Here’s to your Health
Harvard’s Dr. Jerome Groopman and eight other local medical leaders take the pulse of Massachusetts’ healthcare system, reveal why you’re not getting the care you should, and offer prescriptions for taking charge of your treatment.
Doctors are our mind-body experts, our healers, and, sometimes, our heroes. Insurers and policymakers are our protectors (or so we hope); advocates and journalists, our champions. But they’re also all patients themselves, and when they need care, they have to navigate the choppy waters of our overburdened, understaffed healthcare system just like the rest of us.
Dr. Jerome Groopman’s own recent role reversal from M.D. to convalescent reminded him that, despite our area’s first-class hospitals and first-rate physicians, all is not well in Massachusetts’ medical world. After a particularly difficult back procedure, the renowned doctor was left mired in red tape. “I’m insured through a very good plan, but within four or six weeks I had exhausted my physical therapy benefits,” he says. “So I called, I wrote letters, I had my internist write letters—I was denied. Now, if I had gone to another surgeon, I could have been reoperated on for six, eight, ten thousand dollars. Or I could have gone to the pain clinic and had them inject steroids into my back, which probably wouldn’t do a damn thing, for $1,000. All this opposed to another, I don’t know, $400 for an additional four weeks of physical therapy? It was very eye-opening.”
We wondered: What other insights could be gained from asking people who know how the system works to consider some common healthcare frustrations? What could they teach us about why our doctors and hospitals don’t always live up to their reputations? To find out, we got Groopman and a panel of healthcare gurus together in a room—our conference room, specifically—and let our tape recorders roll. —Sascha de Gersdorff
1. What’s really behind our high healthcare costs?
Jerome Groopman: Despite the feeling that this is a great mecca of medicine, we have a very high level of unhappiness: Physicians are unhappy. Many patients are unhappy. Administrators feel beleaguered. Insurers are routinely demonized. Some feel our government isn’t doing enough. So the question is: What are the roots of this unhappiness, and how can we address them?
Charles Baker: Healthcare is always going to be about putting 50 pounds of stuff into a 30-pound bag. As the population continues to age and technology gets more sophisticated, and as people continue to look to healthcare to solve their problems, I think there will always be people wondering whether it’s enough. I’m working on the theory that healthcare costs will, for better or worse, continue to rise. So the issue about how much we spend, it’s always going to be out there.
Paula Griswold: I completely agree. I think that costs will go up because we’re going to have more demands. But I also think it’s a terrible shame. We can improve the quality of care, we can improve the safety of care, and we can make care relatively more affordable if we change our approach.
Teresa Schraeder: If you look at the history of the medical profession, which really began as a nonprofit public service, there are whole industries that have sprouted up within it. Whether it’s the pharmaceutical industry, the insurance industry, the malpractice industry, the medical publishing industry, the hospital supply industry—these are enormously successful, lucrative professions. In the meantime, physicians have looked around and are still trying to figure out how best to take care of the patient and ensure quality while earning the best salary. We’ve created this environment where the physician really isn’t in charge anymore, and hasn’t been in a long time.
JudyAnn Bigby: We also aren’t looking at, well, are people getting too much of some things, including some very expensive things, that have become standard practice without adding any value or quality? In fact, this may be jeopardizing quality, because we all know what happens when you deliver too much of something.
JG: So should we all be at the barricades to spark some sort of revolution? Are we wrong or unfair in saying there’s a lopsided set of financial incentives?
CB: I talk to people in the healthcare world all the time, and I don’t hear anybody saying they think the way our healthcare system is structured, the way money moves around in it, makes a heck of a lot of sense. But the one thing everyone says is that changing the system is—
JG: Impossible.
CB: Profoundly more difficult than most people realize.
2. How can we improve—and find a fair way to measure—the quality of care that patients receive?
Jerome Groopman: Everyone is complaining about eight-minute, ten-minute doctor visits. I sent a friend of mine to a very good internist, and she came back and said, “You know, he has a template. He’s in front of his computer. He’s not even listening. He’s got one eye on the clock, the other on the screen, and I’m over here, and he’s typing away because that’s efficient for billing.” He’s meeting the metrics he has to—it’s a real sense of industrialization as opposed to intimacy and the art of medicine. Are we deluding ourselves when we set up ways to measure doctors’ performance and go for lowest common denominator? Is that what real quality is?
Teresa Schraeder: Measuring quality is enormously complex, and we haven’t even begun to figure it out. There are some basic questions we ask: Did the surgeon give antibiotics before operating? Did the person having a heart attack get the aspirin when they walked in the door, and an EKG? But these are just the embryonic stages.
Charles Baker: I think the fundamental problem with a lot of this measurement stuff is that most practicing docs I know value their autonomy above all else. They despise, in their soul, the whole idea that somebody else is going to determine for them what providing quality care looks like. And it’s not even the guy in the suit doing it, okay? It’s even having other people in their own department telling them there needs to be a standard of X. I have no idea how you climb over that hill, because the reason a lot of people got into medicine in the first place is that they wanted to be independent. They didn’t want to have to perform to a group standard. They want to have a personal standard.
JudyAnn Bigby: I agree that physician autonomy has always been an important thing, but I think people are resistant to quality measures because they’re not sure what’s being measured is valid. They don’t know that it improves patient care.
CB: What I hear when I hear that is, “I don’t want to be measured.”
JB: That’s not true. People do want to deliver quality care.
CB: That’s something different. They do want to deliver quality care. But they don’t want to be measured.
JG: My wife’s an internist and she says, “I don’t mind if someone assesses me.” But she also says, “Well, are they assessing the fact that I’m in the hospital until quarter of 9, calling people back, giving them their results and explaining what it means to have metastatic thyroid cancer? Or are they assessing me on whether I’m taking a hemoglobin A1C [a blood sugar level test]?” So I think the resentment—and some of it may just be doctors wanting autonomy—is because these tests can trivialize the real fabric of medicine. Physicians and nurses want to feel they’re practicing a healing art. And that’s very hard to quantify. I’m not sure whether this can be captured, or whether she’s delusional and we should all think of it as an industry, where we ratchet down to our regressions and means.
Paul Levy: Well, it is delusional. [Laughter.] But I don’t think that we ratchet down to the lowest common denominator. We’ve been working throughout our hospital on this, and some of our medical staff are saying, “Yeah, we want to be measured, and we want to be measured publicly.” Certain things just matter and can be measured: What’s the chance the hospital is going to do you harm when you have a catheter put into your chest or your neck? We know some percentage of every central-line infection is going to kill someone. Should I, as a member of the public, know what Beth Israel’s or Mass General’s or the Brigham’s rate is, so that when I’m in an ICU, I know what my chance of getting harmed is? Shouldn’t Charlie, as the head of an insurance company—as well as his corporate subscribers—know that, so they can choose which network to buy into? I would say yes. These are legitimate measurements. I agree with Charlie. The medical profession has been remarkably defensive and obstructionist to many measurements—and to its own harm, in terms of its credibility with the public.
JG: When Charlie said doctors don’t like to be assessed—
CB: That wasn’t quite what I said. I said they value their autonomy more than anything else.
JG: Okay—value their autonomy. But a lot of physicians I know feel these measurements are sort of like paper tigers, that they’re hollow.
Victoria McEvoy: Look, we doctors are type-A personalities, and if you give us measurements to do, we’ll do them. We don’t mind being measured, but we want it to be fair. A recent study showed almost 300 preventive healthcare measures have been added to the pediatrician’s list—asking kids about seatbelts and home safety and poisoning. It’s just going on and on. And so an unintended consequence of wanting us to have good quality is that we’re not having time to listen to our patients anymore, which to me is the ultimate measure. Now we’re all striving for these perfect report cards. Is it fair to ask the healthcare system to go out and drag so-called noncompliant patients out of their house, which is literally what is happening now, in order to get a doctor’s grades up? I mean, nurses are going out to houses, knocking on doors. It’s almost like a cartoon.
Kathleen Davidson: My husband and I had a physician who took care of us. He was wonderful. But he just retired. He couldn’t take it anymore because he couldn’t be autonomous. The healthcare system was changing, wasn’t agreeing with how he thought he should practice. So I can see that side. But as far as measuring patient safety, at least in the hospital, you know, we just thrive on goals. It takes a lot of energy, but I think it focuses us.
JG: One other small point: It’s a conservative estimate that 15 percent of all patients are misdiagnosed. Some people think it’s 20 to 25 percent, and half of those are really serious. And it’s a question of cognition, of how physicians and nurses and others think about the problems they encounter. Part of what amplifies and perpetuates these misdiagnoses is the commodity of time. You know, you can’t think when you’ve got one eye on the clock and another on the computer, and you’re being told by your practice plan that you’d better move people through in eight- to ten-minute visits. It’s not a question of ignorance, that the physician or nurse is ignorant about what the actual disease is. And it’s not a question of technical things, you know, that the lab screws up the test, or the X-ray is mislabeled with John Doe’s name and not Erin Smith’s. It’s thinking errors, and no one has really grappled with that.
John Wong: The RAND Institute did a study three years ago showing that across the United States, there was roughly a 50-50 chance that a patient would get the routinely recommended care for his condition. Now, most doctors would not want a 50
percent grade on any of their tests.
CB: It’s 50 percent here, too.
JW: So on our own, as a profession, we’re hitting about 50-50. Can we start to provide incentives to increase what we know is effective? You try to get it under better control, with the intent that, in the end, we’d have a better outcome. But those things take a long time.
Paula Griswold: Clinicians want measurements that are valid, but a crucial part of that is: Don’t evaluate us with something that isn’t meaningful. Doctors are saying, “Involve us, don’t just tell us what to do.” They want to provide better patient care, but they feel like they’re the ones who know, on a day-to-day basis, what works and what doesn’t. They want to be part of devising and establishing those changes, and not just have them delivered. Yes, there need to be meaningful, transparent measurements, but clinicians need to be part of the solution.
CB: Every plan will tell you that they would much rather have the clinicians themselves determine the rules of the game. But there’s an absence of any agreement from them about what the rules should be, so we have to do it. And the reason we do is because we’ve got the employer community beating our brains in over coming up with valid ways to measure performance.
TS: Well, we are public servants in a
public-service industry, and as physicians the most important thing we can do is be the patient’s advocate. If the patient is ill or dissatisfied with the system, their coverage, or their preventive care, it’s our responsibility to try to figure out the solution. And I think the problem is, yes, that physicians haven’t been as involved as they should with quality control measures. Doctors and nurses need to help create solutions, and not just be in their offices seeing patients.
PG: It all goes back to finding that middle ground. Let’s have the outreach, the support, the education for patients, and also preserve the physicians’ time for the things that they are really uniquely skilled at and expected to do.
3. What’s going on with our primary care doctors?
Jerome Groopman: If you see a surgeon, which I have, and he spends about 10 minutes putting in a needle, making an incision, or tying a suture, he may get $300, $400, or $500. If you have a laminectomy done, the doctor may get $1,500 or $2,000. Or a spinal disc fusion—that’s $5,000 to $15,000. Now, what if you go to see a primary care doc, who’s going to spend 45 minutes to an hour asking about your home situation, talking about how to manage care, making sure you get to a therapist, and then following up? He or she might get $50 or $70. There is a tremendous lopsidedness in terms of what the system rewards.
Victoria McEvoy: Right now primary care doctors, especially around here, are facing a terrible crisis. I go to a meeting twice a month with all the primary care team leaders at Mass General, and there’s a huge level of unhappiness. Part of it is this lofty goal of measuring quality we’ve talked about. We’re so busy running a list, clicking our
computers, we’re not even looking at our patients. We’re creating a monster, and the job is essentially undoable. We can’t recruit people into primary care anymore as a result.
Kathleen Davidson: At Boston Medical Center we were almost closed to new patients for six months because of a lack of primary care physicians. And for some of the ones that have left, it’s about salaries. It’s about lifestyles.
VM: Well, you get what you pay for. If you want all the primary care doctors to do all these big things, you have to pay for it. What’s happening now is people are saying, “You know what, I’m not doing it, I’m just going to do what I’m going to do.” And so we’re not looking at the patient, we’re not listening. What’s the average time it takes a doctor to make up his mind on a diagnosis?
JG: It’s 18 seconds.
VM: Eighteen seconds. So, no patient input. Zero. I think, “I know, you’re coughing with a fever”—I practically just tell the patients what’s wrong with them now. I’m going so fast and I’m clicking off my list: Do you wear seat belts? Sun block? Do you go to the dentist? So, again, you get what you pay for. And who’s going into primary care? Nobody. Who are we attracting to medicine, period, with hedge funds paying what they’re paying? I don’t know.
Paul Levy: In England they were having trouble recruiting primary care doctors and finally decided to raise the salaries of their general practitioners. The problem is well known—the cognitive specialists don’t get paid well, but the procedurists do. And it’s persisted for decades.
Charles Baker: If you go to Canada, the ratio of primary care to specialty doctors is around 50-50. In the United States it’s 20-80, and most people think it will be 15-85 a decade from now.
JG: In the end, cognitive physicians, primary care doctors, internists, pediatricians feel incredibly undervalued in terms of their salaries compared with their colleagues’. And now you’re telling them, “You need to show me this or that test.”
Paula Griswold: We’re still only paying the doctor if the patient goes into his office for a visit. If there is something that would best be handled with reassuring someone or answering questions over the phone, that’s not what’s paid for. We still haven’t made those changes.
CB: Our fee schedule, just like everybody else’s, is set as a percent of the Medicare reimbursement, and we basically pay across specialties the same way. Now, I would prefer not to do that. I would prefer, actually, to have a fee schedule that was better about the primary care stuff, for all the reasons we’ve been talking about. But if I chose to do that, what would happen is I would run into a buzz saw of “If you’re going to pay them 150 percent of Medicare, you have to pay all of us 150 percent of Medicare. You can’t just pay them more.” Then I would say, “No, we think we need to do this because there are shortages and problems and all the rest.” And then I would get run over by the medical director, or the medical director would get run over by everybody else in the practice group, who would come to the medical director and say, “You can’t do this.” So that automatically builds into the reimbursement model all these oddities and sort of unusual factors.
VM: Another thing nobody’s brought up is the emergency room situation, which I think is just a disaster waiting to happen. There are literally bodies in the hallway because you can’t get people out of beds.
KD: In our emergency department, we have frequent fliers that come every day. If it’s too long a wait on one side, they go to our other ER.
JG: Just go to Children’s Hospital on a Saturday night. It’s like the Crimean War.
VM: And why are they there? Is it access?
JG: They’re there because they don’t have primary care doctors, and the emergency department is the surrogate for people who are poor, disenfranchised, frightened, mentally ill, or whatever the social or cultural or personal factor. Or they do have a primary care doc, but the primary care doc says, “It’s 11 p.m. Get to the ER and they’ll call me at 6 in the morning.”
4. So, what’s to be done to fix these healthcare problems?
Jerome Groopman: What would it take to change healthcare? Are we saying the government sets the tone and everyone follows like lemmings?
Charles Baker: Someone said to me one time, “If you could have one job in healthcare, what job would you want?” And I’ve always said I’d want to be the head of the National Institutes of Health. Because I think if you want to flip the culture of healthcare on its ear, the only way you can do it is to say, “Let’s put 5, 10, 12 percent of every institute’s research budget toward studying care delivery.”
JG: Do you think that would turn the Titanic?
CB: I think it would make it a lot more interesting to researchers and practitioners. The way we do it now, almost all the money we spend on research goes into the next new thing. And there’s nothing wrong with spending money on the next new thing. But I think if, over a 10-year period of time, the federal government made a sustained investment in research and medical education and care delivery, it would create sustainable momentum that would have an impact on the way some of this works.
Paula Griswold: It’s also a systems issue. To take Paul’s earlier example of the central line: We know an effective way to prevent infections is to make sure people are washing their hands and are using the appropriate sterile precautions. But we haven’t put together a cart with the 18 pieces of equipment needed to do that. And in the meantime, we’re letting poor, beleaguered staff run to 18 different places to get that equipment before they insert the central line. Not surprisingly, they often omit several steps. That’s not supporting the patient; that’s not supporting the staff. You could have a checklist that helps the person performing the procedure remember each step. And then—this could be a little more challenging—you might empower a nurse to watch over and make sure that each step is going perfectly. That may mean some changes in our culture of teamwork, but it could have a huge impact on cost and quality.
Victoria McEvoy: As a patient, what I would like when I go to the doctor is to show up and have everything done in that one place at that one time. That, to me, would be a real quality experience, with somebody friendly, kind, who listened to me. But I also think a key point is that patients have to have some skin in the game. Most of the dollars in end-of-life care just go right down the rat hole, with people saying, “Oh, I want you to do everything you can for my father.” Or you end up with these militant patients, saying, “My back hurts, I want an MRI,” and they get it, because it’s not worth going down that road. Well, if they had a little skin in the game, those would be different conversations. There’s a lot of resistance to that, and obviously you’d have to scale it to people’s needs, but they’d be part of the equation. And that’s been, I think, part of what’s wrong.
Teresa Schraeder: We need to focus on recruitment and retention of family practice doctors—on how we can pay for them, how we can keep them in this state. And we need to encourage patients to have a primary care doctor who can take care of them, who isn’t trying to manage a 5,500- or 7,500-patient load.
John Wong: It’s all about access. Can you, if you’re ill, call up and get to see your doc that day? Do you have somebody who is coordinating your care? Are you getting the right procedures at the right time? Can you even get a primary care doctor now, if you don’t have one already? Patients also need to have an agenda when they go in to see their doctor. Be geared and ready to interact, because the more engaged you are, the better care you’ll get. If you can identify what your major problem is, then your doctor, in the amount of time that he has, can focus his attention on what you need.
PG: And if you think something’s wrong, speak up. Don’t assume it must just be you.
JW: Exactly.
This is an edited transcript. The opinions expressed by our panelists are their own and do not reflect the opinions or positions of their various employers.