That we have lost 500,000 souls to COVID-19 is hard to process. It really doesn’t help much to hear 500,000 dead Americans from the COVID pandemic is more lives lost than in our summed casualties of World War II, the Korean Conflict, and the War in Vietnam. I was planning to let the moment pass without comment until I listened yesterday evening to President Biden’s acknowledgment speech and then witnessed the moments of reflection on the South Portico of the White House that he shared with his wife and Vice president Harris and her husband. The steps to the balcony that overlooks the south lawn of the White House, the same steps that President Trump ascended last October on his return from his own COVID treatment at Walter Reade, were covered with 500 candles as you can see in today’s header.Â
What is also hard to do is to let go of is the anger associated with the failures of the Trump administration’s management of the pandemic through 2020 and up until Biden’s inauguration on January 20. It is true that during that time vaccines were developed, but it is also true that lives were lost because of denial and mismanagement. We aren’t the largest nation on the planet but we are the richest, and we have the greatest capacity to respond to a threat with science. When the challenge came we retreated into a state of incompetence. People of color had a disproportionate percentage of deaths because they had the worst care, the greatest burden of healthcare disparities, the poorest access to care, and the greatest exposures from their roles as “essential workers.”Â
One of the major points of Heather McGhee’s new book, The Sum of Us: What Racism Costs Everone And How We Can Prosper Together is that our structural racism hurts the majority white population more than it realizes. People of color may die at higher percentages but more than half the deaths have been in the more privileged white population. Denying healthcare, adequate housing, adequate education, and equal opportunity to people of color has huge blowback consequences for the privileged white population. The link above associated with The Sum of Us is to Michelle Goldberg’s column in The New York Times where she wrote:
So McGhee is trying to shift the focus from how racism benefits white people to how it costs them. Why is student debt so crushing in a country that once had excellent universities that were cheap or even free? Why is American health care such a disaster? Why is our democracy being strangled by minority rule? Why is our democracy being strangled by minority rule? As the first line of McGhee’s book asks, “Why can’t we [all] have nice things?” Racism is a huge part of the answer.
Perhaps that is too simple for you to accept. But, it is hard to deny that over the last year we have been caught in a conflict between taking care of people or protecting the economy when our best economists were telling us that taking care of all our people was the best way to protect our economy.
Our last president cared a lot about the economy, a lot about himself, and not so much about all of the people and some of the things that in retrospect should have been managed with more focus and consistency. There was a piece on NPR yesterday that tried to put the failures of last year in perspective. Learning lessons from our failures is hard. The people in Texas learned that again this last week. They were challenged by freaky cold and snow ten years ago and their electrical grid failed then also. They resolved to fix it, but then they did not.Â
What would be even worse than losing what will probably eventually be more than 600,000 Americans to the pandemic would be to not recognize how we failed ourselves. We must resolve to honor those who were lost by committing to changes that will ensure that their loss will convince us to make changes that will ensure that it won’t happen again. Without deep and difficult changes in the structure of healthcare and resolution of our many social inequities and crimes against the planet, it will happen again.
Capitalism can do many wonderful things, but it always has its eye on the short-term bottom line. It will take a long view, a refusal to deny the reality of what has happened, and a willingness to forego easy profits to recognize the wisdom of deep structural changes and investments in redundancies that are protective in times of stress. Those insights and investments require collective actions that are not driven by a profit motive for wealthy individuals and corporations. Those insights can only come from an appreciation for science, human compassion, and the intelligent and unbiased consideration of risks that are incompatible with the desire to make sure that the best interests of a controlling wealthy minority are the nation’s highest priority. Ronald Reagan’s greatest lies were that good things trickle down if we cut taxes and focus on profits and that the best government was the least government. Many times, as with the nation and the pandemic and with Texas and the winter blast is that what trickles down when the government is limited and taxes are controlled to the advantage of a few are greater losses for everyone.Â
Commonwealth Fund Task Force Report, Imperative 5: Reduce Administrative Burden
My intent for this post before I was overcome by President Biden’s speech was to continue the process of reviewing the “six policy imperatives” from the task force on Health Care Payment and Delivery System Reform chartered by the Commonwealth Fund. If you have not read the last four posts and have not already gotten your copy of the report, click on the link and download your own copy of the full report. I will complete this journey with this Friday’s “Healthcare Musings.”
This section is very important. The “business” of American healthcare drives much of the expense and creates many of the inequities in our system of care. The most readable account of the origins of much of the business-driven problems in healthcare is Elisabeth Rosenthal’s 2017 book, An American Sickness: How Healthcare Became Big Business And How You Can Take It Back. Jacob Hackler’s New York Times review of the book summed up much of Rosenthal’s thesis and the conclusions of the task force.
The difference between the United States and other countries isn’t the role of insurance; it’s the role of government. More specifically, it’s the way in which those who benefit from America’s dysfunctional market have mobilized to use government to protect their earnings and profits. In every country where people have access to sophisticated medical care, they must rely heavily on the clinical expertise of providers and the financial protections of insurance, which, in turn, creates the opportunity for runaway costs. But in every other rich country, the government not only provides coverage to all citizens; it also provides strong counterpressure to those who seek to use their inherent market power to raise prices or deliver lucrative but unnecessary services — typically in the form of hard limits on how much health care providers can charge.
I know that that quote will reak of “socialism” for many, but it isn’t. In other countries, consumers are protected. Here there is an “open season” on consumers of healthcare. The public is the prey of a system that they are afraid to change because of their lack of understanding of how it really works. That is why Dr. Rosenthal’s book is so important. We pay for things that we don’t need and won’t benefit us. “Overuse and misuse” of care is a money-producing strategy in a system of care that adds hundreds of billions of dollars in expense and generates enormous confusion and frustration for its customers and practitioners in the form of its administration which is primarily designed to collect as much money as possible. Sister Irene Kraus’s famous statement, “No margin no mission” has been misunderstood and misused to provide a lot of cover for predatory business practices that have few parallels in legitimate enterprises. The authors of the task force say it “softly” and address the issues more from the position of providers than consumers which may suggest some bias.Â
Administrative burden is hobbling our health care system. The U.S. spends as much as one-third of national health expenditures on administrative costs, far more than any other high-income country. The complex business of credentialing, contracting, obtaining prior authorization, documenting visits, billing, and more is not only costly but a major cause of clinician burnout. Administrative burden hurts patients too: as clinicians devote more time and resources to administrative tasks, they spend less time with patients, compromising access to care, quality, and patient experience. These issues loom even larger for independent practices, safety-net providers, and providers in rural communities, where there are often fewer resources to devote to administration.Â
As the COVID-19 pandemic continues to place greater strains on the health care workforce, the need to reduce unnecessary and costly administrative tasks has become clearer. Without taking on the administrative complexities in our system that contribute to waste and burnout, we will not be able to achieve a high-performing delivery system.Â
I spent a significant part of my professional life trying to reduce administrative costs. Before the financial collapse of Harvard Pilgrim in 1999, my practice had very little administrative overhead. After the collapse, we were forced to migrate away from the prepaid care that we had provided for thirty years, what we would now call value-based reimbursement, toward fee-for-service practice just to survive. By 2008 when I became CEO more than two-thirds of our revenue was from fee-for-service practice, but those dollars came at a great cost. We had acres of people in cubicles who did the work of generating bills, cleaning claims, resubmitting claims that were denied, and all of the other tasks of getting paid piecemeal for every little thing that added no value for the patient or for our practice. Ironically our profitability was marginal on our fee for service practice and was always much better on the prepaid business where we were at risk. Perhaps our fee for service margins were small because we managed all of our patients the same way no matter how we were paid. As a result, our measured quality was market-leading.Â
The next statement of the task forces is a conclusion that I support:
As the COVID-19 pandemic continues to place greater strains on the health care workforce, the need to reduce unnecessary and costly administrative tasks has become clearer. Without taking on the administrative complexities in our system that contribute to waste and burnout, we will not be able to achieve a high-performing delivery system.Â
I will take it further. Unless we control and reduce the administrative costs of our system of care it will continue to deteriorate, and the marginally acceptable care at a cost that is increasingly difficult to afford will become even worse.Â
“You can’t get there from here” was the punchline from one of the best “Bert and I” routines of comedians Marshall Dodge and Bob Bryan, “Which Way to Millinocket?”. I hate to undercut the task force but on the subject of “Reduce Administrative Burden,” I don’t believe their suggestions produce a reliable map to our destination. We can’t get there from here if we continue on the road of Fee-For-Service payment with all of its complexities and non-value-adding expense. I don’t disagree with any of their recommendations which you can read, but as long as our primary way of financing care delivery is Fee-For-Service payment, little progress will be made toward the Commonwealth Fund’s objective of “Affordable, quality healthcare, for everyone.” That sounds like the Triple Aim to me. The broad topics under which their recommendations fall are:
- Develop Uniform Standards for Billing and Payment
- Streamline and Standardize Performance Metrics
- Remove Unnecessary Administrative Obstacles in Care Delivery
- Increase Portability of Clinicians’ Professional Credentials and Licenses
There is nothing wrong with any of these objectives especially if you are continuing to try to do the impossible, lower the cost of care without changing the mechanism of finance. Of all of the suggestions, the last one may be the easiest to accomplish. Believe it or not, we employed and compensated doctors for whom we could not collect fees for months. We needed to provide services but “the credentialing” process with insurers took months so we provided “free for service care” for several months as they provided services to our patients for which we could not be reimbursed because the insurance company was still “credentialing” them.
Perhaps the greatest contribution of the business consultant who is most credited for making management a science, Peter Drucker, was his observation that management was reluctant to discontinue a failing line of activity that had once been profitable. Rather than cut its losses and move to a new product or innovation the standard path to failure was to continue to try to prop up an activity, product, or line of service long after realities suggested that the time had come to dump it. I feel that the frustrations of the last fifty-plus years are largely attributable to medicine’s reluctance to move to more creative methods of finance. Ironically, the resistance to change may be coming more from the providers of care than from the government or the insurance industry. There is clear evidence that many commercial insurers are preparing for a shift to value-based reimbursement. Some of the recommendations of the task force like “Streamline and Standardize Performance Metrics” apply to all forms of payment and would decrease barriers to a transition to payment methodologies that will be more likely to contribute to lowering the cost of care and improving the satisfaction of patients.
Finally, in my new role as a consumer of healthcare rather than a provider, I am stunned by the unnecessary care I receive as providers seek to make a profit from providing me care. The fact that their efforts to make a profit are at my expense and are associated with the personal frustration of no value-adding administrative barriers that could be engineered out of the system just makes me more frustrated. The system was not designed to support or improve care. It was designed by those who fear the effort to change will create transitional uncertainties in their margins. When I began reading this section I assumed that it would be more patient-centric. I was disappointed. I feel compelled to say that it would have been more encouraging had the task force included more ideas in their many recommendations that would directly encourage the shift in payment methodology to a more efficient system while lowering administrative barriers for patients and healthcare professionals.
