Asinof: Why Not Choose a Nurse?

Nurses and Richard Asinof agree--get your flu shots!

As the iconic TV ad once remarked about Charlie the Tuna, there is a big difference between good taste and what tastes good. And, in health care, there is big difference between good health practices and the practice of medicine.

Medical costs keep rising, despite all the conversations about reforming health care, and the heated political rhetoric around what to do to solve the problem. Meanwhile, what happens in a doctor’s office impacts only about 10 percent to 15 percent of health outcomes in the U.S., despite the exorbitant cost of the health care delivery system. It’s what some have termed a “wealth extraction” system.

The rise in infant mortality rates in the U.S., and the decline in life expectancy rates, is both a tragedy and a scandal. The way to improve those outcomes is not by more investments in the practice of medicine, but improving health equity at the community level.

Three titans of the business world – Jamie Dimon of Goldman Sachs, Jeff Bezos of Amazon and Warren Buffett of Berkshire Hathaway – recently announced that they have chosen Dr. Atul Gawande, 52, a surgeon, a Harvard University professor, and a staff writer at the New York Magazine, to head their new nonprofit venture to solve the conundrum of administering health care for their more than 1 million employees combined.

Gawande may prove to be an excellent choice. That choice, however, exemplifies the difference between the practice of medicine and what is needed to achieve good health outcomes.

The provocative question to ask is: Why didn’t Dimon, Bezos and Buffett chose a nurse to head their new nonprofit?

Nurses hold up two-thirds of health care

Anyone who is deeply involved in the delivery of health care recognizes that nurses run the day-to-day operations of most hospitals, not doctors. The future of health care will be rooted in primary care and prevention in community-based health care, not in surgery or in the preservation of the financial health of hospitals.

If women hold up more than half the sky, as the Chinese adage goes, nurses hold up more than two-thirds of the health care delivery system.

There are innovative solutions on the ground here in Rhode Island that reflect a much different approach to health care, such as health equity zones now operating in nine Rhode Island communities and Neighborhood Health Stations operating in Central Falls in Scituate, putting the emphasis on good health practices.

The Neighborhood Health Station in Central Falls, with a new facility under construction that will open in September, will provide integrated primary care services to approximately 80-85 percent of the residents of Central Falls, at one location, coordinating dental, mental health, pharmacy and behavioral health services.

My guess is that many will be reading about a Neighborhood Health Station for the first time. The disliked fact is that most politicians – and most health care reporters in Rhode Island – cannot describe what a health equity zone or a neighborhood health station is, or, for that matter, what an accountable entity is. Why is that?

One need to look no further than the recent two-page chart prepared by The Providence Journal that attempted to untangle the health care landscape in Rhode Island by defining that landscape as being solely derivative of large hospital systems. The difference between the practice of medicine and good health practices strikes again.

Patient-centered care

Rhode Island is also home to what is known at the Care Transformation Collaborative, an all-payer patient-centered home initiative that now serves roughly about one-third of all Rhode Island residents, with an increased use of nurses and nurse care managers to deliver services.

Another primary model that the yet unnamed nonprofit enterprise headed by Gawande may look at adopting is the model developed by Iora Health, created by Dr. Rushika Fernandopulle, co-founder and CEO, which markets its approach as “restoring humanity to health care,” putting people first.

That model, as Fernandopulle described it during a talk at the Warren Alpert Medical School in September of 2017, is dependent on deploying a network of community health workers focused on better management of employer health benefits.

Pre-existing conditions

Pre-existing conditions, once a health insurance company barrier to securing coverage that was ended by the Affordable Care Act, are now back in play, as the Trump administration seeks to make that policy the law of the land again.

The estimate by some researchers is that more than half of women and girls nationwide – some 67 million – have pre-existing conditions. There are approximately 6 million pregnancies each year, once a commonly cited reason for denying insurance coverage before the Affordable Care Act.

Any attempt to control medical costs as part of the new nonprofit enterprise will be threatened by the Trump administration’s efforts to revive pre-existing conditions as a potential barrier to health care insurance coverage. Will Dimon, Bezos and Buffett intervene legally and politically?

How onerous can be the way that pre-existing conditions are applied? Let me share a personal story: In 1989, my wife had to refuse a job she had been offered by a major health care agency in Providence, because, newly pregnant, she was told by the health insurance carrier for the agency’s employees that her pregnancy was a “pre-existing” condition. The estimated medical costs of up to $20,000 of health care during pregnancy and birth would not be covered.

Times and policies have changed (thankfully). There are far more egregious examples, many for cancer patients, related to health insurance policies related to pre-existing conditions.

Finally, there is the reality that to combat the ever-escalating medical costs, we must confront the need to change the way we think about disease, particularly chronic disease, putting the focus on prevention, public health and environmental protection.

Richard Asinof
Richard Asinof is an award-winning journalist who frequently writes about health, innovation, science, technology and community in Rhode Island. He is the founder and editor of ConvergenceRI, an online newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island. He can be reached at