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The down & dirty on women's wellness
No Laughing Matter
No Laughing Matter
April 2, 2020
We are a jovial bunch in this office. We like to see the lighter side of things. We like to laugh & have fun. Each of the women in our office really enjoys a good time & truly sees laughter as the absolute best medicine. If you’ve ever met us, you know that we are not uptight, that we are whimsical, that we adapt easily & readily, & that we can find the humor & good even in some of the worst scenarios. Let us be clear: not one of us is laughing right now. We did not engage in any April Fool’s Day trickery, nor have we been finding ways to giggle outside of that jocular holiday. What is before us, both from an economic perspective & from a public health perspective, is no laughing matter.
We have been appalled, but not surprised, by the incredible lack of guidance, awareness, & preparedness surrounding the COVID-19 crisis. These shortcomings are in part because we, as a collective, DID NOT PAY ATTENTION. It is also, though, because our health care system is inexcusably inefficient & tethered to profiteering spearheaded by non-clinical MBAs & other nebulous administrative personnel, mythical images of “quality care” & “centers of excellence” designed by non-clinical public relations & marketing professionals, & our national cultural proclivity to shameless self-promotion & lack of insight or retrospection that would allow us to honestly assess the reality of our assertions. America’s health care systems—pluralized because we are not, in fact, one unified system, but instead many privatized entities that have been called upon to do the public work of providing healthcare—are tremendously profitable.
American healthcare is a big-ticket item. Insurance premiums are outrageously expensive, deductibles remain astonishingly high, & the cost of care is an elusive, phantom-like figure that no one seems capable of dragging into the light. This healthcare provision is a total cash cow. It is extremely high cost & has been consistently extremely low value. The more care gets fragmented into different systems competing for consumers, the more distant the actual care providers get from making decisions that impact the care they can provide & the actual, human outcomes of that care. As a result, the value of the care provided treacherously erodes. As healthcare entities vie for customer preference, marketing professionals develop enticing slogans that then get bandied about to attract a larger volume of paying patients & the true meaning of those words (“Excellence in Women’s Care,” “Caring for the Community”) vaporizes, because the fixation has been on ensuring high volumes of patients, not on measuring the actual outcomes of the care provided. In the midst of this, patients are also losing their choices even among the increasingly similar options that are rapidly decreasing in number as larger systems continue to threaten & then absorb smaller clinics or practices, as non-clinical negotiations that have little to do with care provision & everything to do with financial exchanges between health systems administrators & insurance company administrators determine which facilities & providers will receive contractual preference.
A list of in-network options for provider and facility “choices” is then provided to the consumer, who is given little to no information about how or why she would elect to receive care in a particular location or from a particular provider, except as dictated by a monetary agreement that had nothing to do with her. In the midst of all of this, the healthcare providers, who are the people who are personally responsible for the provision of the care that is the supposed commodity being sold, lose autonomy to practice, partly because health systems dictate how many patients must be seen in a day, how rapidly those patients must be seen, what can be provided in a single visit, & how the patient might get shuffled about within the system, all of which are decisions aimed to ensure each encounter is as lucrative as absolutely possible for the healthcare system, & none of which are decisions aimed at enhancing clinical outcomes. The clinical outcomes cannot even be understood by the people making the decisions, because they have absolutely NO medical training.
The other major player in the erosion of healthcare provider autonomy is the particular insurance company providing benefits for the patient, which, based on a separate financial negotiation made with pharmaceutical companies & other distinct negotiations made with health systems offering diagnostic testing, will determine which medications & which tests a provider is allowed to order for any particular patient. It is both the health system’s intent to maximize their profit & the insurance company’s intent to maximize their profit. The people who are caught in the middle of all this financial juggling are the patient, who is directly paying for the service of healthcare & the provider who is providing but not being paid for the provision of any specific service.
This is a recipe for disaster. Patients are left feeling lost & confused. Providers are left feeling overwhelmed, morally injured, frustrated & burnt out. Patients disengage from their care because it has lost purpose & value & providers try their damnedest to get as far away from the provision of direct patient care as possible: the administrator roles offer better salaries, a greater degree of respect, & much more manageable lifestyles. As clinicians scramble to try to keep up with the pace & patients scramble to try to be seen as more than a number, health systems & insurance companies profit off of what has now become a largely hollow service that is profoundly removed from any semblance of actual care and any concern for outcomes, well-being, effective treatment, accurate diagnoses, & individual improvements.
This has long been the greater picture of healthcare in America, but the extent to which it has been corporatized has accelerated astronomically over the course of the past 2 decades. Fewer & fewer clinicians are opting to practice in an independent manner & more & more smaller practices are being absorbed into one dysfunctional monolithic system that removes any personal accountability for care. The people who are getting wealthy off of this model are not the medical providers. They are the executives, the administrators, the ostensible leaders of the hospital systems: the same people who didn’t think it mattered that they have a stockpile of masks.
As long as there is not a national crisis, the healthcare systems have been allowed to putter along without having to be accountable for the many ways in which they are failing the American public. Occasionally, someone will call out the insane expense & inquire as to the value of the expensive care being provided. Occasionally, someone will point out that we have outcomes that are the worst among developed nations. But, generally, we just accept it for what it is & go about our business. Individuals may be adversely affected. Some groups may find themselves systematically disenfranchised. Someone’s loved one might be unnecessarily harmed. For the most part, though, we have turned a blind eye & put our trust in the systems that we believe are truly there to serve the public good. Enter COVID-19. Suddenly, the strawman falls apart.
Suddenly, we see that the administrators did not have the public’s interest at heart. If they had, they would have planned for the worst-case health scenarios that could occur in their communities. Even if COVID-19 hadn’t emerged, it’s clear now that they weren’t prepared for ANY degree of outbreak of droplet-transmitted or airborne pathogen, including tuberculosis, which continues to be endemic in many countries worldwide. Suddenly, we see that the systems that employ our healthcare providers are not interested in ensuring they have the most basic equipment required to safely perform their jobs & provide the most fundamental acute care services. We see doctors falling ill because they were not properly protected. We see nurses having to choose between infecting their own vulnerable loved ones or continuing to respond to the public need for their care. We see swaths of staff threatened, fired, retaliated against all in the name of protecting the public appearance & reputation of the systems, which are faltering to provide much-needed care to the very public whose relations may be in jeopardy. We see, suddenly, the importance of clinical acumen, & why it matters that someone who is making major public health decisions have an understanding of global public health happenings as well as the clinical implications for our own public health & an ability to predict & respond appropriately to moving targets. Now, in crisis, we see that the research findings were not being routinely perused, that evidence was not truly driving the care that was being provided, that appearances have mattered infinitely more than any measurable clinical metric.
The news stories that are currently scattered throughout the media about various practitioners, respiratory therapists, housekeepers, nurses & the like receiving retaliatory actions for exposing a failure in the health system that employs them are not new. The gaslighting & threatening of employees that is coming to light in the midst of this colossal crisis are routine occurrences. Individual providers have been punished for years for pointing out flaws & have been treated as though they are disposable, as though their relationship with & understanding of the consumer/patient & their clinical needs is the least important aspect of the healthcare transaction. Now that we see that this grand emperor is naked, now that the failure of these systems to provide care for our communities is abundantly apparent, now that we can publicly observe the lack of dignity & basic care offered health system staff & consumers alike, none of us should feel like laughing. These failures have cost the US in lives: both of patients & of their providers. These failures should make us all profoundly uncomfortable. The question is: will this discomfort be enough for us to demand a change?