31 January 2020

Dear Interested Readers:

 

Between The Way Things Were And What They Might Become

 

As I write this edition of “Healthcare Musings,” the Senate trial of President Trump stumbles toward its conclusion. It is difficult for me to accept that Lamar Alexander and other Republican Senators do not want to hear from reliable witnesses who have something to add. The opinion of every analyst seems to be that with or without further testimony the president will not be removed from office. I am not going to discuss the issue further than to say it is a political process, and the party that controls the Senate will control the process, and rationalize a way to argue that they did the right thing. Even if the House Managers succeed in getting new evidence before the Senate for testimony by John Bolton and others or through documents, the biggest protection that the president has is that removal requires a supermajority of 67 votes. The real test of the issues will occur in November, which means that we are back to discussing the importance of the election to the future direction of healthcare.

 

Perhaps when the impeachment and Senate trial process are behind us we will be able to focus more effectively on some of the foundational issues that limit access to care and make care so expensive in ways we often ignore when we just focus on the high price of pharmaceuticals and unexpected out of pocket expenses for those who have coverage without disturbing the world of those who are satisfied with their employer based coverage. Over the course of my adult life the structure and function of our care delivery system has changed dramatically. There is no question that there has never been a time when healthcare could use a more impressive array of technology to treat diseases that will no longer be debilitating or as deadly as they were even a decade in the past. But is is also true that there has never been a time when healthcare professionals were more distressed, and when patients felt more forgotten, unheard, or challenged by barriers to the care they want.

 

The cost of healthcare is not the only growing concern. The sacrifices that are being made by professionals everyday everywhere because of pressures to be more “productive” has led to “empathy fatigue” and burnout among a growing number of professionals. A great tragedy is that despite the high monetary cost of care, there is a high emotional and personal cost of care.  The price in emotional stability and professional satisfaction that is being paid by dedicated professionals, and the emotional expense to patients and families are growing complaints. It is so ironic that when we can do so much, we are so inept in how we do it that there are still very high levels of dissatisfaction and unmet needs among patients. I sometimes think that the only individuals who are really satisfied with what they have are the ones who have never needed to use the system. Most of us are paying more while getting less than satisfactory service from people who feel overwhelmed. It is an unstable situation. Can those challenges ever lead to a positive transformation of our system of care?

 

There has been much analysis of what the primary or root causes of our dissatisfaction with healthcare might be. I have been distressed by the fact that the political discussions have assumed that our healthcare problems can be solved by giving everyone access to care and simultaneously doing something that might reduce the cost of pharmaceuticals. Access problems and costs are real, but we must go further upstream to understand where we are, how we got here, and what much change to bring about noble goals like the Triple Aim, or the Quadruple Aim which considers the well being of the providers of care

 

I would agree that the cost of drugs is out of control and that some drug companies are scoring profits that are far beyond their cost of developing new drugs that we need, but I am yet to hear a proposal that considers the aspect of the problem of drug expense that arises from the overuse and misuse of some of our more expensive drugs. I rarely hear anyone point out that there are expensive drugs that we are not using that ultimately lower the cost of care. Dr. Zeev Neuwirth recently interviewed Former Secretary of Veterans Affairs David Shulkin. They discussed the fact that Dr. Shulkin made the decision that despite the high cost of the drugs the VA should identify all of the veterans with hepatitis c and treat them. Over 100,000 veterans were identified and treated. Almost 100,000 are now cured of their hep c infection. The drugs cost a billion dollars, but I would imagine that the money saved in hospitalizations, liver transplants, and efforts to treat the complications of neglected hep c saved many billions. More importantly, many years of life were saved, and much human misery was prevented for veterans and their families. Dr. Shulkin and Zeev discuss the fact that such a decision could be made only in a system that paid for value. It was also a great example of a population approach to financing care delivery that enabled the use of team based care. 

 

I have quoted Dr. Robert Ebert many times over the years, but I feel strongly that his ideas should always be considered in any discussion of the search for the way forward in healthcare. In case you have somehow missed it, in 1965, Dr. Ebert, then Dean of Harvard Medical School who was in the process of founding Harvard Community Health Plan, said:

 

“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”

 

Over the intervening 55 years I have come to believe that we should consider this statement as gospel. Let me unpack it for you. I see at least four points:

 

• Resources alone are not enough. 

 

• How the resources are organized and deployed is important to effectiveness, safety, and quality.  The operating system or organization of care is critical to the efficiency and effectiveness of care delivery.

 

• The finance system is a key determinant of the operating system.

 

• We should be focused on populations if we want to optimize the health of the nation. 

 

Dr. Ebert’s statement was a hypothesis. He understood scientific method. An hypothesis calls for an experiment. Harvard Community Health Plan, a prepaid system of care was his experiment. HCHP organized personnel, facilities and financing into a conceptual framework and operating system that was an attempt to provide optimally for the health needs of the population by emphasizing preventative care and developing innovations in care delivery to facilitate the right care at the right time by the right professional. HCHP piloted the use of computerized records to facilitate data analysis of outcomes. It innovated with efforts to promote team based care. It espoused community rating of risk. It fought the tendency for overuse seen in fee for service systems by putting its professionals on salaries with bonuses for value and at risk for the efficiency of the system. 

 

Sustaining such an effort in a hostile world is hard. Eventually, outside forces prevailed, and to survive in a world driven by marketing and exclusive contracts, a second generation of managers felt the need to conform more and more to demands for contracts and patterns of practice that were similar to conventual insurers. I remember a second generation Chief Medical Officer who confided in me that he did not believe in prepaid practice or our ability to change practice in a way that others would emulate. I was shocked. In retrospect, he was burned out and did not know it. the work of change is hard. The status quo pushes back with all of its momentum and the combined efforts of its self interested components.

 

As long as the initial principles of HCHP were practiced, I never experienced anything that was suggestive of burnout. I always felt that I had the time to do the job that I wanted to do for my patients. Even after some of the original components of the recipe were forgotten there was a residual culture of quality, concern for waste elimination, clinical efficiency, quality, safety, and patient centrality that had been fostered by the original principles that enabled the practice to deliver measurably better results at a lower cost than other practices in Eastern Massachusetts and at a level of the best practices in the country.  

 

In the late seventies, a young psychiatrist who had done an internship in medicine at the Beth Israel Hospital in Boston published a raucously funny novel about medical training in a major academic medical center. The House of God was written under the pseudonym, Dr. Samuel Shem. Several of my colleagues at HCHP had trained at the BI with “Dr. Shem” and the discerning reader could recognize them since personal characteristics tend to persist. A discerning reader could also recognize that The House of God was really an angry protest against the inhumanity of medical training that was wrapped in humor. At a party sometime in the early eighties, I was talking with one of the attendees whom I had never met before, a psychiatrist named Stephen Bergman, it took a few minutes to recognize that I was talking with “Dr. Shem.” It was the only interaction that I ever had with this gifted and insightful physician writer, but I remember the conversation as both funny and enlightening. In the intervening forty plus years “Dr. Shem” has written several other novels, plays, and essays. Perhaps you have read The House of God. In the preface to a later edition of The House of God, John Updike compared it to Joseph Heller’s Catch 22. I highly recommend an opinion piece that Dr. Shem recently wrote in Newsweek, “Why Computerized Medical Records Are Bad for Both You and Your Doctor.”

 

Dr. Neuwirth decided to interview “Dr. Shem” because he has recently published a new novel, Man’s Fourth Best Hospital. As Mara Gordon writes in a review for NPR:

 

In The House of God, set several decades before I set foot in a hospital, where were the smartphones? Where was the talk of RVUs — relative value units, a tool used by Medicare to pay for different medical services — or the push to squeeze more patients into each day?

That’s where Shem’s new book comes in. Man’s 4th Best Hospital is the fictional sequel to The House of God, and Basch and the gang are back together to fight against corporate medicine. This time the novel is set in a present-day academic medical center, and almost every doctor-patient interaction has been corrupted by greed and distracting technology.

 

Dr. Neuwirth interview with Dr. Shem allows the author to expose his concerns and motivations behind his story.  If you have thirty five minutes I would recommend the interview because what they discuss is more important to the Triple Aim and to the principles of care that motivated Dr. Ebert than you find now in our political discussions of healthcare. Shem’s objective in writing the new novel is to focus on the similarity of the abuse and damage that corporate medicine and the current finance systems in healthcare have inflicted on healthcare professionals and patients alike. It is anger softened by humor. It focuses on the fact that both professionals and patients have been robbed of the ability to have meaningful encounters. Shem contends that the opportunity for empathy has been stolen. Golden’s article includes an interview with Shem where you can read his answers to her questions that cover much of the same material he discussed in the interview with Dr. Neuwirth. 

 

Shem is now 75. He was not practicing five years ago when he got a call from NYU. They asked him if he would like to teach. He took them up on the opportunity to transmit his image of what healthcare could be to NYU students. The last five years have been a reintroduction for him to the power of our scientific advances in medicine. He celebrates what we can do at our best for patients. That is not the problem. The problem is the associated price that patients and providers pay as we attempt to live in a system driven by money. In the interview with Golden he says:

 

On the one hand, it’s absolutely amazing what medicine can do now. I remember I had a patient in The House of God [in the 1970s] with multiple myeloma. And that was a death sentence. We came in; we did the biopsy. He was dead. He was going to be dead. And that was that. Now it’s curable.

At Bellevue, I saw the magnificence of modern medicine. But like someone from Mars coming in and looking at this fresh, I immediately grasped the issues of money and effects of screens — computers’ and smartphones’.

And it just blew me away. It blew me away: the grandeur of medicine now and the horrific things that are happening to people who are really, sincerely, with love, trying to practice it. They are crunched, by being at the mercy of the financially focused system and technology.

 

Our “screens” do get attention from both Dr. Shulkin and Dr. Shem. Both point to their sense that the EMR has been co opted as a tool of finance. In a system that is driven by money that is derived primarily by what we do rather than the effectiveness of our care we must document every item delivered and act performed. We must generate a story that justifies the complexity of the problem for which we are asking to be paid. RVUs need to be quantitated. Time is money. Time is also required for a meaningful human interaction.

 

Shulkin and Shem seem to imply that the problem with the EMR is that it replaces the patient as the object of the clinician’s time and focus. Patients recognize their secondary position in the tension between giving time to them or the medical record. The EMR diminishes the satisfaction of most patients and clinicians since there is inadequate time allotted for the combination of a satisfying encounter and the time it takes to adequately feed the computer what it demands.  

 

The computer is demanding your attention while you are hearing the patient’s concerns, asking appropriate questions that might reveal more clinically useful information, reviewing the pertinent information that is in the record, doing any appropriate exam, discovering the patient’s preferences, synthesizing the information discovered into plans for a diagnostic work up and an appropriate plan of care, providing the patient with a useful explanation of your analysis, explaining the treatment plan and potential outcomes to the patient, listening to the patient’s concerns about the workup and proposed treatment, and a host of other interactions that should occur while providing appropriate empathy or sympathy. That is a lot to do in the fifteen minutes that is often all the time that is allotted for the encounter and the documentation required for payment. Which presidential candidate is addressing those issues?

 

Both Shem and Shulkin are hopeful. Shulkin thinks that there are lessons that we can learn from the VA. Shem thinks things will get better because they are too bad to persist as his answer to Gordon’s question about the current election reveals: She asks: 

 

Health care is a big issue for the upcoming election. What kind of changes are you hoping we’ll see?

 

He answers her in a way that suggests both realism and positive expectations:

 

There will be some kind of national health care system within five years. … You know, America thinks it has to invent things all over again all the time. Look at Australia. Look at France. Look at Canada. They have national systems, and they also have private insurance. Don’t get rid of insurance.

The two biggest subjects for the election are health care and health care. … The bad news is, it’s really hard to get done. The good news is, I think it’s inevitable. The good news is, it’s so bad it can’t go on.

 

I agree, mostly. I’ve frequently said if something can’t go on forever, it won’t. My opinion differs only in that I hope that we will move in the right direction. After 2016, I know that collectively we can make some bad decisions. I hope that we will resume our efforts to move to something better in less than the five years he anticipates. We have been desperately holding on to the gains made between 2009 and 2016 for the past three years, and we have another year of jeopardy to go. I do not want to think about what might be left after four more years of abuse. 

 

We are stuck in the moment somewhere between the way things were and what they might become. They can get better. But first,  we must make the effort to keep them from getting worse. 

 

Soaking Up The Local History 

 

The header in today’s post shows two of the older buildings in my town. In the distance, at the far end of the town green you can catch a glimpse of the New London Inn which has been in business since 1792. The building in the center houses the town offices. It’s where I cast my absentee ballot earlier this week. It was the original building of Colby Academy founded in 1837 which evolved into Colby-Sawyer College. 

 

 As New England towns go, my little town is not that old. It was founded in 1779. There are many houses that date from the 1790s. My church, which sits between the town green and Colby-Sawyer College was built in 1826. It is a magnificent white clapboard structure with a tall steeple that holds a Paul Revere bell that rings out the hours. 

 

While I walk around town, I try to imagine what things were like fifty years ago, a hundred years ago, and two hundred years ago. The views are surely the same as are many of the buildings. What I wonder most about is how our sense of community might have evolved over the years. I asked that question of one on my contemporaries who has a great memory of things going back to the early fifties. I am sorry to say that he thinks that we are now less connected. He reinforced his story by telling me about the town drunk. It seems that when he was a teenager and employed by one of our local merchants, one of his duties was to go by the town cemetery on “Old Main” (the town moved its center early in its history, but the graveyard did not move) and check out the mausoleum where the town drunk usually slept. His boss just wanted to be sure that Oscar was OK. During the day, Oscar was often up and down Main Street helping out anyone who needed an extra hand. I am trying to collect as many stories as I can. 

 

We have a museum in town that has many wonderful old cars that were collected by the man who owned the Ford dealership, when we had one. My favorite exhibit in the museum is the framed longjohns of Ausbon Sargent. The undies are well worn and have some patches. Ausbon was the old bachelor farmer who was the maintenance man at Colby-Sargent. He never spent much money on himself. He just bought land. Lots of land. When he died all the land went into a trust. Since his death other land has been added. Now our town is surrounded by land in conversation, and the region has close to 12,000 acres of land that will remain undeveloped forever. 

 

Many of my hikes and walks are on land in the trust. I find stone walls in thick woods that suggest that there is a story to learn. I hope that this weekend you might get out and explore the history of your neighborhood. 

 

Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

 

Gene