kaleta, DO Shreela Natarajan, MD Elhaam N. Jawadi Matthew Heyward Wessinger, MD Linda Camaj Deda, MD
NEW MEMBERS
Minu Mary Mathew, MD Peter Angelo Lore, DO Anand Adhikari,DO John Lin, DO Christopher Stauch, MD Glenn Scott Slick, Jr. Joseph Shawn Smith, MD Lawrence Victor Klomps III, MD Jessica Lauren Emrich, MD Aaron Tolpin, MD Samuel Pinkston Dungan, MD Ambroise H. Gille, MD Justine Julien, MD Charlotte Emmanuelle Floria, DO Ashley Mariam George, MD Samer Nabil Muallem, MD Jason Paul Mercando Derrick Russell May, MD Alexis Danielle Cash, DO Brett Benzinger, DO Elaine Blackman Rajan Anil Lala, DO Matthew Evers, MD Chase Knowles, DO Bradley Klienstuber, DO Christopher Noty, DO Matthew Oplinger, MD Janet Chan Gomez, MD Anjum Kazi, DO Brittany Cuff, DO Nathan Staidl, MD Sparsh Gola, MD Farid Zeineddine, MD Darya Nesterova, MD Nathan Moore, DO Ji Ho Park, MD Robert Maris Simms, MD Alex Geertsen, MD Nina Eng, MD Aroh Jamanadas Ribadiya, MD Marissa Kay Burchette, MD Peter James Schaefer, MD Aidan J. Hintze Agustey Mongia Deborah K. Monko Elizaveta Makarova Ruth Elizabeth Gardner, MD Jake N. MacDonald
REINSTATED MEMBERS
Asha Zachari, MD Sanjib Das Adhikary, MD Megan Sue Wheelden, MD Laura Sohren Ruggiero, MD Sallyann Blaine, MD Fabian Alcaraz-Angulo, MD Lisa Macnabb McGregor , MD
Complete your re-licensure requirements!
Suspected Child Abuse & Neglect and Opioid Education with DCMS
September 17, 2022 8:00am-12:15pm
http://www.dauphincms.org/events.html
Keep an eye on your email for more information and registration!
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Contact a Penn State Health neurosurgical expert near you: Penn State Health Neurosurgery
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St. Joseph Medical Center Medical Office Building 2494 Bernville Road, Suite 201 Reading, PA 19605
