Our health system: Not equitable, not effective, and not even efficient. Bad business!

Over a year ago, deep in the pandemic, a close friend felt she had a bladder infection. She went to the local Urgent Care (run by the large hospital system that also runs our University Medical Center) to be sure; they did a test on her urine, verified it was a bladder infection, and gave her a prescription for an antibiotic. It got better.

Not long ago she began getting dunning notices for the bill for this visit. She was surprised, as her primary insurer (Medicare) and her Medicare Supplement policy should have covered it all. Hours on the phone, with the health system and insurers, she determined it was because the system had not submitted the bill on time. Note that they have a year to submit a bill to Medicare. She talked it out, and thought that it was resolved. More recently, she received another dunning notice, followed by more phone calls. The billing department did not have her insurance information on file. She was surprised, she noted, as the Urgent Care clinic had taken photocopies. “Oh,” she was told, “that’s the clinic. We’re the billing department. We don’t have access to those.” Wait, you’re the billing department for the Urgent Care, but you don’t have access to the photocopies of the insurance cards that they took solely for the purpose of billing? What kind of an operation are you running here?

Sadly, and perhaps surprisingly, an operation of health care in the US, and perhaps business in the US altogether. Not efficient, not effective, poorly designed, and, of course, set up to make the victim – in this case the patient or the client – take the blame. Spoiler alert: It is their fault, not yours!

Every few years the Commonwealth Fund assesses the performance of health systems in 11 high income countries around the world. Since 2014 it has been called “Mirror, Mirror on the Wall”, and each time it comes out the US ranks last in overall performance, and also last or near last in most sub-areas (Healthy Lives, Quality,  Access,  Efficiency, Equity). It is worth looking over the whole report from 2021, but I am going to focus on Efficiency. When I first looked at the 2006 and 2008 reports (then called “Dimensions of a High-Performance Health System”) I was a bit surprised that the US’ worst score was on efficiency. Access, yes, I could understand. Equity, yes, of course not. Even Quality, depressed as it would be by the lack of access and equity. But efficiency? I thought of the waste that came from so many private systems which had (especially in those days before Electronic Health Records,  EHRs) so ability to share information. So you got a lab test or x-ray at one place, maybe an ER, but the next place couldn’t access it, so they did it again. Inefficient, and costly. And not good for you.

 

So did it get better with EHRs? Well, not per the 2014 report, in which the US ranks 11 out of 11 in Efficiency (as well as in Equity and Overall). Maybe it takes time, but the 2021 report shows that the US is – still dead last, now presented with 3-digit scores rather than simple ranking. Even though our health system’s corporations are, as I have often said, about making money for themselves rather than taking care of your health, their business systems are poorly designed, inefficient, and cause you no end of grief even if you are insured and not too sick. Of course, woe to you if you are uninsured and very ill! THEN you really suffer!

 

 

I once sat on the Billing Steering Committee of a large practice plan, and one of the issues that kept coming up was people not paying their bills. As a patient there, I suggested that it was hard when you got a bill for, say, your doctor visit, paid it, and then a few days later got the bill for the lab test or x-ray or something else. Since one of the purposes of creating the practice plan was to have a unified bill, I asked why they didn’t send out a monthly bill, so people could pay everything at one time. We do, they said, but only after we send out the individual ones. Gee, I noted, one monthly bill works for credit card companies. Can you imagine if you got individual bills all month for all your MasterCard or VISA charges that indicated that you had to pay them then, rather than one monthly bill? T What, I thought, if you got a bill today for a lunch you had 3 days ago, and tomorrow for the shirt you bought last week, and a few days later for the vacuum cleaner you’d ordered? And each indicated you were to pay it today? What would be the point of a credit card? What is the point of integrated practice billing? he concept of not sending out each individual bill was not only foreign to them, but incomprehensible.

They remained unconvinced, and it was dropped. The reason that they remained unconvinced is it wasn’t how they did things. And management of health systems (and, to a large extent, US business) is doing things how they do things. And congratulating themselves on how well they do. And rewarding  themselves handsomely for it. And blaming someone else (usually the client or patient) when it doesn’t work. They are wrong, they are fooling themselves, the data is in, but they persist. Because they have the power.

After World War II, a statistician named W. Edwards Deming developed systems for enhancing quality in business and manufacturing, a data-driven approach that became known as Continuous Quality Improvement, CQI (there are a number of good books by and about Deming and his methods, some very easy to read). It caught fire in a Japan trying to rebuild after the war, but was ignored in the US because, in the 1950s and early 1960s, US businesses were doing great. The reason, of course, was that the manufacturing capability of every other developed country had been decimated by the war, so US business had essentially no competition. It could have been run by monkeys and would have done well. But the monkey-impersonators who were actually running it convinced themselves that it was because they were so good! Then, of course, by the late 1960s Japan and Germany were outperforming the US in terms of quality, and profit. US industry was still not that concerned about quality, but they did want profit, and many CQI models were adopted (famously at Ford, but also at other large companies).

But progress, as those who study history or at least are old enough to have lived through a fair portion of it know, is not linear. Traditional bad practices are hard to erase, and without continuous reinforcement of better ones continue to recur. Especially difficult to control are those which can be (and are) interpreted by the management (who like to call themselves “leaders” though that is rarely what they are) as showing how good and smart (and deserving of high pay) they are. So, they do recur. These attitudes, that things are best when Wise Managers are in charge, has permeated not only for-profit business but even non-profits and membership organization, not always to the good. In “Good to Great for the Social Sector” business guru Jim Collins has observed that while non-profits are often urged to operate “like a business”, since most businesses are poorly run and operate poorly this is not always a good idea!

Very recently I learned of a health system which contracted for the services of a doctor from a government agency. Since the doctor was not their employee, the system couldn’t bill for the doctor’s services. So, they assigned a nurse practitioner who was their employee to accompany the doctor and bill under the NP and health system’s name. Except the doctor worried that this would be Medicare fraud, and consulted the attorneys for their actual employer, who agreed. This surprised the health system; they worked – as almost all of them do – under the assumption that the whole thing is a game, to maximize their income and profit. Heck, they upcode all the time to get more money from Medicare and other insurers!

So, what is the upshot? Health systems (and US businesses in general) have a total focus on making money, even when they are pretty inefficient at it. This sometimes clouds their attention to obeying the law. It certainly is more important than the quality of your care, or your financial health. As always, while it affects everyone, the most disadvantaged – the poorest, worst insured, least educated, and least empowered suffer the most. So what can we do?

For starters, we need a universal health insurance system, like improved an enhanced Medicare for All (HR 1976 this year). This will not by itself bring us up to par with the other nations, but it is a necessary start.

 

Doctors need to care: It's about the patients, not about you

 

 Recently, a friend of a friend had an accident and fell in her driveway. After two days of pain that did not improve, she went to an urgent care center where an x-ray was taken and the PA told her that there was no rib fracture and her lung had not collapsed, so she went home. The next day the urgent care center called back and said “whoops, there is a rib fracture and you do have a collapsed lung”. They said they’d call her primary care doctor, but didn’t. The patient tried to, but the doctor was on vacation. The covering physician refused to see her. So our mutual friend, who is a physician and surgeon who lives 1000 miles away, called someone who lived in the patient’s town to take her to the emergency room. There, they re-x-rayed her, and admitted her to the hospital, telling her that they would need to insert a small tube to remove the air (called a pneumothorax) from around her lung. The doctors said she refused the procedure, although she says she just asked some questions about it. She was admitted for “observation”, and given oxygen. In the morning, since the x-ray was no better, they said that they would have to keep her in the hospital, but this later was reversed on a visit from the resident on the hospitalist service, who said she could go home.

 Our mutual friend called the resident, asked about it, was told that it was OK to discharge her (quoting the “resident’s best friend”, the medical information website UpToDate®) and would not put the friend in touch with the attending physician. However, the patient was terrified about going home, especially given her accident, that she lived alone, that she had had her bad experience with the urgent care center, and that her physician was out of town. I suggested that our mutual friend might try to contact a hospital administrator to see if the attending physician could be reached. Then I got a message that there was a new hospitalist over the weekend, who happened to be a family physician, and who tried a novel approach: she talked to the patient, examined her, and reviewed the chest x-rays. After this, she decided to call a pulmonary specialist, and it was decided to insert a chest tube. The patient, with the proper treatment, improved and should get better.

 So probably the story will have a happy ending, at least from the point of view of ultimately getting the right treatment. The woman who was the patient may recover physically, but is unlikely to recover a lot of faith in what is amusingly called our health care “system”. The number of things done wrong were many, and most could be blamed on the individuals; the PA in urgent care who mistakenly thought that they could accurately read the chest x-ray, the provider in the emergency department who was apparently in too much of a rush to answer her questions and decided the fact that she had them meant she was refusing the recommended treatment, the hospitalist service who changed their mind about her need for hospitalization without explanation, the resident who would not contact the attending physician, and the attending physician who apparently did not want to be contacted.

 But to blame just the individuals would be incorrect, although we can be very enthusiastic in lauding the weekend hospitalist who decided to actually care for the patient. The system is critical here. I do not know that hospital, but I imagine the doctors in both the emergency department and on the hospital floors are stressed an overworked, and that the way they responded to the patient in question, while unjustifiable, was probably caused in part by that overwork and stress. The resident may have been the “point person” in contact with the patient, but the service attending was ultimately the one making the decision. Poor role modeling by attending physicians and senior residents is common and leads to poor behaviors by residents, who are often more concerned with their own workload or pleasing their bosses than providing proper patient care. In such busy situations, patients are often assessed quickly, and judgements are made not just regarding their medical problem, but their personality. Are they going to be a “good patient” – meaning that they will quickly accede to doing what I am recommending -- or are they going to cause me “trouble” and cost me time? That trouble can be real if the patient is aggressive, intoxicated with alcohol or other substances, or has a serious mental health diagnosis, but it is sadly true that the label “troublesome” patient can even be applied to someone who asks perfectly appropriate and reasonable questions about the treatment being proposed for them.

 Racism provides us with a bit of a metaphor, in the sense that there is both an individual and a structural (or institutional) component. Yes, behavior by individuals can be inappropriate and wrong and blameworthy. But if we leave it at that, if we do not understand the overall structure that encourages or facilitates such individual behavior, we will never solve the problem. We will never decrease or end racist behavior, and we will never ensure that patients get treated with the respect and concern that they should. Racism affects the medical system and medical education as it does the rest of society, but disrespect and self-centeredness can inhibit appropriate medical care even when race is not involved. Indeed, in this case the patient was a 70-ish middle-class white woman. One can imagine with what frequency, and to what degree, people are treated with disrespect – and poor medical care – when they are members of minority groups, poor, homeless, have a psychiatric diagnosis, are not clean and nice-smelling, are not coherent, are under the influence of a substance, etc. Of course, if one is a health care worker, one need not imagine it; one sees it all the time.

 As a family doctor, I would like to take pride in the fact that the “hero” of our story also was one. In fact, I will. I actually believe that the training of family physicians, and the emphasis on caring for the patient rather than a particular problem, makes a difference, and enhances the caring characteristics of the individuals who choose to enter this specialty. That is, I think it is more than a coincidence. However, of course there are wonderful caring physicians, including resident physicians, in every other specialty, as well as family physicians who are jerks. I just think that it is a smaller percent.

 Should there be any jerks in medicine? I have heard it argued that in some specialties, it is not necessary to have good “people skills”. In pathology, or diagnostic radiology, or even anesthesiology, where the doctor spends little or no time with living patients. Or in surgical and other procedural specialties, where technical skill, not “bedside manner”, is what matters. Sometimes I have acknowledged that this made some sense. Until I thought about the colleagues I have had in every specialty. And in every case the good ones cared about the patients they were involved with, whether or not they met them face-to-face.

 The pathologist or radiologist knows it is also their patient, and the use of their skills in the performance of their jobs may make the difference in a person’s life, or death. They care. Caring may not be the same as “people skills”; we recognize that some people have greater difficulty connecting directly with others, and are certainly not trying to create a profession full of hucksters and snake-oil salesman with false charm. But we do want one whose practitioners can convey concern, and caring, and at the minimum not disparage the people who are in their care.

 So, yes, I think that everyone admitted to medical school should care about people. And, yes, I think that we need to ensure that our medical education does not beat or role-model it out of them. Our residents need to have schedules and lives that are reasonable enough that, when they are tired or frustrated, they don’t act out. Our attending physicians need to be available.

 Even when you are tired or overworked, it is not ok to be cruel or insensitive any more than to be racist or sexist. After all, there is a reason that this profession exists, and it is not to provide a good life for the practitioners. It is to try to maximize the health of the people for whom it cares.