10 August 2018
Dear Interested Reader,
Why Is Healthcare Such A Nightmare For Patients (Consumers)?
I am sure that as the 2018 election process moves forward from the statewide primaries to final events in the fall the continuing controversies over healthcare will remain as one of the top issues that determine which party will control the next Congress. The question on the mind and lips of every political pundit is whether or not the Democrats will “take back” the House and even possibly the Senate. Recent history favors the party that opposes the president in “mid term” elections.
If you are lucky enough to have employer provided insurance, you may not be so worried about healthcare as a political issue unless you have empathy for those 44 million Americans who do not have coverage at all, or the 38 million who have inadequate coverage. Perhaps you are wise enough to know that none of us can count on coverage if we lose our employment. All of us could lose our freedom from worry about preexisting conditions even though the ACA survived the last Congress. You can count on continuing Republican efforts to undermine the ACA if they retain control of Congress. The residual benefits of the ACA will remain in jeopardy as long as Trump is in the White House. His administration is getting better and better in their continuing efforts to undermine the ACA, Medicare, and Medicaid through administrative directives. We can only imagine the potential of decisions that will negatively affect healthcare once we have a solidly conservative majority on the Supreme Court.
If you are not worried about losing your own coverage, or about your own rising out of pocket expenses, you are most likely not worried about the vulnerability of coverage and slim benefits of those who depend on Medicare or Medicaid. If you think that no one should get anything for free and that a lot of the people getting “welfare” are “shiftless low lives” who spend their days in a drug haze, you are probably not cognizant of the fact that a large portion of the public dollars spent on Medicare, Medicaid, and the CHIP programs are going to provide care for the elderly, the disabled, and the young whose parents are the working poor. The underserved and neglected members of the community may not be a concern that interests you, and they are certainly not your problem or a high priority.
If you are a self reliant, entrepreneurial type of person who sees the government as the major obstacle to your personal success then you will probably pull all the Republican levers you can find in any voting booth for fear that if you are not vigilant Nancy Pelosi will take over despite the best efforts of Vladimir Putin. Perhaps you are thinking: “The stock market is up. I got a big boost from the tax bill. With a little luck, maybe we can keep this show going long enough to free me from the monthly payments that the ACA saddled me with for the insurance coverage for my employees.”
At a high level it is easy to see how the political debate over healthcare coverage and who pays for it is a divisive issue grounded in issues of personal philosophy, life experience, culture, and world view. What surprises me is how rarely the poor service, extraordinary out of pocket expenses that are coming to more and more people who have “coverage,” and the barriers to quality care that we all experience, whether we are covered or not, are not issues that initiate a bipartisan call for improvement. If out of pocket costs and unreliable service and quality do not unite us, then surely getting generally gouged in a very egalitarian way by big pharma, or collectively having millions of hours lost from life waiting for medical services should pull us together into a united front for some sort of change.
Why should the citizens of those NATO nations that the president says are not paying their fair share for defense while also using unfair trade policies to rob us get such better deals than we do from big pharma? Why do they live longer? We really must be chumps as the president implies. Putting it all together, it would seem that if the Democrats could focus on the service and expense disasters experienced by consumers of healthcare that are exacerbated by Republican policies or neglect, they should be able to attract enough independent voters to overcome the amazing Republican ability to get people to vote against their own best interest by making them afraid of their neighbors and progress.
I have never liked to talk about “consumer issues” in healthcare. It has felt to me that too much of the healthcare conversation has taken on “business” overtones. Perhaps that is the result of the universal misinterpretation of Sister Irene Kraus’ famous statement, “No margin, no mission.” If her words were not misunderstood, I feel at times that they have been twisted to yield an alternative meaning, “The mission is to make a margin.” Either way, whether you are from my camp that favors a focus on the charitable mission of healthcare and feel that healthcare should be an entitlement for everyone, or if you have a different world view, invest in healthcare, and see it as a business that should be operated to make a buck, we should be able to form a consensus around the shared necessity of a good consumer experience for patients and families.
Much has been written about how healthcare is so different from other industries. Some healthcare strategists have bemoaned the fact that very few effective examples exist in healthcare that demonstrate a coordinated product or service across all providers, institutions, and suppliers. Kaiser may be the exception. Kaiser does the best job of delivering a complete product at a scale of any significance. In the world beyond healthcare good businesses usually succeed by focusing on improving the consumer experience. Why healthcare has been so slow to become aware of the importance of improving the consumer experience as a path to success compared to other industries is a very interesting question that most of the experts who study healthcare rarely try to explain. Until this week, the best attempts that I had read were Elisabeth Rosenthal’s An American Sickness: How Healthcare Became Big Business and How You Can Take It Back and Robert Pearl’s Mistreated: Why We Think We’re Getting Good Healthcare — And Why We’re Usually Wrong. Both are well written, incorporating personal experience with sold business analysis, and are an accurate representation of facts. Now there is a third book to add to our understanding of why things are the way they are. I think this new book may get us even closer to the real answers that we can use to guide more effective strategies to improve the experience of all patients and perhaps lower the cost of care. A clear understanding of what is really happening is the first step in the search for effective solutions. Choice Matters: How Healthcare Consumers Make Decisions (and Why Clinicians and Managers Should Care) written by Gordon Moore, John A. Quelch, and Emily Boudreau may be the book we that we need. If you click on the link you can read about a third of the introduction; that is enough to give you a flavor of the book and help you recognize that it is a special book that may provide the answer to questions like the ones I posed above about why things are the way they are.
I became aware of the book when I received an email last week from Gordon Moore, the lead author, who is also an occasional “Interested Reader,” and is an old mentor and colleague of mine from Harvard Community Health Plan and Harvard Vanguard. Gordon was hoping that I would look at the book and if favorably impressed perhaps tell others about it. I immediately went to Amazon and ordered my own copy which I received just three days ago. The book is published by Oxford Press, a prestigious academic publisher. It is a very scholarly offering with the sort of documentation that makes it seem like a very long article in the New England Journal of Medicine. Despite the academic rigor it is very well written and reads easily while dense with important observations. If you like to underline what you read, you will go through a few markers.
Gordon is now a Professor of Population Medicine at Harvard Medical School. Years ago he was the first leader of the Cambridge office of HCHP which opened in 1977 as the second site of Dr. Ebert’s organization. Later he had a stint as the Medical Director and Chief Operating Officer of HCHP and then found his real calling as one of the leaders of the teaching arm of Harvard Community Health Plan and then Harvard Pilgrim Healthcare. Through his long career he has been a great PCP and always a scholar.
John Quelch is the Miller University Professor at the University of Miami, Dean of the Miami Business School, and Vice Provost for Executive Education. Emily Boudreau is a PhD candidate in Health Policy and Management at Yale. The authors weave their individual talents and expertise together as one very thoughtful voice. I am envious of their prose.
It did not take long for me to realize that this book contains fabulous insights into the question of why healthcare has done such a poor job of addressing the issues that frustrate patients and families. I like footnotes, long lists of references, and links. Early in their lengthy introduction they use a footnote to address a pet peeve of mine, using a business term, consumer, instead of a medical term, patient. I accept their reasoning.
The distinction between patient and consumer is an important one in this book. At times, medical consumers, such as when they chose an insurance plan, are not patients. At times they are a consumer and a patient simultaneously, such as when they are making a financially influenced choice about whether to pay for a test or a treatment. And when a person is severely or urgently ill, individuals are almost always predominantly patients. In this book, we try to use the convention of referring to people as consumers in the first two categories, and patients in the dire circumstances of the latter or when the context is specifically only medical…
Their explanation is a first step toward answering my question, “Why is healthcare such a nightmare for patients (consumers).” Until now my aversion to “consumer” was that it felt like part of the reason healthcare was feeling more business oriented than care delivery oriented. “Consumer” resonated with me as dissonant in the context of “patient centric.” The second insight that followed the course correction on “consumer” was that for several decades now American healthcare has more often been arranged as a business to business concern rather than as a business to consumer concern.
I will not reproduce much of their excellent analysis and historical presentation, but it is worth your attention. Employers do buy services in bulk from insurers and insurers deal with providers who accept patients in groups and not as individuals. The patients’ concerns, or consumers’ concerns, are secondary to the business to business concerns. That one concept alone provides as much new insight as the entirety of the Rosenthal book which did not describe the system as it functions in a B2B mode and never clearly explained just how the business structure of healthcare, which is a function of its finance and complexity, is the root cause of so many of the ways in which it frustrates and fails its consumers. Their second observation, which adds to the enlightenment of their first point, is that healthcare, because of the B2B structure, is “product centric” rather than customer centric. Because of competition, the availability of many choices, and social media with reviews and comments on the Internet other businesses are more consumer centric than is healthcare. The next insight should be obvious to us all: Things are changing. Healthcare can no longer avoid the best interests of its consumers. In the future success will require a greater understanding of what consumers want to chose that will give them a better experience.
My personal experience is consistent with their observations. I am at an age where most of my contacts need to go to the doctor and the hospital more and more each year. When we gather we talk about our illnesses and experiences with healthcare. In those conversations with friends and family I hear more complaints about service defects and disappointments than ever before. The service defects have become an expected burden that are born as unfair and needless additional sources of pain even as the individual portion of the cost of coverage and the out of pocket expenses are rising. Paying more and getting less is not a good trend for your customers, clients, or patients to experience. Those conversations suggest that there is a sense of being trapped in a situation beyond one’s control and that feeling generates anger and demands for change that could rise to the level of political action. The authors suggest that:
“The key tasks for healthcare are to understand how individuals form opinions and make decisions, how segments of consumers differ, and importantly, how organizations should respond to that information.”
In last Tuesday’s posting I referred to the fact that few physicians and healthcare professionals really understood how funds flowed into their practices and hospitals. In essence they did not know how they were paid. After getting into Gordon’s book I am ready to accept that many professionals really do not understand or think about how the complex web of providers and suppliers work together for their own best interest putting what really matters to the patient into a strangely secondary position.
Patient centric thinking can only increase if we follow their advice. I plan to read on and hope to pass on many more “pearls” as I come to them. Better yet, I would say that if you are looking for the next good book on healthcare to read, Choice Matters: How Healthcare Consumers Make Decisions (and Why Clinicians and Managers Should Care) written by Gordon Moore, John A. Quelch, and Emily Boudreau is a good choice.
August Thoughts: Joys and Realities as Summer Days Dwindle Down
As you can surmise from seeing another header on this letter that pictures loons, I never tire of looking at them. This week you see our youngest loon, who is not yet two months old, getting a snack from one of its parents. My wife was delighted when they appeared a few yards off shore from our home last Monday. She moved quickly and was lucky enough to catch them with her Nikon as they cruised by on their morning rounds of the lake.
You may remember that the loons on our lake have had a hard time over the past few summers. Last year the mother laid eggs and sat on them for about three weeks, but then for some reason she abandoned the nest. The experts from the Loon Preservation Committee could not determine why. As I reported in June, this summer was different. Two baby loon chicks were hatched. About a month ago I was sorry to report that one baby loon had been lost. Just what happened remains a mystery, but it has been a joy to watch the surviving chick grow. As this week’s picture shows, the focus of our interest, and some affection, has been on an amazing growth spurt as you can see by comparing today’s picture with the one from July 17. The juvenile loon has a lot to learn. He/she is learning to dive and fish. I expect to see some flying lessons soon because by mid October the youngster will need to fly to the coast of Maine for the winter.
Hearing the loons call at night can send a thrill through your whole body. Seeing them pop up near your kayak unexpectedly is a surprising and exciting experience. Last weekend my wife and some friends were sitting by the lake when they heard something unusual that she then posted on her Facebook page:
We saw an amazing sight this morning. The eagle’s cry alerted us to look in his direction just in time to see him swoop down toward a loon on the lake. The loon dove for cover as the eagle hit the water, then flew to the top of a nearby tree where he sat vigil for over 10 minutes. The loon popped back up and gave a couple of guttural cries, then just floated quietly. The eagle finally starting flying in ever larger circles until he finally flew away.
As she describes, we have a nasty eagle that considers the lake to be his kingdom. It “shares” the lake as an impressive predator with the loons, as well as a mother merganser with ten chicks.The mergansers are a quirky bunch that move in close order drill under the cover of bushes along the shoreline. I favor the theory that it was the eagle that got the baby loon we lost.
It’s been a wonderful summer, though we have had more hot days with violent afternoon storms than I can remember in the past. I wonder facetiously about “normal cause variation” versus global warming. It’s approaching that time in August when I review all the things that I had planned to do and realize that the even though it is not yet September in my mind’s ear I can hear Sinatra singing “the days dwindle down to a precious few.” The NFL is beginning its preseason, and the Patriots seem to be a continuing soap opera not unlike the White House, in which the rich and famous continue to vie for the attention of a press that wants to write every day about innuendo laden events. Unlike so many years in the past, the Red Sox offer a daily thrill and seem assured of post season play, but it’s not baseball that puts me in a reflective mood.
Despite a great season I have some angst that must arise from realizing that there is not much summer left. We have had a drove of wonderful guests, and we are anticipating great visits from friends and family in the next couple of weeks. I think my occasional moments of pensiveness do not arise from what I have either seen or done, but rather from a tinge of regret over what I did not do.
I had planned to do a lot of sailing this summer. I have not. My boat sits at the dock and I spend more time pumping out the most recent deluge of rain than hoisting the sail. I’ve done less fishing than in most years. I am out on the lake frequently, but I have not fished the Sugar, Mascoma, White, or Connecticut rivers this summer as I have done so often in the past. I have purchased items from the hardware store for projects that have not even been started, much less completed. These realities do not rise to the level of legitimate regrets; they are just the result of a summer that has been overscheduled with travel that has taken me away from where I love to be. There has been much to enjoy, but there are choices to make in the “zero sumness” of every summer.
I hope that you have been a good steward of your summertime, and that over the weekend you will build another great summertime memory that will be available for reflection on some cold winter day in the not too distant future, or if you prefer, an experience worthy of a post on Facebook.
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
