The rocky rollout of the Covid-19 vaccines is emblematic of many of the problems with the U.S. health care system. The United States is blessed with highly trained, excellent, and compassionate care providers and terrific research and development that has led to novel medical treatments. Yet, despite these many advantages, its health care system has an inability to deliver that excellence to patients in a consistent, high-quality, and cost-effective manner.
The current struggle to vaccinate the U.S. population is but one illustration of several larger and more-fundamental challenges facing the country’s health care system.
The System’s Shortcomings
Here are some of the system’s major deficiencies:
Product innovation is valued over process innovation. New treatments, many of which are truly life changing, flow constantly into and through the health care system. These are to be celebrated. Just as important, however, is process innovation, which slowly and steadily alters the delivery of care.
Process innovation is inherently incremental; it only leads to radical change when it is practiced over extended periods of time. Yet without it, we are left with a system that allows errors to proliferate, fails to coordinate activity, and remains stagnant.
A prime example is the system’s unwillingness to develop and deploy checklists in situations where they have been known to be effective. In his writing on the topic, Atul Gawande notes the challenge of spreading process innovation through checklists, even when checklists for common procedures, such as the insertion of central lines, had been shown to be essentially 100% effective in reducing infections. Despite broad support for improvement throughout the health care system, the lack of a broad-based commitment to process innovation has led to failures in execution and, in some cases, lower quality.
The workforce is used inefficiently. Well-trained, highly compensated providers are critical to any health care system. However, not every task requires the highest level of training and licensure. Unfortunately, due to regulatory and professional limitations, highly credentialed individuals are forced to perform many tasks that don’t require their level of expertise. This has led to a shortage of frontline providers, from doctors to nurses to social workers. There have been many manifestations of this during the pandemic: a lack of clinicians to vaccinate people in many areas of the country, a dearth of a public health workers for services like testing, and a shortage of staff to help address critical social needs related to health such as access to transportation, food, and housing.
‘Known unknowns’ aren’t adequately planned for. The effort to create the vaccine was truly heroic. Numerous people came together to create, test, and manufacture multiple vaccines in record time. Even with all of these efforts, the last-mile problem of putting the vaccine into individuals’ arms received too little attention. For example, most people still do not know how they will get the vaccine once they are eligible to do so. Yes, we don’t necessarily know exactly when doses for particular groups will arrive in particular geographies, but we do know that those doses will arrive at some point. So why not plan for it now, or, even better, why not have planned for it three months ago?
This deficiency in planning for known unknowns — which is a failure of project management — is common in the U.S. health care system. A prime example is coordinating care needed by individuals with multiple comorbidities, which consumes a huge portion of U.S. expenditures on health care. These patients typically need to see a number of different specialists, and, if their treatment is not planned and coordinated, costs will soar and quality will suffer. While this is known, figuring out how to provide such care in a high-quality, efficient way remains a challenge, although some providers have recently introduced some promising models.
Supply of care isn’t brought to those who demand it. Physician house calls, which were common 50 to 60 years ago, are today a rarity. Patients now need to travel to providers for even the most-basic forms of care. Yes, pharmacies have figured out how to take strep throat cultures and give flu shots in their retail clinics and have been allowed by government authorities to administer Covid-19 vaccines in nursing homes. But despite such steps, many patients — especially those in disadvantaged populations — still face challenges in obtaining routine care due to the limited access to social services, such as transportation, that we noted above.
Further, we have failed to use technology to close these gaps. In addition to the lack of access to the internet that makes telemedicine unobtainable for a significant number of the poor and elderly, there are other obstacles; they include the unwillingness of certain insurers to pay for telehealth visits and state licensing rules that restrict or prohibit physicians in one state from practicing in another. While these restrictions have been eased during the pandemic, it remains to be seen if they will be reinstated once the pandemic ends.
Another example of underutilized technology can be found in electronic health record (EHR) systems. Their widespread adoption in the past decade was heralded as an opportunity to capture information and allow it to be shared seamlessly among providers and between patients and providers. The goal of this information sharing was to enhance collaboration among providers and coordination of care for patients while eliminating waste (e.g., by reducing the ordering of redundant tests).
Though many health systems have developed patient portals to facilitate communication between providers and patients and at least physicians within the same system can now commonly share patient information, problems with EHRs abound. The burden of entering data into EHRs has added to physicians’ workloads, contributing to burnout. Physicians complain that finding the information they need in EHRs is anything but easy. And critics contend that health systems’ priority has been to use EHRs to maximize billings rather than to improve the quality of health care.
How to Address the Shortcomings
The good news is that while the pandemic has exposed many of the deficiencies in the U.S. health care system, the efforts to manufacture, distribute, and administer Covid-19 vaccines are illustrating methods for addressing those shortcomings.
Prioritize and create a project plan. Too often during the Covid-19 pandemic, rather than clearly prioritizing the current challenge to be addressed while remaining mindful of the work to follow, the response has seemed more like running from one fire to the next. For example, an important initial need was to discover a safe and effective vaccine. The subsequent need for manufacturing, distributing, and getting the vaccines injected into patients, however, was given too little attention.
Unfortunately, this is not unusual in health care. All too often the focus is on the urgent problem of today and predictable problems and contributing factors are ignored. The knee-replacement patient who can’t get rehab services and the repeat emergency department (ED) patient who lacks stable housing are two of the many cases in point. Both policymakers and health care leaders need to simultaneously prioritize today’s issues, understand the contributing factors, and plan for tomorrow’s next steps.
Expand the ranks of frontline caregivers. In addition to rethinking the qualifications that are needed to perform given tasks, we need to expand the ranks of people with lower levels of expertise to carry out tasks that don’t require physicians or nurses. These range from vaccinations to conducting home visits with older patients or those with stable chronic conditions to ensure they are taking their medications, getting adequate meals and exercise, and so on. This will require significant funding and training.
Delineate authority and accountability. A combination of abandoned responsibility, finger-pointing, and shifting of blame has led to significant questions around who is responsible for both decision-making and outcomes regarding vaccine distribution. Whether these responsibilities are best held centrally (e.g., by the federal government) or locally (e.g., by states, cities, or private organizations) depends on the nature of the problem to be solved.
Problems that are more universal, such as considerations about the impact of changing recommended vaccination schedules or doses, may be best addressed centrally. Those that require local solutions — such as how to design and operate vaccination clinics in a particular city — should be handled locally. Once responsibilities are appropriately allocated, accountability for outcomes can be clearly assigned.
Beyond the Covid-19 crisis, health care is filled with situations that require such an approach. For example, while recommended approaches for cancer screening are often established by national or international organizations, determining how those recommendations are implemented depend on local decision-makers such as specific hospitals, medical groups, or, in some cases, insurers.
Deliver service where it’s needed. The expansion of sites that could apply Covid-19 tests, the rollout of Covid-19 vaccines, and the easing of restrictions on telemedicine hopefully mark the beginning of a shift in the focus of the U.S. health system from maximizing the efficiency of suppliers toward increasing convenience for consumers.
Indeed, the pandemic has made this expectation the norm among consumers. Witness the explosion in home deliveries of food and packages and online service calls. It is not surprising that companies that began outside of health care — including Amazon, Walmart, and Best Buy — continue to train their sights on the industry through retail clinics, home health care, and digital health tools to help manage chronic disease. If anything, the deficiencies exposed by the pandemic and consumers’ growing intolerance of them is likely to accelerate their moves into health care. Incumbent care providers had better take them seriously; they might even consider forming partnerships with them.
The creation, distribution, and administration of the Covid-19 vaccine serves as a microcosm of the challenges facing the U.S. health care system: grand innovation followed by struggles with execution. The Biden administration has announced plans to address the execution difficulties. Ideally, these steps forward will not only address today’s challenges but will also create an opportunity for learning and lasting improvements throughout the health care system. Prioritizing issues and creating a project plan, expanding the ranks of frontline caregivers, delineating authority and accountability, and delivering service where it is demanded may seem incremental in nature, but such a steady and consistent approach would be radical indeed for the U.S. health care system.
