Delivery of Care

The coming health care revolt

An interview with Dr. Michael Fine, who is writing a new book to encourage health care workers to organize around community-driven health care priorities

Photo by Richard Asinof

Dr. Michael Fine talks one-on-one with ConvergenceRI about what he sees as the coming health care revolt.

By Richard Asinof
Posted 8/21/17
Amidst a multitude of distractions, Dr. Michael Fine takes a deep dive into what he envisions as the future of health care, previewing the content in his upcoming book, The Health Care Revolt.
Why is it so difficult to have the kind of provocative public conversation about the future of health care and the potential of a revolt by health care workers within the current environment? What are the opportunities to create public health research studies in Rhode Island that look at the diseases of despair? What are the potential uses of data analytics within a smaller community health system to improve public health outcomes? How can the role of nurses be expanded so that they become participants at the table of decision-makers?
The development of accountable entities under the direction of the Reinvention of Medicaid, as well as the continuing deliberations around the State Innovation Model of health care delivery transformation in Rhode Island, are discussions that need to be revisited in light of the changing priorities in Washington and at the State House. The current efforts of the R.I. Executive Office of Health and Human Services appear to be focused on rescuing UHIP, now projected to cost nearly $500 million by the end of 2018.
Who within the Raimondo administration – and who within the R.I. General Assembly – is in charge of monitoring these developments? Are there any public status reports that are planned to be disseminated?

PROVIDENCE – Talk about distractions. There is a solar eclipse today. President Trump has scheduled a major prime time address tonight to talk about policy changes in the war in Afghanistan. The White House is still reeling from a week of disruption, from the firing of strategic advisor Steve Bannon to the President’s seeming embrace of the KKK, neo-Nazis and white nationalists. The threat of war still looms large on the Korean peninsula. And, the Powerball jackpot will grow to be about $650 million in advance of Wednesday’s drawing, the highest ever.

Congress is in summer recess, having failed to repeal Obamacare and replace it with Trumpcare, in large part due to strong resistance from the public. The investigation into potential Russian collusion in the 2016 Presidential election continues apace, with increasing focus on the President and his family’s financial dealings.

In Boston, tens of thousands of marchers drown out a rally of white supremacists on the Common, in the midst of a critical series between the Yankees and the Red Sox.

Here in Rhode Island, we finally have a state budget, as politicians and pundits gear up for the 2018 elections. The start of the school year is just around the corner.

So, it seems like a good time to have a serious conversation about the future of health care.

All health care is personal; it is also expensive. Yet, under the current health care delivery system infrastructure, it is often difficult to try and figure out how all the pieces of the puzzle fit together.

All too often, health care appears to be constructed as a kind of complex Rube Goldberg contraption, in which a series of tasks are linked together in a domino effect, where one device triggers a cascading episode of similar devices. But, what do health outcomes have to do with it?

Dr. Michael Fine, the former director of the R.I. Department of Health, is adamant in refusing to call it a system.

“We do not have a system,” Fine told ConvergenceRI. “All we have is a market. We do not have a health care system; what we have is a way to pay for services. We have people who want to sell services, but we do not have a defined set of services that we bring to every Rhode Islander or every American.”

The fact that we have failed to build a health care system based upon public health, Fine continued, “underlies our current malaise, because what we are doing is writing checks for things, without knowing whether those checks are going to bring us any value.”

One of the problems, Fine believes, is the fact that health care workers have become caught up in performing on what he described as the hamster wheel of health care: what health care professionals want, Fine explained, was not the work of spinning on a hamster wheel, trying to get an incentive payment for seeing 10 more patients a week.

“If we understand the psychology of what attracts people to practice primary care, it is about the relationships to families and communities,” Fine said.

In turn, part of the problem is that health care workers have acquiesced to being cogs in what he termed the medical industrial complex. “I think we’ve let the politicians and the health care policy wonks and the people who are academics, and who are good at admiring the problem, admire the problem long enough,” Fine said.

If you watch the agony of what’s happening in Washington around health care policy, he continued, “It’s particularly painful, because nothing either side is talking about has much to do with improving the health of the population or creating health services in a way that is affordable. What you really see are contending lobbies trying to figure out whose ox is going to get gored.”

The answer, according to Fine, is for health care workers to organize and for communities to build health care systems for themselves.

“What’s the chance of that happening?” Fine asked rhetorically. Honestly, he answered, he did not know.

The question is not so much whether he is crazy to suggest it, or whether it can be done, Fine continued. “The question is: what happens if we don’t.”

Here is the ConvergenceRI interview with Dr. Michael Fine, in a provocative conversation about his prescription on how to change the current equation on health care by fostering a revolt of health care workers, in partnership with patients, families and communities.

ConvergenceRI: How do we shape the future health care model? What replaces the current model that we have now?
I think that’s an important question, in part because of the health care cost, which is becoming more and more unsustainable every year.

In 2003, 17 percent of average family income went to [pay for] health care; now it’s 30 percent. The projection is [it will be] 50 percent by 2025; and 100 percent somewhere between 2031 and 2038.

These are not my numbers; they are Congressional Budget Office numbers. In what economy does 100 percent work?

I can’t imagine what that means or how that works. And so that, to me, is the critical question. At the same time, we see the first declines in life expectancy in a generation, or a couple of generations.

So, this health care enterprise is costing more and becoming less effective.

ConvergenceRI: For the past hundred years or so, we have had a health care enterprise that has been built around hospitals. Is that accurate?

ConvergenceRI: And, that model grew for a number of reasons: because there were urban centers with lots of factory workers who needed to be cared for; because there were particular religious groups that couldn’t get services at other hospitals.
I think there is actually a third reason. There were clinicians – almost all physicians in private practice, who saw themselves as small business people, and whose business interests were in protecting their role as small business people.

They focused on their role as small business people instead of conceptualizing a role for themselves as part of a public health enterprise.

They were pretty instrumental in staying independent, in a small “e” entrepreneurial fashion, maintaining their small businesses. They [chose not to] band together and build a health care system to compete with the power center that the hospitals became.

So there was no population-based power center, with services and the ability to marshal services other than the hospitals. Hospitals became a de facto system by default.

ConvergenceRI: And, after World War II, when the insurance companies came into the picture, they became the arbiters, if that’s the right word, of the purse strings for health care benefits in the workplace.
Totally. And they took advantage of the weakest sector of the market, which is always the primary care sector. Specialists were a little less weak, but they had a monopoly service, so the insurers couldn’t make much progress with the hospitals in terms of their attempts to save money.

Instead, they went after savings from the group that could resist them the least, which is the primary care community. Even though, and we didn’t know this then, but we would learn it later: primary care services turn out to be the most important service from the perspective of public health in the market as a whole.

ConvergenceRI: Fast forward to where we are now. Hospitals are in the midst of a consolidation boom, health insurers are in the midst of a similar consolidation trend, and the Big Pharma companies are doing fabulously.

But, at some point, what goes up must come down. If the system collapses, are there business models that you can build upon that are not hospital-centered?
The first such existing model is actually community health centers, which are a stealth health care system that serves a small but significant portion of the population.

In the U.S., there are 1,375 different community health centers, operating at 9,000 sites, which take care of some 25 million people, providing the best measured primary care in the nation.

These community health centers are way more able to take care of a bigger swath of the population, in a much more sophisticated manner, than the old entrepreneurial model of primary care practices. And, they have been funded to begin to build to scale.

In Rhode Island, community health centers take care of somewhere between 150,000 and 175,000 Rhode Islanders; that’s 15 to 17 percent of the population.

By itself, that’s a big number. But when you think about the total number of patients who are actively involved in primary care services, it’s probably a third to a quarter in providing all the primary care in the state.

That’s one potential chassis. We also have a couple of large primary care practices in Rhode Island that have become multi-specialty [groups]. Bristol County Medical Group, the Aquidneck Island Medical Group in Newport, Anchor in Lincoln. When you put it together, you begin to see that what we’ve got in Rhode Island is the beginning of a shadow system.

What no one has done is thought out how to resource these [primary care groups] appropriately and direct them toward a population base and pull them together as an integrated delivery system, which is really what they should be. And no one has given them a goal other than to try and survive financially.

ConvergenceRI: Could you define what you mean by public health and population health, and what are the differences?
The differences are subtle. Public health is how we understand and measure the health of the population of a place. So, we think about the public health of the state of Rhode Island.

We’re talking about what is the infant mortality rate, what is the life expectancy, what is the years of preventable life loss, and what is the cancer mortality rate.

What public health is, when you really understand it, is a bunch of measures that allow us to compare places [with] their health-relate outcomes, which reflect upon the social organization of the places.

[In other words], here’s a place where people are doing better; here’s a place where people are doing worse. Now, let’s figure out what it is about these places that is different. Is there more income inequality? Is there a different take on race? Is there better employment? Is there better safe and healthy housing? What are the things that make one place better than another place?

These are measures that help us think about how well the entire population of place is doing.

Population health is related; but it’s not so restricted to place. Population health is about how well a population not defined by place is doing. The group does not necessarily have to be rooted in geography.

ConvergenceRI: Where is the conflict? Is it about how future reimbursements are paid, in the measured improvements in population health, versus public health?
In population health, when you talk about an accountable care organization, what you want to ask is: how well is the ACO doing in improving the population health of the people it cares for, as well as the specific health of individuals.

From a public policy perspective, we should be thinking about public health: how is the entire number of people who live in a place doing, because when you really get down to what a health care system is for, it exists to strengthen democracy, by giving everybody an equal shot at participation.

If that is the goal, then what you want to think about is everybody in the place, not just the people who are insured by Blue Cross, or the people who used the Lifespan [health system]. You want to think about the entire population of the state.

ConvergenceRI: In your opinion, how do we change the equation?
The question is: whether the public and the health care workers are at the point where we are ready to revolt. Because I am pretty clear that is the only way that this is going to change.

It isn’t going to change if Washington does this; it isn’t going to change if insurers do that; it isn’t going to change if hospitals do this.

The equation is only going to change when people in the communities figure out that they are getting screwed. It’s going to change when health care workers get totally exhausted from the industrialization of their lives. The progressive alienation from their jobs is remarkable; what is also remarkable is that they haven’t stood up and pushed back yet.

ConvergenceRI: Why haven’t they stood up?
I think it is complicated. I think that health care workers are chosen, in some ways, for their complicity, for their willingness to stand on line and take directions.

If you’ve ever had to study organic chemistry, organic chemistry requires a kind of arcane thought process, but it has nothing to do with providing health care.

It really involves lots of memorization. I think of it as a hazing ritual; it’s there to screen out anybody who has some originality. There are some creative people who survive anyway, but they are the exception, not the rule.

We also have a culture that emphasizes a certain kind of material success. So, I’m going to button my life and suffer, and the good news is that I’m paid pretty well to suffer, so I’m not going to rock the boat.

ConvergenceRI: Within your changing equation, what role do patients play? In my experience, it’s often very hard to tell a doctor no. For instance, let’s say that I have read Dr. Barbara Roberts, and I choose to refuse a prescription for statins. But my primary care physician says, you have to take it, or else you may be determined by your health insurer to be non-adherent.
There is a huge kind of social pressure that the medical-industrial complex brings to the table. It is hugely powerful and hugely effective at demanding compliance, both from professionals and from patients.

I think the patient revolt begins to happen around cost. I think we are rapidly getting to that place where the patient says: I don’t care what my doctor says about my cholesterol levels; I just can’t afford this stuff any more.

When you see one health care profiteer after another jack up the price of what should be an inexpensive medicine that most people didn’t need anyway, eventually people figure out that they are getting sold a bill of goods.

They see their communities that used to have community centers; and that used to have late buses serving the high school; and that used to have music and art taught in the high school; they begin to see that their communities have been stripped to next to nothing.

Here is where I think the opportunity is: I think if we can activate the health care workers who have had their professional lives taken away from them, who have had their hearts broken by the way their professionalism has been destroyed, those health care workers know the numbers, or at least they can learn them pretty quickly.

I think those health care workers have the opportunity to start standing up and speaking out, and helping people in the communities learn how to fix this themselves.

ConvergenceRI: Is there a natural alliance that can be created between health care workers and patients, to have a shared voice in this process?
It is tricky; people have different roles, and the challenge is to help people stand up inside those different roles and realize that this is both a collaboration and a partnership.

My colleagues may think that I’m totally crazy, but if you’re going to build a health care system [based upon public health], you have to have an organizing effort. And, there is only one group of people that I can see funding this organizing effort, and that is health care workers themselves.

ConvergenceRI: When you say health care workers, can you be more specific about what you mean?
I mean everybody – doctors and nurses and nurse practitioners – and also their colleagues in physical therapy and occupational therapy and mental health.

Nurses are such a potent group; they have been more effective than any other health care workers at organizing and advocating for better patient care. Nurses are hugely important in this, as are everyone in community health centers, and everyone in primary care practices.

ConvergenceRI: What is the role that data will play in supporting the future community-based public health care system?
Everything we do is built on relationships. I think the role of data is interesting. I guess I’m a believer in small data, not big data.

ConvergenceRI: What do you mean by that?
I think that when you create small health care systems that care for communities of 10,000 to 20,000, it is relatively easy to collect the data that you need to understand where your liabilities are, and where your opportunities are.

It is also nice to have some bigger data into which the smaller data sets fit.

For example, in Central Falls, it was helpful to learn that the city’s adolescent pregnancy rate was four times the state average. From that bigger data set, we can take that guidance and then drill down locally.

In Central Falls, when we understood that we had 42 adolescent girls a year who were pregnant, our job was then became how to find the people who were most at risk for getting pregnant, and in one-on-one relationships, find ways to help protect them from becoming pregnant, lowering the adolescent pregnancy rate.

On the ground, the small data approach is based on relationships. What no one seems to yet understand is the power of this approach.

In Central Falls we are looking at the data, counting every ambulance and EMS transfer. We do some things to reach out to people who are taking an ambulance ride; there are roughly 150 to 200 ambulance runs a month in Central Falls.

And, as we drill down, we can begin to understand how many are for pain, how many are for alcohol intoxication, how many are for abdominal pain, how many are for mental and behavior health issues, and how many are for overdoses.

When you look at how many folks really needed to go to a hospital and how many of them didn’t, it turns out that 50 percent to 70 percent never needed an ambulance; what they needed was to be seen by a good primary care clinician.

That helps us target people who are at risk, and people who are having difficulty and who are not being reached by the existing delivery system.

In May and June of this year, for instance, we saw a sudden jump in the number of transports for alcohol intoxication, and we said: wow, what’s that about?

We know from data that is coming out of Europe is that one of the best things you can do is to reduce the incidence of alcohol intoxication is to shrink the open hours of establishments selling alcohol.

What we learned, in talking to the city solicitor, is that there is a statewide pre-emption. That is to say, state government is the only organization that can change the open hours of an alcohol establishment.

Here’s what got interesting. Somewhere at the beginning or the middle of May, the statewide opening hours changed to a summer scheduled, moving from 9 a.m. to 10 p.m. at night to 8 a.m. to 11 p.m.

Suddenly, you could see this relationship between social policy and how it was causing population and public health injury. So, now we are working on the process of trying to get special legislation for Central Falls so that we can shrink these open hours and deal with a very local problem that we could identify by looking at small data in the real-time world.

ConvergenceRI: There are numerous ongoing discussions, looking at how to identify patients who are most at risk. But sometimes, it seems that focus is on patients who are at most risk to costing the health care system money. Is that accurate?
When people talk about risk in the health care world, they often talk about the risk for cost, not the risk for bad health outcomes. Because the people who are the most costly, in general, are those who are already struggling with one disease condition or many disease conditions.

Often, people with substance use disorders, and with emotional and behavioral issues that are compounded by other issues of physical health, obesity and diabetes, high blood pressure and heart disease, at the end of the day, those are a group of issues that come out of mental and behavioral issues and personal choices that are probably conditioned by early stress and trauma.

We kind of know who is at risk. But the challenge is not to figure out who’s a risk, but to prevent the injury that happens to people when they are young.

Trying to mess with people who are most expensive now, in general, [doesn’t acknowledge that] the horse is out of the barn.

And, one of the things we have figured out, even if you manage those people, if you bring more resources to bear, you can reduce the costs, but it doesn’t have anything to do with improving the health of the population. It only has to do with trying to control the costs of the most expensive segment.

Sometimes I think this kind of activity is like an answer looking for answer. The real opportunity is to help communities develop resiliency and build relationships, so that everyone in the community is well cared for, because that’s the way to prevent higher costs in the future.

ConvergenceRI: To accomplish that, how does the practice of primary care need to change?
When you think about it, the primary care clinician is with a patient for 15 minutes, two or three times a year, and that’s a huge problem. The ability of primary care clinicians by themselves to affect behavior change is next to nothing.

This is where you do need a village if you’re going to get behavior changes. You need a city government that’s talking about creating opportunities for physical activities in that community, and building community centers so that kids have a place to go after school.

You’ve got to think about primary care from a public health perspective. There are 40 percent of the people who don’t get routine primary care, because when you are working with primary care practices, you’re essentially dealing the problem of regression to the mean. That is, the people who have a primary care doctor they see regularly are probably the least risky people of all.

Those people who are most at risk, who are going to have the most health risks, are the people who don’t go near primary care providers. And, they are a part of the community as much as those people who regularly use primary care.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
My tiny plug is that next fall, I will have a book coming out called “Health care revolt.”

It will go through many of the ideas we’ve talked about. Maybe the thing to ask, that you haven’t asked, is this: You’re talking about getting health care workers to revolt, and getting communities to build health care systems for themselves. Are you crazy? What is the chance of that happening?

But, what is the chance of the United States having survived this far as a democracy? What is the chance of human life existing? Those are all tiny changes.

We sit, as a people and as a culture, on a knife’s edge; we exist essentially because of a bunch of lucky accidents.

The choice is not the question of whether it can be done, the question is: what happens if we don’t? Do we have an alternative?


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