Assistant Professor
Department of Internal Medicine
Tufts Medical Center
Tufts University School of Medicine
Boston, Massachusetts

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This is the third installment of our new series, Flattened By the Curve, which features the voices of doctors, nurses, healthcare workers, and others on the front lines against COVID-19. For information on how to submit, click here.

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The Pandemic Has Laid Bare a System In Shambles

In the before times, the New York Times published a visual depiction of what all the Democratic candidates’ plans for the health care system looked like. Medicare for All. A public option. Expanding the Affordable Care Act. The image represented varying degrees of change to an already abysmal system.

I am a primary care doctor and researcher. My research area of expertise is how well the health care system is equipped to face social challenges faced by our patients. A question I hear frequently in my line of work is if the health care system should even be in the social care space at all. I spend a lot of my time asking patients about this. I have asked social service organizations and providers about this too. That was in the before times.

Now my research is unfolding in front of me. I have spent two of the last three weeks taking care of patients who were admitted to the hospital during a pandemic, but not for coronavirus. The patients fall into two categories. In the first category are patients who are so sick, no amount of fear could keep them home. They needed to be seen, admitted, and treated. Patients with sepsis, bleeding ulcers, heart attacks, strokes. This is bread-and-butter medicine — the stuff I was trained to do in medical school and residency.

The second category include the people who showed up to the hospital out of fear. In a time of a global pandemic, they had no safe place to live. I received no training on this in medical school. (Despite a former dean suggesting it would have been a waste of time anyway. Twice. I digress.) My team took care of people facing homelessness in one of the scariest times in recent history to be homeless. Whether or not hospitals should be acting as social service providers is moot. We are, by default. We kept patients a day, maybe two, longer than “medically necessary.”

The health insurance companies started calling, telling us they were no longer going to pay for unnecessary hospital days. Hospital administrators would email, instructing my team to discharge the patients. If they were medically cleared, we wouldn’t get paid for any more days. Across the country, sites were set up to shelter homeless patients who tested positive for the coronavirus. I had to break the news over and over again to the patients, all who tested negative. I had no other option to offer besides the local shelter. It was an unpopular option. The hospital could not afford to also be a home for the homeless.

My hospital is losing millions of dollars caring for patients during the pandemic. We are hardly alone. The CARES act allocated 100 billion dollars to hospitals to save the health care system. As I round on my patients, I keep thinking about all the arguments from the before times about why we couldn’t overhaul our health care system. It doesn’t work very well, and the current incentives make it a terrible social service system. You know the arguments against reform. People were afraid to lose their beloved insurance. Change needed to be incremental. And we certainly couldn’t afford to make big changes.

Now that the system is imploding, I don’t understand the barriers to building a better system. The health care system is broken. The safety net is gone. The work of doctors and nurses is driven by a for-profit system that has seen a 3200% increase in administrators in my lifetime. The business of medicine is built on insurance companies reimbursing for how much we “do” – a hip replacement, an x-ray, a stress test. Hospitals are going bankrupt providing pandemic care because those procedures, what insurance companies pay highest for, have stopped. Talking to my patient about why her mother kicked her out, brainstorming where else she might be able to go, has a very low reimbursement rate. It’s zero.

Contrary to our system’s design, doctors and nurses take care of people, not a collection of diseases. We ask our patients, now more than ever, if they have a safe place to live and enough food to eat. Providing care to maximize the health and wellbeing of my patients requires that I take all of these factors into account. It also requires that the health care system sees value in these activities so I can keep doing it.

I find myself scanning articles by thought leaders on health care reform, looking for the call to arms, a need to start from scratch and build a health care system that works, that is fair, and that prioritizes health instead of sickness. Instead I find articles about alternative payment models, re-opening insurance enrollment periods, and hospitals furloughing non-essential employees. Luckily, the employee to remind me to add the diagnosis code for “acute kidney injury, acute” to make sure we can bill for it is still around to do her job.

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Elena Byhoff is a primary care doctor and health services researcher at Tufts Medical Center. Her research focuses on where social services and primary care meet. She lives in Massachusetts with her husband and daughter, who both had helpful contributions when trying to come up with a title for this essay.