The High Cost of Prescription Drugs in the United States

By Dr. Sudip Bose, MD, FACEP, FAAEM

Spending on prescription medications is higher in the US, per capita, than in any other country in the world, according to a recent Journal of the American Medical Association study. And, the report said, those costs are “largely driven by brand-name drug prices that have been increasing in recent years at rates far beyond the consumer price index.”

An NBC News report noted that, “Paying for medicine can be the most expensive out-of-pocket health cost for Americans.”


If you look at the landscape of prescription drugs in America, you’ll notice there is nothing in place to keep drug prices low. There are no specific regulations to keep a ceiling on costs. The pharmaceutical manufacturers have the very tempting opportunity to charge whatever they think a drug’s demand and the market will bear. It’s simply possible for a drug company to charge high prices if they want to, just because they can. There’s nothing regulating whatever cost they want to charge. So the opportunity to charge more exists.

Drug companies will tell you immediately that their costs to research, develop and bring a drug to market are astronomical, and they have to cover those costs and make a profit to continue to stay in business and develop even more innovative prescription medications that will help save more lives. That’s a primary reason pharmaceutical companies will point to as a reason for escalating prices on all the medications they manufacture. And that’s true – to a degree.

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The Opioid Crisis in the United States

By Dr. Sudip Bose, MD, FACEP, FAAEM

“The opioid crisis is an emergency, and I’m saying officially right now it is an emergency. It’s a national emergency. We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis,” President Donald Trump said yesterday.

It’s likely that President Trump was influenced by an interim report that was presented to him last week by the Commission on Combating Drug Addition and the Opioid Crisis, which compared the nation’s overdose death toll to the toll that resulted from the terrorist attacks on 9-11: “With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks,” the commission’s interim report noted. And the commission urged the president to declare a national emergency under either the Public Health Service Act or the Stafford Act.

President Trump and the commission are right in placing such an emphasis on this national crisis – and it is a national crisis. It’s the biggest epidemic to have hit our country since the HIV epidemic of years ago, so much so that in the emergency room as an emergency physician, I’m seeing patients come in dead from opioid overdoses. People are getting addicted and are coming into our emergency rooms and they’re dying from this. A couple of those instances I remember very vividly – one where a young girl went downstairs at her house to find her older brother and his girlfriend blue and not breathing; in another case a man looked out of the window of his house and saw a teenager lying still on his lawn. I know the stories, because the brother, the girlfriend and the teen on the lawn all came through my emergency room and all were dead from overdosing on opioids. You don’t forget those kinds of things.

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Transgenders in the Military: A Cause for Concern?

By Dr. Sudip Bose, MD, FACEP, FAAEM

President Trump announced via Twitter last week in a series of three Tweets that United States government would no longer accept or allow transgender individuals to serve “in any capacity” as the military “cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail.” His three Tweets compiled:

“After consultation with my Generals and military experts, please be advised that the United States Government will not accept or allow transgender individuals to serve in any capacity in the U.S. Military. Our military must be focused on decisive and overwhelming victory and cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail. Thank you”


That’s quite a stance President Trump has taken, and a change to the military’s current policy of allowing gay, lesbian and bisexual people to serve openly after President Bill Clinton opened the door with his implementation of a “don’t ask, don’t tell” policy beginning in 1993 when it came to sexual preference/orientation in the military. The debate on this issue has gone back and forth over the past seven decades. Even as far back as World War II, those policies were the subject of substantial debate as the military eventually brought in some 18 million men over the course of that war. One of the “deviations,” as it was termed then, that physicians giving physicals to incoming soldiers joining to fight in WWII were asked to look for was listed as “homosexual proclivities,” which would disqualify someone trying to enter the military. Various administrations wrestled with the subject over the next five decades with the result being that of exclusion throughout the armed forces, until 1993, when Congress passed and President Clinton signed a law instituting the policy commonly referred to as “don’t ask, don’t tell” (DADT), which allowed gay, lesbian, and bisexual people to serve as long as they did not reveal their sexual orientation.

Then in 2010, the ban on openly gay, lesbian, and bisexual service personnel was ruled by two federal courts as being unconstitutional, and a federal appeals court suspended the DADT policy. In December 2010, Congress passed and President Barack Obama signed the Don’t Ask, Don’t Tell Repeal Act of 2010 and, under its provisions, restrictions on service by gay, lesbian, and bisexual personnel ended as of Sept. 20, 2011. Transgender people were allowed to openly serve starting June 30, 2016.

Now, let’s remember, this recent discussion was started by a Tweet from President Trump. And a Tweet is not an official directive. A day after the president Tweeted about transgenders in the military, Joint Chiefs of Staff Chairman, Gen. Joseph Dunford, announced that the current policy – meaning that policy set in place over a year ago regarding transgender people being allowed to openly serve in the military – will remain intact until the president issues an official directive.

Since that set of Tweets, there has been quite a bit of back-and-forth on both sides of the issue. Much of the discussion has been around a couple of things:

  1. The medical costs of being transgender and maintaining a transgender status in the military and,
  2. That the armed services should not be a place of implementing progressive social engineering and that the military should not have its readiness impacted by transgenders.

I have experience on the medical side of things as well as military (Dr. Sudip Bose’s profile). As far as the medical side of things go, most transgender patients do not undergo sexual reassignment surgery, which is expensive, has risks, and has a long timeline. Patients do have cosmetic surgeries to help assume a more masculine or feminine appearance, depending on the transformation aesthetics they’re looking for. Hormone therapy is common.

Also, making a transition from one gender identity to another is not just about a physical, outward appearance. That’s important to understand. Transitioning to become a man or a woman is an important part of a patient’s identity. A vast number of transgender people see themselves as, and identify themselves with being a male or female – opposite of the way they were born – at a very young age, often as children. For example, that “tomboy” girl who always wanted to play with the boys and associated with more traditionally masculine activities and possessions; then there’s the young boy who always wanted to play with the girls and befriend them, who felt more comfortable in his own identity playing with dolls or wearing a dress – typically more traditionally feminine behavior.

Becoming a transgender person is a long and complicated process for an individual. Some people may modify the way they look and dress and become more feminine or masculine in appearance and may even change their name before doing it legally. Some transgenders will make the transition in only part of their lives, for example assuming a male or female persona personally, while at home, but may remain the opposite gender at work. There are those who have come into the emergency department and present themselves as their original birth gender, despite having made the transition to the opposite sex in every other aspect of their lives.

However a transgender person presents him or herself – male or female –however they identify themselves, regardless of what you might initially perceive them to be, is the way they need to be treated. It’s actually pretty simple to do and not a deterrent to their care if you just focus on the issue they’ve come to the ED to get treatment for.

On the military side of things, and having been in combat on the front lines, you don’t much care who is what – male or female – as long as they’re doing their jobs. When you’re fighting the enemy, you’re not taking an attendance check to see who’s showed up next to you to join in the fight – male, female, straight, gay, lesbian, bisexual, transgender – none of that matters. You engage your enemy with an application of force to make sure the enemy goes away and you remain living, breathing and standing. The readiness argument, in my opinion, is a bit of a red herring. You fight together. And you really don’t care whether it’s Bruce or Caitlyn Jenner fighting next to you as long as they’re engaged in the fight keeping your butt and their butt safe. When bullets are flying at you, you become instantly ready to apply lethal force, transgender or not.

At his confirmation hearing on Capitol Hill prior to his becoming President Trump’s Secretary of Defense, Gen. James “Mad Dog” Mattis was asked a question by Sen. Kirsten Gillibrand (D-N.Y.) pertinent to this debate. She asked of the general, “Do you believe that allowing LGBT Americans to serve in the military, or women in combat, is undermining our lethality?”

“Frankly senator,” Gen. Mattis replied, “I’ve never cared much about two consenting adults and who they go to bed with.”

“So… the answer is ‘no’?” asked Sen. Gillibrand.

“Senator, my concern is on the readiness of the force to fight, and to make certain that it’s at the top of its game,” he said. “So, when we go up against an enemy, the criteria for everything we do in the military up until that point when we put our young men and women across the line of departure, is that they will be at their most lethal stance.”

An important perspective to remember as this debate moves forward.

To learn more about Dr. Sudip Bose, MD, please go to and visit his nonprofit where 100% of donations go directly to injured veterans.

The Threat to America That No One is Talking About

By Dr. Sudip Bose, MD, FACEP, FAAEM

Our country has to maintain a strategy to use against a potential microbial attack that would strike terror in the hearts of every American if we’re not prepared for it when it hits. And make no mistake, it will come. It’s only a question of when.

Are we ready for the next pandemic? I would say no. We’ve made a start in preparing, but we’re not ready for a full-on microbial assault by any stretch.

According to a 2013 assessment by the World Bank:

“Pathogens with pandemic potential continue to emerge, and most of them are of animal origin (zoonotic). They include, for example, Ebola, H5N1 avian flu, H7N9 avian flu, HIV/AIDS, and two kinds of coronavirus: severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS).”

The World Bank also points out that that:

“The 1918 pandemic flu, the most severe of the four flu pandemics in the last 100 years, infected up to 40 percent of some national populations and killed 50–100 million people.”

Let’s start at the beginning: a pandemic is an epidemic of infectious disease that spreads through human populations across a large region – a country or countries, a continent, or even worldwide ― usually resulting in health issues serious enough to cause massive death among those infected.

“If anything kills over 10 million people in the next few decades, it’s most likely to be a highly infectious virus rather than a war. Not missiles, but microbes.”

That’s a quote from a TED Talk given by Microsoft co-founder Bill Gates in early 2015, only about a year after the start of an Ebola outbreak in West Africa, which ultimately claimed almost 29,000 lives. It’s now two years later, and the warning Gates gave still rings true as a very valid concern. In his talk, he said that there was no need to panic about this, but that, as a country, “we need to get going.”

He may have been right about not needing to panic. But it’s time to get going now.

The big question, though, is how? What do we do? How do we prepare for something that is ultimately unknowable until it hits?

We have a fairly recent example of a viral outbreak that can help us get ready for that fight – the Ebola virus outbreak in West Africa of just a few years ago that I just mentioned. It was an unprecedented epidemic with an unprecedented response that took years to get under control. The independent medical humanitarian organization, Medecins Sans Frontieres (MSF) – more widely known in the U.S. as Doctors Without Borders – organized a global response to the outbreak. The group is primarily made up of doctors who volunteer their time and expertise to any given global medical threat.

At its peak, MSF employed nearly 4,000 national staff and over 325 expatriate staff to combat the epidemic across the three countries.

In Liberia – just one of the three primary countries where the Ebola outbreak extended to – 189 health care workers died after contracting the virus. That’s one of every 10 workers who dedicated themselves to stopping the spread of the outbreak. Unfortunately, that pales in comparison to the general mortality numbers of the outbreak, which show that of the total 28,636 documented cases of people infected by the Ebola virus between 2014 and January 2016, there was a resulting 11,315 deaths, according to the World Health Organization (WHO). That’s a mortality rate of nearly 40 percent. Very scary stuff.

According to the non-fiction book, The Hot Zone, written by Richard Preston and published in the mid-’90s after the Ebola virus first emerged from the jungles of Africa and claimed its first human victim, Preston writes:

“A hot virus from the rain forest lives within a twenty-four-hour plane flight from every city on earth. All of the earth’s cities are connected by a web of airline routes. The web is a network. Once a virus hits the net, it can shoot anywhere in a day – Paris, Tokyo, New York, Los Angeles ― wherever planes fly. Charles Monet and the life form inside him had entered the net.”

Charles Monet was the man initially infected with that life form – the Ebola virus ― who Preston was writing about in The Hot Zone. Monet was trying to get to a hospital in Nairobi, Kenya, flying aboard a Kenya Airways flight. It was nothing more than luck that Monet didn’t infect anyone on the plane and luck that the virus really didn’t “enter the net” and spread worldwide. And this was some 35 years before the Ebola outbreak in 2014.

The next big viral outbreak doesn’t necessarily have to be something as exotic as an Ebola virus or some other as yet unknown zoonotic pathogen. It could simply be the next strain of influenza – the flu – that we’ve never seen before that could turn deadly. The source could be a natural epidemic, or it could be bio-terrorism.

Here are some of the steps we need to take to avoid at least a major worldwide health scare or at worst a pandemic:

Speed is the first factor. We’ve got to be able to quickly identify the threat and move to treat it as fast as possible. Speed is the ultimate weapon. Identification usually the easy part. Then what, though? How do we minimize the spread of the infection and contain it?

Reserves – in a word – just as in we have now as part of our current military. We need medical reservists who can be called up to handle an infectious outbreak – a U.S. medical dream team ready to be deployed to the hot spots and begin front-line treatment and containment.

We need a group of key epidemiologists also ready to evaluate the disease and formulate a plan for the most effective treatment of the “microbial missile.” We need dedicated researchers who can identify and formulate treatment protocols, develop vaccines and research the most effective ways to eliminate the threat. Modern advances in biology should lessen the turnaround in the time it takes to look at a pathogen and then find a quick path to manufacturing drugs and vaccines at scale that could work against that pathogen or develop a universal treatment protocol to be implemented.

Exercises – practice. Now is the time to identify the personnel who would make up these teams and train them. We need to perform military-like exercises – “germ games” as Bill Gates called them in his TED Talk – to be ready for an outbreak. We’ve invested a lot as a nation to build up our military defenses – people, weapons and weapons platforms, hardware, software, logistics, networks, command structure – all of it. But if the next big threat to US human lives is microbial, what do we have invested right now to stop a major epidemic? Very little.

So we’ve got to get a response team ready. We’ve got to get a preparedness team ready to roll.

WHO is funded to monitor epidemics, but not to take action to stop them. We can’t let that gap go unfilled here in America.

The World Bank estimates that if we have a worldwide flu epidemic, we’d have millions of deaths. And they also say that as a result of the epidemic, global wealth would depreciate by more than $3 trillion. Not million, not billion – trillion.

Invest now. If we invested even a small fraction of that astronomical amount of money in readying to stop such an outbreak, wouldn’t it be worth it? And this kind of investment would evolve significant benefits beyond just being ready for the next pandemic. This should absolutely be a priority. We can build a terrific response system.

Leverage technology. Technology is advancing at such a rapid pace that we’re barely able to keep up with and implement the improvements made on a monthly and yearly basis. So who knows the kind of technology we’d be able to leverage in the future. But even so, currently we can use modern technology that is now as simple and basic as cell phones. Cell phones can get information fed in from the public and can also be used to get information back out instantaneously. Satellite tracking can monitor people movement.

Response. Why not pair the medical people with the military to take advantage of the military’s ability to move quickly in response to a threat? It’s an idea Bill Gates surfaced in his talk, and I would agree with the strategy. There’s not one area of America we couldn’t get to quickly if we paired up the medical personnel with military movement and transportation.

There is a lot of room for progress and a lot we can do to be ready for the next pandemic. And we need to start now.

To learn more about Dr. Sudip Bose, MD, please go to and visit his nonprofit where 100% of donations go directly to injured veterans.

Obamacare: Three Keys for Improvement

By Dr. Sudip Bose, MD, FACEP, FAAEM

As the 2016 presidential campaign came to a close and we elected a new president, polls showed that of the half-dozen things that most concerned Americans, health care was one of the major topics. No real surprise there.

There are advocates for the Affordable Care Act, also known as Obamacare, who say that statistics show that 21 million more Americans got health care who didn’t have it before, and that those least able to afford it were the ones who benefitted from the ACA.

There are advocates against the Affordable Care Act who point to what they say is a broken system, with insurers exiting the marketplace and premiums rising by double and in some cases triple digits — so much so as to render plans in the “Affordable” Care Act unaffordable.

Where do you start with a topic as broad and overwhelming as this? Trying to look at it on balance, there are some things the ACA got right and some it didn’t. Let’s look at a few key issues that I think need to be addressed:

Get Costs Under Control

The future of Obamacare is uncertain with president-elect Donald Trump about to be sworn in. There are a couple of things that we know for certain, however — insurance premiums will spike next year, and things will change under Trump. Trump has pledged to repeal and replace Obamacare, so stay tuned, there are going to be ongoing conversations about this.

A recently released government report says that health care premiums are going up in 2017. They’re going up a lot. In order for the Affordable Care Act or any health insurance to work, you need everyone in the pool, so to speak. But what’s happening is that only the sick patients are joining the pool. So the healthy patients are opting out and not paying premiums – they’re not getting health insurance in many cases. Health insurance companies are losing millions of dollars and they’re pulling out and not providing coverage under the Affordable Care Act. We’re seeing that across the country.

According to a report by the U.S. Department of Health and Human Services (HHS), prices across the country could go up by double digits, although not everywhere. Premiums in some states could double while premiums in other states could actually drop. A mid-level benchmark plan could increase an average of about 25 percent. But there’s going to be less choice. One fifth of consumers can only pick plans from one insurer.

Let’s take a worst-case scenario. Let’s talk about the state of Arizona. One of the unsubsidized premiums for a hypothetical single, 27-year-old male and the benchmark second-lowest cost silver plan — that premium would jump significantly. So what does that look like? A $200 monthly premium in 2016 would become close to $400 in 2017. People who get their insurance through work probably won’t see the spikes as much, because they’re not going through for their insurance, which is what this article is focusing on. But their prices will be going up as well. It’s happening across the country. And we’re talking right now about the basic plan sticker prices. There are subsidies available if you qualify that will bring the price down, and as people make less, there will be increased subsidies for that. So the key lesson is a simple one: you need to do your homework, look at different health plans, get a good review of the plans and see what’s best for you.

Have you ever been to a restaurant, paid what you thought was your bill, left, and then weeks later gotten a half-dozen or so bills in the mail related to your service at that restaurant? No? You say you haven’t? Perhaps you got a bill from the sous chef, who was an independent contractor not working directly for the restaurant? Maybe one from the food expediter, and then the one from the pastry chef, the maitre’d who escorted you to your table, the busboy who cleaned and set the table before you sat down and then cleared dishes after each course and filled water glasses? No? And just think — some of those people were in your preferred network of restaurant service providers (and you got a good deal on the cost of their services), but some weren’t (and you were charged what looks like an exorbitant amount).

Another issue related to costs is transparency. We must know clearly what treatments will cost. Have you ever been to a restaurant, paid what you thought was your bill, left, and then weeks later gotten a half-dozen or so bills in the mail related to your service at that restaurant? No? You say you haven’t? Perhaps you got a bill from the sous chef, who was an independent contractor not working directly for the restaurant? Maybe one from the food expediter, and then the one from the pastry chef, the maitre’d who escorted you to your table, the busboy who cleaned and set the table before you sat down and then cleared dishes after each course and filled water glasses? No? And just think — some of those workers were in your preferred network of restaurant service providers (and you got a good deal on the cost of their services), but some weren’t (and you were charged what looks like an exorbitant amount). Of course, you had no idea on the night you visited and no control over whether or not any of your preferred restaurant service providers were on duty.

Sounds kind of silly, doesn’t it? I mean, who would go to a restaurant that charged like that? Who would go to a restaurant that blind-sided you with bills weeks after you dined there until your total bill at that restaurant ended up being about 10 times what you thought you would pay? Certainly not I, not you … not anyone, I would suspect.

So why should we put up with an arrangement like that with our health care costs? We need simplified, complete and total transparency into the costs of our care when we enter the hospital for a scheduled procedure, or even for emergency treatment. There should be no hidden costs that a patient gets hit with weeks or months after the fact.

How, then, do we get costs under control? I would propose the kind of plan that Dr. Ben Carson has championed — that we create Health Savings Accounts (HSAs) for people from the day that they are born to the day that they die, at which time they can pass any money in their HSA on. We can pay for these HSAs with the same traditional dollars that we currently pay for health care. Even if the government populates everyone’s Health Savings Account — all 315,000,000 of us in the US at $2,000 a year, that’s $630 billion dollars. That’s not a whole lot compared to what we’re spending now, and everybody would have health care and you could always add more to your plan on your own. What you add on your own should be pretax and never be taxed, thus allowing everyone to save taxes and save for their heath. Your employer could add to it, anybody could add onto it; but everybody would have basic care. And that’s what we’re trying to do. If we bring it into the free market, that makes it work much better. But we also need to incorporate tort reform, and digital, electronic medical records. I would embed those records in a microchip that the patient can keep, rather than have them floating in cyberspace. I think people’s medical records are much too important and much too private to be drifting in cyberspace. Those are some of the major components of the program, and I think that could be done for considerably less money than we’re spending now.

Also, to expand on a point above, we need to give people the ability to shift HSA funds within a family or to anyone of their choice. So if one member of a family or a friend or anyone needs a little more help with coverage during a challenging illness or injury, people can shift some of their funds to that individual. We’re essentially making each family their own insurance company. This can provide families with an enormous amount of flexibility; and when a person dies, they can pass their HSA funds along to a family member or members. It gives you enormous flexibility without a middleman.

Now, it doesn’t take care of catastrophic health care, but you can buy a catastrophic health care policy, and it’ll cost you a lot less because the vast majority of medical issues will be taken care of through your HSA. Because 80% of the medical encounters a patient has are going to be handled through HSAs, you won’t have a big burden on major medical or catastrophic insurance. So the costs of that will plummet, and it will be much easier to acquire. And I would make that something you could acquire from any place in the country or even any place in the world that met our US insurance standards.

By doing this, we’re putting the responsibility for health care in the hands of the patient and the health care provider. What do you need for good health care? You need a patient and you need a provider. Along came a middleman to facilitate the relationship and now the middleman is the primary entity with the patient and the health care provider at its beck and call. That doesn’t make any sense.

Having individual HSAs also can help incentivize people to become more immersive in their overall health care rather than just looking for ways to treat the symptoms of their illnesses. This helps get to the core of and individual’s health care, and that is to help that individual understand, manage and maintain proper health as best they can through proper nutrition and exercise and by “keeping your inner army strong.” Now, to preserve as much of that $2,000 a year HSA money provided by the government and the additional amount people choose to add (funded with pretax dollars so individuals have less taxes and become incentivized to shelter even more funds for health care), individuals may become more aware of the impact of their own health care decisions on their own bottom line. Maybe they’ll consume fewer cheeseburgers or milkshakes within a month and eat more fruits and vegetables; or perhaps smoke less or quit smoking altogether; or engage in a regular walking or workout routine. Who knows where it could lead?

Many people won’t save — after all HSAs aren’t a new concept and a vast number of people don’t have them, even though they’re currently available through some employers. But with baby boomers retiring and younger workers transitioning to self-employment as technology and artificial intelligence take over jobs people were previously performing, the focus should be on decreasing a person’s overall tax burden by being able to spend for health care with pre-tax dollars.

Recognize that in America we spend twice as much per capita on health care as many other countries. And yet we have these horrible access problems. So we have adequate resources, we just don’t use them in an efficient way.

“What I propose we should do to open access up to more individuals is to expand the emergency room model. If you think about it, there’s only really one place where, 24-7, 365 days of the year, you can be seen by a physician — and that’s in the ER. So we need to expand on that model. Let’s multiply what works.”

Improve Access to Health Care

Even if you have an HSA, even if you have catastrophic insurance, if you can’t get access to your doctor, that’s a problem. And right now, it can take weeks to see your primary care doctor for an appointment. Averages vary widely, depending on location, and hover around 14-24 days.

In our current system, even with the advent of Obamacare, it won’t get better; it will get worse. I’m worried, because if you look at it statistically, by 2030, which isn’t that far away, one out of two people — 50 percent of the US population — are going to be obese. One out of three of us, by 2030, are going to have diabetes. In addition to that, there are aging baby boomers, and we’re only at the beginning of that generation’s march to retirement age. That will be ongoing for another 20 years. So there’s a big stress on our system that will continue to grow over the next couple decades.

What I propose we should do to open access up to more individuals is to expand the emergency room model. If you think about it, there’s only really one place where, 24-7, 365 days of the year, you can be seen by a physician — and that’s in the ER. So we need to expand on that model. Let’s multiply what works.

What does the anatomy of that solution look like?

Emergency rooms have become dangerously overcrowded (see my write-up on ER issues: The Emerging State of Medical Care In Our Nation’s Emergency Rooms). It may sound counter-intuitive, but sending more people to the emergency room is my proposed solution. Instead of offering only emergency services, however, the ER would encompass mental health and primary care clinics and in essence create a “central care system,” allowing more people to be seen. Emergency rooms already provide 24-hour care to people who are in need of urgent medical attention, but also for those whose work schedules or other issues make it impossible to be seen during regular clinic hours. In the ER, the infrastructure already exists to see anyone with a common cold to mental health issues to heart attacks and strokes 24 hours a day, 7 days a week; obtain labs, X-rays and CT scans. Within an ER environment, people can get these done same-day; right now, it takes days to more likely weeks to get these scheduled through a Primary Care Physician (PCP). It’s logical to use what already works. It’s also logical to provide significantly more funding to these emergency departments to carry this extra burden. We don’t even need to spend more, we just need to redistribute already allocated health care funds, since currently emergency care represents less than 2 percent of the nation’s health care expenditure.

However, it is a dangerous fantasy to think that urgent care centers or mini-clinics can eliminate ER overcrowding. While urgent care facilities are staffed with competent medical providers and use the best technology for many injuries and illnesses, they lack the expertise and the amount of resources to handle true emergencies. The wrong patient visiting an urgent care center in order to save money or time could well wind up costing a life. Urgent care centers are very much needed and should continue to be available, but they are no substitute for emergency care. We need to increase funding these safety nets within our health care system. I think the problem with ERs, as I’ve mentioned previously, is that they must treat you even if you don’t have any insurance. So there has to be a mechanism by which when people walk in for treatment and they’re uninsured, the facility has to be compensated by the work they do for patients from somewhere — and this is where the government comes in. The government has to fund ERs to some degree.

With today’s 24-hour lifestyle, we can buy groceries, fly across the world, tweet a message to thousands of people, and even work out at the gym at any time, day or night. Medical care has to adapt to the fast-paced world in which we live. When a patient comes into the hospital central care system, he or she will initially present to a main check-in area where staff will determine how urgently the individual needs to be seen. A person experiencing a heart attack will be sent immediately to the emergency department, but a child with bronchitis will be directed to see another qualified practitioner quickly in the adjacent clinic or urgent care. By the same token, patients presenting with problems that do not need urgent treatment will be asked to schedule an appointment with a doctor at a local clinic within a couple of days.

With the central care system, there will be physician assistants and nurse practitioners who are available to treat less urgent issues and thereby reduce waiting times. In this way more people can be seen appropriately, without sacrificing quality or timeliness of care. Think of a place like this as a hub. Patients come into a central location initially to be triaged. For a patient who is having or has had a heart attack — off he goes through the big double doors for immediate care; for someone with a broken leg — off he goes through door No. 7 to the orthopedist for a complete workup; for an elderly woman who is feverish, coughing uncontrollably and has had a history of pneumonia recently — off she goes through door No. 3 for treatment.

Of course patients needing to see providers for less critical situations will still spend some time in the central care waiting room, just as they currently do in doctors’ offices and urgent care clinics. Using that time to educate people will improve understanding about disease prevention, healthy living, vaccinations, home treatments for common illnesses like flu and colds, and other issues related to health – call it “wait to educate”. Introducing basic health education while people wait to see providers in the central care system may help them to avoid or more effectively manage chronic diseases and other common health issues. If we use the wait to educate concept, the information can be spread by word of mouth and it has the potential to benefit the entire community. In addition, there can be a virtual arm to this waiting room using a platform like liveClinic (described below).

Get Third Parties Under Control

The center of the epicenter of health care is the doctor-patient relationship. Any other forces or third-party entities that come in should not be inserted between the doctor and the patient, but should be aligned behind the patient, supporting the patient, and/or behind the doctor, supporting the doctor.

Now, the first two ideas I’ve outlined above are certainly workable, but unless you manage the special interest groups and protect the doctor-patient relationship — the insurers, the lawyers, the lobbyists to name a few — it will chip away at that doctor-patient relationship, which is the core. Third parties pull down the relationship, making it more difficult for the doctor and more difficult for the patient.

With respect to health care, a third-party is typically known as the insurance company that pays the provider on behalf of the insured. In our current system, the consumer pays a co-pay — only a small portion of the actual cost. At first glance, you may be just fine with that arrangement. You probably don’t know and will never know the full retail value of the procedure and what negotiations the health care companies have done behind the scenes. So you don’t really get a true sense of what something costs.

Let’s look at this from the perspective of a health insurer — and we’re not bashing health insurance here, health insurance is a good thing. Insurers have saved countless families from going bankrupt due to health care costs (which is the number one reason for bankruptcy in America). Insurance is NOT about saving money — it’s about protecting people financially and protecting people’s assets when they have a catastrophic loss. People pool their money together by paying premiums every year so that when they have a big loss they don’t get hit so hard financially. Originally insurance was supposed to be for big catastrophic losses but insurance companies adapted and started paying out for smaller claims.

Another thing I’m worried about regarding rising costs of health care is that it’s having a chilling effect on people even trying to see a doctor. I’ll reference a publication put together by the American College of Emergency Physicians (ACEP — of which I’m a member) that shows that patients are delaying their health care. They’re holding off even seeing a doctor because they don’t know how much things are going to cost and they have a high deductible; they’re afraid they’ll get hit with unexpected bills that they won’t be able to afford. (Remember that first section above regarding the restaurant scenario?) And the insurance companies, what they’re trying to enact in the way of cost cutting is really, if you look at the numbers, profit boosting. On the one hand, the ACA contains provisions to protect consumers from being gouged by insurance companies at the worst and from unfair premium increases at the least. The ACA contains two checks — a “Rate Review Provision” that requires insurance companies to justify rate hikes of more than 10% — as well as an 80/20 rule, which defines how insurance companies can use the monies from premiums collected. Insurance companies offering ACA plans are mandated to spend at least 80% of premiums they receive on individual health care and “quality improvement activities” and not on overhead, administrative and marketing costs. If they don’t hit that mark, then they have to return money to the insured in the form of a rebate. This was written into the ACA regulations to ensure that health insurance companies couldn’t raise premiums to boost profits. On the other hand, the largest companies had the funds to merge. They increased their profits by offering less. (After all, you either maintain your profit margin by increasing revenue or cutting costs – sometimes both.) They’re narrowing their network plans, for example, and all of a sudden your doctor is not covered in the network plan, you don’t have enough primary care physicians in your plan, there isn’t a specialist for you out there. You get a head bleed, and a neurosurgeon is not covered. That means more money coming out of an insured individual’s pocket. That’s a problem.

That’s why I started liveClinic ( Our vision is to “take care of the rest” so doctors can focus on taking care of patients. The platform allows patients to communicate safely and conveniently with a doctor of their choosing. Regulatory codes and quality guidelines often hinder the free flow of information between patients and their doctors. At liveClinic, we aim to break down these barriers without breaking the rules. Designed with doctors in mind and patients at heart, this powerful and intelligent web platform and the corresponding interactive mobile applications saves the physician time and money by giving doctors the freedom to handle routine visits quickly and remotely, via voice or video chat. Having more options not only increases productivity, but encourages self-management among patients and extends clinical reach. This very same technology provides patients with more options for communicating with their doctor, and reduces the amount of time spent in the waiting room, away from work and school.

liveClinic incentivizes doctors by decreasing their time on tedious administrative burdens so they can focus on patients. And I think you have to incentivize the doctor. People always focus on the patient, and that’s OK, but if you incentivize the doctors you get happy doctors. Most doctors go into medicine to help their patients; so they will do that. But right now, under the status quo system, doctors are burning out. It’s not good.

According to a report in US News and World Report from earlier this year:

“Awareness is growing around the stress that doctors-in-training and those practicing medicine experience. The statistics are alarming to some degree. Approximately one-third of physicians report experiencing burnout at any given point. As a matter of fact, doctors are 15 times more likely to burn out than professionals in any other line of work, and 45 percent of primary care physicians report that they would quit if they could afford to do so. Physicians have a 10 to 20 percent higher divorce rate than the general population and, sadly, there are 300 to 400 physician suicide deaths each year.”

Doctors are getting jaded because of all the paperwork, the decreasing reimbursements, constantly growing administrative burdens, and the fact that we can order a pizza, a hotel room, an Uber ride immediately on a smart phone, but our patients can’t even get access to us, so they seek care elsewhere (see my previous write up on the state of emergency rooms). Fantasy football websites have better user interface and functionality than do most electronic health care record databases. (The average ER doctor clicks on a mouse 4,000 times in a 10-hour shift according to a recent study – while still trying to see patients!)

Everything’s getting disjointed; people are going to ERs and urgent care clinics instead, and then their primary doc has no idea what’s going on. So change has to focus on the center of the epicenter — the doctor-patient relationship. That’s what the liveClinic platform does.

There are ways, given the current state of health care in America, that we can make positive, even transformational changes if we allow our thinking to evolve and focus on a different way of setting expectations on the patient side, the doctor side, and the third-party side — all three phases. We must change, we can change, and change will be good for the entire health care industry and our overall economy. As a nation we can excel and lead the world in health care just as we do in other areas. After all, our health is our MOST valuable possession; without it we cannot lead our lives or the world.

To learn more about Dr. Sudip Bose, MD, please go to and visit his nonprofit where 100% of donations go directly to injured veterans.