The Human Toll of Red Tape in Healthcare

CHRISTIANE AMANPOUR, HOST: Health care in America is not yet a big election issue despite patients facing many hardships. Dr. Chavi Eve Karkowsky is a maternal fetal physician and she has written an article that details the false that she is found in the system. She joins Michel Martin to discuss how red tape complicates access to care and also endangers lives.

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MICHEL MARTIN, CONTRIBUTOR: Dr. Karkowsky, thank you so much for joining us.

DR. CHAVI EVE KARKOWSKY, WRITER, “THE OVERLOOKED REASON OUR HEALTH CARE SYSTEMS CRUSHES PATIENTS”: Thank you for having me.

MARTIN: You wrote a page for “The New York Times,” an op-ed piece, about the administrative burden that Americans experience in the U.S. health care system. Now, that’s kind of a formal way of talking about what we are talking about. But we’re talking about paperwork, right? Is that what we are talking about here?

DR. KARKOWSKY: I think we are talking about paperwork, but everything in medicine is also boring and also heartbreak, right? So, we are talking about paperwork, but we’re also talking about human suffering.

MARTIN: You open the peace with a scenario that just is — just terrifying and heartbreaking, and encouraging in some ways. So, as briefly as you can, would you just tell us how you opened the piece for people who haven’t had a chance to read it?

DR. KARKOWSKY: Sure. I started the piece with the story from several years ago. I am a high-risk obstetrician, a maternal fetal medicine specialist. I was in the hospital working a shift on labor and delivery, and I was called emergently to our triage unit, just our small emergency room that we have for pregnant patients. And there, I found a patient who was about 20 weeks pregnant. She had a very high fever and she wasn’t breathing well. And the story that she told me was that she had started to have symptoms of urinary tract infection, which is very common in general but is very, very common in pregnancy. She had gone to her doctor and gotten a prescription, but when she went to the pharmacy, they wouldn’t fill it. Then, she wasn’t very clear on why, whether there was a trouble with payment or identification, but she just didn’t her medicine. And over the next few days she started get progressively sicker. Back pain, started to contract and she eventually called 911 when she became short of breath. When she came to see us, we very quickly were concerned about a kidney infection, which is something that happens if you have an untreated UTI. And also, can lead to preterm labor or even respiratory distress, breathing difficulty if it’s really uncontrolled.

MARTIN: So, then, what happens is people rush in, they focus all their attention, you know, years of training and expertise and dedication to saving this patient’s life, but you juxtapose with — what — how much would that antibiotic have cost?

DR. KARKOWSKY: I mean, I did some searches and I think it depends. But the one we tend to use and the one I believe she was given is a really old, generic medication, I think $12 to $20 for a five to seven-day course. We are talking about — you know, it’s very cheap, you know, for what it is.

MARTIN: So, a $12 antibiotic, if she had gotten it on time when she was supposed to get it, when it was prescribed to her, she didn’t. Not to put a dollar, a price on this, but how much do you think all that medical intervention cost to save her life when she didn’t get that antibiotic?

DR. KARKOWSKY: I hesitate because I can’t fact-check any of this. But I will tell you this. Ballpark, a day and a half bill like $2,000 to $3,000. But you add ICU level care, which is what we often managed to provide on a labor and delivery unit for somebody who is experience preterm labor and needs that higher level of nursing, higher level of doctor care, it’s often $5,000 a day, right? So, it’s very cost-effective to prevent that kind of admission. Even at the same time, I’m really, really proud of my team that can assemble and often does assemble so quickly for a patient who is sick and brings so much expertise and so much passion and so much devotion. You know, I’ve got a team that’s obstetricians and anesthesiologists and the NICU team, we are ready. But you are right, we are very expensive.

MARTIN: You’ve also written a book called “High Risk: A Doctor’s Notes on Pregnancy, Birth, and the Unexpected.” And you also wrote an op-ed in 2021 for “The Atlantic” titled, “Vaccine Refusers Risk Compassion Fatigue.” And of course, the reason we called you today is for the op-ed you wrote for “The Times” called “The Overlooked Reason Our Health Care System Crushes Patients.” But taking those altogether, do you think that there is a through line there?

DR. KARKOWSKY: You know, it’s really interesting. One of the chapters in my book, my book that came out one week before the pandemic, which would not recommend as a marketing technique, just in general. My longest chapter is about systems. And systems always sound like such a boring topic, right? Paperwork and rules and work flows and algorithms. But I think what I am hoping I have shown in that chapter is that it is also people’s lives and people’s time and people getting sick or people getting what they need because of those rules and algorithms and administrative burdens. And this has been something that as I have become more experience in medicine, as I become somebody who manages more and more of my colleagues, I am starting to see the bigger picture and I am trying to put that together in my writing to show all of us, to show all of you so that we could have these conversations. So, it’s something that I talked about in my book. And then, I think that you can see in my evolving understanding of the systems that I work in that I sometimes say, I swim in like a fish in the ocean, and trying to bring that to everybody, because I actually think that it has a bigger effect on your care. And the care that I give and the care that you receive and anybody really knows and I think it deserves some attention.

MARTIN: Your piece is titled “The Overlooked Reason Our Health Care System Crushes Patients.” I got to tell you that before our conversation today, you know, I mentioned to a couple of people I was going to talk to you, to a person, everybody had a story, everybody had a story. How is this overlooked?

DR. KARKOWSKY: I have to tell you that I think is sort of the curriculum that I learned in med school, right? Immediately after learning all of the pharmacology and all of the anatomy, you start working with patient, and the first thing that you start to learn is that nothing that you need to do is helpful in any way until you can get it to the patient, right? And then, getting it to the patient is its own discipline. Its own sort of academic pursuit. It’s an own complicated experience. And I think for patients, they are learning that as well. Sometimes, over years of a chronic illness and sometimes very, very quickly as they get very abruptly sick.

MARTIN: How did it start that filling out forms became so fundamental to American health care?

DR. KARKOWSKY: I don’t know a historical view for you. What I can say is this, the American health care system — and when I talk about that I don’t just mean me or a hospital or even a clinic, I mean all of it. Your insurance provider, their claims adjusters, every single one of us who is adjacent to how health care gets both provided but also paid for and approved and disapproved, all sorts of things. It’s a massive multitentacled beast of an industry, right? Most of which is there to help you, but like any large system, I think, has to make rules. I sometimes compare to like the military, except unlike the military, you are all going to end up in it at some point because it’s very rare to not be a patient at some point in your life. And there’s going to be a lack of transparency and orientation to the processes which are going to govern your life, often when you are at your most stressed or feeling your least well, unable to handle them. So, I think there are things that are particular about the American sort of medical system that we can talk about that make it particularly difficult, even as some of those things are things we are very proud of.

MARTIN: Would you say more, you know tell us, you know, a couple of other stories?

DR. KARKOWSKY: I mentioned in the piece that I was in the clinic, I have a clinic where I oversee our high-risk fellows on a Wednesday and had a patient who have not been able to pick up her glucose finger stick, the testing strips. And she had been three, four weeks without them, which for pregnancy is an eternity, right? Every week counts. Everything I do is time sensitive. And she had taken off the morning off of work. She’s an hourly worker, that’s not work she’s ever going to get back, it’s not time she’s ever going to get back so that she could ferry between, you know, her insurance office and the Medicaid office and the pharmacy, and she finally got the test strips. And I helped her. I went with her to the Medicaid office, because it’s right across the street, and I went with her to the pharmacy and we cleared it all up. And she got her test strips for, I think, $5 or $10 copay, but it also cost or all of the morning and whatever childcare she had to get for all her other children, right? On the other hand, I was happy to do it because it was much cheaper than admitting her for a diabetic coma. That depends on who you think is paying for the diabetic coma, right? So, I know that especially if you worked with an underserved population. I work in an area that serve some of the poorest ZIP codes in the entire United States, you are often working with patients where life is very hard already. These barriers become sometimes insurmountable but very onerous. And a large part of providing good care in this setting ends up being this administrative work.

MARTIN: A lot of people are going to be like, well, you know, this is folks who are minimally insured, who are uninsured or, well, maybe people whose English isn’t their first language or people who are under resourced, who don’t really navigate systems. You cite in your piece a Harvard Medical School study that found a quarter of insured adults reported that their care was delayed or missed entirely because of administrative tasks.

DR. KARKOWSKY: Yes. I work in New York State. In New York State, and I feel very blessed by this. If every single pregnant patient is insured, done. Eligible for Medicaid. I feel very, very lucky in this setting. I never have to worry in that way. Postpartum coverage could be better. Preconceptual coverage can be better. But once they’re pregnant, and because I exclusively take care of pregnant patients, that’s all of my patient population, and I still see this tremendous burden. It’s not just about being uninsured. I think everybody who has insurance handles this, how many phone calls did you have to make to get to a specialist? How many forms did you have to fill out to get your right medication? How many times did you press the wrong number on a phone tree and you spent another hour waiting for somebody who really knew what the right answer was and could provide you that expertise?

MARTIN: Has the medical establishment itself played a role in this? To be fair.

DR. KARKOWSKY: I guess I feel like I work with some of the most devoted people, right? Like what I would say is this, I spent a lot of my time overcoming administrative burden for patients. And that itself is both very beautiful and extremely dumb. It’s a dumb use of, let’s say, my time, right? I am somebody who if I could go see five more patients, I’d say, that’s probably better, right? Probably a more economical use of my particular 20 years of training time. But I work in a system that I can be smart and give you the right insulin, give you the right antibiotic, but if it does not get to you, you will end up sicker, I’m going to take that 10-minute, that 15 minutes, that 30 minutes, talk to your pharmacy, talk to your insurance office. The choice I often have is not, do you want to be optimally efficient for the — you know, for medical system at large? That’s not the choice in front of me. MThe choice in front of me is, are we getting this patient what she needs or not? And I have always gotten the patient what she needs. But I will tell you to be angry at providers or doctors I think is the wrong thing. I am doing something that is suboptimal because the system I am in a suboptimal and the choices that I have are bad.

MARTIN: And I am asking you, though, have not medical professionals been obstructionist in — for figuring out how to provide affordable care and access across the board. Is that not the case?

DR. KARKOWSKY: I don’t know if that is the case. I don’t know who medical professionals are. You know, is medical professional me and my doctors? I don’t know. We are pretty in the trench’s kind of folks, right? We’re taking care of the patients in the hospital. If medical professionals are CEOs of insurance companies or giant medical systems, that — they have a different agenda. I am extremely clinical. I am both very focused on the patient in front of me, but as I have become more senior, more aware of the way the system affects them all.

MARTIN: In the real world, do you think that policymakers think about the time costs for both patients and providers, physicians in their rulemaking?

DR. KARKOWSKY: I think that’s it. I think we do not count time cost. And time cost is a really, really interesting subject, because time costs is valuable only if you value someone’s time, right? So, a lot of these tasks are done by people who — the insurance company doesn’t pay their salaries. So, two hours spent on the phone doesn’t show up on the bottom line. I mean, I would argue that many of these tasks are done by women and are a part of the unpaid work that many women do to sustain their households. And historically, we tend to not value a lot of that. But it is costly. It does take time and it should be counted. When it is not counted, we don’t ultimately value it because we don’t even understand what we are paying.

MARTIN: How do you fix this? How would you fix this?

DR. KARKOWSKY: You know, it is very interesting because I asked this question to some of the people that I spoke to for the article, and they really said that they didn’t have a lot of great ideas. It’s very, very hard to estimate time cost. It’s very, very hard to know a much time people are spending. But I will say this, I see how we fixed other things. So, for example, the way that we pay attention to maternal mortality and morbidity. The way we pay tension to not delivering babies before 39 weeks at a very good reason, causing complications of early term birth. The way we do that is we pay attention. We publish metrics. We grade people. We sort of shine light on the subject and we also make that knowledge public. We tell people this clinic has an A plus. This clinic has B minus. Where would you rather go? And I guess I wonder if there is any room for calculating time costs and requiring a metric that reflects that kind of time. Maybe something that we would do across the country so that people would know, this place is a place that values my time and has soothes the way. This place doesn’t. And that would allow, I think, for more knowledge for patients to pursue things that are in their best interest perhaps.

MARTIN: Well, you know, I mean, the IRS does that. I mean, the IRS will describe how long they estimate it will take to fill out one form or another in tax compliance. In other spheres, this was a part of public conversation, but it doesn’t seem to be when it comes to this, and I am just wondering if you have a theory about that?

DR. KARKOWSKY: I do think there’s something here that we haven’t discussed, which is cost. You know, the United States pays more, overall and per person and, you know, as a percentage of GDP for health care than anywhere else. And there are ways in which we get less for it, right? There’s — our maternal mortality is awful. Our maternal mortality for women of color is truly shameful. And we spend more money than anyone else. And some of this, I think, is from the complexity of the system we are in. We don’t have a single payer. We don’t even have a single payer per region. We have a capitalist marketplace, right, mostly combined with public insurance, which is a very large player. And so, I think it’s just a very strange and complex scenario and one that’s very, very hard to drive, one that’s very hard to drive change in because it’s really complicated. There is a fair amount of government interference but there’s also a fair amount of just market forces. And because of the unique mix that we have, we have some wonderful things. I am really proud of my team that could gather and provide amazing care in under an hour for our sick patients, but we also have these cost, which is that everybody’s got six different forms because if six different insurance companies and seven different pharmacies and nobody has come to any sort of agreement or standardization. But the cost, I think, is real and a real driver. And I don’t think it is wrong to want to bring that cost down. I mean, we all pay for, that right? We pay for premiums. We pay in the federal budget. Bringing the cost down is something I think we are going to have to do. It is just that sometimes companies make the decision to bring the cost down by making the administrative burden higher, and that only works if you don’t count the administrative burden as a cost.

MARTIN: I have heard anecdotally, and I think there may be data to back this up, but there are doctors who have left the field because of the paperwork burden. Have you experience that with your colleagues? Has anybody, friends, people you want to med school with, do you think that that might be true?

DR. KARKOWSKY: This is very personal to me because I feel like I am just seeing such profound burnout in the medical profession right now, which is hard. Most of us love the work we do. We love our patients. We spent a long time becoming good at this work, and this work is very, very hard. But it is also true that many of us spend hours and hours and hours on administrative burden. You know, these are tests that they don’t bring revenues, they are not billable for the most part. And so, because of that, depending on what setting you work in, they may or not be supportive. And I do think it all adds up, it all adds up and adds to the dissatisfaction on top of sort of post pandemic difficulties, fatigue and malaise. I think there’s a true burden here that is contributing to clinician burnout, and I think it’s going have to be addressed.

MARTIN: Dr. Chavi Eve Karkowsky, thank you so much for talking with us.

DR. KARKOWSKY: Thank you so much.