Q&A: Dr. Kirsten Meisinger on promoting health workforce well-being and system changes for best care
Kirsten Meisinger, M.D., practices family medicine and is Medical Director at Cambridge Health Alliance’s Union Square Family Health in Somerville. She is CHA’s Director of Provider Engagement and former Medical Staff President. Dr. Meisinger teaches at Harvard Medical School, Tufts University and the MGH Institute of Health Professions and was Faculty Co-Chair for the Centers for Medicare & Medicaid Services’ Transforming Clinical Practices Initiative. In addition to a medical degree from Case Western Reserve University, she has a Master of Health Care Delivery Science degree from Dartmouth College and consults on state, national and international initiatives in team development and medical system transformation.
Betsy Lehman Center: You have worked for years to support provider engagement at Cambridge Health Alliance. What is your initial reaction to the National Academy of Medicine’s “National Plan for Health Workforce Well-Being”? Is it helpful?
Dr. Meisinger:The National Plan resonates with my work tremendously. In organizations across the country, we find commonalities in the shortcomings of our current system.
I’m glad the plan includes a focus on teamwork, as the quality of relationships among patients and members of the caregiving team is now central to health care. Particularly in primary care, it's important that my patients trust me and all the members of our team. Adjusting to team-based care has taken us some time; patients, of course, tend to catch on more quickly than we give them credit for. It’s a joy to deliver care in a team format. Among other things, the National Plan points out that health care funding hasn’t caught up with this shift to team-based care.
The National Plan is well-constructed; in fact, I think it can form the basis of a movement, which is what I think we need now. We do have the power to make different choices, many of which will represent a big shift in how everything happens day-to-day in health care.
Betsy Lehman Center: Are there specific parts of the National Plan that resonate with current priorities in your work on the state level?
Dr. Meisinger: I serve on the Massachusetts Medical Society/Massachusetts Health & Hospital Association Task Force on Physician Burnout and can say that the National Plan’s priorities match those of our state plan. However, despite three years of continuous work by a group of talented, dedicated people, the Massachusetts group’s focus on reducing unproductive work for providers — prior authorizations and other paperwork, which I call “silly work” — until now has fallen on deaf ears.
We have burnout among the people trying to champion addressing burnout because it feels like the system is not listening. Although I am excited to see this issue attract national attention, I'm not terrifically optimistic that we will see fundamental change if our system remains focused on profit. Even not-for-profit hospitals must earn enough to stay in business because all U.S. healthcare is run as a business. Other countries have made different choices, with better results.
Better health care, better primary care, better psychiatric care are cost-effective only when managed on a scale that's felt at the governmental level, not at the level of private business.
Scale is part of the problem. Better health care, better primary care, better psychiatric care are cost-effective only when managed on a scale that's felt at the governmental level, not at the level of private business. In health care, economy of scale is huge and long, which is why most countries with wealth comparable to the United States have switched to a government-funded health care system.
Betsy Lehman Center: What strategies did you use at Union Square to help staff and clinicians deal with the stress of the pandemic layered on top of other challenges?
Dr. Meisinger: Some of things we did made a big difference. But first I’ll say, I've been really fortunate to be Medical Director at Union Square Family Health, which is part of the Cambridge Health Alliance, a public health care system where many of the factors that result in moral injury and provider burnout are absent.
During the earliest part of the pandemic, we actually found that provider and staff engagement went up because we were doing the work we had been trained to do and the silly work retreated.
Some granular changes helped, too. For example, we hadn’t been allowed to prescribe 90-day supplies of medicines even when patients had been taking them for years. They had to go to the pharmacy every month, which is a huge burden for someone who works two or three jobs, which is typical in my patient panel. Suddenly that restriction went away. Our patients were so happy, and so were we!
Referral networks opened up, and information sharing got easier. We felt like everybody in in the Boston area was on the same page, taking care of people, taking the silly work out of health care.
Telemedicine has helped, too, because it allows me to decide together with my patients what kind of interaction we want to have. MassHealth reacted quickly to the pandemic and said reimbursement would be the same regardless of how we reached patients — by phone, video or in person. That transformed our ability to maintain a level of contact and continuity with our patients — it was phenomenal. Hats off to Massachusetts for doing that!
Recently we hired some community health workers as digital navigators to help patients get on video because we fear it may be required in the future, as has already happened in the private insurance market. It’s lovely to see patients on the screen, but it’s not always necessary. If lack of video prevents patients from getting the care they need, it's not worth it. I'm very hopeful that telemedicine continues because it works so well in a continuity relationship like primary care. Telemedicine has decreased stress for everyone.
Sadly, it took a cataclysm in our system to move aside things we've always known don't matter. And now, of course, they're coming back. How do we hang on to that sense of inner purpose and joy for our employees at every level? How do we continue to fund changes that made a huge difference to our patients’ experience of care?
Telemedicine has decreased stress for everyone.
To be sure, in the public sector we deal with other things that contribute to burnout. As a physician, I know I can’t solve poverty in a 20-minute visit. But at CHA, taking care of the people in front of me is my chief priority — payment is secondary. That is incredibly liberating for me and my colleagues.
Betsy Lehman Center: What advice you do have for practices in Massachusetts that want to address workforce well-being and are not sure where to start?
Dr. Meisinger: Through my work at the Harvard Center for Primary Care, I talk with practices across the country and around the world to think through these problems. We've all come to realize that it’s necessary to give the work of patient care the time it requires. You simply have to figure that out, which gets back to your question about priorities. Is our business to improve health or make a profit? At Union Square, which is admittedly an outlier, we pushed for longer visits with our patients more than 10 years ago. CHA has been very supportive of that effort.
Teamwork is an important part of our approach to longer visits. We need to make sure that the whole team is engaged, which takes time, especially to make sure we cover any gaps, schedule screenings and check on social determinants, too. If we don't do all of those things, we may miss an opportunity to change the trajectory of the patient’s life. When I, as the doctor, come in as the closing act, patients can focus on telling me what they need me to know because we’ve addressed other things ahead of time. Patients should feel cared for the moment they enter the door and begin their personalized journey at the reception desk.
We’ve had this approach in place now for over a decade, and it's worked really well. It's joyful to work on a team and feel that I'm not alone.
Betsy Lehman Center: What's it’s like practicing medicine today compared with when you first became a doctor?
I’ll say again, working as a team has been a huge improvement.
The electronic medical record is another change. EMR systems were terrible in the beginning, having been set up for billing, not for health care. But they’ve gotten much better. It’s very helpful, prior to seeing a patient, that I can quickly review everything that’s happened since our last visit: urgent care, other hospital visits, anything that happens locally, medications.
Specialist visits, too. Before the EMR, I sometimes had to send patients to see specialists just because I had a question. On some level, that was disrespectful of everyone’s time. Now I can just send the chart and ask the specialist for a quick analysis; they tell me what I need to know, and we’re done.
So many changes have happened in such a short time. It shows we have the potential to increase everyone’s health and well-being. We just have to get the fundamental structures right, and then we can really make a difference.