Dr Richard Baron of the American Board of Internal Medicine: In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System
An Interview With Luke Kervin
Inventing several safe and effective vaccines and getting shots into millions of arms as quickly as we did may be one of the greatest scientific achievements of the last century. But we can’t stop there. This pandemic is not over, the Delta variant is rapidly spreading throughout the US, telling us that COVID-19 is not going away for quite a while — most likely when the majority of the world’s population has been vaccinated. And even then, patients may need boosters and treatments for the coronavirus variants beyond supportive care. We must make additional investments in biomedical science before the next outbreak, but we must also make investments in the infrastructure to deliver testing, tracking and vaccine delivery.
The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.
In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.
As a part of this series, I had the pleasure to interview Richard J. Baron.
Richard J. Baron, MD, is President and CEO of the American Board of Internal Medicine and the ABIM Foundation. He practiced general internal medicine and geriatrics for almost 30 years in Philadelphia and continues to teach residents and see patients during his twice-monthly clinic rotation.
Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a bit about your backstory and a bit about what brought you to this specific career path?
Sure, I practiced internal medicine and geriatrics in the Philadelphia community that I lived in for almost 30 years. Living in the community was very important to me and something I knew I wanted to do very early in my career. I was able to go to medical school thanks to the National Health Service Corps Scholarship Program, where they give you money to go to medical school and in return, when you finish you are sent to work in an area that has a shortage of physicians. My first practice setting was in rural Tennessee, and having lived my whole life in New York City and the North East, it was quite an experience. There I saw what community doctors do and I knew that’s what I wanted to do in my career. I wanted to live in the community I served and help that community. And the other piece of my backstory was when I initially launched my own solo practice. I needed a part-time job because I worried that as I was getting started I wouldn’t have enough patients to survive and pay all my bills. So, I took a job as the part-time medical director at a Medicaid HMO at the very beginning of the HMO movement and the Medicaid managed care movement. I stayed with the organization as it grew rapidly and learned so much about Medicaid and organizations and information technology and leadership and all those things that I still use today. A substantial chunk of the time I was in community practice I divided my time between community practice and leadership in a Medicaid managed care organization.
Can you share the most interesting story that happened to you since you began your career?
We made the decision in 2004 in our four-doctor practice to adopt electronic health records, and it was the most difficult thing I have ever done professionally. We had created a complex computer network that none of us knew how to support, maintain, or operate despite our training and so many things went wrong that it was extraordinarily frustrating. We experienced a virus attack that crashed our system, we lost our telephone and data service after the virus was removed, we had to reduce the number of office visits and we had to call in experts to help with so many situations that we had not budgeted for. We wrote an article about the trials and tribulations of a small office adopting electronic health records for the Annals of Internal Medicine titled “Electronic Health Records, Just around the corner? Or over a cliff?” It was before the days of Meaningful Use, and that year our practice revenue went down, expenses went up and the misery factor went up. But at the end of the year, we figured things out and were glad we had moved to electronic health records. None of us would have gone back to paper.
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?
I took care of a patient when I was a resident at Bellevue who I would see every few months. He was on a number of prescriptions and I would write him prescriptions at every one of the visits. And during my final year of residency, on what he knew was going to his last visit with me, he brought out a pile of paper of all the prescriptions I had written over the last three years and asked me “doc, what do you want me to do with these?” From that experience I learned doctors cannot assume that patients are taking the medicine that has been prescribed!
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My father sold textiles in the garment center in New York City and he had a saying: “The sale only begins when the customer says no.” He would say that if they say yes, then you’re just a clerk writing down the order. It’s when they say no that you have to go into sales mode and explain to them why they really need this thing. Which I thought was something salesmen tell themselves and was a cute salesman story. But I realized over the course of my career that it was a deeply resonant story, and that if I said to a patient you really should get a colonoscopy and they would say no, the sale only begins. And that could be true for the COVID vaccine and any number of medical interventions. I wound up finding it a more widely relevant saying than I might have imagined.
Are you working on any exciting new projects now? How do you think that will help people?
ABIM has moved from being “passively non-racist” to committing ourselves to being an “actively anti-racist” leader in healthcare. In the tumultuous summer of 2020, we made a public commitment to explore our role in perpetuating — intentionally or not — racial disparities in healthcare through our Board’s policies and programs. Our initial commitment in 2020 focused on racial justice and ABIM’s Diversity, Equity and Inclusion (DEI) strategy, but it has broadened to bring as many different voices to the table as possible. Our goal is to ensure that our programs and policies are not divorced from the lived experiences of our physicians, including (but not limited to): age, race, ethnicity, ability, faith, sex, sexual orientation, gender identity, geographical location or practice setting. The diversity of our boards and committees has led to some important changes that I think help not only physicians, but patients as well. We already know that the healthcare work force doesn’t look like the patients we serve, and we also know that patients have more trust in healthcare providers who look like them. Our increasingly diverse group of individual leaders that make up our Board of Directors passed several resolutions in spring 2021 that will shape how medical students learn about racial barriers to healthcare and subtle possible differences in how they treat patients of color.
How would you define an “excellent healthcare provider”?
An excellent healthcare provider is someone who understands that it is always about the patient. It is someone who understands that their core responsibility is service, and that while we are supposed to know a bunch of science and we are supposed to know a bunch of standard of care answers, our highest and best function is when we understand how that knowledge helps an individual patient with their particular predicament and use what we know to help them achieve their goals — not just to do what the journals say that we are supposed to do.
Ok, thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?
I think one of the most important places we saw the US healthcare system struggle was in the sphere of primary care services. Primary care, which is what I did for 30 years, was already struggling for a whole variety of reasons. I believe it was chronically underfunded, and it was still reliant on a fee-for-service system. For many primary care practices, when COVID started, their revenue fell off a cliff because it was entirely visit-based revenue and nobody was coming to the office. There was a fairly rapid shift to telemedicine, but telemedicine didn’t occur at the rate and at the volume in a way that it could really replace the revenue that primary care doctors were not getting from office visits. And meanwhile, they continued to have to try to operate practices with payroll and rent and insurance and utility payments due.
How do I think we can correct these specific issues moving forward? I think fee-for-service is the wrong structure for primary care; population-based payment makes a lot more sense. Population-based-payment, which is sometimes referred to as per-capita or capitation based payment, is when you receive payment for the number of people you’re responsible for rather than payment for each thing you do for them. Under this system, the doctors can do what the patients need without necessarily factoring in whether that requires a visit to the office visit or not. In a fee-for-service world, if you respond to a patient’s need by email or by telephone, you just lost the revenue that would have come with a visit. With a population-based payment, you have a stable revenue from the people you take care of, then you can really focus on what’s the best way to care for them. The idea that the doctors would have a revenue stream that comes from agreeing to provide care for a population of patients is a more stable and sane system for paying primary care doctors.
Of course the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving millions of lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.
The development of a safe and effective vaccine in less than a year is nothing less than miraculous. That happened in our country with our research and pharma capacity. I’m not a huge fan of big pharma for all kinds of reasons, but I am in awe of the way in which government and pharma partnered to get so many obstacles out of the way. A lot of people ask ‘how can you get a vaccine so fast,’ but if you look at any work process you know about how much waste and delay there can be in the process.
Years ago, I remember reading a study showing that it took two months to pay the average insurance claim but the amount of time a human was actually engaging with the claim over the two months was about 20 minutes. And I think a lot of the reason it takes so much time to develop this stuff is just various structural delays that the federal government and related agencies managed to get out of the way. So, if you’re looking for an example of stellar performance in health care, I think you have to start there, and it’s really wonderful to see, at least those who have been willing to avail themselves of the vaccine: their lives are really changing and they’re much safer today.
Here is the primary question of our discussion. As a healthcare leader 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.
1) Empowered patients will want more flexibility when the pandemic ends.
Telemedicine has dramatically enhanced access to healthcare during the COVID-19 crisis and I believe the flexibility and convenience it has provided will be something that patients will expect more of when the pandemic ends. The healthcare system changed rapidly out of necessity, and now that we know it is possible to have a patient-centered system, and payers like the Centers for Medicare & Medicaid Services (CMS) have shown they can be more flexible with reimbursements for virtual visits, I believe patients are going to demand more of it and physicians will need to be more willing to try it. I think patients will continue to be more involved in their own care and will ask the really good, but tough questions, such as, do I have to come see you in person? Do I really need that test? And why do I have to come to your office for that test, why can’t I get it done at my local drugstore?
And so, telemedicine will continue to be a powerful and convenient way for some patients to have access to healthcare. People like that the healthcare system was nimble enough to make the seemingly impossible doable, and that there was a safety net to catch them. Under the Affordable Care Act, patients signed up for Medicaid during the pandemic in record numbers and credible proposals have been floated on Capitol Hill to lower the eligibility requirements for Medicare, which would be a dramatic expansion of that program. So, I believe that when the pandemic ends we will have a better informed, trial-by-fire public that is more demanding of a fair and equitable healthcare system.
There are of course challenges here — not everyone has reliable high-speed internet access, making virtual visits not feasible for all. These are often patients who would benefit most from telemedicine — they live in rural parts of Appalachia or the Intermountain West or are three bus rides away from a doctor in a big city and they just can’t make the trip.
But the idea that the healthcare universe revolves around the physician is no longer relevant — making a patient always drive to a physical office and sit in a waiting room reading an old magazine while they wait for an appointment is not always necessary. Patients deserve better and we need to create models that maximize physician time with patients, directly providing care. If patients and physicians keep pushing payers to make the changes we saw under COVID-19 permanent, the system will be forced to adapt.
I also think that physicians will want to maintain the flexibility they have been provided during the pandemic that allowed them to focus on their patients. The Centers for Medicare & Medicaid Services (CMS) and other agencies modified long-standing policies to reduce preexisting constraints on team-based care during the heart of the pandemic, which helped diminish feelings of burnout and fatigue among physicians, and allowed them to concentrate on patient care when it was needed most.
Even after the pandemic has passed, we must continue to allow physicians to focus more time and energy on the direct care of patients. Pre-COVID-19 physicians in ambulatory practice reported that they spent nearly two hours updating electronic health records (EHR) and doing desk work for every one hour of direct patient care, and an additional one to two hours each day on this type of work during their personal time at night and on weekends. The hours of administrative work saved during the pandemic should be preserved so physicians can take the time they need to heal from the trauma of the pandemic. This benefits both physicians and patients and will go a long way to alleviate physician burnout.
2) Science is amazing, but it can’t rest on its laurels.
Inventing several safe and effective vaccines and getting shots into millions of arms as quickly as we did may be one of the greatest scientific achievements of the last century. But we can’t stop there. This pandemic is not over, the Delta variant is rapidly spreading throughout the US, telling us that COVID-19 is not going away for quite a while — most likely when the majority of the world’s population has been vaccinated. And even then, patients may need boosters and treatments for the coronavirus variants beyond supportive care. We must make additional investments in biomedical science before the next outbreak, but we must also make investments in the infrastructure to deliver testing, tracking and vaccine delivery.
And perhaps equally as important, we need to focus on promoting science and assuring the public that science is valid. This means helping them understand that science is a journey, not a destination. In the early stages of the pandemic, when we simply didn’t know a lot about COVID-19, and guideline changes created confusion and distrust, scientific leaders should have been clearer about how the scientific process works. The confusion led to fear and to some people shunning science in favor of misinformation circulating online. This, in turn, has led to behaviors that are dangerous to public health — like not wearing a mask when recommended, or refusing to get vaccinated. We need to do a better job of being more transparent about how science works — and about what we know and don’t know — so that we can restore society’s faith in science and the scientific process.
3) Structural racism has exposed the limits of biomedical science and this must change.
We knew before the pandemic that we are a nation where healthcare is not delivered equally to all. But the pandemic’s uneven morbidity and mortality laid bare our failures, and demonstrated that we need to tear down structural barriers that inhibit access or acceptance of medical care.
It’s one thing to have medical knowledge; it’s a completely different thing to be able to use that knowledge to its fullest when working in a healthcare system, and really a society, that is still based upon a racist structure. We shouldn’t have a system that delivers poorer access to treatments, to doctors and compassionate care depending on the color of your skin. But that’s the reality that millions of Black and Brown Americans face every day.
After George Floyd’s murder last year, we at ABIM and the ABIM Foundation made a commitment to do whatever we could to dismantle structural racism and ensure health equity for all. One way we’ll do this is by adding questions about health equity to our assessment exams that every board-certified physician must take to keep up with the latest trends and practices in medicine.
The additional questions will ensure physicians are aware of subtle differences in the way they treat patients of color. While questions about diversity, equity and inclusion will not be added immediately because we have a vigorous and scientific method of ensuring assessment questions are fair, they will become a permanent part of all ABIM assessments in the near future and will be test questions that every doctor will have to answer
Another barrier to equity is the extraordinary lack of Black and Brown doctors, which is especially stark when you consider the ratio to Black and Brown patients. Currently, 13% of the US population is Black; but only 5% of physicians are Black and only 2% of them are Black men. This has real world implications. Research suggests Black men are more likely to receive preventative services when a Black physician recommended them. And when it came time for Black men and women to get the coronavirus vaccine, many declined because they were getting advice from white physicians and the American government.
A more equitable system will begin with a more diverse group of physicians. This kind of work needs to start early — some say as early as elementary or middle school — so those young people could foresee themselves as physicians when they enter the workforce.
One promising project is being led by of the Chair of our Infectious Disease Board, Dr. Erica Johnson. At her institution she increased the number of underrepresented in medicine from 9 percent in 2017 to 41 percent in 2018 and kept retention rates up.
This is just one project at one institution. We need to be thinking more broadly and working in a coordinated fashion across all of healthcare to make a lasting improvement. Health equity can’t just be a buzzword. We all need to mean it and take steps towards equalizing healthcare for all.
4) Trust in science and the scientists must be restored.
Just as important as the vaccines and treatments that have been developed during the pandemic is restoring the public’s faith and trust in the preeminence of medical science as an unchallenged paragon of truth. No magic wand is going to fix that problem overnight, but we must make scientific discovery accessible and relatable.
Unfortunately, trust in physicians and the healthcare system has declined in recent years — and some of that decline is understandable. Payment systems are often opaque. Patients feel like they don’t get enough time with their physician. And of course, the internet, and more specifically, social media, have served as disseminators of misinformation. It’s incumbent on scientists to serve as beacons of fact and truth, and to get better at using their positions as experts to inform the public about science and evidence. This is incredibly difficult work. As the saying goes, a lie can travel halfway around the world while the truth is still putting on its shoes.
An important component to rebuild trust in the medical care system is clear and consistent communication. Public health officials must always use accessible, understandable language that builds confidence in what the system will deliver for them, and obviates skepticism and is free from political bias. And, if they are still working to understand a novel coronavirus, they need to let the public know that, too. If we cannot regain the public’s trust in science, I fear we are in deep trouble.
5) None of us are safe unless all of us are safe.
This is frustrating to me, and I’m sure to a lot of others in healthcare; the country remains divided about how to battle the pandemic. Many areas have high vaccination rates and are safely unmasking and reopening. Others have seen low vaccine uptake, and are experiencing COVID-19 resurgence. As the Delta variant spreads and the rate of vaccinations wanes, we need to enhance our efforts to address vaccine hesitancy and make the vaccine even more available in our prisons and jails, our cities and rural enclaves; and in some workplaces. And the FDA, working with states and local organizations must take steps to ensure that the public is confident and secure in knowing these vaccines are safe, effective and necessary if we want to get back to our pre-pandemic lives. Much like the other vaccines for smallpox and polio, there should be a more effective campaign to provide information on the necessity of the COVID-19 vaccine.
People trust those who are closest to them — their own physician, their community leader, their preacher. It’s important for larger organizations, like the FDA and the CDC to spend more time working with community leaders who help spread important messages in a way that they are heard and accepted by the public.
It’s understandable for people to ask questions about a new medical treatment or vaccine; but I can tell you unequivocally the COVID vaccines are safe (I’ve gotten them myself) and whatever your hesitations are, the vaccine is far safer than getting COVID-19.
Let’s zoom in on this a bit deeper. How do you think we can address the problem of physician shortages?
That’s a good question. The Association of American Medical Colleges (AAMC) projects that the country will face a shortage of between 54,100 and 139,000 physicians in the next decade, so this is a serious problem. I think there are several things we can do to help address the problem of physician shortages in the US. As I noted earlier, I think virtual office visits can help in rural and underserved areas where it is not always easy for people to physically access a doctor.
But that’s not going to be enough. I think we need to start recruitment earlier, and make medical school more accessible to students who have the desire, but not necessarily the funds to complete the required training. I myself was able to go to medical school with the support of a federal government program that still exists: National Health Service Corps Scholarship Program. In exchange for my agreement to serve in a physician shortage area, they paid for my medical education. My experience at a Community Health Center in rural Tennessee was both a wonderful opportunity to give back to an underserved community and a chance to understand more deeply how medicine is practiced outside of training centers. This program could be more generously supported than it is currently, making loans and grants available to idealistic students who are wishing to serve. And I think we need to make it easier for international physicians to practice in the United States.
How do you think we can address the issue of physician diversity?
We need to introduce children of color to the idea that they can be a physician — that there are Black and Brown physicians who are practicing in their communities and elsewhere. We can do this by having physicians of color go into elementary schools, middle schools and high schools and talk with students.
Then we need to make sure “underrepresented-in-medicine residents” have what they need to be successful. They need to be nurtured and paired with mentors who can help them navigate through medical school, residency and practice. At ABIM, we made a commitment to actively move from being passively non-racist to actively anti-racist. For us that has meant working to diversify our staff, our board and committees and working toward enhancing the diversity of the physician population in the country.
Through the diverse group of physicians, we have recruited to our committees and boards, we have learned a lot and are putting their advice into practice. I mentioned Dr. Erica Johnson, who has been very successful in increasing the number of Black and Brown physicians in the residency program she leads, but we have many more examples of physicians doing great work in the area. Dr. Deidra Crews, who is on our Nephrology Board, is working to eliminate structural barriers to patients of color receiving equitable kidney care. And Dr. Robert Roswell, who is on our Board of Directors and chairs ABIM’s Diversity, Equity and Inclusion Committee (DEI) is working with several organizations to promote DEI and to help reduce structural barriers to equitable healthcare for patients, but to also help pave the way for more physicians of color to be successful within the system. Dr. Vineet Arora, a member of our Board of Directors is a new mother, and she helped to make sure the lactation rooms at the testing centers used by our physicians are adequate, and our that our policies are appropriate for nursing mothers who sit for an ABIM exam.
So, I think it is imperative to enhance diversity and to listen, learn and to implement policies and practices that will eliminate the barriers.
How do you think we can address the issue of physician burnout?
As I mentioned earlier, a lot of positive changes were made in the heat of the pandemic that eliminated some of the preexisting constraints on team-based care and reduced the overwhelming burden of paperwork that takes so much of physicians’ time. These changes made by CMS and others should remain in place and, in some instances, be expanded.
During the pandemic ABIM spent a lot of time speaking with physicians about how we could help them manage the unprecedented stress and trauma caused by the sheer volume of gravely ill COVID-19 patients they were seeing on a daily basis. Many reported feelings of burnout and difficulty coping — they were exhausted, afraid for their own safety and traumatized by the number of patients they were unable to save. One thing that we determined was that we — and everyone in healthcare — can take greater action to reshape the healthcare system to help physicians heal today and for the long-term.
As one course of action, the ABIM Board of Directors unanimously voted to extend Maintenance of Certification (MOC) requirements through 2022. Multiple factors influenced this decision. While MOC is intended to help physicians know they are keeping their medical knowledge current, we know that during the pandemic physicians spent a significant amount of time learning and understanding the science of the new coronavirus and finding new treatment regimens in caring for their patients.
As the immediacy of COVID-19 wanes and physicians’ grief and sorrow about the past year surfaces, we have been thinking about the well-being of board-certified physicians and how the healthcare system can be reshaped to help physicians heal and learn how to prevent burnout. I encourage all those in the healthcare system to look at what is within their control — unnecessary paperwork, EHR servitude, and ways to improve teamwork — and to find ways to prevent physician burnout and to allow them to preserve their cognitive bandwidth for what is truly important — caring for themselves and their patients.
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. :-)
I would love to eliminate the subtle and not so subtle racism in our healthcare system and make it fair and equitable for all people. People of color have a lower life expectancy, have died at a higher rate of COVID-19 and are often not listened to or treated with the same respect as white patients. If I could change anything, that’s what I would change.
How can our readers further follow your work online?
I’m pretty active on Twitter (@RichardBaron17) and LinkedIn. We also post regular updates on the ABIM blog.
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.
