5 Things We Must Do To Improve the US Healthcare System: “We must reduce the amount of red tape and administrative barriers” With Limor Weinstein & Tufts Medical Center CEO, Dr. Michael Apkon
…A second way we can improve our healthcare system is to reduce the amount of red tape and administrative barriers in order to increase access to care and lower costs. Our payer options are too complex and administrative costs are passed on to patients in the form of health insurance premiums. The cost of care and the administrative barriers can cause patients to wait for a problem to be severe before seeking treatment, which increases the complexity of the care they need.
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. Michael Apkon, President and CEO of Tufts Medical Center and Floating Hospital for Children in Boston, Massachusetts. Dr. Apkon is a healthcare leader who has led organizations in two countries and worked with healthcare systems on four continents. He previously served as president and CEO of The Hospital for Sick Children (SickKids) in Toronto and as senior vice president for medical affairs and the chief medical officer for The Children’s Hospital of Philadelphia. Dr. Apkon also served in executive roles at Yale University School of Medicine and Yale-New Haven Health System. He is a Pediatric Intensive Care specialist and has held faculty positions at Yale, U. Penn, and University of Toronto, where he was Professor in Pediatrics. Dr. Apkon has served as a director with several life-science innovation enterprises including MaRS Innovation. He has a BSc degree in biomedical engineering from Northwestern University, as well as MD and PhD degrees from Washington University School of Medicine in St. Louis and an MBA from the Yale School of Management.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I started my career as a physician-scientist, but migrated to becoming a healthcare executive because I realized I could have a bigger impact by working with people to create change that leads to better care for patients and better systems of care for caregivers to rely on in helping people thrive.
It all started with me asking some questions among our group of intensive care doctors and nurses. We were discussing the way we took care of kids with life-threatening infections — most of which occurred in the intensive care unit. We had a child die, and I started asking how our care compared to other centers — how we were doing in treating a very difficult disease. Although we felt comfortable the care was excellent, I had to ask — how do we know? When we actually studied the question, we found our care compared favorably, but that the outcomes in virtually all places were unfortunately too grim. This caused us to question whether the current approach to care was as good as it could get. Digging into those questions led me to examine the systems of care to try to find ways to make those systems safer and more effective. I came to realize I could have an impact, not only by taking care of people as a physician, but also by making care better for all.
Can you share the most interesting story that happened to you since you began leading your company?
All hospitals have to deal with facility problems that pop up periodically — power outages, minor floods, and the like. A few weeks ago, we had an interruption of the main water supply into the hospital when a city pipe burst outside the hospital. There should have been a redundant supply of water, but we had no way of knowing that it had been interrupted by an earlier repair. For several hours we had no running water in the hospital. I had a chance to see how well our team performed in dealing with an unexpected and significant challenge. There isn’t a playbook for that kind of situation and you really see how a team comes together to creatively figure it out and keep everyone safe. Fortunately, the city was able to restore service before we got to the point of having to interrupt patient care. It was gratifying to see how well the organization functioned and how resilient we are when things go wrong. I also learned the rate limiting factor in keeping the hospital functioning in that kind of situation may well be sanitation — having working bathrooms for staff and patients.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
As a newcomer to an organization, the hardest thing for me has been to learn who everyone is and what their roles are. I’m not normally great with names to begin with and I try to make a deliberate effort to get it right. In a few instances, I kept referring to members of my team by the names of the people that had held their roles in my former organizations. They had enough resemblance that I must have subconsciously retrieved the names of former colleagues, but it wasn’t the best way to start a relationship.
It’s a reminder that the brain works in surprising ways. We automatically pull things out of the recesses of our mind without intent and can take actions without a lot of thought. It can be helpful to stop and think before we speak or act. It was also a reminder that being wrong — in this case picking the wrong name — feels exactly the same as being correct, right up until the mistake gets pointed out. At least with this particular mistake, we were able to laugh about it.
What do you think makes your company stand out? Can you share a story?
The Boston healthcare market is one of the most influential in the world — it’s the nexus of medical and clinical innovation and the leader in healthcare delivery across the county. Tufts Medical Center and Floating Hospital for Children play a critical role in that ecosystem, both as an academic institution and in its delivery of care. I am honored every day that I was chosen to lead this outstanding organization and be part of the growing and innovative Wellforce system. Wellforce brings together the strengths of academic medicine and community care in a model that values the balance of both equally. Independent-minded, value-driven members are dedicated to providing patients with the highest-level of care when and where they want it.
I recently met a man as he was about to be discharged from our hospital. He had been struck by a car near his home and had a life-threatening injury to the main artery carrying blood from his heart. We used an experimental device to repair the injury and then cared for him through a very difficult recovery. We are one of just a few hospitals testing this device — without which, he likely would not have survived. Once the device makes it to market, we’ll have an opportunity to train others how to use it. It is places like Tufts Medical Center that shape the field by inventing or testing new approaches to care and teaching the next generation. At the same time, we offer the most specialized, cutting- edge care available.
What advice would you give to other healthcare leaders to help their team to thrive?
I see a leader’s primary responsibility as being a sense-maker — helping people understand the connection between actions, strategy, and purpose. It makes more sense for people when we ask them to take an action if we have first created a purpose to drive engagement. Leaders must help people understand how the intended actions will support a strategy that allows us to fulfill our individual and organizational purpose. It is far easier to align and direct people’s energy to a common end when it all makes sense. At the same time, a leader also often needs to help the world beyond the organization make sense of the unique value the team brings to the enterprise or society. They need to help enlist support and sell that value so that the team has the resources and the customers to fulfill its purpose.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
It’s clear that we need a new approach for success in American healthcare. As we all know, our healthcare costs are high in the United States. In fact, we spend a higher percentage of our GDP on healthcare than any other country — nearly twice as much per capita compared to our neighbor to the North (Canada). Our outcomes do not justify what we are spending. I’ve come to see that there are no perfect systems. Every system is built around a number of different tradeoffs and factors. They differ in terms of the minimum level of healthcare that people have a right to access, the tolerance for disparities based on ability to pay, the role of markets, and the role of government.
I think one of the key differences in the US compared to Canada or most European countries is that the only part of the healthcare system that all people in the US have a right to access is the Emergency Department, whereas in the other countries, all people have a right to basic preventive and primary care. We take care of people only when they get sick enough to be at the hospital, while other countries are focused on keeping people out of the hospital.
We also tolerate a lot more disparity in the access to healthcare than other countries. People here have access based on ability to pay or their level of insurance. This leads to different patterns of healthcare use, different waiting times, and different choices by people deciding whether they can afford their treatments. Canada has a very low tolerance for that kind of disparity, and all people have exactly the same access to physician and hospital services. Other countries tolerate some disparity but generally provide a much higher level of service as a basic right.
The US also relies very heavily on markets for the financing and delivery of healthcare. Although this may well spur more innovation than in other countries, it creates a range of unintended consequences — like gaps in services — if there isn’t a compelling market for providers to enter. It also creates a greater risk for over-treatment, a tendency that is exaggerated by people’s impatience or insistence for certain therapies that the market is happy to provide.
In part, because of our dependence on the market, we also rely on a multi-payer system with complicated systems of fee schedules and contract arrangements. This creates a high administrative burden for payers, providers, and patients that diverts funds from care delivery and amplifies barriers to access or coordination of services.
Without the government being more active in healthcare, the US also has depended on voluntary collaboration across healthcare providers, with respect to the exchange of information and the coordinated approach to patient care between local, regional, and specialized centers. In other countries, government has facilitated the interconnection across providers. For example, many of the provinces in Canada are working towards a single electronic health record that will allow all caregivers to seamlessly participate in the care of a patient.
In many ways, we may have a stronger foundation and greater innovation than anywhere else. Our challenge is to harness our strengths towards a clearer common goal that will extend the lives and improve the quality of life for all people.
You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
In order to improve our healthcare system, we need to change our mindset and look at what other health systems are doing well. First, we need to raise the level of service that all people can access. We need to make primary care and basic services — including hospital services — available to all. In Canada, if you are born with Cystic Fibrosis (CF), a life-threatening inherited disease, your life expectancy is 10 years longer than if you are born with CF in the US. Knowing both systems, I think the most likely explanation relates to the easier and more universal access to services in Canada compared to the US.
A second way we can improve our healthcare system is to reduce the amount of red tape and administrative barriers in order to increase access to care and lower costs. Our payer options are too complex and administrative costs are passed on to patients in the form of health insurance premiums. The cost of care and the administrative barriers can cause patients to wait for a problem to be severe before seeking treatment, which increases the complexity of the care they need.
We also have an opportunity to improve the system by using information more effectively. If we think about healthcare compared to other industries, we have a long way to go. In healthcare today, we generate about 100 Megabytes of data per person per year and fragment that data across multiple systems that don’t talk to each other. Aside from using that data as a repository, we make little use of it in analyzing and improving our systems. In contrast, think about a company like Tesla. A Tesla car generates as much as 4 Terabytes of data per day and Tesla collects data for 1 million miles of travel every 10 hours from its fleet of cars. They use that data to improve the way their cars perform and upload changes to your car while you sleep. Imagine the power of bringing data together, with proper security and privacy protection, in the way other industries do.
Increasingly, we are recognizing healthcare delivery accounts for a small fraction of our health and well-being. Finding better ways to bridge and coordinate across the boundaries between our healthcare and social care systems will change the trajectory for helping people thrive. Addressing food security, safe housing, and poverty are important to our patients and their well-being. If we can create strategic partnerships and alliances, we can help address some of these systemic issues.
Most importantly, we can continue our focus on innovation, which leads to better patient outcomes and experience. The medical industry will advance more in the next 10 years than we have in the last 100 years and the U.S. is integral to that advancement because we lead in innovation. We must also continue to invest in research and teaching the next generation of healthcare providers. At Tufts Medical Center, we are working to be at the forefront of these changes, seeking to improve the healthcare delivery model through research, as well as through strategic alliances and partnerships that increase access and coordinated care for our patients.
Ok, its very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
There are times when I think that real changes to our healthcare system are going to require a social movement that creates the political motivation to disrupt the status quo.
Leadership and vision will be important if we are going to see change but followership will be just as — if not more — important.
Individuals need to be better educated about the current system — who benefits and who doesn’t; how the system generates perverse incentives and barriers to improvement; and how policies or regulations reinforce the status quo. A more equitable approach to access will only occur when enough people demand it of their politicians and are open to the changes in the current system that will be necessary to bring that about.
Corporations, which fund nearly half of healthcare expenditures through employer-purchased health insurance, can demand greater accountability for better outcomes and greater value. They can also favor approaches to healthcare purchasing that promotes greater coordination across the system, more effective use of technology, and greater flexibility in meeting the needs of the people they insure. Healthcare corporations can adopt a mindset of what Brandenburger and Nalebuff called “co-opetition” or more popularly known as “frien-emies” — the ability to cooperate across competitive lines — so that we can find more creative solutions within the current healthcare system.
Communities have a role in highlighting disparities and surfacing the unique needs of the community. They also have a key role in connecting the healthcare and social-care systems. There are some really interesting partnerships that leverage community services — like transportation, police, fire, ambulance, and social services — to partner in new ways to help people thrive at home, instead of within the hospital-based healthcare system.
Leaders need to help us clarify and then focus on the objectives. They need to model the willingness to think differently and disrupt their own worlds. They need to help make sense of needed change and help illuminate a safe path that navigates between today and a better tomorrow. They also need to address head-on, the fear of losing out or not keeping up when people face change.
As a mental health professional myself, I’m particularly interested in the interplay between the general healthcare system and the mental health system. Right now we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
Health and wellness lives at the intersection of physical, psychological, and social well-being. We know that physical illness contributes to psychological distress and mental illness complicates physical illness in very significant ways. We also know that social well-being — whether a person has access to shelter, food security, and a support system — has a considerable inter-dependence with physical and mental well-being. Traditionally, our systems have addressed the body through one track, the mind through another, and we’ve largely left a person’s social welfare to an entirely different set of systems. We can deliver a greater impact on health at a lower overall cost to society if we take a more integrated approach and build systems that care for people more holistically — particularly through the integration of behavioral and physical healthcare services.
How would you define an “excellent healthcare provider”?
An excellent caregiver is one who ensures they are always prepared for the role s/he plays, recognizes his or her success depends on a broader team including the patient, approaches his or her work with empathy and compassion, and is committed to improving the system as well as the patient.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
I am intrigued by the process of change — in particular the tension between people wanting a very different outcome while passionately resisting having to change the systems generating the current outcome. We get attached to the systems, but sometimes dislike the outcomes. This certainly seems to be the case when we consider our current healthcare system. There are a number of people who have written about change. Machiavelli has some great quotes on the subject, but they are awfully dark. I like Einstein’s take on the subject: “The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking.” It speaks for the importance of education, understanding the problems we are trying to solve, and the need to adjust the mental models we hold to explain our world. My brother is an award-winning documentary filmmaker and has a non-profit organization called Reconsider, which is working to create new narratives to help us think through societal issues, such as conflict. There are many problems — conflict, climate change, and healthcare to name just a few — where we need to reconsider the ways we think about causes, consequences, and systems.
Are you working on any exciting new projects now? How do you think that will help people?
I am currently working with stakeholders at Tufts Medical Center and our partners across the Wellforce system to develop a strategic plan that considers what we need to do today, tomorrow and the day after tomorrow to position us for success and continue to deliver high-quality healthcare to our patients. A big part of that is thinking about the role of innovation and technology, as well as how we distribute the value of the academic medical center through partnerships, so that people can benefit closer to home and not have to make the choice between convenience and having the benefits of specialized high quality care.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I read and listen widely. There are a lot of thought leaders who have influenced my own thinking in significant ways. Roger Martin’s Opposable Mind is one book that recently influenced my thinking about creative problem solving through seeing the inherent tension between different choices. Leaders constantly have to balance different interests and we often see choices as a decision between two sub-optimal choices. Martin offers ways to find solutions that take advantage of inherent tension to create solutions that optimize by embracing those tensions. That thinking complements what I’ve taken from another favorite author, the late Eli Goldratt, who has shaped a lot of my thinking about how to address resistance in leading change. One of the works I’ve shared most widely is Weick and Sutcliff’s Managing the Unexpected, which establishes the foundation for the high reliability mindset I’ve tried to support in my organizations.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
The issue I believe will impact the most people is climate change. The rate of rise in global temperature we are experiencing is likely to threaten hundreds of millions of people within my lifetime and that of my children. Rising temperatures threaten housing, food security, and health as new patterns of disease emerge with the poorest segments of society at the greatest risk. Climate change is likely the greatest public health risk of our time. While there may be respectful disagreement (or not-so respectful disagreement) about the causes, the pace of change, or the effectiveness of different solutions, failing to act casts our fate to the winds.
Healthcare as an industry can and should do its part. As an industry, we have a disproportionately large impact on the environment in terms of our carbon footprint and the harmful impact of our waste streams. In the spirit of “first do no harm,” we need to do more about reducing the harm we cause to the environment and ultimately the populations we serve.
We need to address climate change now.
How can our readers follow you on social media?
I can be followed on Twitter: @MichaelApkon or LinkedIn: https://www.linkedin.com/in/michael-apkon-49242314