October 15, 2021
Dear Interested Readers,
Thinking About Our Failures And The Challenges Ahead
My wife enjoys Facebook and Instagram despite the recent controversies generated by the whistleblower revelation of the darker side of Facebook management. She follows many people who share her progressive worldview and has been “unfriended” by a few of her friends who are conservative and not interested in reading some of the items that she posts or reposts. On Wednesday she shared an Instagram post with me that arrived under the group heading “beingliberal.” It was posted by someone who calls himself “binkybrain.” The sentence structure and punctuation aren’t perfect, but my guess is that the person who wrote it could have cared less about the presentation. He was angry and wanted to vent his feelings to the virtual world. Here is his post.
My wife has cancer, it took 5 months to wipe out 20 years of life savings and that was with insurance. The experience has turned me into a hateful, bitter person. We did everything we were told. We went to college, got degrees, avoided credit card debt, spent wisely, saved a nice chunk of money in savings accounts and retirement accounts and minded our own business. The USA healthcare system took all of our savings and retirement and forced us to refinance our house so that we lost 15 years of equity. This is a country I am supposed to be proud of? I hate this system and anyone that defends it.
Mr. “binkybrain” is not alone in his financial distress induced by medical expenses. Prior to COVID in 2019 CNBC reported:
A new study from academic researchers found that 66.5 percent of all bankruptcies were tied to medical issues —either because of high costs for care or time out of work. An estimated 530,000 families turn to bankruptcy each year because of medical issues and bills, the research found.
One disappointing fact is that the ACA has not made much of a difference in the number of bankruptcies related to medical expenses. Part of Senator Elizabeth Warren’s rise to recognition was that she published similar information in 1999. There has been some pushback on this claim from conservatives, but the pushback does not negate the fact that medical expenses do cause bankruptcy for many families. Perhaps in 1999, the issue was a lack of coverage or inadequate coverage because of policies with limits on preexisting conditions. If that were so, one would have expected improvement after the ACA which curtailed the practice of denying coverage for preexisting conditions and the selling of policies that provided limited coverage. The fact that a high number of bankruptcies from medical expenses still occur after the passage of the ACA suggests to me that the problem is much more complex than a defect in coverage. There is no doubt that the cost of care in America is the highest in the world. It’s been that way for as long as I can remember and the gap between us and the rest of the world continues to grow despite a little flattening of the curve in the nineties and after the ACA took effect.
In August 2020 The Commonwealth Fund published “U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2020.” The “topline finding” reported by the Commonwealth Fund was:
More than 43 percent of working-age adults had inadequate health insurance when the COVID-19 pandemic hit…
The article is a brief report, but its findings deserve your attention since there has not been much interval change. It is very likely that as the pandemic has persisted the results could now be even worse 14 months later since there has been no new legislation that might have caused an improvement. There have been some policy changes at HHS since President Biden took office, and it is true that Arkansas, Missouri, Nebraska, and Oklahoma have accepted the Medicaid expansion since August 2020, but as you can see from a recent map prepared by the Kaiser Foundation there are still 12 states, some with very large populations like Texas, Georgia, and Florida that still deny the benefit of Medicaid coverage to many of their working poor who earn less than 138% of the Federal poverty level. The study has been repeated every two years since 2004. There was essentially no change between 2018 and 2020.
The staggering fact is that 40% of people who are working are still uninsured, or like “binkybrain” are underinsured. “In February 2019 Commonwealth Fund researchers concluded that there were over 85 million underinsured Americans. By his own description, “binkybrain” and his wife were likely to be members of this underinsured group. I doubt that anyone elects to be underinsured. I would imagine that most of the underinsured think they are adequately covered until they develop a complex medical issue that exposes the inadequacy of their coverage. From the anger in his posting, it is clear that “binkybrain” and his wife were surprised to find their insurance left so much of the expense of her illness uncovered that their savings were exhausted by her cancer treatment. It is very likely that until a severe illness occurred they did not know that their coverage was inadequate for the financial challenge they might face. I would hope that you share the same sense of personal failure that I feel when I hear a story like “binkybrain’s” story. If that statement surprises you, you are likely not to be accepting responsibility for the world in which you live and work.
For at least as long as I have been a doctor I have been concerned about the cost of care and those without adequate access to care. Being concerned and actually doing something are not the same. My guess is that most of the readers of these notes have shared the concern that the care they provide is too expensive. We have frequently heard our patients talk about the stress they feel from the unexpected or “surprise” charges associated with their care. We are aware that many employers are reducing the percentage of premiums that they cover. Copays and deductibles are rising. We know that the cost of medicines continues to rise at rates higher than inflation. We are lucky in a perverse way because most of us are not held accountable for our role in the cost of care or our lack of effort to lower the cost. “Binkybrain” did not complain about the doctors. He probably doesn’t understand how the costs are generated. He looked past us and placed the blame at the “systems” level or maybe even higher at the level of the government:
The USA healthcare system took all of our savings and retirement and forced us to refinance our house so that we lost 15 years of equity. This is a country I am supposed to be proud of? I hate this system and anyone that defends it.
Perhaps because “binkybrain” did not understand the role of doctors in the cost of care, you and I, and other healthcare professionals, dodged the bullet that was fired by his pain, financial loss, and subsequent rath. I would guess that he appreciated the care that the oncologists, radiation oncologists, and oncologic surgeons offered his wife. It may have been too upsetting to “binkybrain” for him to ever consider that the compassionate professionals who tried to treat his wife’s horrible disease were culpable at any level. Were we?
Shortly, after I became CEO of Harvard Vanguard and Atrius Health, and at least a couple of years before we had moved as many of our hospitalizations and much of our specialty care away from Partners Health Care to the Beth Israel Deaconess Medical Center and Lahey Clinic because Partners was substantially more expensive without any measurably better quality, I was invited to attend, along with a few other outsiders, a presentation being offered by a visiting dignitary at Partner’s corporate offices at the Prudential Center in Boston. At the time we were theoretically “business partners” although it felt to me at the time that a more accurate description of the relationship was that we were “a source of business for Partners.”
The speaker was Dr. Ed Murphy, the brilliant and innovative young CEO who had transformed a regional system of seven very ordinary hospitals with traditional interests located in and around Roanoke, Virginia into The Carilion Clinic, a powerhouse of innovation. Even though his system had its origin in the hospitals, under his leadership Carilion was moving as much care as possible into the ambulatory environment. Ed eventually was the prime mover in the creation of a new medical school at Virginia Tech. You can read Ed’s story in his obituary. Unfortunately, he died of cancer in 2017 at the age of 61. At the time I attended his presentation, I did not know that Ed was a graduate of Harvard Medical School who had an atypical interest in primary care and had worked at Harvard Community Health Plan during his student years. Wikipedia identifies Carilion and the impact Ed had:
In 2006, Carilion’s management warned that trends in the health care sector threatened to undermine the organization’s financial position. In response, Carilion announced plans for a significant business reorganization to change its emphasis from running hospitals to hiring more doctors in a larger number of medical specialties, with a primary goal of better coordination of patient care and an emphasis on medical education and research.
The plan was developed after visits to the Mayo Clinic and other similar organizations. As part of the reorganization plan, Carilion renamed itself Carilion Clinic. The vision for moving Carilion toward the “clinic” model was spearheaded by CEO Ed Murphy, who left Carilion in 2011 to work with a New York and London based firm in order to help develop ways to better manage and coordinate physicians and services provided by hospitals…Carilion and Virginia Tech partnered to form the Virginia Tech Carilion School of Medicine and Research Institute, which was established on January 1, 2007, and accepted its first class in 2010.
I don’t know if the Partners execs who invited Ed to speak knew that his presentation was going to be about the cost of care, and the responsibility that doctors and hospitals had to change it. Ed pointed to doctors and hospitals as the sources of the overuse, the misuse, and the inappropriate lack of use of healthcare resources in some populations that were the prime causes for the high cost of our care. He laid it all out with a breathtaking presentation that explained how he was trying to lead Carilion to make a difference in Western Virginia by shifting the focus of care from the hospital to the clinic. Of all his many slides the one I best remember was a picture of a Mont Blanc pen. His point with that slide was that physicians were the ones that wrote the orders for the excessive testing, the unnecessary procedures, the expensive drugs that often were not indicated, and were the source of medically avoidable hospitalizations for chronic disease complications. Those complications and the expensive hospitalizations were often precipitated by a lack of adequate ambulatory management or as readmissions after an avoidable hospitalization was followed by insufficient aftercare.
That was 2008. Ed and I remained in frequent contact over the next few years. We exchanged many ideas in emails, phone calls, and at the occasional meeting that we both attended until he left Carilion. I think that both of us believed that healthcare organizations like Carilion and Atrius could be leaders that would reverse the findings that Ed presented as evidence that healthcare in America was leaving the needs of millions unattended and was bankrupting many of those who fell victim to it.
It is interesting to remember that several months later at another meeting of Boston healthcare executives that was precipitated by the business community’s concern about the cost of care, one of those executives who was a surgeon and who had heard Ed stress the need for better primary care announced that he thought primary care was a waste of time. It was his position that most patients in Boston did not need a PCP. He thought that our patients were well informed and could just schedule themselves to see a specialist whenever they needed care. That statement, the polar opposite of Ed’s opinion, left me feeling pretty depressed. It was an unexpected and startlingly honest expression of opinion that made me realize that our problem was much greater than I had imagined.
I never knew exactly why Ed left Carilion. I left Atrius a couple of years after he left Carilion. I can’t speak for Ed, but I know that for all the change and improvement that I had hoped to be a part of at Atrius, only a few lasting changes did occur. One could say the same for the ACA. Many of us hoped that it would be the beginning of a wave of improvement that would sweep the nation. One could say the same thing for the pioneers that joined with Don Berwick to launch the IHI in the early nineties. We could say the same for the insightful academics at the IOM (now NAM) who wrote Crossing the Quality Chasm in 2001. They believed they had written a guide to better care for everyone at a sustainable cost. I am sure that had they been polled in 2001 the authors would have expressed great hope for a more equitable and affordable system of care twenty years later in 2021. The same hopes launched the Triple Aim in 2007 when that great condensation of objectives was first published.
Over the more than fifty years since the launch of Medicare and Medicaid, we have all learned is that there is a long road between insight and action, and even a longer road between action and lasting change. I am left with an intense need to understand why caring doctors and other healthcare professionals have developed intelligent plans and armed with data that describes a disastrous state of affairs can’t lead an improvement that renders situations like the one that infuriated “binkybrain” and his wife to a time in the past that we would all like to forget. Why is the plight of the uninsured and the underinsured which is a national disgrace and a source of economic loss for all of us a continuing problem that now has a history of over fifty years of failure? It is not for a lack of understanding. Books like Elisabeth Rosenthal’s American Sickness and Robert Pearl’s books, Mistreated and Uncaring have spelled out in painful detail the origins of our current pain. It seems to me that what is missing is not insight, it is action.
I know that there are extenuating circumstances. Doctors are exhausted from trying to function in a dysfunctional system that misallocates its resources. It is easy to say, “I’ve done my part to provide good care today.” It’s easy to say, “My role is to practice, not to develop policy or reengineer the system.” In the end, we find it easy to join “binkybrain” in his condemnation of the system and somehow not recognize ourselves as the patient-facing part of that system.
Shoulda, coulda, woulda, or some variation is a mantra that most of us can chant from time to time. What we pay less attention to when we bemoan our lost opportunities is the power we held but did not use. Why didn’t we when we shouda? What prevented us from doing what we coulda done and didn’t? What woulda happened if we did what we shoulda and coulda done when we did do what we did? I ask myself those same questions and wish that life offered “do-overs.” It doesn’t. My hope now is that there might be some of you who are still “on the field” who might hear “binkybrain’s” complaint and resolve to do something.
If you do accept the challenge, expect that the “status quo” will push back mightily and accept that Congress is years away from offering help to you or the public that will make a real difference. You may be our best chance for change, or you may join my generation that gave it a shot but so far has come up short of the goals we set.
When I was in leadership and speaking to physicians who were “newly minted” and that we had just hired, I would tell them that they should realize that the change we needed depended on them. Their colleagues who were in their fifties and sixties were mostly hanging on for retirement. I told them that I was sorry to put pressure on them, but we were depending on them, our younger physicians who faced decades of continuing dysfunction to do something to help patients like “binkeybrain” and his wife who would continue to suffer from our profession’s inability to effect meaningful change unless they used their youthful energy and commitment to transform practice. The future was their responsibility.
I am praying that change is possible before there is moss on my tombstone because there are millions of “binkeybrains” who will suffer and cry for help to a system that is more interested in business success than in their health. Like “binkybrain,” they will have every right to be very angry when they realize how we have failed them. I hope that I am wrong.
Soaking Up The Fall Beauty And Reveling In Joy Of The Red Sox
What a glorious week it has been! With each passing day, the sky has become bluer, the clouds have been fewer, and the colors have become brighter. The humidity is low. On top of that, the temp has been in the high-sixties to the mid-seventies during the day. I usually pick the picture for the header of Friday’s letter by Monday or Tuesday at the latest. Settling on the picture on Monday gives my son who crops the picture, adds the lettering, and does anything else that needs to be “fixed” plenty of time to provide me the favor of his technical expertise as a graphic artist.
When I set out on my bicycle on Monday morning the sky was still overcast but I was eager to see the view from one of my favorite lookouts. Morgan Hill Road is one of those long country roads that ends at a trailhead near the top of a mountain. Near the top of the road, there are several large homes that were obviously sited for their views of Pleasant Lake and Mount Kearsarge. My favorite lookout is from a dip in the road just before its final climb to those lookout homes. Across the road from my lookout is a red antique farmhouse that is surrounded by a few old cars, stone walls, and huge maple trees. The road to the lookout passes a couple of old farms with barns and fields. About a third of the way “the hard road turns to clay.” That is always a good sign that something interesting lies ahead.
When I arrived at my destination I realized that the scene was a little shy of perfect, but it was “good enough.” The colors were not quite “peak” and the sky was still a little overcast, but there was the promise that things would be looking up. I decided that even though the scene was not picture perfect, I would send it to my son for his magic touch.
Out of curiosity, I traveled back to the site on Wednesday, but it was still not peak. The sun was brighter, the sky was clearer, but I decided that I liked the effect of the overcast sky in the header from Monday’s picture that my son had prepared. If I am lucky, I will be there on the day when the colors are peak, probably sometime next week. I hope that when the colors peak, the sun will be out, and the sky will be very high. If I get that perfect picture, you can be sure that I will share it with you.
Speaking of sharing pictures, my neighbor from across the road who walks as much as I do just shared a great picture with me. I frequently walk with her or her husband. She had some unexpected excitement this week when she encountered a mother bear and her cubs. The meeting occurred less than a quarter-mile from my front door on one of my favorite routes, Burpee Hill Road. This scenic byway runs through some open fields that are closely bordered by woods. At its peak, there are open fields with cattle and a gorgeous panorama of Lake Sunapee at the foot of Mount Sunapee. On a clear day, you can also see Croyden Peak, Grantham Mountian, and all the way to the mountains in Vermont. I frequently see turkeys in the open fields. The bears had come out of the woods and were near the road when my neighbor first saw them. Mother bear stood up straight to warn my neighbor not to cross her path, and then she casually shepherded her cubs across the road and into the woods on the other side.
I am jealous because I have only seen one bear this summer. At the time I was on my bicycle so that I did not get a picture. I have had no bears in my yard this summer since I took down the bird feeders which were also squirrel and bear feeders. I do miss seeing the yellow finches and all the chickadees.
The pressure will be on the Red Sox this weekend in Houston. I always dream big. A sweep in Houston would mean they could rap up their bid to the World Series in Boston early next week. That would be nice! Between the color, the Sox, and a weekend in Maine watching my granddaughter and her Bowdoin volleyball teammates play Amherst and Middlebury, I am sure that I will be having a very full weekend. I hope that will be true for you as well.
Be well,
Gene
