June 23, 2023
Dear Interested Readers,
Last week, I reviewed Dr. Robert Pearl’s speculations about the recently announced intent of Kaiser to expand its network by acquiring Geisinger Health. As a review, let me remind you that he discussed the issue from three angles.
- Why Did Kaiser Acquire Geisinger?
- How Much Value Will Kaiser Give Geisinger?
- Will The Deal Work?
I tried to use Pearl’s analysis and my own experience leading a large medical group to draw some conclusions about how we got to this moment and what it all means for the organization and the finance of medical practice in the future. I finished the discussion with what was essentially a statement of “to be continued.”
Pearl’s analysis of the proposed affiliation of two of our best medical organizations in an attempt to survive underlines just how tenuous our situation has become. What should concern us even more than the state we are in is that we are not taking effective measures to turn things around and go back to where we made the wrong turn. I will write more about that next week.
There is no one simple answer to the question of how we got here and what the future holds for healthcare professionals and patients. I have recently come across two articles that don’t completely describe the complexity of this current moment, but together they can carry us closer to understanding the moment even if they don’t constitute a complete road map to better times.
The first article is “I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours” and was written by Dr. Aaron E. Carroll who is a professor of pediatrics and the chief health officer at Indiana University’s medical school.
Dr. Carroll begins with COVID where a lot of articles about improving healthcare begin these days. He shares my concern that we just seem to be shrugging our shoulders and moving on despite the injustices and inadequacies in our healthcare system that the pandemic made manifestly obvious. He shares my concern that healthcare seems to be rarely considered a pressing problem or a top issue for discussion over the next eighteen months as we wind our way toward the 2024 presidential election. I have done some bolding of his prose for greater emphasis. He begins:
Although we just experienced a pandemic in which over one million Americans died, health care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best.
:
To paraphrase scripture (Proverbs 2012), since we have “ears to hear and eyes to see,” we should be able to recognize that we are in need of significant change, but our attention seems to be elsewhere. Perhaps the biggest liability of having Donald Trump pursue a second term past the possibility that through some freak turn of events he was to be reelected is that with him in the race there is little opportunity to focus on more substantive issues. I will also concede that the average voter seems more concerned with the country’s fiscal health than the physical health of its citizens, and they fail to realize that the two are closely connected. I am not sure whether the health of the nation is more important in the short run than the health of the planet, but neither concern ever seems to get much attention as long as all eyes are on Trump and past him the greatest concern seems to be avoiding taxes.
Dr. Carroll is like Jeremiah, the prophet. He is trying to warn us that we need to get our priorities in order or there will be trouble. He continues:
When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s… no one has a system quite as complicated as ours.
His advice is to look to the more successful systems in the world and try to adapt their learning and success to our mess.
A more productive debate might benefit from looking around the world at other options. Many people resist such arguments, however. They think that our system is somehow part of America’s DNA, something that grew from the Constitution or the founding fathers. Others believe that the health care systems in different countries couldn’t work here because of our system’s size.
Dr. Carroll is not accepting those arguments. He contends that we could do better if we wanted to do better.
Our employer-based insurance system is the way it is because of World War II wage freezes and I.R.S. tax policy, not the will of the founders. And much of health care is regulated at the state level, so our size isn’t really an outlier. We could change things if we wanted to.
Dr. Carroll went on a quest. His objective was to visit the countries that were outperforming us and to understand the secrets of their success. What he discovered was that no two systems were exactly alike, but in most places, consumers had choices between public and private systems of care. Some did require consumer participation and had out-of-pocket charges. The primary function of private care was a combination of less waiting for elective procedures, and some extra amenities. His conclusion was:
America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost… Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do.
So what did Dr. Carroll discover were the common factors of success that we lack?
Universal coverage matters, not how we get there.
The pandemic should have been an eye-opener in terms of how much work we need to do to repair the cracks in our health care foundation. Unfortunately, we seem to have moved on without enough focus on where we fall short and what we might do about it. It’s outrageous that the health care system hasn’t been a significant issue in the 2024 presidential race so far…
All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.
Dr. Carroll goes further with his disparaging remarks about our system. He points out that beyond the fact that we don’t cover everyone, the people that we do cover get their care from a patchwork of inadequate systems.
We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.
What would be the benefit of settling on a simpler-to-understand system that covered everyone?
If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services.
He continues his presentation about what he learned on his travels:
…they largely depend on public delivery systems… each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more… to get care in a different system…The same doctors often work in both settings…
In the United States,…most care is provided by private hospitals, either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost. Our focus on what pays — acute care — also leads us to ignore primary care and prevention to a larger extent.
It’s been over fifty years since Dr. Robert Ebert pointed out what Dr. Carroll is describing as a new observation. The organization and finance of care determine its effectiveness and cost. Pouring more money into a poorly organized system that exists for its own purposes and is not coordinated with other systems does not produce better outcomes or patient satisfaction, and it does not produce a system that satisfies its professionals.
So far Dr. Carroll has noted that better outcomes are produced by universal coverage in coordinated systems that focus on the importance of primary care, but those are not the only characteristics shared by the countries that put us to shame in terms of quality, cost, and patient and professional satisfaction. Once again, I feel like I can sing along with his next verse. He points out that:
Strong social policies matter.
I have been to Singapore twice now to learn about the country’s health care system, and twice I’ve watched my hosts spend significant time showcasing their public housing apparatus…
Other social determinants that matter include food security, access to education and even race. As part of New Zealand’s reforms, its Public Health Agency, which was established less than a year ago, specifically puts a “greater emphasis on equity and the wider determinants of health such as income, education and housing.” It also seeks to address racism in health care, especially that which affects the Maori population…
So why don’t we follow the lead of these countries that augment their delivery systems with aggressive approaches to improving the Social Determinants of Health? Dr. Carroll has a ready answer.
Addressing these issues in the United States would require significant investment, to the tune of hundreds of billions or even trillions of dollars a year. That seems impossible until you remember that we spent more than $4.4 trillion on health care in 2022. We just don’t think of social policies like housing, food and education as health care…Our narrow view too often defines health care as what you get when you’re sick, not what you might need to remain well.
Nicely said, but Dr. Carroll has more:
In the United States, conversely, we argue that the much less resourced programs we already have need to be cut further. The recent debt limit compromise reduces discretionary spending and makes it harder for people to get access to government programs like food stamps.
I should interject here that two of the “clients” that I follow through Kearsarge Neighborhood Partners are disabled and lack the cognitive ability to respond to mailed notices. Both had their SNAP (food stamp benefits) arbitrarily discontinued this spring. It would be impossible for them alone to jump through the hoops necessary to get this benefit reinstated, The social services required to comply with these arbitrary “cost-cutting” measures of our bureaucracy add unnecessary costs to an expensive system that is top-heavy with management and a philosophy more concerned with limiting access and fraud than providing assistance to those who really need it.
All of the countries that Dr. Carroll visited would like to be able to spend more. Like us, they have financial restraints. We are already spending and wasting more than they can imagine spending. They don’t envy our outcomes, but they do envy our resources which is sort of sad. As Dr. Carroll says:
We are already doing what other countries can’t.
These other countries’ systems are not perfect. They face aging populations, expensive new technologies and often significant wait times — just like ours. Those problems can make some people quite unhappy, even if they’re not more unhealthy.
When I asked experts in each of these countries what might improve the areas where they are deficient…, they all replied the same way: more money. Some of them lack the political will to allocate those funds. Others can’t make major investments without drawing from other priorities…
That is, all of them except the United States. We currently spend about 18 percent of G.D.P. on health care. That’s almost $12,000 per American. It’s about twice what other countries currently spend.
With that much money, any of these countries could likely solve the issues it faces… it’s intolerable that we get so little for what we spend…
But this is also what gives me hope. We’ve already decided to spend the money; we just need to spend it better.
Over the last few years and especially during and after the stress of COVID we have come to realize that our healthcare problems are not limited to poor outcomes, inequities that target minorities, or enormous expenses that are increasingly a burden for consumers and the government alike. There is no debate over the fact that all of the concerns that we expressed when Crossing the Quality Chasm was written in 2001 or when the Triple Aim was articulated in 2008 have gotten worse and have been further complicated by “workforce issues” that also threaten the quality of care and add to the expense of our dysfunctional system of care.
“Burnout” at every professional level is a legitimate concern, and so far no one seems to have devised an effective answer to the problem. I have seen hospitals and practices put enormous resources into behavioral health solutions to combat burnout. I believe there is merit in considering systems engineering solutions like LEAN to reduce the burden of the work professionals might be asked to endure. I hope that as controversial as AI is that one of its greatest benefits might be that it improves the environment of work. I have argued that much of the work and an enormous amount of the time spent working adds little value because it is more devoted to finance than to practice. Despite a lot of effort and high levels of concern, the issues seem to getting worse.
My own conclusion has been that burnout is a systems issue plus the result of our failure to keep up with training enough professionals to match the evolving complexity of care in an aging population or address the needs of the healthy as we practice more and more preventative care. It is wonderful that there are so many things that we can “fix” now like hips, knees, and hearts that we could not “fix” before, and that with better chronic disease management people are living longer with a whole host of chronic medical problems that we couldn’t manage as well back when I was in training in the early seventies, but since then we have failed to match our greater longevity with adequate professional resources.
Last December I featured an article on the “Political Determinants of Health” written by a prolific young physician and anthropologist, Eric Reinhardt, MD. Dr, Reinhardt has an impressive list of recent publications in periodicals like The New York Times, The Nation, The New Republic, Slate, Stat, and Time. In early February he published a guest essay in the “Opinion” section of The New York Times entitled “Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System.” He presented the same ideas in an eighteen-minute interview with “Amanpour and Company” on CNN International and PBS later in the month. Reinhardt who is both a psychiatrist and political anthropologist begins his piece:
Doctors have long diagnosed many of our sickest patients with “demoralization syndrome,” a condition commonly associated with terminal illness that’s characterized by a sense of helplessness and loss of purpose. American physicians are now increasingly suffering from a similar condition, except our demoralization is not a reaction to a medical condition, but rather to the diseased systems for which we work.
That is a bold statement that posits the problem of burnout and its implications for the healthcare system with the defective system that Dr. Carroll described and not in the personal weaknesses that hospitals and medical practices describe in those professionals who are giving up and leaving their profession or persist and perform like zombies devoid of all the positive motivations that enabled them to devote many years to rigorous training and the self-denial required to gain the skills that the system abuses.
Dr, Carroll could have written the next two paragraphs of the essay:
The United States is the only large high-income nation that doesn’t provide universal health care to its citizens. Instead, it maintains a lucrative system of for-profit medicine. For decades, at least tens of thousands of preventable deaths have occurred each year because health care here is so expensive.
During the Covid-19 pandemic, the consequences of this policy choice have intensified. One study estimates at least 338,000 Covid deaths in the United States could have been prevented by universal health care. In the wake of this generational catastrophe, many health care workers have been left shaken.
We are all aware of what is happening, but Reinhardt gives us some quantitation of the problem. He describes the emotional distress of one doctor working in one of our most depressing practice environments, New York City’s Rikers Island prison complex, and then writes:
Thousands of U.S. doctors, not just at jails but also at wealthy hospitals, now appear to feel similarly. One report estimated that in 2021 alone, about 117,000 physicians left the work force, while fewer than 40,000 joined it. This has worsened a chronic physician shortage, leaving many hospitals and clinics struggling. And the situation is set to get worse. One in five doctors says he or she plans to leave practice in the coming years.
Reinhardt then disagrees with those who want to focus on the emotional frailty of the 67% of physicians who are suffering from “burnout.” Again, I did the bolding.
…the burnout rhetoric misses the larger issue in this case: What’s burning out health care workers is less the grueling conditions we practice under, and more our dwindling faith in the systems for which we work. What has been identified as occupational burnout is a symptom of a deeper collapse. We are witnessing the slow death of American medical ideology.
He continues with this new insight:
It’s revealing to look at the crisis among health care workers as at least in part a crisis of ideology — that is, a belief system made up of interlinking political, moral and cultural narratives upon which we depend to make sense of our social world. Faith in the traditional stories American medicine has told about itself, stories that have long sustained what should have been an unsustainable system, is now dissolving.
Reinhardt believes that the pandemic magnified the deep flaws in our system.
During the pandemic, physicians have witnessed our hospitals nearly fall apart as a result of underinvestment in public health systems and uneven distribution of medical infrastructure. Long-ignored inequalities in the standard of care available to rich and poor Americans became front-page news as bodies were stacked in empty hospital rooms and makeshift morgues. Many health care workers have been traumatized by the futility of their attempts to stem recurrent waves of death, with nearly one-fifth of physicians reporting they knew a colleague who had considered, attempted or died by suicide during the first year of the pandemic alone.
The height of the pandemic woes has passed. Now physicians and nurses emerge like the survivors of a tornado that has destroyed everything in sight and the sense of trauma persists even after the storm has passed. Reinhardt backs up his assertions with examples of what the pandemic revealed.
Although deaths from Covid have slowed, the disillusionment among health workers has only increased. Recent exposés have further laid bare the structural perversity of our institutions. For instance, according to an investigation in The New York Times, ostensibly nonprofit charity hospitals have illegally saddled poor patients with debt for receiving care to which they were entitled without cost and have turned large profits by exploiting tax incentives meant to promote care for poor communities.
Reinhardt may be considered a radical by those who manage our healthcare institutions. He has a dark opinion of them:
…Little of this is new, but doctors’ sense of our complicity in putting profits over people has grown more difficult to ignore.
Resistance to self-criticism has long been a hallmark of U.S. medicine and the industry it has shaped. From at least the 1930s through today, doctors have organized efforts to ward off the specter of “socialized medicine.” We have repeatedly defended health care as a business venture against the threat that it might become a public institution oriented around rights rather than revenue.
He builds his case with skill and then delivers his conclusion:
Addressing the failures of the health care system will require uncomfortable reflection and bold action. Any illusion that medicine and politics are, or should be, separate spheres has been crushed under the weight of over 1.1 million Americans killed by a pandemic that was in many ways a preventable disaster. And many physicians are now finding it difficult to quash the suspicion that our institutions, and much of our work inside them, primarily serve a moneymaking machine.
Reinhardt finishes with a call to action. I have the sense that if doctors responded in the way he suggests many of those who are now burned out would be revived and reinfused with the enthusiasm and sense of purpose that they once had.
Doctors can no longer be passive witnesses to these harms. We have a responsibility to use our collective power to insist on changes: universal health care and paid sick leave but also investments in community health worker programs and essential housing and social welfare systems.
Neither major political party is making universal health care a priority right now, but doctors nonetheless hold considerable power to initiate reforms in health policy.
I think he is right. For almost a century our collective voices have successfully prevented the adoption of a program of effective universal coverage for care. That same political power, or as Reinhardt has offered in other pieces, the use of our political power, what he has called the political determinants of health to improve the social determinants of health may do more for the individual healthcare professionals who are suffering from burnout than all the relaxation exercises and group therapy sessions for burnout that are meant to improve the frailty of individuals who are less personally weak and defective than painfully aware of the perversions and deficiencies of the systems where they try against overwhelming odds to improve the health of the nation.
As Dr. Carroll also implies, it doesn’t have to be this way. We could exercise political will and choose to provide better, more equitable care that would benefit both patients and providers of care.
Summer Is Here And COVID Persists
There are many reasons that I am happy that I migrated from the South and the Southwest to New England, not the least of which is the weather. The weather reports from Texas to the Carolinas this week describe days that are over 110 with dozens, if not hundreds, of tornados that rip the roofs off of big buildings and flatten trailer parks. Where I live we have enjoyed temps in the sixties with occasional bumps to the low seventies. We have had more rain than usual and everything is growing and green which is preferable to unbearably hot and blown apart.
I was headed out to get the mail at the post office earlier this week when I almost ran over a huge turtle that was crossing our drive. I phoned my wife who has had a rebound of her COVID symptoms and a return to a positive test after Paxlovid to tell her to look out the garage door and see the visitor who was on the move. She took the picture in today’s header.
There are some very large turtles in our lake. I once looked into the water at the end of our dock and saw a turtle with an enormous head and a shell with a diameter that looked to be over two feet in diameter. This one was a little fellow by comparison with a shell that was probably 16-18 inches in its long axis (the estimate is based on the ten-inch granite stone pavers under the turtle). He/she was headed toward the lake. I have discovered turtle “nests” along the road on my walks. The distance from where the turtle was to the lake was about fifteen yards through the woods. The turtle had covered about five yards from when I first almost ran over it until my wife got its picture. I feel fortunate that almost every day nature presents something for me to enjoy.
I hope that you will be pleasantly surprised this weekend by some unexpected manifestation of the glory of the world around you.
Be well,
Gene
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