The frustration of actually trying to get health care: the other meaning of access

I have written about the quality of care that people in the US receive, and about access to and the cost of care, but another very important issue is the actual process of obtaining appropriate care. This is a major source of frustration for patients and their families, and can drive anger against the system, against doctors, against insurers, against the government. People who experience this frustration and anger want it to change, and sometimes want to lash out, offering an opportunity to be intentionally misled by influential others for their political ends. The demonization of the Affordable Care Act (“Obamacare”) is a good example. Obamacare actually did lots of good things, starting with insuring tens of millions who did not previously have coverage; it also forbid insurers from charging more to those with pre-existing conditions, and allowed children to stay on their parents’ plans until they are 26. Actually, it did little or nothing bad, if the criterion is access to care. A few people saw increased premiums, mainly the healthy young and those who previously had such terrible policies that they were both cheap and essentially worthless. While the Republican congress tried to repeal it, it turned out that, surprise, people would be worse off without it.

On the other hand, frustration with the obstacles to obtaining appropriate care are real, every day, and in-your-face for patients and their families. I have recently been experiencing these from the perspective of the patient (or family) rather than that of the provider, as I work at getting care for my 92-year-old father. My experience with the provider perspective helps me to understand the situation from both sides, and hopefully to try to figure out which obstacles are rational and which are simply unnecessary.

Let me start by largely absolving any of my father’s individual providers; all those involved with him – physicians both general and specialist, physical therapists, and more recently the nurses, social workers, and nurse practitioners through the palliative care agency – are committed, caring and hard-working. They do their best to help him, to be available, to respond when a problem, minor or urgent, arises. However, there are obstacles in the way. Many services require a referral from a physician, from calling in prescriptions, to ordering lab tests or x-rays (and getting the results), to getting physical or occupational therapy, to enrolling in palliative care. While none of these individually may seem to be burdensome for the doctor, there can be many for any individual patient, multiplied by the number of patients a physician sees who need these services. While it is sometimes the specialist who makes such a referral or fills out such a form, it most often “rolls downhill” to the primary care provider. That provider has to have a very large number of patients to get by and make a living, so the phone messages and faxes and lab results pile up while s/he is spending all day actually seeing his/her patients. Rationalizing the delivery of care means trying to get nurses or other staff to deal with as many as possible, but lots of these require a doctor (or other licensed provider, such as a nurse practitioner) to interpret, approve, or sign off on.  And having more staff costs more money, and means (particularly for the primary care provider, whose reimbursement is much lower than for many specialists) having more patients. Thus, a vicious circle, often compared (from the provider’s point of view) to running on a hamster wheel; for patients, this often seems like obstructionism.

Of course, it often is obstructionism, but rarely on the part of the individual provider. The reason is, unsurprisingly, money. For the providers of care, or more usually the companies for which they work (whether for-profit or not), the issue is reimbursement by insurers, including Medicare and Medicaid. There are rules that must be followed, forms that must be filled out, referrals that must be signed, and procedures to go through, or payment will not be forthcoming. And then the provider, whether physician, nurse practitioner, physical therapist, pharmacist, or social worker, whether self-employed or working for a company, doesn’t get paid. And, depending on how often this occurs, will make less, fire staff, or go broke. In addition, insurance companies themselves often create obstacles to payment (such as the time-honored one of just refusing to pay the first time or two, because maybe the provider will give up), but this is more often true for costly surgeries than lower-cost preventive and treatment services. And sometimes the practices seem almost incomprehensible as in insurers requiring patients to use brand-name rather than generic drugs and thus have to pay more out of pocket (“Take the generic, patients are told. Until they are not”, NY Times, August 6, 2017); one word, not used in the article but clearly described: kickback.

To be fair, many of the rules that seem to be obstructions are not only about saving money; they are about both preventing fraud and even patient safety. There absolutely are major fraudsters out there, doctors and home-health companies and nursing homes and every sort of medical support provider (even hospitals), who try to and often succeed in bilking Medicare (and other insurers) out of millions of dollars in inappropriate (“do you want a scooter at no cost to you?” – but someone else is paying!) or truly fraudulent (there is no patient) care. In fact, some care, even if you want it, even if someone is willing to provide it (if they get paid), is not appropriate for you, or your family member. Medicare and other insurers do set criteria, and require that it be documented. This can actually be good, not only for all of us as taxpayers but for our health and safety.

But often it isn’t good. It sometimes makes care that is appropriate, evidence-based, and desired, hard to get. It takes a long time. It takes lots of phone calls, and hours on hold or waiting for calls back. It has messages lost in piles, or over the weekend. It should not happen, but it does. And it is frustrating. The “Triple Aim” guiding progressive health care has received a lot of attention. It is to deliver high-quality care in a cost effective manner that is satisfying to patients. To document the last, many hospitals, provider groups, and companies send out “patient satisfaction” surveys, which are at best cosmetic and at worst destructive. People don’t fill them out “right”; they tend to reflect an overall impression that leads people to mark each of the ostensibly-separate questions “great” or “terrible”. Also, in forming this global impression, folks understandably often overvalue the things that they can assess (like the quality of food or attractiveness of the facility) compared to things that they cannot (such as the actual quality of care). This is, by the way, where providing good customer service makes a big difference, and while some places are getting better, the medical care industry is generally weak in this critical area.

As in almost everything, those with the least get the least. The uninsured, the poorly insured, and the just poor, provide the least incentive to providers (getting paid) to meet their needs. Government regulations that require certain services for Medicare or Medicaid without paying for them result in greater strain on those providers who provide care to people in these groups. Many providers, especially in some fields or medical specialties or geographic areas, try to avoid them. They locate in wealthier neighborhood, don’t take folks who are uninsured (or on Medicaid, and sometimes even Medicare), or offer indulgent, wonderful “concierge” services for those who can pay a significant retainer. Thus works the “market” in health care. A terrible way to go.

A universal health insurance system won’t make all these problems go away; even with it, systems can still be poor, providers can be uncaring. But it will help a lot. Because everyone is covered, there is no “vendor lock”; the market can function well because people choose their providers based on service, not because they are forced to because they are locked in to a limited pool. Information flows between primary care and specialists and therapists and labs and imaging because if it doesn’t folks are free to take their business elsewhere. The way competition should work; competition on providing the best product and service.

And, because we would all be in it together, in the same system, the most empowered will make sure it works for them, and thus, hopefully, for us all.

Outside Your Own Backyard

A couple of weeks ago, I spent an invaluable day at the corporate headquarters of American Express in New York along with key members of my marketing team. The former CEO of American Express, Harvey Golub, sits on our Finance Committee. Harvey was generous enough to facilitate this opportunity so we could learn directly from global leaders more about the practice of consumerism - marketing products and services directly to consumers.

Until recently, health care has been strictly a wholesale business. By this I mean, we dealt only in volume and negotiated our fees directly with insurance companies. As a wholesale business, they were able to leverage access to their clientele for discounted rates. We were also told what we would get paid by CMS, based on the volume of services we provided. As the health care landscape dramatically changes, with consumers taking a more active role in their health care choices and managing their health care spending dollars, we find ourselves entering the retail business which means marketing directly to consumers. Since the retail model is new for the health care industry, we need to reach outside our sector to learn best practices from some of the leading companies in the consumer business.

During my meeting with American Express, not only did I gain some valuable insights on how they market to consumers, but it underscored the knowledge gained by stepping outside my own environment to learn from others. Throughout my career, I have discovered the extraordinary value in learning from leaders of other industries - from manufacturing to hospitality to fast food - and then applying that knowledge to the work I do in health care. These experiences have directly impacted the organizations which I work for and the way in which I lead them.

One of my most profound professional experiences came from three days I spent at the corporate headquarters of Ritz Carlton to learn more about the practice of top-notch customer service. While I learned a great deal about the way we should treat customers (and have applied that to patient relations at the medical centers at which I have worked), the most valuable moment for me came in a session with a hotel operator as he explained that at the Ritz they refuse to focus their energy on difficult employees. Instead, they cut loose team members who do not want to subscribe to their culture and their values so they can focus time and resources on those who either get it right away or the individuals that want to learn and be developed.

I have brought this lesson to every leadership position since then and it has been incredibly illuminating. In fact, it has radically changed the environment and culture of the businesses I lead. I have learned that in order for an organization to be innovative, entrepreneurial, and downright successful, you need to stock your team with the overachievers. Underachievers and overachievers simply do not get along, so you sometimes have to let those underachievers go so the overachievers can thrive. I admit that this practice is not easy. It can be unsettling and it makes some people angry, but it has created a work environment of accountability and a place that demonstrates the care and value it has for its team members.

Finally, I was fortunate to spend time in the last few years with Jack Welch of General Electric. Jack has provided a wealth of insight on a wide-range of subjects but it was his discussion of transparency and candor in the work place that left a lasting impression on me. Jack explained that it is our tendency as managers to tell our team that when a colleague has been let go - for whatever reason - that he/she “has moved on to bigger and better things.” Jack warned against that, saying that offering this sanitized explanation signals to your remaining team members that you do not value them enough to be honest with them. It also denies you the opportunity to reiterate to your team members the core values of your organization and expectations you have of them. I have taken Jack’s advice and put it into practice. Doing this has allowed me to cultivate a more open and honest environment, and signaled to employees that I live and breathe the values of our organization. It also signifies that I expect the same out of each of them.

In closing, I cannot stress enough the value of getting outside your own backyard to discover new practices by those in other fields. While industries outside your own might operate on a different scale than your company and there will certainly be aspects of their business that will not apply to your work, there is still a tremendous amount of knowledge to be gained from them – we can learn from their systems, their culture, their processes and their leadership style. You never know where your next inspiration will come from. 

A Value Added Proposition

This past Sunday morning, while at home reading the Palm Beach Post, an article immediately caught my attention. The piece, How Medicare Penalizes Hospitals for Being Too Careful, was a reprint of an article that had appeared in the New York Timesearlier in the week. I suddenly wondered; “could hospitals actually be penalized for being too safe?”

As I read the article, I quickly realized that the title was a play on words and even though a few hospitals referenced in the piece believe they are being penalized for doing the right thing, there is much more to this story. The reality is that as the health care industry shifts its focus from volume to value, the government is looking at ways to pay for appropriateness of care rather than the volume of care. Like any new program, it takes time for folks to adjust and an industry to absorb the paradigm shift.

The government is now beginning to penalize the industry for unnecessary readmission for certain conditions and as a result, the health care industry is being rewarded—or penalized—for utilization of certain tests, among other things. Is this bad or good?

While the article suggests that this shift in focus might be less than ideal, I disagree. I believe it is important that we, as an industry, shift from volume to value as quickly as possible in order for the health care consumer to receive the best value for their dollar. The threat of being penalized for unnecessary readmissions or prescribing unnecessary tests is critical in our ability to reduce cost over the long term.

When health care providers complain, “their patients are sicker or present with more complex symptoms,” the government should review the complaint. And they often do and adjust for complexity of care or other organizational differentials. This is commonly referred to as a risk adjustment.

There is no question that teaching hospitals operate differently than community hospitals; however, in all health care environments the practice of medicine needs to be evaluated to determine where protocol and clinical pathway development makes sense. I realize that there are some growing pains and adjustments, but I believe that we need to create an environment where physicians and other care givers can determine what is appropriate for their patients while at the same time managing the unnecessary testing that often occurs. 

The article also suggests that health care organizations are intentionally gaming the system. For the most part, I do not believe that hospitals are deliberately trying to get away with anything. To think this is happening as a matter of standard practice is wrong. You have to remember that these measurement systems are relatively new and very complex, and that it takes time for organizations to adjust to the new protocol. In addition, this new mode of operation is creating an environment that is making organizations think about new approaches to care - which is a good thing.

The bottom line is that we have good people from health care organizations, payers and the government all trying to make the necessary adjustments in the industry to improve service, outcome and cost. We all need to work together so we can create a safe, reliable and reproducible system of care for our health care consumers.