Penn Healthcare Review Spring 2018

SPRING 2018

PENN HEALTHCARE REVIEW PRODUCED BY

WHARTON UNDERGRADUATE HEALTHCARE CLUB

On mental health where business meets HEALTHCARE

in society today

Where Business Meets Healthcare Editor-In-Chief Vaishnavi Sharma

Editorial

Dear Readers, I am so excited to present to you the fifth issue of Penn Healthcare Review this spring.

Grace Mock Jason Grosz Noa Ortiz-Langleben Brian Zhong Robleh Hussein Farah

There are several issues currently affecting the world of healthcare and our writers have done an amazing job of giving them a voice. These issues range from being related to mental health to organ donation to pharma. This issue also goes into depth on several changes that may affect healthcare in the years to come such as telemedicine, new innovations, and Amazon’s new interests in healthcare.

Strategy and Design

I would wholeheartedly like to thank the editors for working so closely with the writers in perfecting their pieces, the design team for bringing color and creativity to the articles, and to the business staff for bringing this PHR issue to life!

Judy Choi, Co-director Chloe Le, Co-director Elaine Ma Alexis Megibow Sarah Nam

Business Catherine Ruan, Manager

Web Sabina London, Manager Interested in writing for Penn Healthcare Review? Email wuhcpublications@gmail.com for more information.

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 04/05/2018 to 05/04/2018.

Cover designed and graphically created by Judy Choi using Adobe Photoshop.

Our team hopes you find these articles informative, interesting, and thought-provoking.

Sincerely, Vaishnavi Sharma Editor-in-Chief, PHR

CONTENTS

WHARTON UNDERGRADUATE HEALTHCARE CLUB

INNOVATION

4

THE USE OF BIOLOGICAL MOLECULES FOR THERAPEUTIC PURPOSES Jason Grosz

NEW ANTIMICROBIAL BIOMATERIAL DEVELOPED AT U. OF PENN’S SCHOOL OF DENTAL MEDICINE 6 Judy Choi HEALTHCARE INEQUALITY GAPS IN ORGAN DONATION 8 RACIALGrace Mock

10

ARE WE KILLING OUR CITIZENS WITH UNINSURANCE?

12

HOW CRITICAL DISEASES VARY WORLDWIDE: COMPARING CARDIOVASCULAR DEATH IN THE US WITH LEADING CAUSES OF MORTALITY ACROSS SUB-SAHARAN AFRICA

Dominic Gregorio

Robleh Hussein Farah

FEATURES

14

PHYSICIAN BURNOUT

Karthik Prabhakaran

HARDENED INMATES, RETURNING VETERANS, AND A COLLEGE FRESHMAN ALL HAVE IN COMMON 16 WHATVictor Diaz FASHION ANOTHER ELEMENT TO ADD TO THE PERIODIC TABLE 20 FASHION: Marina Gialanella MINDFULNESS THERAPIES IN CHILDBIRTH 22 MINDFULNESS-BASED Elaine Ma TECHNOLOGY FRONTIER FOR TELEMEDICINE: SCHOOLS 24 A NEWJoyce Tien AMAZON DISRUPT HEALTHCARE? 26 WILLMadeline Covington PHARMACEUTICAL DRUG MISUSE ON COLLEGE CAMPUSES 28 PRESCRIPTION Sarah Nam IN FREEFALL: MEDICAING ON A SPACE STATION 30 PHARMACY Nicolas Nelson BUSINESS ECONOMICS 32 BEHAVIORAL Hoyt Gong OF NEUROSCIENCE TO BUSINESS 34 APPLICATIONS Brian Zhong

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Title graphic designed by Judy Choi

O

ver the past few years, the pharmaceutical industry has been undergoing a dramatic shift.

As diseases become more and more complicated to treat and cure, small-molecule therapeutics, which were once the bread and butter of the pharmaceutical industry, are increasingly being overshadowed by biologic therapeutics.1 This shift has the potential to radically disrupt all stakeholders in the industry, from big pharma to payers to patients.

Small-molecule therapeutics are chemically manufactured drugs that comprise about 90% of the drugs available on the market today.2 As the name suggests, small-molecules do not have a large structure and are typically smaller than 900 Daltons. They include some of the most well-known brands in pharma, such as aspirin (pain relief), Lipitor (a cholesterol lowering static drug), Prilosec (antacid) and more. They are what most people typically think of when they think of pharmaceutical drugs. For decades, they have been the cash-cows of the pharmaceutical industry, generating billions of dollars of profits for the industry every year.

Biologics, on the other hand, are drugs manufactured by living organisms, frequently using recombinant DNA technology. They tend to be much larger than smallmolecules- some have molecular weights of tens-ofthousands of Daltons. In 2016, six of the top eight drugs by revenue were biologics, and thanks to many new breakthrough biologics, this trend is poised to continue into the future.3 The largest class of biologics, known as monoclonal antibodies, or mAbs, have existed as therapeutics sine 1986 and are the current backbone of the biologics industry. According to TMR, a company that compiles market research reports, monoclonal antibodies produced $90.2 billion in revenue 2016 an account for 43% of the total biologics market share.4 The most successful mAb on the market today is Humira (Adalimumab), which is an immunosuppressive drug produced by Abbot Laboratories to treat arthritis, Crohn’s disease, and plaque psoriasis. mAbs are proteins produced in the immune system that bind specifically to the same region of target antigens and flag them for the immune system. In contrast, polyclonal 4 | PENN HEALTHCARE REVIEW | SPRING 2018

antibodies bind to different regions of the same protein and are frequently derived from different immune cell lineages.5 Although mAbs have been the gold-standard of biologics for decades, a few emerging therapies promise to reshape the industry in the future. One of these therapies is a cancer vaccine that was developed here at the University of Pennsylvania and was recently approved by the FDA and licensed to Novartis. It is known as chimeric antigen receptor T-cell therapy, or CAR-T Therapy. CART-T Therapy is a process by which physicians harvest a patient’s own immune cells, bring them to a centralized lab, genetically engineer them with lentiviral vectors to express receptors that bind to ligands on the surface of cancer cells, and re-infuse them into the patient’s bloodstream.6 The results of this treatment have been astonishing for some patients. According to the first results published in 2011 in the New England Journal of Medicine, a patient with chronic lymphocyte leukemia was cured 23 days after the re-infusion of T-cells.7 This process has also been successful for many subsequent patients with hematopoietic cancers such as leukemia.

Another breakthrough biologic therapy that has recently reached market is a one-time gene therapy treatment developed by Spark Therapeutics for a rare form of congenital blindness.8 This specific type of genetic blindness results from a mutation in both copies of the RPE65 gene, which codes for a protein that converts light into electrical signals that are transmitted to the brain.9 Spark developed an adeno-associated viral vector that carries a functional copy to RPE65 and is injected into the eye. Once the virus is injected into the eye, it gains entry into retinal cells, inserts itself into the AAVS1 locus of the human genome, and uses the cell’s internal machinery to express the carried gene, in this case the replacement for RPE65.10 Even though there are only about 1000 cases of this form of inherited retinal disease in the United States, Spark Therapeutics’ success provides hope for the success of future gene therapy treatments for a wide array of other diseases.

Despite the promises of emerging biologic therapies, biologics such as the ones described above have a unique

INNOVATION

set of drawbacks. For one, both the CAR-T therapy and the gene therapy are extremely expensive. The price of the CAR-T therapy is $475,000 for a one-time treatment, and the price of a one-time treatment for the Spark gene therapy is $850,000.11 This is because both therapies are cuttingedge, first-in-class treatments that required years of research to develop and target small patient populations. In the case of the CAR-T therapy, the costs are also exceedingly high, as each treatment is unique to the patient and requires processing in centralized laboratories with high trained technical staffs.

Another drawback of biologic therapies is that they are harder to convert to biosimilars, or generic biologics, than small-molecules are to convert into generics.

This is because all biological molecules, such as proteins, nucleic acids, etc. have Infographic designed by Judy Choi natural variation that is impossible to eliminate.12 For example, monoclonal antibodies are produced are mass produced in microorganisms, whereas small-molecules are mass produced using standardized chemical reactions.

Natural variations in each of the microorganisms will result in natural variations in each mAb. Thus, it is challenging for biosimilars to be approved because they will never be identical to the original treatment, and therefore undergo a more stringent regulatory process than smallmolecule generics.13 This also means that biosimilars that are approved are not as inexpensive as small-molecule generics.

The use of biological molecules for therapeutic purposes has existed since monoclonal antibodies were first used in the 1980s. That being said, the number and importance of biologics has skyrocketed in recent years, led by breakthrough therapies such as CAR-T therapy and gene therapy. As of today, biologics are poised to entirely disrupt the pharmaceutical and biotechnology landscapes as their growth trajectory threatens to overtake smallmolecules in market share and revenue.

Going forward it will be interesting to see how payers, providers, and patients balance the benefits of biologics with their drawbacks.

1. Gautam, Ajay, and Xiaogong Pan. “The Changing Model of Big Pharma: Impact of Key Trends.” Drug Discovery Today, vol. 21, no. 3, Mar. 2016.

2. Cohen, Yuval. “Small Molecules: The Silent Majority of Pharmaceutical Pipelines.” Xconomy, 20 Nov. 2015.

3. Walker, Nigel. “Biologics: Driving Force in Pharma.” Pharma’s Almanac, 5 June 2017.

4. “Monoclonal Antibody Therapeutics Market to Be Worth US$245.8 Billion by 2024: Spike in Cancer Cases Around the World to Ensure Swift Uptake, Predicts TMR.” PR Newswire, Transparency Market Research, 12 Jan. 2017.

5. Nelson, PN, et al. “Demystified: Monoclonal Antibodies.” Journal of Clinical Pathology, vol. 53, no. 3, June 2000.

6. Porter, David L., et al. “Chimeric Antigen Receptors-Modified T Cells in Chronic Lymphoid Leukemia.”

New England Journal of Medicine, vol. 365, no. 8, 2011, pp. 725–733., doi:10.1056/nejmoa1103849.

7. Ibid.

8. LUXTURNA™ (Voretigene Neparvovec-Rzyl) for Patients. Spark Therapeutics, luxturna.com/.

9. “RPE65 Gene.” U.S. National Library of Medicine, National Institutes of Health, ghr.nlm.nih.gov/gene/ RPE65.

10. Ward, P, and CE Walsh. “Targeted Integration of a RAAV Vector into the AAVS1 Region.” Virology, vol.

433, no. 2, 25 Nov. 2012, pp. 356–366., doi:10.1128/jb.00245-17.

11. Herper, Matthew. “Spark Therapeutics Sets Price Of Blindness-Treating Gene Therapy At $850,000.”

Forbes, Forbes Magazine, 3 Jan. 2018.

12. Cronstein, BN. “The Benefits and Drawbacks of Biosimilars.” Clinical Advances in Hematology Oncology, vol. 13, no. 10, Oct. 2015.

13. Ibid.

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Title graphic photographed and designed by Judy Choi

n November of 2017, researchers at the University of Pennsylvania’s School of Dental Medicine published an assessment of a new dental composite material that they developed to be used in fillings that can kill bacteria and resist biofilm growth. This new material is determined to be safer and stronger than other drug-tethered dental materials.

Composite materials are used for restorative procedures like cavity fillings. Ideally, these composites should perform similarly too or better than the tooth’s natural enamel. Like tooth enamel, biofilm can form on composite materials, leading to plaque growth and tooth decay. Biofilm is a thin, slimy film of bacteria that forms on the surface of the tooth. The most predominant bacteria

within the human oral cavity is Streptococcus mutans, an anaerobic, gram-positive round bacterium. This substance contributes significantly to tooth decay.1, 2 Pre-existing antibacterial composite works by slowly releasing a drug into the material, the tooth, and its surroundings. Infusing large amounts of antimicrobial agents into the new composite material to maximize the killing efficacy compromises its strength and the condition of the surrounding tissues. The newly developed biomaterial works by killing the bacteria that comes into contact with it, allowing it to be effective with minimal toxicity to the surrounding areas. The composite has imidazolium—an antibacterial agent—embedded into the resin. This design keeps the antibacterial agent from

Infographic designed by Judy Choi with information sourced from article.

6 | PENN HEALTHCARE REVIEW | SPRING 2018

INNOVATION

leaching the surrounding tissues, reducing cytotoxicity to them and the likelihood of antimicrobial resistance. A small dosage of imidazolium (2% by weight) was observed to kill bacteria effectively without weakening the material.3 According to Dr. Geelsu Hwang, research assistant professor at the School of Dental Medicine, researchers should keep two things in mind when developing an improved dental material. First, if it is tethered with a microbial compound, it should effectively kill pathogenic microbes. Secondly, because the material will be used to fill in the missing space that was previously occupied by the tooth’s natural composite and enamel, the material must withstand the force and pressure caused by biting and chewing.4 The new biomaterial was evaluated for efficacy in killing bacteria by assessing how much shear force was needed to remove biofilm from the control composite, as well as from the treatment composite. Furthermore, analysis was done concerning how biofilm formed on the surfaces of these composite materials.

Biofilm that formed on the tooth treated with the new dental material was easier to remove than the one formed on the surface of an untreated tooth. Upon observing the

biofilm structure on both composites, researchers found that the treatment composite inhibited the accumulation of the biofilm matrix, an adhesive that clumps bacteria together on the tooth’s surface. On the treatment composite, less amount of biofilm accumulated, and the architecture of the bacterial cell accumulation was sparse, amorphous and less dense. On the control composite, researchers observed a constant, organized, and structured buildup of biofilm.5 An evaluation of the shear force needed to remove biofilm from both the control and experimental biomaterials revealed that there was a notable difference in the force needed. The materials were exposed to 10-minute long constant shear stress of 0.18, 0.81, and 1.78 N/m2.

Whereas the shear force from drinking water (~0.18 N/ m2) could remove biofilm from the new material, a force almost ten times as large (1.78 N/m2) could not remove biofilm from the control composite material.6 With this novel development in the dental industry, patients and dental care professionals alike can hope to expect less oral problems, including but not limited to tooth decay and antibacterial resistance, arising from dental composite materials.

1. Ryan KJ, Ray CG, eds. (2004). Sherris Medical Microbiology(4th ed.). McGraw Hill. ISBN 0-8385-8529-9.

2. Loesche WJ (1996). “Ch. 99: Microbiology of Dental Decay and Periodontal Disease”. In Baron S; et al.

Baron’s Medical Microbiology (4th ed.). University of Texas Medical Branch. ISBN 0-9631172-1-1. PMID 21413316.

3. Geelsu Hwang, Bernard Koltisko, Xiaoming Jin, Hyun Koo. “Nonleachable Imidazolium-Incorporated Composite for Disruption of Bacterial Clustering, Exopolysaccharide-Matrix Assembly, and Enhanced Biofilm Removal.” ACS Applied Materials & Interfaces, vol. 9, no. 44, 2017, pp. 38270–38280., doi:10.1021/ acsami.7b11558.

4. University of Pennsylvania. “New dental material resists plaque and kills microbes.” ScienceDaily. ScienceDaily, 4 December 2017. <www.sciencedaily.com/releases/2017/12/171204162229.htm>.

5. Geelsu Hwang, Bernard Koltisko, Xiaoming Jin, Hyun Koo. “Nonleachable Imidazolium-Incorporated Composite for Disruption of Bacterial Clustering, Exopolysaccharide-Matrix Assembly, and Enhanced Biofilm Removal.” ACS Applied Materials & Interfaces, vol. 9, no. 44, 2017, pp. 38270–38280., doi:10.1021/ acsami.7b11558.

6. Geelsu Hwang, Bernard Koltisko, Xiaoming Jin, Hyun Koo. “Nonleachable Imidazolium-Incorporated Composite for Disruption of Bacterial Clustering, Exopolysaccharide-Matrix Assembly, and Enhanced Biofilm Removal.” ACS Applied Materials & Interfaces, vol. 9, no. 44, 2017, pp. 38270–38280., doi:10.1021/ acsami.7b11558.

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M

ore than 120,000 Americans are currently on the national United Network for Organ Sharing waitlist to receive organ or tissue transplants.1 Organ transplants are lifesaving procedures for many individuals suffering from a range of illnesses and disabilities. Cornea transplants can restore sight while heart transplants can effectively result in a new chance at life.

Becoming an organ donor does not come at any financial or medical cost and is widely considered as a way to make an impactful contribution to society after death. However, despite the large need for organ donation, only 45% of Americans are registered organ donors.2 While this organ donation deficit harms all individuals in need of a transplant, it has a larger impact on racial and ethnic minorities.

Individuals from minority backgrounds are more likely to need an organ transplant. In Texas minority individuals make up over 50% of the transplant waiting list.3 This is partly because, similar to family history, race and ethnic background are factors that can increase the likelihood of an individual developing certain health conditions. For example, African Americans and Mexican Americans have greater risk to develop type II diabetes and heart disease4 while Caucasian Americans have a greater risk of developing Cystic Fibrosis.5 African Americans, Hispanic, and Pacific Islanders are three times more likely to suffer from kidney failure than Caucasians.6 There are ways individuals can monitor various health risks through lifestyle choices such as diet and exercise, but there is still an overall trend that predisposes minority groups to an increased need for organ transplants.

The same health factors that increase the likelihood of minorities needing organ transplants also decrease the like8 | PENN HEALTHCARE REVIEW | SPRING 2018

Title graphic designed by Chloe Le

lihood that minorities can be eligible candidates to serve as living donors.7 Living donors are individuals who elect to donate non-vital organs, such as a kidney, while alive. Living donor transplants increase the likelihood that the body accepts the organ, resulting in better outcomes for the organ recipient than deceased donor organ transplants.8 Living organ donation commonly occurs between family members or friends who are found to be compatible matches, but can also be arranged between anonymous donors found to be compatible to individuals needing transplants. One recent living organ donation occured when actress Selena Gomez, who has Lupus autoimmune disease, received a kidney transplant from her friend and fellow actress Francia Raisa who served as a living donor.9 According to studies conducted by the National Kidney Foundation, African Americans have between a 35% to 75% lower chance of receiving an organ from a living donor.10 In 2014 African Americans were 30.1% of the organ waitlist, 20.1% of organ recipients, and 10.4% of living organ donors.11 Similarly Hispanics consisted of 18.7% of the organ waitlist, 14.2% of organ recipients, and 13.8% of living organ donors.12 Lastly, Asian Americans were 7.2% of the organ waitlist, 5.2% of organ recipients, and 3.9% of living organ donors.13 There are many factors considered when matching individuals needing transplants with donated organs from deceased individuals. The United Network for Organ Sharing is a private, non-profit organization that runs the national database of organ matching.14 Blood type, organ size, medical urgency, and time on the waiting list are some of the many factors that determine eligible matches between donors and transplant candidates.15 However, race and ethnic makeup

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are also indirect factors that influence compatibility since organs matched by blood group and tissue type are mostly found between individuals in the same ethnic group.16 Since there are fewer deceased organ donors in minority communities, minorities are less likely to be matched with organs from deceased donors. In 2014 only 32% of deceased organ donors were minorities, while 42% of those receiving transplants were minorities.17 This gap in donation is partly caused by misconceptions about organ donation that are prevalent in all communities, but especially in multicultural and ethnically diverse communities. One of the prominent health myths is that medical teams are less motivated to deliver life-saving care if they know you are an organ donor.18

Another misconception is that organ donors are responsible for costs associated with the organ transplant, which is also false.19 Overall, the racial gaps in organ donation are alarming.

There is decreased access for minority groups to receive donated organs while there is increased need. Organ transplantation is a great resource for medical treatment, and obstacles that prevent it from being fully utilized need to be eliminated. The best way to solve this problem is by continuing to engage in dialogue about the merits of organ donation and combat common health myths that cause people to refrain from becoming organ donors.

Infographic designed by Chloe Le

1. “Facts About Organ Donation.” National Foundation for Transplants. Accessed March 08, 2018. http:// www.transplants.org/facts-about-organ-donation.

2. Ibid.

3. “Donation Among Minorities.” Life Gift. Accessed March 08, 2018. http://www.lifegift.org/multicultural-perspective 4. “Age, Race, Gender, and Family History.” American Diabetes Association. Accessed March 08, 2018. http://www.diabetes.org/are-you-at-risk/lower-your-risk/nonmodifiables.html 5. “Carrier Testing for Cystic Fibrosis.” Cystic Fibrosis Foundation. Accessed March 08, 2018. https://www. cff.org/What-is-CF/Testing/Carrier-Testing-for-Cystic-Fibrosis/ 6. Maron, Dina Fine. “Racial Gap in Kidney Transplants Combated by Policy Changes.” Scientific American. September 03, 2015. Accessed March 08, 2018. https://www.scientificamerican.com/article/racial-gap-in-kidney-transplants-combated-by-policy-changes/ 7. “African Americans Least Likely to Receive a Living Kidney Donation.” National Kidney Foundation. May 30, 2012. Accessed March 08, 2018. https://www.kidney.org/news/newsroom/nr/racial_transplant 8. Maron, Dina Fine. “Racial Gap in Kidney Transplants Combated by Policy Changes.” Scientific American. September 03, 2015. Accessed March 08, 2018. https://www.scientificamerican.com/article/racial-gap-in-kidney-transplants-combated-by-policy-changes/ 9. Rubin, Rita. “Selena Gomez Brings Attention to Organ Donor Need and Fact That Lupus Is More Common In Young Women.” Forbes. September 15, 2017. Accessed March 08, 2018 https://www.forbes.com/sites/

ritarubin/2017/09/15/selena-gomez-brings-attention-to-organ-donor-need-and-fact-that-lupus-is-morecommon-in-young-women/#37603b1e75ee 10. “African Americans Least Likely to Receive a Living Kidney Donation.” National Kidney Foundation.

May 30, 2012. Accessed March 08, 2018. https://www.kidney.org/news/newsroom/nr/racial_transplant 11. “National Minority Donor Awareness Week.” US Department of Health and Human Services. Accessed March 08, 2018. https://organdonor.gov/awarenessweek/awarenessweek.html 12. Ibid.

13. Ibid.

14. “How Organs Are Matched.” United Network for Organ Sharing. 2017. Accessed March 08, 2018. https://unos.org 15. “Organ Donation and Transplantation. Cleveland Clinic. February 21, 2017. Accessed March 08, 2018. https://my.clevelandclinic.org/health/articles/11750-organ-donation-and-transplantation 16. “Closing the Donation Gap.” Association for Multicultural Affairs in Transplantation. Accessed March 08, 2018. http://www.amat1.org/about-amat/closing-the-donation-gap/ 17. “National Minority Donor Awareness Week.” US Department of Health and Human Services. Accessed March 08, 2018. https://organdonor.gov/awarenessweek/awarenessweek.html 18. “Closing the Donation Gap.” Association for Multicultural Affairs in Transplantation. Accessed March 08, 2018. http://www.amat1.org/about-amat/closing-the-donation-gap/ 19. Ibid.

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H

ealth insurance is a lot like salt. A sprinkle of it is good--vital to healthy life, even. A shortage is as good as starvation, but heaping it on is inevitably destructive: excessive table salt will cause heart problems, while too much of the table salt substitute potassium chloride is literally a medium of lethal injection.

Markets for medical care require the same state of balance between costs and benefits. And governments have just as much opportunity to abuse citizens by restricting the quantity available or compelling an overdose. Through a complex web of insurance laws, state and federal governments prevent U.S. consumers from buying beneficial insurance policies that stand capable of increasing both life expectancy and quality of life. The result is a swath of uninsured citizens, dying for the sake of a public policy with no sense of balance.

Regulations are far from the only factor determining the level of coverage a population obtains. Income, information access, policy types available, and personal values all play key roles in either the desire or ability of an individual to get insured. But the fact is that governments are incredibly influential in health coverage choice, partially because public policy already has so great an impact on markets in general. If insurance has a significant impact on public welfare, then this means we have to be incredibly careful to pick policies that result in longer lives and more happiness rather than the borderline murderous alternative in which the norm is instead characterized by compulsory excesses or shortages.

For example, government impacts income and wealth, both of which are directly related to health coverage. After all, uninsurance is fundamentally a money problem. As seen in Figure 1, lack of health coverage is directly related to income level:1 the more you make, the more likely you are to get covered (Figure 1). In addition, the higher the gross state product (GSP), the lower the uninsurance rate, making states with higher-performing economies more evenly insured (Figure 2).2,3 It is not too much to ask, then, for governments to seek policies which maximize disposable income and avoid throttling economic growth.

Doing so will require regulators to think carefully about the effects of regulatory, monetary, and fiscal policies which do have important, if indirect, effects on citizens who seek health coverage. However, government

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Title designed by Elaine Ma

has expanded its power over the insurance world. Not only taxing the populace and setting interest rates, it also has a say in what types of coverage are permitted to be sold, to whom, by whom, and at what prices. Governments control premiums, or the annual price of insurance. They control actuarial value, or the expected payout of a plan.

They legislate risk rating, whereby an insurance company offers premiums to consumers based on expected costs.

They even control how comprehensive plans are: that is, how many types of services the plan will pay for.

The reader is surely familiar with the Obama administration’s Patient Protection and Affordable Care Act (PPACA). The PPACA took admirable steps to reform Medicare spending but also served to accentuate existing distortions to premium rating. In fact, states had been perverting premiums prior to the ACA, such as by requiring insurance prices not to reflect risk on countless dimensions, including sex, gender, health status, and even tobacco use. Since implementation of the PPACA, and since before then for a number of states, adjusted community rating policies have kept premiums from varying on many risk-linked dimensions. This locks out the young, healthy, and risk-tolerant from the market, because they are not willing to pay the same high premiums that riskier individuals will pay.6 On top of this, there is an array of mandated health benefits, meaning medical insurance policies are required to be particularly comprehensive. According to the National Committee of State Legislatures, “Prior to passage of the PPACA, between the states and the federal government there are upwards of 2,000 health insurance mandates.”7 Requiring coverage to be excessively comprehensive blocks many consumers from buying policies, because they are only willing to pay for some intermediate level of coverage that is no longer available. If insurance is lifesaving, this means state and federal laws are effectively preventing their citizens from saving their own lives.

The thoughtful reader might be thinking, “Isn’t it natural that some people choose not to buy insurance?

Not everyone feels it’s worth it!” The point is valid; the demand for insurance is downward-sloping, meaning customers choose to enroll or not to enroll based on price (premiums and deductibles, etc.), so economists like Einav and Finkelstein agree that it’s “not necessarily efficient to

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allocate insurance coverage to all individuals.”8 I argue, however, that the amount of uninsured is currently far above the efficient quantity. Further research is needed in order to estimate the number of buyers that are priced out, if not outright banned, from coverage due to misguided regulations.

A skeptical reader might press further: “Market failures make public insurance a far better option than these private plans. After all, information is asymmetric, and consumers can’t make rational choices in such a complex industry.” continue to prioritize genetic privacy. Customers must continue to remain informed about their option to engage or not engage in genetic research and decide if the privacy risks are worth the excitement of connecting with a new expanded personal history.

The first market failure of concern is moral hazard, meaning enrollees behave in more costly ways once they get insured. However, not only do insurers have methods of mitigating moral hazard, but there is also an upside: Patients are incentivized to use lifesaving care once they know they are covered.9 Perhaps because of this, even after controlling for risk, the uninsured are dying at far faster rates than the insured. As many as 45,000 annual deaths are attributable to uninsurance.10 Meanwhile, Medicaid does no better than uninsurance in terms of health measures.11 The evidence implies that private coverage is not only a consensual contract; it is also one that saves lives. A wider range of contracts--and lives saved--should be permitted to thrive.

But is consensual a strong word? Abaluck and Gruber (2011) found elders made unreasonable choices in Medicare Part D plans,12 and NBER researchers (2015) commented on choices which “reflect a severe deficit in health insurance literacy...rather than a sensible comparison of plan value.”13 However, according to the NBER working paper, seniors made objectively better choices when presented with more information and more time to practice choosing.

In addition, authors from Brookings propose decision support for ACA exchanges, arguing that a search tool and a “smart default” system would help enrollees pick the plans most beneficial to them. Information and decision supports are in demand and in development. Asymmetric information will not be the death of private insurance.

Instead, a lack of private insurance will mean undue death for thousands of Americans again this year, unless state and federal regulators act to unthrottle markets for its provision. What constitutes “consumer safety” to regulators constitutes “dying of easily preventable aortic aneurysm at age 50 because of uninsurance” to a price-sensitive patient. With Kaiser Family Foundation’s 2016 estimates at over 28 million, or about 9 percent of the U.S. population, the uninsured are no small group.14

Politicians and bureaucrats need to seek ways to fortify the pocketbooks and expand the permissible options of their uninsured constituents. The evidence implies that any less effort is, at best, involuntary manslaughter.

1. “Uninsured Rates for the Nonelderly by Federal Poverty Level (FPL).” The Henry J. Kaiser Family Foundation. September 19, 2017. Accessed March 02, 2018. https://www.kff.org/uninsured/ state-indicator/rate-by-fpl/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D. 2. “Total Gross State Product (GSP) (millions of current dollars).” The Henry J. Kaiser Family Foundation. September 06, 2016. Accessed February 25, 2018. https://www.kff.org/other/state-indicator/ total-gross-state-product/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D. 3. “Health Insurance Coverage of the Total Population.” The Henry J. Kaiser Family Foundation. September 19, 2017. Accessed February 25, 2018. https://www.kff.org/other/state-indicator/total-population/?dataView=1&activeTab=graph¤tTimeframe=0&startTimeframe=3&selectedDistributions=uninsured--total&selectedRows=%7B%22wrapups%22%3A%7B%22united-states%22%3A%7B%7D%7D%7D&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D. 4. “Small Group Health Insurance Market Rate Restrictions.” The Henry J. Kaiser Family Foundation. February 22, 2017. Accessed March 01, 2018. https://www.kff.org/other/state-indicator/small-group-health-insurance-market-rate-restrictions/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D#note-1.

5. “Individual Market Rate Restrictions (Not Applicable to HIPAA Eligible Individuals).” The Henry J. Kaiser Family Foundation. July 18, 2014. Accessed March 01, 2018. https://www.kff.org/other/state-indicator/individual-market-rate-restrictions-not-applicable-to-hipaa-eligible-individuals/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D. 6. Roy, Avik. “Myths of the ‘Free Rider’ Health Care Problem.” Forbes. August 26, 2013. Accessed March 03, 2018. https://www.forbes.com/sites/theapothecary/2011/02/02/myths-of-the-free-rider-health-careproblem/#201b30b62ad9.

7. “STATE INSURANCE MANDATES AND THE ACA ESSENTIAL BENEFITS PROVISIONS.” NCSL. October 13, 2017. Accessed March 3, 2018. http://www.ncsl.org/research/health/state-ins-mandates-and-aca-essential-benefits.aspx#Understanding.

8. 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:10.3386/w16723.

9. Bhattacharya, Jay, Timothy Hyde, and Peter Tu. Health Economics. Basingstoke: Palgrave Macmillan, 2014.

10. Wilper, Andrew P., Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein. “Health Insurance and Mortality in US Adults.” American Journal of Public Health 99, no. 12 (December 2009): 2289-295. doi:10.2105/ajph.2008.157685.

11. Baicker, Katherine, Sarah L. Taubman, Heidi L. Allen, Mira Bernstein, Jonathan H. Gruber, Joseph P. Newhouse, Eric C. Schneider, Bill J. Wright, Alan M. Zaslavsky, and Amy N. Finkelstein. “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes.” New England Journal of Medicine 368, no. 18 (May 02, 2013): 1713-722. doi:10.1056/nejmsa1212321.

12. Abaluck, Jason, and Jonathan Gruber. “Choice Inconsistencies Among the Elderly: Evidence from Plan Choice in the Medicare Part D Program.” American Economic Review 101 (June 2011): 1180-210. doi:10.1257/aer.101.4.1180.

13. Bhargava, Saurabh, George Loewenstein, and Justin Sydnor. Do Individuals Make Sensible Health Insurance Decisions? Evidence from a Menu with Dominated Options. Working paper no. 21160. Cambridge, MA: National Bureau of Economic Research, 2015. 1-55.

“Health Insurance Coverage of the Total Population.” The Henry J. Kaiser Family Foundation.

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Graphics designed by Alexis Megibow

A

ccording to the Center for Disease Control, one in every four deaths tallied in the United States is caused by heart disease.1 It has remained the leading cause of mortality in this country for the past eighty years,2 contributing to a per annum average of 600,000 deaths nationwide.3 Upon publication of the CDC’s Public Health Action Plan to Prevent Heart Disease and Stroke, it was estimated that the economic cost of these two conditions alone was more than $351 billion in 2003,4 a price that has continued to level out to nearly $1 billion a day in medical expenses and lost productivity annually.5 Although cardiovascular disorders persist as the primary cause of mortality in America, it should be noted that all of the top five causes of death nationally share heart disease’s non-communicable nature, interpreted here as afflictions that aren’t transferrable or infectious. In order of prevalence, such a list would include cancer, chronic lower respiratory disease, accidental death by unintentional injury, and the aforementioned stroke.6 Our state of affairs lies in stark contrast with the health concerns affecting developing nations of the collective global south, particularly within the defined World Bank region of sub-Saharan Africa, a label that currently incorporates 48 different countries. Even though the seriousness of NCDs is beginning to rise in the context 12 | PENN HEALTHCARE REVIEW | SPRING 2018

of this broad domain, communicable diseases, such as HIV/AIDS, lower respiratory tract infections, diarrheal diseases, and malaria are still the major killers here.7 As specified by the latest mortality dataset administered by the WHO over all World Bank regions, a health statistics report logging information from 2000-2015, 56.7% of deaths in said bloc are caused by communicable, maternal, perinatal, and nutritional conditions.8 In relation to the US, this percentage lies at a lowly 5.4% for the North American populace.9 These figures can be at least in part attributed to the fact that both long-term epidemics, such as the ever continuing, decades long scourge caused by HIV/AIDS, as well as shorter term variants, like that witnessed through the 2013-2016 West African Ebola crisis, are exacerbated by a widespread lack of well-funded sub-Saharan public health systems.11 Although our predicaments are no less sobering than those listed above, the United States still benefits from common, advanced medical infrastructures, networks taken for granted across the highly industrialized, G8 nations of the Western world.

Furthermore, it has been readily documented how foreign intervention, mainly considered a chief responsibility of various NGOs and international bodies, has a tendency to be carried out only after infectious problems have already

TECHNOLOGY AND INNOVATION

well set in across this distinct African zone, a propensity for immediate inaction that curbs the ability to quell these types of illnesses on a quicker basis.12 The chronic, lifestyle ailments fundamentally affecting Americans, specifically heart disease, fortunately do not contain what may be referred to here as “crucial viral windows”, or key periods of time where idleness leads to an irreversible, contaminatory spread. Thus, down-the-road planning with respect to lifestyle changes can be more easily applied to our quandaries, a privilege that many entities, like Guinea, Sierra Leone, and Liberia, do not share.

The key takeaway, however, is uniting our country with this precise overseas constituency is that both outlined provinces could benefit from courses of preventive action.

For the United States, investments in health education, as well as a drive towards more affordable, universal healthcare models, could serve to decrease the advancement of heart and lung related diseases domestically, possibly

mitigating against the risk of cardiovascular symptoms as a whole.13 Moreover, in the context of morbid obesity and overweightness, a financial commitment to improve access to nutritionally dense foods (i.e. fruits, vegetables, natural products, etc.), currently not subsidized near the level of processed foods and grain through the USDA, could lower the number of food deserts nationally, areas where acquiring such perishable goods necessary for noncommunicable health is next to impossible.14 Concerning sub-Saharan Africa, as stated previously, on the ground improvements for foundational well-being, such as the socioeconomic promotion of hospitals, vaccines, and products protecting against pathogens (i.e. malaria nets, contraceptive commodities, etc.), could duly head off the area’s sicknesses.15 Overall, in a twenty first century world linked by unavoidable, if largely beneficial, globalism, it behooves us to learn of our medical differences, as well as our similarities, going forward.

Title graphic designed by Alexis Megibow

1 “Heart Disease Facts: Heart Disease in the United States.” National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, 28 Nov. 2017.

2 “Prevalence of Heart Disease --- United States, 2005.” Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, 16 Feb. 2007.

3 Johnson, Nicole Blair, et al. “CDC National Health Report: Leading Causes of Morbidity and Mortality and Associated Behavioral Risk and Protective Factors - United States, 2005–2013.” Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, 31 Oct. 2014.

4 Gerberding, Julie Louise, and Elias A Zerhouni. “A Public Health Action Plan to Prevent Heart Disease and Stroke.” Center for Disease Control and Prevention, U.S. Department of Health and Human Services, 2003.

5 Stinson, Claire. “Heart Disease and Stroke Cost America Nearly $1 Billion a Day in Medical Costs, Lost Productivity.” CDC Foundation, U.S. Centers for Disease Control and Prevention, 29 Apr. 2015.

6 “Deaths and Mortality: Number of Deaths for Leading Causes of Death.” National Center for Health Statistics, Centers for Disease Control and Prevention, 3 May 2017.

7 “Factsheet: The Leading Causes of Death in Africa in 2012.” Africa Check, Agence France-Presse, 31 Oct. 2014.

8 Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva, World Health Organization; 2016.

9 Global Health Estimates 2015. Geneva, World Health Organization; 2016.

11 Kirigia, Joses Muthuri, and Saidou Pathe Barry. “Health Challenges in Africa and the Way Forward.”

International Archives of Medicine, BioMed Central, 18 Dec. 2008.

12 Belluz, Julia. “Seven Reasons the Ebola Epidemic Is Still Raging.” Vox, Vox Media, 4 Sept. 2014.

13 Dalton, Andrew R. H., et al. “Impact of Universal Health Insurance Coverage on Hypertension Management: A Cross-National Study in the United States and England.” PLoS ONE, Public Library of Science, 8 Jan. 2014.

14 Jacobson, Kristi and Lori Silverbush, directors. A Place at the Table. A Place at the Table, Magnolia Pictures, 2013.

15 Kirigia, Joses Muthuri, and Saidou Pathe Barry. “Health Challenges.” BioMed Central, 18 Dec. 2008.

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O

ne afternoon during my second week of work at Penn Medicine, I moved from working in my professor’s office to the 6th floor orthopedic surgery resident computer lab. I met most of the residents and nodded to each of them as I prepared to go home. The next morning, I arrived at the lab and will never forget what I saw.

The residents I met the previous day were sprawled across the lab in deep sleep. They were wearing the same clothes as the day before, and I saw more cups of coffee in the lab than I had ever seen in a room in my life. Not a soul stirred as I walked from the door to my computer station. One of the residents was sleeping in my chair, so I tried to gently tap him. No response. A light shake? No response.

Asking verbally? No response. I finally gave him a vigorous shake. He woke up and said something unintelligible, so I just pointed to the chair.

He got up, took two steps, and slumped into the chair right next to me, seemingly falling asleep in a matter of seconds. About an hour later, the chief resident came into the room, woke up the resident who was sleeping next to me, and told him to prepare for surgery. In my head, I was thinking, “Surgery? This guy’s a zombie. He can’t just operate on someone, right?”

Before I left work, I talked to the “zombie” resident and found out that he had consecutive overnight shifts, was running on two hours of sleep, and felt miserable since this was a regular occurrence. He told me the sur14 | PENN HEALTHCARE REVIEW | SPRING 2018

Infographic designed by Judy Choi

gery was successful, but I was still shaken by the fact that these sleep-deprived, burned-out residents operated on patients and had to continue working in this state.

Today’s healthcare environment in America for beginning physicians and residents is characterized by “packed work days, demanding pace, time pressures, and emotional intensity.”1 Many physicians are overworked and are so exhausted that they are unable to recover, rest and relax after coming home from work, ultimately leading to the phenomenon known as “physician burnout.”2 The Agency for Healthcare Research and Quality (AHRQ) defines physician burnout as “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of

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Title graphic designed by Judy Choi

sense of personal accomplishment.”3 Physician burnout is dangerous and undesirable for several reasons.

First, physicians themselves suffer from poor mental health, which can lead to further health complications.4 For example, it is alarming and tragic that about 400 doctors-in-training (across the world) commit suicide every year.5 Second, burned-out physicians are more likely to quit, which exacerbates America’s physician shortage. 6 This requires the remaining physicians to do more work, which in turn leads to more burned-out physicians.7 Finally, physician burnout has been linked to lower quality of care, depersonalization, worse interactions with patients, and impaired functionality (attention, memory, and executive function).8 This not only results in suboptimal and even compromised patient care but also causes major medical errors. 9 In fact, physician burnout was reported as one of “the strongest predictors of a surgeon’s reporting of a major medical error.” 10 Physician burnout is a major problem, especially because of how common it is. The Washington Post reports that “1 in 2 physicians report at least one symptom of burnout…within 10 years of joining an academic medical faculty, 5 of every 10 doctors leave, and four leave academic medicine entirely.”

11 Since sleep deprivation is the single strongest predictor of physician burnout, obvious solutions include reducing physician hours and increasing the number of physicians. 12 However, these solutions go against the deeply ingrained culture of medicine, which dictates that physicians “show no weakness,” “suck it up,” and “[prove their worth by withstanding] rigorous training.” 13 The Stanford Department of Emergency Medicine has managed to implement a creative program to combat physician burnout. 14 The “time banking” program is “aimed [at easing] work-life conflicts for the emergency medicine faculty.” 15 Since physicians, on average, work 10 hours more per week than other professionals, this program allows physicians to “’bank’ the time they spend doing the often-unappreciated work of mentoring, serving on committees, covering colleagues’ shifts on

short notice or deploying in emergencies, and earn credits to use for work or home-related services.” 16 These services range from meal deliveries from companies like Blue Apron, housecleaning, babysitting, and more; the aim is to save physicians’ time and relieve some of the stress they face at home.17 The program, started in 2013, has shown substantial “increases in job satisfaction, work-life balance, [and even helped to] stave off the steep attrition rate of women in academic medicine and science [since women faculty tended to spend more time at home].”18 There are different programs in hospitals around the world to combat physician burnout, but this specific program has received notoriety for its effectiveness.

Although physician burnout is an increasingly dangerous problem that requires continuous improvements in medical education and training, programs such as the one instituted by the Stanford Department of Emergency Medicine have the potential to combat physician burnout and ultimately improve the quality of healthcare for patients and the quality of life for physicians.

1. “Physician Burnout.” AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care. July 21, 2017. Accessed March 13, 2018. https://www.ahrq.gov/professionals/clinicians-providers/ahrq-works/burnout/index.html.

2. AHRQ, “Physician Burnout.”

3. AHRQ, “Physician Burnout.”

4. Oaklander, Mandy. “Stress, Burnout and Depression in Doctors.” Time. August 27, 2015. Accessed March 13, 2018. http://time.com/4012840/doctors-on-life-support/.

5. Time, “Stress, Burnout, and Depression in Doctors.”

6. AHRQ, “Physician Burnout.”

7. Time, “Stress, Burnout, and Depression in Doctors.”

8. AHRQ, “Physician Burnout.”

9. Time, “Stress, Burnout, and Depression in Doctors.”

10. Time, “Stress, Burnout, and Depression in Doctors.”

11. Schulte, Brigid. “Time in the bank: A Stanford plan to save doctors from burnout.” The Washington Post. August 20, 2015. Accessed March 13, 2018. https://www.washingtonpost.com/news/inspired-life/ wp/2015/08/20/the-innovative-stanford-program-thats-saving-emergency-room-doctors-from-burnout/?utm_term=.9d3701f54a06.

12. The Washington Post, “Time in the bank.”

13. The Washington Post, “Time in the bank.”

14. The Washington Post, “Time in the bank.”

15. The Washington Post, “Time in the bank.”

16. The Washington Post, “Time in the bank.”

17. The Washington Post, “Time in the bank.”

18. The Washington Post, “Time in the bank.”

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B

eing sick stinks. Years ago missing a day from school meant a one-day pass to full unadulterated freedom in the unsupervised confines of home. Now, however, being sick in college just means sitting in bed while work slowly piles up – and yes, I speak from recent experiences.

Usually, as an outgoing, native Philadelphian and freshman at UPenn, I never have problems with making new friends or dealing with distance from family. Though one morning, while suffering from a stomach bug and stuck in bed under a mountain of blankets, I felt disconnected, homesick and just sad. Though it may have been the constricting rooms of Hill College House, I suspect the dorm was not the culprit.

In reality, I was feeling the very antithesis of our biology, millennia of culture, and moral reasoning: isolation.

So what? What does a case of the sniffles have to do with me? This voice in my head may have a point – but before you write off this story as another homesick freshman with the flu, I would like to argue that the ways in which our society fosters isolation may lead it to tear itself apart.

In reality isolation can cause or exacerbate health disadvantage through higher levels of stress and consequences of isolation such as lower income. To further explain, I’ll first unload the term “isolation”, explore contemporary examples, the effect of isolation on health (directly and indirectly), and finally possible solutions.

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To begin, let me define what is meant by isolation. Most importantly, it doesn’t necessarily mean a far geographic distance away from others. As long as one has some significant barrier to physical human interaction, one is isolated. Modern society does not value teamwork and communal living the same ways tribal society once did, as evident in modern culture. For example, those who do not leave home after college are typically categorized as lazy or unsuccessful - even though those who do leave home seperate themselves from important social and financial supports that come from family. Additionally, with recent studies showing that fewer Americans trusting each other and starting less families, it is easy to see how we find ourselves increasingly alone.1,2 In fact, it is in this theme of societal isolation that one can better understand the dire health implications of living in socially-isolated groups such as veterans or inmates, as implicated in the title. By examining their histories and issues, one can see what happens when whole scores of Americans are similarly isolated from mainstream society.While contemporary values tells us to value one group much more over the over, isolation occurs in and affects both similarly. For once a group is separated from the whole, their interests and well being can be marginalized and ignored, either willfully (in the case of prisoners) or not (in the case of veterans). To understand more, let us unpack the histories of both groups.

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Title graphic designed by Chloe Le

To learn more of how mainstream society alienated prisoners, one must first accept the criminal justice system is racially biased in the United States. Michelle Alexander’s The New Jim Crow provides readers with a great, condensed history with how American society turned on its own and became the hyper-incarcerated society it is today. After the death of Jim Crow, and its many codified segratory laws, many southern authority tried desperately to associate the civil right movement with criminal activity. To oversimplify, many prominent segregationist took up the “tough on crime” values that still nonetheless targeted blacks and subsequently changed which issues took center stage in political debates for decades to come. During his campaign, Ronald Reagan capitalized on these sentiments and made racially framed discussions on crime a center piece to his speeches. Once elected, he cut funding to white-collar crime divisions and drug treatment programs and supersized budgets to street crime divisions, growing the DEA’s budget during 1981 -1991 from $86 to $1,026 million.3 As crack ravaged black communities where a legacy of Jim Crow’s segregated and underfunded education made it harder for the black community to find decent jobs, the mainstream media sensationalized hyper-graphic images of black “crack babies” and “crack whores”. Seeing this, presidential candidate Bill Clinton similarly made being “tough

on crime” a large part of his platform in order to get elected. When elected, he slashed welfare and housing, making it hard or impossible for drug criminals to receive these services. He also increased the national budget for corrections by 171% and imposed harsher mandatory minimums and sentencings for drug related crimes.⁴ So, with criminal population exploding in size and following where Jim Crow era racism had left off, a patchwork of discriminatory practices entered American society. Policies such as “the box” – a question asking for prior convictions listed on job applications meant for quick screening of ex-felons – that effectively make it harder for ex-felons to live a normal life after serving their time to the state.⁵ At any rate, these policies were created willfully and helped to perpetuate a social stigma against former inmates.

For veterans, this separation was more serendipitous because without the conscious actions of some willing agent, veterans and their issues slowly moved to the backburner of Americans and politicians.⁶ Historically, Americans have been more woven into the military largely because so many Americans fought as soldiers. Therefore, any isolation of soldiers must be due to demographics of the United States – a fact that statistics bears to be true. At its peak in World War 2, around 17% of the population served in the armed forces - today, that figure is less than 1%.⁷ The psychological burSPRING 2018 | PENN HEALTHCARE REVIEW | 17

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den of war is concentrated amongst this minority of Americans. As a result, the needs of our soldiers are increasingly pushed further and further from the spotlight. Just skimming recent headlines reveal how poorly managed vital services such as the VA are kept.⁸ Ironically, an organization made specifically for their health interests made their alienation from health care much easier. Another sad yet telling example at how isolation allows for society to ignore the issues of marginalized groups.

With the isolation in place, the first noticeable change is cultural. Once these minority groups become alienated from the whole, their lives may be interpreted or classified however the mainstream society sees fit. For example, look to the negative stereotypes society attributes to these members, such as veterans being “ticking time-bombs” from PTSD or ex-offenders being deemed untrustworthy.

We can see examples of such portrayals in movies such as 2014’s American Sniper’s violent scenes of protagonist Chris Kyle’s explosive battle with PTSD that eventually led to him claiming his own life. We, as a society, use these stereotypes to justify the ways in which we treat them differently and in turn perpetuate and deepen their alienation them from mainstream society. Because of these public images, many soldiers fear admitting to mental health issues until it is too late⁹, and many ex-offenders find trouble gaining admittance into schools or jobs, no matter how hard they work.10 Once the separation is established, the dark mechanisms of isolation go to work. According to Shonkoff et. al, one subtle, disastrous mechanism is “toxic” stress -- tolerable stress ( or stress from negative life experiences such as death of a love one) in the absence of an interconnected social support group.11 In fact, McEwen writes this type of stress can physically wear down multiple organ systems and decrease your lifespan.12 Biologically, environmental stressors induce our bodies into releasing copious amounts of hormones such as cortisol into our systems. Anyone who has ever been in a fearful situation has experienced a small dose of its effects manifested in a faster heartbeat, shorter breaths, and a decrease in mental acuity. A part of the body’s natural “fight or flight mode”, prolonged exposure to this heightened sense of alert - caused by societal factors such as high-crime neighborhoods or the aforementioned example of being unable to land a job - wears the body down and increases the chance of heart disease, stroke, diabetes, and mental conditions such as depression as well.13 In addition, studies find that the more uncontrollable one perceives their predicament to be - say, already working two jobs and still not having enough to pay the bills - the more likely one is to experience such harmful levels of stress. This can pose a huge issue as ex-offenders and veterans find less, lower-paying jobs partially due to the afore18 | PENN HEALTHCARE REVIEW | SPRING 2018

mentioned stigmas.14,15 In turn, reduced wages or income due to fewer job offers can limit your housing options, which affect your health in considering both physical (air pollution) and social (crime rates) factors.16 Furthermore, studies are emphasizing that such environmental stressors can even translate to disparities across generations. According to authors Braveman & Barclay, the stress a pregnant mother is exposed to to increase the likelihood of complications for the child, such as preterm birth and low birth weight.1⁷ After chronicling the stories of these groups, what can be done? Well, if the problem is isolation, the solution therefore is integration.

Once these groups are integrated into mainstream life, the public (and therefore policy-making politicians) will recognize them and care for them. One approach to integration is by abolishing all “separating” policies – like solitary confinement (or the current concept of prisons in general) for inmates. Using figures released by the first congressional hearing on solitary confinement and the Bureau of Labor Statistics, all the money American taxpayers spend of solitary confinement can be diverted to pay up 60 hours of 1-on-1 mental health counseling for every prisoners in the United States annually.18,19 This could translate into huge savings if these appointments could screen for mentally-ill individuals who need treatment or additionally give inmates proper coping mechanisms and intervention to reduce recidivism rates.

Besides reducing segregation, we could help promote integration across these minority lines. For the military, unorthodox solutions such as bringing back the draft may hold the key. The draft sparked outcry during the Vietnam War and was no doubt a large factor in the war’s end. People around the nation suddenly found themselves apart of a war effort they didn’t believe in for a variety of reasons. But once the draft was disbanded, and the military become volunteer-run, mainstream society no longer had a direct link to the war effort.

And once this link was severed, mainstream society lost in-

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terest in the military and many of issues - such as the often cited Veterans Affairs - fell into disrepair. In other words, we must shake this “out of sight, out of mind” mentality to be empowered to care for our fellow citizens. Again, I believe the best way to accomplish this is through the aforementioned integration.

At the end of the day, we aren’t always in the position to wake-up and change national policy. In light of this, there lies a powerful and personal message. Feeling socially connected involves every single one of us - we all have equal responsibility and power in determining the mental

health of all Americans. Fortunately, for most of us - like myself, a sick college freshman who had too much time to reflect on isolation - nothing means more than say… a Campbell’s can of chicken soup and a quickly-scrawled out get-well-soon note taped on the side. (Thanks Sarabeth!) So if we reach out and pull each other in from an individual and societal level, we can rebuild the micro and macro-community in order to heal ourselves on the national scale.

Graphics designed by Chloe Le

1. Cass, Connie. “Poll: Americans Don’t Trust One Another.” USA Today. November 30, 2013. Accessed March 28, 2018. https://www.usatoday.com/story/news/nation/2013/11/30/poll-americans-dont-trustone-another/3792179/ 2. Livingston, Gretchen. “Fewer than Half of U.S. Kids Today Live in a ‘Traditional’ Family.” Pew Research Center. December 22, 2014. Accessed March 28, 2018. http://www.pewresearch.org/fact-tank/2014/12/22/ less-than-half-of-u-s-kids-today-live-in-a-traditional-family/ 4. Ibid.

5. Khimm, Suzy. “States Push to Provide Some Ex-felons a Second Chance.” MSNBC. September 17, 2014.

Accessed March 28, 2018. http://www.msnbc.com/all/states-push-provide-some-ex-felons-second-chance 6. Tavernise, Sabrina. “As Fewer Americans Serve, Growing Gap Is Found Between Civilians and Military.”

New York Times, November 24, 2011. Accessed March 2, 2018. http://www.nytimes.com/2011/11/25/us/ civilian-military-gap-grows-as-fewer-americans-serve.html.

7. Vox.com. YouTube. March 30, 2016. Accessed March 28, 2018. https://www.youtube.com/watch?v=ad75ahK2z60.

8. Rein, Lisa. “Trump Eyes ‘Fox & Friends’ Personality Pete Hegseth to Take over Veterans Affairs.” The Washington Post. March 15, 2018. Accessed March 28, 2018. https://www.washingtonpost.com/politics/ trump-eyes-fox-and-friends-personality-pete-hegseth-to-take-over-veterans-affairs/2018/03/15/f8d03ef6284e-11e8-b79d-f3d931db7f68_story.html?utm_term=.958ae8684f77.

9. Vlahos, Kelley Beaucar. “Stigma of the ‘damaged Veteran’ a Barrier to Treatment, as Suicides Claim More US Troops.” Fox News. January 19, 2016. Accessed March 28, 2018. http://www.foxnews.com/politics/2016/01/19/stigma-damaged-veteran-barrier-to-treatment-as-suicides-claim-more-us-troops.html.

10. DePillis, Lydia. “Millions of Ex-cons Still Can’t Get Jobs. Here’s How the White House Could Help Fix That.” The Washington Post. January 22, 2015. Accessed March 28, 2018. https://www.washingtonpost.

com/news/storyline/wp/2015/01/22/millions-of-ex-cons-still-cant-get-jobs-heres-how-the-white-housecould-help-fix-that/?utm_term=.5a44e6b92aed.

11. Shonkoff et al. 2012. “The Lifelong Effects of Early Childhood Adversity and Toxic Stress.” Pediatrics 129(1): e232-246.

12. McEwen, Bruce. “How Stress Works in the Human Body, to Make or Break us.” Aeon. July 11, 2011. Accessed March 28, 2018. https://aeon.co/essays/how-stress-works-in-the-human-body-to-make-or-break-us 13. Ibid.

14. Rep. No. USDL-17-0354 (2016) 15. Flake, Dallan F., B.S, M.S. “When Any Sentence is a Life Sentence: Employment Discrimination Against Ex-Offenders.” Washington University Law Review, no. 1 (2015): 45-101. Accessed March 2, 2018. http:// heinonline.org/HOL/Page?handle=hein.journals/walq93&div=5&g_sent=1&casa_token=&collection=journals#.

16. Robert Wood Johnson Foundation Commission to Build a Healthier America. 2008. “Where We Live Matters for Our Health: Neighborhoods and Health.” http://www.commissiononhealth.org/PDF/888f4a18-eb90-45be-a2f8-159e84a55a4c/Issue%20Brief%203%20Sept%2008%20-%20Neighborhoods%20and%20Health.pdf 17. Braveman, P., & Barclay, C. 2009. “Health disparities beginning in childhood: a life-course perspective.” Pediatrics 124(Supplement 3): S163-S175.

18.”Durbin Chairs First-Ever Congressional Hearing on Solitary Confinement.” Newsroom | U.S. Senator Dick Durbin of Illinois. June 19, 2012. Accessed March 28, 2018. https://www.durbin.senate.gov/newsroom/press-releases/durbin-chairs-first-ever-congressional-hearing-on-solitary-confinement.

19. Bureau of Labor Statistics. Occupational Employment and Wages, May 2016. March 31, 2017. Raw data. PSB Suite 2135, 2 Massachusetts Avenue, Washington, DC.

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FASHION

Title graphic designed by Sarah Nam

H

ave you ever been afraid to walk into a hospital out of fear that you would get sick? Or if you are a germophobe like me, have ever been worried about catching something even though you’ve been extra careful?

Have you ever wondered if your doctor has been washing their hands? Or maybe have been afraid to walk into a hospital or the nurse’s office when you were younger out of fear that even though you were healthy, you would get sick? Or if you are a germophobe like me, worried about catching something even though you’ve been extra clean and careful?

Physicians, nurses, surgeons, and others involved in the medical world usually wear scrubs and/or a white long coat to avoid contamination. However, a study1 published in 2012 released jaw dropping results about the amount of bacteria that was left on medical professionals’ uniforms.

The question was whether nurses should wear their uniforms outside of the work environment, and the findings were as many would predict. The results showed that there were so many infections, diseases, and bacteria spreading on these uniforms that they did not even feel it was necessary to continue the study with other tests since they had grasped so much just from the four tests they performed.

This is not just dangerous for those wearing the uniforms, but also for those that interact with these people wearing the uniforms, including the doctors and nurses themselves. As a result of these findings, some hospitals are starting to implement revolutionary new hygiene strategies. The Hospital of the University of Pennsylvania2 for example is working on new strategies to prevent diseases before they even surface by prioritizing washing your hands and hand hygiene over anything else. This is not enough.

We have seen in numerous studies such as in the one above

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as well as in a study published by the American Journal of Infection Control (APIC) 3, which concluded that “More than 60 percent of hospital nurses’ and doctors’ uniforms tested positive for potentially dangerous bacteria.” Yet with these studies done again and again, the question becomes: what is the solution?

Scientists collaborating from The University of Manchester and universities in China seem to believe they have an answer to decrease the amount of bacteria spreading by contaminated uniforms and surfaces. Their answer is cooper-coated uniforms.

“Doctors, nurses and healthcare professionals could soon be wearing uniforms brushed with tiny copper nanoparticles to reduce the spread of bacterial infections and viruses.”

The University of Manchester4 shared on February 15 of 2018.

Healthcare providers wouldn’t just be wearing copper on its own. They have also developed a way of binding the copper to materials such as cotton and polyester. This is done by a process called “Polymer Surface Grafting” 4 in which “the research team tethers copper nanoparticles to cotton and polyester using a polymer brush, creating a strong chemical bond.”4 Silver and gold are other good options to consider for this procedure, yet they are very expensive, especially to use in clothing. On the other hand, copper is cheap and can still act as an anti-bacteria agent just as well as silver and gold because it has similar properties such as being good conductors of heat and electricity, being ductile, and being malleable, among other properties. In addition, when these bacteria spread, hospitals are not just losing life, but also funds. With copper being a cheaper alternative, hospitals can save money for research and other projects in the future.

How do we know this process with copper will real-

FASHION

ly work? Researchers at these various universities decided to test5 the success of the copper by brushing the copper nanoparticles on cotton and polyester with just 1-100 nanometers (nm), which is a very small amount considering 100 nm= 0.0001 mm.

“The team4 found that their cotton and polyester coated copper fabrics showed excellent antibacterial resistance against Staphylococcus aureus (S. aureus) and E. coli, even after being washed 30 times.”

Alexandru Micu, a writer for ZME Science6, also shares that “The issue becomes worse still after you factor in the rise of drug resistance in most strains, which is rendering our once-almighty antibiotics more and more powerless. So, we need to look for alternative ways of dealing with them, ones that do not rely on antibiotics.” Could copper uniforms be the new way to save numerous lives?

Dr. Xuqing Liu6, the lead author from the University of Manchester’s School of Materials, definitely thinks so.

“Now that our composite materials present excellent antibacterial properties and durability, it has huge potential for modern medical and healthcare applications.” He also shared that companies are already reaching out to the team

with curiosity and consideration, and believes these new uniforms will be ready to sell in a couple years once the two main goals of making this process simpler and cheaper are met.

By 2020, we will hopefully not need to worry about getting sick when walking and working at hospitals, and instead be able to focus on the real priority- the unwell patients themselves.

1. Sanon, Marie-Anne, and Sally Watkins. “Nurses’ uniforms: How many bacteria do they carry after one shift?” Journal of Public Health and Epidemiology. December 2012. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4180417/.

2. Sapega, Sally. “Clean Hands Save Lives- PR News.” News Blog. June 19, 2015. https://www.pennmedicine.org/news/news-blog/2015/june/clean-hands-save-lives.

3. Elsevier. “Doctors’ and Nurses’ Hospital Uniforms Contain Dangerous Bacteria a Majority of the Time.” Research and Journals. August 31, 2011. https://www.elsevier.com/about/press-releases/ research-and-journals/doctors-and-nurses-hospital-uniforms-contain-dangerous-bacteria-a-majority-of-the-time.

4. The University of Manchester. “Infection outbreaks at hospitals could be reduced by copper-coated uniforms.” Manchester 1824. February 15, 2018. http://www.manchester.ac.uk/discover/news/infectionoutbreaks-at-hospitals-could-be-reduced-by-copper-coated-uniforms/.

5. Sun, Chufeng, Yi Li, Zhi Li, Qiong Su, Yanbin Wang, and Xuqing Liu. “Durable and Washable Antibacterial Copper Nanoparticles Bridged by Surface Grafting Polymer Brushes on Cotton and Polymeric Materials.” Journal of Nanomaterials. January 29, 2018. https://www.hindawi.com/journals/ jnm/2018/6546193/.

6. Micu, Alexandru. “Copper-coated uniforms for medical staff could help shred bacteria in hospitals.”

Science. February 16, 2018. https://www.zmescience.com/science/copper-clothes-hospital/.

Infographic designed by Sarah Nam

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MINDFULNESS

M

Mindfulness can be loosely defined as the act of being consciously present in the current experience, allowing individuals to diminish overreactions and negative emotions.1 Though neophytes may perceive it to be a rather rudimentary concept, mindfulness is a powerful tool with vast applications. Everybody is capable of it and the premise is simple, but it is not easy to do properly. It is a skill that can be cultivated and improved with continuous practice. Certainly, it requires setting aside time to meditate and detach from the daily stressors that consume so many of us. There are common misconceptions that meditating has a narrow allowance for how it can be practiced “the right way”. Images of a stereotypical hippie meditating on a yoga mat in a dark, candle lit room may come to mind. However, experts assure that there several ways to practice mindfulness. It can be practiced anytime and almost anywhere, alone or with company.2 For those that are not inclined to seek such formal resources, guided meditations can easily be found online or on smartphone apps. Overall, mindfulness-based practices are not about repairing people, but rather accessing a skill that we all inherently possess.

Through patience and persistence, there are many benefits to be derived from mindfulness-based practices in general. Several forms of therapy have arisen around the ideology of mindfulness-based practices. Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), and Mindfulness-Integrated Cognitive Behavioral Therapy (MiCBT), just to name a few. Overarching benefits include, but are not limited to: improved pain management, sharpened focus, lowered stress, and reduced negative thoughts.3 With these abilities, life can be lived to the fullest as people connect deeper with friends and family, find enjoyment in simple daily experiences, and sleep restfully on a regular basis. It has been proposed by researchers 22 | PENN HEALTHCARE REVIEW | SPRING 2018

Title designed by Elaine Ma

that the mechanism through which mindfulness meditation acts is a process of enhanced self-regulation, which encompasses enhanced attention control, emotion regulation and self-awareness.4 These numerous benefits are also observed in clinical settings and have proven to be impactful when utilized in therapeutic action.5 The effects of mindfulness-based therapies are palpable and certainly not limited to anecdotal musings. A group that could particularly benefit from these effects is laboring women.

Mindfulness based-approaches can serve as natural, non-invasive, yet very effective form of pain management during childbirth. This may come as a surprise to those who are not familiar with the concept. The mindfulness approach is unique in that it does not aim to “wall-off ” pain; rather it tries to modulate the relationship between pain and its associated emotions.6 It does this by de-escalating the negative emotions that compound the overwhelming sensations of fear. This uncoupling of the mental intimidation and physical sensation reduces the anxiety of “losing control”.7 This born coping mechanism allows women to non-judgmentally experience bodily pain during delivery. Unlike many pharmacological methods, it does not compromise the health of the baby in exchange for pain relief. It also does not contribute to increased feelings of helplessness and chronic disappointment, which is not uncommon in postpartum women.8 A hospital’s standard drug-based interventions for labor pains typically involve administering an epidural, which impedes contractions and then necessitates giving Pitocin to accelerate delivery with induced contractions.9 Pitocin is administered intravenously through a needle and the flow of fluid is adjusted to a specific rate based on the doctor’s discretion. The flow of infusion may be increased by nearly two-fold if the doctor sees no reaction after half an hour.10 Several factors must be constantly observed to ensure that Pitocin is being given safely. The procedure is highly complex and convoluted to anyone who is not a medical professional,

MINDFULNESS

and thereby obstructs the woman’s ability to make her own informed decisions during her child’s birth.

Mindfulness lets women be in complete control of their own bodies. Induced contractions negatively affect not only the mother, but also the baby as it is quite literally forced out of the womb. Pitocin increases risk when administered during normal births, which constitute almost all cases.11 Our country treats childbirth as pathology, and consequently there are several repercussions for perceiving it as an issue that needs to be resolved. The overuse of medical interventions often hurts women more than it helps them, as it pathologizes a natural, unproblematic event that could happen successfully

1.1 Guyaux, Francoise. “Mindfulness: Getting Started.” Mindful, Foundation For A Mindful 2 Ibid.

3 Ibid.

4 Tang, Yi-Yuan, Britta K. Hölzel, and Michael I. Posner. “The neuroscience of mindfulness meditation.”

Nature Reviews Neuroscience 16.4 (2015): pp. 214.

5 Melbourne Academic Mindfulness Group. “Mindfulness-based psychotherapies: a review of conceptual foundations, empirical evidence and practical considerations.” Australian and New Zealand Journal of Psychiatry 40.4 (2006): pp 285.

6 Hughes, Annie et al. “Mindfulness Approaches to Childbirth and Parenting.” British journal

on its own accord. Despite the normalization of this potentially dangerous intervention, we must question if it is really in the best interest of the woman and her child, or for the benefit of a doctor in a hurry. The insistence upon medical intervention frequently invalidates the women’s child birthing experience and strips them of self-empowerment. Conversely, women who opt for natural birth often describe their experience as incredibly empowering and positive.12 By accessing their own powers through mindfulness, they channeled a strength that society influenced them to believe they were not capable of.

of midwifery 17.10 (2009): pp 632.

7 Ibid., pp 632.

8 Ibid., pp 634.

9 Ratzan, Wilford J., and Abraham Shulman. “Intravenous pitocin and elective induction of labor.”

Obstetrics Gynecology 6.5 (1955): pp 493.

10 Ibid., pp 496.

11 Ibid., pp 497.

12 Hughes, Annie et al. “Mindfulness Approaches to Childbirth and Parenting.” pp 632.

Infographic designed by Elaine Ma

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TECHNOLOGY

Title graphic designed by Chloe Le

I

n late November of last year, a second-grader at Ducketts Lane Elementary School, stepped into the office of school nurse, Veronica DeSimone, reporting issues with her breathing. Upon examination, DeSimone determined that the girl was having an asthma attack and that the problem could be easily alleviated by relieving medication – but there was one catch. Permission forms to administer medication had not been signed by the girl’s parents, and they not previously delivered her medication to the school nurse. Her father worked over an hour’s drive from the school, and there simply wasn’t enough time to wait for him to come pick her up.

Traditionally, this situation would have forced DeSimone to call an ambulance to take the second-grader to the emergency department, but telemedicine saved the day.1 By 2015, the central Maryland elementary school had become the sixth telemedicine center in the Howard County Public School System to be sponsored by their local health department.2 Thus, DeSimone was able to respond to the situation by connecting to the emergency room pediatrician at Howard County General Hospital via online video and a digital stethoscope that allowed the physician to monitor the girl’s status remotely. With the diagnosis quickly confirmed and the medication promptly administered, the child was back in class within just 10 minutes.3 Telemedicine, or the purposing of information and communications technology towards increasing patient access to medical care, remote diagnosis, and treatment, is poised for tremendous growth within the next decade.4 Although it has long been heralded as a tool of the new age of medicine for those who reside in remote areas, its benefits may in fact extend to medically unrelated institutions: schools. In a time when school nurses do not simply hand out Band-Aids and provide aspirin, but are also expected to attend to conditions ranging from diabetes and asthma to abuse and teen pregnancy, only a disconcerting 39.3% of U.S. schools employ full-time 24 | PENN HEALTHCARE REVIEW | SPRING 2018

nurses.5 Since many of these schools that do not employ full-time nurses are subject to the double jeopardy of being located in highly impoverished areas, the school nurse may very well be the only health care provider that the child ever sees. This shortage, coupled with the critical role of the school nurse as a primary health care provider in certain underserved communities, underscores the incredible potential that telemedicine has in school settings.

In an empirical analysis of teacher, nurse, and administrator perceptions of school-based telehealth, school nurses described telemedicine as, “enhancing [their] nursing skills,” rather than identifying it as a burden to their already-existing responsibilities.6 Allowing for the use of devices such as video-conferencing, audio links, and computer-connected stethoscopes and otoscopes would not only facilitate nurses in doing their jobs more effectively and efficiently, but would also broaden the scope of healthrelated issues that schools can help manage. This has already proved to be the case at Ducketts Lane, where physicians part of the telemedicine program can confirm DeSimone’s diagnoses of conjunctivitis versus allergic reaction when a student comes in with a reddened eye. DeSimone, who was previously forced to send kids home on the chance that the symptoms indicated pink eye, could now keep many of them who simply had allergic reactions in school.

Another major advantage of school-based telemedicine is the relieving of health disparities for children who have low socioeconomic statuses (SES). Children spend five days a week and approximately eight hours a day at school; given the significant chunks of the day that are spent in the school setting, school-based telemedicine programs hold the promise of creating a link to health care providers for kids who do not otherwise have access by creating easier, more regulated access to care and medical resources. It would allow for greater potential for follow-up visits, increased continuity, and hence, greater quality of care for low-SES students, who typically have limited access to healthcare and poor clinical follow-up rates.7 Since a lot of research

TECHNOLOGY

Infographic designed by Chloe Le

has demonstrated the inextricable link between health inequalities and education, with health disparities strongly associated with reduced student academic performance, it is critical to redress these disparities in school-aged children.8 Beyond its benefits within the realm of healthcare, telemedicine is a powerful, yet inconspicuous, way of boosting academic success.

However, the issue of convenient access to health care doesn’t encompass the whole story. Even when children have access to providers, hours upon hours can still be spent sitting, watching, and waiting in the emergency room – only to find out it is a minor, easily manageable issue.

According to one practitioner who worked at St. Vincents Hospital Manhattan, which has since closed down, it often took hours before patients entering the emergency department were seen, then an additional half a day to a full 24 hours if inpatient care is required, due to the shortage of beds.9 That was New York City. In other parts of the country, especially rural, wait times can be even more variable. School-based telemedicine programs can reduce the likelihood of a child missing school for a trip to the doctor’s office, make the care process more streamlined, and allow students to return to their classes with minimal interruption.10 This aspect of telemedicine is especially important for children who suffer from chronic conditions such as diabetes, ADHD, and mental disabilities, all of which require routine medical visits that whisk students away from the classroom and to the waiting room of the doctor’s office. These programs prevent kids and their parents from choosing between what they shouldn’t have to in the first place: their health and their education.

Several studies thus far have demonstrated the success and effectiveness of telehealth technology in delivering acute care to elementary school aged children in both urban and rural settings.11 However, before telemedicine programs can be successfully implemented in schools

across the nation, one important limitation that must be considered is financial viability. School districts that may benefit most from telemedicine programs may also be in the least financially solvent positions to implement it.12 While some states have passed laws that allow Medicaid payments for school-based telemedicine programs, many continue to have limited Medicaid reimbursement.13 With the ability of these programs to transform the landscape of pediatric health care, schools, local government, and private healthcare should perhaps be working side-by-side to make this issue one of top priority.

1. Stateline, “Telemedicine In Schools Helps Keep Kids In The Classroom,” Huffington Post (blog), January 4, 2017, https://www.huffingtonpost.com/entry/telemedicine-in-schools-helps-keep-kids-in-the-classroom_us_586d0eb2e4b014e7c72ee528.

2. “Ducketts Lane Now Has a School-Based Wellness Telemedicine Center! | Ducketts Lane Elementary School,” accessed March 3, 2018, http://dles.hcpss.org/news/2015/11/ducketts-lane-now-has-schoolbased-wellness-telemedicine-center.

3. Stateline, “Telemedicine In Schools Helps Keep Kids In The Classroom.”

4. “Goe_telemedicine_2010.Pdf,” accessed March 25, 2018, http://www.who.int/goe/publications/goe_ telemedicine_2010.pdf.

5. “2016 School Nurse Workforce Study Results - SchoolNurseNetMain,” accessed March 4, 2018, https:// schoolnursenet.nasn.org/blogs/nasn-profile/2017/05/10/school-nurse-workforce-study-results.

6. Pamela Whitten et al., “School-Based Telehealth: An Empirical Analysis of Teacher, Nurse, and Administrator Perceptions,” Journal of School Health 71, no. 5 (May 1, 2001): 173–79, https://doi. org/10.1111/j.1746-1561.2001.tb07311.x.

7. Gulshan Sharma et al., “Outpatient Follow-up Visit and 30-Day Emergency Department Visit and Readmission in Patients Hospitalized for Chronic Obstructive Pulmonary Disease,” Archives of Internal Medicine 170, no. 18 (October 11, 2010): 1664–70, https://doi.org/10.1001/archinternmed.2010.345; Whitten et al., “School-Based Telehealth.”

8. “Disparities | Adolescent and School Health | CDC,” accessed March 4, 2018, https://www.cdc.gov/ healthyyouth/disparities/index.htm; “A Look at the Health-Related Causes of Low Student Achievement,” Economic Policy Institute (blog), accessed March 4, 2018, http://www.epi.org/publication/a_look_at_the_ health-related_causes_of_low_student_achievement/.

9. Roni Caryn Rabin, “Fewer Emergency Rooms Available as Need Rises,” The New York Times, May 17, 2011, sec. Health, https://www.nytimes.com/2011/05/18/health/18hospital.html.

10. Stateline, “Telemedicine In Schools Helps Keep Kids In The Classroom.”

11. Thomas L. Young and Carol Ireson, “Effectiveness of School-Based Telehealth Care in Urban and Rural Elementary Schools,” Pediatrics 112, no. 5 (November 1, 2003): 1088–94, https://doi.org/10.1542/ peds.112.5.1088; “School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) (R01/NHLBI) - Projects - Jill Halterman Lab - Labs - University of Rochester Medical Center,” accessed March 4, 2018, https://www.urmc.rochester.edu/pediatrics/labs/jill-halterman-lab/projects/sb-team.aspx.

12. “School-Based Telehealth Programs: Integration and Process,” Telehealth and Medicine Today TM, April 1, 2016, http://www.telhealthandmedtoday.com/school-based-telehealth-programs-integration-and-process-2/.

13. Stateline, “Telemedicine In Schools Helps Keep Kids In The Classroom”; “2017 NEW_50 State Telehealth Gaps Analysis- Coverage and Reimbursement_FINAL.Pdf,” accessed March 4, 2018, https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46f7-916c-692c11d78933/ UploadedImages/Policy/State%20Policy%20Resource%20Center/2017%20NEW_50%20State%20Telehealth%20Gaps%20%20Analysis-%20Coverage%20and%20Reimbursement_FINAL.pdf.

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TECHNOLOGY

Title graphic designed by Alexis Megibow

I

n January 2018, Amazon, JPMorgan Chase and Berkshire Hathaway, announced that they would be joining forces to form an independent health care company for their employees in the United States. This announcement landed like a thunderclap -- immediately depressing the value of traditional health-insurance companies and dragging down the broader stock market as analysts produced optimistic predictions of major reform in this notoriously complex industry. The staggering impact reflects the strength of the new entrants: Amazon, the online retailer known for disrupting major industries; Berkshire Hathaway, the holding company led by the billionaire investor Warren E. Buffett; and JPMorgan Chase, the largest bank in the United States by assets.1 Focusing solely on Amazon, the retail and tech giant has flourished by innovating and expanding endlessly. So how will this technique translate into the health industry?

Objectively, the U.S. healthcare system is the antithesis of Silicon Valley.2 Both grossly inefficient and userunfriendly, it is one of the least transparent operations in the nation. The $3.3 trillion that Americans spent on healthcare in 2016 accounted for an astounding 18% of the U.S. gross domestic product, and the return on investment was actually a decrease in life expectancy.3 Amazon’s success has stemmed from its ability to cut out the middlemen in interactions. This is in stark contrast to the experience between a patient and a provider, where the list of intermediaries is impossible to count. In fact, administration accounts for about a quarter of the cost of healthcare in the U.S.4 This alliance is a sign of just how

26 | PENN HEALTHCARE REVIEW | SPRING 2018

frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment.

The exact plan for how extensively these three partners will overhaul their employees’ existing health coverage is unclear. The group said they would initially focus on using technology to simplify care, but made no mention of plans to bring down costs. Perhaps they will make it easier for workers to find their local doctors in the form of an online health dashboard? Perhaps they will steer their employees toward telemedicine services? Another potential avenue could be to use their combined muscle to negotiate for lower prices for drugs and procedures.5 Many possibilities exist.

But, while this triumvirate brings successful management, technological expertise, and substantial capital to the venture, there is still plenty of doubt about whether their results will match their ambition.6 First and foremost, none of these players have expertise in health care or direct experience in providing health insurance.

Both Chase and Berkshire Hathaway have invested in the industry, but neither have worked extensively in health benefits or the management of providers, networks, and pharmaceuticals. Healthcare is a complex entity with vast regulatory compliance and pre-established players, so while a new entrant could bring innovative approaches to old problems, it may also become stymied by the industry’s complexity.7 Second, this is not a unique endeavor. Over the years, many employers have banded together to come up

TECHNOLOGY

with novel approaches to health insurance benefits in an effort to combat rising costs. Some have been pioneers, working directly with health systems or achieving significant savings, but none have made a dent in overall health care spending. Health care is inherently local, and companies often do not have enough leverage to prevent hospitals and providers from raising prices or delivering poor quality care.8 The third reason for doubt is that the economic principle of disruption rarely applies in health care. A disruptive company enters a market with a product that is lower in value than that of the incumbents, but also much lower in cost. In health care, consumers don’t usually settle for the lower-quality product, even if it costs substantially less. Additionally, highly compensated employees, like those working at Amazon headquarters, may be drawn to cutting-edge treatments or the latest prescription drugs. If

their new health plan cuts out such services to save costs, it may hurt their ability to recruit and retain the workers needed to succeed.9 In economic terms, if health care had pure inefficiency, progress via disruption would be easier; the problem arises from every part providing some small benefit.

Optimists about the venture say, if the companies succeed, they will most likely do so by finding strategies that improve care and reduce cost. By lowering prices paid to monopoly hospitals, eliminating services with little or no value, and tightening supply chains for drugs and medical devices, the partners may be able to wring real inefficiencies out of health care. While the alliance will apply only to their employees, these corporations must be closely watched so that whatever successes they have can become models for other businesses.

Infographic designed by Alexis Megibow

1. Wingfield, N., Thomas, K., Abelson, R. “Amazon, Berkshire Hathaway, and JPMorgan Team Up to Try to Disrupt Health Care.” The New York Times, (2018).

2. Vick, K., “What Happens When Amazon Takes on Health Care.” TIME, (2018).

3. Vick, K., “What Happens When Amazon Takes on Health Care.” TIME, (2018).

4. Vick, K., “What Happens When Amazon Takes on Health Care.” TIME, (2018).

5. Wingfield, N., Thomas, K., Abelson, R. “Amazon, Berkshire Hathaway, and JPMorgan Team Up to Try to Disrupt Health Care.” The New York Times, (2018).

6. Sanger-Katz, M., Abelson, Reed. “Can Amazon and Friends Handle Health Care? There’s Reason for

Doubt.” The New York Times, (2018).

7. Sanger-Katz, M., Abelson, Reed. “Can Amazon and Friends Handle Health Care? There’s Reason for Doubt.” The New York Times, (2018).

8. Sanger-Katz, M., Abelson, Reed. “Can Amazon and Friends Handle Health Care? There’s Reason for Doubt.” The New York Times, (2018).

9. Sanger-Katz, M., Abelson, Reed. “Can Amazon and Friends Handle Health Care? There’s Reason for Doubt.” The New York Times, (2018).

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PHARMACEUTICAL

Title graphic designed by Sarah Nam

P

rescription drug misuse (PDM) is a significant, growing problem across college campuses.1 Researcher William C. Watkins defines PDM as using a drug (not formally prescribed) simply for the feeling and experience associated with it. Researchers studying PDM seek to explain why college students abuse prescription drugs and address the detrimental consequences that accompany it.2 Alarming statistics emphasize the need to confront this issue. An estimated 20% of Americans above the age of 12 have abused prescription drugs at some point in their lives.3 The number of people reporting prescription drug misuse has doubled since 1993.⁴ Palmer et. al state that while extensive research has been conducted on alcohol misuse among college students, there is a lack of research on PDM. I can easily recall countless presentations and discussions on the dangers of alcohol from high school and college; however, I do not remember learning about prescription drug misuse. Researchers in this field seek to learn about and offer solutions to this problem.⁵ McCabe et al. contribute to this discussion by presenting correlates between prescription drug misuse and college campus characteristics.⁶ For example, they found that most colleges with non-medical drug misuse had extremely high and difficult admissions standards and were found in either the North-east or Southern regions of the United States. They also found correlations with individual student characteristics; those who earned a B or 28 | PENN HEALTHCARE REVIEW | SPRING 2018

lower grade were twice as likely to report drug abuse than those who earned a B+ or higher. In addition, they found that students from higher-income families were more likely to participate in non-medical prescription stimulant use. Although these results shed light on the issue of prescription drug misuse, it is important to note that these findings are merely correlations. Researchers concede that “inferences about causality are limited.”⁷ There are many harmful consequences associated with prescription drug abuse. Participants in the study conducted by Palmer et al. admitted that they often felt guilty and embarrassed. 17-19% of participants lost interest in their activities and began to take the drugs in larger doses for greater periods of time.⁸ Teter et al. build on this discussion by stating how college students who use prescription drugs through the intranasal route may be increasing their dependence on the drugs.⁹ They emphasize that more research must be done concerning how drugs are administered into the body to minimize harmful effects. McCabe et al. found that those engaging in prescription stimulant abuse participated in additional risky behaviors, such as alcohol, cigarette, marijuana, ecstasy, and cocaine use.10 Unfortunately, many of these detrimental consequences remain hidden and go unnoticed. Palmer presents an alarming statistic that less than 10% of the students in the sample reported negative effects of the drug that actually came to the attention of the school administration. Therefore, these researchers

PHARMACEUTICAL Infographic designed by Sarah Nam

suggest that “a substantial amount of problematic drug/ medication misuses is going undetected.”11 I believe that this problem must be addressed first. If schools are unaware of their students’ medication misuse, administrators will be unable to prevent it.

Researchers have made significant strides in understanding why college students engage in illicit stimulant use. Teter et al. found that 65.2% of users abused prescription stimulants in order to concentrate. Other popular reasons were that they made students more alert and helped them study. Based on these results, Teter et al. suggest that the academic environment, more specifically, how competitive it is, plays a significant role in illicit prescription use.12 Studies have also analyzed sex-based differences that underlie motivations to engage in PDM. Teter et al. discovered that women were more likely than men to use the drugs to enhance academic performance.

However, these researchers label this claim as a hypothesis and suggest that further research must be done regarding sex-based differences.13 Although researchers have greater insight into misuse-related correlations and college students’ motivations to take these drugs, there is still more to study. They offer future directions of research and intervention techniques to alleviate the consequences of this problem.

McCabe et al. suggest that students outside the United States could be surveyed as well in order to see if the patterns found in America are found in other countries.1⁴ Teter et al. emphasize the importance of studying illicit prescription misuse in nonacademic settings.1⁵ Researchers also offer possible solutions. For

example, Palmer et al. suggest drug prevention programs, self-assessment, and counseling centers.1⁶ Illicit prescription drug misuse is a serious threat to many college students on different campuses. Because this topic is often overlooked, researchers in the field are actively trying to find the most effective ways to manage this problem. For example, research could involve a study of the present opioid crisis. Researchers have found that addiction to prescribed opioid pain relievers often leads to heroin abuse.1⁷ From this, we see that prescription drug misuse has the potential to yield devastating consequences that reach far beyond college campuses.

1. William C. Watkins, “Prescription Drug Misuse Among College Students: A Comparison of Motivational Typologies,” Journal of Drug Issues 46, no. 3 (July 1, 2016): 216–33, https://doi. org/10.1177/0022042616632268.

2. ibid 3. ibid 4. ibid 5. Rebekka S. Palmer et al., “College Student Drug Use: Patterns, Concerns, Consequences, and Interest in Intervention,” Journal of College Student Development 53, no. 1 (2012), https://doi.org/10.1353/ csd.2012.0014.

6. Sean Esteban McCabe et al., “Non-Medical Use of Prescription Stimulants among US College Students: Prevalence and Correlates from a National Survey,” Addiction 100, no. 1 (January 1, 2005): 96–106, https://doi.org/10.1111/j.1360-0443.2005.00944.x.

7. ibid 8. Palmer et al., “College Student Drug Use.” 9. Christian J. Teter et al., “Illicit Use of Specific Prescription Stimulants Among College Students: Prevalence, Motives, and Routes of Administration,” Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy 26, no. 10 (October 1, 2006): 1501–10, https://doi.org/10.1592/phco.26.10.1501.

10. McCabe et al., “Non-Medical Use of Prescription Stimulants among US College Students.”

11. Palmer et al., “College Student Drug Use.” 12. Teter et al., “Illicit Use of Specific Prescription Stimulants Among College Students.”

13. ibid.

14. McCabe et al., “Non-Medical Use of Prescription Stimulants among US College Students.”

15. Teter et al., “Illicit Use of Specific Prescription Stimulants Among College Students.”

16. Palmer et al., “College Student Drug Use.” 17. Abuse, National Institute on Drug. “Opioid Overdose Crisis,” March 6, 2018. https://www.drugabuse. gov/drugs-abuse/opioids/opioid-overdose-crisis.

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PHARMACEUTICAL

Title graphic designed by Sarah Nam

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he vacuum of outer space: full of wonders, full of threats to the health of astronauts, and full of exotic considerations for countering them. Aboard spacecraft, pharmacology—one of medicine’s most versatile tools—must adapt to factor the environment into its practice.

Microgravity—the experience of weightlessness—carries with it the burden of upward “fluid shifts,” which increases pressure in the skull and contributes to a form of visual impairment known as spaceflight-associated neuro-ocular syndrome.1 Weightlessness also causes a constellation of other health concerns like muscle atrophy and bone loss, as well as changes in cardiovascular regulation.2 When astronauts aboard the International Space Station (ISS) experience weightlessness, it’s not because they are “out of range” from Earth’s gravitational tug; they feel weightless because they are in freefall, falling all the way around the world every 92 minutes. Without a daily light-dark cycle, their circadian rhythms are thrown out of sync.3 This can lead to mood disorders, impaired cognitive function, and other hormone-mediated issues. Moreover, living in the isolated, confined, and extreme (ICE) environment of spacecraft can and does manifest in psychological health problems.3,4 It’s not quite known how microgravity, circadian disruption, and ICE environments weigh in with a fourth potential factor—exposure to radiation—to cause changes in astronauts’ immune systems and microbiomes.5 They may be more susceptible to infection or abnormal inflammatory responses, and it’s been shown that their core body temperatures steadily increase while in space.5,6 Moreover, astronauts experience a sharper increase in body temperature during exercise, which is a crucial part of their daily routine.6 So how can we approach all of this? Enter the drug world.

Pharmacology considers two things. The first is pharmacodynamics—how a drug acts on the body. This is how drugs accomplish their effects at a molecular level. The second is 30 | PENN HEALTHCARE REVIEW | SPRING 2018

pharmacokinetics—how the body acts on a drug. This considers how the body distributes, processes, and eliminates drugs.8 It’s the pharmacokinetics that get really interesting after blastoff.

We can take a look at a few pharmacokinetic factors relating to spaceflight, beginning with bone loss. One class of drugs used to treat osteoporosis in terrestrial patients is the bisphosphonates, like alendronate. Despite resistive exercise, astronauts can still lose 1–2% of their bone mass for every month spent in microgravity (known as spaceflight osteopenia), but adding weekly doses of oral alendronate has been shown to maintain their bone mineral density.2 The ISS has an extremely tight formulary, so launching a full supply of alendronate into space would not be practical for long-duration missions; however, a single injection of zoledronic acid, another bisphosphonate, could help prevent bone loss for up to 2 years. It exits the circulation and binds tightly to bones, only released in tiny amounts as it inactivates new osteoclasts (bone-breakdown cells).

Astronauts tend to use medications similarly to patients on Earth, with one striking exception: sleep aids.5 Sleep can be negatively impacted by the noisy acoustics and ICE-environment stressors of spaceflight, as well as disruptions in circadian rhythm.3,7,8 ISS crewmembers consume sleep medications in quantities 10 times greater than the general population.5 Hypnotic medications known as Z-drugs (“sleeping pills” like zolpidem) are most popular, although astronauts do have access to the less habit-forming melatonin, which is a time-keeping hormone that the brain releases to let the body know when dusk has fallen.3,5,7 Melatonin has a brief half life in the circulation, so doses should be properly timed.

Exposure to blue light suppresses the secretion of endogenous melatonin, so light itself has been used in therapies to “entrain” proper circadian rhythms in patients with seasonal affective disorder.7

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Elevated core body temperatures are a threat to health and cognitive performance, so why not turn to acetaminophen’s antipyretic powers?6 It produces toxic byproducts, but with normal dosage these are inactivated in the liver and filtered out through the kidneys.8 Acetaminophen works in part by crossing the blood–brain barrier, and we already described how microgravity alters the normal balance of blood flow: blood moves up toward the head, and cerebrospinal fluid pressure increases.1,8 The ways in which drugs and their byproducts distribute within the body have to be rethought under the conditions of spaceflight, and their effects on the nervous system have to be reexamined. One analog study simulating a full-length, 520-day mission to Mars showed that specialized activity trackers are valid methods for detecting changes in movement, psychosocial behavior, and sleep quality, with possible applications in monitoring neurobehavioral drug responses in space.4 Astronauts are prone to different forms of radiation exposure, which can lead to DNA damage, gastrointestinal syndrome, bone marrow injury, and death. Antioxidants may provide some protection against chronic and low-dose exposures, but they would do little against a burst of “high

linear energy transfer.” The quest for more potent radioprotectants led to the development of amifostine, used today to protect chemotherapy patients from organ damage by virtue of its affinity for DNA. It seemed like a promising countermeasure for astronauts, but amifostine posed a disqualifying side effect: hypotension.9 Low blood pressure is bad news for astronaut performance, especially considering the cardiovascular stress they already experience in microgravity.

In space, pharmacokinetics must consider not only how the body acts on a drug, but also how the environment acts on the body. The environment also acts on drugs themselves; seizure-blocking benzodiazepines may have a shorter shelf life in space.3 The relevance of the space environment spans all the way into the pharmaceutical industry; microgravity makes it possible for researchers to analyze molecular drug targets with more precision than on Earth, potentially spurring faster, more effective drug development.10 Some seemingly unrelated developments on Earth might find applications beyond it; tablets of Abilify MyCite® (aripiprazole, used to treat schizophrenia) contain a sensor that, when ingested, sends information to a smartphone app. Reciprocally, discoveries made about the pharmacokinetic properties of weightlessness will have a direct benefit for patients on headdown bed rest, which has been shown to be a good model of microgravity.1 Because it considers the context of drug–body interactions, environmental pharmacology is an important perspective as we broaden the horizon of manned spaceflight.

Infographic designed by Sarah Nam 1. Zhang, L.F. and Hargens A.R. “Spaceflight-Induced Intracranial Hypertension and Visual Impairment: Pathophysiology and Countermeasures.” Physiology Review 98 no. 1 (2018). doi:10.1152/physrev.00017.2016.

2. Gardina, Christopher. “Bone Mass Preservation and Fracture Risk Assessment with Bisphosphonate Therapy During Spaceflight.” Master’s thesis. California Polytechnic State University, San Luis Obispo, 2008. doi:10.15368/theses.2008.18.

3. Friedman, Eric, and Brian Bui. “A Psychiatric Formulary for Long-Duration Spaceflight.” Aerospace Medicine and Human Performance 88, no. 11 (2017): 1024–33. doi:10.3357/amhp.4901.2017.

4. Johannes, Bernd, Alexej S. Sitev, Alla G. Vinokhodova, Vyacheslav P. Salnitski, Eduard G. Savchenko, Anna E. Artyukhova, Yuri A. Bubeev, et al. “Wireless Monitoring of Changes in Crew Relations during Long-Duration Mission Simulation.” PLoS One 10, no. 8 (2015). doi:10.1371/journal.pone.0134814.

5. Wotring, Virginia E. “Medication use by U.S. crewmembers on the International Space Station.” FASEB Journal 29, no. 11 (2015): 4417–23. doi:10.1096/fj.14-264838.

6. Stahn, Alexander C., Andreas Werner, Oliver Opatz, Martina A. Maggioni, Mathias Steinach, Victoria

Weller von Ahlefeld, Alan Moore, et al. “Increased core body temperature in astronauts during long-duration space missions.” Nature: Scientific Reports 7, no. 16180 (2017). doi:10.1038/s41598-017-15560-w.

7. Fucci, Robert L., James Gardner, John P. Hanifin, Samar Jasser, Brenda Byrne, Edward Gerner, Mark Rollag, and George C. Brainard. “Toward optimizing lighting as a countermeasure to sleep and circadian disruption in space flight.” Acta Astronautica 56, no. 9–12 (2005): 1017–24. doi:10.1016/j.actaastro.2005.01.029.

8. Kast, Johannes, Yichao Yu, Christoph N. Seubert, Virginia E. Wotring, and Hartmut Derendorf. “Drugs in space: Pharmacokinetics and pharmacodynamics in astronauts.” European Journal of Pharmaceutical Sciences 109, no. 15 (2017): S2–8. doi:10.1016/j.ejps.2017.05.025 9. Weiss, Joseph F. “Pharmacologic Approaches to Protection against Radiation-induced Lethality and Other Damage.” Environmental Health Perspectives 105, no. 6 (1997). PMID:9467066.

10. Howard, Jenny. Ed. Kristine Rainey. “Space Station Crew Cultivates Crystals for Drug Development.”

International Space Station Program Science Office, Johnson Space Center (2017). https://www.nasa.gov/ mission_pages/station/research/news/lmm_biophysics.

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he first thing we learn in classical microeconomics is to base assumptions on rational consumption decisions. However, we also understand how the choices we make aren’t perfect – from making that extra purchase you didn’t expect yourself to buy to underconsuming healthcare by forgetting to take your medications. Specifically applied to the healthcare space, the irrationality of different players contribute to the common challenges faced by the industry. Such awareness provides the opportunity for the principles of behavioral economics, centered on studying information processing and decision making from an empirical, non-ideal lens, to influence health policy and strategic design of healthcare systems. In fact, the structuring of these behavioral influences, termed “nudges” by behavioral economists Richard Thaler and Cass Sunstein in their renowned novel Nudge: Improving Decisions about Health, Wealth, and Happiness, has grown in recognition among researchers and health decision makers alike, suggesting that there is potential to leverage empirical lessons from the field with both cost-saving and quality-improving benefits to health systems at large.

First, insights gained from perspective-based behavioral studies can be used to create novel methods of interactions between the physician and care center.

Drawing from the principles of psychological framing, we see that healthcare practitioners fall susceptible to the perspective in which a choice is presented: patients and physicians alike are more favorable towards selecting a surgery presented with a “90% survival rate” than a “10% risk of mortality” despite the identical nature of the data.1 The method that such information is provided thus has a large role in encouraging or dissuading surgical enrollment 32 | PENN HEALTHCARE REVIEW | SPRING 2018

Title graphic designed by Elaine Ma

depending on each player’s position in the market. This “framing,” a key principle in behavioral economics, illustrates how the field indeed can shape healthcare.

From the physician perspective, framing influences their prescription behavior – particularly the positioning of non-branded pharmaceuticals, termed generics, on an electronic health record (EHR). From a cognitive standpoint, since physicians understand that off-label and on-label drugs have the same chemical composition and utility, barring personal preference, the physician often prescribes what is more convenient to access on the EHR. This presents opportunities for medical interventions to lower healthcare spending as costs of generic drugs are, on average, 85% less than their brand name counterparts.2 In fact, a study at the Perelman School of Medicine focused on changing default prescription options, namely through an opt-out intervention program. Specifically, the EHRs were defaulted to a generics prescription and physicians had to check an “opt-out” box in order to prescribe the brand name. Comparing prescription rates pre and post intervention showed that there was an increase in generic prescription rates from 75 percent to 98 percent.3 “If a simple, low-cost change like adding an optout checkbox to prescription settings can make such a significant impact, there are likely other refinements that can be made just as easily that will also result in cost savings for patients and health systems. It’s a valuable area of research to continue exploring,” said C. William Hanson, MD, chief medical information officer at Penn Medicine and a co-author on the study.

On the note of simple changes that can drastically affect clinical outcomes, principles of behavioral economics have potential to shape the pressing issue of

BUSINESS

drug adherence. It is estimated that patient non-adherence, or inability to follow treatment recommendation plans, costs the U.S. health system between $100 billion and $289 billion annually along with 125,000 treatable deaths.⁴ While realistically there is no way to guarantee a 100% adherence rate to all medication plans, there are however opportunities in system design that can improve adherence rates. Logically, cognitive factors are at play, including the health literacy of patients regarding how valuable they view the treatment presented and the extent of forgetfulness to take the medication itself. Nonetheless, additional challenges in noncompliance involve a lack of dynamic communication – a behavioral variable of concordance between the prescriber and the patient, both involved in the decision making process, allows for stronger reciprocity on treatment understanding and adherence.

While there is no optimal strategy to resolve these factors, there certainly has been movement in the healthcare space to leverage concepts from irrational behaviors. For example, pharmaceutical companies have taken note to formulate easy-to-follow instructions to take medications (e.g. Once per day instead of three times per day) and physicians now offer patients the opportunity to prepay for their next appointment, strengthening their reason to return.

Beyond the traditional healthcare system, however, start-ups have sought to approach this challenge differently.

Drawing ideas from telemedicine, a novel pill dispenser technology developed in 2007 by MedminderTM aims to enhance prescription reminders. With built-in cellular connections, the dispenser has a variety of auditory and visual features to encourage the user to take medications

on time that range from text messaging to flashing light sensor reminders. ⁵ A Brooklyn-based start-up tackles the issue from a different perspective. Founded in 2014, Wellth aims to improve care plan compliance through an mobile app that uses incentives to reward patients for taking their medication.⁶ However, amidst the various med-tech and tech companies focused on prescription adherence, Wellth holds a different belief of its company: “Wellth is a behavioral economics company.

Technology alone won’t solve our medication adherence problem — many have already tried that route: lights on pill boxes, microchips on the bottles, chips in the pills,” said co-founder and CEO of Wellth Matthew Loper.

Loper has a strong point when he emphasizes behavioral economics. Ultimately, applications of behavioral economics in the healthcare space present novel opportunities to reduce the growth of healthcare spending costs. As players in the industry fall susceptive to irrational behavior, we must evaluate the validity of the use of rational models to explain clinical choices and instead turn to explanations given by irrational economic modeling. Based on the current academic literature on healthcare behavioral economics, future studies ought to expand on greater data-driven research of physician behavior economics in order to fully model variable financial and framing effects on tangible metrics of endpoint outcomes. While such interventions to physician behavior are more less tangible to measure, empirical data grounded in randomized control trials with strong evidence for comparative effectiveness can serve as points of insight to be recommended in healthcare management leadership or in health policy.

Infographic designed by Elaine Ma

1. Tversky, Amos, and Daniel Kahneman. “The Framing of Decisions and the Psychology of Choice.” Science 211, no. 4481 (1981): 453-458.

2. Center for Drug Evaluation and Research. “Generic Drugs - Generic Drug Facts.” U S Food and Drug Administration Home Page.

3. Patel, Mitesh S., Susan C. Day, Scott D. Halpern, C. William Hanson, Joseph R. Martinez, Steven Honey well, and Kevin G. Volpp. “Generic Medication Prescription Rates After Health System–Wide Redesign of Default Options Within the Electronic Health Record.” JAMA internal medicine 176, no. 6 (2016): 847-848.

4. Viswanathan, Meera, Carol E. Golin, Christine D. Jones, Mahima Ashok, Susan J. Blalock, Roberta CM Wines, Emmanuel JL Coker-Schwimmer, David L. Rosen, Priyanka Sista, and Kathleen N. Lohr. “Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review.” Annals of internal medicine 157, no. 11 (2012): 785-795.

5. https://www.medminder.com/ 6. https://wellthapp.com/home

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I

t consumes 20 percent of our daily caloric intake.1 Our body has evolved to keep it alive above all else.

The brain, consisting of 100 billion neurons, serves as the central hub that mediates all our bodily functions and drives our thoughts and decisions.. While an individual neuron’s function – to fire action potentials – seems simple, the networks formed among these billions of excitable cells make the nervous system so intriguing and challenging to study.

Anyone seeking greater insight into people’s thoughts and decisions – whether in business, research, or healthcare – should analyze brain activity to understand how the external environment affects individuals’ thought processes and ultimately their decision-making.

The brain is indeed complex; however, our brain activity can reveal – with increasing accuracy – the thoughts, motivations, and emotions governing our daily lives. The implications of these insights extend far beyond one individual – data gathered using functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) have predicted nationwide trends, such as movie sales nationwide and product sales among all consumers who had seen a specific commercial.2 Research labs and companies predominantly use fMRI and EEG to record human brain activity, analyzing the data to extract insights into our behaviors and decisions. fMRI measures changes in blood flow across different regions of the brain, computing blood oxygenation level dependent (BOLD) signals to indicate the relative activity of specific regions across the entire brain.3 An EEG comprises sensors attached to the scalp that each aggregate electrical activity across hundreds of thousands of neurons in close proximity, providing a real-time readout of brain waves – rhythmic activity in the brain.⁴ While fMRI and 34 | PENN HEALTHCARE REVIEW | SPRING 2018

Title graphic designed by Alexis Megibow

EEG differ in their approach to measuring brain activity, both techniques have transformed the way researchers study how the brain governs our thought processes and emotions.

Measuring brain activity affords a more accurate and extensive understanding of our mental state and thoughts than traditional approaches to market research – such as self-reporting, willingness to pay, or focus groups. These methods rely on subjective accounts of participants, which are notoriously unreliable in measuring consumers’ true behavior. Factors such as mood, unrelated preferences, and even the ambient temperature have shown to diminish the predictive power of self-reporting.5,6,7 The removal of participants from the actual experience – such as watching a movie trailer or reading a news story – also means they must recall the event by memory, further subjecting their accounts to biases intrinsic to the retrieval of memories.3 Neuroimaging tools such as fMRI and EEG permit the continuous collection of data, allowing researchers to chart individuals’ brain activity as they’re watching a commercial or engaging in a task. Such temporal precision has prompted researchers to conclude that brain activity during the first 16-21 seconds of a movie trailer correlated most strongly with ticket sales and recall, underscoring the importance of those first couple scenes in capturing the audience’s attention.2,3 Given the pitfalls of conventional methods, EEG recordings of brain synchrony across different subjects has the unique ability to shed light on the characteristics of successful movie trailers, underscoring how EEG can be leveraged in different industries to understand our preferences and decision-making.

These studies demonstrate that even with a small sample size, analysis of brain synchrony, BOLD signals, and other physiological metrics can accurately predict

BUSINESS

market-level trends. For instance, as users read New York Times articles, more pronounced brain activity – measured using blood oxygen levels detected by fMRI – in the ventromedial prefrontal cortex corresponds with greater inclination to share the article.⁸ Even the synchrony of heart rate can predict the strength of bonds between group members, as evidenced by a study of fire-walking rituals that concluded the heart rates of spectators and performers had become synchronous because of the collective actions of both groups during the ritual.⁹ These findings suggest that measures such as heart rate can predict cooperation among different groups, demonstrating how companies can potentially use physiological activity – such as heart rate and brain synchrony – to enhance teamwork and bonding among their employees.

The ability of imaging techniques to reveal our preferences and emotions have spawned new products claiming to enhance performance or cognition. Individuals experiencing chronic stress or seeking to improve their athletic performance can now turn to transcranial Direct Current Stimulation (tDCS), a device consisting of electrodes that deliver electric current to stimulate neurons. tDCS in the prefrontal cortex has shown to reduce cortisol levels and improve mood.10 While such devices have been approved in Europe to treat pain and depression, the over 500 tDCS studies currently registered with the National Institutes of Health demonstrates a heightened interest in investigating the potential of tDCS to improve memory or increase creativity.11,12 Less intrusive than electrical stimulation, our dietary choices can affect the synthesis of neurotransmitters key to circuits mediating reward and learning. Studies have found that individuals who regularly consume a high-carb breakfast have lower levels of a precursor molecule to dopamine, suggesting they may lack sufficient dopamine to regulate those pathways.13 The findings made by researchers in the

laboratory have generated new ideas and approaches that could reshape everyday decisions involving our health and well-being.

The use of brain activity and other physiological measures – as measured using fMRI, EEG, and heart rate monitors – to evaluate our emotions and preferences has enabled neuroscience to seep into domains spanning healthcare, business, and technology. These tools will become ever-more present in our lives, from their use by law enforcement as lie detectors to their use by tech and retail companies as indicators of our buying preferences.

Indeed, the expansion of such products raises questions about the privacy of our brain data and the misuse of such information by governments and companies. But the push for more research is only intensifying.

1. Brady, Scott, George Siegel, R. Wayne Albers, and Donald Price. 2005. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. Elsevier.

2. Boksem, Maarten A. S., and Ale Smidts. 2015. “Brain Responses to Movie Trailers Predict Individual Preferences for Movies and Their Population-Wide Commercial Success.” JMR, Journal of Marketing Research 52 (4): 482–92.

3. “What Is FMRI?” Center for Functional MRI - UC San Diego School of Medicine. 2018. Accessed March 29, 2018. http://fmri.ucsd.edu/Research/whatisfmri.html.

4. “EEG.” Biomedical Signals Acquisition - The McGill Physiology Virtual Lab. Accessed March 29, 2018. https://www.medicine.mcgill.ca/physio/vlab/biomed_signals/eeg_n.htm.

5. Barnett, Samuel B., and Moran Cerf. “A Ticket for Your Thoughts: Method for Predicting Movie Trailer Recall and Future Ticket Sales Using Neural Similarity among Moviegoers.” Journal of Consumer Research, 2017.

6. Thomas, David L., and Ed Diener. 1990. “Memory Accuracy in the Recall of Emotions.” Journal of Personality and Social Psychology 59 (2): 291–97.

7. Palinkas, L. A. 2001. “Mental and Cognitive Performance in the Cold.” International Journal of Circumpolar Health 60 (3): 430–39.

8. Baek, Elisa C., Christin Scholz, Matthew Brook O’Donnell, and Emily B. Falk. 2017. “The Value of Sharing Information: A Neural Account of Information Transmission.” Psychological Science 28 (7): 851–61.

9. Konvalinka, I., D. Xygalatas, J. Bulbulia, U. Schjodt, E-M Jegindo, S. Wallot, G. Van Orden, and A. Roepstorff. 2011. “Synchronized Arousal between Performers and Related Spectators in a Fire-Walking Ritual.” Proceedings of the National Academy of Sciences 108 (20): 8514–19.

10. Austin, A., Jiga-Boy, G. M., Rea, S., Newstead, S. A., Roderick, S., Davis, N. J., … Boy, F. (2016). “Prefrontal Electrical Stimulation in Non-depressed Reduces Levels of Reported Negative Affects from Daily Stressors.” Frontiers in Psychology, 7, 315 11. Landhuis, Esther. “Do DIY Brain-Booster Devices Work?” Scientific American, January 10, 2017.

12. Gooneratne, Inuka Kishara, Alexander L. Green, Patricia Dugan, Arjune Sen, Angelo Franzini, Tipu Aziz, and Binith Cheeran. “Comparing Neurostimulation Technologies in Refractory Focal-onset Epilepsy.” Journal of Neurology, Neurosurgery & Psychiatry 87, no. 11 (2016): 1174-182.

13. Wurtman, Richard J., Judith J. Wurtman, Meredith M. Regan, Janine M. Mcdermott, Rita H. Tsay, and Jeff J. Breu. “Effects of Normal Meals Rich in Carbohydrates or Proteins on Plasma Tryptophan and Tyrosine Ratios.” The American Journal of Clinical Nutrition 77, no. 1 (2003): 128-32.

Infographic designed by Alexis Megibow

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PENN HEALTHCARE Review WHARTON UNDERGRADUATE HEALTHCARE CLUB

is a student-led 36 | PENN HEALTHCARE REVIEWThis | SPRING 2018initiative; all articles were written and edited by Penn undergraduates and therefore do not reflect the opinions of WUHC or the University of Pennsylvania.