In the next post, I will write about some shining lights in our American healthcare system—but not today! Today’s post is about the darkness that is American healthcare. We all know Frodo’s story. The Lord of the Rings is one of the most beloved tales of our time, and it is not just a fairy tale. It is so powerful because it points to the hard reality of human existence. It is so difficult to have power and not abuse it. Here is part of the inscription on the ring: “One Ring to rule them all, One ring to find them; One ring to bring them all and in the darkness bind them.” If the Dark Lord could get this final ring, the last glimmer of light would be lost for ages.
The most powerful lesson of the Lord of the Rings is that “greed can destroy you”. Don Berwick believes the problem is so pervasive in our healthcare system, the whole thing is at risk. But it is not just greed, it is the desire for money and power, and the willingness to do anything to get it that is so destructive. Power and money provide control and the ability to dominate others. That makes it possible to get even more power. The most frightening thing about greed is that its origins seem harmless and innocent. It begins as an entirely wholesome goal of being successful, but, as with the ring, the greater the desire for “success”—for power, money, and influence— “the more it takes us over and begins to define who we are.” When the desire for success becomes a willingness to do anything to achieve power and dominion over others, that is when the work of the one ring is complete.
Too much? No, this is no exaggeration! Consider this personal experience. A few years ago, I attended a statewide meeting which claimed to be about improving health and lowering costs for employers. All the good old boys were there: leaders from major American businesses, the state health department, the leaders of the major health systems, the hospital association, leaders of physician practices etc. etc. The first speaker was an impressive man. He was a family practice doctor from a major American city. He began by describing three of his patients who suddenly dropped dead of a heart attack in their 40s. He was very upset about their deaths, and they motivated him to do something.
He spoke with other primary care doctors in the city. They all knew that heart attacks could be prevented by best practice risk factor management. (Optimal medical therapy) They all knew that expensive procedures in the hospital to open arteries don’t prevent heart attack or sudden death. They put together an organization to identify patients with a high risk for heart attack. They negotiated contracts that rewarded them for excellent performance. Within two years they had dramatically reduced the heart attack rate in their community, and they were doing it at lower cost. They were saving millions of dollars a year with better care. The program was highly successful. They were saving lives and saving money. They were keeping people out of the hospital by keeping them healthy.
As they thought about their success, they knew they would have a much larger impact if they worked with the large local hospital system, and they invited them to join. The hospital system was not interested, but six months later they came back and offered to buy the program. That sounded great! The program would reach more people and have more resources for the mission with the backing of the hospital. The sale went through, and the hospital system took over. They moved the administrative staff for the program into the main hospital campus and as soon as the move was complete, the CEO of the hospital system began reassigning the members of the team to other jobs within the organization. He was dismantling the program—destroying it!
The speaker learned of this activity and visited the CEO and confronted him. The CEO said, you are right, I am taking down your program. It was hurting our hospital system. It was costing us money and I can’t have that. I know that our wives are friends, but if you try to start something like this again, I will fight you every step of the way. We will do everything we can to stop you.
The administrator won. Sudden deaths due to heart attack picked up again and the system in that community was once again focused on hospitalizing patients late in the disease process for stress tests, heart catheterizations, and bypasses. That is just one story, but it is repeated over and over again in our country. These big systems are dominant. They have the power, money, and influence and they are winning.
The story shocked me because it was so explicit. The issues were so clear. What happened when the speaker finished shocked me even more. There were 200 health leaders in attendance. There was no gasp of surprise! There weren’t even any questions. This was business as usual! This was just the way that it was! I was so surprised and disturbed; I was literally speechless.
Now please step back and think about that with me. I will give that hospital CEO the benefit of the doubt and say that he entered the healthcare arena to help people, but along the way his desire for success became corrupted and was replaced by a desire for power and dominance that ruined healthcare in his community. It does not serve patients. It serves his institution and the people who run it. It does not work for anyone else. You can rationalize it any way you want. In the end it is killing people. That CEO deliberately took down that life saving system and more people died as a result.
The path to better cardiovascular care at lower cost lies with independent primary care practices with advanced medical home teams that provide best practice medical management or optimal medical therapy. The speaker had started to deliver that kind of care, but the hospital CEO destroyed it. Think about that. Think about the consequences. Once again, husbands, fathers, and brothers are dying suddenly in their mid-40s. But it is not just sudden death and heart attack, the same best practice outpatient treatments for artery disease prevent the catastrophes of stroke, dialysis, and congestive heart failure. Because that CEO and others like him are willing to do anything to increase their own power, influence, and money your sister is on a dialysis machine all morning three days a week. Your husband can never tell you he loves you again because he lost his ability to speak when he had his stroke. Your mother is short of breath with the slightest exertion and feels like she is drowning because of congestive heart failure, all because the CEO in your town was willing to do anything to dominate healthcare in your community.
This is not about the CEO. I am not condemning him. It is the one ring that is evil. It is the money and the power that it means. Our healthcare science, systems, and financing are so complicated that very few people understand how they work. Many of those who are making arrangements to pay for your healthcare services don’t understand it. The people at the very top make it deliberately confusing and hide the facts so that it is impossible to comprehend. If you combine that with a system that pays a lot more for dramatic rescue procedures like bypasses and stents, it is like a license to steal and apparently almost no one can resist that temptation. No one can wear that ring and run a healthcare system that serves the people in their community by helping them live longer, healthier lives that keep them off the operating table and out of the hospital. It is too great a temptation. It has not worked, and it cannot work.
Here is some good news. We are no longer helpless. There is a new law, the Consolidated Appropriations Act (CAA), that can protect us. Jeff Hogan is an expert on this topic. Here is his take. “Employers … because of CAA, are required to determine “What matters most” in their health plan spend. It’s fascinating/amazing that so few employer CFOs, who are often the named fiduciaries for their employee health plans, have no idea that the biggest problems and expenditure categories are in their plans. In addition, most have no idea what specific health services cost, what they should cost or what they could cost. Basically, they give a blank check to vendors. CAA has changed this or is in the process of changing this. Plan fiduciaries are now personally responsible for the exercise of their fiduciary duty and this duty extends to their boards of directors. They must act solely in the interests of their members and plan beneficiaries. They must certify, by the end of this year, that gag clauses have been removed from their contracts…….and that they are receiving data/analytics which shows them what they are paying for health services and quality or the lack of it. They must secure disclosures relative to what brokers/consultants are being paid for their services and they must be able to furnish accountability for contracted services tying back to the population needs of their specific group. Health services must be procured in an unbiased fashion.”
The lesson in the end is simple. You can’t trust large health systems to act in your interest. They act in the CEO’s interest and in the systems interest. It is a system straight out of the fiery pits of Mordor. The tortures of chronic disease are as real as any delivered by an orc. Our answer is the same as it was for Frodo. He had to destroy the one ring at any cost, and you must do the same. You can’t trust anyone with a license to steal, but you can trust a system that your community owns and governs. We will need good hospitals forever. Their CEOs just can’t be trusted to set the priorities. Leaders from your community must do that and perhaps some enlightened CEOs will start to develop the systems that will keep people healthy and out of the hospital. We can hope. More on that in the next post.
I thought I was alone in my journey to awakening and completing the lifelong mission of delivering the proverbial "RING" (The MCG technology), Bill! Our experience is the same, except we are facing resistance and attempts to destroy us by the ACC and its allies in the industry. Thankfully, many of us have awakened and walked away, just as I did in 1997, and the numbers are growing dramatically. They are now our customers, and we are thriving. That's the real good news!
Thank you for sharing this ! You are definitely not alone. You gave me Hope 🙏