February 16, 2024
Dear Interested Readers
Medical Ethics, Access, and Personal Experience
There are huge variations in care in America’s healthcare system. One has a different experience in quality, cost, and access, depending on your location and your need. If you are a pregnant woman in a rural environment, the obstetric service that once existed at your local hospital may have recently closed because it was “not cost-effective.” In New Hampshire, nine hospitals have closed their labor and delivery services since 2000. My local hospital no longer offers labor and delivery care. It is also very difficult to find a primary care doctor with an open practice. An article in The Nation published last November puts some perspective on the evolution of practice. The article was written by Dr Luke Messac an emergency room physician at Brigham and Women’s Hospital and the author of Your Money or Your Life: Debt Collection in American Medicine (Oxford University Press, 2023). In the article, Dr. Messac writes:
Between 1983 and 2014, the percentage of physicians practicing alone in the United States declined from 41 percent to 17 percent. By 2022, 74 percent of physicians were employed by hospitals, health systems, and other corporate entities, including private equity firms and health insurers. The image of the independent physician with a shingle outside the door and a satchel of instruments for home visits is a comforting bit of nostalgia, but it is not, for most of us working in the US, a present reality. We are, more and more, employees of large entities run not by physicians but by financial executives with no role in or even experience with the care of the sick. This lack of connection to direct patient care fosters a skewed understanding of patients as “clients,” “consumers,” or “customers,” rather than vulnerable people who have allowed us to enter into a sacred trust.
I was always an employed physician. In retrospect, much of my discomfort that pushed me into organizational politics was that I was frequently on the verge of moral injury that was the result of decisions that were driven by the financial concerns of non-physician executive leadership. I felt that these “suits” were not committed to Dr. Ebert’s vision that launched our practice and inspired me. A recurrent theme in all of my actions was a desire for us to be a physician-led organization, or at least a physician-influenced organization, that valued first and foremost the responsibility to put patients and the quality of their care at the top of the list of our concerns. I felt that what was best for our patients should be the primary concern in every corporate decision. Management was hired to advance the mission. With an apology to Sister Kraus, If we forget our mission there was no justification for a margin.
Our nation’s system of care is the result of the evolution of the focus of care from the solo practitioner who delivered care in an office and the homes of the ill to the hospital as the primary focus of practice in the mid-twentieth century. Ironically, hospitals evolved as places to care for the poor who could not pay for doctors to provide care in their homes. It was the mid-twentieth century explosion of technology that moved the focus of care for those of means to the hospital.
Until the last forty or fifty years, the majority of doctors were not employed by hospitals. Many of the hospitals that provided care for the poor were maintained as charities by religious organizations. Doctors often provided pro bono care in their offices and on the wards of charitable institutions. In large cities, some of the hospitals where the poor received care were public institutions. Before 1965, only Veterans and native Americans got care that was directly funded by the federal government, although the Hill-Burton Act which was passed in 1946 and funded the construction of thousands of community hospitals and nursing homes did require they agree “to provide a reasonable volume of services to people unable to pay and to make their services available to all persons residing in the facility’s area.”
Almost no one had insurance that covered hospital care before the thirties when Blue Cross was created in Texas by the teachers union and most outpatient care was an out-of-pocket expense until the sixties. If you click on the last link you can read an article that describes America’s system of care in the sixties written by a person from the UK who marveled at our technologically advanced care that lacked any coordination or planning. The author writes:
…the structure and financing of the health system made little intuitive sense. More than 70 percent of the population had some form of hospital insurance by 1965 (though less than one-half of the elderly population did), 67 percent had surgical insurance, and there was a growing market for major medical insurance (Health Insurance Institute, 1980). But few were insured for primary or out-of-hospital care.
I was a child in the mid to late forties and through the fifties into the early sixties. My parents never had to pay for care because the culture of the day in the South was to provide ministers and others in charitable occupations and their families with free care as a “professional courtesy.” Hospital expenses by today’s standards were very low. In 1962, I was hospitalized by my PCP at the Baptist Hospital in Columbia, South Carolina for an inpatient workup of hypertension. It was a traumatic experience for me. The first night I was in a three-patient room between two very ill old men. I remember that the room fee was $13. After a terrible night during which both of my “roommates” hallucinated and groaned loudly, my father opted to have me moved to a semi-private room at $21 per day. I don’t know why those numbers stick in my head.
I saw my first patient as a medical student in an open ward at the old Boston City Hospital, a publically-funded institution. The ward, Peabody 1, had at least twenty beds that were separated by only a few feet and a thin white curtain. My internship began on the medical “public ward” for men with no private doctor, F Main, at the old Peter Bent Brigham Hospital. There were also male and female public surgical wards. The remainder of the hospital was made up of private and semi-private rooms for patients with insurance and a private physician.
On F-Main the medical ward for men, most of the patients, at least twenty, were in a large circular room with the beds separated by curtains. The ten or so men of F-Main who required a ventilator or more intense care were lined up in a smaller room. There was also a room for isolation, and there was one semiprivate room where some patients were placed when they were dying, or because they were noisy or disruptive with the DTs or some psychiatric problem. Things have changed.
I relate my experiences with healthcare from the forties to the mid-seventies to demonstrate how things have changed. I contend that over the decades we have introduced even more variation when we could have opted for greater integration. Care that is driven by the bottom-line contributions of individual specialties is not going to produce a system that is as efficient as you might plan to get if care was organized around the needs of a population. Care driven by a pursuit of profit will always produce the pockets of inadequate care that we see among the urban poor and rural populations. A system that is not designed to provide care to the entire population will always disadvantage some of the population.
Our medical knowledge and technologies have been remarkably advanced over the past fifty years, but we still have a system of care that evolved haphazardly and that does not give everyone the care they need and deserve. You can partially explain what we have now by American medicine’s reluctance to accept any direction from the federal government that is coupled with a predominantly fee-for-service finance system that seems to make decisions based on the motivation of profitability more often than its sense of responsibility to meet the needs of a population.
Most of the time when we talk about our uninsured population we are talking about those of us who were born here, are naturalized citizens, or some legal immigrants. As of now due to the benefits of the ACA, there are around 26 million people or a little less than 8 % of the “legal” population without health care coverage. There is another population that is not included in that statistic. We have 45.5 million immigrants and about 24% or about 10 million of them are “illegal.” It is estimated that about 50% of illegal immigrants have some coverage. When we think about those who lack any coverage, we need to include every person: citizens, legal non-citizen immigrants, and illegal immigrants. Where does our uninsured population of perhaps 35 to 40 million people get their acute and chronic care? The answer is that many of them get care at Federally Qualified Health Centers (FQHCs) and Safety Net Hospitals. Because of our history of variation, there are at least five types of safety net hospitals including Disproportionate Share Hospitals (DSH). If you click on the last link you will find a recent article from NYU that describes the problems introduced by the variation in our Safety Net Hospitals.
The previous 1500 words of this letter are a long introduction to a paper about the practical and ethical challenges facing safety net institutions and the physicians and other clinicians who try to provide care in a difficult environment. The article appears in this week’s New England Journal of Medicine and is entitled “Ethical Issues in Providing Care in Safety-Net Health Systems.” The authors are Dave A. Chokshi, M.D. and Frederick P. Cerise, M.D., M.P.H. The authors are from two safety net hospitals, Bellvue Hospital in New York and Parkland Hospital in Dallas. They begin their article:
Safety-net hospitals have a common mission to provide care for Medicaid beneficiaries and those who are uninsured, but there’s no universal definition for these hospitals—complicating . efforts to allocate funding.
In a new analysis published in JAMA Network Open and led by researchers at the NYU School of Global Public Health, the research team looked at five established definitions for safety-net hospitals and found that different criteria captured varying hospitals and characteristics. As a result, when the Centers for Medicaid and Medicare Services (CMS) use one definition to allocate funding, some hospitals are excluded and may not receive the necessary funding to continue providing care…Safety-net health systems provide essential care to people who are uninsured, underinsured, or low income. Their fundamental mission is to serve patients…who have limited access to health care services. This mission, within a context of constrained resources, shapes the most salient ethical issues faced by safety-net clinicians and leaders, as well as by the broader health care ecosystem.
I have some expertise in the problems facing safety net institutions from serving on the board of the Boston University Medical Group which employs more than a thousand physicians and advanced practice clinicians in the Boston Medical Center and its affiliated practices in clinics around Boston. I also served on the board of The Guthrie Clinic which operates hospitals and outpatient clinics that function as safety net providers in the small towns and rural communities of south-central New York and north-central Pennsylvania. Both systems have been identified by an analysis from the Lown Institute as being in the top five for the highest-quality safety net institutions in the nation. The cited article from The Washington Monthly lists the top one hundred safety net systems.
The authors introduce us to two philosophical concepts to help us understand the ethical challenges that face those who work in the safety-net environment.
Utilitarianism or consequentialism, for example, argues that limited resources should be allocated so as to maximize the health benefits for the population served. But a narrow focus on maximizing benefits ignores equity considerations, such as distribution of benefits and costs among individuals and subgroups.
Under another framework, targeted universalism, organizations would seek an ethical balance by setting universal goals while allocating resources in a more targeted way, “based upon how different groups are situated within structures, culture, and across geographies to obtain the universal goal.” In the safety-net context, a targeted universalist approach might be to offer all patients a primary care appointment within a certain time frame, while allocating resources to opening a new clinic in a neighborhood with poor access to primary care.
At the system level, leaders have to calibrate service capacity to satisfy unmet demand — particularly for critical but poorly reimbursed services such as inpatient psychiatric care, trauma care, or rehabilitation — while stewarding overall resources.
When I think of the resource challenges that face safety net systems, I am reminded of the report that Jesus was able to stretch five loaves and two fishes to feed a crowd of five thousand (Matthew 14: 13-21). Whether or not that ever happened, it feels like safety net institutions face a similar challenge. They have limited resources with which to address great needs. Their need to stretch the relatively limited resources available to them compared to what is available to other parts of our care system creates huge challenges for those who work in safety net systems. We can’t be oblivious to the manifestations of the inequities in our support of the underserved who get their care at safety net institutions. We must satisfy these needs if we expect to improve the health of the nation. Until we treat safety net patients equitably, the clinicians working with them will be vulnerable to moral injury. As the authors say:
“Nobody turned away” and “regardless of ability to pay” are part of the credo of U.S. public hospitals and community health centers. Yet remaining true to that credo in every case presents its own ethical dilemmas.
The proposition of addressing patients’ unmet social needs, such as homelessness and food insecurity, is vexing for safety-net health systems. For most patients served by such systems, social factors certainly influence health outcomes. Yet redressing entrenched economic inequities and structural racism is a tall order for organizations with limited resources, and it raises concerns about mission creep.
I am reminded of a complaint that my father used to voice in jest, “The harder I try the behinder I get!” I am sure that the clinicians working in safety net institutions frequently feel that despite great efforts they are losing ground in the struggle to improve the health of their patients with limited resources. Most of us can easily avoid thinking about or caring about the underserved. We can avoid going to the parts of town where they live in dilapidated houses and under bridges.
As we motor toward ski lodges and other recreational opportunities in our rural area, we can ignore the underserved rural communities scattered along the Interstate highways while enjoying the scenery. We can easily avoid those exits that lead to back roads where we would see the rusted mobile homes of many of the rural Americans who don’t enjoy easy access to the care they need.
We also don’t see the “dormitories” where immigrant dairy workers live. They work long hours to keep the cost low of our milk, ice cream, and yogurt. It might surprise you to learn that 70% of American farm workers are foreign-born. We use and abuse many immigrant farm workers. Some are legal some are not. I wonder about their access to healthcare in places where “legitimate” Americans have difficulty getting the care they need. The authors realize that “Burt” was right when he said, Come to think of it, you can’t get there from heyah,” They conclude:
Without universal health coverage, “fair share” issues will continue to plague health care in the United States…
…Undocumented people living and working in the United States remain ineligible for most public insurance covering nonemergency services…This restriction frustrates patients, clinicians, and administrators alike: it adds to emergency-department wait times, saps hospital resources, and results in inferior care.
So, what is the impact of working in such a resource-constrained environment in the face of so much need? The authors who live and work in such an environment can speak with authority about what happens:
Moral injury, which is associated with clinician distress more broadly, takes on a particular valence in the safety net because of both the patients’ circumstances and the workers’ backgrounds…Clinicians working in the safety net may be more likely than others to encounter countervailing ethical guidelines, requiring them, for instance, to balance respect for patient autonomy with culturally sensitive care.
My experience on the boards in two systems that face the challenges of institutions that provide safety net care makes me very sympathetic to the challenges that face the clinicians who work there. Studies of the emotional status of clinicians at the Boston Medical Center revealed that more than 50% were burned out. I assume that burnout for many of these dedicated clinicians was secondary to their moral injuries.
I am embarrassed to say that while I was CEO of Harvard Vanguard and before I was on the BU Medical Group board, we hired several very talented clinicians from the Boston Medical Center and their ambulatory offices. I made it a practice to interview all of our new hires in groups as part of their orientation to our system and its values. Some of the hires we made from the Boston Medical Center told me how hard it was to work in an environment where the need was great and the resources were limited. They seemed embarrassed to admit that they were “escaping” to an environment where they were better supported and better compensated. Perhaps we should have felt guilty about taking advantage of the BMC’s challenges by offering a greener pasture with more resources to their burned-out clinicians.
The Story Continues: The Big Move
Long before I became the CEO of Harvard Vanguard and Atrius, I knew that no matter how successful our internal quality and safety program was and even if we achieved huge systems improvements, our survival and success would be challenged by the external environment. My bias was that the biggest external factor that added to our difficulties was the impact that Partners Healthcare, now Mass General Brigham, had. They were the metaphorical 800-pound gorilla in our market.
Partners Health Care was the dominant force in our market, and my bias was that their market dominance gave them the ability to get the best rates from payers making our market the highest-cost market in the country. If expense is the combination of what is done and the price paid, I felt that Partners frequently practiced overuse and they were always overpriced. What compounded the problem for us was that they were our principal source of hospital services. Even when the care provided in their hospital was provided by our surgeons, medical specialists, and ob-gyns the costs were inflated by high lab costs and the overuse of practice patterns that were adopted by the house staff that supported us.
I knew the score because I rounded on our cardiology and cardiac surgical patients. I was occasionally an attending physician on the medical and cardiology consult services. I read medical records. I knew that we frequently lost patients when they were discharged to the care of Partners’ specialists rather than returned to our specialists who had admitted them. When I reviewed the records of patients that I had known who were captured by the Partners Cardiologists, I saw many examples of unnecessary use of nuclear stress tests, echocardiograms, and other tests that I would never have ordered and which provided no new useful information. At one point I received an influx of several cardiology patients who had lost access to Partners because their insurer had canceled their access to Partners over contract issues. I was amazed to see stable patients getting echos and other tests that added no value with every follow-up visit.
After becoming CEO, I had one other origin of bias against Partners which was the evaluation by diagnosis for the care of our patients at Brigham and Women’s Hospital versus Beth Israel Deaconess Medical Center that was done by Beth Honan our Vice President for Contracting. Beth’s analysis was based on our cases that were admitted to BIDMC when BWH was on “diversion” because it was at 100% occupancy and had no beds. What the charges showed was that we paid huge amounts more at BWH than at BIDMC for similar services.
Some of the differences exceeded 30%. When the differences were extrapolated to cover all of our patients at BWH, we were paying a premium that amounted to tens of millions of dollars a year. I knew from public information that in every aspect of measured care, the BIDMC was essentially equal to or better than the BWH. I also knew that patient satisfaction was higher at BIDMC than at the BWH. Both institutions were integral parts of Harvard Medical School and were colocated on either side of the medical school quadrangle. I mused that the hospitals were so close to one another that Dwight Evans, the right fielder for the Red Sox who had a very strong arm, could stand at the back of the Brigham and hit Beth Israel on the fly with a baseball.
I was reflecting on all of this information and what to do about it before I was summoned to the office of the Brigham CEO to be told that they were increasing our charges to make up for the loss of other revenue. There must have been steam coming out of my ears as I left his office. I knew that we had a situation that we could no longer tolerate, and I knew that it was a problem that I could not ignore. I had to do something about it despite our long history of collaboration and the fact that some of our patients and almost all of our surgeons and medical specialists would be upset if they were asked to get and give care at the BIDMC rather than the Brigham
The LEAD project of Blue Cross that I mentioned in early reflections brought me into close contact with the very interesting CEO of the BIDMC, Paul Levy. (Please take a look at Paul’s many accomplishments by clicking on the link.) Paul was not a doctor. He was an MIT grad and faculty member with a well-known history of solving complex problems like cleaning up Boston Harbor. He is a risk taker who is a master negotiator and communicator. People who know Paul fall into two groups, those who passionately admire him and and those who passionately oppose him.
I was in the group of Paul’s admirers because of what he had accomplished before I got to know him. After I spent some time with him, I admired him even more. Paul became CEO of BIDMC in 2002 when the hospital was in poor shape in part because of the market control of Partners. Paul engineered the hospital’s recovery through his energy, his business acumen, and his utilization of his unique version of Lean. With his skill with social media, and through the transparency of his widely read blog about the challenges of being the CEO of a hospital, he had led the BIDMC to new success by the time we began seeing each other at monthly LEAD meetings in 2008. I also observed him in the ad hoc meetings of system CEOs that were occurring in and around healthcare reform in Massachusetts. All of Paul’s skills worked together to improve the finances at the BIDMC without compromising care. BIDMC’s quality metrics improved as its finances improved by focusing on systems issues. By the time I began to have frequent contact with Paul at the LEAD meetings, he had revived the BIDMC and was a hero to those who cared about the BIDMC.
Moving as much of our hospital care as possible the few yards from the Brigham to the BIDMC was a big task. Since both organizations had some proficiency in Lean thinking, it became a big Lean collaboration. Our side of the project was led by one of our most gifted and committed clinical leaders in whom I had great trust, Dr. Michael Pinnolis who for a long time had been our Chief of Surgery. We knew that we might lose some clinicians and some patients who felt highly aligned with the Brigham.
The transition was a multi-year process, and some of our specialists did leave us, but we began to reap benefits almost immediately. The BIDMC never diverted our patients to their specialists, and they placed some of their clinicians in our sites to back up some areas where we needed more staff. Throughout the entire process, Paul and I had frequent meetings at a mutually convenient breakfast site in Newton Center which was conveniently located for both of us. Those meetings became a highlight of the week for me.
As the process evolved, I did not know that Paul would resign as CEO over a controversial issue in his private life. I was confused by conflicting stories about the details of the controversy. It was none of my business, but I tried to support him. Fortunately, by the time he left his position as CEO in 2012, the project was mostly completed and there was a positive momentum that was easy for his successor, Kevin Tabb, to continue.
I grieved my loss of the frequent chances to work with Paul. I felt that together we had accomplished some innovative things and had together had our organizations had done something to bring a little more balance to our market.
I am delighted that as you can read in the link above, Paul has continued to be a force in the community and a contributor to many organizations as an author, teacher, and board member. For a while, he continued his blog as a former hospital CEO. I was an avid reader, and I was sad when I wrote his last post.
When I reflect on the evolution of my moral sensibilities in medicine I see Paul as a contributor to my development. While I worked with him I sensed his deep commitment to quality and safety in the hospital. He believed in the Triple Aim. He was a collaborator who was able to visualize the win-win possibilities of sharing a common goal. We would have a much better system of care if we had more leaders in healthcare like Paul.
We are nearing the end of my journey of reflection, but there is a little more to tell and a few more heroes to introduce to you.
Forest Looking at the Forest
My new grandson, Forest, will be four weeks old this weekend. Reports with lovely pictures about his progress arrive daily via text messages. His feeding tube came out yesterday. He has spent all of his time on Earth at Maine Medical Center, but will probably go home this weekend.
He has been out of the NICU for at least two weeks, but he was a slow learner when it comes to nursing. On a combination of feedings by breast, bottle, and NG tube which he was pulling out almost every day, he has gotten bigger. He now weighs over seven pounds.
When he does get home he will see the beautiful mural which his father has painted on one of the walls of his room. His dad completed it this week. The forest theme seems very appropriate given Forest’s name and the reality that a forest scene is what Forest will see if he looks out of almost any window in his home. I thought it would be a great header for today’s letter. I hope that you enjoy it.
Forest has most of my attention these days. It is great that he is less than three hours away. One thing that I have missed with my first three grandchildren is the opportunity to see them frequently and be a significant part of their lives. During my childhood, my family lived more than a thousand miles from my grandparents. There were no digital pictures to send, and my father who was always cost-conscious, used an egg timer to limit the expense of long-distance phone calls. When the sand had run out the calls could be terminated in mid-sentence. We did “go home” to the Carolinas for a month every summer. Based on my limited experience with my grandparents, I decided to do better with my grandchildren.
When my granddaughter was born in Miami, Florida in 2002, I resolved to see her every six weeks. I was able to keep that commitment until she became a teenager. I would fly from Boston to Miami to see her for the weekend every six weeks. When she entered middle school she was spending more and more of her weekends with her friends which left me alone with her parents. By that time communication with far away family members had been transformed by iPhones and digital photography.
My grandsons in California are even farther away. Their mother does send us several new pictures and videos every week plus descriptions of all of their activities. Among her many skills, she is a wonderful communicator. Digital communication is great, but it is not the same as a hug. I look forward to being a more frequent presence in Forest’s life than I have been able to be in the lives of my three older grandchildren.
Winter temps have returned to New London. We had a couple of inches of snow last night. The forecast suggests that we will not exceed freezing for at least the next week after temps hit sixty this week and have been at least ten degrees warmer than average for the first ten days of February. Those ten days have been the warmest first ten days of February in the last 150 years. I plan to enjoy this encore performance of winter, and I hope that whatever is on your agenda for this weekend you will be able to set aside the worries and cares of a world in chaos from wars and crazy politicians and find a little peace and quiet. Perhaps looking for a tranquil forest scene is what we all need to do.
Be well,
Gene
