July 1, 2022
Dear Interested Readers,
Does Healthcare Improvement Still Have A Chance To Get Any Attention?
It seems like a long time since I have heard or read much about Medicare For All or any other proposal to expand coverage to the ten percent of Americans who have no coverage. It seems that we have come to expect that high out-of-pocket charges are a reality. Do you just take a deep breath, shrug your shoulders, and fork over more cash than you expected to pay when you pick up a prescription? I have had those experiences. My wife and I just hope that we don’t need care because we don’t want to be surprised by the “unexpected charges” we fear might occur. If they add a little contrast to an MRI, the bill changes dramatically. I know that being afraid of getting the care you need doesn’t make sense, but for many people, it is a part of the dystopian mood of the moment.
In much of America, the idea of primary care is becoming a fantasy or a distant memory. It is the rare PCP who is accepting new patients in the “Upper Valley” where I live. The Upper Valley is an economic area composed of the communities lying along a long swath of New Hampshire and Vermont on either side of the Connecticut River and along Interstate Highways 89 and 91 that runs from a little north of Concord north almost all the way to Montpelier. Dartmouth Health is the primary provider of care in this region and most of its practices are closed. If you think that is an exaggeration, click on the link and read the article from the Concord Monitor published less than two months ago.
We have known for a long time that rural America has had a problem with access to care. The pandemic has made a big problem worse as was noted by David Blumenthal and colleagues in a New England Journal article entitled Covid-19 — Implications for the Health Care System. The article is a great review of all the cracks in our healthcare system that have been revealed by the pandemic. Early in the article, they reference the impact on rural hospitals, safety-net hospitals, and their primary care practices:
For the first time since the Great Depression, crippling financial losses threaten the viability of substantial numbers of hospitals and office practices, especially those that were already financially vulnerable, including rural and safety-net providers and primary care practices.
As I have winded down my professional responsibilities, I have had a window on the stresses that the pandemic has placed on both safety-net and rural healthcare systems. In December I retired after ten years from the board of Guthrie Health a large rural system in the “twin tiers” of south-central New York and north-central Pennsylvania. Guthrie provides care to a large area of small towns, and a few small cities that dot a very rural landscape. This last Wednesday was my last board meeting at the Boston Medical Center, the largest safety-net hospital in the northeast where for two terms I have served as an “independent trustee” and chairman of the compensation committee on the board of the Boston University Medical Group which employs more than 1000 physicians and advanced practice clinicians that provide care in the hospital and clinics of the system.
I have thoroughly enjoyed both experiences. Both institutions advocate the values that I respect and have always sought to advance. Both institutions serve very large disadvantaged populations. Many of Guthrie’s patients are working-class White Americans who live on farms or work in small local companies. Many of these patients have known the difficult economic times that induce deaths of despair and substance abuse. During my time on the board “fracking” became an economic and potentially toxic reality in the region. The shooter in Buffalo who was out to kill African Americans out of his distorted concerns about “replacement theory” lives in one of the counties in New York that Guthrie serves. The population at BMC is very diverse and demonstrates all of the difficulties associated with the challenging social determinants of health.
If you examine the websites of both organizations it is easy to see that they are dedicated to achieving the objectives of the Triple Aim. They speak the language of quality and safety. Both boards have strategic plans to improve the quality and safety of the care they provide. Both organizations have invested in technology like Epic that can help them in the challenge of continuous improvement. Guthrie utilizes Lean in its efforts to improve care and find efficiencies that improve finance and all the domains of quality.
All of the clinicians I met during my time on both boards demonstrated a desire to provide care that was patient-centered, safe, timely, efficient, effective, and equitable. Both organizations are concerned about clinician burnout and are making efforts to provide gender and racial equity in their clinical and leadership opportunities. The Boston University Medical Group board has done intense surveys of clinician satisfaction and has taken dramatic steps to rectify and erase all inequities in compensation and professional opportunities. Both organizations try hard to effectively support their clinicians and are concerned about the time and effort clinicians must spend at home on their computers.
Recruiting new doctors and nurses is harder for both organizations than it might be if they were located differently and served less challenged populations. My assumption has been that many young physicians and nurses are not interested in living in a small town without the cultural activities of a large metropolitan area or working in the inner city where extreme poverty, homelessness, and other social difficulties burden their patients. I have always believed that those clinicians who are willing to practice in challenged communities deserve our respect because the work is often harder and the pay is frequently not matched to the extra effort required. Despite those barriers, I had the pleasure of meeting many clinicians who had with missionary zeal lovingly dedicated over thirty years of service to their very challenged patients.
The populations of both institutions superficially appear to be quite different, but if we look past “race” and location they become strikingly similar. Large portions of both patient populations are poor. Both practices have large patient populations with complex chronic conditions. I don’t have exact numbers but my educated guess is that life expectancy is lower in both groups. The pandemic was a huge challenge to both organizations because of the services required, supply chain problems, workforce shortages, and great shortfalls in revenue precipitated by the lockdown. Both organizations depend primarily on fee-for-service income. Both derive much of their revenue from Medicare and Medicaid. Both are disadvantaged in their contracts with commercial insurers.
I know they are disadvantaged because as the CEO of an organization that did not face nearly as many workforce or demographic disadvantages we were able to negotiate commercial contracts that paid more than twice the revenue that Medicare offered. Most of our patients had insurance from employers. Most of the communities we served were “upscale” or solidly “middle class.” When I began to practice all my patients were employed. My oldest patients were in their late fifties or early sixties. We needed pediatrics, obstetrics, and psychiatry more than we needed systems of chronic disease management. When I retired from the practice 38 years later, some of those who were in their fifties when I started were in their nineties and on Medicare and we were one of the original Medicare Pioneer ACOs, but still, Medicare and Medicaid were not our primary payers.
In our country organizations that depend on fee-for-service income can’t survive without elective procedures. It’s the “hearts, hips, and knees” that pay the bills. Fee-For-Service income fell like a stone the moment that COVID became an obvious problem to the health of the nation and the nation’s economy. As I sat in board meetings, I was aghast at how fast the budgets of the organizations for which I shared some fiduciary responsibility headed into oceans of red ink. Both organizations did survive because they are blessed with very competent management teams, rapidly switched much of their care to virtual visits online, and were the recipients of tens of millions of dollars provided by the CARES Act (the “Coronavirus Aid, Relief, and Economic Security Act”) passed in March of 2020 during the Trump presidency and the emergency federal support through ARPA, The American Rescue Plan Act, passed early in President Biden’s administration and other programs. In Massachusetts, there were extra funds and efforts from the state to minimize the losses.
You might say, “So what’s the problem?” It is true, that emergency measures were employed, and the financial meltdown of critical institutions was avoided through the efforts of competent local managers and supplemental payments from the state and federal governments. At my last board meetings of both institutions, it was obvious that problems persist, but unfortunately, the relief funds are drying up fast and a “resupply” of outside support seems unlikely in this environment.
The next financial cycles look very challenging because of the substantial increases in workforce shortages and the need to pay much more for professional services in the post-COVID world. Workforce problems are a “double whammy” that reduces access and increases expenses for care recipients and care providers. In what we hope is the twilight of COVID, many people who need care can’t get the appointments they need, and when they do get in to see a doctor they are challenged by the costs that have been shifted to them. The surprises continue when they pick up their prescriptions.
The Blumenthal paper noted earlier deserves your attention. It was written two years ago, but Dr. Blumenthal is prescient and was asking the questions then that are still the questions we should be addressing, and are not. He writes:
The United States has fiercely debated for nearly a century whether and how to protect Americans against the cost of illness. That debate has generated steady incremental progress that most recently, through the ACA, reduced the numbers of uninsured Americans to a historic low of 28.6 million in 2015. Will a sudden increase in uninsured Americans create the political will to expand coverage again?
I don’t hear that debate now, and I don’t think Dr. Blumenthal is surprised that most of his observations and suggestions have failed to stimulate much discussion. He and his colleagues end the article by saying:
The Covid-19 pandemic recalls once more the old truism attributed to Winston Churchill: one should never let a crisis go to waste. We may now have the opportunity to reform a flawed health care system that made the novel coronavirus far more damaging in the United States than it had to be.
I bolded the words above that give me the feeling that he did not expect much. He does not say, “I anticipate that we will take this opportunity to reform a flawed healthcare system…” Whether in July of 2020 he thought a positive change would occur or not, once we were over COVID, there is no evidence now two years later that any near-term improvement is likely. Healthcare improvement seems to be way down the list of priorities that politicians are discussing now as we approach the midterm elections this fall.
Our attention is directed toward an illegitimate Supreme Court populated by a supermajority of conservative judges appointed by a process controlled by minority leaders that thumbed their noses at the “norms” that make our Constitution work. The opinions of this court feel like they are more aligned with the political motives and values of a repressive theocracy/kleptocracy coopted by a wealthy elite in collusion with religious conservatives rather than the thoughtful pronouncements of the wise and unbiased court of a vibrant democracy. A controlling minority of about a third of the country is more concerned about a loss of their sense of supremacy and short-term earnings and inflation than the habitability of the world that they will bequeath to their children and grandchildren or improving the health of all Americans. On the international scene, we are beginning to expect that heating homes, filling tanks, and keeping Europe’s industries humming will be considered more critical than holding Putin accountable for his atrocities. Healthcare improvements seem to be far down the list of anything a divided government can accomplish.
We live in a country where a football coach’s ability to say a prayer at midfield on public school property is more likely to be granted by the courts than any effective effort to keep concealed weapons off the streets or AR 15s out of the hands of those who have some need to kill school children or people who have always been an oppressed minority. With the abolition of Roe, the New York gun decision, and yesterday’s decision to curtail the regulatory responsibilities of the EPA our Supreme Court has become a public health hazard. It seems to me that there are many political issues to be resolved before we will be able to effectively consider the improvements in healthcare delivery, healthcare finance, or public health that should be high bipartisan priorities. Between now and whenever, or if ever, our politics allow a return to a consideration of healthcare, many people are going to suffer as patients and providers of care in systems that want to be better but are challenged by external difficulties largely generated by a deep partisan divide between a controlling minority and a poorly organized and diffuse majority.
I keep hoping for a miracle. I don’t think we should ask God to fix things that we have brought on ourselves and have the ability to resolve if there was a collective will. I was listening to a theological podcast this week that was entitled “Christianity as a Set of Insistent Questions.” I may have interpreted the message incorrectly, but they seemed to be saying that perhaps all religions should be asking more pertinent questions than making definitive statements about what is right and wrong and who is in or out. One of the voices, a gifted African American woman, made a statement that captured my attention and got me thinking. She said something like, “We are hiding in the collective where no one is responsible.”
I did an Internet search on that phrase and found some interesting comments from pop psychologists who talk about the “diffusion of responsibility” as an explanation for group behaviors. It is a possible explanation for why problems go unaddressed or why it seems so hard for us to avoid some collective disasters. I wonder how many more people would have voted in 2016 if they could have had a preview of what the next six years would be like. I can only hope that a supermajority of Americans come to the conclusion that their votes count, and if they want to live in a country where they can be sure that they and their children and neighbors will get the care they need, have control of their own reproductive lives, and can rest assured that their children will come home from school alive, they need to immerge from the silent and uninvolved “collective” and assume the responsibility to speak up about what is wrong and vote for what is better.
Beautiful Evenings
I love long summer evenings. The world may be crazy, but on a quiet summer evening, I can easily imagine it is very far away. We have been enjoying a spate of the most beautiful days with mostly clear skies, bright sunshine, and temps in the mid-seventies with low humidity. The days are predicted to be warmer this weekend. We may hit ninety again, but it is the Fourth of July weekend and some heat feels appropriate. I love the summer days, but the peaceful summer evenings are what I enjoy most this time of year.
As much as I enjoy a cloudless sky during the day, I must admit that I do like a partly cloudy evening. The other difference between the daytime and evening is the wind. During the day we often have a breeze that ruffles the water. The breezes are great for sailing unless the wind really blows and the ripple becomes a chop. I don’t know why it happens, but as the day fades to evening any wind we have usually abates and the surface of the lake becomes a giant mirror.
The picture in today’s header was taken on Monday evening. It reveals my ideal of the perfect summer evening. I like a few clouds to make the sky more interesting. The picture looks north from my dock. Although I can’t see it, I know that the sun has just set below the horizon to the left, but it is still lighting up the sky, and the clouds reflect the last light of the sunset onto the water below. I know that this is true because on many other similar evenings I have been out on the lake in my kayak watching the sun go down.
Monday evening I was enjoying the tranquility of my lake from a comfortable seat on our dock. I was just waiting to see if the loons would cruise by or if some other unexpected pleasure might appear. My reflection was broken by the sudden realization that the day was fast becoming night, and I wanted to capture the peaceful feeling of the moment. I was being treated to a feast of muted colors with various hues of blue, gray, and some gold that were fading fast. A few minutes earlier there had been some pink and muted red that had already faded. The surface of the lake was a mirror that multiplied the beauty of the experience. At that moment, I had a need to try to capture the scene. I hastily took a couple of pictures and then the show was over, and I was left feeling that perhaps the world is not completely spoiled, yet. It was a transcendent experience.
I hope that this Fourth of July will be both fun for you and safe if you are one of the millions who will be traveling. In the midst of all the travel and socializing I hope that you might be surprised by a moment of unexpected beauty and transcendence.
Be well,
Gene
