Photo by Eyasu Etsub | Unsplash
Since the start of their relationship 22 years ago, Institute for Healthcare Improvement (IHI) President and CEO Kedar Mate and IHI President Emeritus and Senior Fellow Don Berwick have been having an ongoing discussion about the joys and complexities of improving health and health care. The following is an excerpt of a recent exchange they had about their hopes for taking their conversation public with IHI’s Turn On the Lights podcast.
On the need to lift the veil on the current state of US health care
Kedar Mate: Don, you and I have worked together for a long time. Today, I get to lead the Institute for Healthcare Improvement (IHI) which you helped to create. We’ve been talking about how health care isn’t meeting the nation’s needs in all sorts of ways, and what it would take to set things right. There are reasons for optimism, yes. But there are also big problems. There is not a lot of clarity about how the system works. People get bills they cannot possibly understand and are asked to complete insurance forms that make no sense. People are confused, and that includes a lot of people who work in health care. You and I get to have conversations with people across the country – indeed, around the world – who have insights about all of this. Many of them are change agents. So, you and I have been wondering if it might help if we could share some of those conversations more widely.
Don Berwick: Like you, I get to see real gems of change in health care – organizations, individuals, sometimes even entire countries that are doing something fresh and badly needed. But I also want to talk about the broken parts of the American health care system. Health care in the US is more unsafe than most people realize. It’s insanely expensive compared to other countries, and it’s full of waste and, frankly, profiteering. Our primary care system is fractured, and patients can feel almost abandoned by its lack of continuity. And the racial, urban-rural, and income inequities are truly shameful. I don’t want to be too pessimistic but I’m not sure the will to change lies within the system. Too many of the incumbent power centers just don’t want to change. I think one of the only ways out is through a mobilized public. We need voters to understand what’s going on and to understand the remedies. We have to break out of the bubble of American exceptionalism and learn from what's happening in other countries, other regions that you and I get to work with.
On going beyond the typical health care stories
Kedar Mate: In the US, there’s a tendency think that what’s happening in Washington or in the big metro areas or in the big hospitals is where the action is. I think we often miss the stories of the small primary care practices, rural communities, or entire counties that have broken through on one serious health care problem or another. We don’t hear enough about how health care can and should work to improve the forces that create or harm health, like housing or food security or climate change or the education of young kids. You and I know about lots of examples of work between health care organizations and community partners – here and abroad – that are having an impact.
Don Berwick: The bigger picture — one that you’ve been so constant about showing us, Kedar — includes the health-producing influences in our nation and our communities. It’s actually not health care for the most part. Health care can never make us healthy. It can only repair damage done elsewhere in our lives. We have to move upstream and stop the damage from happening in the first place.
On the struggle to heal and create health in a system designed for profit
Don Berwick: A few months ago, you said that if you asked American hospital leaders confidentially about some of what they are forced to spend a lot of their time doing, they might say, “No, that doesn’t make sense.” Can you say more about that?
Kedar Mate: Well, first, we’re seeing workforce challenges today that colleagues have labeled “moral injury.” That’s what comes from asking people to do things in the health system that are out of touch with their original mission: healing. Clinicians today — doctors, nurses, and others — have to spend hours a day in sometimes senseless record keeping, billing processes, and fighting to get approvals for what they know their patients need. They are forced to take part in financially driven games around upcoding diagnoses, seeing more and more patients per hour, and driving revenues. This is not what they thought they were going to be doing when they chose healing careers. Patients can often see it: doctors and nurses spend a much smaller percentage of their time actually helping patients.
Don Berwick: One of the generators here is that we, unlike many other countries, have allowed the pursuit of profit to dominate too much of American health care. Leaders who should be trying to figure out how to generate health are focusing on how to raise prices or increase volume. They are figuring out how to keep their beds full, even though, when you think about it, it would be better if they were empty.
Kedar Mate: But, Don, it’s not that those leaders are bad people. They’re not trying to create a system that keeps clinicians from doing their best work or keeps patients from getting healthier. Many of them sincerely believe they are trying to create a better system. Yet, they seem to be locked into a cycle that forces them to put more patients through operating rooms or keep their beds full to keep the revenue flowing. I think they’re victims of the same broken system.
Don Berwick: I agree. There is a lot of profiteering and greed, but most people in health care truly do want to do the right thing for patients and communities. The problem is that they’re doing what the payment system says to do. And, by the way, they’re also doing what their boards say to do. In the end, what you and I are talking about has to do with hospital boards of trustees and what they regard as their duty and what success looks like to them. We are spending almost twice as much per person on health care in the US among similarly large and wealthy countries, and yet we have the lowest life expectancy compared to our peer nations. That’s not what success looks like.
On why eliminating inequities is essential
Kedar Mate: You mentioned IHI’s commitment to reducing health inequities in the world, and particularly here in the US. There was a report published recently that estimated that inequities in the US health system cost approximately $320 billion today and could hit $1 trillion in annual spending by 2040 if left unaddressed. This is needless waste that can be eliminated from the system. If we could reduce or eliminate inequities, all that money could be freed up to help public schools, repair roads and bridges, and improve housing and food security. We waste more money on inequities than the federal government spends today on public housing and public education combined.
Don Berwick: The same problems of waste and extra costs come from other quality problems, including problems of patient safety, poor access, and not focusing on what matters most to patients and their loved ones. I see both equity and improvement of health care generally as big opportunities. We can have better care for individuals, better health for populations, and much lower per capita costs all at the same time. But to do that, we need to invest in change, and the problem is that the investor who has to spend the money to improve health and health care and make it more equitable may not be the same party who is going to reap the benefits. It’s what some call the “wrong pocket” problem.
Kedar Mate: But ultimately it is the same party that reaps the benefits because every person in this country benefits from better health care and better equity, period. It’s all our money. In the big picture, there is only one set of pockets: our collective set of pockets.
Don Berwick: It’s our lives; it’s our health, and it’s our money. We, the American people, need to take control.
Editor’s note: This has been edited for length and clarity.
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