Achieving a Healthcare System That Works for All – Dr. David Blumenthal, President of the Commonwealth Fund

Dr. Rishi Desai: Hi, I'm Dr. Rishi Desai. According to a new study, the relative rapid distribution of the COVID-19 vaccine in the U.S. saved an estimated 279,000 lives. We also learned recently from another report that more than half of U.S. adults who contracted COVID or lost income during the pandemic also struggled with medical debt.

Now, these are very different subjects, but they have something in common. Both studies were released by the Commonwealth Fund, which over many decades has become an essential source of research for policymakers and healthcare providers. We're going to find out more about the Commonwealth Fund and discuss the impact of COVID on health care access and affordability with its president, Dr. David Blumenthal.

Before joining the fund, Dr. Blumenthal had a long career in academia, with a focus on health information technology and health policy. He's a member of the National Academy of Medicine and serves on the editorial board for the New England Journal of Medicine. Thank you so much for being with us today.

Dr. David Blumenthal: I appreciate it.

Dr. Rishi Desai: Absolutely. I'd like to start out by diving into your background. What got you first interested in medicine, and particularly in primary care?

Dr. David Blumenthal: Well, I had a complicated entry into medicine that was very much influenced by the time in which I was making career decisions. I was a government major as an undergraduate, and also a newspaper undergraduate, a newspaper editor. I was considering academics and journalism. But I also graduated from college in 1970, and at that point, there was a draft lottery and my lottery number made it virtually certain that I would be drafted and sent to Vietnam.

Medicine was one of the few remaining sources of deferment of draft status. I had the required credits that I needed to go to medical school, so I made a decision that I would try to pursue my interest in writing and policy through medicine. That's how I ended up where I am now. And there are no do-overs in life, so I've enjoyed my career, no idea what it would have been like otherwise. I've found the combination of clinical care, policy, writing, and academics to be very gratifying.

Dr. Rishi Desai: What about primary care? What got you into primary care as an area of expertise?

Dr. David Blumenthal: I wanted a clinical discipline that I could maintain on a less than full-time basis and I thought primary care would provide that option. I think that the instincts you learn about diagnosis and therapy and treatment in medical training are quite enduring. You need to keep up with changes in medication and changes in practice. That's intellectual work that you can keep up with through reading and through journals. But you can't keep up with the eye-hand coordination required to do surgery or put a stent in an artery. For that, you need to be active clinically on a pretty much full-time basis. So, that was an important consideration for me.

Dr. Rishi Desai: You've had an incredible career. As you step back and look at your own career, what are the things that you're most proud of?

Dr. David Blumenthal: I think my work with electronic health record dissemination is probably the most impactful thing I've done in my career in terms of the effects on the day-to-day practice of medicine and the potential quality, and also the long-term value to improving practice. Enabling us as a country, as a species, to put into digital form the quadrillions of data points that now exist in the cloud to be mined for value, for knowledge, to relate to genotype, phenotype to genotype—all that required, at some personal inconvenience and cost for caretakers like physicians and others, is to take the time to put that data into electronic form.

I think the dissemination of electronic health records was a critical part of that. The real value will be realized over generations and through the application of artificial intelligence, properly tested and validated. I think that was the most important thing—which to me is astonishing because I am not at all a technical person. It was often said when I was the national coordinator of health information technology that my wife takes care of the computers at home, and that's true. I have 12 fingers when it comes to using my iPhone, and they get in the way of each other. They don't magnify my ability. I approached it as a practitioner and as a policy person, and those were the critical insights from my standpoint to being effective in that role.

Dr. Rishi Desai: It's really interesting that you chose electronic health records. I trained in an era where that was not used, and I've been working in an era where that is used. I've seen both sides, and the pros and cons. You've mentioned a couple of these, and I just want to flash them out a little bit with your help. On the one hand, you've got trillions of data points and there's no way a human brain can compute that—so we need AI to help us do that, and the only way to do that is to input the records into in a form that would make sense.

On the other hand, you also mentioned personal inconvenience for providers that are inputting the data, and we know that it affects the clinical relationship between a patient-provider. What do you say to folks that say, "Gosh, things were so much better way back when I could just talk to my patient. I didn't have to worry about the laptop getting in the way of my relationship." What is your response to that?

Dr. David Blumenthal: Well, there are multiple responses. First of all, things weren't better for patients in the paper era. They may have been more convenient for physicians, but they weren't better for patients. Too often physicians see the world through the lens of their professional experience, without putting themselves in the position of their patients.

Now, I don't mean to say that patients like the fact that physicians are working at keyboards and looking at monitors. They do complain about that, but they also like it when all the physicians who care for them have access to the same information. When they can move between institutions in the same system, or from a physician's office to an ambulatory surgery center, to an emergency room. And every caretaker they see has their medications, their allergies, their problem list, and verified validated information about their medical history. 

I do think that obviously with every advance there are downsides. I'm not in this world any more, the way I was a decade ago. I've broadened my interests, but my sense, especially talking to my children and their colleagues—my children are in their late 30s, early 40s, and they are physicians and they trained in the electronic age. They couldn't imagine writing a note by hand and they couldn't imagine working without electronic health records.

We can do a lot to make electronic health records more usable. And we should be doing a lot to make them more valuable for supporting clinical decisions and supporting therapeutic interventions. That's a matter of misaligned incentives, and a healthcare system that doesn't reward that generation of value. But it's not the technology that's the problem. It's the incentives that are the problem.

Dr. Rishi Desai: Yeah. I agree with that assessment. I think that incentive misalignment is a rampant issue in many sectors, and this is probably no exception to that rule. Do you mind speaking a little bit more about the Commonwealth Fund then and its mission? We started talking about a couple of studies that have come out. What is the core mission of the Commonwealth Fund and what was the need that existed that the fund aimed to solve?

Dr. David Blumenthal: Well, the Commonwealth Fund is 103 years old, so the needs that it has addressed have changed over time. In our very first work—I'm using "our" in the institutional sense—our very first work when we were formed in the aftermath of World War I was to provide aid to, of all things, Syrian refugees who were fleeing the Ottoman Empire, which took shape in the aftermath of World War I. The fund was involved with migration assistance back in the day.

We have gone through many phases, but the last 20 years, we've been focusing on delivery system performance. I'd like to say, we're focusing on the $4 trillion, and we're trying to make sure that money is better spent. We're also trying to make sure that it's better spent for people who need it and get the least attention. That means people of color, vulnerable populations, and low-income people. We are after creating a higher-performing health system, trying to make sure that people are covered for acute care and chronic care and when they are the money is well used, and that the burden of illness is minimized, and that happens with equity and cultural sensitivity.

Dr. Rishi Desai: There have been a lot of wins, and you can define that word however you think is appropriate, for the Commonwealth Fund. What are some wins that stand out for you? I don't just mean things that the Commonwealth Fund has done in isolation. Certainly, there has been a landscape of partners that you all have worked with. What are some proud moments, maybe in the field of equity, like you've just mentioned, for the fund in your time either observing or leading?

Dr. David Blumenthal: There are multiple areas where I think we've made a difference. For more than 20 years, the Commonwealth Fund has produced a report that compares the performance of the U.S. Health System to 10 other high-income countries using 71 indicators in five domains. There's been enormous consistency in the findings of those reports over time and the U.S reliably comes last in performance. The gap between us and other countries is growing. And our performance is so much worse that it's not clear that we even should be compared with countries like Australia and New Zealand and the Netherlands, Norway, even the UK. They are just doing so much better for their populations that it's as though we're not a high-income country anymore. I think that work has helped bolster the commitment of reformers given confidence that we can do better. We can do substantially better. We just have to use our money appropriately. So that's one type of work.

The second type of work we've done is we have consistently over decades tracked the numbers of people who are uninsured and the people who are underinsured. And that information we have reported yearly or more than yearly in well-consumed ways. We've continued to pay attention to that issue. And we have advanced specific reforms that have found their way into law. They've been proposed by members of the fund, sometimes before my time, sometimes during my time. They found their way into the Affordable Care Act, and continue to inform state and national policy development. We've worked hard to support advocates of Medicaid expansion in a number of states, and some of those states have successfully expanded Medicaid through ballot initiatives. And we can't claim credit for it, but we've certainly put our shoulder to the wheel in that regard.

Dr. Rishi Desai: You made a pretty provocative comment there that I don't think a lot of folks think about—the sense that there is this group of countries: the UK, Australia, New Zealand. And we're not really in that group according to the data around healthcare outcomes. That’s pretty striking. Why is it that this continues to be a piece of knowledge that you have, that I have, yet a lot of people don't have or don't recognize? What is your sense of why that isn't common knowledge at this point?

Dr. David Blumenthal: Well, it shows we're not doing a good enough job communicating it. I think it's hard to hear that kind of news. And very smart people, including a lot of policymakers, will still tell you with great conviction that we have the best health care system in the world. And what they really mean by that is that they have the health care in the world. Not that the average person does and certainly not that the poor or people of color do, but that they do. They can go to Mayo if they want to. They can go to their local Academic Health Center if they want to. They can get primary care because they have the connections that enable them to get access to closed primary care practices.

And technologically, United States is certainly equal to any other country. What we have is luxury in the midst of poverty and famine. We have centers of excellence that are unexcelled. I’m not saying they don't have equals, but they're unexcelled. This is cheek-by-jowl with infant mortality, maternal mortality, diabetes mortality, that is way higher than any other developed country. Part of this is a failure of cognition and imagination. But also a self-interested perspective.

People who think the United States has the best health care system in the world will often say, well people come from all over the world to get healthcare in the United States. And usually, they're talking about princes and heads of state and billionaires, who can take a private plane to fly up to Mass. General or Mayo or UCSF or Texas Medical Center. They do get the best health care in the world—or as good as anywhere else. But that's just not true for many of the people who take care of our homes and our gardens and who bring us our meals on bikes and all the people who keep our country running.

Dr. Rishi Desai: Yeah, I would add, who take care of our kids as well, and our elderly. You know, another group that strikes me is the group that doesn't have great health care: A lot of folks over the last five, six years, as we know, have lost trust in experts, and expert institutions. I used to work at the CDC and very publicly, the authority that the CDC once had has corroded.

I'm curious about whether you found the same to be true for the Commonwealth Fund, another place of authority. Among some groups, do you find that the message doesn't stick simply because you represent, maybe, academia? Researchers' knowledge? Whatever it may be? Does that feel true for the Commonwealth Fund, and if so, how are you managing that?

Dr. David Blumenthal: We certainly worry about that. I can't say that we have done any polling or systematic inquiry to document our comparative influence now compared to 20 years ago or 10 years ago. And we've changed over time. We were 15 years ago, regarded as left of center. I think that's less true now. Some observers do think of us that way.

One thing we've done is become a lot less academic. By that I mean we are using much more diverse forms of communicating our work. We're much more active on social media. We're much more likely to do tweet threads. We're much more active on Instagram and on Facebook. We've dramatically reduced the length of our publications. We rely a lot more on blogs. We used to rely on issue briefs that were brief only in name: They were 2,500 to 5,000 words. I don't think people read that kind of work anymore, at least not a lot of them. We hope we're getting better at messaging to a distracted, busy population with a lot less attention span than was expected 30, 40 years ago.

We still pay an awful lot of attention to the quality of our data and to the validity of our work. Fundamentally, our reputation is what we rely on. And that's true of most groups and organizations live and die by the quality information they provide. Perhaps naively, I think we're doing pretty well on that score. If you judge our influence by our followership on social media, email, it's grown. It's tripled or quadrupled over the last 10 years. And the traffic on our website has gone up dramatically. I think by those criteria we're doing okay, but those are not final indicators of influence.

Dr. Rishi Desai: That makes sense. You sit in a very interesting space because you personally have been involved in health information technology for a long time and you know the U.S. healthcare system quite thoroughly. What is your take on how the healthcare system as a whole has adopted health IT in the last 5-10 years? And maybe even if you could comment on how, during COVID, things have shifted with telemedicine and whatnot?

Dr. David Blumenthal: We would not have needed to pour billions of dollars into the pockets of hospitals and doctors to get IT adopted if the free market was working well and if medicine were not insulated from market forces. But the market wasn't working well, and the medicine is insulated from market forces. Medicine has been slow to the game with IT. I think it's picking up, but it's been slow. Again, I think the issue is incentives. One of the things I like to point out about our health care system is, unlike any other sector of our economy—virtually any other sector—it has no international competition. You think about autos or silicon chips, you name it—all those industries have to keep innovating and improving in order to keep their market share. 

Not true in healthcare. The only competition healthcare has is from other local firms, for the most part, who are basically functioning at the same level, with the same practices and procedures, and technologies that they are.

You can find exceptions to that. But on the whole, that's true. People say all healthcare is local. That means all healthcare is unchallenged to fundamentally transform itself. And I think that's been one of the many factors that has been in the way of medicine joining the information technology revolution. That's changing now. But it won't fundamentally take hold until we start paying for value. And until we put patients really in control, or at least give patients enough choice, so that they will choose health care providers who are at the cutting edge of information technology.

I just want to correct one minor thing. I had this brief period where I was heavily involved in IT and I did some policy studies related to health information technology. I've since moved on. One of the great luxuries I have as president of a place like the Commonwealth Fund is I see everything we do. I'm involved in everything we do from Medicare and Medicaid to cost control to prescription drugs to managed care, to promoting primary care, to defining value-based care, to social determinants of health. I'm all over the map and I love that. So, I mean, I was a primary care doctor, a generalist, and I love variation. I love change.

I do keep a finger in IT. But I see it as part of this panorama of issues. With respect to telehealth and telemental health and all the things that have happened—COVID had very few silver linings— but that was one of them. We undervalued and underpaid for and underused telehealth for decades. All of a sudden we couldn't avoid it. And it has come into common use in a way that was never true before. Now, the technology had to be there and the kinds of technology that we're using right now to communicate weren't available 10 years ago. So we've been fortunate in that way.

I believe as a practitioner that teleservice is one tool. It is not going to save healthcare. It's not going to transform healthcare by itself. It has its pluses and it has its minuses. It should be used in the ways that physicians and patients find advantageous.

One thing that doesn't happen through telehealth is you don't check blood pressures. You don't check rhythm. You don't pick up on undiagnosed AF. You don't pick up undiagnosed hypertension. You don't see diabetic's feet and you don't see when people are paler than they were on their last visit and start to wonder about anemia. You have a very blindered view of the patient. That's putting aside all the non-tangible psychological issues related to bonding of confidence-building.

When I was a primary care physician and I saw one of my patients in the emergency room during an acute illness, I had a total picture of that patient in health. Their weight, their body posture, their previous physical exam. And that was always very helpful and grounding for me and I think we give up something we don't have.

Dr. Rishi Desai: Do you feel like now that we're seeing more community clinics, more care outside of the home, that captures some of that, like the foot exams, the ability to check a blood pressure—that can be done maybe at a CVS. It can be done by a home health aide in the home. These sorts of things are shifting outside of the four walls of the hospital. Do you see that happening more and more?

Dr. David Blumenthal: It's certainly happening. I go back to thinking about how the United States compares to the rest of the world. There is no other country, developed country that relies on CVS, Walgreens, Wegmans, Walmart for primary care.

Dr. Rishi Desai: Yeah.

Dr. David Blumenthal: None. There's no other country that has urgent care centers on every street corner. I see us backfilling with what some might call a typical American ingenuity, and what others might call desperate compensation. I see us backfilling for a vestigial primary care infrastructure that is failing and that failing has created an opportunity for mostly for-profit companies to jump in with a service that meets selected needs that are profitable.

Tomorrow, I'm getting my Moderna booster and I'm going to CVS. And for that it's great. I check my own blood pressure at home. But if I had to, I could go to the Minute Clinic and get it checked. But as somewhat of a certain age, I much prefer to know that there is a physician or a nurse practitioner who knows me, who has the totality of my record in one place, who has a stable of specialists to refer me to in case I need special care, and who can advise me—when I say this I'm trying to imagine myself as a non-physician patient—who can advise me on who should operate on my hernia, and which cardiologist I should see about my chest pain. And all those things that those alternative primary care sites don't provide.

Dr. Rishi Desai: Yeah. It really feels like the absence of a primary home has created a situation where your kitchen is owned by this group, and your living room is owned by this group, and your dining room is owned… and so of course, it feels very disconcerting to even think of that as your home... [laughs] …for the patient.

You have an incredible career. We've mentioned this a few times now, and a lot of students in our audience are intrigued by paths outside of a traditional clinical pathway. What advice would you give someone that's interested in dabbling? That's kind of the sense I get for you—you're a dabbler. You like to kind of try different things out. You have a curious mind. A lot of folks would be curious how to get into that sort of line of work. What would you tell that person?

Dr. David Blumenthal: I am very curious and I'm somewhat impatient. I like having variety in my work, but I've always taken the time to get the training that I need to prepare me for the alternative career path that I pursued. I tell people who are interested in health policy or management, that they ideally should get additional training. MPH, MPP, MBA, if you're interested in academics, Ph.D., And more research training.

I don't think it's something that you can “dabble in.” You can put your toe in the water and see what appeals to you. Especially when you're a student. You can take a summer and intern in a state legislature—or if you're lucky, in Congress. Or work in a state government or a company. There are tons of options available to health professionals. Tons. There's an almost limitless variety of careers. From startup work, to IT professionals, to bench research, to government service, to academics, to journalism—it’s a huge range.

But I do think that to really make your way in one of these alternative pathways, it requires commitment over a period of time. If you want to be serious, you should get additional training. Medicine is a great profession. Second oldest profession, common truism, but medical school doesn't teach you how to think. And it doesn't teach you analytic skills other than differential diagnosis. If you want to venture out into the other world, the world outside of the clinic and the hospital, you need the training to enable you to function in those worlds.

The other thing that it requires is a certain amount of courage and commitment. It is very hard when you're an intern or resident to depart from the pathway that most of your colleagues will pursue toward specialization. Either in surgical or non-surgical or other discipline. It is sort of the natural thing to do, and to take healthcare management or policy or as an alternative—it can be very scary. It's not the doing one of those specialty trainings is inconsistent with leadership of various types, but it does tend to lead you into the management of healthcare organizations, rather than into public policy or one of those other strange types of work.

Dr. Rishi Desai: That makes a lot of sense and I think a lot of folks in the audience probably are looking to figure out exactly what sort of additional training opportunities make the most sense for them. So thank you for that endorsement. And thank you more broadly for taking the time to join us today with your incredible insights and thoughts. That was great.

Dr. David Blumenthal: Appreciate it. Good luck to you. And good luck to all your listeners.

Dr. Rishi Desai: I'm Rishi Desai, thanks for checking out today's show. Remember to do your part to flatten the curve and raised line. We’re all in this together.