Why U.S. Healthcare Isn’t Better At Getting Better


The question I am going to grapple with in the column is one that has become increasingly important and personal as I have started along something I will admit is a bit of a midlife crisis.

My journey to the work of trying to improve healthcare has been a strange one with lots of twists and turns.

I have recently started to wonder—not just wonder, but obsess—about why healthcare has not been better at getting better.

Much of the last 20 years of my career has been spent trying to make healthcare better in every way that I can—from different vantage points of the healthcare system.

I have worked in the highest levels of the federal government.

In the leadership of a multi-specialty group practice and “pay-vidor.”

In the leadership of a national health plan.

And also even in the senior ranks of a major pharmaceutical company.

I have worked with well-capitalized private equity and venture capital-back companies.

For-profit and not-for-profit companies.

And in every seat, I’ve watched healthcare get worse.

To be clear, I am not talking about our pace of scientific innovation, which has continued at breathtaking pace.

I am talking about our system of care.

How we organize, structure, and pay for the delivery of care.

The experience of being a patient—and the experience of being a healthcare worker.

Which for anyone who has watched the whole movie unfold has come to be known as more of a dark drama—than a feel-good film.

We Are Who We Are Waiting For

The last two decades have seen an unprecedented wave of activity centered on making healthcare better in America.

We have journals filled with studies and bold proposals.

Conferences that bring together the most eminent thought leaders in the field.

And the best-funded startups in the world staffed by highly ambitious people who want to use the powers of competition and capital to reform the system.

And yet, by so many measures—most notably cost relative to population outcomes—our system not only often lags behind those of our peer countries—but it fails to live up to the incredibly high standards most of us expect of our healthcare system.

There are 5 dominant hypothesis in public discourse about why healthcare hasn’t gotten better:

1) How we pay for care – which creates incentives for more services

2) Our lack of universal coverage – which creates a balloon squeeze of healthcare costs

3) The fragmented nature of our information systems – which silos information

4) The failure of antitrust enforcement – which leads to the creation of payer and provider monopolies and high prices

5) The failure of diffusion of information on how to improve – which creates uneven implementation

With forces as big as these at play, our minds usually go to advocating for, hoping for, wishing for some bigger, fundamental reform or disruptive event.

There are several flavors of imagined fundamental reform:

Some of us advocate for universal healthcare coverage as the ultimate solution.

Single-payer if you will.

Some of us get excited about the potential for your favorite tech company and set of technologies—Apple, Google, Amazon—to be the savior that we have always needed.

Some of us hold hope that startup companies—with their new app or tool or care model —will revolutionize care.

And some us, still, believe that some big new ideology—value-based care being the most recent iteration—will be our ultimate salivation.

The objective reality of the last few decades suggests that this form of escapism is palliative in nature—it makes us feel better—but offers little by way of a cure.

Tech company healthcare initiatives have come and gone.

Few startups have achieved on their promise of scale and impact.

And fundamental policy reform has been its own mixed bag with starts and stops.

For every solution—if ever it comes—comes with its own incompleteness, unintended consequences, costs, and added complexities.

A new set of problems for us to address.

And in each case—we might find ourselves waiting a long time for solutions to emerge.

So years into trying to make healthcare better—I am convinced more than ever that we need to stop waiting for some external force bigger than ourselves to fix all of our problems.

We physicians need to stop investing false hope in massive fundamental reform or some new ideology.

We physicians must definitively take ownership of healthcare ourselves.

To which you will all say—easier said than done.

And you would be right.

But what is the alternative?

Continue waiting? Continue waiting for what? Or Whom?

I would argue that our waiting—waiting for someone else—may be what got us here in the first place.

In many ways, we—physicians—are who we are waiting for.

I repeat: We are who we are waiting for.

Changing Our Self Image

What would it look like for physicians and other clinicians to take charge of reforming the system?

For starters, it would require that we change our self-image.

For far too long, we have seen ourselves as cogs in a machine.

Objects rather than subjects.

This sentiment has intensified and been reinforced both externally and internally as we have become employees of larger and larger institutions—destined to feel overwhelmed by growing (and overwhelming) size and scale.

We sometimes are made to feel invisible—and often we see ourselves as invisible.

But it is precisely this growing size and scale that will require us to enhance our participation and raise our voices.

To speak up for what we believe is right.

To quit normalizing the abnormal.

To begin offering our voice more forcefully as advocates for change.

It would require that we use our moral authority to more intensely and more broadly advocate for our patients and our profession and the system-at-large.

This advocacy could be at the system level—at the interface with payers and external partners—or it could be a the level of state and federal government.

You could find yourself fighting for a change in an unjust policy.

Or at the head of a table reorganizing care process.

Princeton philosopher Michael Waltzer suggested that the best kinds of reformers are what he called embedded critics—people who are within institutions but who take a special interest in reforming them.

These embedded critics derive unique insight and power from their position.

They understand the common concerns and values of an institution, and can leverage this shared understanding in their critiques.

We need to become embedded critics.

It’s time for each and every one of us to stand up and reject the things we find objectionable.

To quit living as helpless frogs in boiling water and use our moral authority in ways that advance patient care.

At first, this can seem like a very lonely act.

Every group of people has that person who stands up and speaks uncomfortable truth.

And the usual reaction to that person is—why is he/she speaking up?

But what if rather than criticizing that behavior—we stood by that person—and said our peace too.

And we were joined by another supportive colleague at our side.

And another.

And another.

And another.

Pretty soon—the odd solitary voice—becomes the voice of reason and change.

The mantle of leadership—oftentimes a very lonely place—becomes less lonely.

A culture of corporate compliance would be replaced with a culture of celebrated empowerment.

The fragments of inspiration that pass through our mind become seedlings for institutional change that we could nurture aloud.

Leaning Into New Roles

With that self-image change would come the requirement that we assume roles that we have historically left to others.

For years, physicians have left the administration and finance of healthcare to others in order to free themselves up for patient care responsibilities.

While at first this division of labor made sense—the separation at times became so profound that policies and practices governing the practice of medicine were being developed by people who had no clinical knowledge.

And we let it happen to us.

Let that sink in.

We let it happen to us.

We let operational performance and productivity standards be set by people who had never done clinical work themselves.

We let formularies be developed by people who had never prescribed medicines.

Cost was regularly prioritized over clinical efficacy and sense.

We let utilization management guidelines for cancer be developed by people who had never cared for cancer patients.

We have begun to see the results of this abdication.

Physicians have unintentionally become employees of organizations that don’t fundamentally understand or appreciate them.

That see them as replaceable or expendable.

But we can change the tide.

To do so, we will need to roll up our sleeves and involve ourselves in areas of work that previously felt beyond us.

To lend not only our voice and advice to operations, finance, and facilities—but also our time, presence, and leadership.

To be sure, this type of engagement can feel awkward or challenging at first.

But if awkwardness is the price of being heard—then let it be awkward for a time.

And if it is challenging—I can assure you that it is no more challenging than the heroic and remarkable work you do every day to address the needs of your patients.

Physicians in healthcare organizations need to redefine their roles—and operate as stewards of the system.

Big S and little s.

Meaning both the system in which you practice.

But also the larger health care system in which we are all grounded.

Will that involvement really make a difference, you may ask?

I can guarantee you that it will.

At SCAN—the organization that I lead—our physicians and pharmacists grew tired of feeling that the medicines that they felt were best for patients—drugs like Xarelto, Eliquis, Januvia, and Entresto—were beyond their financial reach.

So they stood up and demanded change. And with their advocacy and leadership and engagement in financial decision-making— these drugs are being made available to patients for $0 and $11 copays.

To be sure, the physicians and pharmacists could have just accepted the formulary as it was—the formulary that our PBM handed to us.

But their concern for our patients grew to the point where they felt like a change needed to be made—and they made it happen.

And you can too.

To be clear, I’m not advocating that every physician get an MBA or assume a leadership role over some part of healthcare with which they aren’t familiar.

But I am suggesting that you lean in where you can.

And fight to be heard where your voice can matter.

More positive, systemic change on behalf of ourselves and our patients is always within our reach.

New Expectations of Pace and Scale

Unleashing our leadership will also require that we demand a new pace and scale of ourselves AND others.

In almost any clinical settings, we physicians are a quick to think and quick to act.

We make snap clinical adjustments and adjust our decision-making based on new data as it arrives.

But, when placed in positions of leadership outside of those clinical settings, something strange happens.

We slow down to the speed of molasses.

We become uncertain.

Large, unwieldy committees become a form of governance that minimizes risk.

But they also minimize and slow the pace of progress.

And we hide behind those committees—rather than questioning the need for their existence.

We take common-sense ideas that we know will make care better and we wrap them in stage-gated pilots with change management timelines that stretch from days, to weeks, to months, to years.

We convince ourselves (and others) that change is necessarily slow.

Any of us who desires to change health care must not just challenge the system with new ideas, but also with new expectations of pace and scale.

We must awaken from our self-imposed slumber.

I often jokingly say that pilot is a 4-letter word.

We need fewer pilots and more will, momentum, and frankly, courage to implement change.

Our experience of managing through COVID-19 proved that when armed with real courage and a burning platform—we are able to make momentous things happen.

Not in years.

Not in weeks.

But in days.

A healthcare system that was waiting for years to adopt digital health seemed to do so—and do so well—when there was sufficient urgency and a crisis that demanded it.

What we fail to recognize—

What we fail to acknowledge—

Is that there is crisis all around us—if we just see it as such.

When I led CareMore Health, our clinical leaders recognized every day that loneliness was a problem in a large fraction of the older adult patients that we served.

When we sought to address the issue with an intervention—we didn’t think about it as a pilot.

We went immediately to thinking about a program that we could build at scale.

And within months—we had a friendly visitor and friendly caller program that provided support to hundreds of patients who most strongly identified as lonely.

And we used our early experiences with the program at scale to drive improvement of that program.

The view I’m articulating is not without its skeptics—and flies in the face of conventional wisdom about how to lead change in healthcare.

And, to be sure, the nation is populated with health care leaders who have lost their jobs by pushing a change agenda too far, too fast—and without enough forethought.

But there is actually an ethical imperative to our pace that we must reckon with.

Namely that if we take too long to implement changes to health care delivery that we know will benefit patients, we are withholding necessary improvements of care.

It is not unlike withholding a medicine or intervention that we know will benefit our patients.

And so we must push forward our best new ideas to transform care at scale, because it is the right and ethical thing to do for patients.

Operating More As A Profession Than A Guild

But to maintain our credibility, we must also occasionally advocate for things that aren’t in our best interest but that are in the best interests of the system or our patients.

I’ve been paying attention to hospital mission statements lately.

Here’s one: “The mission of X Hospital is to provide competent, innovative, and accessible emergency and acute care services for the residents of Y City.”

Sounds good, right?

How about to keep people healthy? To eliminate the need for most of the hospital’s services In the first place?

Where physician leaders have occasionally lost credibility have been in instances where we have acted more like a guild than we have like a profession.

Where we have focused more on our own self-perpetuation than what is right.

What do I mean by that?

A guild is defined as an association of people with similar interests and pursuits.

Guilds often band together to secure their economic future.

And they will often do so at the expense of other stakeholders.

A profession, on the other hand, is a group of highly trained individuals who are bound together by a skill set and a set of professional values and ethical standards.

Where physicians have occasionally lost their way in their leadership is where they have advocated for positions that deviate from those ethical standards.

Where the economic and personal interests of the members of the profession have superseded the interests of patients.

This doesn’t mean we have to be perpetually self-sacrificial.

Far from it.

But we do have to maintain the capacity to occasionally put our interests aside for a greater good.

Such equipoise is critical to our credibility.

Indeed that is at the heart of ethical and principled leadership.

And where we have sacrificed that credibility for short-term parochial interests—we have eroded trust in our judgment and advocacy.

We Can’t Afford Not to Have the Time

Now—I know for certain that many of you are sitting and saying my plate is full.

Where will the time come from?

I acknowledge we are all extremely busy people. You have your research programs.

Your clinical programs.

Your existing administrative responsibilities.

Your families and personal lives.

And even a few bold enterprising among you have your hobbies.

To which I will respond that I am not adding to your plate – so much as asking you to think about your role differently.

To think about showing up differently.

To expand your mandate and your sense of ownership.

To change your self-image and set of responsibilities.

Some of you might think that this institution or institutions don’t need or want or even welcome your engagement.

Don’t make it optional.

Show that your engagement enriches the quality of decisions being made.

Show that your passion and pace are critical not just for the institution to survive through changing times, but also to thrive.

And it may indeed take more time.

But there is something fundamental here – which is that we’ve run the experiment when we’ve hidden behind our busy calendar.

And none of us particularly cares for the result we have achieved—which, of course, is our broken status quo

So let’s try it a different way.

With all of us operating more as owners and as stewards and less an employees and as objects.

Our system of care has not evolved in a vacuum.

Things are the way they are because someone wants it to be that way.

If you want it to be different, then we all need you to be the person who leads it that way.

And I’ll say a final thing on this topic—which is if the people in one of the most challenging professions don’t have the ability to lead change—then what will others do without the resources and capability and intelligence behind them?

If not from you, where will the leadership come from?

Better Leadership

Years ago, when people asked me what we needed to improve healthcare, I would say:

Better policy.

Better financial incentives.

And better technology.

These days, I answer differently.

I no longer say better policy.

We’ve run the experiment—and the HITECH Act and the ACA made some things better and some things worse.

I no longer say better financial incentives.

Value-based care, for all its promise—has had mixed results at best.

I no longer say better technology.

Information technology’s influence on the practice of medicine has been neutral at best— and nefarious at worse.

No—these days, my answer is simple: I say we need better leadership.

And occasionally people look at me and laugh.

They say good luck with that.

They smile because they think it’s a quaint and cute answer.

The say people are just pawns in the system in which they operate. Make the system better. The system is what it is.

But then I ask—who will make the system better? From where will that change come.

And the smile leaves their face.

I still believe that a few well-intentioned people can make a difference.

I still believe that leadership is the act of sometimes sacrificing one’s own personal or institutional interest to advance the greater good.

Such leaders are in rare supply in healthcare—but they exist.

If we just will ourselves to assume this important role as change-leaders in this critical time in the evolution of our profession.

This is an adaptation of the Grandberg Visiting Lecture given today at the Beth Israel Deaconess Medical Center and Harvard Medical School.

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