May 24, 2024
Dear Interested Readers,
A Conversation That Gives Us Guidance
Regular readers of these notes know that I have high regard for the Commonwealth Fund. I quote their articles frequently. I am grateful that in the sixties Dr. Ebert won significant financial support from the Commonwealth Fund that enabled the founding of the Harvard Community Health Plan. I have referred dozens of times to the letter that Dr. Ebert wrote to the president of the Commonwealth Fund in 1965 asking for financial help to fund his dream. It was from that letter that I lifted the quote that I use most often as the best foundation for strategies to improve healthcare.
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
I love what you read when you go to the homepage of the Commonwealth Fund where they boldly state:
We are a foundation dedicated to AFFORDABLE QUALITY HEALTHCARE. FOR EVERYONE.
We support independent research on health care issues and make grants to promote better access, improved quality, and greater efficiency in health care, particularly for society’s most vulnerable, including people of color, people with low income, and those who are uninsured.
I know of no other organization with a statement of purpose that resonates better with me and the messages that I try to deliver week in and week out in these notes. I don’t mean to slight the efforts of other like-minded organizations like the Robert Wood Johnson Foundation, the Milbank Foundation, and the Institute for Healthcare Improvement (IHI). They are all great, and they are all contributing to the effort to improve equity, quality, and cost in our system of care.
For many years, Dr. David Blumenthal was president of the Commonwealth Fund. Last January, in these notes, I introduced Dr. Joseph Betancourt who had just completed his first year as Dr. Blummenthal’s successor. In that post, I introduced Dr. Betancourt with a review of his accomplishments and qualifications before summarizing some of his observations after a year of talking with people who work at the Commonwealth Fund and reviewing their ongoing programs. He also briefly discussed the state of healthcare in the country.
You can imagine my excitement when I noticed in the newsletter from the Commonwealth Fund this week the following notice:
Betancourt’s Blueprint for an Equitable Health System
In Dr. Joseph Betancourt’s vision for the future of U.S. health care, “any patient who goes to any health care system around the country should get the highest quality of care, no matter who they are or where they’re from.” As the Commonwealth Fund’s president, he’s tackling some of the biggest challenges facing the U.S. health system while trying to ensure equity is embedded in health care policy, coverage, technology, and practice. Join host Joel Bervell for a wide-ranging conversation with Betancourt on The Dose podcast.
The podcast was terrific. It is 28 minutes long, and in that brief period of time, Dr. Bettencourt touched on almost every theme that I discuss in these notes. Click here to listen to the podcast or read the transcript. Read on to get my comments about the high points of the conversation. Dr. Betancourt’s interviewer is Joel Bervell, a Ghanaian-American medical student at Washington State University and the regular host of The Dose podcast which is produced by the Commonwealth Fund. In the introduction, Mr. Bervell reviews Dr. Betancourt’s impressive resumé.
JOEL BERVELL: My guest today on this episode of The Dose is Dr. Joseph Betancourt, president of the Commonwealth Fund. It’s a role he stepped into just about one year ago, and it’s a bit of a full-circle story, because as a freshly minted M.D. and researcher deeply invested in health equity matters, Dr. Betancourt was a Commonwealth Fund fellow.
In the intervening years, he was most recently senior vice president for equity and community health at Massachusetts General Hospital and was founding director of the Disparity Solutions Center. He has devoted his career to improving the quality and value of health care for diverse populations. As an associate professor of medicine at Harvard Medical School and a board-certified internist, he has spent much of his career providing primary care to a large Spanish-speaking patient population. And he’s also an Aspen Institute Health Innovators fellow and was named one of Modern Healthcare’s Top 25 diversity leaders in 2022 and in 2023, one of the top 50 clinical health care executives in the United States.
The first question to Dr. Betancourt zeros in on why Dr. Betancourt cares so much about healthcare equity. Throughout the interview, I will bold the statements that I see as particularly impactful. I will not be presenting every question that Mr. Bervell asks. I hope that the ones I do present will encourage you to invest the half hour necessary to hear the whole interview. Dr. Betancourt speaks with passion.
JOEL BERVELL: So health care in America is highly complex. It’s dramatically divided, and it’s a space where equity is an ideal and hardly a reality. You’ve been on the front lines clinically, and you’ve even created frameworks to address disparities. Why come to the Fund and what’s the impact you most want to have?
JOSEPH BETANCOURT: Well, thanks so much. It’s a great question and it’s really an amazing journey. I’d say that, as you mentioned, the issue of health disparities, of health equity is not an academic pursuit. It’s not a research pursuit of mine. This is a life passion. It comes from my lived experience growing up in a bilingual white culture home from a Puerto Rican family.
I got to see firsthand the impact of race, ethnicity, culture, and class on health care delivery, getting a chance to really aspire and live out the dream, despite a lot of challenges along the way to be a doctor.
It became very clear to me when I was in your shoes as a medical student that, number one, in medical school there weren’t a lot of people who looked like me. Number two, the simple fact that I spoke Spanish made me an asset on clinical rounds. And number three, that people were receiving different quality of care based on personal characteristics like race before we started talking about minority health or health equity.
So that was a springboard really for me, trying to think about ways in which I could improve health care for more than just my patients who I saw, but really with a focus on public health and health policy….
The conversation continues:
JOEL BERVELL: I’d love to know what’s the impact that you’re wanting to have while at the Commonwealth Fund?
JOSEPH BETANCOURT: We have had impact throughout our hundred years in a lot of different ways. The Commonwealth Fund, which, by the way, was founded by a woman, Anna Harkness. A lot of people don’t know that — really, really important. Made early operational contributions to create the first public health departments, the first medical schools in urban areas, the first public hospitals that led to the Hill-Burton Act that led to the construction of hospitals across the country. That led to a lot of the research that ultimately launched the Affordable Care Act.
So as I think about the future, right now we operate across a series of programs that really focus on three areas, I’d say, maybe with a fourth: coverage. So how do we improve coverage and make it more affordable, accessible; care, how do we make sure it’s equitable and high quality; and cost, how do we make sure that all of this is cost-effective. We do this not only domestically, but we do it internationally.
I would say that equity is embedded in everything we do. Of all of our programs, our health equity program is our largest. But I think what I’ve learned over the course of my career is while I want to lift up our equity work, we really, really need to think about how equity is integrated in all the different areas of our work.
Because in fact, when you think about coverage, when you think about cost, when you think about care, you cannot achieve any of those effectively if you’re not considering equity. And if you’re not considering how these issues impact all people, no matter who they are or where they’re from, and we know we have fallen short on that historically, and even to this day.
JOEL BERVELL: There’s been a huge amount of innovation in health care in the past century. And as you mentioned, the Commonwealth Fund has been around for a little over a hundred years. Is race at the core of the persistent gaps today in health care?
JOSEPH BETANCOURT: There’s no doubt that race has been a major factor in American history. And it not only impacts health care — and we have now thousands of papers that have documented differences in health care quality, health outcomes, based on race — but it impacts all facets of our society. It certainly intersects with other things, like class and gender and sexual orientation…
…So, we need to have the courage to talk about them, and race needs to be part of that conversation, absolutely.
JOEL BERVELL: Are there specific areas that you think need elevation at this particular moment?
JOSEPH BETANCOURT: Absolutely. I think we understand that any major health care issue has an equity component and vulnerable populations are always at greater risk when we talk about any major health care issue…We are undoubtedly seeing a significant pendulum swing, perhaps to an extreme, as it relates to what many are calling the commercial drivers of health and health care or the financial drivers.
… while we do need financial investment to make the health care system more efficient and effective, that financial investment and the return on that financial investment also needs to yield better health care quality and better outcomes for people. That alignment of financial value with value around health care cost, quality, safety is really, really critical.
… So these commercial drivers, whether it be private equity’s larger role in health care, whether it be consolidation of large health care systems, we will study that. Our view is that any investment, while certainly appropriate to yield financial returns, should also be required to demonstrate improvements in health outcomes…
I’d say the second, and to some degree related to that, are issues that are really pertinent to the health care workforce. So the health care workforce is no doubt coming out of the pandemic fatigued and burned out, but what I would argue is the health care workforce is also going through another very significant challenge…. I’m a primary care provider, so I could speak to this very directly, the increasing demoralization, sense of moral injury, administrative burden that we’re facing…
Dr. Betancourt continues to practice primary care and what follows is based on his “lived experience.”
Really finding that meaning in health care and in places like primary care, this is a real crisis, a worsening crisis. The primary care workforce is thin… People are retiring from that workforce. People are not going into primary care due to some of these challenges around administrative burden and compensation.
I’d say finally, a couple other things that we’re going to stay focused on. Certainly equity. Behavioral health is a major challenge. Climate obviously a major issue. And I don’t think anybody in health care is not discussing artificial intelligence. So, we’re trying to see what role we could play in those areas, but those are some of the pressing areas that we’re thinking about as a foundation.
Mr. Bervell asks a follow-up question to dig deeper into Dr. Betancourt’’s insights about the crisis in primary care and how the Commonwealth Fund is seeking to address this critical problem.
JOEL BERVELL: So hopefully I’m not overstating this, but I’m alluding to something you mentioned in that answer, and that’s that primary care in this country right now is in crisis…
I’m wondering if you see a roadmap. How do we shift their way of resources and attitudes to focus on well-being rather than disease treatment and this increasing specialization of health care?
JOSEPH BETANCOURT: …I’ve been a primary care provider for over 25 years. I’ve seen the landscape change. There’s been really incredible advancements, some that are in many ways a blessing, but in some ways a curse, even the electronic health record.
How I could engage a patient now is incredible with the amount of information I have about where they’ve been, what they’ve done, their results in a moment’s time, incredible innovation, and improvements in quality. But we need to mitigate the administrative burdens, and I think primary care faces that disproportionately compared to other specialties.
… I think all research shows that primary care providers really are essential to any society’s quality of care and health outcomes. We look at this internationally, we see it very, very clearly.
The key challenge here in the U.S. is we absolutely underinvest in primary care. I think we absolutely don’t pay appropriately for primary care services, and by that I mean this fee-for-service model just really doesn’t do well by primary care providers in particular…
…it’s going to be tough to train our way out of this in a timely enough way to really catch up…
JOEL BERVELL: Absolutely. I actually just finished my internal medicine rotation and exactly what you said, I mean, it is the lifeblood and the heartbeat of medicine. It’s the place where people come when an issue first affects them, and so entirely agree that there needs to be more investment there.
Another issue is insurance eligibility, and there’s a lot of complexity within that, but there’s a constant activity to solve for these problems…How do you think about this problem, and the most likely, most efficient ways to fix the coverage gap?
JOSEPH BETANCOURT: …I think we should all be very proud as a nation with what the Affordable Care Act has yielded by way of improvements in coverage. We just saw upwards of 20 million people enroll in the Affordable Care Act, a real demonstration that the American population sees the value of the Affordable Care Act and also sees the importance of coverage. So that’s exciting, and I think that’s been a milestone victory…
So, I’d say a couple things. First, we need to continue to drive on coverage both through the Affordable Care Act and through being more thoughtful about the way we manage redeterminations. Our incredible team that does work on coverage, particularly in I’d say areas of Medicare, Medicaid, commercial insurance, the Affordable Care Act, is working on all of these things and thinking about ways in which we can make this easier and not make it so challenging for people to reenroll. I’d say that’s one.
I’d say second, we clearly also understand that an insurance card does not affordable, accessible access to care make, and so just having insurance doesn’t mean that people are able to see a provider when they need them and they could afford it. We’ve gone a long way to make care more affordable and accessible, but certainly coming out of the pandemic, we have capacity challenges around the country where even in places like Boston where I practice medicine, the wait times to see a primary care provider could be months if you could see one at all.
So our ability to address these issues will absolutely help, not eliminate, but close some of the disparities gaps we see. Coverage does matter, and it does help eliminate disparities. It doesn’t eliminate them completely.
At this point in the interview, Mr. Bervell begins to ask what the Commonwealth Fund is doing to try to support and influence the development of policies that will address the concerns that their conversation has identified.
JOEL BERVELL: You’ve been talking about some really complex health care issues that are occurring right now in our country. What is the work of the Fund in attempting to influence the agenda setting in health care, especially when it comes to policymaking arenas in Congress, and in places beyond as well?
JOSEPH BETANCOURT: We have a long history of real significant engagement with policymakers at the federal and even at the state level. Our teams focused on health care coverage, access, and tracking. Medicare, Medicaid really, really engage leaders in those spaces in very significant ways by determining what research is needed, trying to identify researchers, and leveraging our own subject matter expertise to answer some of those pressing questions, to provide proposed solutions in those spaces.
I would say above and beyond those spaces, we do a lot by way of delivery system reform and thinking about primary care. I’ve been heavily engaged in those discussions. I’ve been engaged in discussions, quite frankly, around private equity and health care. Even at the White House this year, around climate this year, we’ve done a lot by way of, let’s say health equity this year with significant engagements at the federal side and at the state side.
…We’re nonpartisan. Our goal is to provide information that’s timely that drives towards our mission, …
JOEL BERVELL: Absolutely. I am one of a few Black medical students at my medical school, was also one of the first few Black medical students. So it’s hard for me not to think about the various institutional challenges that seem to be shifting slowly and the efforts from professionals of color to accelerate expanding pathways to encourage, recruit, and train more people of color who can provide competent care.
But at the same time, there’s been legislation that’s been introduced that flies in the face of this. Most recently, a bill that was introduced about banning diversity, equity, and inclusion. I’m wondering how do we balance these competing interests of knowing that there’s needed increases in diversity to create access to health care, while at the same time realizing that there are efforts to stifle this?
JOSEPH BETANCOURT: Yeah, sadly, and I think I heard you talk about this in one of your posts, there’s a series of words that have been actively weaponized today, and certainly diversity, equity, and inclusion are among those words. I would argue that what we’ve seen over the last few years with the Supreme Court decision, what we’ve seen with the leveraging of new bills and really trying to restrict this work.
As you mentioned, I think many don’t even understand what they’re trying to undo. I think it’s a weaponization for weaponization’s sake. It’s a politicization of these topics, and I think we need to go back to first principles and really explain what we’re trying to do. Fundamentally, when we think about diversity, all we’re saying is that research definitely and unequivocally states that when you have individuals of different backgrounds, that bring different lived experiences to any situation, that improves decision-making, that improves effectiveness of teams, and health care is absolutely no different.
…it is in no way about changing or lowering standards. It is about finding excellence and promoting that excellence…
When we think about equity, exactly the same thing. Who wouldn’t rally behind the idea that any patient who goes to any health care system around the country should get the highest-quality of care no matter who they are, where they’re from? I don’t have to say equity for us to mean that. People could rally behind that.
When it comes to issues like inclusion, who wouldn’t agree that people want to feel comfortable at work, that they want to feel heard, valued, respected? So that’s I think the challenge in front of us is how we stick to our values, but really try to reel this back to say, we’re not going to get caught up in this kind of woke weaponization, politicization, of what we’re trying to do. We really need to describe what we’re doing in ways that people could rally behind and could deweaponize what we’re seeing today and explain it with clarity. And I think get people to understand this in ways that right now, there’s individuals who are trying to confuse people about these things…
The conversation moves on to a discussion of “tech” in healthcare.
JOEL BERVELL: …So, I want to talk about tech a little bit, and is tech being aimed at the right targets in health care?…
…what about tech investments more broadly in health care? I’ve had one conversation on this podcast about AI solving for racial biases, which seems very promising, but we’re also seeing massive investments without major returns or better outcomes. Does tech have a real role or is there something seductive about thinking tech is going to save us when we should focus elsewhere and on other solutions?
JOSEPH BETANCOURT: I think that there’s no doubt that the science revolution, the tech revolution, genomics, genetic medicine, all this, number one, it’s moving faster than ever. Number two, it absolutely will be promising for the health and well-being of humanity. I believe that.
I think a big challenge will be affordability around all these things, because that’s the one big challenge that we’re facing as we develop these things…
…Here’s the challenge. In my career we’ve always seen, and I think across history, we’ve always seen, recent history, that when we have therapeutic digital and other innovations, there’s always a five-to-seven-year lag to them arriving to vulnerable communities and communities of color. I think that lag costs lives, costs money, and I think that’s a real challenge…
…tech is here. It’s not going away. It’s evolving… we who care about equity need to be involved in the distribution, development, and scale and democratization of all of them.
It was a lively conversation. I don’t know if it was spontaneous or scripted. I assume it was a mixture. What impresses me most is the reality that a focus on healthcare equity is essential to the removal of much of the confusion about what is wrong with our healthcare system and the poor results it achieves. Other takeaways are the need to repair primary care and the threat that the pursuit of profit is to the health of our patients and the professional and emotional well-being of our providers. I was thrilled that Dr. Betancourt identified “moral injury” as an important concern. I believe that a major source of moral injury for many healthcare professionals is their awareness that they work in a system where equity is not a priority. Equity is an assumption in the Triple Aim. Perhaps equity should be considered more demonstrably as a necessary prerequisite to any effective effort to move us toward the lofty goals of the Triple Aim.
The Commonwealth Fund is “non-partisan.” As Dr. Betancourt suggests their success will be dependent upon their ability to articulate concerns and potential solutions that can be acceptable on both sides of the political divide in our multicultural society. It occurs to me that without a deep commitment to equity by all parties on both sides of the political divide, progress will continue to be very slow and dependent on progressive majorities at all levels of government. I wish him well in his responsibility to guide the continuing mission of the Commonwealth Fund. His task will not be easy, but his passion is an asset.
Could It Be A Visual Healthcare Metaphor?
Did you study the picture in today’s header wondering what was shown and why I used it? The picture was sent to my wife because of her role on the board of the Little Sunapee Protective Association. The picture was taken by our neighbor, Peter, who is a drone photographer, and an avid kyaker. I initially felt left out, but I do not think he had my email.
Along with the picture he sent an explanation.
I went out on the lake this morning, my loon friends hung out very close for a while, then while paddling back, I saw a white thing on the surface. I thought it was trash I should pick up so I paddled in close and saw something that seems almost impossible. This is a large small mouth bass, I am guessing around 14-15” long, and it is trying to swallow another fish (not sure the species but seems like a sunfish). The problem is that it’s eyes (and mouth) are bigger than its stomach.
I thought the big fish was dead, but when the breeze blew my boat up against the fish, it moved a bit. It was certainly alive, although probably not for too much longer by the looks of it. No way it can imbibe and ingest a meal that size, right?
Peter is not a fisherman. He was wrong about both fish. The “ingester” is a largemouth bass. The victim is not a sunfish. It is a smallmouth bass. Largemouth bass are predators. They will eat anything they can get down. The diet of a largemouth bass includes other fish, frogs, mice, and anything that crosses its path that it can get into its very large mouth. The question that Peter can’t answer is what happened. Did the largemouth bass finally get his meal down, or did he make a fatal error? I don’t know the answer.
It occurred to me that the picture must be some sort of healthcare metaphor. The best I could come up with was that the picture might represent the acquisition of hospitals and medical practices by private equity firms. If that is the case, could it represent the acquisition of Caritas Christi Health Care by Cerberus Capital Management as I discussed last week. That meal did not go down well.
While much of middle America was under the threat of tornadoes and floods, we have had a pretty good week on the lake. It was clear, dry, and 85 on Wednesday. Yesterday was a little cooler, but just as beautiful. On Monday I began my daily swims. I wore a wet suit because the water temperature was still in the low sixties. It felt great. All my post-op deficiencies are negated when I am in the water. Now that I have proven that I can swim, I am ready to sail. I will need to be satisfied with my old 1972 Sunfish for a while because I need new sails for my old (1972) O’Day Javelin. By coincidence, all my boats, the Sunfish, the Javelin, and my old aluminum fishing boat were all made in 1972 and are still “lake worthy.”
I plan to be in the lake over Memorial Day weekend, but I will not forget the sacrifices that the holiday commemorates. I hope that you are looking forward to something special this “first weekend” of summer. If you come up with a better metaphor to attach to the hungry bass that was choking on a meal that was too big to swallow, let me know.
Be well,
Gene
