Expected Surprises

It was 1981. I was about to graduate from a top law school, with honors. I had worked as nursing administrator at a major urban hospital before going to law school, learning a tremendous amount about the challenges of delivering patient care. It inspired a passion in me to improve the system while also opening a door to a job as a law clerk for one of the largest firms in the Nation specializing in health law.

The time seemed right to attack something that had been bothering me about the health care system- my health insurance coverage. Not the coverage, per se, as I was young with little need for coverage other than an occasional broken bone and peace of mind for some unlikely calamity. No, what was bothering me was the actual policy, the long and jargon-filled document sent to me whenever I paid my annual premium.

I had skimmed through it before- and couldn’t understand it. Now, with my years of knowledge and experience, I thought it time to unravel the mystery of this document. Surely this would provide me some answers to the craziness of the health care system I’d confronted as an administrator and at the law firm. Maybe it would even offer some rationality to what seemed like a very disorderly system.

One quiet afternoon at work, I took out my contract from my book bag, gathered my pencils and rulers that I used to review legal documents for clients, and began to pour through the document.

Minutes ticked off the clock as I toiled away. Then an hour, heading towards two. I put down the contract and contemplated what I had learned. I had to face the reality of my research- I didn’t have the foggiest idea what the contract said or meant.

I felt a bit like an idiot. My mind shifted to discerning why this was so. Not wanting it to be my mental defects, I dug for a better explanation. Two thoughts came to me- it was either the most complicated system known to mankind that could produce such a document, or the authors were intentionally using it to hide something.

I also contemplated it in the bigger picture. If I couldn’t understand this contract, with my background and recent experiences, who could? Not many, it seemed. No, this wasn’t a health care system easily explained to – or understood by- most Americans.

Forty years later, I now know this is the case. I’ve had experience after experience in my professional life, and a few personally, that reinforce my conclusions from 1981. That it is both an obtuse system and intentionally complicated by those in control of it.

I guess that would be fine if it was working well. Few think it is, despite the clinical miracles that occur every day. And while there are mysteries of clinical care and other matters that will always remain technically beyond the grasp of many of us, the relationship of these matters to our personal state of being and wellness cry out for greater individual knowledge and involvement.

We know it has an attraction, as many have pledged their belief in related concepts, or at least for marketing purposes. Many a health care system or provider brags of their “transparency”. Or their “patient centeredness”. Some claim that it is the defining difference between them and their competitors.

Maybe so. My experience has found some who really believe this, and a lot who mostly like the possibility that the brand might curry favor from the public, while leaving them still in the dark.

The gap of understanding about the health system to people has real consequences. A good contemporary example is surprise billing, where a patient discovers after their care that they owe all sorts of money because of the consequences of some largely unknown part of their health insurance contract or practices.

The discovery usually comes in the form of a bill, or worse, a bill collector, unleashed by the health care provider. Sometimes for tens of thousands of dollars. Let’s be clear- it might be a surprise, but it is not entirely an unexpected one.

Another contemporary issue is hospital pricing. Laws have been passed to help consumers to shop based on price- for various services and tests. Good luck trying to navigate what is out there as tools for this, though many of us find that the spread in prices is a large one across the system if we can get the information. It doesn’t necessarily help us with our choices, though.

Maybe solutions to these and other problems will finally lead the way toward helping the average person and buyer understand the system and what it means to them. But it sure seems like there is a long way left to go to get to this reality.

The Washington Health Foundation has explored this territory before. Back in 2010, we formed a Center for People’s Health, and used this to explore innovations to truly build health care around people. We based much of our approach on Donald Norman’s work on user friendly consumer design in his groundbreaking book “The Design of Everyday Things.” We even held a symposium on redesigning patient care around the person.

Our most important innovation was the design and production of a series of “Health Home Tools”. We still have over twenty of these tools free to anyone who wants to download and use them. They can be found on our new website at washhealthfoundation.org, under the Tools and Resources section. They cover a variety of topics, such as “Managing Your Hospital Stay”, or “Rx for Your Physician Visit” a guide to taking control of their physician office visit. Some of our tools are available in Spanish.

Perhaps we will get to develop more of these tools as we figure out our next steps as a Foundation and change agent. Or perhaps we will act more in policy circles. But for sure, the notion of building a health care system around the people it serves will remain a core tenet of our work. This blog rekindles our intent to do so.

All I ask in return, personally, is that I don’t have to try and read a health care coverage contract again.

Moral Hazard

A conservative talking point around the longstanding health care reform debate has been that providing insurance coverage to Americans drives up health care costs because of what is called “moral hazard”. It is an economic term meaning there is an artificial shift up in the demand curve for goods or services because of an incentive. The assertion is that too many Americans seek health care largely because they have coverage to pay for it, not a real medical need.

This has never, to my mind, really been proven. For example, how many men do you know who clamor to go to regular physician office visits because they have coverage? More likely, they go because their spouse tells them they must. A different kind of moral hazard is in play in this model!

Many free market theories toward health care like this fall apart in practical application. But the idea has circled around health reform debates for years saying we should let market forces govern health care distribution decisions, not the government or even insurers. Usually as an argument against government-based reform rather than the basis for serious proposals for reforming health care around one’s personal ability to buy services.

I am not going to re-plow that broader intellectual turf in this post now- that is for another day. But it is a useful context for asking a big question about current anti vaccine behavior and the conservative inkling to use the marketplace to govern decision-making for health care.

Like many, I am getting increasingly frustrated by the resistance of millions of Americans to the science or responsibility to others reasons for getting prompt receipt of an exceptionally safe and effective and free vaccine. Not doing so increases the social risk for everyone, and especially those who are compromised.

Space Travel and Health Care

I read with great interest the recent announcement by several large health care systems of a joint effort to form “Truveta”, a new company aimed at leveraging big data analytics to enhance health care knowledge and action.Providence Health System in Washington is one of the organizations involved, along with 13 other large hospital and health systems located in other regions across the country.According to their announcement, these systems collectively care for tens of millions of patients and operate thousands of care facilities across 40 states.News reports suggest these systems comprise in the order of 15% of national health care activity.

Public statements of these health systems emphasized the good they believe their endeavor will produce.For example, Providence Health’s statement speaks to the benefits of bringing patient data together in order to improve care, develop better therapies and drugs, and to promote more equitable treatment of underserved groups.

The Truveta announcement coincided closely with news of the space ventures by two multi billionaires.The obvious personal rush that Jeff Bezos and Richard Branson sought was also wrapped around suggestions of a broader purpose to their adventures for greater good, such as beginning an age of “private” space exploration or saving our planet.

Perhaps broad benefit will be the product of all of these efforts.But experience would tell us to take these overtures of beneficial intent with a grain of salt.

I am not so well versed in space travel, but have borne witness to a large number of new health care ventures.Many related to data, but others around different health care strategies.Most public expressions of these have emphasized wonderful social and public aims of the enterprises. Underneath, all had one more overriding characteristic- a presumption that “bigger is necessarily better” in health care, and that the many would benefit from accumulation of health care activity.

Back to Work with Attitude

As the virus subsides in the face of vaccines and our great desire to return to normalcy, millions of Americans are facing a return to work. More likely than not, they will experience a new version of normalcy as to what it means to “go to work”.

Many organizations found they could get their work done without having employees physically together all the time in an office setting. Employees produced quite ably from home, and some even found happiness with being able to work from there, or at least under the circumstances of a pandemic.

Now, some companies and staff have begun to transition back to their former office centric world. But many have begun to conceive of a new workplace, one where “work at home” has a more central place in a new order. Some because of employee happiness, some because of the realization that expensive offices can be downsized or re-conceptualized, and others for their own reasons.

The notion of working from home or flexible hours or the like is not really a new idea. Many organizations began to walk this road well before the pandemic, even decades ago. Many have found it to be a worthy experiment.

The Washington Health Foundation was among those entities. We grew out of a flexible and positive workplace culture within the Washington State Hospital Association. As we grew and became independent, at one point to over 50 employees and in a downtown Seattle office, we realized that the nature of our work allowed us to think more creatively about how to structure it on a day to day basis.

Memorials of the Future

Memorial Day weekend seems a good time to reflect on history, and our place within it.I have been pondering this recently in the context of Tom Brokaw’s book “The Greatest Generation”.

Sometimes referred to as the WWII Generation, Brokaw celebrates the contribution of those who survived and won this world war, the Great Depression, and other calamities of their time, including public health scourges like polio.Brokaw called them the greatest generation because of the sacrifices they made in these times, for others as much as themselves.They usually describe the logic for their actions as just “doing the right thing”.

I was drawn to Brokaw’s argument when the book came out in 1998.Since, only more stories have come out convincing me of the worthiness of his assertion. This Memorial Day weekend saw even more of such poignant stories about this generation.

It is hard to not compare this through the lens of our current collective response to Covid-19.I was struck especially by the contrast with extraordinary incentives being announced to recruit Americans to get vaccinated against Covid-19,For example, the State of Ohio enters those who get vaccinated in a pool for a drawing of $1 million.Other states, including Washington, have or will join in the approach.An interesting use of federal pandemic funds, for sure.

States and municipalities are offering other incentives.Businesses have also been encouraging their employees to get the vaccine through incentives.I suspect we are just scratching the surface of the efforts to use incentives encouraging Americans to get vaccinated.

An Ounce of Prevention

Among a multitude of major programs for the Washington Health Foundation during its active period of 1992 to 2013 was a Prevention Initiative (for a full recording of our activities and accomplishments, go to washhealthfoundation.org). Our Prevention Initiative was an attempt to bring major attention, investment and collaborative action toward preventing health ills for the people of Washington state. It was supported by a number of Washington state organizations, public and private.

We scored some important health improvement points with the Initiative, but it failed to scale up as fully as we would have liked. The barrier to greater success was not a mystery to us- indeed it was the reason to try. That is, the strong orientation of the medical care system to addressing illness care, even when many of these maladies could be avoided with an ounce of prevention. The medical care system absorbs an inordinate amount of resources and attention to its needs. Changing this pattern was the intent of the Initiative, and while we did some good, we ultimately did not have enough capital to more than marginally change the status quo.

It was not our only attempt to tackle this bear throughout our history. From the Healthiest State in the Nation Campaign to many of our grant making investments to an assortment of programs and activities, the fundamental aim of health improvement, rather than just more medical treatment, was central to our mission. We are satisfied that we made progress, but still disappointed that we could not have achieved more.

Now we find ourselves contemplating some form of a return to the field of play following a mothballing of our activities for several years due to budget limitations. The objective of prevention remains high on our priority list. But how the context around prevention has changed recently- and made the proposition even more daunting than before.

The dominant context being, of course, the virus. The horror of a half million lives lost showed the critical importance of having a medical care system that can respond to mass casualty situations. This justifies the need for great resources, even more than before, in this moment. To be clear, having a robust medical care system was never anything we opposed; only that we needed to invest in building a similarly strong capacity to promote health and prevent disease and injury.

What’s Next?

For many years, the driving force to my work was stimulating fundamental change in America’s health care system.While doing so, I recognized the miracles of modern science and the overwhelming predominance of good intentions on the part of those engaged in health care delivery.But the defects of our system were evident- high cost, mediocre outcomes for the massive investment, and inequities galore- and crying out for big solutions.

Then, as now, my view was that the core defect was the excessive fragmentation of health care service and financing, and its inability to function like anything resembling an effective system.

Recent events reinforce this diagnosis.It came as no surprise that an initial vaccine distribution premise of providing doses to the nodes of the health care system with a hope that these nodes would expeditiously and fairly provide it to the public was fraught with danger.Thankfully, we have turned the corner and replaced this premise with tactical distribution through a myriad of health care, public health and social methods. Bewildering yes, but far more effective than before.

The vaccine experience is but another example of the true cost of our disorganized and at times grossly ineffective health care system. The stakes were already high in needing a solution and have escalated further.Unfortunately, the past year has also left me questioning like never before our capacity to engage in the honest and hard work to achieve a fundamental change of our health care system.

There was some personal good news on this front- the lockdowns gave me the time to contemplate my own thoughts on fundamental change substance and process. This largely translated to my completing a health policy novel called “The Theory of IRV”. I wrote most of it during the March to May lock down and finalized a prepublication version in the Fall.

Shooting for the Moon

Despite my hopes, I can’t get off the topic of vaccinations in these WHF Blogs (previous blogs are found at our new website at washhealthfoundation.org). Reality is that this is the health issue of the moment, and maybe the century. Vaccinations hold the key to our short term and long term health prospects, and our economy, security and more.

Recent developments are most encouraging. More supply is on the way, more ways to get the doses into are arms are being rolled out, and science is back in charge of key decisions. There is now focused national action on this imperative, and far less denial and political grandstanding.

There is not a moment to lose in getting people vaccinated, as the gap between where we are now and herd immunity is a big one. In the United States, and even more so as we look to the global challenge that is the only path to build true and lasting protection. Meanwhile, mutations driven by the high prevalence of the virus threaten to make our problem exponentially greater, while our solutions are more linear.

All to say we need to keep pondering ways to open the vaccination spigot to where it converts to a full out fire hose. Lately, I’ve been assuming that those who really want the vaccine will get it. Maybe not tomorrow, but in the foreseeable future of Spring-Summer.

But we will likely see the problem of vaccine hesitancy raise its head again as a barrier to achieving herd immunity. Many just don’t trust vaccinations, and there is an anti vaccination movement in our Nation which will cultivate this fear. This will supported by a still underlying political division. These may not be dominant, or even strong minority, views, but it won’t take many naysayers to threaten our ability to get to the 70-85% of the population needed for herd immunity.

Bottlenecks and Resolutions

Happy New Year! Like most, I am happy to put 2020 behind me. Other than our revival of the Washington Health Foundation, there was little this past year to celebrate. On to a better year- starting with a resolution for better health for all.

Achieving this better health seems directly linked to our success with the distribution and efficacy of COVID-19 vaccines. Our Healthiest State in the Nation program of years gone by (washhealthfoundation.org) included an annual New Year’s Resolution challenge. It sure seems like our 2021 resolutions need to start with one to make this vaccination work, and soon.

The scourge of the virus is now bursting on top of the Thanksgiving surge, reaching record heights nationally and in many states. To add to the threat, the virus is also changing, with a new variant strain that spreads even faster now among us.

Social distancing and masks will continue to be important tools in our defense this year. We must resolve to be vigilant in these efforts as we work on the bigger solution- vaccination.

My last WHF blog discussed the problem that historic and general public resistance to vaccinations will present to our solving the danger. But, with the start of the new year, the greater problem is not really this but the slow distribution of vaccines to people quite ready to take them. Tens of millions of doses have already been manufactured and much more is on the way. Yet, as I write this, we have only actually vaccinated a little over 4 million people.

To Vaccinate or Not

About fifteen years ago, back when I was a full-time President and CEO of the Washington Health Foundation, I got a telephone call from a participant in our then annual Governor’s Bowl Health. The Bowl was a 6 week statewide health competition within our innovative Healthiest State in the Nation Campaign. It engaged thousands of Washingtonians to improve their health through both personal responsibility and group action (washhealthfoundation.org).

The caller began with compliments about our organization and the Health Bowl. She was appreciative of our support to people and organizations looking to improve their health, and events like the Governor’s Bowl.

The conversation soon turned to our position on childhood immunizations. Our position was public support and encouragement that parents immunize their children per state health department guidelines. We even provided bonus points in the Bowl to those who had gotten these vaccinations.

She asked about an editorial of mine published in a Seattle newspaper about the issue. I shared with her our extensive review of vaccines and why we reached our conclusion that childhood immunizations were on a short list of priority health behaviors that would pave the way toward Washington becoming the Healthiest State in the Nation.

This was when the phone call went off the rails. She challenged our position, asserting that vaccines led to autism. She cited Jenny McCarthy and a discredited research study. I offered to share the extensive research base we had relied on in our conclusion that they were safe and effective.