First Opinion is STAT’s platform for interesting, illuminating, and provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others.
To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.
The story
“I’m a medical student. RFK Jr. is right about medical school and preventive care,” by Lauren Rice
The response
I don’t think anyone is arguing nutrition and preventive care isn’t important, and for medical students who want to learn more, the resources are out there, but is “lack of education” really what we think the problem is in prevention care? If we approach health and well-being with the idea that disorder within the individual is solely the result of processes internal to the individual (a virus replicates within a cell, triggering immune response; a person doesn’t eat enough fiber, causing weight and blood sugar issues), then failure to progress in a specified manner rests with that individual, and better education is the solution.
But health and well-being aren’t siloed. The original article provides a nod toward that, with mentions of metabolic dysfunction, chronic inflammation, and an obesogenic environment, but comes to the conclusion that discussing more behavioral changes with patients will solve those problems. But patients cannot diet and exercise their way out of poverty; they cannot diet and exercise their way out of high cortisol associated with long work weeks, financial strain, and weathering; and they certainly cannot diet and exercise their way out of an increasingly car-centric society and a food supply riddled with chemicals and sugars.
Beyond “root sources” of illness, America has a fundamental problem with accessibility. Roughly half of U.S. adults say it is difficult to afford health care and one-third avoid health care because of the cost, putting off care long enough to trigger those organ-specific consequences that require specialists.
And what of patients who risk facing racism, sexism, and queerphobia in health care settings? What of patients whose first language is not English and who tend to receive less and worse health care? If patients are not even making appointments, how can we provide them with preventive care?
All the nutrition education in the world will not solve the problem of the fact that Americans can’t access care in the first place. It is impossible to separate health and illness from the economic and political realities that patients face. If we genuinely want to improve chronic illness rates in this country, then we need to address the social determinants of health that are preventing so many people from being healthy and accessing care. By all means, increase nutritional education in medical school, but let’s not pretend that telling a patient to eat more vegetables and exercise tri-weekly will overcome the material conditions making people sick.
— Ellie Passmore
The response
I wanted to offer a brief rebuttal for the author to consider, given they raised many meaningful points from their personal medical school experience, which many can appreciate, while also acknowledging the strong responses in either direction. There is a difference in legitimizing a person’s agenda versus finding common ground. To say that Secretary Kennedy is “right” about medical school and preventive care, when he has not attended medical school, engaged with medical school leaders regarding recommendations, or shown any willingness to engage in evidence-based preventive care such as vaccination, is an argument that is not grounded in reasonable supportive evidence. The pain points are well-taken. Many can agree, based on their medical school experience, that allopathic education regarding nutrition and preventive care (I can only speak from this experience) is limited, and in many schools, these curricula may not exist.
But the author and Kennedy are simply re-stating a fact, not outlining a reckoning of the medical school system. While no one is discounting this, it does not make Kennedy “right” about medical education needs, already overburdened by curricular demands. It does create an invitation to explore solutions in a nuanced, comprehensive way. What is the “right” answer to a question rooted both in societal norms and standardized medical education practice? There may be no single right answer.
I would encourage the writer to consider that neither learning nor collaboration regarding complex, nuanced challenges with our patients stops at medical school graduation. Perhaps we can embrace our humility in not knowing everything and rely on our other colleagues who also round on our patients. Perhaps an answer could be to invite nutrition and preventive care experts to the rooms where these important conversations occur to provide their expertise. Perhaps that means we advocate for our registered dietitians to receive fair and reasonable insurance reimbursement for outpatient preventive care measures — their services are necessary for care, not ancillary. The doctor does not have to be or do everything, when there is an entire community of medical professionals with whom we can connect, liaise, and build partnerships to address problems in tandem. That is as much a culture shift as it is a policy or educational adjustment.
— Marc Hem Lee
The story
“Exposed and invisible in an ER hallway bed,” by Jay Baruch
The response
This problem engulfs ERs across the country, yet we still keep reducing and eliminating funding, increasing the demand on the staff to do more with less and eliminating support resources. This recipe for catastrophic disaster is going to come to a head. If we had a member of congress needing emergency care, we should require them to wait in the same lines, be left in the same hallways, and let them feel the delay of care that they so adamantly seem to be ignoring.
— Katie McNamara, Rhode Island Hospital
The response
Jay Baruch’s article “Exposed and invisible in an ER hallway bed” remarkably highlights the challenging realities of working in the emergency department and the real harms to patient and physician morale that hallway care imposes.
However, not all patients are at equal risk of physical harm from this type of care — health systems need to protect those most vulnerable patients. As an emergency physician in a busy New York City hospital, I admitted an 84-year-old man with pneumonia yesterday who was in the hallway. I returned today to find him still there, but newly confused and with his oxygen cannula tangled around his face askew. Yesterday, this patient was aware of his surroundings. Today, he did not know where he was due to delirium: an acute confusion that occurs frequently in older adults and is precipitated by acute illness. Being in an unfamiliar place, getting poor sleep, and constant stimuli from lights and noise all contribute to delirium. The emergency department is one of the worst places for adults prone to this, especially if they are in a hallway. The longer an older adult boards in the ED, the more likely they are to become delirious and agitated. In fact, spending an overnight in the ED rather than the wards may increase the risk of death. Our research shows that older adults with dementia may be at especially high risk of delirium and agitation in ED hallways. Additionally, chilling patient quotes describe the experience as feeling like a “prisoner” or “homeless.” Health systems need to find ways to protect such patients who are at highest risk of harm, whether through improved physical infrastructure, staffing models, or prioritization for those at risk to move to upstairs rooms — unless, of course, they fix the entire inhumane practice of boarding.
— Sarah Perelman, M.D., and Shan Liu, M.D.
The story
“Congress must fix the No Surprises Act before it bankrupts patients and employers,” by James Gelfand and Patricia Kelmar
The response
The op-ed on the No Surprises Act (NSA) misdiagnoses the problem. As head of human resources for TeamHealth, I share Gelfand’s responsibility to keep health care affordable for employees. But I also see how insurers are profiting from this well-intentioned law.
The NSA rightfully protects patients from surprise bills. I’m proud to work at a company with a longstanding policy against sending surprise bills.
The NSA sets out a clear process for insurers and clinicians to resolve payment disputes through an independent dispute resolution process.
Most clinicians want to be in-network with insurers — it’s better for patients and provides stable, predictable reimbursement for care. But insurers leverage the protections of the NSA to make offers that are financially unfeasible. Many offers are lower than clinicians’ contracted rates in 2019. How many people would agree to take a pay cut from their 2019 salary?
Insurers also generate billions in profit from shared savings schemes as long as clinicians remain out-of-network. Insurers know the NSA protects their members from out-of-network bills, decreasing their incentive to negotiate in-network contracts. This leaves the IDR process as the only mechanism for clinicians to seek fair reimbursement.
Clinicians aren’t abusing the IDR system. Data self-reported by insurers show that only 6.6% of eligible claims are even submitted to the IDR process. Moreover, clinicians are winning more than 70% of IDR disputes because independent arbiters recognize that insurers are underpaying. Data from Americans for Fair Health Care backs this up. In more than 60% of IDR disputes, insurer-reported benchmark payments — called qualifying payment amounts — are below the median contracted amount.
As the sponsor of TeamHealth’s employee health plan, I also see the IDR process from the employer side. The NSA was designed to incentivize the losing party to seek an in-network contract by requiring them to pay a substantial share of arbitration costs. That has not happened. Insurers have no “skin in the game,” passing these costs directly to employer-sponsored plans, ultimately resulting in higher premiums for employees.
Meanwhile, insurers continue to benefit financially from the law. The seven largest health insurers reported $71.3 billion in profits in 2024 while patients face greater difficulty accessing care. More than one-third of rural hospitals are at risk of closing.
If insurers can leverage NSA protections for profiteering, the NSA will fail to facilitate in-network contracts as Congress intended. IDR claims will only continue to rise.
— Eric Norman, chief human resources officer, TeamHealth
The story
“The AI push in health care is deepening medicine’s trust crisis,” by Oni Blackstock
The response
Dr. Blackstock’s piece on AI and medicine’s trust crisis is important and largely correct. Institutional adoption of AI has exceeded the speed in which we can add necessary guardrails to AI implementation in order to protect patient privacy, ensure equitable access, and build trust with our patients.
But the essay leaves a critical use case unexamined: AI in the hands of patients themselves. Last October, my mother developed acute-onset renal failure after restarting rifampin. She was healthy and had no prior kidney disease. Within a matter of days, she was in the ICU on dialysis. As a practicing physician, I was able to translate lab values, urine output trajectories, and care plans from the medicine and critical care teams into terms she could understand. But I also watched my mother nod at explanations she did not fully understand either because she did not want to seem uncooperative or because she lacked the medical vocabulary to ask the follow-up question that was forming in her mind. That is not a failure of any clinician, but rather it is a structural problem of knowledge asymmetry between clinical expertise and patient understanding.
During her hospitalization, I became her health advocate, and I was able to because of my training. Most families cannot. The communication gap between physicians and patients is not only a minor inconvenience, it is a outcomes issue. For patients with limited health literacy, estimated to be up to 36% of U.S. adults, the gap is compounding. These patients are less likely to ask clarifying questions, more likely to misinterpret discharge instructions, and more likely to present later and sicker.
The use of AI by patients themselves — not deployed by insurers and health systems — offers a genuinely underexplored solution to bridging this gap and empowering patients with their own health. Teaching patients how to build a symptom timeline, generate targeted questions for their physicians, and identify red flags before an appointment will not replace our jobs as physicians, but augment our ability to care for our patients.
Dr. Blackstock is absolutely right that health care must move at the speed of trust. We can build that trust by empowering patients to actively participate in their own care, not feel subjected to physician’s prescriptions and plans. With more oversight, we can give patients more autonomy in their care.
— Nicolas Leighton, M.D.
The story
“How the insurance system quietly undoes recovery from addiction,” by John Fomeche
The response
The part of this that really stayed with me was it wasn’t about trauma or cravings — it was when the doctor said his patient’s voice changed when she talked about her insurance going up. I grew up watching my friends be treated like they didn’t matter once addiction entered the picture. Like they lost their humanity. I remember being a teenager when OxyContin started being passed around at the parties. I lost my best friends to this disease and I’ve been to more funerals than I should have before I even hit my 30s.
But I’ve also seen what recovery looks like when people are treated with dignity and given the right support — and how quickly that stability can be shaken by something like an insurance change. This isn’t a small policy issue. It’s the difference between stability and relapse for real people. For my friends fighting every day to stay sober. I wanted to say thank you for bringing attention to something that too many people don’t understand until it’s too late.
— Angela Dion
The story
“There is a successor to 340B lurking on the horizon,” by Sujith Ramachandran
The response
The government’s 340B drug purchasing program is simple: Buy low, get paid high. The largest users of 340B — starting with mega-consolidated hospital systems — purchase drugs at large discounts, often 50% or greater. Then, they are reimbursed well above the discounted cost. Studies have documented that the discounts are often not passed on to patients in need but are pocketed by the hospital. It is, in effect, government-sanctioned arbitrage.
Some mistakenly believe that the Inflation Reduction Act provides the same arbitrage opportunity for private practice physicians. I have heard this from some health staffers on Capitol Hill and recently read the STAT First Opinion article drawing parallels between the IRA drug price negotiation and 340B. It’s not just wrong — the IRA price negotiation is a “reverse-340B.” 340B and the IRA drug price negotiation operate in diametrically opposite ways. With the IRA, Medicare creates a “maximum fair price” (MFP) that will discount Part B drugs. Physician practices, such as community oncology practices, will be reimbursed at the lower MFP but must acquire the drug at higher market rates.
Consider a simple example: A $2,000 cancer drug negotiated down to an MFP of $1,400. The drug costs the practice $2,000, yet is reimbursed off of the lower MFP price. The drug is immediately underwater — reimbursed below cost. 340B flips this math on its head. The $2,000 drug costs the hospital $1,000 after discounts but then gets reimbursed by Medicare off of the $1,400 market price. Although hospitals will also be exposed to lower MFP negotiated pricing, they can absorb the impact because all their Part B drugs are discounted by 340B, not just those subject to IRA negotiations. And in the commercial market, large 340B hospitals can mark up cancer drugs an average of close to five times.
The result of the reverse-340B will be cancer care migrating to the more expensive hospital setting. 340B will continue to grow — now close to $150 billion in market dollars — costing patients and the government more. The IRA reverse-340B is a threat to physicians — not the boon that 340B is to hospitals. Conflating the IRA with 340B is wrong — 340B provides hospitals with enormous drug margins, while the IRA does the reverse for independent physicians. It is a dire threat and an accelerant to the consolidation in health care that is bankrupting Americans.
— Ted Okon, Community Oncology Alliance
