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As patients, we generally do not think too much about emergency care until we face a situation that forces us to call 911. However, emergency care, which is a critical part of our medical system, warrants our attention. I recently spent some time in the emergency room (ER) and it was an interesting and frightening experience, because the ER is not functioning the way it should be on many fronts. The reasons are complex and not easily solved. They include the following:

• The ER has become a dumping ground for every patient who does not have access to basic health services, or a primary care physician to turn to when feeling ill or running a fever, including the uninsured, and the homeless. When I was wheeled into the ER by the EMTs recently, I saw at least 25 people lined up along a wall waiting to get into a room where they could receive care. Many of the same people were still lined up when I was leaving the ER, three hours later.

• According to a study conducted by the National Institutes of Health in 2020, the American Medical Association Physician Masterfile data set showed that there were 48,835 clinically active emergency physicians who designated emergency medicine as their primary or secondary specialty. Of those, the median age was 50 years. Overall density of emergency physicians per 100,000 population was 14.9. Most emergency physicians were in urban areas (92%), only 2,730 (6%) were in large rural areas and 1,197 (2%) in small rural areas. As of May 2024, there were 582,296 emergency medicine specialists active in the United States, and most of them were men, also with a median age of 50.  Most emergency physicians located in rural areas (71%) had completed their medical training more than 20 years previously.

  National Study of the Emergency Physician Workforce, 2020 by the NIHChristopher L Bennett 1, Ashley F Sullivan 1, Adit A Ginde 2, John Rogers 3, Janice A Espinola 1, Carson E Clay 1, Carlos A Camargo Jr  DOI: 10.1016/j.annemergmed.2020.06.039 Pub Med

• It is obvious from these statistics that the United States is experiencing a shortage of ER doctors, particularly in rural areas: The number of new residents in emergency medicine residency programs has decreased significantly since 2021. In 2023, 555 emergency medicine residency positions went unmatched, a 253% increase from 2022. The reasons why emergency medicine has become less desirable include the impact of COVID-19 and the unbelievable pressure it put on the ER doctors, economic workforce projections for the future, increasing economic control by contract management groups (CMGs). The growing clinical demands on ER docs are outpacing pay, and their student loan burdens are enormous. Physician suicide, inadequate staffing to support the doctors and growing malpractice exposure are all factors.

• When I was in the ER, I never saw a doctor. I saw a very competent nurse and a competent physician assistant. I was not a trauma case or a cardiac or stroke patient, so apparently there was no need for me to see a doctor. However, in past experiences, which were also not trauma or life -threatening, I saw at least one doctor and often more than one.

With an increasingly aging population in the U.S. this is an alarming, growing problem, especially for rural areas where there are also increasing numbers of hospitals closing. Thus, the question becomes, “who is going to take care of the patients who rush to the ER because they have no other place to go for care? “

This problem is for the healthcare industry along with the Department of Health and Human Services to solve. One solution would be the expansion of community health centers throughout rural and urban America to serve the poor, uninsured, homeless and underinsured populations who have such limited access to basic health services and default to the emergency room. Other solutions would be a focus on lessening the burden of costly medical education to all medical students and more attractive payment packages to lure more Med school graduates into ER and primary care medicine. One thing is certain. We must act quickly to address this problem before the system implodes and people begin to die in the ER corridors. We are, after all, the richest, developed nation in the world. It is time to begin acting like it when it comes to critical health servi

For more than 200 years, Massachusetts General Hospital (MGH) has been a leader in medical discovery.  As the nations’ largest hospital system with a significant research enterprise, MGH, ten years ago, launched the World Medical Innovation Forum (WMIF), to discuss research and innovation that represents key medical breakthroughs of the 21st century. This year is the 10th anniversary of the Forum and discussions included more than 20 sessions on cutting edge topics from generative AI, to new cancer paradigms; from weight loss drugs, to use of psychedelic therapy in mental health, from advances in immunology to gene and cell therapy.

The Forum led off, with their unique “First Look,” 14 rapid fire presentations from MGB researchers on breakthrough technologies across a variety of clinical areas ranging from: Lipid abnormalities in the brain, to a mobile app for integrating patient reported outcomes to help clinicians determine when an in-patient visit is needed. AI was a big theme this year, including First Look “AI to streamline cardiovascular clinical trials”.  Other First Look research ranged from autoimmune skin disease to development of a robotic bronchoscope to diagnose and treat hard- to- reach lung cancers. A highlight of the First Look was presentation of Virtual Reality Training followed by a Virtual Reality Lab that was open to attendees throughout the three-day program.  Equally diverse and interesting were the many panels and fireside chats on topics varying from Gene and Cell Therapy to using AI in various facets of delivering care and analyzing therapeutic results. 

What this Forum and so many other meetings continue to prove is that there is so much research and innovation that produce such purposeful results that change how medicine is viewed, evaluated and executed on behalf of the patient. So, instead of looking at the problems we usually discuss, it is sometimes worthwhile to take a breath and look at the amazing strides we are making. 

The Inflation Reduction Act of 2022 (IRA P.L. 117-169),which was signed into law on August 16, 2022, expands Medicare benefits by lowering drug costs. The Act empowers The Centers for Medicare & Medicaid Services (CMS) to select initially 10 single source drugs without generic or biosimilar competition, in 2024, an additional 15 drugs in  2025 and annually, thereafter  to negotiate the price of  additional high expenditure drugs  The IRA mandates that  CMS  negotiate the prices of these high expenditure drugs with the manufacturers. These are drugs that senior citizens particularly, rely on. They include those used for treating diabetes, heart disease and cancer. Once the new, lower prices take effect in 2026, all Medicare enrollees are expected to save an estimated $1.5 billion dollars.   Additionally, everyone enrolled in Medicare prescription drug coverage will have their out-of-pocket costs capped at $2,000 beginning in 2025. 

The concern about high drug prices arose among people who had to take insulin. It has been an ongoing discussion for a long time. That is because an individual with Type I diabetes paid $9 per vial in 1972; $33 per vial in 1996 and $275 in 2017.  Most people need one shot of long-acting insulin per day, but some may require up to four shots per day, at a cost of $1,100 per day. It does not take much effort to understand how few people can afford these prices. The  changes, outlined, will improve drug affordability for people with diabetes, by capping out-of-pocket spending for insulin at $35 per one  month’s supply of each insulin product covered under a Medicare Part D plan, with similar limits for out-of-pocket costs for insulin supplied under Part B.

On another front, to control the high price of drugs in the U.S. the FTC (Federal Trade Commission) is moving forward with an agenda that will also help to reduce drug costs for the patient.  They are suing middlemen – called Pharmacy Benefit Managers – who for years, have had a reputation of pocketing discounts they negotiate on behalf of the consumer with the Pharma companies.  The PBMs work for and are beholden to the largest drug selling chains including Cigna Group’s Express Scripts. United Health Group’s Optum Rx, and CS Health’s Caremark They claim that they have achieved deep discounts, “as a result of their negotiations with Pharma so that the people will pay less.”  They blame the manufacturers of insulin: Eli Lilly, Novo Nordisk, and Sanofi for the high prices assessed to many patients.  The drugmakers contend that they are providing discounts and the PBMs were not passing those along to the healthcare consumer. In reality, Caremark, Express Scripts, Optum, and their affiliates created a broken rebate system that inflated insulin drug prices, boosting PBM profits at the expense of vulnerable patients.

Regulations that help encourage Pharma to continue to research new drugs, innovate and produce solutions for desperate health conditions are essential. Just as critical, however, are fair prices to the American public which cannot continue to assume higher costs for the same drug compared with our counterparts around the world, simply because we have allowed the system to work against the patient. That is just counterproductive for the nation and an undemocratic way to treat our citizens.

Insulin is just one, blatant example of drug price manipulation and how the supply chain is  broken and without proper oversight. With the enactment of The Inflation Reduction Act, Medicare will be allowed to  negotiate directly with drug companies, cap prices and improve access for the healthcare consumer for some of the costliest single-source brand-names.  Currently, Americans have been paying three to eight times more than their counterparts in other countries for the exact same drug. That situation exists  because most other developed nations have national health systems that negotiate the prices of all drugs they approve. The fight to lower drug costs here has just begun! ies.  The PBMs work for and are beholden to the largest drug selling chains including Cigna Group’s Express Scripts. United Health Group’s Optum Rx, and CS Health’s Caremark They claim that they have achieved deep discounts, “as a result of their negotiations with Pharma so that the people will pay less.”  They blame the manufacturers of insulin: Eli Lilly, Novo Nordisk, and Sanofi for the high prices assessed to many patients.  The drugmakers contend that they are providing discounts and the PBMs were not passing those along to the healthcare consumer. In reality, Caremark, Express Scripts, Optum, and their affiliates created a broken rebate system that inflated insulin drug prices, boosting PBM profits at the expense of vulnerable patients.

Regulations that help encourage Pharma to continue to research new drugs, innovate and produce solutions for desperate health conditions are essential. Just as critical, however, are fair prices to the American public which cannot continue to assume higher costs for the same drug compared with our counterparts around the world, simply because we have allowed the system to work against the patient. That is just counterproductive for the nation and an undemocratic way to treat our citizens.

Insulin is just one, blatant example of drug price manipulation and how the supply chain is  broken and without proper oversight. With the enactment of The Inflation Reduction Act, Medicare will be allowed to  negotiate directly with drug companies, cap prices and improve access for the healthcare consumer for some of the costliest single-source brand-names.  Currently, Americans have been paying three to eight times more than their counterparts in other countries for the exact same drug. That situation exists  because most other developed nations have national health systems that negotiate the prices of all drugs they approve. The fight to lower drug costs here has just begun!