Where Business Meets Healthcare Editor-In-Chief Elaine Ma Editorial Aleksandra Golos Grace Mock Vedick Navale Neelu Paleti Leah Ragno Madeline Smith Jianghan Xu Brian Zhong Strategy and Design Judy Choi, Director Sarah Nam Lachlan Cormie Business Yiwen Li (Finance Committee Liaison)
Interested in writing for Penn Healthcare Review? Email wuhc.pennhealthcarereview@gmail. com for more information.
Dear Readers, I am so excited and honored to present to you the sixth issue of Penn Healthcare Review this spring! This year, we received a record number of excellent submissions. The pieces contained in this publication display the exceptional writing and passion for health of the undergraduate body. They engage several salient topics ranging from AI technologies in healthcare to nutritional inequities in the Philadelphia community. Our featured article by Jacob Soifer explores crucial tensions in drug pricing that deeply affect our nation today. Though the range of topics are diverse, they are all united under a veneration for the dynamic, ubiquitous nature of healthcare and its implications. Notably, I would like to acknowledge every member of the editorial board for their valuable insight and time. In addition, I thank the talented design team for their tireless work to create this stunning magazine. Each member has been an indispensable part of the extensive efforts required to bring this magazine to the reader’s hands. Congratulations to all the writers and board members of Penn Healthcare Review. Sincerely, Elaine Ma Editor-in-Chief
Infographics were designed by the Strategy and Design team members using Piktochart: “Easy to Use Infographic Maker.” Piktochart. https://piktochart.com/ Subscription to Pro Plan from 2/21/2019 to 3/21/2019. Cover designed and graphically created by Judy Choi using Adobe Photoshop.
by Elaine Ma
Physician shortage in Hong Kong: Are the proposed policies good enough? by Kelly Liang
disparities in Chinese public health 6 Urban-rural by Patrick Beyrer
The sci(l)esce behind #MeToo by Laleh Pandora
26
What happened to Menstrual Education? by Folasade Lapite
28
Nurse Migration: Impact on Healthcare 10 Global Economics by Shreya Parchure
Words: 12 Weighting Healthcare Dialogues In an Obese Society by Grace Mock
14 16
The Business of Dying: Addressing the Growing Need for Terminal Care in Aging Populations by Miyu Ono AI and the Transformation of Healthcare by Arshia Faghri From Technology to Trained Alert Dogs: Novel Approaches to Type 1 Diabetes Management by Aleksandra Golos Cloud-based technology transforming healthcare industry by Leah Ragno Food Deserts: The Effects of Not Having a Choice by Chizoba Onyekere
Learning and Surgical Robots 18 Machine by Sydney Lee
High Costs of Medical School Tuition 20 The by Jason Yan
24
TA BLE O F CO N T E N T S
and Insect Disease Vectors: 4 Colonialism Sleeping Sickness and Zika
Eating Healthy on a SNAP Diet: Regulating Nutrition Decisions by Grace Mock
Flat Soda: The Shortcoming of the Philadelphia Sugar-Sweetened Beverage Tax by Elisheva Blas
How Much is Too Much? 22 FEATURED: Looking at American Healthcare Spending through a Value Based Lens. by Jacob Soifer
Why We Should Celebrate the Death of the Mandate by Dominic Gregorio
30 32 34 36 38 40
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n 2004, six-year old Joseph Mutombo undergoes treatment for sleeping sickness. His mother tries to comfort him as he moans from the pain of a lumbar puncture and struggles to even hold his head up.1 In 2016–across the ocean–the first U.S. death tied to Zika is reported in San Juan, and the victim dies from internal bleeding within 24 hours of being hospitalized.2 Structural racism in the historical management of insect disease vectors, as seen in Uganda and Puerto Rico, are rooted in colonialism, politics, and uninformed decision-making. Such policies inflict lasting harm on vulnerable populations. The management of trypanosomiasis, commonly known as sleeping sickness, in Uganda is historically intertwined with colonial activity around the 19th century. As the British territorial empire continued to expand competitively, it conspired to exploit Africa through the governing of black bodies. Experts generally agree that the parasite and tsetse fly vector caused few epidemics in pre-colonial eastern and central Africa.3 The methods of indigenous farming and animal husbandry created buffer zones that were spatially unfavorable for the parasite and its insect vector to spread.4 Methods of colonial disease management included forced depopulation and resettlement, which proved to be counterproductive in stopping disease spread. The low population densities prior to colonial enforcement actually curtailed the size of the parasite’s human reservoir.5 By displacing indigenous populations from their homes, the colonizers tightened British
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control of the geopolitical landscape.6 Due to this history of entangled colonial manipulation, sleeping sickness continues to persist in Uganda and several sub-Saharan African nations. African governments have united to set up the Pan African Tsetse and Trypanosomiasis Eradication Campaign (PATTEC) in a collective effort to abate the issue.7 Today, sleeping sickness continues to kill more than 50,000 people every year.8 Areas once rendered tsetse-free experience resurgences of disease incidence and increases in tsetse infestation in following years.9 Evidently, colonial tsetse-control interventions were not created in the interest of sustainability. The disease has new implications in modern contexts, where war-torn zones such as Angola, Sudan, and the Democratic Republic of Congo, are hit the hardest.10 The most vulnerable populations that live in these states of political and social unrest are thereby disproportionately harmed. Institutions of power such as the Centers for Disease Control and Prevention (CDC) leverage their expertise to impose neglectful, thoughtless policies on Puerto Rico. In 2016, the municipality of San Juan filed a striking lawsuit against the CDC after a highly controversial proposal to combat Zika virus was released. Thomas Frieden, the director of the CDC, called for the aerial spraying of Naled in the Commonwealth of Puerto Rico.11 Naled is a toxic compound unapproved in the EU.12 Naturally, this mosquito control initiative was met with great resistance. San Juan litigated a citizen suit, citing
a section in the Endangered Species Act (ESA) to argue that Naled would “pose a significant risk to the well-being of several species of fish, wildlife, and plants.”13 It is notable that the plaintiff, San Juan, sought injunctive relief, in which the court orders the defendant to stop a specific act or behavior rather than requiring a monetary payment for a wrong civil action.14 Evidently, the motivations of San Juan are not for seeking financial or economic benefit, but rather for their environmental safety. The same cannot be said about the mainland’s motives, as there was widespread suspicion that there was an economic interest for the U.S. to get rid of the Naled product.15 Frieden himself notes that lingering suspicions related to “historical activities” have impeded Zika interventions in Puerto Rico.16 He acknowledges that these tensions exist, yet he provides no alternative solution to ameliorate the distrust. The Journal of the American Medical Association (JAMA) published Frieden’s article just three months after the CDC released their initial media statement. Currently, Zika is considered to be a relatively rare
disease that poses a minimal public health threat. However, the U.S.’s response to other forms of human health crises in Puerto Rico also demonstrates colonial neglect. In September 2017, hurricane Maria tore through the island and left millions of citizens without access to electricity or safe drinking water.17 Puerto Rico struggled to receive federal aid for the devastation, as the U.S. government was despicably slow to mobilize. The lead political figures displayed an attitude of condemnation and apathy. President Trump took to social media to tweet the unsubstantiated claim that Puerto Rico was responsible for the devastation due to its “massive debt” owed to Wall Street financiers.18 The implications of colonial legacies and sentiments are beyond insect disease vectors solely, as they also extend to other human crises. The political dynamics that interplay with this damage are particularly harmful to disadvantaged populations. It is perhaps best stated by Yarimar Bonilla, an associate professor of anthropology at Rutgers University, “Vulnerability is not simply a product of natural conditions; it is a political state and a colonial condition.”19
1. Ann-Marie Sevcsik, “A Hope for Surviving Sleeping Sickness: Joseph’s Story”, DNDi, 2008. 2. Donald G. McNeil, “First U.S. Death Tied To Zika is Reported in Puerto Rico”, The New York Times, 2016. 3. Douglas M. Haynes, Framing tropical disease in London: Patrick Manson, Filariaperstans, and the Uganda sleeping sickness epidemic (2000), 471. 4. Haynes, Framing tropical disease in London…, 471. 5. Ibid. 6. Haynes, Framing tropical disease in London…, 488. 7. John P. Kabayo, Aiming to eliminate tsetse from Africa (2002), 474. 8. Kabayo, Aiming to eliminate tsetse from Africa, 473. 9. Ibid.
10. Kabayo, Aiming to eliminate tsetse from Africa, 473. 11. CDC News Room, Centers for Disease Control and Prevention, 2016 12. Jason Beaubien, “Puerto Rico’s Efforts To Stop Zika Are Hampered By Mistrust.” NPR, 2016. 13. San Juan v. CDC, Case 3:16-cv-02382-CCC, 2016. 14. Ibid. 15. Beaubien, “Puerto Rico’s Efforts…” 16. Thomas R. Frieden, Anne Schuchat, and Lyle R. Petersen, Zika virus 6 months later, (2016). 17. Tharoor, “Puerto Rico Is Still…” 18. Ibid. 19. Ibid.
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n modern China, disparities in healthcare are as poignant as ever. Specifically, rural southwestern China is a hotbed for these differences, due to its high minority population, low income, and ineffective public health organization as compared to urban areas. In order to understand how geographic differences in China influence healthcare access, it is important to understand how governmental regulations and local factors exacerbate differences in healthcare between urban and rural areas. At its root, China’s health system is organizationally flawed. It is fashioned as a top-down organization, where provincial governments control major provincial hospitals, sub-district governments control smaller urban hospitals, and so on. As shown by this figure, each government organization grows smaller as the size of the health institution decreases. While this management system sounds logical in theory, it is inherently flawed, as major funding and attention is directed towards the larger urbanized provincial hospitals and taken away from the smaller local sub-district hospitals and clinics. This automatically places emphasis on large, urban hospitals that have the most doctors, resources, and, naturally, patients. Therefore, the Chinese health care system fails to manage rural clinics and hospitals effectively by not providing crucial specialized facilities. This is in large part due to governmental organization. Rural Chinese villages and communities have councils of residents that oversee clinics, as opposed to professional government institutions that run hospitals.1 China boasts a large amount of these rural primary care clinics—645,470 to be exact, nearly two-thirds of all health institutions in China as a part of the 2009 reforms—but many lack significant resources.2 These
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primary care clinics can only function as institutions for fast outpatient diagnostic services. Even in terms of outpatient care, these institutions are not nearly as well equipped as those in cities. Rural clinics face a scarcity of technology, funds, and staff experience necessary to address modern medical needs. For example, a study conducted in Guangxi, a predominantly rural southern province, found that there
Source: Sun, Gregersen, and Yuan, “Chinese Health
were only 3.23 CT scan machines for every million people, compared to 7.60 in Shanghai3. CT scanners are crucial to diagnosing internal injuries and especially virulent illnesses, such as cancer, so such technological deficits play a large role in health outcomes. Due to the organizational contrast that exists geographically, rural health facilities are not afforded the technologies or resources that are needed. In addition to technological contrasts, the distribution of doctors and nurses supports the evidence of urban-rural health disparities. In 2011, urban centers had 3.23 nurses per 1,000 people compared to 0.98 per 1,000 in rural areas.4 Poorer and more rural areas were also found to have health professionals with worse educational backgrounds and less professional experience. In fact, Chinese doctors are generally not expected to have any education past a bachelor’s degree due to high doctoral demand. While this number already seems startling, rural arh Care System and Epidemiology.” 1 eas have an even worse
margin for doctoral education—a mere 12.9% of doctors hold a bachelor’s degree or higher, compared to 42.8% in cities5. This difference in doctor quality and quantity foreshadows the stark contrast in health outcomes in these areas. As demonstrated by technological and staff disparities, there is no doubt that rural populations receive worse primary care than urban populations in China. Next, health access differences between urban and rural populations can be traced back to economic disparities—both for the citizens themselves and for government spending. As of 2009, urban citizens bring in 3.36 times the earnings rural citizens do annually.6 While this gap is logical due to the financial gains of agricultural work compared to the more dominant white-collar professions in urban areas, it does not excuse the lack of emphasis China places on taking care of its rural citizens. China spends 5.6% of its GDP on healthcare, but rural areas only receive 20% of the funding.7 This is evident through a cross-sectional study of healthcare expenditures (HCEs), where a team of researchers found how much insurance the government covers per capita. In 2004, Shanghai residents received an average HCE of 91.06 RMB, the highest in the country, while rural Guizhou received 11.83 RMB in coverage, one of the lowest markers in the country.8 To portray the direct connection, the map below shows that Guizhou ranks among the poorest provinces, 40-50% below the mean provincial income, while Shanghai’s income approaches nearly 100% above the mean income.9 Again, while these income gaps and medical demands partially warrant these coverage and insurance differences, the significant disparity in coverage is unnerving by any measure.
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Source: The Atlantic, “Mapping China’s Income Inequality.” 9
tic or outpatient service. Furthermore, the UEMBI grants an 80% reimbursement rate for any out-ofpocket purchases for both inpatient and outpatient services, whereas NCRMS only grants 75% for inpatient and 50% for outpatient services.12 This makes a significant difference in which healthcare services urban and rural citizens are able to access and pay for. The difference in economic attention and insurance coverage traces back to another contrast between urban and rural health institutions—specialized healthcare. While primary care is distributed fairly evenly between urban and rural China, there is a severe lack of secondary and tertiary care available to rural citizens. Specialized care for surgeries, procedures, and virulent disease treatment seems to solely exist in city centers in either hospitals or Centers of Disease Control (CDCs). And of the secondary-tertiary care hospitals, only 66% are government-owned.13 For a country that primarily relies on its public health system, this creates a large issue for rural citizens when they are forced to 11 UEMBI’s 1962 yuan per person. The 411 yuan translates face more debilitating illnesses, as private hospitals to $62, which is only enough to cover a basic diagnos- do not accept NCRMS. On top of that, public city o compound on economic gaps for rural citizens, insurance provided by the hukou system creates more issues for rural medical access. Under the hukou system, there are three distinct types of insurance—Urban Employment Based Medical Insurance (UEBMI), Urban Residence Based Medical Insurance (URBMI) and the New Cooperative Rural Medical Scheme (NCRMS). While it is quite impressive that China has made public health insurance available to all citizens, there are some obvious discrepancies between the two main forms of insurance (URBMI and NCRMS). First, it is important to note that city-dwellers have access to insurance from both the government and their employers, which grants them many more benefits than the sole government insurance that rural citizens hold. Regardless, most prevalent distinctions between urban and rural insurance lie in which conditions they cover, their set premiums, and reimbursement rates. First, the combination of URMBI and UEBMI covers nearly all health needs—outpatient/inpatient services, critical illnesses, and the ability to purchase pharmaceuticals from hospitals.10 In contrast, NCRMS does not allow pharmaceutical purchases from hospitals, but only primary care clinics, where the selection is often of much worse quality. The coverage is also inextricably tied to the premiums, where the biggest disparity exists. NCRMS’s premium is 411 yuan per person as compared to
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hospitals generally do not even accept NCRMS, so rural citizens are forced to travel great distances to regional rural hospitals. This makes secondary-tertiary care near impossible. Upon arriving at these regional hospitals, rural citizens will find yet another startling truth—public health corruption. Chinese hospitals are riddled with corruption nationwide, from health prefects all the way down to clinic doctors. Hongbao, or red envelope bribes, are common incentives for doctors to speed ahead a patient while waiting for surgery. These bribes generally range from 1,000 to 1,600 yuan as an expected courtesy, where people who do not hand over a bribe will “stand out.”14 In addition, health prefects, doctors, and even drug providers are also known to peddle pharmaceuticals. One company was even indicted on charges of earning up to 490 million dollars by sending drugs to health professionals to be sold at inflated rates.15 From small pharmaceutical deals and bribes to larger scheme operations, corruption is an issue that plagues hospitals and specialized care in China. Therefore, between insurance discrepancies, organizational challenges, and widespread corruption, secondary-tertiary care is nearly impossible to achieve for Chinese citizens, especially in rural areas. Finally, the most important urban-rural disparity is arguably the health outcomes between patients. This information can be the most telling, as researchers are able to genuinely discover what happens when Chinese citizens fall ill and how they use the health system. While it is important to note that urban and rural populations are generally hospitalized with very different conditions—urban citizens are generally less disposed to large surgeries or catastrophic health events—the outcomes of rural Chinese citizens can often be less-thanstellar. The health outcomes that have been most heavily researched are childhood nutrition, infant mortality, and cancer survival. According to one study, rural Chinese children have significantly lower nutrition indexes, known as z-scores, when compared to urban children. Rural children had a mean z-score of 0.23 in height and 0.09 in weight, as compared to 0.25 and 0.15 for urban children.16 It seems that rural children are at a disadvantage to living healthy lives from the onset. Another pressing health issue in China is its remarkably high in-
fant mortality rate. The Chinese Ministry of Health noted that mortality rates are nearly five times higher in rural areas than wealthier urban ones—123 and 26 deaths per 1,000 live births, respectively.17 Another important health indicator, cancer survival rates, has very disparate outcomes as well. While cancer diagnosis rates remain relatively similar across all areas of China, in 2015, 109.5 urban citizens per 1000,000 people died of cancer as compared to 149 in rural areas.18 As seen by these alarming health outcomes, there is a serious issue with healthcare access in rural China as compared to urban China. The disparities in healthcare between urban and rural populations exist between the lines of insurance coverage and financial relief, obstructing care quality and equity of access. This most importantly trickles down to health outcomes, which ultimately demonstrate the geographic inequalities in Chinese healthcare. The state of the Chinese healthcare system is undoubtedly one of improvement, but also one of salient disparities between urban and rural citizens. As seen in rural southwest China and beyond, disparities continue to arise from population demographics, income gaps, resource allocation, governmental restrictions, and a variety of health indicators.
1. Sun, Gregersen, and Yuan, “Chinese Health Care System and Clinical Epidemiology.” 2. Ibid. 3. Jian Sun, Hai Gu, Qiulin Wen, and Hongye Luo, “Assessing Equity in the Distribution of High-technology Medical Equipment in Guangxi: Evidence from an Ethnic Minority Region in Southern China.” Accessed November 6, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5434632/. 4. Qi Wang and Jie Jiao, “Health Disparity and Cancer Health Disparity in China,” Asia-Pacific Journal of Oncology Nursing (2016): accessed November 4, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5214866/. 5. Sudhir Anand et. al, “China’s human resources for health: quantity, quality, and distribution,” Lancet (2008): 1774-81, Accessed November 19, 2017. https://scholar.harvard.edu/files/vfan/files/Anand_Fan_et_ al_2008.pdf. 6. “China rural-urban wage gap widens.” BBC News, January 16, 2009. http://news.bbc.co.uk/2/hi/asia-pacific/7833779.stm. 7. Win Lin Chou and Zijun Wang, “Regional Inequality in China’s Health Care Expenditures,” Health Economics (2009): accessed November 6, 2017, http://onlinelibrary.wiley.com/doi/10.1002/hec.1511/epdf. 8. Ibid. 9. “Mapping China’s Income Inequality.” The Atlantic, September 13, 2013, https://www.theatlantic.com/ china/archive/2013/09/mapping-chinas-income-inequality/279637/. 10. Sun, Gregersen, and Yuan, “Chinese Health Care System and Clinical Epidemiology.” 11. Ibid. 12. Ibid. 13. Ibid. 14. “How Corruption Blights China’s Health Care System.” Time, August 2, 2013, http://world.time. com/2013/08/02/corruption-blights-chinas-healthcare-system/. 15. Ibid. 16. Hong Liu, John A. Rizzo, and Hai Fang, “Urban-rural disparities in child nutrition-related health outcomes in China: The role of hukou policy,” BMC Public Health Journal (2015): accessed November 12, 2017, https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4657335/. 17. Qi Wang and Jie Jiao, “Health Disparity and Cancer Health Disparity in China.” 18. Ibid.
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urses form the cornerstone for healthcare institutions and delivery practices globally – from primary care in areas underserved by doctors, to playing crucial roles in complex critical care. Since the last 3 decades, international migration of nurses has intensified in scope and magnitude, creating a modern-day big business model of global health workers. Increasing nurse migration has prompted a global debate at the International Council of Nurses Congress in Copenhagen. It has affected domestic healthcare and training, as well as international immigration policy and human resource flow economics. The emerging trends of international nursing migration have traditionally been from developing and low-income countries towards the developed and wealthy nations. Nurses in developing home countries face expanded nursing duties as well as high volume of non-nursing tasks due to lack of manpower, leading to a high burnout rate. In addition, they do not receive sufficient remuneration for these long and grueling hours. As a result of these push-factors for foreign migration many developing nations are facing a “brain drain” of talented healthcare professionals, further exacerbating the problem.3 Nurses from Latin American and Caribbean countries largely migrate to the US not simply for better salaries, but instead spurred by deficient work environments at home and in pursuit of opportunities.5 Developed and wealthy nations exercise pull-factors on healthcare workers in poor working conditions: with improved pay, better quality of life, and career development. In developed countries, researchers have observed that the greatest pull occurs to certain geographic clusters like urban healthcare systems in California, Florida, and New 10 | PENN HEALTHCARE REVIEW | SPRING 2019
York. 4 A newer pattern of developed countries extensively recruiting nurses from each other 2 has created cyclical routes of migration. Bilateral agreements facilitate the efficient migration and exchange of human resources, especially in nations with comparable educational systems, post-colonial associations, or a lack of language barriers in English-speaking nations. For example, 40% of newly registered UK nurses were from Ireland before 2000. But with changing economies, Ireland began importing over half their new nurses, primarily UK nurses moving to Ireland in a reverse migration. 2 This situation is also beginning to affect US states, where nurses are recruited by large hospital systems from long-distance and multi-state areas with lucrative signing bonuses and perks. 6 International nurse migration adversely affects the healthcare and nursing initiatives of countries that nurses are pulled away from. For example, in Botswana, international resources like distribution of free ARVs (antiretroviral drugs) were available to address the HIV/AIDS epidemic. But this effort to improve immunization coverage was undermined not due to lack of funds- but largely by a lack of healthcare personnel to implement the public health efforts. 1 In the Philippines, government policy supports nurse export to developed nations, because the remittances sent home boosted their economy. But recently immense volumes of Filipino nurses seeking to work abroad, are straining the national nurse availability and patient-healthcare provider ratios.1 The benefits to rich and developed nations attracting healthcare workers include a seemingly “quick fix” of patient-provider ratios. In the US, a more diverse nursing force can better care for an increasingly diverse patient population.
For example Latin American nurses are in demand for their Spanish fluency. Exposure to nurses from different backgrounds also sensitizes domestic nurses to the spirit of providing care even in limited resources 5. However, this is having negative effects on the developed nations’ healthcare professional workforce projections 2 . Sending for readily trained nurses leads to neglect of domestic nurse education. In the US, though foreign nurses form a stop-gap 3.5% of the workforce, projections show severe deficits in the future which will not be met by domestic nursing students of today. This is largely a product
training, are in fact exceeded in these high costs to utilize foreign labor 2. Ultimately, such an “exporting” of the scarcity problem eventually accumulates as strong migration pressures on nurses from the poor or developing nations. In 2006 the World Health Organization implemented restrictions governing developed countries in foreign healthcare workers’ recruitment. But nursing migration remains relatively unchecked where some countries benefit at the cost of others 2. For example, “ethical recruitment” guidelines implemented in 1999 prohibited the direct recruitment of nurses from vulnerable regions in Africa by the NHS in England.
of the aging nurse workforce caring for an aging population. It is contended that women in developed countries prefer higher paying jobs to nursing, since the education must be financed by the student. So nursing schools are now promoting non-traditional applicants like men, minorities, and older returners.2 Another effect of this heavy nurse exportation is the lowering of quality in the nursing educational system of nurse-exporting countries like Philippines. Due to the inundation with students and non-availability of nursing scholars to teach the future candidates, very few new leaders of the field are produced and recognized 3. In order to counter this, some Latin American nations allocated more resources to creating and training their own domestic nurses as a sustainable solution. 1,4 But these well-qualified applicants were recruited to the developed countries, leading to loss of return on investment for developing countries. 5 As a result, an increasingly disputed topic is whether foreign recruitment is economically efficient for both the developing and developed nations. 5 Due to constant migration, developed countries must expend considerable resources in recruiting professionals from one developed country, and then on incentives to retain existing nurses. This means the apparent savings from neglecting to fund domestic nurse
Yet African nurses still migrate in high numbers to UK via the private sector. 1 Suggested solutions to address the fundamental deficiencies in each system are that countries should each develop a domestic nursing workforce that can serve their own population. On this flipside, many look toward a UK-Spain bilateral model, where nurses transition between the countries for fixed periods, as a template for novel ‘win-win’ strategies. In this era of globalization, it may no longer be feasible for each nation to create a self-sustainable workforce. 2 As healthcare becomes increasingly globalized, nurse migration will profoundly determine the impact on global healthcare initiatives of the future. 1 Aiken, Linda H., et al. “Trends in international nurse migration.” In Health affairs 23.3 (2004): 69-77. 2 Buchan, James. “Nurse migration and international recruitment.” In Nursing inquiry 8.4 (2001): 203204. 3 Brush, Barbara L. “Sending for nurses: Foreign nurse immigration to American hospitals, 1945--1980.” (1994). 4 Brush, Barbara L. “Global nurse migration today.” In Journal of Nursing Scholarship 40.1 (2008): 20-25. 5 Jacobson, Joy. “The Complexities of Nurse Migration.” In AJN The American Journal of Nursing 115.12 (2015): 22-23. 6 Kavilanz, Parija. “Hospitals offer big bonuses, free housing and tuition to recruit nurses.” In CNNMoney (New York) 8 Mar. 2018, 10:00 AM ET, http://money.cnn.com/2018/03/08/news/economy/nurse-hiring-bonuses/index.html 7 Thupayagale- Tshweneagae, G. “Migration of Nurses: Is There Any Other Option?” In International Nursing Review 54 (2007): 107–9.
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t is difficult to talk about weight in a healthy, productive manner. Fitness and health undeniably look different across body types and individuals, and it is important to recognize that weight is only one data point in the health assessment. Still, it is apparent unhealthy trends are present in regard to the nation’s obesity epidemic. In 2018, American obesity rates ranged nationwide from 22.6% in Colorado to 38.1% in West Virginia.1 The normalization of large meal portions, processed food, and physical inactivity have altered the body composition of today’s average American and threatened public health.2 The effects of the obesity epidemic are present across almost all facets of society. Obesity increases an individual’s risk for heart disease, hypertension, and Type II diabetes. Obesity is also linked to social stigma, as Western society moralistically assigns negative attributes to obesity in a manner unique 12 | PENN HEALTHCARE REVIEW | SPRING 2019
from other health concerns.3 It is imperative to promote healthcare access to those impacted by obesity beyond the fundamental barriers present in addressing weight and body image. Promoting healthcare access for the obese population in America starts with how healthcare providers communicate about obesity. Problems with how obesity is handled in healthcare start with definitions based solely on BMI. BMI calculates a person’s weight in kilograms divided by their height in meters. To be classified as obese, an individual must have a Body Mass Index (BMI) of 30 or higher. However, there are severe inconsistencies in using BMI as a health tool since it only measures excess weight, not excess fat.4 BMI is unable to distinguish between fat and muscle in particular, leading some healthy athletic individuals to falsely flag as at-risk for projected health concerns. The entire Denver
Broncos team, for example, is classified as obese despite their athletic and active lifestyle.5 Additionally BMI was first invented in 1830 as an economic census tool by Belgian mathematician Lambert Adolphe Jacques Quetelet, who warned it should be used as a generalization and not as a diagnosis of individual health.6 Also, BMI is interpreted using ranges and classifications, which provide mere suggestions and advisement of general trends. An individual on the border of classifications for example with a 29.9 BMI is classified drastically differently from a 30 BMI individual even though in reality they have similar body mass. Therefore BMI should not be the primary source of defining weight-related health projections. Obesity and associated health concerns are not assigned the impartial labeling of typical health factors.
Scientific, impartial language is an important component in diagnosis and treatment planning for most common illnesses and conditions, but there is a severe lapse when articulating the health concerns of obesity. At wellness or sick medical visits, patients expect clinical and impartial explanations from their practitioner that inform and educate them on the best options to improve their health. When seeking treatment for health conditions, patients commonly hear about medication in combination with potential lifestyle adjustments. Arguably most medical problems are well-defined even if there is not a cure or accessible treatment. The medical community generally can identify what is unknown and known in the field and concisely but thoroughly explain it to the patient. Precision of language when dealing with health topics is important for many reasons and is an integral component of both health access and medical consent. Obese patients should be made aware of their options and the different ways their choices will impact their health to the same extent as other patients. Therefore, it is up to the US health system to create norms for respectfully and responsibly communicating about obesity with patients.
It is also imperative that obesity not be treated as a patient’s only health factor. When obese individuals seek health treatment, all too often practitioners entirely associate presented symptoms with obesity without further investigating other factors. On average doctors spend 28% less time with obese patients and conduct less diagnostic testing.7 In a study with medical students 54% of obese patients experiencing shortness of breath were given lifestyle recommendations while only 13% of nonobese patients received such advisement.8 In the same study 23% of non-obese patients were recommended medication while only 5% of obese patients received medication, demonstrating heavy bias.9 Dr. Louis Arrone founded the American Board of Obesity Medicine to combat this trend. He quoted patients saying, “Nobody has ever treated me like I have a serious problem. They blow it off and tell me to go to Weight Watchers.”10 One instance of this overlooking occurred when Patty Nece went to an orthopedist for hip pain, and he diagnosed her with “obesity pain” without ever physically examining her.11 She later was diagnosed appropriately with progressive scoliosis, an unrelated condition. Obesity healthcare gaps are not an isolated problem but an overlying issue that demonstrates a lack of holistic adaptation in the medical field. 21% of overweight respondents in a Johns Hopkins survey reported feeling judged by their primary care doctor, discouraging them from attending regular checkups.12 Implicit and explicit bias from practitioners stemming from stereotyping is shown to produce worse healthcare and poorer health outcomes for obese patients, validating this concern. In many cases these interactions are centered around what labels are used to discuss the role of obesity in both personal health, public health, and the healthcare industry. In order to best promote health, the American healthcare system needs to better define and appropriately communicate to patients about obesity in a way that prioritizes health access and empowers patients. 1. “Obesity Rates and Trend Data,” The State of Obesity, Robert Wood Foundation, September 2018. 2. “Obesity in America,” Public Health Public Awareness, 2018. 3. Alexandra Brewis, Amber Wutich, Ashlan Falletta-Cowden, Isa Rodriguez-Soto, “Body Norms and Fat Stigma in Global Perspective,” Current Anthropology, 19 IX 10, September 19, 2010. 4. “Body Mass Index: Considerations for Practitioners,” Department of Health and Human Services Center for Disease Control and Prevention. 5. Angus Chen, “If BMI Is The Test of Health, Pro Athletes Would Flunk,” Shots Health News from NPR, February 4, 2016. 6. Keith Devlin, “Top 10 Reasons Why the BMI Is Bogus,” National Public Radio, July 4, 2009. 7. S. M. Phelan, D. J. Burgess, M. W. Yeazel, W.L. Hellerstedt, J. M. Griffin, M. van Ryn, “Impact of weight bias and stigma on quality of care and outcomes with obesity,” Obesity Reviews, vol 16, 4, March 5, 2015. 8. Ibid. 9. Ibid. 10. Gina Kolata, “Why Do Obese Patients Get Worse Care? Many Doctors Don’t See Past the Fat,” The New York Times, September 25, 2016. 11. Ibid. 12. Tory Johnson, “Fear of Fat Talk Kept Me From My Doctor for a Decade,” Evidence-Based Diabetes Management, October 2014.
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rtificial intelligence (AI) is at the forefront of medical innovation. Companies in the healthcare space have begun implementing AI technologies to make predictions and approximate decisions through analysis of vast amounts of medical data. Bill Gates’ Microsoft has recently ventured into the realm of healthcare —the company recently unveiled a new Healthcare Bot chatbot service. The technology provides a platform that empowers healthcare organizations to build and deploy an AI-powered conversational healthcare experience. With Microsoft’s immense capital and technological resources, they are equipped to make rapid innovations in the field of healthcare, resolving some of America’s most pressing health needs. All the jargon aside, the technology includes a builtin symptom checker and can even understand medical terminology. Other functions associated with the product include triaging patients, understanding insurance claims and co-pays, or simply identifying the closest in-network hospital.1 The Healthcare Bot is part of Microsoft’s Healthcare NExT Initiative, which “aims to accelerate healthcare innovation through artificial intelligence and cloud computing.” The Healthcare Bot is just one of many services that Amazon intends to develop for commercialization, including Microsoft Genomics and Project Empower MD, both of which employ AI-based technologies.2 Healthcare Bot chatbot began as a hackathon innovation but was commercialized within a mere year under Microsoft’s healthcare partners, including Aurora Healthcare and Premera BlueCross.3 At its core, the technology is similar
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to a conversational flow with text boxes. The service taps built-in triage protocol databases, handles appointment scheduling, and uses Microsoft Azure’s natural language processing (NLP) technology, which can handle topic changes, human error, and complex medical questions. The technology is encrypted and fully compliant with HIPAA, the U.S. laws that provide data privacy and security for guarding personalized health information (PHI). Seeking to cut inefficiencies in the healthcare system, the chatbot eases burdens from the healthcare system and helps health providers optimize their time. The technology also lets disparate health systems talk to each other, providing better connectivity and more information to providers. In a sense, the venture is also empowering for the the patient, who has more control over his or her own health. A study by Juniper Research found that chabtots could lead to cost savings of over $8 billion by 2020. Another study published by Statista found that 27 percent of people would prefer to answer their questions by virtual assistants than by people.3,4 Therefore, Microsoft is making headway in a market with significant potential for growth. They are working in a growing market of Healthcare Bot chatbots, which have had a measurable real-world impact. For instance, multibillion-dollar Quest Diagnostics employed a bot that helped people who visited their website during call center hours to find testing locations and schedule appointments. In a post-deployment survey, 50 percent preferred engaging with such a chatbot. Microsoft has long had interests in healthcare. In 2007, the company launched a web-based personal health record (PHR) that stored and
maintained health and fitness information. Acting as a repository of information, the website expanded beyond the United States in June of 2010, spreading to parts of the United Kingdom and Europe.5 The technology integrates Microsoft’s cloud computing services (i.e., Azure) into the healthcare field, which makes data processing more efficient. There are several benefits to utilizing artificial intelligence in healthcare. Learning algorithms can become more precise over time, contain vast quantities of data, and process routine requests much easier than traditional analytics and clinical decision-making techniques.6 However, there are several concerns these technological advances pose. The growing role of cloud computing infrastructure has presented legal and regulatory challenges. Protecting data security and patient privacy can cause pitfalls such breaches. There are questions concerning accountability and ambiguity surrounding data collection processes. Although there are no ready solutions, Microsoft has been taking steps to ensure that its technology is HIPAA-compliant, as
previously mentioned.7 It is an exciting time in the healthcare industry—organizations are utilizing their capital and resources to address inefficiencies in the market. That also means competition for Microsoft. Most recently, Amazon-Berkshire-JPM announced its goal to address the problems of the country’s high-cost, convoluted medical infrastructure. Working messaging app Slack also announced that it is HIPAA compliant, and Apple has began work on making medical records portable.8 The healthcare industry is ripe for some major changes, and Microsoft’s work is only a step in the right direction. The company has lofty ambitions, but one thing is for sure: if it cuts healthcare costs through safe and secure means, then it is a step in the right direction. 1. Thorne, James. “Microsoft Healthcare Reveals More of Its Strategy with New Cloud and AI Products for Hospitals.” Geekwire. 2. Lee, Peter. “Microsoft’s Focus on Transforming Healthcare: Intelligent Health through AI and the Cloud.” 3. Wiggers, Kyle. “Microsoft’s Healthcare Bot service becomes generally available in Azure Marketplace.” VentureBeat. 4. Bass, Dina. “Microsoft Aims to Connect Patient Health Records in the Cloud.” Bloomberg. 5. Hachman, Mark. “Microsoft Launches ‘HealthVault’ Records-Storage Site.” PC Magazine 6. Bresnick, Jennifer . “Top 12 Ways Artificial Intelligence Will Impact Healthcare.” Health IT Analytics. 7. PokitDok Team. “The Challenges And Opportunities Of Implementing AI In Healthcare.” PokitDok. 8. Thorne, James. “Microsoft Healthcare reveals more of its strategy with new cloud and AI products for hospitals.” GeekWire.
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he upcoming years will be crucial for the healthcare industry as there is an inevitable migration of healthcare data to digital platforms and technologies. Cloud-based technology, for instance, is driving healthcare systems towards a delivery of care centered on information, efficiency and accessibility, and healthcare cloud computing services are transitioning from service managers to service providers—and, in doing so, are changing the face of healthcare. The implications and possibilities for innovation arising from rapidly-changing healthcare IT infrastructure and data services open the door to clinical considerations and capabilities never before considered. Starting with the basics: what is cloud-based technology? Cloud-based platforms enable access to data, applications, and storage not stored on the physical computer in use. Cloud computing technology delivers computing in a manner akin to a power grid delivering electricity, and just as people can access electricity without being electricians, healthcare providers can utilize computing services without requiring specialized technical knowledge or additional IT infrastructure.1 The result is a cost-effective, highly-agile system that delivers its software, platform and infrastructure components as services—not products. Integrating healthcare information, connecting healthcare institutions, and managing patient records, scheduling, billing, and charting is faster and easier for healthcare providers, who in turn provide a more modern and efficient service to patients. Cloud-based technology’s ability to expand patient and provider possibilities is no secret; growth in the industry has been exponential as private companies race to offer innovative, sleek software to healthcare institutions moving along with a mass migration of their data to digital platforms. Med Tech Solutions—which offers a cloud technology boasting security, speed, convenience, scalability, and disaster recovery – recently acquired healthcare-focused IT provider Compex with the goal of promoting continued growth by expanding its presence in the Pacific Northwest and amplifying its IT expertise.2 On the other side of the world, with hospitals across India, Fortis Healthcare embarked upon a mission to 16 | PENN HEALTHCARE REVIEW | SPRING 2019
transform its IT into a service provider rather than a service manager. The company, constrained by a localized and fragmented IT, migrated to Microsoft’s cloud computing service Azure. As a result, the complexity of testing and expanding new applications—such a Hospital Information System, Oracle Financials, Oracle Supply Chain, and more—markedly decreased, allowing for exploits such as Fortis launching its Patient Care Portal in one day as opposed to the 3 to 4 months the project was previously estimated to take. Fortis has also reported improved patient care experiences.3 With cloud-based technology, healthcare institutions are equipped to deliver better outcomes that bolster their bottom line, provider performance, and patient satisfaction. As a new era in healthcare data systems begins, it must account for the rapidly-changing laws and regulations governing the highly-sensitive data it seeks to utilize. The collection and privacy of private health information – or PHI —is tightly controlled, creating unique challenges in the healthcare industry’s adoption of cloud-based technologies as it navigates considerable security requirements and compliance with healthcare standards. Several service providers have emerged whose primary function is ensuring that cloud-utilizing clients adhere to certified standards of security and compliance. One of those service providers is ClearDATA – which employs compliance and security safeguards, purpose-built DevOps automation, and healthcare expertise to provide solutions to healthcare security needs.4 ClearDATA recently announced a partnership with Google Cloud to advance healthcare innovation and scale healthcare IT infrastructure. Darin Brannan, CEO of ClearDATA, stated: “Our partnership with Google Cloud gives those wanting to innovate on Google Cloud Platform the chance to do so in a secure and compliant environment without fear of compromising sensitive health data, ultimately increasing their opportunities to advance healthcare and improve patient outcomes.”5 And less than one week later, ClearDATA announced the launch of a healthcare compliant offering for Microsoft Azure. “Many healthcare organizations today face an increased strain of pursuing a digital transformation
strategy while also remaining compliant with an evolving regulatory landscape,” said Dr. Simon Kos, chief medical officer at Microsoft. “Organizations working with ClearDATA technology on Azure get an added layer of security and compliance capabilities that are critical to the healthcare industry.”6 ClearDATA is just one of many companies enhancing the innovation within and security of healthcare-related cloud computing services. The revolution of cloud-based technologies transforming the healthcare industry has just begun. On the horizon loom reduced business costs, heightened flexibility and performance, improved provider and patient experiences, and an innovative and secure environment for developers
working in the healthcare industry. And as cloud companies race to provide solutions to the needs of healthcare clients, the boundaries of what was once thought to be possible are pushed—revealing a landscape of yet more opportunity. 1. “Cloud Computing Overview,” Apprenda, , accessed October 21, 2018, https://apprenda.com/library/ cloud/. 2. “MTS Expands Services in the Pacific Northwest,” Med Tech Solutions, September 18, 2018, , accessed October 21, 2018, https://www.medtechsolutions.com/blog/med-tech-solutions-announces-acquisition-of-compex-inc/. 3. “Fortis Healthcare: The Tech Edge,” General OneFile, July 10, 2018, , accessed November 3, 2018, http:// go.galegroup.com/ps/i.do?p=ITOF&u=upenn_main&id=GALE|A546044424&v=2.1&it=r&sid=summon#. 4. “Solutions,” ClearDATA, , accessed November 3, 2018, https://www.cleardata.com/solutions/. 5. “ClearDATA and Google Cloud Form Partnership to to Accelerate Healthcare Innovation,” General OneFile, July 23, 2018, , accessed November 1, 2018, http://go.galegroup.com/ps/i.do?p=ITOF&u=upenn_ main&id=GALE|A547391613&v=2.1&it=r&sid=summon. 6. “ClearDATA Introduces Healthcare Compliant Cloud Offering on Microsoft Azure,” Business Insights: Global, July 29, 2018, , accessed November 2, 2018, http://bi.galegroup.com/global/article/ GALE|A548063817?u=upenn_main&sid=summon.
Infographic designed by Chloe Le
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ith the advancement of artificial intelligence, there arose many concerns regarding a potential takeover of many job markets, including healthcare and medicine, by robots. Automation is predicted to have a momentous impact on the global workforce, and it is estimated to eliminate 73 million jobs in the United States by 2030.1 With enough advancement in artificial intelligence, machines could potentially be programmed to treat patients in hospitals in the absence of doctors or nurses. Using computers and robots could be significantly more efficient than relying on human healthcare providers. In fact, robots are already used in surgical procedures today. These robots, however, are not programmed to replace surgeons; instead, they are fully operated by surgeons.2 Technology still needs to undergo a lot of work and improvement to make autonomous surgical robots possible. Although surgeries conducted by autonomous robots cannot happen in the near future, machine learning, which is a type of artificial intelligence, will increasingly affect physicians and their patients. Artificial intelligence is machine-demonstrated intelligence that allows computer systems to perform tasks that would normally require human intelligence by processing immense amounts of data and recognizing patterns in them.3 Machine learning is a branch of AI that makes use of algorithms that can recognize, learn, and respond to big data sets by identifying patterns with minimal intervention by humans.4 Techniques of artificial intelligence help improve precision, accuracy, and dexterity of surgical robots. With the approval of robot-assisted surgery by the Food and Drug Administration in 2000, the technique has been expanding for use in treatment of a variety of conditions.5 Currently, hospitals are using robots to help out with surgical procedures with more flexibility, precision, and control than is possible with human 18 | PENN HEALTHCARE REVIEW | SPRING 2019
techniques. Robot-assisted surgery is used mainly for minimally-invasive surgeries, but certain open surgical procedures utilize it as well. Robots contain a camera and mechanical arms that are equipped with surgical instruments. Surgeons controls the robotic arms while observing the operation from a computer console, which provides a magnified, high-definition view of the surgical site that is unable to be seen with the naked eye.6 Then the surgeon leads other members who are assisting the surgery. There are notable advantages of robotic surgery. As mentioned above, performing surgery by using the robotic system enhances accuracy, precision, and control during the operation. Surgeons are able to perform complicated and delicate surgical procedures that could have been difficult or not even possible by traditional surgical methods. Another benefit of robot-assisted surgery is that minimally invasive surgeries are possible. Minimally invasive surgeries are valuable because they lead to fewer surgical complications, faster recovery, less blood loss and pain, and smaller surgical scars.7 In the future, robotic arms could be able to provide decision support for clinicians through the use of machine learning. With such mechanism, there could be a reduction in the number of operations needed or a change in the type of surgical procedure performed6. Physicians have the responsibility of making decisions after looking though all the available information for each patient. AI can help physicians by comparing the available patient-specific data to data available for thousands of different patients; this process cannot be done manually.8 AI can compare different data and suggest that a certain intervention may or may not work on a certain patient based on previous data sets. Machine learning in healthcare is used to provide increased efficiency and safety of clinical procedures, not to create machines that will take over the roles of human physicians entirely.
However, there are evident setbacks of machine learning. Machine learning performs the best with a predictable world.9 It works well in the digital world inside a computer because such environment is stable and predictable. Machines imposed in the real world will inevitably face trouble because they cannot make sense of the changing, unpredictable environment. For example, interpreting what is happening from a camera image of a soft tissue is beyond the capability of a machine.10 In addition, collecting patient data is not a streamline process.11 Thus, collecting enough quantity of data to allow machine learning to be done is not entirely feasible. Many hospitals still use paper documents as patients’ charts, so it is difficult to extract the right kind of data that algorithms can be applied to.12 Also, surgery is an utterly complicated and complex procedure, and the level of complexity required is unattainable through contemporary robotic systems. Above all, there are humanistic elements, such as empathy, in healthcare that cannot be replaced by artificial intelligence. Medicine, in essence, is about relationships
between healthcare providers and patients. Although machines could provide greater precision and accuracy, it is utterly difficult for robots to even imitate uniquely human components. 1. James Manyika et al., “Jobs Lost, Jobs Gained: What the Future of Work Will Mean for Jobs, Skills, and Wages,” McKinsey & Company, accessed February 16, 2019, https://www.mckinsey.com/featured-insights/future-of-work/jobs-lost-jobs-gained-what-the-future-ofwork-will-mean-for-jobs-skills-and-wages. 2. Aruni, Ghose, Ghose Amit, and Prokar Dasgupta. “New Surgical Robots on the Horizon and the Potential Role of Artificial Intelligence.” Investigative and Clinical Urology 59, no. 4 (July 2018): 221. doi:10.4111/ icu.2018.59.4.221. 3. “Artificial Intelligence – What It Is and Why It Matters.” SAS. Accessed February 16, 2019. https://www.sas.com/en_us/insights/analytics/what-is-artificial-intelligence.html. 4. “Machine Learning: What It Is and Why It Matters.” SAS. Accessed February 18, 2019. https://www.sas.com/en_us/insights/analytics/machine-learning.html. 5. “Robotic Surgery.” Mayo Clinic. January 30, 2019. Accessed February 18, 2019. https://www.mayoclinic.org/tests-procedures/robotic-surgery/about/pac-20394974. 6. “Robotic Surgery.” Mayo Clinic. January 30, 2019. Accessed February 18, 2019. https://www.mayoclinic.org/tests-procedures/robotic-surgery/about/pac-20394974. 7. “Robotic Surgery.” Mayo Clinic. January 30, 2019. Accessed February 18, 2019. https://www.mayoclinic.org/tests-procedures/robotic-surgery/about/pac-20394974. 8. Sayburn, Anna. “Artificial Intelligence in Healthcare | Ccentric Group.” Accessed February 17, 2019. https://www.ccentricgroup.com/2018/12/10/artificial-intelligence-in-healthcare/. 9. Sayburn, Anna. “Artificial Intelligence in Healthcare | Ccentric Group.” Accessed February 17, 2019. https://www.ccentricgroup.com/2018/12/10/artificial-intelligence-in-healthcare/. 10. Sayburn, Anna. “Artificial Intelligence in Healthcare | Ccentric Group.” Accessed February 17, 2019. https://www.ccentricgroup.com/2018/12/10/artificial-intelligence-in-healthcare/. 11. Sayburn, Anna. “Artificial Intelligence in Healthcare | Ccentric Group.” Accessed February 17, 2019. https://www.ccentricgroup.com/2018/12/10/artificial-intelligence-in-healthcare/. 12. Sayburn, Anna. “Artificial Intelligence in Healthcare | Ccentric Group.” Accessed February 17, 2019. https://www.ccentricgroup.com/2018/12/10/artificial-intelligence-in-healthcare/.
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edical school tuition has been steadily increasing for decades.1 Becoming a physician was worth the cost of the education less than two decades ago. The average cost of medical school in 2000 was $100,0002, and most physicians, regardless of their specialties, could pay off their loans for this amount in less than 3 years. Now, it costs $250,000 and many physicians either require 10 years to pay that off, or they go into high paying specialties because they can’t afford to pay off their loans in a low paying specialty.3 This is simply not acceptable, and it is one of the principle driving forces behind the current high cost of health care. In order to reduce the cost of medical care and improve the quality of care in the United States, we must begin by reducing the high cost of medical education. Today, the costs may exceed the benefits, and bright students with potential are forced into financially damning circumstances just to achieve their dreams and help others. Almost half of medical school students graduate with more than $200,000 in debt for the four years of medical education.4 An otherwise bright, motivated student will be at the hands of high tuition costs, unable to pay them or pursue medicine. The dreams of those students of becoming a physician in the future continue to remain as dreams. Furthermore, medical students are led to choosing higher-paying specialties instead of going into primary care due to this high cost of medical education, which is exacerbating the physician shortage, especially in rural and underserved areas, leading to worse population health outcomes.5 According to a study conducted by the Association of American Medical Colleges, students of a higher socioeconomic status are more likely to be accepted into 20 | PENN HEALTHCARE REVIEW | SPRING 2019
medical schools than those with lower socioeconomic status regardless of their MCAT score.6 In the past 10 years, around 15 percent of matriculants of medical schools across the country are students with a lower socioeconomic status. However, 58.3 percent of matriculants are from a high socioeconomic status background.7 Beyond lowering the quality of patient care and discriminating against students from less-advantaged backgrounds, the high cost of medical education increases the cost of healthcare in the United States. It’s not just that the high cost of medical education lowered the quality of patient care. Or that the medical school admissions are discriminating against students from a poorer background The dilemma is that the high cost of medical education is increasing the cost of healthcare in the United States. For most students pursuing a medical education after their undergraduate degree, especially those from expensive, private undergraduate schools, are already covered in debt. Not only that, but they are expected to lose 4 years of pays for their medical education in addition to the already unreasonably high tuition costs from medical school, housing, food, and other inevitable expenses.8 This dilemma ultimately increases the pay of physicians, as well as the cost of healthcare in America. At the end of the day, healthcare consumers suffer the burden of increased costs, or are forced to choose between going into debt and going without sufficient care. According to a study published by Cornell University, the average compensations for specialists and general practitioners in the United States are $230,000 and $161,000 respectively.9 As a comparison, the world’s average compensations (excluding the United States) for
specialists and general practitioners are $107,000 and $78,000 respectively. This is more than doubled of the compensations received by physicians around the world. The origin of this dilemma is the high cost of medical education in the United States as the study also shows that most medical students in Europe and Canada graduate on average with only $129,943 of debt, which is half of what medical students in the United States graduated with. According to the 2016 Census, there are almost 1 million physicians in the United States serving around 323 million people in total.10 With the difference in the compensations in physicians between the United States and European countries, the high costs of medical education costs Americans could potentially be high as 125 billions of dollars each year. Some may argue that even if we reduce the cost of medical education in the United States, it will have no effect on the overall cost of medical care due to the high cost of medical technologies and drugs in the United States. While the prices of life-saving drugs are considerably more expensive in the United States than the rest of the world, the cost of medical drugs are only accounted for 15 percent of the overall cost of the medical care in the United States.11 According to the Centers for Medicare and Medicaid Services, over 55 percent of the costs of medical care in the United States are accounted for by hospital cares (both inpatient and outpatient environments) and services provided by physicians.12 While it might be unreasonable to ask medical school across the country to subsidize the cost of the medical education alone and operate on a loss, it is probable for
the Department of Education in the federal government to increase its funding toward domestic medical students enrolling in the United States or helping them in repaying their loans. As the federal and state governments are often asked to subsidize the cost of medical care for the population of low-incomes, the funding that the federal government spending on subsidizing the medical education of future physicians, it will ultimately decrease the amount of money the federal and state governments are spending on Medicare and Medicaid, which is beneficial to the government and the country as a whole in lowering the overall spending and accessibility of quality healthcare.
1. Amadeo, Kimberly. “See for Yourself If Obamacare Increased Health Care Costs.” The Balance Small Business, The Balance, www.thebalance.com/causes-of-rising-healthcare-costs-4064878. 2. Bunton, S. “An Updated Look at Attendance Cost and Medical Student Debt at U.S. Medical Schools.” Association of American Medical Colleges (2017): 145-158. 3. “IS MEDICAL SCHOOL WORTH IT FINANCIALLY?” Best Medical Degrees, 2017, www.bestmedicaldegrees. com/is-medical-school-worth-it-financially/. 4. Bunton, S. “An Updated Look at Attendance Cost and Medical Student Debt at U.S. Medical Schools.” Association of American Medical Colleges (2017): 145-158. 5. Mintz, Matthew. “Why Aren’t Medical Students Choosing Primary Care (and Why They Should).” Primary Care Progress, Primary Care Progress, 16 Feb. 2012, www.primarycareprogress.org/progress-notes/whymed-students-arent-choosing-primary-care/. 6. Grbic, Douglas, et al. “Effective Practices for Using the AAMC Socioeconomic Status Indicators in Medical School Admissions.” AAMC, www.aamc.org/download/330166/data/seseffectivepractices.pdf. 7. Grbic, Douglas, et al. “Effective Practices for Using the AAMC Socioeconomic Status Indicators in Medical School Admissions.” AAMC, www.aamc.org/download/330166/data/seseffectivepractices.pdf. 8. Grischkan, J., et al. “Distribution of Medical Education Debt by Specialty, 2010-2016.” Journal of the Americna Medical Association (2017): 1532-1535. 9. Peterson, Chris, and Rachel Burton. “U.S. Health Care Spending: Comparison with Other OECD Countries.” Cornell University, 17 Sept. 2007, digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1316&context=key_workplace&seiredir=1. 10. Young, Aaron, et al. “A Census of Actively Licensed Physicians in the United States, 2016.” FSMB.ORG, 2016, www.fsmb.org/siteassets/advocacy/publications/2016census.pdf. 11. “CMS Office of the Actuary Releases 2017 National Health Expenditures.” CMS, The Centers for Medicare & Medicaid Services, 2017, www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2017-national-health-expenditures. 12. “CMS Office of the Actuary Releases 2017 National Health Expenditures.” CMS, The Centers for Medicare & Medicaid Services, 2017, www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2017-national-health-expenditures.
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n the US and around the world, it feels like there is a new article every day discussing how pharmaceutical drugs cost exorbitant amounts of money for patients and pennies to make.1, 2, 3 But if drugs are so expensive, why do insurance companies still cover them? While the simple answer is that people need them, isn’t there some point where people would decide “that’s it, I’m out!” and not buy the drug altogether? That’s the question that drug makers and governments ask when they set drug prices. So, what is this mysterious price point where a drug no longer becomes worth it and how do different governments apply this valuation? In this article, we will look at how drugs are priced in the U.S., compare that to other countries’ systems and go over why the American system needs to change. The tension in drug pricing can be explained as two opposing forces: static efficiency and dynamic efficiency. Static efficiency is efficiency today. A drug exists; what is the most efficient way to get this to as many people as possible? Static efficiency favors low prices and solving operational problems first. Dynamic efficiency is efficiency tomorrow and focuses on risk and return/investment problems. If there is an untreatable disease, money should be raised to discover a new treatment, using the promise of a high reward to fuel the initial investment. Dynamic efficiency favors high drug prices to fund great quality of drugs and innovation.4 The US tends to favor dynamic efficiency over static efficiency. The US does not negotiate drug prices on a national level, allowing companies to set the prices for the drugs they produce. While there are corporate entities like Pharmacy Benefit Managers, or PBMs, that do negotiate down drug prices, the American pricing freedoms have led to the U.S. having the highest drug prices in the world by a significant margin.5 As a result of the U.S. tending to favor dynamic efficiency,
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there are high quality drugs being discovered but access problems for many patients. On one hand, pharmaceutical companies focus primarily on diseases prevalent in the U.S., as shown by the spike in research into diseases that affect the elderly as soon as Medicare Part D came into effect.6 This gives the U.S. a lot of power in ensuring its wealthy citizens are always front of mind for pharmaceutical companies. On the other hand, there are tens of millions who can’t afford adequate insurance in the U.S.7 Are these cutting-edge treatments worth it if nearly one third of the U.S. population can’t access them? There must be some sort of balance between static and dynamic efficiency that would be preferable over this approach. To answer that problem, look to value based pricing, the method of choice in Europe and for single payer systems around the world. Value based pricing is the idea that every drug’s effects can be converted into health units, called Quality Adjusted Life Years, or QALYs.8 If a negotiator sets a maximum willingness to pay per QALY provided by the drug, the negotiator can calculate a price for every drug based not on what the market will bear but instead on the value the drug provides to people. This method of price calculation is what Canada and Europe use in their bureaus of health to negotiate down drug prices. This becomes an incredibly powerful tool in shaping healthcare policy but can only be leveraged effectively if the U.S. decides to negotiate on a national level. However, such a massive change would have huge ripple effects throughout the healthcare economy. First, there are a lot of advantages to value based pricing, such as lower and more stable drug prices. In addition, since prices are directly tied to the effective-
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ness of a drug, there is an incentive to invest more into innovative and novel treatments since those will be the drugs that can be sold for the most. With all of these benefits, what would happen, then, if the US were to implement a national formulary with value based pricing at its core? The US has one key factor that makes it different from Europe when it comes to thinking about lowering prices and that is the size of the market. In Europe, if one country decides they want to pay less, the total rate of innovation doesn’t decrease that significantly since they don’t represent a large enough share of the market to actually dictate the pace of Research & Development. The US is 33% of the global drug market.9 If the US asks for value based prices, which are often lower than current prices in the US, there will be a tangible effect on the rate of innovation. But with this cost comes a potentially worthwhile benefit. Value based prices would mean lower premiums and costs to consumers which would mean greater market access. In addition, groundbreaking drugs would still get invented. The drugs that are truly innovative have value based prices in the hundreds of thousands of dollars, as shown by the Institute for Clinical and Economic Review agreeing with the price of Novartis’s $500,000 CAR-T cancer treatment.10 While the US might lose the power of being a dynamic efficiency focused country, it would gain a balance of static and
dynamic efficiencies that would pull a third of its citizens decades forward by giving them access to insurance and, more importantly, potentially lifesaving medicines. The drug pricing debate is really a debate over whether more money should be invested into research or if we should reap the benefits of research so far. Value based pricing provides a way to fairly balance these two concepts. While it wouldn’t have the same benefits to innovation as an entirely quality focused economy nor the access of an entirely access focused economy, it provides a healthy way to push for the medicines of tomorrow while making sure people can actually access the medicines of today. 1. Wiseman, Paul. “A Political ‘bomb’ over Drug Prices Could Threaten NAFTA 2.0.” San Francisco Chronicle. February 12, 2019. Accessed February 12, 2019. https://www.sfchronicle.com/news/article/A-political-bombover-drug-prices-could-13610301.php. 2. Sable-Smith, Bram. “American Travelers Seek Cheaper Prescription Drugs In Mexico And Beyond.” NPR. February 11, 2019. Accessed February 12, 2019. https://www.npr.org/sections/healthshots/2019/02/11/691467587/americans-seek-cheaper-meds-in-mexico. 3. Frank, Richard G. “Pharmaceutical Industry Profits And Research And Development.” The Physician Payments Sunshine Act. Accessed February 12, 2019. https://www.healthaffairs.org/do/10.1377/ hblog20171113.880918/full/. 4. Pettinger, Tejvan. “Static Efficiency.” Economics Help. Accessed February 12, 2019. https://www.economicshelp.org/blog/glossary/static-efficiency/. 5. “How the U.S. Pays 3 Times More for Drugs.” Scientific American. Accessed February 12, 2019. https://www. scientificamerican.com/article/how-the-u-s-pays-3-times-more-for-drugs/. 6. Kliff, Sarah. “The True Story of America’s Sky-high Prescription Drug Prices.” Vox.com. May 10, 2018. Accessed February 12, 2019. https://www.vox.com/science-and-health/2016/11/30/12945756/prescription-drug-prices-explained. 7. “The Uninsured.” PBS. Accessed February 12, 2019. https://www.pbs.org/healthcarecrisis/uninsured.html. 8. “Glossary.” Guidance and Guidelines | NICE. Accessed February 12, 2019. https://www.nice.org.uk/glossary?letter=q. 9. “Pharma Revenue: Worldwide Share by Country 2017 | Statistic.” Statista. Accessed February 12, 2019. https://www.statista.com/statistics/784420/share-of-worldwide-pharma-revenue-by-country/. 10. “CAR-T Therapies: Final Evidence Report.” ICER. Accessed February 12, 2019. https://icer-review.org/material/car-t-final-report/.
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ong Kong—a city of a dense, growing and aging population—faces an immense demand for public medical care. The population relies heavily on its public healthcare system, yet the problem of a physician shortage in public hospitals surfaced in recent years. Together with the aging population problem, it is important to look into the ways for alleviating the lack of doctors. A few policies were proposed by Legislators: to enlarge the admission in local medical schools, to invite overseas-trained doctors, and to improve the working condition in public hospitals to attract doctors in private sectors transfer to the public one. Before deciding which, or if any, of these proposals could be accepted by the government, it is crucial to understand the reason for the shortage. According to the University of Hong Kong, the physician shortage in public hospitals in the city had reached 400 in 2016,1 which has created various problems. For instance, the quality of public medical care decreases. According to statistics from the Hospital Authority, one third of the public hospitals are not able to meet the target of treating 90% of the patient in the Emergency Department within thirty minutes for the Category 3 urgent cases,2 delaying patients from receiving the medical care needed and degrading the medical care quality. One contributing factor is the decreasing trend in the number of medical graduates. In the year of 1996 and 2003,3 due to an oversupply of medical graduates, two medical schools in Hong Kong decided to admit less students.4 The decrease in the number of medical graduates in turns lowers physician supply. In addition, the situation is exacerbated by the retirement wave taking place. The number of retiring doctors has increased from 27 per year in 2015 to 68 in 2016. Hospital Authority also predicts that there will be a total of 1100 doctors retiring in the coming 15 years.5 Last but not least, the working environment helps make a triple hit to the issue. From the result of the survey con24 | PENN HEALTHCARE REVIEW | SPRING 2019
ducted by Legislative council member Dr. Leung Ka Lau, it is understood that one of the major reasons for the shortage is due to the large outflow of doctors from public hospitals to the private sector due to poor pay and working condition. In 2011, the median working hour (excluding meal breaks) per week of doctors was 64 hours. Around 33% of the doctors in public hospital have to work over 70 hours a week, and 20% have to work 80 hours or above. Moreover, 86.1% of all the surveyed doctors, consisting of 20% of the working public hospital doctor populations, also expressed that they would leave public hospitals should the working condition is not improved.6 In light of these current situations, the three proposals mentioned above could be evaluated in terms of their cost-effectiveness and sustainability. First of all, the current mechanism might not be the most effective one to import doctors overseas. There are two ways for overseas-trained doctors to obtain a license to practice: the ‘Licentiate Medical Examination Path’7 and the ‘Limited Registration Path’. Both schemes require applicants, regardless of previous experience, to work under high restrictions when they start serving in public hospitals, effectively decreasing the attractiveness of the program. The number of doctors successfully admitted through both schemes is extremely low—only 1 to 5 per year.8 This is hardly enough to alleviate the severe situation Hong Kong is currently facing. Regardless of the cost, this measure is highly questionable in terms of its effectiveness.13, 14 The effect of recruiting more medical school applicants will take a long time to be seen due to the long years of training. Thus, the short-term effectiveness is relatively low. Moreover, increasing the number of places available in medical schools is expensive. The average amount of government subsidy for a medical student is at least HKD$3,000,000 (approximately $40,000 USD).9, 10 This renders the measure of low cost-effectiveness overall. However, in terms of sustainability, enrollment expan-
sion in medical schools may be a self-sustaining way in the future. The expenses might become a burden when considering the financial sustainability. Furthermore, adjusted enrollment would not be effective without detailed planning and projections on changes in population structure. If medical places are expanding blindly without reasonable prediction of future demand, resources will fail to allocate efficiently. Working conditions improvement in public hospitals would be a desired method for retaining doctors and stop the continuous outflow of doctors to private sectors. Only by retaining doctors are we able to effectively raise the number of public doctors. Since successful retention of doctors does not equate to an immediate rise in the number of doctors in public hospitals, the society still needs to take other solutions on top of retaining doctors. However, in short term, this measure widens the gap of the doctor shortage in public hospitals and poses a challenge for the government in implementation as more doctors or supporting staff are needed to cope with the decrease in working hour of doctors. In terms of sustainability, it is also believed that by improving working conditions of doctors can solve the root of the problem, which is high staff turnover, and ensure a stable supply of doctors in public hospitals in the future. A high-quality public health care system is vital in ensuring a high living standard. It is in my belief that the government should consider improving doctors’ working conditions by lowering working hours and improving their welfare to address the root of the shortage. Careful projection of future demand of public hospitals’ service is also required to design long-term and effective policy to ensure a steady supply of doctor so to adequately adjusting the number of medical school places, thus the quality of future healthcare in Hong Kong.
1. Food and Health Bureau. MANPOWER PROJECTIONS FOR DOCTORS, DENTISTS AND NURSES. PDF. Hong Kong: LC Paper No. CB(2)978/14-15(03), March 11, 2015. 2. “五急症室輪候時間不達標 緊急病人等逾一小時.” Apple Daily 蘋果日報. Accessed February 21, 2019. http://hk.apple.nextmedia.com/news/art/20120821/16622243. 3. Oversupply of Doctors. July 31, 1997. Accessed February 21, 2019. http://www.hkma.org/english/newsroom/news/d-supply.htm. 4. Hospital Authority Statistical Report. PDF. Hong Kong: Hospital Authority, 2015. https://www.ha.org.hk/upload/publication_15/491.pdf 5. Food and Health Bureau. MANPOWER PROJECTIONS FOR DOCTORS, DENTISTS AND NURSES. PDF. Hong Kong: LC Paper No. CB(2)978/14-15(03), March 11, 2015. 6. “Admissions to CUHK Medicine.” Med.cuhk.edu.hk. Accessed February 21, 2019. http://www.med.cuhk. edu.hk/eng/Education/UndergraduateProgrammes/bachelor_of_mbchb/bachelor_of_mbchb.jsp. 7. LCQ6: Healthcare Manpower of Hospital Authority. June 19, 2013. Accessed February 21, 2019. http:// www.info.gov.hk/gia/general/201306/19/P201306190489.htm. 8. LCQ6: Healthcare Manpower of Hospital Authority. June 19, 2013. Accessed February 21, 2019. http:// www.info.gov.hk/gia/general/201306/19/P201306190489.htm. 9. Bachelor of Medicine and Bachelor of Surgery (MBBS) | HKU Li Ka Shing Faculty of Medicine. (n.d.). Retrieved April 02, 2016, from http://www.med.hku.hk/v1/education/undergraduate-studies/undergraduate-admission/bachelor-of-medicine-and-bachelor-of-surgery-mbbs 10. The Chief Executive’s 2017 Policy Address - Policy Address. Accessed February 21, 2019. http://www. policyaddress.gov.hk/2016/eng/p235.html. 11. “Medical Education in Hong Kong.” Wikipedia. January 15, 2019. Accessed February 21, 2019. https:// en.wikipedia.org/wiki/Medical_education_in_Hong_Kong. 12. Patient Experience and Satisfaction Survey on Specialist Outpatient Service 2014 http://www.ha.org.hk/haho/ho/pred/Report_on_2014_PESS_on_Specialist_Outpatient_Service.TCHI. TXT.pdf 13. “Foreign Doctors Quit Hong Kong Public Hospitals over Licence Red Tape.” South China Morning Post. October 20, 2014. Accessed February 21, 2019. http://www.scmp.com/news/hong-kong/article/1620172/ foreign-doctors-quit-hong-kong-public-hospitals-over-licence-red-tape. 14. Hurdles for foreign-trained doctors in Hong Kong reveal double standards, SCMP, 8 April 2015 http://www.scmp.com/comment/insight-opinion/article/1760234/hurdles-foreign-trained-doctors-hongkong-reveal-double
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he #MeToo movement has recently taken the world by storm. Prolific cases such as that of Brett Kavanaugh have publicized a matter that deserves a deeper analysis and give women a voice to shed light on their silence. Further, this movement has the potential to decrease alarming statistics, such as the estimated 60% of unreported sexual harassment cases as stated by the National Sexual Violence center.1 Women are standing up to the men who have harassed, abused and taken advantage of them in increasing numbers to show that they will no longer back down. However, why were they silent in the first place? What prompted them to silently comply with their injustice until someone else gave them the courage to stand up? These questions can be explained through various psychological theories. The first and most instinctual mechanism involved is the ‘Fight or Flight’ phenomenon. There is a high correlation between fear, shame and demoralisation after instances of harassment or abuse.2 The most common way of processing these
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feelings is to mitigate their presence. Biologically, the body chooses to suppress the memory and feelings related to it due to insufficient cognitive appraisal. These improper methods do not allow information processing to occur in an efficient manner. Thus, later, if someone or something triggers their memory, they are able to recall the aspects they tried hard to repress. Shame also plays a large role in delaying their will to speak up. The abuse or harassment leaves women feeling dehumanised and wanting to withdraw from human contact. This inward feeling of shame unfairly results in women blaming themselves for the perpetrator’s behaviour. In order to justify their experience, they use poor self-defense mechanisms such as denying or doubting the event and thus choose to remain quiet. They protect themselves from the details of these incidents as a poor coping strategy. A significant proportion of the fear and stigma associated with reporting stems from the woman’s lack of control over the incident and the consequences she would face
on speaking out. Internalising the blame provides a sense of control over the situation that can allay their fear, causing them to remain silent. However, the circularity of such a psyche has recently begun to break with the advent of the #MeToo movement.3 Statistically, low rates of self reporting or anonymous reporting skews data and produces inaccurate measures. The true magnitude of the issue can and will only be deciphered when women come forth to report it. Hearing other women speak about their experiences allows women to draw parallels with their own. The cathartic process of sharing stories help women to heal and realise that they are not alone. This was seen in the case of Harvey Weinstein. After one of his victims stepped forward to file a formal complaint, they managed to garner 80 more names in the industry and reveal the truth. This suggests that when a victim realizes that they are not alone in their struggle, it becomes easier to tell their stories. On the other hand, Individual therapy can sometimes leave the victim feeling more vulnerable and isolated.4 A study observed mean trends in sexual abuse survivors that showed increased levels of positivity and reduced symptomatology once they engaged in group therapy.5 Group psychology is what is often applied to self-help groups or groups for abuse survivors to seek solace with the help of others’ stories.6
Though the #MeToo movement is characterized by the empowerment of survivors, it transcends into something much deeper. The mass movement is created from each instance individual struggle, and the personal choice to break the silence. The victims are standing up not only to perpetrators but also for themselves.
1 “Measuring the #MeToo Backlash.” The Economist. October 20, 2018. Accessed November 06, 2018. https://www.economist.com/united-states/2018/10/20/measuring-the-metoo-backlash. 2. Russell, Cristine. “Confronting Sexual Harassment in Science.” Scientific American. October 27, 2017. Accessed November 06, 2018. https://www.scientificamerican.com/article/confronting-sexual-harassment-in-science/. 3. “Why Don’t Victims of Sexual Harassment Come Forward Sooner?” Psychology Today. Accessed November 06, 2018. https://www.psychologytoday.com/us/blog/the-compassion-chronicles/201711/why-dont-victims-sexual-harassment-come-forward-sooner. 4. Monitor on Psychology. Accessed November 06, 2018. https://www.apa.org/monitor/2018/05/ sexual-harassment.aspx. 5. Carver, C. M., C. Stalker, E. Stewart, and B. Abraham. “The Impact of Group Therapy for Adult Survivors of Childhood Sexual Abuse.” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie. November 1989. Accessed November 06, 2018. https://www.ncbi.nlm.nih.gov/ pubmed/2819638. 6. Rajendran, Sowmya. “’Why Didn’t She Speak up Then?’: 8 Questions on the ‘Me Too’ Movement Answered.” The News Minute. October 10, 2018. Accessed November 06, 2018. https:// www.thenewsminute.com/article/why-didn-t-she-speak-then-8-questions-me-too-movement-answered-89742.
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here are many lessons that are taught both in schools as well as homes, but why is it that no one wants to teach about menstruation? In the early twentieth century, the concept of “menstrual education” was a common term used by the general population. By the late 1960s, the term “menstrual education” vanished and became a component of sexual education (sex education).1 This transformation of menstrual education occurred between the 1920s and 2013 and sparks the following questions: Who was an expert on menstrual education? How and why did the delivery of menstrual education to the younger female population drastically change from the 1920s to current day? In order to answer these questions, the conversation of the following actors: (1) families, (2) teachers, (3) physicians, and (4) menstrual product manufacturers— involved in educating women about menstruation—must be traced and analyzed. The changes in menstrual education occurred due to previous experts’ discomfort surrounding the conversation of menstruation. In the 1920s, American families and teachers questioned which actor was the appropriate source to educate the female population about menstruation. According to Marvin Levy, a supervisor of health and safety education, parents should teach their children about topics such as menstruation.2 Unfortunately, parents expe28 | PENN HEALTHCARE REVIEW | SPRING 2019
rience difficulty teaching their children about such topics because (1) they could not “give objective information and advice” to their children—due to the emotional involvement existing within their relationship— and (2) mothers felt inadequate giving their daughters information about menstruation, because they, themselves, did not know the essentials.3 Therefore, this conversation surrounding menstruation was pushed outside of the home and into the formal education system. However, few school teachers were qualified to teach menstrual education, so schools requested trained menstrual educators from Tampax and Kotex—a free service—to educate both their students and parents.4 Since these menstrual product manufacturers inserted themselves into conversations avoided by teachers and mothers, they gained credibility as menstrual experts. Although it seems bizarre that Tampax and Kotex taught menstrual education, they took advantage of long-standing stigmas existing in society to promote themselves as the experts within the field. By referring to menstruation as a hassle for women while providing hygiene management products to aid in “passing” as a “non-menstruator,” these corporates reinforced what society already believed while gaining credibility as a source of information not only for menstruation but also womanhood. Despite menstrual product manufacturers’ incen-
tives for sales of their menstrual hygiene products, families and physicians, alike, looked to these manufactures as the experts in menstrual education. Corporations were able to do this because they (1) mobilized the taboo and societal silence that surrounded women’s bodies and expectations, in order to fashion themselves as experts in women’s health and menstrual education and (2) utilized menstrual education to depict norms, “ideals,” and standards for women. Menstrual product manufacturers’ creation of menstruation pamphlets granted them leeway in the transformation of menstruation. They included lists of exercises and diets that promoted “better menstrual cycles,” but they would subtly change these list in different editions. Their creation and usage of pamphlets to educate women about menstruation in a private manner was well received by society. In fact, Kotex’s pamphlets were one of the most widely-used sources for disseminating menstrual education to both the young and adult female populations.5 These manufacturers had an educational department dealing with the pamphlets’ content, which, according to Dr. Lara Freidenfelds, a historian of women’s health, “contributed tremendously to [the] revolution in the availability of information about menstruation” in the 1920s.6 Menstrual product manufactures impacted not only menstrual education but also the general population of the twentieth and twenty-first centuries’ perception of menstruation. Menstrual educational pamphlets, health-related textbooks, and medical findings shifted societal perceptions concerning menstruation. The pamphlets, for example, not only illustrated the information circulated throughout schools between the 1920s and 2013 but also showcased the changes in menstrual education during this timeframe. However, menstrual education was not only documented within these pamphlets but also managed and critiqued throughout this time period. Analyzing these bodies of text showed the intersection between marketing and educating as well as the power of reinforcing
stigmatized culture surrounding menstruation. This story of menstrual education illustrates the profound impact Corporate America inflicted on the perception of women. Menstrual product manufactures not only reflected expectations of women during this time period but also contributed to it. Although it may be 2019, menstrual product manufactures still have a huge presence in current-day menstrual education. The seemingly odd fact that menstrual product manufactures educated women about menstruation is not out-of-the-ordinary. In fact, it makes sense that menstrual product manufacturers fashioned themselves as the experts in menstrual education due to the following reasons. First, the transformation of menstrual education between the 1920s and 2013 allowed menstrual product manufactures entrance into a confused field to dominate. Second, menstrual product manufacturers played on American society’s perception of menstruation—by maintaining theories of taboos. Lastly, menstrual product manufacturers carefully constructed themselves into the experts of menstrual education by following societal norms and culture, and they used this tactic to leverage their education as superior during the 1920s to 2013. Tracing the transformation of menstrual education provides new dimensions to the history of sexual education in the United States. It sheds light as to why sexual education classes masked menstrual education in the late twentieth century. Realizing who the menstrual experts are is important to understanding how society got to where it is with perceptions of menstruation and women. Corporations’ mobilization of taboo and societal silence surrounding women’s bodies and expectations fashioned them as experts in women’s health and menstrual education, in addition, to their utilization of menstrual education to depict norms, “ideals”, and standards for women. There is something to be said about the social context of media education and the multiple waves of feminism that occurred in a time where talking about sex education—let alone menstrual education—was a silenced topic among schools and homes. Identifying and understanding the entities known to be stigmatized, the menstrual experts allows for the unpacking of concepts surrounding menstruation, women, and taboos. 1. James A. Michener, “Sex Education: A Success in Our Social-Studies Class,” The Clearing House 79, no. 5 (2006): 210-14. 2. “What Happens When Children Have Children?,” Philadelphia Inquirer, July 16, 1978, accessed February18, 2018, https://proxy.library.upenn.edu/login?url=https://search.proquest.com/ docview/1849138480?accountid=14707. 3. “Educators Approach Sex Information Lag with Caution,” The Philadelphia Inquirer Public Ledger, January 22, 1967, accessed February 18, 2018, https://proxy.library.upenn.edu/login?url=https://search. proquest.com/docview/1841542084?accountid=14707; Russell Smart and Mollie Smart, “Menstrual Education,” Marriage and Family Living 21, no. 2 (1959): 177-79. 4. Ibid., 178. 5. Lara Freidenfelds, “The Modern Way to Talk about Menstruation,” in The Modern Period: Menstruation in Twentieth-Century America, (Baltimore: The Johns Hopkins University Press, 2009), 38-73. 6. Ibid., 49; Ibid., 56.
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he process of dying has never been so profitable. As we enter the 5th stage of demographic transition, where the death rate exceeds the birth rate, society is facing a demographic crisis. Currently, end-of-life care for the elderly suffers from overburdened systems and a fragmented market, leading to an increasingly attractive opportunity for new business models. But at what expense? We live in an aging society. Globally, life expectancy at birth rose by 3.6 years between 2010-2015 to 70.8 years. However, this growth was not driven by new births. Rather the fertility rate is dropping, meaning that population growth is concentrated in the elderly population. In 2017, there were an estimated 962 million people aged 60 or over in the world, comprising 13 percent of the global population. This demographic bracket is also growing about 3% per year -faster than any younger age group.1 While world populations are living a longer life, they are not living a better life. The key difference lies between life expectancy and health expectancy, of which the former is growing faster. Decreased quality of life is exacerbated by the fact that chronic health problems have replaced infection diseases as the leading health care burden.2 In 2010, a typical Medicare patient spent 7.4 years with disability, but in 2030 is projected to spend 8.6 years with disability. Each patient will need an average corresponding increase in spending of $131,000 to $223,000 respectively, leading to considerable 30 | PENN HEALTHCARE REVIEW | SPRING 2019
political and economic strain.3 This is where end-of-life care becomes crucial. Terminal care systems aim to improve a patient’s quality of life through compassionate comfort care. One model is hospice care, which forgoes curative care for people facing a terminal illness with a prognosis of six months or less. This typically occurs in a patient’s home and is covered by Medicare.4 Similarly, palliative care also provides relief from symptoms and can run simultaneously with disease treatment.5 Both have proven benefits and are even recognized by the UN to be human rights.5 Being on hospice during last 3 months of life can decrease patient costs by $12,000. There is also a 34% reduction in hospital admission during final month of life through protection from avoidable emergency room visits through in person home visits and telemedicine. Prognosis can even improve about 29 days in certain cases for patients referred early.4 However, the increasing elderly population and correlated increased demand for end-of-life services has created an overburdened system. The number of beneficiaries of hospice care in the United States is expected to increase from 1.3 million in 2010 to 2.3 million by 2030.3 The industry is highly fragmented as well, with the four largest firms generating less than 10% of revenues.7 Yet Medicare’s trust fund, the
primary cover of these organizations, is set to run out in 8 years.8 Beyond the US, many countries struggle with similar problems. Internationally, of 14.1 million over the age of 60 need palliative care but do not receive services due to regulations for controlled medicines and lack of training or awareness.5 One especially critical location is Japan, which houses the world’s oldest population—over a quarter of its population is currently over 65. The number of elderly eligible for nursing care services from ailing conditions will increase from 6.29 million in 2017 to 7.71 million in 2025. This crisis has received much government attention. For example, 16 different types of home healthcare services qualify for reimbursement. However, there is still a shortage of care workers because of training barriers and the prioritization of cancer patients in large hospitals. For example, 1800 hours of training are required to become a certified elderly caretaker. By 2030, they are expected to have a shortage of 470,000 hospital beds and 380,000 nursing care staffers as demand overwhelms supply.9 Pain points in the status quo leads to an attractive value proposition for new hospice providers. The current fee-for-service model in the US correlates the intensity of healthcare provided and revenue collected by the provider. This has created a $17 billion home health care industry in which for-profit hospice average profit margins of up to 15.4% (figure 1).10 Looking forward, private equity deals will serve as a model for healthcare service investments, and for good reason the average return on equity generated over 12 months for home health care services is 65.9%. In 2017, $5.1 billion was spent on mergers and acquisitions in this space on 27 total deals. In just Q1 of 2018, 21 deals were completed, showing the rapidly growing interest in this
business model.11 However, for-profit hospice within the USA faces significant criticism for prioritizing profits over patients. Evidence has shown that hospice margins increase when patients are discharged before death. A 50% increase in live patient discharges over 10 years has led to a 5x increase in profit per patient. One motivation for live discharges is to avoid paying for costly hospital procedures by discharging, and then re-enrolling a patient after treatment. This shifts the financial burden away from hospice providers.12 Furthermore, they may be incentivized to enroll healthy patients who require fewer visits and stay enrolled longer. For example, while the average length of stay in a non-profit hospice was 69 days, the for-profit system totaled 105 days. Finally, as the market grows, these systems reach a size able to offer economies of scale and are encouraged by investors to become even more efficient. But the quality of care is far from acceptable – 55% of hospices were cited for violations over a 3-year period. The fragmented market increases inefficiencies and difficulties in controlling standards.13 The US, and the international community will need to adapt to serve the growing needs of the elderly through policy and innovative technology. Changes in national legislation regarding the frequency of inspections, questionable profiting practices, and lack of data surrounding these businesses is necessary to combat this problem. For example, the recent shift from a fee-for-service model to value-based care may help ameliorate this problem by incentivizing proper treatment. Furthermore, the integration of novel technology such as telemedicine and accessible medical devices in treatment is an exciting area for growth. Let’s treat death with dignity, not dollars.
1. United Nations. Department of Economic and Social Affairs. Population Division. World Population Prospects: The 2017 Revision. ESA/P/WP/248 (2017). 2. Beltrán-Sánchez, Hiram, Samir Soneji, and Eileen M. Crimmins. "Past, present, and future of healthy life expectancy." Cold Spring Harbor perspectives in medicine 5, no. 11 (2015). 3. Gaudette, Étienne, Bryan Tysinger, Alwyn Cassil, and Dana P. Goldman. "Health and health care of Medicare beneficiaries in 2030." In Forum for Health Economics and Policy, vol. 18, no. 2, pp. 75-96. De Gruyter, (2015). 4. Lustbader, Dana, Mitchell Mudra, Carole Romano, Ed Lukoski, Andy Chang, James Mittelberger, TerryScherr, and David Cooper. "The impact of a home-based palliative care program in an accountable care organization." Journal of palliative medicine 20, no. 1, pp. 23-28 (2017). 5. Alliance, Worldwide Palliative Care, and World Health Organization. "Global atlas of palliative care at the end of life." London: Worldwide Palliative Care Alliance (2014). 6. Kelley, Amy S., Partha Deb, Qingling Du, Melissa D. Aldridge Carlson, and R. Sean Morrison. "Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay." Health Affairs 32, no. 3 (2013): 552-561. 7. Allen, Patrick, and Kristofer Blom. Industry Flash Report – Home Health and Hospice. Report. Kaufman, Hall & Associates, LLC. Skokie, IL: Kaufman, Hall & Associates, LLC, 2016. 8. Winter, Damon. "Medicare’s Trust Fund Is Set to Run Out in 8 Years. Social Security, 16." The New York Times, June 5, 2018. Accessed October 10, 2018. https:// www.nytimes.com/2018/06/05/us/politics/medicare-social-security-finances.html. 9. Annear, Michael J., Junko Otani, and Joanna Sun. "Experiences of Japanese aged care: the pursuit of optimal health and cultural engagement." Age and ageing 45, no. 6, pp. 753-756 (2016). 10. Hallman, Ben, and Nicky Forster. "The Business of Dying Has Never Been More Lucrative." The Huffington Post. July 24, 2015. Accessed October 12, 2018. https:// www.huffingtonpost.com/entry/hospice-report_us_55b1307ee4b0a9b94853fc7a. 11.Baxter, Amy. "Home Health, Hospice M&A Spikes at Start of 2018." Home Health Care News. April 23, 2018. Accessed October 12, 2018. https://homehealthcarenews.com/2018/04/home-health-hospice-ma-spikes-at-start-of-2018/. 12. Prsic, Elizabeth, Mike Plotzke, Thomas J. Christian, Pedro Gozalo, and Joan M. Teno. "A national study of live hospice discharges between 2000 and 2012." Journal of palliative medicine 19, no. 9 (2016): 987-990. 13. Teno, Joan M., Jason Bowman, Michael Plotzke, Pedro L. Gozalo, Thomas Christian, Susan C. Miller, Cindy Williams, and Vincent Mor. "Characteristics of hospice programs with problematic live discharges." Journal of pain and symptom management 50, no. 4 (2015): 548-552.
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“Hey – sorry to bother you, but is that a Freestyle Libre on your arm?” Perking up at the cheerful voice, I instinctively reached towards the coin-sized plastic sensor on my tricep. I turned around to face a young woman, who introduced herself as a Penn graduate student and fellow person with type 1 diabetes (T1D). She explained that her endocrinologist had recommended the Freestyle Libre Continuous Glucose Monitor (CGM) over the Dexcom G5 CGM that she was currently using, and asked me about my experience with the Libre. I quickly outlined the differences between the two devices, emphasizing the convenience of not having to calibrate the Libre with twice-daily finger-pricks while acknowledging its lack of low blood glucose alarms and smartphone integration. Prior to my diagnosis in May 2017, I would have been extremely confused by this exchange – but so would anyone living with T1D a mere decade ago. In the past few years, technological advancements and novel treatment options have revolutionized T1D management. Ordinarily, the body’s blood glucose level (BGL) is regulated through the secretion of insulin by pancreatic beta cells. When beta cells are destroyed in the autoimmune process that results in T1D, subcutaneously-administered insulin is an astoundingly effective substitute.1 Nevertheless, it is not a cure 32 | PENN HEALTHCARE REVIEW | SPRING 2019
for T1D. Managing the disease is a round-the-clock commitment, requiring extreme diligence to maintain BGL within a range of 80-180 mg/dL. Countless aspects of daily life, including diet, exercise, temperature, and stress, can tip the scales towards acute hypoglycemia (which can be life-threatening) or hyperglycemia (which can lead to long-termcomplications).2 Despite a near-century’s efforts to develop a cure, seemingly-promisingavenues are hindered by the autoimmune nature of T1D. Pancreatic islet cell transplants, for instance, necessitate immunosuppressive protocols.3 Still, numerous innovations—faster-acting insulins, finger-prick glucometers, and cellphone-sized insulin pumps—have considerably eased the burden. More recently, CGMs such as the Freestyle Libre and Dexcom G5 have revolutionized T1D management. While finger-prick glucometers measure BGL at a given point in time, CGM sensors automatically take readings at set time intervals through a small filament placed under the skin, then transmit the data to a receiver or smartphone.4 CGMs can also be paired with certain insulin pumps, creating a closed-loop system that adjusts the pump’s infusion rate according to the user’s BGL.5 Coincidentally, the aforementioned graduate stu-
dent had approached me during a meeting with Libby Rockaway (C’19), leader of Penn’s chapter of the College Diabetes Network. While Libby does not have T1D herself, she is closely involved with the community. Laying by her side was Franklyn, a miniature Golden Retriever puppy and Libby’s newest Diabetic Alert Dog-in-training (DAD). DADs can detect changes in BGL by smelling an organic chemical (possibly isoprene) in saliva and sweat.6 The idea of a dog performing the same functions as my high-tech CGM was difficult for me to grasp at first. Midway through our meeting, though, Franklyn began to fidget. She placed her paw on my shoes, her way of alerting to a low. Sure enough, my CGM indicated that my BGL was trending downward, and I soon began feeling the familiar symptoms. Amazed, I delved further into the topic with Libby, and came out of the conversation with an entirely new perspective on the role a DAD can play in T1D management. Aleksandra Golos: Can you give me a quick overview of what training a DAD entails? Libby Rockaway: “I start training DADs when they are eight weeks old. I don’t have T1D, but I periodically check my BGL with a glucometer, especially whenever I feel shaky or dizzy. If I’m under 80 mg/dL or over 180 mg/dL, I place some cotton in my mouth, saturate it with saliva, and freeze the sample for training. I first introduce the sample to the dog while giing them a reward. I then add the alert behavior by withholding the reward, getting the dogs slightly frustrated so that they paw the sample. Eventually, they learn to paw my leg if they smell low or high blood sugar.” AG: You’ve been training DADs for five years, three of which have been as a full-time Penn student. How do you balance these responsibilities? LR: “The dog’s training always comes first. As service dogs, DADs are considered medical equipment. I have to take that extremely seriously. In terms of being a Penn student, if Franklyn even slightly looks like she’s going to misbehave in class, I have to take her outside.” AG: How do you make sure that everyone at Penn is aware of your needs? LR: “I go through Student Disability Services. They contact my professors beforehand to ensure that every-
thing is in order. My professors are very receptive, and it’s been smooth ever since I initially got permission from Penn. That took quite a while, because nobody had trained a service dog on campus before. Penn didn’t know how to handle somebody who had a service dog without having a disability themselves.” AG: With all the recent advancements in diabetes technology, some might ask whether a DAD is worth the effort. What are some advantages a DAD brings? LR: “T1D is tough – it’s a 24/7 battle with no explanation. Having a dog by your side through it all is so much different than wearing a CGM. The emotional aspect is important, especially with kids. Having a dog alert about a high or low BGL feels less like nagging than having an alarm go off. It brings the focus off diabetes and makes it more about interacting with the dog and building that supportive relationship.” AG: Support is crucial, especially in a disease where so much blame is placed on “your number." LR: “And a lot of guilt. ‘Maybe I shouldn’t have eaten this, or should have done that.’ You can feel guilty for every single aspect of it, when in reality you shouldn’t.” AG: What’s the most rewarding part about the work you do? LR: “As hard as it is, giving the dog up and watching new relationships form. And then getting updates, texts from parents saying that the dog alerted to low blood glucose during their kid’s lacrosse game. I get to see the difference they’re making. That’s the best part – technology and parents help a lot, but I can help in my own way through the dogs.”
1. Yun, Ji-Won and Hee-Sook Jun. “Autoimmune destruction of pancreatic beta cells.” American Journal of Therapeutics 12, no. 6 (2005): 580-591. 2. “Type 1 Diabetes Facts.” JDRF International. https://www.jdrf.org/about/what-is-t1d/facts/ (accessed October 12, 2018). 3. “Islet Transplant for Type 1 Diabetes.” University of California San Francisco. https://transplant.surgery.ucsf. edu/conditions--procedures/islet-transplant-for-type-1-diabetes.aspx (accessed October 12, 2018). 4. “Continuous Glucose Monitors.” diaTribe. https://diatribe.org/continuous-glucose-monitors (accessed October 13, 2018). 5. “Automated Insulin Delivery.” diaTribe. https://diatribe.org/automated-insulin-delivery (accessed October 13, 2018). 6. Los, Evan A. et al. “Reliability of Trained Dogs to Alert to Hypoglycemia in Patients With Type 1 Diabetes.” Journal of Diabetes Science and Technology 11, no. 3 (2017): 506-512.
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enn students are constantly prompted to make choices. We choose where we live, what we major in, and what clubs we join. Most importantly, we get to choose where and what we eat. Penn students have a plethora of food options, ranging from The Fresh Grocer, found right off campus, to multiple dining establishments nearby. We are provided with resources to ensure that we can sustain a healthy diet. However, how would Penn students react if their food options were stripped away? What would happen if Penn students did not have access to fruit, vegetables, and other foods that make up a healthy diet? How would it change the health of the students on campus? What would Penn look like? Although this scenario may seem unthinkable for some, it is the reality of many people living in West Philadelphia and all over the United States. Growing up in West Philadelphia, I never noticed the lack of grocery stores in my community. As a child, I was accustomed to having a corner store on every other block in my neighborhood. Honestly, I enjoyed having these stores because they were convenient and stocked with all of my favorite chips, candies, and sodas. It was not until I started traveling outside of my neighborhood to go to school in a wealthier neighborhood that I realized corner stores were not as prominent in higher-income areas. When I started my Health and Societies major at Penn, I realized that these corner stores were found primarily in food deserts. Food deserts are defined as areas that lack access to affordable fruits, vegetables, and other foods that make up a full and healthy diet. As seen in many areas in Philadelphia, and other lower income neighborhoods in the United States, 34 | PENN HEALTHCARE REVIEW | SPRING 2019
communities that lack grocery stores often have an abundance of corner stores. Corner stores and other convenience stores have become a vital part of lowerincome neighborhoods, since they are very accessible and offer inexpensive products. However, these stores usually lack the food necessary to create a healthy diet for its residents, like fresh produce and low-fat food items.1 There is not only an exorbitant amount of corner stores located in lower income neighborhoods, but an abundance of fast food restaurants and beverage advertisements. Specifically, lower-income Latino and African American communities are shown to have between “two to thirty-five times the square footage of ad space devoted to food and beverages compared to other neighborhood categories.”2 There also aren’t nearly as many healthy advertisements, like gym memberships, in lower income neighborhoods. The few healthy advertisements are usually sponsored by nonprofits or government organization.3 Thus the exorbitant amount of fast food and beverage advertisements lead those who live in these neighborhoods to think that lesshealthy options are their only options. The effects of a food desert reach far beyond not having many different items to eat; they can greatly affect the health of those who live in the area. It is proven that those who live in food deserts have higher rates of diabetes, obesity, cardiovascular, and subclinical risk factors.4 Coronary calcium is a marker for the subclinical disease, atherosclerosis. It is proven
that having healthy food stores in one's neighborhood can slow the progression of coronary calcium build up. The study done by the Centers for Disease Control and Prevention gave 6,000 adults CT scans for coronary artery calcium and at least one more, the average being three CT scans, over the course of twelve years. The results of this study proved that people who had healthy food stores within one mile of their home had slower coronary artery calcium buildup than those who lived farther away from healthy food stores.5 This shows that people who live in food deserts are at a disadvantage when it comes to their health, due to social circumstances beyond their control. Humans need food to survive. However, if we are not provided with the right types of food, our health is negatively impacted. Having access to affordable fruits and vegetables should not be a privilege, but should be a human right. Thus, it is important that we find ways to guarantee that healthy food is accessible and affordable for all to ensure that everyone has the opportunity to live a healthier life.
1. “Why Low-Income and Food-Insecure People Are Vulnerable to Poor Nutrition and Obesity,” Food Research & Action Center frac.org/obesity-health/low-income-food-insecure-people-vulnerable-poor-nutrition-obesity. (accessed February 25, 2019) 2. Diana L Cassady et al., “Disparities in Obesity-Related Outdoor Advertising by Neighborhood Income and Race,” Journal of Urban Health : Bulletin of the New York Academy of Medicine 92, no. 5 (2015): 835-42. 3. Diana L Cassady et al., “Disparities in Obesity-Related Outdoor Advertising by Neighborhood Income and Race,” Journal of Urban Health : Bulletin of the New York Academy of Medicine 92, no. 5 (2015): 835-42. 4. Heval Kelli et al., “Association Between Living in Food Deserts and Cardiovascular Risk,” Circulation: Cardiovascular Quality and Outcomes 10, no. 9 (2017). 5. “Lack of Fresh Foods in ‘Food Deserts’ Causes Health Risks” https://www.foodqualityandsafety.com/article/ lack-fresh-foods-food-deserts-causes-health-risks/ .(accessed February 25, 2019)
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n 2017 one in eight Americans were food insecure, and an equal number were receiving food assistance from the United States Supplemental Nutrition Assistance Program (SNAP).1 The same year, four in ten Americans had an obese body mass index classification.2 Continued concerns with food access and equity draw the question of whether targeted responses should also attempt to address the high rates of obesity in America. While many health advocates agree that SNAP benefits do not fully support healthy eating habits, most policymakers agree that adding nutritional requirements to SNAP benefits would be a costly change and ostracize recipients. Over 42 million Americans rely on SNAP as a source of food security annually.3 SNAP is the modern version of food stamps, a program first established in 1939 by Secretary of Agriculture Henry Wallace and further developed by the 1964 Food Stamp Act created by President Johnson.4 Eligibility is determined on a state by state basis, but individuals living around the federal poverty line, approximately $12,000 annual income for an individual, are typically eligible to receive benefits. SNAP provisions are established as a part of the Farm Bill, which is renewed by Congress every five years. SNAP comprises 80% of the Farm Bill budget.5 The average SNAP meal costs $1.86, but participants are expected to also fund additional food purchases.6 SNAP benefits are intended to purchase food for the household. Specific foods covered by SNAP include bread, cereal, fruit, vegetables, meat, poultry, dairy, and fish.7 Alcohol, tobacco, household products, and vitamins are not covered by benefits.8 Additionally, SNAP does not cover any hot food or food to be eaten in the store.9 However, soft drinks, candy, cookies, ice cream, and bakery cakes are all eligible within the SNAP program outlines.10 The inclusion of these seemingly innutritious foods prompts debate as to whether SNAP food eligibility should be reformed. 36 | PENN HEALTHCARE REVIEW | SPRING 2019
Currently more than half of Americans have chronic health conditions, many related to poor nutrition.11 In the 2015-2020 Federal Dietary Guidelines for Americans, the Department of Agriculture advises the importance of drinking less added sugars to reduce risk of cardiovascular disease and obesity.12 To do this, the guidelines recommend individuals limit their total daily consumption of added sugars to less than 10% of the total calories they intake daily.13 Despite this recommendation, the availability of carbonated soft drinks within SNAP benefits promotes the consumption of these often sugary beverages. While SNAP has not chosen to eliminate the coverage of sugary soda drinks, some cities have created their own legislation to encourage healthier nutrition choices for the public. In 2017 Philadelphia established a Soda Tax on sugary and artificially sweetened drinks.14 This approach impacts the entire public, not only those eligible for SNAP benefits, ultimately creating a more equitable nutrition-based policy. According to the United States Department of Agriculture, no clear standards exist to determine if individual foods are good or bad, alternatively if they are healthy or unhealthy.15 National nutrition guidelines are created in the context of the total diet as opposed to individual foods, so the challenge of creating purchasing standards concerns health officials. Additionally, the complexity of different living styles calls for personalized diet choices that are difficult to generalize into regulations on individual foods for such a large group of the population. The Department of Agriculture also argues that there is no clear evidence that enrollment in food assistance programming contributes to obesity.16 Officials also agree that any additional regulations on food eligibility would be costly as it would be nearly impossible to analyze the nutritional benefits of all of the individual foods on the market to determine value. Also to change the benefits
would cause confusion and result in embarrassment for participants confused by new policies as mistakes inevitably would draw attention to the status of SNAP enrollees. Ultimately, while nutrition-based policy decisions such as Philadelphia’s Soda Tax create equitable incentives for the public to make healthier choices, additional changes in SNAP eligible food purchases will challenge policymakers to generalize highly personal health choices. It is also nearly impossible to categorize individual foods as healthy or unhealthy without fuller context of an individual’s diet needs. Changes would be confusing, costly, and difficult to apply to the many individuals relying on SNAP as a source of food.
1. Feeding America. “Understand Food Insecurity.” 2. McCarthy, Niall. “U.S. Obesity Rates Have Hit An All-Time High.” Forbes. 3. National Conference of State Legislatures. “SNAP Work Requirements Fact Sheet.” 4. United States Department of Agriculture. “A Short History of SNAP.” 5. National Conference of State Legislatures. “SNAP Work Requirements Fact Sheet.” 6. National Conference of State Legislatures. “SNAP Work Requirements Fact Sheet.” 7. United States Department of Agriculture. “Supplemental Nutrition Assistance Program.” 8. United States Department of Agriculture. “Supplemental Nutrition Assistance Program.” 9. United States Department of Agriculture. “Supplemental Nutrition Assistance Program.” 10. United States Department of Agriculture. “Supplemental Nutrition Assistance Program.” 11. United States Department of Agriculture. “Dietary Guidelines for Americans 2015-2020.” 12. United States Department of Agriculture. “Dietary Guidelines for Americans 2015-2020.” 13. United States Department of Agriculture. “Dietary Guidelines for Americans 2015-2020.” 14. “The Soda Tax: Will Your Favorite Beverage Cost More?” The Inquirer Daily News, 2017. 15. USDA Food and Nutrition Service. “Implications of Restricting the Use of Food Stamp Benefits Summary.” 16. USDA Food and Nutrition Service. “Implications of Restricting the Use of Food Stamp Benefits Summary.”
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n January 1, 2017, the Sugar-Sweetened Beverage (SSB) Tax came into effect in the city of Philadelphia. The policy added a tax of 1.5 cents per fluid ounce to any non-alcoholic drink, syrup, or concentrate containing a sugar-based sweetener or artificial sugar substitute, with few exceptions such as baby formulas and milks.1 With this tax, Philadelphia has joined the ranks of American cities, including Berkeley, California and Seattle, Washington, and numerous countries worldwide, that are pushing to drive down sugary drink consumption through financial incentives. Yet while many such governments have had moderate to significant success in achieving improved health outcomes, Philadelphia’s two-year-old tax has not experienced similar outcomes. What did Philadelphia do differently—or perhaps, what did Philadelphia do wrong—and what kind of policy could have been more impactful for Philadelphians’ sugary drink consumption? In 2016, Philadelphia was in search of funds for its Pre-K initiative, which would provide free pre-Kindergarten education to thousands of Philadelphia children. Inspired by the success of Berkeley’s new soda tax policy, Philadelphia pushed for similar legislation in hopes of generating revenue for the Pre-K programs.2 Rob Dubow, Philadelphia’s Director of Finance, noted that the tax would “create health benefits… but [their] primary motivation [was] the revenue”.3 The tax would generate funds by reducing consumption of unhealthy beverages, which would also lower obesity rates and therefore overall healthcare costs for the city. Interestingly, the two-pronged nature of this policy may have influenced its ability to truly achieve success. As one city councilwoman pointed out, the goals were to some extent conflicting because “on the one hand, [we] say we want consumption to go down, but we want it to go down to a point where it levels off so we can pay for early childhood education”.4 38 | PENN HEALTHCARE REVIEW | SPRING 2019
While the policy is still relatively new, preliminary results demonstrate that there has in fact been a drastic 42% reduction in the purchase of taxed beverages in Philadelphia. However, that decline has been offset by an increase in purchases outside of the city limits. Further, the absence of a significant increase in the purchase of healthy drinks in Philadelphia indicates that, despite the reduction, the policy goals have not been actualized. Revenue generation was projected to be $92 million, but the city only brought in $79 million—almost 15% short of the goal. The secondary goal of health benefits has likewise fallen short; measuring changes in individual beverage consumption is not an easy feat, but data on demand for beverages in and around Philadelphia indicate that there has not been a significant decline in beverage consumption and, therefore, that the health goals have not been achieved. It is also interesting to note the policy’s differing effects on subpopulations. Higher income individuals tended to substitute their soda purchases with soda from outside Philadelphia, while lower income individuals tended to continue purchasing sodas at a higher price, thereby making this, albeit unintentionally, into a regressive tax.5 What prevented this tax from having stronger outcomes? Why did the Philadelphia SSB Tax not have the same outcomes as policies in other cities and countries? Mexico provides a positive example of a behaviorally informed soda tax policy that proved quite successful. Mexico’s policy recognized that a tax alone would not suffice; rather a nudge—defined by behavioral scientists as a reframing of “the choice architecture [to] alter people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives”6—was necessary to implement significant and sustainable change. In order to achieve this goal, the policy included a “highly visible [media] campaign to increase knowledge of SSBs and enhance motivation”.7
This media coverage seems to be responsible for the tax’s effects. One in-depth survey found that respondents who were aware of the tax from the media campaigns were more likely to report a decrease in SSB consumption than two years prior, at a 23% higher rate than those who were not aware of the campaigns.8 The reason for this is that the public health campaigns, which focused on the sugar content of SSBs, the health consequences of high SSB consumption, and the rationale of the SSB tax, nudged people towards making the right decision. The campaign was also coupled with nutrition education, regulation of unhealthy foods and beverages in schools, regulation of food and beverage advertising, and a prosocial proposal for building purified water fountains in schools.9 As such, consumers had increased exposure to health messaging and understood the consequences of their beverage choices simply because of the ways in which the tax was framed to consumers. Mexico’s tax, unlike Philadelphia’s, triggered consumers to think about their health goals because of its media campaign that focused on the health components. Humans tend to have a present bias, placing greater value on immediate satisfaction and benefit than on future moments. By attaching a higher economic cost to the decision to purchase an unhealthy drink, the tax pushed the costs to outweigh the benefits of purchasing the drink for many consumers. That is, the tax and the media campaign led to a broader shift in social norms and attitudes about SSBs in Mexico. Data show a 6.1% decrease in purchase of taxed beverages and a 4% increase in untaxed beverages, relative to the purchases that would have happened without a tax.10 Interestingly, the greatest impact was on the lowest-income segments, who saw the highest reduction in SSB purchase and consumption. Where did Philadelphia go wrong? First, because the main policy goal in Philadelphia was revenue generation, the media emphasized that goal, rather than the need for health improvements. As such, Philadelphians did not receive the underlying message about the health consequences of consuming such beverages, as evidenced by the high rate of substitution outside of Philadelphia. The case of Mexico is different in that individuals could not just cross the border to purchase untaxed beverages. However, because Mexicans understood the reasoning
for the policy and were convinced by the need to improve health outcomes, the country saw actual improvements in health outcomes. Secondly, the policy was not behaviorally-informed, meaning that it tried to impose top-down behavioral change rather than allowing individuals to choose to change their behavior, which ultimately kept people from making real changes. As a city where over two-thirds of adults are obese or overweight, Philadelphia policymakers are in a position to drive significant changes.11 Soda taxes have the potential to bring down the high rates of lifestyle disease, but only when those policies use the proper mechanisms for driving individual behavioral change. To achieve both the revenue and the health goals, Philadelphia must reevaluate its existing policy, for the SSB Tax falls short of providing citizens with the nudge that they need to improve their personal health.
1. Council of the City of Philadelphia. Bill No. 160176. (2016, June 16). 2. Hagenaars, L. L., Jeurissen, P. P. T., & Klazinga, N. S. (2017). The taxation of unhealthy energy-dense foods (EDFs) and sugar-sweetened beverages (SSBs): an overview of patterns observed in the policy content and policy context of 13 case studies. Health Policy, 121(8), 887-894. 3.Council of the City of Philadelphia. Meeting of the Committee of the Whole. (2016, May 11). 4. Council of the City of Philadelphia. Meeting of the Committee of the Whole. 5. Seiler, Stephan, Anna Tuchman, and Song Yao. “The Impact of Soda Taxes: Pass-through, Tax Avoidance, and Nutritional Effects.” Tax Avoidance, and Nutritional Effects (December 16, 2018) (2018). 6. Thaler, Richard H., and Cass R. Sunstein. Nudge: Improving Decisions about Health, Wealth, and Happiness. London: Penguin Books, 2009, p. 6. 7. Álvarez-Sánchez, Cristina, et al.. “Does the Mexican Sugar-sweetened Beverage Tax Have a Signaling Effect? ENSANUT 2016.” Plos One13, no. 8 (2018). doi:10.1371/journal.pone.0199337. 8. Colchero, M. A., Popkin, B. M., Rivera, J. A., & Ng, S. W. (2016). Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. bmj, 352, h6704. 9. Ibid. 10. Ibid. 11. “Community Profile: Philadelphia, Pennsylvania.” Centers for Disease Control and Prevention.
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remember the first time I saw a patient of mine receive compressions for cardiac arrest. It was the day after my 20th birthday, I was still pretty young for an EMT. I was relieved to find several coworkers had already arrived with a fire department unit. That meant CPR was well underway when I entered the room. It also meant all there was left to do was schlep equipment, operate the radio, and mostly, watch across a crowded room as my partners thrust their body weight into the patient’s chest 100 times per minute. Every two minutes, the paramedic watched the EKG monitor I had brought him with a grimace, realizing all the drugs and compressions were still resulting in asystole: zero electrical activity in the heart. The patient’s massive body heaved as another responder resumed compressions. The patient—let’s call him John—was only in his 50s, but he didn’t make it. The paramedic called medical command, where a doctor declared the patient dead after over 15 minutes of CPR. All signs pointed to a sudden cardiac event. In a last-ditch effort to understand the patient’s illness before his body went to the morgue, we asked his wife: “Who was your husband’s doctor?” We wanted to know about his medical conditions and how they were treated. “He doesn’t have one,” she replied, exhausted. She had rushed home from work only to learn full resuscitative efforts were being performed on her husband to no avail. “He didn’t have insurance.” The realization that John, a working father, felt he could not afford to see a doctor hit me like a punch to the gut. What if health insurance meant regular physicals and treating John’s heart problems? What if, in a world that isn’t ours, John saw a PCP and a cardiac specialist and received 40 | PENN HEALTHCARE REVIEW | SPRING 2019
treatment at a cost he felt he could afford? What if, in that world, John would be alive today? Admittedly, we will never know the answers to all the what ifs surrounding John’s tragic death. But surely we know that the individual mandate, intended to create a state of near-universal insurance in America, didn’t work for him—he lacked coverage a full three years after the mandate’s 2014 implementation. More than unhelpful, the mandate has actually been unfairly harmful to Americans like John. The poor and the sick are some of the most vulnerable among us. Why should Congress single out these groups to bear the social cost of insuring their neighbors? Best intentions or no, the individual mandate did exactly that: workers like John who can neither qualify for Medicaid nor afford private insurance owe the IRS a penalty without getting any care themselves. According to The New York Times, millions of Americans pay the penalty every year1, remaining uninsured as John did. Bearing all the costs and none of the benefits, John and company were like ritual offerings on the altar of misguided policy goals. But starting next year, this backwards policy will reverse. A provision of the Tax Cuts and Jobs Act of 2017 means that the penalty is reduced to $0 for individuals uninsured during the year prior to their early 2020 tax filings. In effect, Congress has killed the mandate. We should celebrate its death knell, because through it the IRS was required to take money—up to thousands of dollars per family2—from those who needed it most. If not from me, take it from The Washington Post: this particular element of President Obama’s signature
health law is a tax on the poor. “It’s overwhelmingly lower-income Americans who pay the penalty for being uninsured. So repeal of the mandate amounts to a tax cut for them,” Paige Cunningham wrote for their website last November.3 Of course, the mandate’s harms are only half the story. What about the great boon it was supposed to be for insurance markets and the healthcare system? What about reducing emergency room usage, mitigating adverse selection (where riskier individuals disproportionately opt in to insurance plans, thus driving up premiums), or increasing access to care? It’s true that access to care is a valid concern— uninsurance kills, as I wrote in PHR last year. It may not even reduce adverse selection: letting patients choose whether to buy insurance may lead to advantageous selection, as Einav and Finkelstein showed.4 That means killing the individual mandate could actually make insurance markets less risky, contrary to the claims of its proponents. Additionally, the idea that mandating coverage would reduce ER overuse is not necessarily true, as emergency room visits reached an all-time high once the ACA was implemented in 2014.5 One starts to suspect that imposing coercive purchases on the vulnerable is not the best strategy for expanding access or reducing overuse. Instead, superior health policy solutions will focus on increasing the variety of insurance plans available and allowing premiums to vary. That way, more patients like John will feel they are able to afford the health plan they are looking for.
We could also address the shortage of physicians and hospitals which is endemic to rural areas in the United States. We ought to reduce barriers to entry and allow hospital systems to integrate, so that the less-affluent and the sick who live there are more likely to receive care. The policy strategies for increasing access and reducing unnecessary costs—especially for the ill and indigent—are countless. But forcing undesirable plans on them under threat of financial penalty should never have been one of them. For that reason, I am thankful that Congress signed the individual mandate’s death warrant. I am thankful that, as of this April, it has breathed its last.
1. Rebecca, K. K., and Alicia Parlapiano. “Millions Pay the Obamacare Penalty Instead of Buying Insurance. Who Are They?” The New York Times. November 28, 2017. Accessed November 1, 2018. https://www.nytimes.com/interactive/2017/11/28/us/politics/obamacare-individual-mandate-penalty-maps.html. 2. “ACA Individual Shared Responsibility Provision Calculating the Payment | Internal Revenue Service.” ACA Individual Shared Responsibility Provision Calculating the Payment | Internal Revenue Service. March 29, 2019. Accessed April 15, 2019. https://www.irs.gov/affordable-care-act/individuals-and-families/ aca-individual-shared-responsibility-provision-calculating-the-payment. 3. Cunningham, Paige Winfield. “The Health 202: Republicans Are Right. The Individual Mandate Is a Tax on the Poor.” The Washington Post. November 20, 2017. Accessed September 30, 2018. https:// www.washingtonpost.com/news/powerpost/paloma/the-health-202/2017/11/20/the-health-202-republicans-are-right-the-individual-mandate-is-a-tax-on-the-poor/5a0f2dc030fb045a2e003215/?noredirect=on&utm_term=.1e502cb37f3c. 4. Einav, Liran, and Amy Finkelstein. “Selection in Insurance Markets: Theory and Empirics in Pictures.” Journal of Economic Perspectives 25, no. 1 (2011): 115-38. doi:10.1257/jep.25.1.115. 5. Castellucci, Maria. “Emergency Room Visits Hit All-time High during ACA Implementation.” Modern Healthcare. September 13, 2017. Accessed September 30, 2018. https://www.modernhealthcare.com/article/20170913/NEWS/170919951/emergency-room-visits-hit-all-time-high-during-aca-implementation.
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