February 3, 2023
Dear Interested Readers,
At 11:31 AM on Tuesday, it was 23 degrees where I live. I was enjoying the almost cloudless sky and bright sunlight. I was out “early” for my walk because the temperature was falling fast. I knew it would be less than 20 degrees by early afternoon. The weather function on my watch said it would be around 10 degrees by sundown and in the low single digits by sunrise. 11:31 AM was the time stamp on the email sent to me from the Commonwealth Fund that contained a link to an article entitled “U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes.”
I was back home around 12:30 having retrieved my local newspaper from my roadside mailbox. With a cup of coffee, my newspaper, and my laptop, I sat down in front of a blazing fire to relax from my effort. After a quick look at the paper, I began to scan my email. I always look at emails beginning with the most recent and then scrolling back in time. I noticed that at 12:24 PM an old friend and “Interested Reader” had forwarded me an email that he had received from the Commonwealth Fund. With the forwarded article, he added one line in the message space that made me chuckle to myself. It was:
Brings to mind your favorite quote from Dean Ebert!
If you don’t remember my favorite quote from Dr. Robert Ebert, I quoted it once again last week. It is:
“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.”
I noticed in his email that he had received the note from the Commonwealth Fund at 11:31. When I scrolled back to 11:31 in my email, I discovered that I had received the same message. I am on a lot of mailing lists, but the three organizations that contribute the most useful information to my ongoing education are the Commonwealth Fund, the Robert Wood Johnson Foundation, and Kaiser Health News. All three send out free newsletters and opinion pieces. If you are not on their distribution lists, I would suggest that you take advantage of their work like my friend and “Interested Reader” and I do. I consider the people who plow through these notes to be a community of concerned citizens who care about the future of health and healthcare in America and the wider world. It is essential that we are informed, and these three sources are an excellent way for us to stay up to date on the latest information about what is really happening in healthcare. All three are dedicated to working toward a better healthcare future for all people. I really like the Mission Statement of the Commonwealth Fund:
The Commonwealth Fund was established in 1918 with the broad charge to enhance the common good. Its founder, Anna M. Harkness, is among the first women to start a private foundation.
Today, the mission of the Commonwealth Fund is to promote a high-performing, equitable health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including people of color, people with low income, and those who are uninsured.
The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.
Below their Mission Statement they continue with more detail about equity, diversity, and inclusion:
Commitment to Equity, Diversity, and Inclusion
The Commonwealth Fund has made a commitment to become an antiracist organization. That commitment extends not only to our research agenda, our grantmaking, and our communications, but also to all aspects of our internal operations and interactions — from our endowment management and hiring practices to the ways in which staff members relate to one another. Click to learn more.
Equity, diversity, and inclusion should be like motherhood, the flag, and apple pie, but they are not. Consider the aspirations and actions of the governor of Florida, Ron DeSantis. He explicitly says that any discussion of equity, diversity, and inclusion has no place in our society or in the curriculum of a state-supported college, and in his pursuit of the presidency he is willing to dramatically emphasize his objections to these concepts. A Washington Post article reporting on DeSantis’s most recent attack on the educational system said:
Under DeSantis’s plan, which he will ask the legislature to take up in March, the state would defund diversity, equity and inclusion programs, which are common in higher education and often described by the abbreviation DEI. Proponents of DEI say the programs provide critical training to combat implicit bias against specific groups, and support for students and employees of different beliefs, races, genders and sexual orientations.
My expression of disgust with Governor DeSantis is a diversion, but those of us who are energized by the messages in the Commonwealth Fund publications should remind ourselves that it is not out of the realm of possibility that someday a demagogue like DeSantis could convince enough Americans that ideas of diversity, equity, and inclusion are not in their best interest and see DeSantis as their champion. I will leave this diversion and the potential it represents for future nightmares to your exploration, and return to my discussion of the Commonwealth Fund and its recent publication.
The paper that was released on Tuesday may have been one of the last projects done under the leadership of David Blumenthal, former Obama appointee as administrator of the office that manages and coordinates health information technology, Massachusets General Hospital physician, Harvard Medical School professor, co-author of an influential book about the evolution of our system of care (The Heart of Power), and brother of Richard Blumenthal, the senator from Connecticut. The new president of the Fund is Dr. Joseph Betancourt who has a passionate interest in, and long experience working in, all aspects of the social determinants of health.
Well, that is a long introduction to the review of how we are doing as a nation compared with our peers which I imagine none of us really imagine are our peers. I must admit that I am a product of American culture constructed and programmed between World War II and the war in Vietnam, Sixty years later, my attitude is that we are not always number one, but we should be. I was instilled with the attitude that Americans had no peers. We stood head and shoulders above all nations and were the leaders of the free world. We were number one. European countries were “has-beens.” Canada was populated by nice but indecisive people. Mexico and every country south of it were hostile environments that were full of corruption and potentially fertile ground for communism. Africa was a jungle that would always be a good place for missionaries to go. China and the USSR were the earthly capitals of Satan and were led by his disciples. To plant this worldview in my little mind took the concerted efforts of a lot of adults who believed the analysis themselves and were blind to the fact that they were recipients and beneficiaries of the products of many oppressed and impoverished people who had built what they believed God had given them. The last sixty-five years have been a gradual unwinding of the myth and the revelation of the reality that the USA is not number one in all domains. The Commonwealth Fund has published a lot of data over the last decade. Four years ago in 2019, the Commonwealth Fund did the same review. (I have quoted this article before.) That report card should have been a source of shame and motivation for improvement, but it was not. I hate to tell you we are still cellar dwellers in the world of healthcare outcomes in economically advanced countries.
In both papers, we were most closely compared to Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom. For completeness’ sake, we were also compared to the OECD (Organisation for Economic Co-operation and Development) average for the 38 high-income countries for which data are available.
The paper looks at our cost of care, outcomes, access, workforce, life expectancy, suicides, deaths from gun violence, and several other dimensions of quality and safety. In very few areas we were not the worst. Japan and Korea do have higher rates of suicide than we do. In some areas, most notably in “deaths from assault,” we were four times higher than the closest competitor, New Zealand. There are pages and pages of interesting graphs which you should review, but here are the highlights that the Commonwealth Fund offers:
Highlights
- Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage.
- The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.
- The U.S. has the highest rate of people with multiple chronic conditions and an obesity rate nearly twice the OECD average.
- Americans see physicians less often than people in most other countries and have among the lowest rate of practicing physicians and hospital beds per 1,000 population.
- Screening rates for breast and colorectal cancer and vaccination for flu in the U.S. are among the highest, but COVID-19 vaccination trails many nations.
One obvious question arises from the fact that we pay more, cover fewer people, have fewer hospital beds, see the patients we do see less often and less effectively and have a lower ratio of healthcare professionals to people in the population. That question is: “Where does the money go?” Another question: “How do so many countries that share our economic status consistently outperform us?”
The authors end their report with a discussion that sheds some light on these and other questions. I am bolding the points as I see them.
While the United States spends more on health care than any other high-income country, the nation often performs worse on measures of health and health care. For the U.S., a first step to improvement is ensuring that everyone has access to affordable care. Not only is the U.S. the only country we studied that does not have universal health coverage, but its health system can seem designed to discourage people from using services.
Affordability remains the top reason why some Americans do not sign up for health coverage, while high out-of-pocket costs lead nearly half of working-age adults to skip or delay getting needed care. The Inflation Reduction Act, which will help reduce the high cost of certain drugs and cap out-of-pocket costs for older Americans, is a step in the right direction. But it will take much more to make health care as easy to access as it is in other high-income countries.
A second step is containing costs. Other countries have achieved better health outcomes while spending much less on health care overall. In the U.S., high prices for health services continue to be the primary driver of this elevated spending. U.S. policymakers and health systems could look to some of the approaches taken by other nations to contain overall health spending, including health care and administrative costs.
A third step is better prevention and management of chronic conditions. Critical to this is developing the capacity to offer comprehensive, continuous, well-coordinated care. Decades of underinvestment, along with an inadequate supply of health care providers, have limited many Americans’ access to effective primary care.
The findings of our international comparison demonstrate the importance of a health care system that supports chronic disease prevention and management, the early diagnosis and treatment of medical problems, affordable access to health care coverage, and cost containment — among the key functions of a high-performing system. Other countries have found ways to do these things well; the U.S. can as well.
My interested reader who wanted to make sure that I saw this article was right to say that the article is consistent with the quote I love from Dr. Ebert. It’s not about more money. It’s about developing a system of care and finance mechanisms that support a better and more equitable deployment of our resources.
Other countries focus on equity in access and chronic disease management. They address the social determinants of health through more robust systems of support for the disadvantaged members of their communities. We often disdain better social services, better support for housing, and income support as left-leaning and a slippery slope toward communism and away from capitalism. Ironically, capitalism, entrepreneurism, and the health of the population are doing better in countries where there have been more productive discussions of diversity, equity, and inclusion than we have been able to generate.
I hope that under the leadership of Dr. Betancourt the Commonwealth Fund will continue to do this periodic reevaluation of our “standing” in relation to our economic peers. We are making some efforts. I agree with the Commonwealth Fund authors that the last big bill that President Biden was able to sign before the Republicans took over the House, the Inflation Reduction Act of 2022, does offer some small steps toward better access and lower costs. How we practice, by that I mean our attention to chronic disease management and patient engagement, are cultural. I would add that the inherent biases that make outcomes for minorities worse for people of color are areas where our medical professionals can support positive change that doesn’t require any legislation, just introspection and ownership of the problems.
My letter last week was an expression of some of my biases. One bias that I have is that we are more focused on personal and institutional finance than we are on the challenges that face our patients. I believe this position is easy to prove by attending many board meetings, management meetings, and meetings of clinicians. I also am convinced that no one will readily admit that their focus should or could change. I know that statements like mine will create denial and pushback with solid data about how vulnerable organizations are and how hard they are trying to solve the difficult problems that stand between them and optimal care consistent with the Tripple Aim.
No part of our care system is under greater pressure than rural systems of care and our DSH Hospitals in the poorer neighborhoods of our cities. Many will not survive without a significant change in resources. I focused most of my comments last week on Dartmouth Health and the community (small-town and rural) hospitals it has put together in a system that is under great financial pressure. It is only fair that I inform you that Dartmouth Health has pushed back, not against me, but against the local paper that published the editorial that I quoted.
This week the paper published the response from Dartmouth’s Chief of Nursing for the system and one of the hospital CEOs in the system. Their response was entitled “Health care in Upper Valley has improved.” I hope you read their response. Everything they say is probably true. Unfortunately, their well-intended actions, future plans, and references to the difficult challenges they face don’t change the reality of the problems they face or the current cost of care and lack of access to care that patients experience in their system.
One of the things that I was trying to imply by bringing the problems to your attention was that I doubt that the problems are solvable without an infusion of resources and healthcare policy changes by our state and federal government. My concern is that the state of our healthcare system is awful as documented by the Commonwealth Fund report, and there is not a realistic strategic plan at any level to make it better. I think that a process of radical change will be required to gain lasting improvement that achieves equity and outcomes that are equivalent to those enjoyed by other advanced nations.
What deeply troubles me is that the changes that are needed are no longer on our political agenda. Nothing is a more direct indicator of how far we are from the right conversation than the fact that we have at least one politician who is a potential nominee for president deciding that our most pressing need is to eliminate discussions of diversity, equity, and inclusion from our public schools and state-supported colleges and universities.
Walking While I Can
It’s very cold here. It was zero at 9 AM. It will be minus five at 3 PM when this letter is published. By six PM it will be minus 12, and sometime this evening it will be minus twenty, the predicted low for the day. Saturday’s predicted low is minus twenty-one. We have a brisk wind, and the wind chill factor makes it feel even colder. The weatherman warns that ten minutes of exposure to these temps can cause frostbite. Outdoor walking for me is on hold until Sunday when someone will shut the door to the artic wind and the predicted afternoon high will be a balmy thirty-six!
I am good for walks until the temp is in the low teens as long as there isn’t much wind and there is a little bit of sun. My injuries from two falls are much better, and earlier this week I decided to move back to the road as long as the temp was in the twenties. I also decided to add some variation to my recent walks by going on a hillier walk with distant vistas.
One walk that I enjoy but that I take only about ten percent of the time takes me up Burpee Hill. If you ever travel up Interstate 89, you will pass the highest rock wall on the Interstate highway system in New Hampshire as you approach exit 12 which is my exit. The wall was created when the west side of Burpee Hill was blown away to make room for the highway. This time of year that vertical wall of a few hundred feet is covered in ice. Before they blasted the granite to make way for I 89 there was a gentle downslope from the top of Burpee Hill all the way to Herrick Cove on Lake Sunapee which is about half a mile away.
I know this story about Burpee Hill is true because I have friends who live on the top of Burpee Hill and the wife’s grandfather once owned all the land from the top of Burpee Hill down to Lake Sunapee. Back in the early sixties, when the highway was under construction, there had been a fierce debate about the route of I 89. It could have run west of the lake near Mount Sunapee through Newbury where trains once brought tourists from New York and points south to enjoy the resorts that were around the lake. The final decision was to make it a tangent along the outskirts of New London on the eastern side of the lake which explains why the side of Burpee Hill was blown to smithereens, and we have what we have now.
I don’t go looking for hills, but I do enjoy the view from the top of Burpee Hill. The picture below captures what I saw on Monday from the top of the hill. I have taken this picture at least a hundred times over the years, and every time I feel like I am seeing it for the first time. I am always inspired by the view. The white at the base of the mountain is Lake Sunapee. The mountain is about ten miles away. Out of the picture to the right and out of sight from you are Croyden Peak and Grantham Mountain. If I had turned to the right, and if it were a clear day, you could see past those two mountains, and on the horizon fifty miles away you would have seen Killington Mountain and other peaks in Vermont.
The scene from today’s header is from halfway up Burpee Hill on the east side of the road. The picture shows cows on a working farm that is travel brochure worthy as an example of a New Hampshire farm. The main house and the barns are one continuous structure.
My grandsons like to go up the hill to see the cows. I like to go up the hill to see the cows. I thought that you might like to see the cows. I have been there in warmer weather when the farmer puts a wooden yoke on a couple of the big bulls and uses them to lead the other cows up the road and to the other side road where in summer the snow-covered fields that look toward Mount Sunapee that you see in the picture above are lush pasture.
I am told that a hundred years ago the fields that are behind the farm ran down to my lake about half a mile north and east of where the cows are feeding. One fantasy that I enjoy is to imagine that I could go back in time to the early 1800s to see just what things were like before we filled the area with roads, superhighways, and lakehouses.
I’ll be indoors until Sunday when it is reported that the temp will be in the thirties again. I hope that your weekend is interesting whether you are outside or inside. Stay warm!
Be well,
Gene
