Big, rich hospitals can do much more to battle asthma, opioid drug abuse

asthma-300x123Even as they rake in big bucks and ride  a tsunami of mergers and consolidations sweeping the U.S. health care system, big hospitals and academic medical centers must step up on patients’ behalf, doing much more, for example, to battle America’s growing asthma woes and the opioid drug abuse epidemic.

Kaiser Health News, the Capital News Service, and the Washington Post deserve credit for their report on “Forgetabout Neighborhood,” the “worst asthma hot spot” in Baltimore. This part of the city is filled with “decrepit houses, rodents and bugs” that “trigger [asthma] and where few community doctors work to prevent asthma emergencies,” the news organizations have found. They say that residents of this neighborhood “visit hospitals for asthma flare-ups at more than four times the rate of people from the city’s wealthier neighborhoods.”

This area, zip code 21223, also sits in the shadow of not just one but two renowned medical centers, noted, among other things, for their respiratory expertise: Johns Hopkins, and the University of Maryland Medical Center. As the news organizations have reported:

Both receive massive tax breaks in return for providing ‘community benefit,’ a poorly defined federal requirement that they serve their neighborhoods. Under Maryland’s ambitious effort to control medical costs, both are supposed to try to improve residents’ health outside the hospital and prevent admissions. But like hospitals across the country, the institutions have done little to address the root causes of asthma. The perverse incentives of the health-care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.

Area hospitals, including Johns Hopkins and UMMC, took in $84 million between 2012 and 2015 for treating Baltimore asthmatics and inpatients or in emergency rooms. Further, the news organizations have noted:

For each emergency room visit to treat Baltimore residents for asthma … hospitals were paid $871, on average. For each inpatient case, the average revenue was $8,698. In one recent three-year period, hospitals collected $6.1 million for treating just 50 inpatients, the ones most frequently ill with asthma, each of whom visited the hospital at least 10 times.

But for 21223 residents, there’s a much cheaper, potentially more effective therapy: Instead of forking over tens of millions to the hospitals, they—and public health and housing officials—could attack the research-proven triggers of asthmatic attacks. They could do so, for example, by forcing slum lords to clean up housing for the poor so apartments are less ridden with molds, mildew, and vermin—especially, roaches, rats and mice, which are some of the leading sources of asthma triggers. Hospital staff could work more closely with patients to identify asthma triggers and to help patients take medications correctly and follow regimens beneficial to their respiratory health.

Johns Hopkins and UMMC officials have praised these ideas. But they say they’re hard to put in effect, especially as the city, state, and region struggle with other huge health challenges, including diabetes, drug overdoses, infant mortality and mental illness among the homeless. Both medical centers operate asthma-fighting programs, including UMMC’s school-visiting “Breathmoblies,” and a John’s Hopkins summer camp.

But the Baltimore institutions differ from hospitals like nearby Children’s National in Washington or St. John’s in Los Angeles, both of which have made asthma a priority, inside their walls and in their surrounding poor, minority communities. They have recognized that asthma is its own major health bane, as the news organizations have reported:

The disease causes nearly half a million hospital admissions in the United States a year, about 2 million visits to the emergency room and thousands of deaths annually. That drives the total annual cost of asthma care, including medicine and office visits, well over $50 billion.

Hospitals and opioid drugs

With research showing that patients’ earliest interaction with powerful painkillers can play a huge role in whether they become abusers, University of Michigan surgeons have looked at the significant role their own hospital might play in helping to curb the opioid drug abuse epidemic.

As Kaiser Health News has summarized the doctors’ new research and subsequent initiative at UM hospitals:

It’s a simple enough idea: Surgeons should give patients fewer pills after surgery — the time when many people are first introduced to what can be highly addictive painkillers. They should also talk to patients about the proper use of opioids and the associated risks. That seemingly small intervention could lead to significant changes in how opioids are prescribed and make inroads against the current epidemic.

The researchers looked at 170 gallbladder surgery patients, surveying them a year after their operations to better understand the pain they experienced and how they treated it. They were asked detailed, specific questions like how many opioid drugs they were prescribed, how many pills they took, and if they found pain relief with other, less powerful and risky drugs like ibuprofen.

Based on this information, doctors set up new prescribing guidelines, slashing the dosage and number of opioid pills they gave to a test group of 200 surgical patients—and substituting less powerful meds. They found that the studied patients didn’t complain more than before about pain, and they suffered fewer drug side-effects and complications. They took far fewer opioids and pills altogether, meaning the hospital reduced by 15,000 the number of painkilling pills they would have issued.

The Michigan surgeons not only published a paper in JAMA Surgery about their findings. They also have posted online their recommendations for painkiller dispensing and counseling patients about appropriate handling of these potent drugs.

It’s not a panacea, experts have said, noting that many patients get into trouble with opioids prescribed by doctors in offices, not the hospital. Still, this is a good step to cutting off yet another way that the opioid drug abuse epidemic has spread. Overdoses of opioids and related illicit drugs like heroin and fentanyl killed at least 64,000 Americans in 2016, becoming the leading cause of death of Americans 50 and younger. The drug abuse epidemic now kills more Americans than HIV-AIDS, guns, or cars did in their peak, lethal years.

In my practice, I see not only the harms patients suffer while seeking medical services but also the carnage caused by dangerous drugs. It may see excessive to some, I know, to insist that hospitals shoulder an even larger role than they carry now in tacking big social ills like the opioid drug abuse epidemic or the debilitating problem of asthma, a major woe in poor communities of color. Still, as the biblical wisdom advises: To those whom much is given, much is required.

A health system awash with wealth

More pragmatically speaking, the financial pages in recent days have been filled with news about the money sloshing around U.S. health care—Americans spent $3.3 trillion in 2016 on this sector and its products and services. Hospitals may have grappled with slim margins for patient care but they also “reaped more than $21 billion last year from their Wall Street investments, mergers and other investment options,” Axios, a news and information site, has found.

The business pages also have been filled with big headlines about:

Big changes—unpredictable in their outcomes for already struggling ordinary consumers like you and me—are clearly transforming health care, yet again, even as the GOP in Washington stampedes across the sector, too. Here’s hoping the brave new world betters our health care. We all need not only to stay engaged in how its run and who does so, but maybe we should ask the moon from it—so when the profiteers carve it up we get at least some crumbs.

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