Do No Harm in a Broken System?

How a Business Model Hurts the Health Care System and the Well-being of Patients and Communities

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By Grace Lim
Nov 11, 2018 | min read
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Our health care system is broken. Few, if any, would disagree, though some might argue the extent of its brokenness. Despite having experienced my family’s own financial struggles to pay my brother’s medical bills during my childhood, I myself did not fully realize the impact of this statement until I became a physician. It wasn’t until I experienced the frustration of coordinating how a patient without transportation might go to an urgent appointment with a far-away specialist, and not until I saw a young girl develop a wound infection while recovering from surgery on a bench at the park where her family lived, did I truly understand how people of color, especially those in poverty, are disproportionately affected by the flaws of our health care system.

People of color, especially those in poverty, are disproportionately affected by the flaws of our health care system.

I entered medicine with the idealistic picture of a physician spending emotionally rewarding days with families. Figuratively, I wanted to be like the old country doctors who dedicated their lives to their towns, willing to drop anything at a moment’s notice to pick up their tools and run out the door to heal. Coming from an immigrant family, I wanted to work with underserved communities, to fill a need and be a part of the solution to improve well-being — holistic health of the mind, body, and soul in all arenas of life. I thought medicine would be the means by which I could best communicate God’s love to others.

But medicine has drastically evolved from the days of the country doctor. It is no longer a simple profession with the intent to treat lives, but a complicated business with a need to cut financial losses, and for some, to create profit. Currently, the American health care system largely relies on the “Fee-for-Service” (FFS) payment model, where a physician is paid according to services they provide. This may have worked in earlier times when a simple doctor’s visit to your house could be paid or traded for, but with the extreme specialization of the medical system today, this model is insufficient and has led to many unintended consequences.

To start, with the FFS model, employers might value quantity without caring about or knowing how to measure quality of care. At a clinic where I previously worked, a senior physician was touted as somewhat of a superstar for the number of patients he saw in clinic each day. Seeing almost double the number of patients that other physicians saw meant he brought in more money for the clinic. However, after meeting some of our shared patients in follow up, I began to realize that this efficient “feat” was actually accomplished to the detriment of thoroughness. I was soon regularly diagnosing developmental delays much later than expected as a result of his rushing through an impossible schedule. These misses prevent children from receiving early in-home therapy that could mitigate delays during crucial periods of brain development and even help a child “catch up” within a few years. The longer a concern is left untreated, the more difficult it becomes for a child to receive services or keep up in school, sometimes resulting in behavioral issues that are born out of her inability to communicate the frustration that something is not right. Furthermore, in the predominant population of migrant workers I worked with at the time, parents often did not have the means to meet with teachers or behavioral specialists. In short, a “small” oversight could result in a large disruption within the patient’s family life.

A “small” oversight could result in a large disruption within the patient’s family life.

Secondly, FFS disincentivizes physicians of different specialties or groups from working together. While working at a children’s hospital, I once contacted the on-call cardiologist to ask for advice on follow-up for a baby I was discharging to another care system. Half-joking and half-serious, the cardiologist said to me, “So you are saying that I will not even get paid for discussing this patient right now.” Most physicians I have met entered the field of medicine to benefit patients. However, because of unrelenting workloads and the fact that physicians have largely become pencil pushers, the lack of financial incentive to collaborate can lead some to simply push away work that does not benefit them. The demands of our day desensitize us and prevent us from remembering the underlying purpose of our profession: the patients.

The demands of our day desensitize us and prevent us from remembering the underlying purpose of our profession: the patients.

This potential lack of collaboration extends beyond physicians. Health care institutions have similarly become accustomed to simply checking off boxes, rather than focusing on prioritizing well-being. For instance, clinics or hospitals may seek special designations as a business model rather than as means for better care. Thus, a “Baby Friendly” hospital meets certain criteria that have been shown to improve breastfeeding rates, such as routine teaching and committing to not use formula or a bottle unless absolutely necessary. In turn, this label can further the hospital’s ability to expand as a business through its use as a marker of quality to aid in provider recruitment and grant eligibility. At one hospital that had just started the process for this accreditation, I found that many mothers did not feel adequately supported outside the hospital and would give up soon after being discharged. In response to my inquiry about community resources for mothers, the hospital asked me instead to focus on improving our inpatient (hospital) numbers before looking at outpatient (community) issues. Prioritizing the business aspect of this designation ultimately failed the spirit of the “Baby Friendly” initiative to improve neonatal health through breastfeeding support.

Finally, FFS is a poor business model if a hospital and its associated clinics’ true mission and goal is to provide quality health care. Holistically caring for a community’s medical needs would consist of annual checkups to prevent or allow for early identification of disease, as well as investment of time, expertise, and money into education programs and community initiatives that actively combat chronic diseases. But if these initiatives are successful, hospital admission would decrease in the long run, resulting in financial loss for the institution. This could be especially hard for a hospital serving primarily Medicaid patients, which already reimburses at a lower rate than private insurances. This may be why a hospital I worked for ultimately ran its clinics as urgent care centers rather than medical homes that aim to manage the ins and outs of a patient’s health care and medical history. Instead of notifying patients when they were due for routine screens, clinic visits largely focused on fixing immediate concerns and ignoring the rest. The more concerns there were, the more business the hospital received.

Poorer communities and communities of color lose out most in these cases, as they often have fewer options for where to receive care and fewer resources at their disposal. In addition to potential language barriers, they need to navigate a complex health care system that is largely made up of patchwork resources that differ between and even within counties. Further compounding immediate health needs are social determinants of health, or systemic issues that extend far beyond clinic walls, which health care providers are limited in their ability to address. For example, gang violence in our migrant community led many children to seek medical excuse notes to pursue home schooling, which potentially affected their social development and parents’ ability to work. In another case, a child was frequently missing school due to headaches that had started when Immigration Customs and Enforcement (ICE) began making rounds in the community. It can often be overwhelming and unclear for pediatricians like myself, self-proclaimed advocates of children and families, to discern the boundaries, possibilities, and limits of our work, and how to most effectively spend our limited time and energy for individual and systemic change.

This is what our health care system does — it prioritizes money and power over lives and allows us to forget medicine’s penultimate purpose by recognizing health as an industry rather than a right. In recent years, new payment models have been theorized and implemented to address some of these issues, but these advances continue to be patchwork solutions until we reach the gold standard of universal health care, which is offered in every other developed nation in the world. In fact, the World Health Organization has identified universal health care as the best way to achieve “equitable health outcomes and well-being”, and the United States has been shown to lag behind all other developed countries in multiple measures of health.

The World Health Organization has identified universal health care as the best way to achieve “equitable health outcomes and well-being”.

I had hoped medicine would be an effective extension of God’s love, but I have found it to be another broken system in which so many who are suffering fall through the cracks. After exploring these inequalities through public health, I have decided to start learning about health care business administration so that I can play a bigger part in making change. I often despair at how much we have to fight against and how far we have to go, but I’m also reminded that there is so much to fight for. My struggle remains in remembering that my strength is not my own and that hope is alive in the people who work daily to improve systems, speak out against injustice, and show up to comfort people in their time of need.

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Grace Lim

Grace Lim (she/her) lives on the central CA coast with her husband and two adorable doggies. She is a pediatrician with a master of public health who dreams of universal healthcare and social justice. Her self-care includes painting, making music, and hot pot.

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