Author Jo Kline: 5 Things We Must Do To Improve the US Healthcare System
An Interview With Luke Kervin
The sooner we recognize how the business of medicine is disrupting the practice of medicine, the better off we’ll be. An overwhelming majority of our health care professionals are suffering the effects of burnout from understaffing and technology that promised efficiency and patient safety and hasn’t delivered. The failure to acknowledge and address our health care workers’ needs is prompting career changes and early exits by many. They have options not available a decade ago, such as concierge medicine, direct primary care, hospital employment and travel nursing. We need systemic changes that give health care professionals the respect and support they deserve and attract others to health care as a profession.
As a part of our interview series called “5 Things We Must Do To Improve the US Healthcare System”, I had the pleasure to interview Jo Kline.
Jo Kline is an attorney, a tireless advocate for health literacy and a writer on health care demographics and medical decision making, most recently the book Patient or Pawn?: Epic fails in health care, the approaching perfect storm and strategies for self-preservation. Over the past two decades, personal experiences as an advocate and patient shifted Jo’s professional focus from real estate and tax law to health care and patients’ rights. She is a frequent speaker and media contributor on health care’s approaching perfect storm and the strategies crucial to patient autonomy and safety, for health care consumers and their providers.
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 story about what brought you to this specific career path?
In 1998, my late brother Wes underwent a stem cell transplant for leukemia, then just as he was about to be discharged from the hospital, his condition took a very bad turn. As I look back, it is shocking how the transplant team vanished once they acknowledged Wes would not survive, leaving him on a respirator and us struggling with how to give him comfort and dignity at life’s end. I witnessed first-hand what the absence of patient-centered care looks like. At the time, I was an attorney who didn’t know the first thing about health care law or even the meaning of “palliative care.” I immediately fixed that, became the chair of Iowa’s largest hospice organization and wrote my first of several books on medical decision making and patients’ rights.
Can you share the most interesting story that happened to you since you began your career?
While going through some family memorabilia about 20 years ago, I came across correspondence written four decades earlier. At first glance, it looked like one of countless letters that had passed between my Uncle Bill and his baby brother, my father. I read it, and then I reread it because this was no ordinary letter. The uncle I had known and loved as an over-achieving, no-nonsense businessman was quoting Voltaire, reciting The Serenity Prayer and dispensing advice on how to find peace. Not what I expected.
Soon after, hospice workers and volunteers shared with me that they were assisting dying patients to compose their Ethical Wills. It was my first introduction to this ancient Jewish tradition of leaving a tangible record of one’s beliefs and values, life lessons and hopes for the future. That’s when I knew. As surely as if he had known I would someday be on a mission of learning and teaching about the meaning of autonomy, my Uncle Bill had written his Ethical Will in March 1963. And my father had stowed it away for safekeeping to be discovered and treasured by me 20 years after his death. The thread of that definitive Ethical Will has been woven throughout my work. I’ve incorporated its lessons on autonomy into my teachings on medical decision making, health literacy and self-preservation in a perfect storm. And I learned there are no coincidences.
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?
It was a medical error near-miss, humorous only in hindsight. I had had persistent shoulder pain for some time, finally went to see an orthopedist and was told I had a torn rotator cuff. Apparently, I then managed to convince the doctor that surgery could wait and we’d try physical therapy in the meantime. Good plan until the PT reviewed my MRI and told me I could lose the use of my arm if it wasn’t immediately fixed. I returned to the ortho, who said he thought he’d communicated that urgency and had taken my reaction to mean I fully understood. That’s when I looked right at him and said, “Why the hell did you listen to me??” We both laughed and I had the surgery three weeks later. Lesson for me: Being an informed decision maker starts with listening and fully understanding. Lesson for my doctor: A patient with an A+ personality and a well-developed sense of humor is not necessarily health literate.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
George Bernard Shaw’s “Life is no brief candle to me; it is a sort of splendid torch which I’ve got ahold of for the moment and I want to make it burn as brightly as possible before handing it on to future generations.” My hospice and Ethical Will work helped me recognize what’s left when we’re no longer here: the positive influence we’ve had on other individuals and on the world at large. I’ll add that because of what I learned through my Patient or Pawn? research and witnessed during the pandemic, I’ve also come to appreciate the wisdom of President John F. Kennedy: “The time to repair the roof is when the sun is shining.”
How would you define an “excellent healthcare provider”?
I’ve been blessed to have physicians on my team who are living examples of excellence, although I will take credit for doing a lot of homework before choosing them. First, each sees the patient as an equal partner in decision making, which makes them excellent listeners. Second, they acknowledge they are not infallible, which makes them effective care team players and open to seeking the expertise of others. Lastly, but most importantly, each has a passion for what they do, which somehow gives them the inner strength to keep showing up every day.
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’m drawn to geeky health care demographics, how access and patient safety are being impacted and ways consumers and providers can be better advocates. My regular online reading focuses heavily on statistics and performance research from government and professional sources such as the Bureau of Labor Statistics, AHRQ, JAMA, Becker’s, the VHA and Google Scholar Alerts for my key areas of interest, e.g., medical errors, health literacy, provider burnout and chronic care management. In podcasts, I get the most from those on health care delivery and workforce issues, such as Dr. Kevin Po’s KevinMD and Dan Gorenstein’s Tradeoffs. Since I come to health care innovation through the patient portal, I’m drawn to health care professionals’ books on the patient-provider relationship: Dr. Paul Kalanithi’s When Breath Becomes Air, Dr. Martin Makary’s Unaccountable or Dr. Atul Gawande’s Being Mortal. Anytime a patient gets to glimpse health care from a provider’s viewpoint, it’s a win-win.
Are you working on any exciting new projects now? How do you think that will help people?
I am very proud of my most recent book, Patient or Pawn?: Epic fails in health care, the approaching perfect storm and strategies for self-preservation. My research took me on an unexpected track as I learned about health care professionals’ frustrations, pervasive burnout and systemic weaknesses in readying for this inevitable clash of demographics and dwindling resources.
In any crisis, it’s important to recognize what elements are in our control. As individual patients and providers, there’s not much we can do to alter demographics or the workforce supply, but choosing to be informed decision makers and care managers is in our exclusive control. Innovative strategies are needed to overcome threats to patient access and safety. Patient or Pawn? tells the fact-based story behind this perfect storm and gives health care consumers and providers straightforward action steps to achieve the best possible health outcomes. Now I’m working on getting that message out to as many as possible.
Ok, thank you for that. Let’s now 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?
For perspective, The Commonwealth Fund study is based on data gathered five to seven years ago from about 4,000 patients and primary care physicians. It does shed light on patient and provider experiences, but I’m not sure they’re sufficient to judge the effectiveness of a system attempting to serve over 320 million people. Having said that, this study highlights the elements of health care that are the greatest challenges to access and safety. Viewing performance through this lens — and many others — it’s painfully clear the U.S. health care system is underachieving, and that is true whether standing alone or ranked.
For example, under “Access,” while over half of respondents say they saw a doctor or nurse within 24 hours, this considers only patient “demand,” rather than “need.” This overlooks the consumer who doesn’t recognize when medical attention is appropriate or doesn’t have the resources to seek care. The study’s “Care Process” category includes preventive care and the U.S. came in at the middle of the pack. Yet we know at least 80 percent of Americans’ premature chronic diseases are caused by bad healthy living choices, and chronic conditions account for 90 percent of all health care spending in the U.S. Those are epic fails, ranking aside.
The Commonwealth Study has inherent limitations, as noted by its authors. But there is real value in acknowledging the lack of data needed to properly identify systemic shortcomings. It is this scarcity of reliable information that I find most shocking and inexcusable.
As 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.
The business guru Peter Drucker put it well: “First measure, then improve.” Our policy makers and bureaucrats have failed in tracking health care needs and capabilities and then making reliable projections — let alone taking remedial steps. For instance, included in the 2010 Affordable Care Act was a commission mandated to study the health care workforce and take affirmative steps to meet future demands. Over the past 11 years, the commission’s 15 members have yet to hold their first meeting. To avert a life-threatening crisis of access in the not-too-distant future, health care leaders must acknowledge needs and support constructive change.
Second, from over thirty years of research and over 6,000 studies we know that when patients and providers utilize health literate practices, hospital readmissions go down, overall health care costs are reduced and we add to the quality, quantity and safety of patients’ lives. Giving health care consumers the practical and user-friendly tools they need to be engaged decision makers — from disease prevention to end-of-life care — is crucial to achieving autonomous health care goals. It is also long overdue.
Third, the sooner we recognize how the business of medicine is disrupting the practice of medicine, the better off we’ll be. An overwhelming majority of our health care professionals are suffering the effects of burnout from understaffing and technology that promised efficiency and patient safety and hasn’t delivered. The failure to acknowledge and address our health care workers’ needs is prompting career changes and early exits by many. They have options not available a decade ago, such as concierge medicine, direct primary care, hospital employment and travel nursing. We need systemic changes that give health care professionals the respect and support they deserve and attract others to health care as a profession.
Fourth, demographics are not limited to issues of aging. Chronic illness, including mental health challenges, has reached epidemic levels in America. Nearly half of all U.S. adults have two or more chronic conditions and one in every eight has at least five. Furthermore, one-fourth of children are chronically ill, and Millennials are not as healthy as GenXrs were. How are we addressing this? Well, HHS starts a new initiative every ten years called “Healthy People,” which now has over 1,300 objectives for health and well being. Over its 40-year history, only one in five goals has been met. Epic fail. We don’t have the human or financial resources to properly manage this growth in chronic illness in America. Consumers deserve an effective campaign of preventive medicine and care management backed by legitimate public health leadership.
Finally, there are those who say medical errors are the unreported third leading cause of death in America. There’s still no mandatory reporting, but HHS statistics confirm that hundreds of thousands of lives are lost every year from pressure ulcers, mistaken diagnoses and medication errors alone. As health care policy makers, stakeholders, clinicians and consumers, we have failed to give medical errors the attention they deserve as a matter of public safety. Just as importantly, medical errors are often symptoms of systemic weaknesses such as understaffing, inaccurate electronic health records and the absence of reliable patient identifiers. It so happens HHS has mandated a systemwide restructuring of electronic health records that’s scheduled to roll out by 2023. Now is the time for stakeholders and clinicians to insist on changes that make patients safer and healthier, rather than simply adding to our providers’ frustration and acting as a source of patient harm.
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?
a) Whether or not deficiencies are adequately addressed, health care consumers and their clinicians are most likely to achieve best health outcomes through patient-centered shared decision making. That level of engagement takes skill, time and effort, but there is no other way to preserve patients’ rights, regardless of available resources. It’s time for patients and their health care professionals to join forces and be the change.
b) The Bureau of Labor Statistics projects 2.6 million additional health care-related jobs by 2030. Corporate stakeholders can do little without a sufficient workforce, which means acting now to address burnout and pursue long-term solutions to recruitment and retention challenges. That may mean practical steps, such as tuition forgiveness, wage subsidies and public messaging, along with true working partnerships between stakeholders, K-12 and medical school educators. And let’s not forget the patients, an obvious choice to team with providers in creating more efficient patient-centered medical homes, practicing preventive care, managing chronic illness and avoiding medical errors. What most patients want is straightforward guidance in being a care team player.
c) Dependency ratios and caregiving support ratios are reaching record numbers, those living alone are at an historic high and one-fifth of all seniors are “friendless,” they have no one to act as advocate. It is doubtful traditional means will adequately meet health care and caregiving needs going forward. Instead, it will fall to communities and their subsectors to become active facilitators for and hands-on providers of health care-related services. Faith communities, fraternal organizations, advocacy groups, large employers, even neighborhoods can adopt care models to meet basic needs and reduce demands for skilled health care. With logistic and financial support from policy makers and stakeholders, non-health care professionals can organize and offer services such as congregate meals, paid and unpaid caregiving, appointment buddies, patient advocates, telehealth intermediaries and hospice care.
d) If “leaders” means policy makers, lawmakers and bureaucrats, they owe it to their constituents to get serious about gathering data on the health care workforce and future needs, if only for others to make constructive use of it. The role of health care governance should be to preserve health care resources and protect patients from harm. That often means simply staying out of the way of industry and community innovators working to achieve the best health outcomes. When the bureaucracy has a regulatory role to play, such as ensuring safety and interoperability for telehealth, electronic health records and patient identifiers, it should be fulfilled with input from those on the frontline, i.e., doctors, nurses and direct care workers.
The COVID-19 pandemic has put intense pressure on the American healthcare system, leaving some hospital systems at a complete loss as to how to handle this crisis. Can you share with us examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these issues moving forward?
Along with a lack of PPE and lost revenue, COVID-19 both intensified and accelerated the workforce shortages already brewing. Furloughs and stress during the pandemic led many to leave the industry permanently; the number of health care workers is now down 460,000 from prepandemic levels. It’s a loss felt most acutely by nursing and care facilities, since those workers account for 80 percent of the missing employees.
As we approach 2030, the number of Americans aged 65 and older will increase by 17 million, chronic illness will most likely continue its growth trajectory and one-third to one-half of today’s health care professionals will reach retirement. The notion that we can solve every problem by throwing money at it only works if there is someone there to catch it. This is not a situational challenge; it is a systemic crisis that can only be overcome with systemic change. It should not surprise anyone that an Elder Boom is following 70 years after a Baby Boom, and yet . . .
How do you think we can address the problem of physician shortages?
An aging population and the upsurge in chronic illness are clashing with the exodus of Boomer health care professionals. To put a face on it, independent sources estimate shortages of 43,000 to 139,000 physicians by 2030, so even a conservative outcome jeopardizes one-on-one medical care for about 180 million Americans.
It takes ten to 14 years of higher education to produce a new doctor, so assuming it’s still possible to minimize this crisis, let’s focus first on early retirements and transfers by those with the expertise and mentorship capabilities. We can slow that trend by addressing physician burnout and job dissatisfaction with meaningful approaches, such as exploring ways for clinicians to spend less screen time and more patient facetime. As for encouraging recruits, every year thousands of medical school graduates fail to get matched with residencies, while CMS funding for those positions was frozen in 1997. In December 2020, Congress finally expanded CMS funding, but by only 1,000 slots to be doled out over a five-year period. It’s a perplexing lost opportunity. And how about making it easier to pay for medical school and incentivizing post-license practice in underserved areas? From the patient side, technology is being used at only a fraction of its potential to assist in managing chronic conditions and encouraging medication and treatment compliance, which would dramatically reduce traditional health care utilization.
To be honest, I’m not confident we will address shortages in time to avoid the loss of lives.
How do you think we can address the issue of physician diversity?
Every person deserves to have health care reflective of their unique values and treatment goals. I know many believe greater diversity means better health outcomes because it encourages more effective patient-provider communication and respect for patient autonomy. Unfortunately, educators and stakeholders have made little, if any, progress toward the goals of diversity and inclusion over the past decade and I can’t explain why. I would suggest, however, that this places a greater onus on all providers to deliver autonomous care by fully exploring each patient’s story, personal and medical. For consumers, it’s another element of health care that necessitates health literate engagement, in spite of the system’s shortcomings.
I’m 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?
We know there’s an abundance of need and a scarcity of resources. Mental health treatment doesn’t have the profitability of other services and providers are in high demand. Those work together to reduce the number who accept Medicaid, Medicare and private insurance, placing the burden of payment on patients already hesitant to seek help due to social stigma or the nature of their disorders. A vicious cycle. Meanwhile, HHS estimates 40 to 45 million people of all ages in the U.S. have unmet mental health needs and suicide remains the second leading cause of death for those aged 14 to 18. For many years, our primary care physicians have been on the frontline of recognizing and treating patients’ mental health needs. With a projected shortage of 17,000 to 48,000 PCPs by 2030, will time constraints allow that to continue? Patients requiring a mental health professional should prepare for projected shortages of nearly 300,000 workers. I’m sorry to say I don’t see any bureaucratic movement away from this status quo. In fact, HHS projections paint the rosy picture of a juvenile psychiatrist surplus by 2030. Clueless.
One area that holds promise is the use of telehealth to address a lack of access, but that will take a conscious effort to keep the pandemic-inspired momentum going. The public health emergency coverage now in place will one day disappear unless Congress and private insurers take action to extend telemedicine and telemetry reimbursements. And there must also be a commitment to provide the needed internet access to less-populated areas of the U.S., the ones with the greatest unmet need for mental health support. The most vulnerable among us have virtually no voice in setting health care policy: those who struggle with mental health issues, the aging, the dying, the illiterate, the homeless, the friendless.
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. :-)
It isn’t every day a person gets a chance like this, so here goes. I observe organizations professing to advocate for health care consumers and the most vulnerable among us, and I see no headway being made. Zero. There isn’t even a realistic acknowledgement of the impediments to progress. I dream of a movement with a twofold mission: 1) to deliver loud and clear public messaging about America’s threatened health care access and what can be done to preserve resources and build reserves; and 2) to provide health care consumers and clinicians with solid, straightforward and actionable guidance and support for effective care management. This crusade would encourage civic engagement — far beyond another pointless advisory committee or task force — and mandate policy makers and stakeholders to act in the best interest of their constituency of health care consumers and professionals.
The approaching perfect storm of health care is a crisis hiding in plain sight. Without radical and systemic change, the clash of demographics and dwindling resources could go very badly, to a time when a specialist’s appointment comes too late, a 911 call goes unanswered and caregiving assistance is nonexistent. We have the resources to address these challenges, we have only to find the resolve. I believe there is still hope that with the right leadership and consumers’ commitment to engagement, health care in America can realize a mission of equitable and patient-centered care.
How can our readers further follow your work online?
Patient or Pawn? at Amazon.com
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.
