October 29, 2021
Dear Interested Readers,
What COVID Has Revealed To Us
I have seen several articles that attempt to tell us what COVID has revealed to us about the inequities and inadequacies in our system of care. My guess is that you have also seen them. Some of the articles go further and attempt to use the experience with COVID to suggest what needs to change or to project what we can expect if COVID is here to stay and will be a persistent challenge.
I think it is prudent to act on what needs to change as revealed through the lens of our recent and continuing experience with COVID. To do so would be to begin to do many things that we have known for a long time that we should do. I am yet to read an article that informs me of something that COVID revealed about ourselves that we did not already know. In retrospect, there was much that we knew about the deficiencies in our care that we just did not have the will to change. Between the early nineties and early 2017 when Donal Trump began his presidency with an attack on the ACA, we had been trying to transform healthcare to be a more equitable, patient-centered, safe, efficient, effective system of care that responded to the needs of individuals and the community in a timely fashion. Between 2017 and the beginning of the pandemic our efforts were a desperate attempt to preserve the heart of what had been accomplished. The expectation of the years before Trump was that if we could transform the system to address those six aspects of quality that had been documented in Crossing the Quality Chasm (2001), we would achieve our “triple aim” of better care for individuals and improve the overall health of the community for a sustainable cost. What COVID has revealed to us in undeniable ways is how far short of those objectives we have fallen despite the great efforts of many.
The quality movement was an attempt to use measurement and the principles of continuous improvement to improve the defects in care that our professional introspection revealed to us. That was necessary but insufficient to achieve the transformation that was needed. We also needed policy changes and changes in healthcare finance if our goal was to be achieved. It is my belief that if the policy suggestions and practice improvement suggestions that were presented in Crossing the Quality Chasm had been universally accepted and implemented, we would have been much better prepared for the challenge of COVID in March 2020, and the experience of healthcare professionals and patients in the pandemic would have been very different.
I am sure that many of you, especially those of you who have been directly involved in providing care to COVID patients, or have had your practices altered by the accommodations that were necessary to respond to the pandemic, have asked: “Why were we not ready?” I have asked that question, and its corollary: “Based on our experience, what do we need to change now?”
If we wanted to deeply analyze our current problem and come up with plausible suggestions for the future, we would need to try to remember the way things were in our hospitals and communities back in the spring of 2020. Perhaps even more instructive would be to ask what we would have seen in December of 2019 or January of 2020 before we realized that COVID would be a challenge. I think that if we could go back in time we would identify some problems that we were overlooking or ignoring before the pandemic that “bit us” once COVID invaded our land. We have painfully discovered the consequences of our lack of attention to three decades of data that suggested the need for significant change. Let me offer for your consideration an incomplete list of some of the problems that we failed to adequately address before COVID.
- There was an almost complete separation between a system of care that had evolved to address the needs of individuals and our system of public health that was neglected, underfunded, understaffed, and unprepared to respond to large-scale challenges.
- Our system of care was structured with an eye on the annual balance sheet. Activities and resources were directed toward what was profitable rather than toward the needs of individuals and populations.
- There were no formal control mechanisms between independent medical institutions and practitioners. We had inadequate central leadership and no reliable controls to ensure coordinated responses to threats. Advice could be offered by the CDC and other governmental agencies, but compliance was not required.
- 8-10% of the public had no access to care, or had only limited access to our system of care. In some states, the states that had not accepted the Medicaid expansion, the uninsured percentage was closer to 25%.
- Financing of care for over 50% of the population was a function of their employment. When they lost their job, they lost their coverage.
- Fee for service payment was the dominant payment mechanism and payment was structured to reward procedures more than the medical management of chronic conditions, acute illness, or the prolonged need for intensive care or supportive care and rehabilitation. When the ORs and offices closed revenue fell precipitously for providers and income rose for insurers who had fewer bills to pay. Had capitation, payment for the care of a population, been the predominant payment mechanism, the shift in services provided would not have resulted in such significant drops in revenue.
- Our finance systems and practice methodology required that a patient be seen in person for the care to count even if other more efficient “touches” like telehealth or email exchanges of information could produce better results more efficiently. We did rapidly make concessions that temporarily reimbursed alternative forms of care, but we could have had the system in place long before it was a critical need.
- We had inadequate supplies of the materials necessary to manage large groups of patients with infectious diseases. We had supply chains for surgical hardware and the stuff of procedures, but we were not prepared to deal with large numbers of patients with infectious respiratory disease. We had insufficient numbers of respirators. Some localities had insufficient ICUs or insufficient training and staffing. We did not have the necessary PPE to protect our providers of acute care to hundreds of thousands of patients with a highly transmissible infectious disease.
- Add your own observations. I am sure that my list of ignored pre-COVID realities is incomplete.
There are other considerations in evaluating the situation in the spring of 2020. Perhaps our most significant handicap as the challenge unfolded was that we lacked consistent and effective leadership. We had a federal government that was led by a president who was woefully unprepared intellectually, emotionally, or managerially to deal with a crisis like the pandemic. Prior to the pandemic, his administration was vigorously dismantling what remained of our public health infrastructure. He lacked both insight and empathy. It was soon revealed that he cared more for the nation’s economy than for the health of many of its most vulnerable citizens. State and local leaders were often not much better, at best there was a wide variation in talent from awful and inept to doing the best job possible under difficult circumstances.
On the positive side of our retrospective analysis, it is important to remember that we had remarkable medical professionals who were willing to risk their own lives while they worked very hard to make up for the shortages and deficiencies that were exposed by the pandemic. Whether they had been reluctant to accept change or were ineffective advocates for change before the crisis, most of them when they were faced with the immediate challenge came together to respond to the need in ways that demonstrated heroism, great clinical skills, the ability to generate creative innovations, and unfailing commitment to the needs of patients
We had strategic and technical abilities that were quickly applied to mitigate the losses and evolve strategies to control the spread while in a remarkably short time frame revolutionary technologies were applied to produce and distribute excellent vaccines to anyone who wanted them. The government mitigated the financial losses of most medical facilities and distributed substantial resources to individuals and businesses to buffer the impact of a suspended economy. It is obvious that when we are faced with disaster we have the ability to respond. What we seem not to have is the ability to anticipate danger and disasters and respond in time to prevent them, especially if that need for response challenges the status quo or diminishes short-term profits.
When solving really complex problems it is a good idea to go even further “upstream” or back in time to understand why actions were not taken long before the problem occurred. COVID was not our first infectious disease challenge of the last quarter-century, and in retrospect, we can see that we ignored the advice of many “prophets” who could see it coming. I have some inherent biases about what we might find upstream. When I look upstream I see a combination of cultural attitudes, personal histories, and government policies that have created enormous inequities that are distributed by race, economics, and geography. We have seen in history that attention to self-interest, the pursuit of corporate profits, or the acquisition of raw political power to preserve the disproportionate advantages of those who control the status quo are dangerous circumstances that can precipitate disasters and create universal misery. Back in the sixties, we used to sing “When will they ever learn?” The reference then was to war, but the question is equally applicable to many of our inadequate responses to challenges that threaten self-interest and the status quo. We look the other way, and in time we suffer the consequences. Our responses to gun violence and to global warming are examples of the same flaw that prevented us from preparing for the possibility of a pandemic. There were many lessons that had not been learned by March 2020.
One good reason for examining where we have been is that the exercise can be the foundation of hope for improvement. Whether COVID magically vanishes or continues to hit us with wave after wave of ever more potent mutations or something in between, I doubt that we will ever return to the pre COVID world. We have been traumatized, and I hope the experience will lead us to make some of the changes now that we could have made twenty-five years ago before we experienced COVID, the crescendo of global warming, and declining life expectancies from guns, drugs, and economic hopelessness.
I was surprised this week to learn that Nicholas Kristof, one of my favorite New York Times columnists is leaving the paper to run for governor in his home state of Oregon. In his last column which he entitled “A Farewell to Readers, With Hope” Kristof wrote:
In particular, I want to make clear that while I’ve spent my career on the front lines of human suffering and depravity, covering genocide, war, poverty and injustice, I’ve emerged firmly believing that we can make real progress by summoning the political will. We are an amazing species, and we can do better.
In the piece, he gives multiple examples of the human suffering that he has covered as a journalist in his travels around the world over the last thirty-seven years. From his experience, he distills three “lessons” that support his hope;
Lesson No. 1: Side by side with the worst of humanity, you find the best…
Lesson No. 2: We largely know how to improve well-being at home and abroad. What we lack is the political will.
Lesson No. 3: Talent is universal, even if opportunity is not.
From those three lessons and from other examples that he references he moves on to announce that he will run for governor in his home state of Oregon. Near the end of his piece, he references a famous quote from one of our most socially progressive presidents, Theodore Roosevelt. Like many people of his time, we can easily unearth TR’s biases and flaws, but we can also admire his desire to improve the experience and health of our poorest citizens and their children. He writes:
I keep thinking of Theodore Roosevelt’s dictum: “It is not the critic who counts, not the man who points out how the strong man stumbles,” he said. “The credit belongs to the man who is actually in the arena.”
I’m bucking the journalistic impulse to stay on the sidelines because my heart aches at what classmates [he wrote a book that identified that 25% of his classmates in rural Yamhill, Oregon have died of “diseases of dispair”] have endured and it feels like the right moment to move from covering problems to trying to fix them.
I hope to convince some of you that public service in government can be a path to show responsibility for communities we love, for a country that can do better. Even if that means leaving a job I love.
Farewell, readers!
I bolded the quote from Teddy Roosevelt because it connects with our hope for better health through the recognition and resolution of our chronic recurrent failures. If we are destined to live in a world of continuing COVID, our health and happiness will require action from you that is empowered by a willingness to make changes in practice and policies that are informed by an understanding of our previous failures. There are those among us in high places who contend that we can’t afford to act. What they never consider is the future costs that we will bear if we fail to act.
I read two other remarkable articles this week that are worth your attention as we ponder where we will go from here. The first is a short post from Ed Jong at The Atlantic. I have quoted Jong in these posts several times before because I think that he has written some of the most informative articles about the pandemic. This week he published “How Public Health Took Part in Its Own Downfall: The field’s future lies in reclaiming parts of its past that it willingly abandoned.” What Jong reviews in the article is pertinent to resolving the first observation that I made about the pandemic:
There was an almost complete separation between a system of care that had evolved to address the needs of individuals and our system of public health that was neglected, underfunded, understaffed, and unprepared to respond to large-scale challenges.
In the article Jong addresses the history that explains in part why we continue to struggle against the inequities that are at the root of our healthcare disparities. He points out that in the late 1800s and early 1900s public health efforts were focused on the problems of labor, housing, child welfare, and healthcare that are at the root of the healthcare disparities that we now seem unable to resolve as we struggle with the social determinants of health that are so important to the health of the underserved members of our society. The first sentence is very informative:
There was a time, at the start of the 20th century, when the field of public health was stronger and more ambitious. A mixed group of physicians, scientists, industrialists, and social activists all saw themselves “as part of this giant social-reform effort that was going to transform the health of the nation…”
That was over one hundred years ago! Jong explains what happened. He explains how we lost the partnerships between mainline medicine and its natural partner, public health, and how public health turned its back on progressive leaders in industry, government, academia, and religion. There was a time when many community leaders were engaged in a partnership to improve what we now call the social determinants of health. Jong suggests that public health shifted its attention away from social issues toward a focus on infections. It needs to be enabled to do both. The pandemic has revealed just how unfortunate it was for public health to lose its focus on the social determinants of health:
If anything, the pandemic has proved what public health’s practitioners understood well in the late 19th and early 20th century: how important the social side of health is. People can’t isolate themselves if they work low-income jobs with no paid sick leave, or if they live in crowded housing or prisons. They can’t access vaccines if they have no nearby pharmacies, no public transportation, or no relationships with primary-care providers. They can’t benefit from effective new drugs if they have no insurance. In earlier incarnations, public health might have been in the thick of these problems, but in its current state, it lacks the resources, mandate, and sometimes even willingness to address them.
Jong’s conclusion informs how we should be thinking about the future:
The future might lie in reviving the past, and reopening the umbrella of public health to encompass people without a formal degree or a job at a health department. Chronically overstretched workers who can barely deal with STDs or opioid addiction can’t be expected to tackle poverty and racism—but they don’t have to. What if, instead, we thought of the Black Lives Matter movement as a public-health movement, the American Rescue Plan as a public-health bill, or decarceration, as the APHA recently stated, as a public-health goal? In this way of thinking, too, employers who institute policies that protect the health of their workers are themselves public-health advocates.
Jong’s suggestions may seem radical, but faced with the possibility of increasing challenges and our continuing decline in a world of increasing challenges, returning to the past to rediscover more effective ways of addressing the social determinants of health seems like it is worth some consideration. Progressives see much of the legislation that the president is trying to get passed as critical to improving the social determinants of health. If something eventually passes over the resistance of Joe Manchin and Krysten Sinema we will have taken a small step forward toward improving the social determinants of health and the health of the nation. We will be better prepared to deal with pandemics and the challenges of global warming.
The other article that I would bring to your attention and suggest that you read is in this week’s New England Journal of Medicine. The title is “Uncomfortable Truths — What Covid-19 Has Revealed about Chronic-Disease Care in America.” It was written by Marshall H. Chin, M.D., M.P.H. from the Section of General Internal Medicine, Department of Medicine, University of Chicago. Near the beginning of his article, Dr. Chin writes:
The Covid-19 pandemic forced the medical field to jump off the cliff and figure it out. It caused rare disruptive innovation by removing previously impenetrable organizational and political roadblocks. Covid-19 also made us walk backward and see the larger worldview, in the process revealing uncomfortable truths about the U.S. health care system — including our approach to managing chronic diseases.
COVID has forced us to drop the usual flow of elective procedures and preventative management. Dr. Chin argues that as we move away from the disruptions of COVID toward a resumption of a pattern of care that feels more familiar we should recognize that much of our previous methodology needed improvement. It’s a short “Perspectives” article but it is packed with insights and suggestions. After reviewing the impact of COVID on our usual method of practice he writes:
In health care, the glory and financial rewards go to surgeries and other procedures, devices, and medications and to the providers, health care delivery organizations, and companies responsible for these interventions…The U.S. health care system undervalues human relationships, connections, and longitudinal primary care, so it’s unsurprising that it falls short in this area. Technology and human capital will need to be integrated if we are going to deliver high-quality, patient-centered care.
That is a powerful indictment of the status quo. Dr. Chin looks to our experience with COIVD to help chart the path to a better future. His primary reference point is chronic disease management, but I think he makes all the points that I would endorse as we examine what we need to change in all of healthcare based on what the COVID pandemic has revealed to us about our deficiencies.
Covid-19 has taught us important lessons… First, our health care system excels at perpetuating its basic structure and supporting the powerful stakeholders who profit from this structure. We should, therefore, design chronic-disease systems to better support the health and experience of patients and the well-being of health professionals trying to meet patient needs.
The article includes a page-long outline of the changes derived from our experience with COVID that Dr. Chin proposes. I will leave it to you to study the list, but I can assure you that ending fee for service payment, achieving universal coverage, moving toward team-based care, and addressing professional burnout are core recommendations. He makes a strong statement about the need to address racism and the inequities in our society.
Health care delivery organizations, payers, and policymakers should intentionally advance health equity and address structural racism. The health care system will continue to put people experiencing poverty and other marginalized populations at the back of the line unless we intentionally value and address their health.
He questions our ability to resolve inequity and racism within the systems we manage because of our self-interests:
As poet Audre Lorde wrote, “The master’s tools will never dismantle the master’s house.” Health care organizations are struggling to address structural biases and racism internally and in the broader health care system. Relying on the same processes will produce the same results.
In the end, he returns to what has been underlined by the pandemic. I share the observations that he so effectively expresses:
The Covid-19 pandemic has forced us to step back, and the wider scenery has revealed uncomfortable truths…Too often, these systems are based on tradition, self-interest, and revenue generation — not on patients’ needs and health. We must recognize the health inequities caused by racism and self-interest…
Pardon my interruption of his thought. Again, his emphasis is on improving chronic disease management, but I would argue that his points apply to all of healthcare. I share his sense of the possible. He continues:
…and advocate for equitable chronic-disease systems that integrate human touch and relationships with lifestyle management, medications, and health technology and that address social needs and structural determinants of health. We can design and implement effective chronic-disease systems if we lock on to the North Star goals of patient health, health equity, and justice. The health care system encourages and rewards what is valued — which should be supporting the health of all people…
And The Rain Did Come, And The Wind Did Blow
Well, we did have a few nice days this fall. Now that most of the leaves are down I have turned my attention to the task of trying to understand the inexplicable icing of the Red Sox bats during the last three games of the American League Championship Series. The Sox scored only three runs over the last three games. Three runs won’t win one game against the Astros. I have no idea who those guys were who were wearing the uniforms of Schwarber, Hernandez, Bogaerts, Devers, Martinez, Renfroe, Verdugo, Arroyo, and Vasquez. It seemed like they were body doubles that did not know how to hit.
There was a time when I would have been very excited to watch the Braves in the World Series. That was in 1957. You may remember that in 1957 the Milwaukee Braves beat the Yankees 4 games to 3. I had all the baseball cards of both teams. The Yankees were loaded, but my heroes were Eddie Matthews, Hank Aaron, Del Crandell, Joe Adcock, Johnny Logan, Red Schoedienst, Lew Burdette, and Warren Spann.
Here is a trivia question for you. What baseball team has won the World Series in three cities? The answer is the Braves. The Braves won in Boston in 1914, Milwaukee in 1957, and Atlanta in 1995. I hope that they win again in 2021, but I have had enough baseball for 2021 and have no idea who the players are on the Braves. I no longer have an emotional connection to Atlanta. Perhaps I am rooting for Atlanta to win because I do know the Astros very well, and do not wish to see them as the champs.
Now that I have “decathected” myself from the Sox, the Braves, and the Astros, I will turn my attention to the weather. We have had weather this week. For the first four days of the week, we had plenty of wind, lots of rain, and it was cold. Forget colorful leaves. The trees have been undressed. There was ice on my windshield on Sunday when I headed to church. The sky has cleared now but the temp dips into the thirties at night and a breeze can make the high forties or low fifties feel a little chilly when I am out on my bike. We are expecting more rain on Saturday and Sunday (Halloween). I hope that by the time there are little goblins and ghosts roaming up and down Main Street the rain will have passed and they can be warm and dry as they collect their sugary loot.
Trees without leaves remind me of the first few lines of Shakespeare’s Sonnet LXXIII which reminds me of “unpleasant expectations” like a shortened fall, inclement weather, and advancing years.
That time of year thou mayst in me behold
When yellow leaves, or none, or few, do hang
Upon those boughs which shake against the cold,
Bare ruined choirs, where late the sweet birds sang.
In me thou see’st the twilight of such day
As after sunset fadeth in the west;
I hope that fall makes a recovery. Last night the temp fell to 30. Now that we have had our first frost and have not had snow, any warm day (over 70) that we might happen to have will qualify as “Indian summer.” It took me years before I knew the “true” definition of Indian Summer.
The picture in today’s header was lifted from a video produced by my neighbor, Peter Bloch. Peter shot the video during what could be a great Indian Summer outing. He often uses his drone to make the many short films that I have enjoyed, but this video was shot on a local pond from his kayak. He describes the situation in the introduction to the video:
Launching my kayak towards the fog-shrouded pre-dawn on Grafton Pond was so full of the sense of wilderness. In the three hours I was paddling around the hundreds of islands, the luminous light of the rising sun embracing the dark coves and islands, ever-so-gradually winning the day and my appreciation.
If you follow the link you can also access “Sunrise with Loon!” which he shot during the same early morning trip. Peter is a person whose example is worth following. He is frequently out in nature looking for the marvelous beauty that is there to be seen if only one will look. I hope that your weekend will be warm, dry, and conducive to a good walk or a trip to some nearby spot where you might be surprised by unexpected beauty.
Be well,
Gene
