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Editor’s Note- This is Part 1 of this conversation. The conclusion of this discussion as Episode 262 will be available on Tuesday, January 28th.
Richard Helppie
Hello. Welcome to The Common Bridge. I'm your host, Rich Helppie. We're back heavy on policy, and the biggest part of the economy continues to be the healthcare economy. We've talked about some of the economics, who the players are; and when it comes down to it, it's the physicians who take care of us, those that diagnose us, treat us, look for the best way to make us better, and, more importantly, to prevent us from becoming ill. Today, we have with us, Dr. David Harlan. He is the William and Doris Krupp Professor of Medicine at the University of Massachusetts Chan Medical School, and co-director of the University of Massachusetts Diabetes Center of Excellence. He also directs the Breakthrough New England Center of Excellence, and his research focuses on the mechanisms underlying type one diabetes and developing new disease treatments. He's also been a little frustrated by the healthcare delivery system, so he co-founded a company called Stability Health; you can look them up, Stability Health LLC, focusing on providing diabetes expertise to patients and their physicians with one goal, one we should all have: improving outcomes in a cost effective way. We're joined also today by Dr. Barry Meisenberg. He's the Chair of Medicine and the executive medical director of cancer medicine at Luminous Health, that's a health system based in Annapolis, Maryland. He led the health system's clinical and research response to the COVID-19 medical crisis, and we'll be talking about COVID today. He's a visiting professor of oncology at Johns Hopkins University and the Kimmel Cancer Center, and he has led efforts to organize cancer services internationally. In addition to his clinical and scholarly activities, Dr. Meisenberg organizes a medical humanities event for medical staff and trainees called the Diastole Hour, which uses medical humanities content to help physicians regain the meaning in medicine. And so much is talked about with economics that we need to get back to what it's all about. Also with us is Admiral Matthew Nathan. Dr Nathan is a retired vice admiral and previously the 37th surgeon general of the United States Navy. He also was a previous senior vice president at Wake Med Health System in North Carolina. He's currently a senior editor for Harvard University Social Impact Review and a previous senior fellow in the Harvard Advanced Leadership Initiative. He's held several faculty and academic positions throughout his career, and he says that one of his hobbies is fact checking Dr. Harlan and Dr. Meisenberg. So listeners, readers and viewers of The Common Bridge, strap in; we're going to talk about all things relative to healthcare and medical treatment. Doctors, it's an honor to have you with us today. Thank you for joining us.
All
Thank you. My pleasure. [Cross talk.]
Richard Helppie
I hope that we're going to have some advice for the people that are listening or reading or watching this episode, they're ultimately going to become patients and/or caregivers, so that they can all understand healthcare. If you were in a single question interview and asked what message would you like to deliver to our audience today, what's that thing you're going to tell them? Dr. Nathan, why don't we start with you, if you don't mind. What is it that you really want people to understand?
Dr. Matthew Nathan
Well, thanks for the question, Rich. It's a wide landscape of good and bad right now in healthcare. My colleagues know that I look at the evolution of healthcare, at least in this country, over the years, and am fascinated, encouraged and disappointed by some of the changes. I think people need to understand that the role of the healthcare giver and - let's say the physician and the advanced practice provider, the nurses - the role has changed somewhat in that autonomy has been ceded from the profession to business. Those business practices have created some very good business practices, which allow mission sustainment, they have also created a gulf and a disparity between the patient feeling a kinship and a personal relationship to their health care provider. And so I think a lot of people feel a drift right now because they don't feel they have a community connection or a personal connection with their providers or the ability to access them. And I think that's something that we have to look at very hard in this country to try to repair or try to reorganize.
Richard Helppie
I think a lot of people can very much relate to that. Dr Harlan, when you think about reaching our audience today, what is maybe the single most important thing you want people to understand?
Dr. David Harlan
I would say that over the last several decades, let's say four or five decades, the role of the healthcare systems has shifted from one where we responded to episodes of care in appendicitis or a broken femur, to chronic disease management. Now the preponderance of the cost of the American healthcare system is for diseases like diabetes, even some cancers like chronic myelogenous leukemia, obesity, thyroid disease. Our current system is not equipped to support that chronic disease management. We have to, as my friend Admiral Nathan has said, we need to find ways to steer the healthcare system back toward that chronic disease management, toward health, not episodes of care, but promoting health.
Richard Helppie
That's, I think, very, very important. A lot of our audience members are going to be able to relate to that. And Dr. Meisenberg?
Dr. Barry Meisenberg
I would like to add to Dr Harlan's comment that there's a term for that called salutogenesis; the creation of health, the opposite of pathogenesis; the creation of disease. I would say that, as I think Dr. Nathan implied, we don't have a single system. We have an conglomeration of multiple experiences because no one designed this health system that we have. And although you're asking on behalf of the listening public who will experience it as patients, I will tell you that from a physician side, we're very concerned about the way this is going in the influence of business, private equity profits, in driving medical decision making. Among physicians who mostly go into the field for the right reason - and the public should be reassured about that - there's a form of moral injury because the system doesn't allow us to practice in the human-centric way that we would have liked and that we still talk about in lofty terms. So yes, there has been a shift, and the fact that most physicians are now employed by entities - some not for profit, some for profit - has contributed to one of the many trends that I guess we'll unpack shortly.
Richard Helppie
Well, I sense a great deal of frustration with all three of you, with the ecosystem around healthcare, and of course, many patients, caregivers, families, feel that. As you were each speaking, I said that's right, there's another party in the room. It's not my physician and me, it's my physician and, gosh, we both have to go ask that payer and what rules that they might have. In the United States, when we look at healthcare and medical care, what are we getting right, and what are some areas that we're getting wrong where we need to improve? I'll just throw it out to whomever would like to go first.
Dr. Barry Meisenberg
I'm very glad you start with this, because we don't want to lose track of that. What we have right, I think, are advances in the field; dramatic in oncology and probably other areas as well. We've got dramatic improvements in technology, if you can access it. We have a cadre of very well trained physicians, the envy of the world, the way American physicians are trained. And I would say, by and large, the same is true within our hospitals. I know I when I'm talking, it sounds like there's going to be a "but," but let me just end it with a period and say those are some of our assets, which I think are very, very strong and we should take pride in them.
Richard Helppie
Great. Matt, Dave, anything you'd like to add or fact check on that? Just kidding about the fact check, but if it's...[laughter.]
Dr. Matthew Nathan
I'm expecting it. I agree with Barry. I think that we've come a long way in patient safety. We have a standardization now in many places. I'm from the Navy, that was where my career was centered and so standardization there, in the Navy Nuclear Reactor program, and the standardization of how you land and take-off a jet an aircraft carrier, that standardization, that template across the operational theater of all those things, results in almost a zero serious mistake or mishap. We haven't quite got there yet in our operating rooms and our clinics and our sedation systems, but it's coming. And so I think that's been a huge improvement, where you can be treated the same way in the same hospital on one coast or another. To Barry's point on education, there are a lot more advances in the technology and how we can train and teach future nurses and doctors and allied health, I think that's wonderful. We cannot remove the two edged sword from the room, which is the advances in technology; AI and imaging and the new ways of diagnosing patients have really been an amazing advance in helping diagnose and stamp out disease. On the same hand, it's removed the some of the humanity of the provider spending time with the patient and getting to know the patient. And so you have to balance the good and the bad of all.
Richard Helppie
That must be quite a challenge. Dr Harlan, what are we getting right? What are we getting wrong?
Dr. David Harlan
I'll start with a couple comments that my colleagues have made. First, Rich, one is [that] both Matt and Barry have been friends for over four decades, so we've known each other for a long time, and Matt, in his fact checking exercises, kind of like the Maytag repairman, he's still waiting for some fact that he can correct. [Laughter.] Then I do want to define for you something that Barry said, which we all use - I don't know if it means anything to you - about moral injury. Do you understand that term, Rich?
Richard Helppie
I'd like to hear your definition for sure.
Dr. David Harlan
Well, what has happened is, in the business world physicians are are very unhappy with their practice, and the leaders of the healthcare systems will say, well, they're burning out. What can we do to prevent burnout? Can we give cookies? Can we have a doctor's lounge? And what they fail to understand, and what physicians have defined, is it's not burnout we are feeling. It's a moral injury; that we went into this profession with a profound mission that is being taken out from under us. So I do want [to say] we all agreed - Barry, Matt and I - agreed that we don't want this to be just a complaining session. There are some great strengths to the healthcare system as it's evolved. I'll just add a little bit that the biotech industry in this country - Genentech, Biotech, Amgen, and now Vertex - they are driving curative therapies that were undreamed of when we were in medical school. It's truly miraculous to see these things coming down the pike. What we're getting wrong is what you said, the fundamental principles of medicine are the sacrosanct relationship between a patient and a provider. Exactly what you said, Rich. When I sit in the room, I say right now, it's just you and me in this room, but it's actually a quite crowded room. And those people that aren't here - the silent partners - say they care about your health but their actions belie that they don't. It's a profit thing for them and that's damaging the relationship. It's creating the moral injury that Barry alluded to.
Richard Helppie
We've always talked about quality, access and cost. Cost is the most difficult, but we seem to default to cost more than anything else. You've all been in practice a long time. You've seen a great number of changes. I know one of the most profound changes... my guess would be you gentlemen worked 70 to 80 hours a week for a long time, the physicians entering practice today, they're 45 hours a week. We're not going to have as many doctors, and we're going to have to rely on AI and allied medical professionals and telemedicine. We don't have a financing system, we have a hodgepodge of financing methods, none of them that work particularly well. I just wonder, have you looked around internationally? Is there a better method for healthcare services in terms of access and choice and diagnostics and treatment and cost? Would it differ if you said, well, somebody's really getting it better on cost and someone else is getting it better on access? What do you think other countries are doing?
Dr. Barry Meisenberg
I think that's a complicated question, maybe even more complicated than you realize. It's because other countries - 120, 160 countries - they could all do it a little differently. One thing that differs is in societal expectations of care and access. We come from a background of individualism and with an expectations of everything's reachable for me and everything's accessible to me and I don't care about the cost. Other societies have, over time - and I'm thinking mostly about the UK system - have sort of got a societal agreement that some things are going to be too expensive to afford, and they're at that decision even before you get the disease that warrants some greater expenditure. You mentioned earlier about changes in physicians' willingness to work many, many hours, long hours. And yes, it's a trend we've noticed. In our training of doctors [it] has become... when we birth them and when the fledglings leave the nest, they go out into the world there... I think this generation - with some exceptions, I don't want to make it too stereotyped - place limits on what they're willing to commit and they seek shift jobs that are amenable to shift. I have my own term for it - which I don't mean to be insulting but [to] recognize the phenomenon - it's called partialism. Partialism, it means that I turn my pager off or I turn my phone off, and I do my shift or I commit to my practice. Now, many physicians don't practice that way, and we've all benefited from their free time that they give. But I think that is shrinking, and it's interesting that it's led to this idea of concierge medicine, this phenomenon. And I know Dr. Nathan has some feelings about what concierge medicine really represents. So Matt, I'm handing it off to you.
Dr. Matthew Nathan
Well, I think access is a failure point in this country. You can look at the anchor studies and see that two zip codes next to each other in the Chicago area have a lifespan difference of ten years, and it boils down to access and preventative health and being able to manage chronic diseases. So I look at concierge medicine as a patch by people, as a symptom of a failing healthcare access in this country. Physicians are overwhelmed. They feel that they are having to load more and more trucks with less and less appreciation. The training that we've given them now... which was born out of too much arduous hours and longevity which would grind you down and lessen your ability to be attentive and on your toes, that was a good thing. But we have, I think, overshot in that we have created a system where physicians no longer feel that they are really in a profession as much as they feel they're in a trade.
Richard Helppie
That's an important distinction, a trade versus a profession. When you think about the advent of hospitalists; if a patient is admitted, the day to day care is done by a physician assigned to the hospital. We're all familiar with the surgeon on call for the ER, you want that specialist, but you might get the more general practitioner. The proponents of concierge medicine, which is where you have a doctor, you pay them a flat fee, and that's your first point of contact for preventive, for diagnostic and for treatment. They'll say, look, that's a throwback to the role of the primary care doctor, the family doctor. But you don't seem to like the notion of concierge medicine.
Dr. Matthew Nathan
Well, I don't like... I know people who practice concierge medicine are very, very good, and they use their time so that they can to do pro bono work for the under-served. I think those are wonderful examples of people who have tried to compartmentalize their practice and leave time to do other things. So I don't necessarily vilify the physicians involved as much as the system which has created the need to pay for access. When you have a country where you have to pay to be able to get a hold of a physician or a provider to take care of you in a retainer fee, you've got a problem. And I'll just finish my one sound byte here with one thing. There's some debate on the legitimacy or the veracity of the story of 15th century China but there are some historical references where in those days, people paid their physicians while they were well or uninjured, and they stopped paying when they got sick or when they injured themselves. So what a great motivator for a healthcare system to keep you robust and alive. In those days, if two Chinese physicians saw a patient about to get run over by an ox cart, they risked their own lives to push them out of the way, to keep them from getting injured. Today, if that happened, and I'm being a little flippant here, they'd say, well, this is going to be a bad accident, I feel sorry for that guy. We're here to take care of him. This gets back to Dave's and Barry's point that we have become centered around remuneration and reward for the care that's provided, not the health that is maintained.
Richard Helppie
Well, if I could be flipping back right at you, it's the model we've got now, the so-called employer-based insurance. If someone's injured or sick, they quit getting covered. Also, maybe in 1500 years, we haven't moved that far. When you think about the timeline in healthcare, we've got prenatal to end of life, and I think there have been advances in all of that - particularly end of life - that there's not the "keep people alive at any cost," there's a point in time where it's palliative care, hospice services, etc. But in your hands-on work, if you said, hey, the best-served people in the United States of America in that spectrum from prenatal until end of life, who are the best-served and who are we really leaving out?
Dr. David Harlan
Well, those that are best-served are those with resources Rich, and that's always the case. One thing I've learned from history - I'm a student of history - is that no one wants to be told what to do or what they can or cannot do. It's best if we have a system that aligns incentives and, I think, affords what Adam Smith called the invisible hand; let individual incentives drive what is delivered. Now, of course, we have to find a way to support those who have the least resources in our country. You asked about concierge medicine, I sort of like the concept of it, except that it leaves out very significant proportions of our population that, even on a discounted basis, can't afford healthcare, so we have to figure out a way to support those people as well. I tell people that I have TB, and by that I mean True Believer disease. I believe in the Hippocratic oath, and that we should provide healthcare for everyone. The last thing I'll say about this is, you asked earlier, what system is best in the world for healthcare delivery, and I think worldwide, people are having a difficult time shifting from the episode of care to the promoting health and preventing chronic disease. No one has figured that out, but I think that the US should lead that charge, and you can do it one of two ways. You can wait for the system to collapse - and I worry that that's happening, providers just don't want to be a part of this anymore - and then build anew and that would be horrible, but it happens periodically. Or someone has to build a better system where people are voting with their feet and going to that better system and then the hearts and minds of everybody else will follow when the dollars go to that new system. But it's yet to be devised. No one's figured it out.
Dr. Barry Meisenberg
I think, as I said earlier, we don't have a system that anyone created. We have a system that evolved; business interests are driving it now, and whether that's actual pharma industry, hospital industry, or just private equity investment in physician practices, patients are not well served. And you know this, the reaction to this healthcare CEO's assassination is evident of the level of dissatisfaction. Maybe the one silver lining that could come out of this horrible event is that people who participate throughout the system recognize the need, that we really need to change aggressively what's been going on. And like David, maybe I'm naive, but I believe we can make some rather rapid reforms if we have the will.
Richard Helppie
Well, it would be surprising if our pathway to health care reform was people being murdered on the streets of Manhattan - which I can't think of anything worse - as an impetus for change. Perhaps we can educate folks; you made mention of history so here are a couple things in history. People used to save money and pay their doctors or they would pay their doctors with farm goods. I had a great uncle who was a physician of some renown. He started in a small Minnesota town. He was literally paid in chickens. Apparently they were good chickens, because he went on to practice at Walter Reed, actually. Then we had the notion of hospitalization. You're going to have hospitalization services insurance, because if you were sick enough, you were going to go into the hospital. Oh, well, things are going to get done outside the hospital so now we're going to start covering primary care through insurance, which is really preventive care, and you're going to consume that anyway. It's not really an insurable event by the definition of insurance, but we started washing money through lots of hands. And at the same time, if you go back to the old adage an apple a day keeps the doctor away, now we have an obesity crisis, and pharmacists are saying, look, we'll give you another drug to treat your obesity. I think our potentially incoming Secretary of Health and Human Services said, for the cost of Ozempic, we can give everybody organic food and gym memberships and deal with obesity that way. When I think about the things that we're getting wrong, how often in your practices do you tell somebody, get off the medications and start jogging, get off the medications and start eating better? How big of a part of your world has that been?
Dr. David Harlan
Matt, you want to say something? I have comments.
Dr. Matthew Nathan
I think that's front and center for you David, but Rich, you bring up a great point, which is we tend to quickly try to admonish the healthcare provision systems when you've just brought up a huge point, which is the reason a lot of people have failing health is because of behavioral health habits which contribute to it. One of the differences in other nations where they have better mortality because the sound byte that everybody loves to talk about is the fact that we spend more per capita on healthcare in the United States than the other country in the world, and yet we don't rank anywhere near the top in wellness and health indicators. Our cholesterols are higher, our weight is higher, our obesity factors are higher, our fitness is poor. In Scandinavia, they have better health, but they also eat better, they have a more fish based diet, and they walk everywhere. Dave's practice is... I'd love to hear his thoughts on this, because he's the one who has to deal with when patients get on the talking scale; it says "one at a time, please." He's trying to figure out how to get people back into a reasonable habitus where they have a fighting chance with their diabetes.
Richard Helppie
Dave, I would like to hear about this, because if we can keep people off that pharmaceutical chain, they have a chance. And gentleman, I think we should come back to the social determinants of health. We know what they are. When I see the spend on healthcare versus the mortality statistics, being a data guy, it's like, yeah, I can take those apart. They're really not cause and effect. What I would tell people, if you're sick or injured, you want to be in the United States of America, that's provable over and over again. People have this idea that Canada, you've got everything. Well, you don't. I live on the Canadian border and I hear the public service announcements, and like every other single payer plan, they control the budget by limiting access. That's why every hospital in the Sun Belt or and on the border have arms wide open for Canadians with resources, who can pay. But before we go down that rabbit hole, Dave, how about it? How do we keep people well in the first place, and how much of the system for finances are you working against trying to get there?
Dr. David Harlan
Well, I have several comments, and I'm going to quote people, which I always do. First quote I'll say is Reagan's, who said the closest thing to perpetual life is a government program and I would rank right up there, prescriptions. My brother is a neurologist, and he knows the people that took care of Barney Clark, if you remember Barney Clark who got an artificial heart. He seized after he got it, and the neurologist went to see him - he was dig-toxic, Barry and Matt - he was on a drug for making the heart squeeze better when he had a mechanical heart! Nobody had stopped it. I mean, that kind of stuff happens all the time. You alluded to the new Health and Human Services guy, Rich, and his uncle was a famous man as well, who famously said, "ask not what your country can do for you, but what you can do for your country." That the least utilized resource for healthcare in this country are the people. And JFK also established the Presidential Fitness Program. We just need to get back to that. We need to have the American public taking care of themselves; not smoking, not drinking to excess, getting out and walking. Those things can influence lives, as we know, from smoking and drunk driving, it can matter, and it does, and those are the most important things. Now, one last thing, and Barry, I'm sorry, that is what we're all facing, what is commonly called the tragedy of the commons as well. There's a limited amount of resources and everybody wants the Cadillac, and that's just not sustainable so we just have to somehow return some ownership to each of us for our own health. We have to. And I do mean that. I get people all the time, I talk to them about their diet and their exercise, and very frequently, we can get them off expensive medicines. And here's the kicker, they feel better at the end of it. I say, do you want to go back? Oh, no. No one's ever helped me get back to feeling this way. Again, it is the right thing to do, but it takes time and commitment.
Richard Helppie
Well, there's never been a medication invented that does one thing. It's always going to affect you in multiple ways. If it's treating that underlying disease, it's going to maybe make you uncomfortable someplace else. In a prior episode of The Common Bridge, we had Dr. Ken Cooper of the famous Cooper Clinic, who coined the term aerobics, and I asked him what is his last message and he said, walk your dog, even if you don't have a dog. I thought it was a great close. So getting in motion is very, very important. But if you think about what we've tried to do legislatively - this is a program about policy - when we started looking at healthcare reform some 35 years ago, Clinton administration, the famous book written by Tom Daschle, then Speaker of the House, he said the problem with Americans is that they want every treatment that might make them better. I thought, well, that was an interesting take on it. And then I looked at the Clinton Care bill, which I read as part of my work, and it said, we don't think people can make good decisions, so we're going to use the law enforcement system keep people in line so that they don't do diagnostics and treatment. By way of example, low birth weight babies, it's going to be illegal to treat them below a certain level. Today, babies can live at 22 weeks gestation; my view is that we were doing much better on the prenatal side. We're doing a little better on the end of life with not trying to do so heroic. But in the middle, are people living healthier lives, and what should we be doing as a healthcare system? Let me tee that up, gentlemen; if you could make one change to the healthcare methods in the United States what would it be? Just imagine it is magic genie or someone that says you get one wish. What would it be?
Dr. Barry Meisenberg
I would start by saying payment reform to pay for the services that you have just mentioned and that Dr Harlan knows he desperately needs for people with pre-diabetes and diabetes. Because, as someone said, there's the ox cart; how we pay for care. We pay for care for advanced disease, and it's disproportionately weighted to intensive procedures, which by the way, is not a new finding. There's a wonderful pamphlet called The Doctor's Dilemma, I think, from the 1890s by George Bernard Shaw. In his preface, he says it's a crazy system which pays you one pound for amputating your foot, pays two pounds for amputating at the knee and three pounds for amputating at the hip, and who gets to decide? The physician doing the cutting? He said, that's a crazy system, and it stole the system we have. I can tell you, as a leader in my health system, we struggle to pay for mental healthcare or preventive care. There's no money in it, and it's therefore easily ignored. Sorry to be passionate but I am on this.
Dr. Matthew Nathan
I echo your sentiment, Barry. You know Rich, all of us, we've known each other for 40 years, and we all met each other in the service. All of us were practicing Navy physicians, and then Dave and Barry went out and did amazing things in the private sector, and I forgot to get out; they just kept promoting me. But I've led in the private sector and not-for-profit healthcare system. What I'm about to say is going to create screams through the hallways of some of the fine physicians that I worked with in that system, who are fine physicians. You have to do away with the fee for service system. It creates a hunger or a thirst for doing more and more care, not because of malevolence or necessarily greed, but it's just human nature to work yourself harder and to try to do more with less. And yet, the other side of the coin - which is more of the socialistic side in the service, where everybody's salaried and the surgeon is making about as much as the non-surgeon - isn't a panacea either, right? You alluded to Canadian system. I was in England for several years participating and watching the NHS. That system is on the rocks right now as well, because it's incentivizing people when they're just salaried and if you don't meter their workload and they're salaried and you're working too hard, people get despondent and burn out, demoralized. There has to be a balance, but we have to be able to figure out how to feel comfortable in a system where salaried providers who have quality of life can give good care, feel unfettered by too much regulation, and that's going to be very hard to get there. You're going to have to basically unplug the computer and reboot all this and plug it back in again to get this done, and it won't be without tremendous gnashing of teeth to get there.
Dr. Matthew Nathan
I guess my one pithy comment, Rich, would be to have somebody come in and look at everything where a healthcare dollar is spent and ask the question, how does this promote the health of our populace? There are layers upon layers of administration and monies handed back and forth under the table that are not viewable by the public, that have zero impact on health; zero.
Dr. Barry Meisenberg
One source of that is the fact that we have so many different insurers that physician offices and hospitals have a large staff just to communicate with all these different payers. And although there is technology used, it hasn't actually simplified much. The word "denial" has been in the news recently, but that actually allows insurers - and I don't want to make it sound like insurers are the only force driving up cost and reducing delivery - it makes it easy for them to do denials, because their systems are so complex for approval. And the delay, even if they ultimately pay later, the longer they keep the money out of the hands of the providers, the more profit they can make on their investments. I'm just cynical enough to believe it's a strategy.
Richard Helppie
I can tell you with absolute clarity, their computer systems are built to do just that, to deny claims and to down-code the claims while the providers are trying to up-code.
Dr. Barry Meisenberg
The question why is it so complex; why is that the default position and why do hospitals have to hire so many people to take care of this transaction? With a single payer perhaps it would not be so complicated.
Richard Helppie
I'll be throwing in the one change I would make. If I could make one change, I would take away the tax preference for employer sponsored benefits. It was put in place in the 1940s to get around wage and price controls. I think if you started showing on people's W-2 the cost of that health plan, there would be a revolution, and the insurance markets would then be reset toward the care for the things nobody wants; the cancers, the broken legs, car accidents, etc. And people would be coming into your offices saying, how do I stay well because it's too expensive to get sick. That would break the back of this money changing hands, it would take out that administrative layer, and it would have the patient coming in to say, let me stay healthy instead of, I'm not sick enough for an insurance claim. Barry, you mentioned fee for service versus caring for a population so let's talk about COVID under the fee for service system. All providers rely on volume. Hospitals, doctors, radiology sensors, have to do enough procedures for the fee in order to cover their costs. During COVID, had the fee for service system remained in place without special legislation, every health system in America would have gone bankrupt. How did we do under COVID, and were there any lessons to be learned that we could carry into normal practice?
Dr. Barry Meisenberg
I would say that physician practices were saved by the government program, and I think that was a wise program. I know it cost money and maybe it generated the subsequent inflation, but it did protect them. Your question about COVID, I think also, on the clinical response, I think that health systems that run hospitals and emergency rooms did well eventually, eventually. Initially the response was somewhat chaotic. It wasn't evidence based. It wasn't even thoughtful and then, within a few months, began to demand evidence for an intervention. There was a lot of hydroxychloroquine used, and it wasn't used [for] a crazy reason, it was used because there was some idea that it might have antiviral capability. But when the evidence began to emerge, it was very quickly dropped in most places, and other therapies like steroids had to be proven. And so the clinical research enterprise mobilized pretty quickly, made innovations to make the trials easier to run. We standardized the care in our health systems guided by the NIH work group on this. So an ICU protocol would be the same across the 11 hospitals of a health system. And then, of course, what the men and women did who cared for the patients, I think, was very, very dramatic. Now I never use the term hero to describe that, and I'm a little resentful when health systems use that term because it moves... the word hero has a psychological burden to it. Because when you're a hero you're not free to complain about work conditions or lack of protective personal protective equipment. You're not allowed to demand hazardous duty pay because that's all expected of heroes. I've written an essay - and others have as well - on this subject because I think it's sort of used somewhat flippantly. There was a time when the world needed heroes, and I guess that was okay if it was spontaneous, but I'm not okay when it's exploited and put on the side of the buildings - "heroes work here" - to make people feel better about it. And by the way, what we do a year after the hero movement? We started firing the heroes who didn't want to get a COVID vaccine.
Richard Helppie
Well, let me ask you this, did the vaccines work?
Dr. Barry Meisenberg
Yes, I believe - I anticipated that question - I believe they reduced deaths, especially in the early phase when they became available. I think there's good data that populations who were vaccinated had a lower death rate than populations that were not. It didn't always keep you from getting COVID, but I think there's good evidence, I believe in the evidence, that it did reduce death. To answer your questions, I think health systems did well after scrambling and there were some terrible prices we paid, including closing down the visitation and having people die alone. If there's a lesson learned after action report, I would question that policy, even if it cost us a few extra face masks. Now, what do we learn? That's a fascinating question, because you're aware recently we had an IV fluid shortage, because one factory in Asheville, North Carolina, which makes nearly half of all the IV fluid, went out with a hurricane. Everyone else is dealing with a shortage. Did we learn about preparing resources, having a warehouse, I don't think so. Have we built more ventilator factories internally? I don't think so. Are we studying our critical supplies and making sure they're available domestically and regionally? No. And I could go on and on.
Editor’s Note- This is the end of Part 1. The conclusion of this discussion will be available on Tuesday, January 28th.
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