Tackling Healthcare Fragmentation: A Conversation with Dr. Lisa Kern

In this episode of SoundPractice, Lisa Kern, MD, MPH, shares her insights into the challenges and opportunities within the U.S. healthcare system. She discusses her career path, starting with her background in psychology and her interest in communication, which ultimately led her to focus on healthcare delivery research. The conversation explores key topics such as healthcare fragmentation, the role of patients in improving care coordination, inter-professional collaboration, and the future of healthcare delivery, including the integration of AI. Through this discussion, Kern provides valuable perspectives on how external factors like insurance and policy influence patient care and outlines innovative approaches to creating a more effective and patient-centered healthcare system.

This transcript has been edited for clarity and length.

Mike Sacopulos: My guest today is Lisa Kern. Dr. Kern is a professor of medicine, an associate chief for research in the division of general internal medicine in the department of medicine at Weill Cornell Medicine. She is a national expert on healthcare fragmentation in the ambulatory setting. Lisa Kern, welcome to Sound Practice.

Lisa Kern, MD, MPH: Thank you so much.

Sacopulos: It is my pleasure to interview you today. Dr. Kern, as you know, this is the podcast of the American Association for Physician Leadership. So, I am interested in your career path to becoming a physician leader. Could you tell me about the path?

Kern: Sure. I am now a professor of medicine, and I study the way that we deliver healthcare in the United States, and I can trace those interests all the way back to when I was in college. I was a psychology major fascinated with communication, how and how people choose to express themselves, what they say, what they don't say, and why. And that interest in communication has shaped my career in many ways. I was a psychology major, and also took a course in medical sociology as an undergraduate at Harvard.

When I went to Harvard Medical School, I had the opportunity to take an elective in health insurance as a first year medical student with Professor Rashi Fein, who has since passed away, and Dr. Fein was a fantastic speaker, and he explained to us at Harvard Medical School that he had been in Washington in the 1960s at the time that Medicare and Medicaid were created. And none of us believed him at the time, but turned out to be true.

And I was absolutely fascinated by the concept of health insurance because here was a social construct that was going to influence the way that I was going to be able to deliver care to my patients. And I kept trying to get my classmates to talk about it, "You guys, we should talk about health policy. It is so interesting," and they were really focused on molecules, which was also valid.

And Dr. Fein lectured and lectured, but he did not really have a lot of discussion in his class. And so, I joke that my whole career has been a way to make up for the lack of discussion in Dr. Fein's health insurance class as a first-year medical student.

But then as a fourth-year medical student I had the next opportunity to pursue some of these interests. I am old enough to have gone to school at the time when the course catalog was still a paper document, and not a digital document.

And in the very back of the course catalog was a course that I enrolled in as a fourth year called, “HMO Management,” and it was taught by Carol Black. And Dr. Black, at the time, was a physician executive in what was then called Harvard Pilgrim Healthcare, now I think Harvard Vanguard.

Dr. Black allowed me to shadow her for the month on how to manage healthcare, and she gave me one assignment. She said, "Lisa, I want you to spend the month developing a program. Imagine that you are running a health plan like this one, and I want you to design an intervention that would prevent patients with asthma from coming to the emergency room unnecessarily," to prevent unnecessary asthma visits to the emergency department. This was in the spring of my fourth year of medical school.

And I looked at her with complete horror on my face. I said, "I'm about to graduate, and you're asking me a completely reasonable question, and there is nothing in my education that has prepared me to answer that."

I had spent four years learning how to take care of individual patients, and I had no idea how to take care of populations. And that omission in my education drove me further.

So, then I did an internal medicine internship and residency at Mount Sinai Hospital in New York, because I am from New York, and wanted to be here. And when I interviewed for residencies, I asked them, I said, "If I come here, will I be able to do health policy research here?" I did not really know what health policy research was, but I had a sense that that was my direction.

Mount Sinai was one of the places that said, "Yes." So, I went to Mount Sinai, and I developed an intervention to teach doctors in training how much patients were paying out-of-pocket for medications. This was at the time that Medicare Part D was being debated. And I loved it. I loved research, and I decided to do a research fellowship after my residency. I did my fellowship at Johns Hopkins in Baltimore where I was a Robert Wood Johnson Clinical Scholar, got a master's in public health, and learned both how to do research, and my MPH concentration was in health policy and management.

I should say that throughout my time in medical school, and residency, I always felt that whatever was happening between a patient and me in an office was somehow being influenced by these external factors like insurance, like healthcare policy that I could not control. Those influences were invisible in the room that I was examining the patient in, and yet I wanted to understand them more fully, and be able to shape them.

So, the Robert Wood Johnson Clinical Scholars Program gave me an opportunity to learn how to do what is called health services research. Health services research is a field that takes the tools of epidemiology and biostatistics, and applies them to healthcare.

We use those tools to understand quantitatively and qualitatively how we deliver healthcare, how can we improve it, and how can we generate generalizable knowledge for other people?

After my fellowship, I joined the faculty of Weill Cornell Medicine. I have been here for more than 20 years now. And I still love what I do. I do research, and I teach. I no longer see patients. For six years, I was on faculty, and I loved seeing patients, but there were some systems problems that got in my way when I was taking care of patients, but I loved talking to patients, I loved teaching.

I would say, "Mr. Jones, you had a heart attack. Do you understand what that means? Let me draw the heart for you on a piece of paper and explain it." And the nurses were always banging on my door because I was going too slowly seeing my patients. I never had enough time. I never had the chance to practice medicine the way that I wanted to.

And, again, those system factors were pressing in on me. And so, I decided to shift my focus to do research full-time and teach, and use my experience as a primary care doctor to shape the research that I was doing, and to try to do the research in a way that would inform policy.

Sacopulos: I am interested about the structural situation that caused the nurse to bang on the door, because it occurs to me that many of your colleagues would claim that that is towards the top of the list of causes for burnout.

Kern: Yes. I would say yes 100%. So, a lot of what I do involves thinking through how the structure around the doctor and the patient influence what they do, and how we pay for healthcare in this country is a huge factor that drives the problem that you have pointed to.

So, the nurse was banging on my door, because I was going "too slowly" because the institution was getting paid for each visit that I did, not for the quality of care that I delivered, not for the amount of satisfaction I gave my patients, but in order for most providers to stay in business, they have to see a certain volume of patients.

And this is a widely recognized problem. There have been some proposals to try to change the way we pay for healthcare to prioritize value over volume. I am not sure that all those proposals are going to work out the way they intend. But this idea that we have to see more patients faster is directly tied to how we pay for healthcare in this country.

Sacopulos: Many health systems pay their providers on RVUs, relative value units, which are a metric, for production, but yet are divorced from actual reimbursements. I would like your thoughts on physicians understanding what they are being paid for specific care versus having the care be commoditized in RVUs.

Kern: I can comment a little bit on that. Again, I have not seen patients for many years. So, it might be better to ask that for a doctor who is currently in practice, but RVUs are a way of capturing the units of care that are delivered.

I think in and of themselves RVUs are not the problem, but the concept of RVUs, but that the real problem is that the way the RVU system works, cognitive services are undervalued compared to interventions.

So, a doctor will get paid much more, a qualified doctor, a cardiologist would be paid much more to put a stent in someone's heart than to talk with a patient about how to prevent the need for that stent in the first place.

I am not the first person to say that this has been widely understood, but I think that it is not that the procedures are not important. People who do procedures have skills that are incredibly important, and are a key part of how we deliver healthcare. That is not the problem.

The problem is that the act of talking to patients, of being compassionate, of listening, of thinking about the whole person, and how all of their different diseases relate to each other, and coming up with a plan that includes respect for that person's preferences, that part is underpaid.

And so, that forces primary care doctors to be in a losing battle of RVU generation. Each visit is worth such an amount that the only way to stay solvent is to prioritize volume, and that I do not think serves patients well, and, certainly, does contribute to provider burnout.

Sacopulos: Let us drill down a little bit on your research, research into fragmentation of healthcare for ambulatory patients, specifically. Can you give me a high-level view of your research?

Kern: Sure. I have been a health services researcher for about 25 years now. But for the past 10 years, I have really focused my work on this problem of fragmentation of care. There are many types of fragmentation. I focus on fragmentation as it applies to the outpatient setting.

What I mean by that is a phenomenon in which patients see many different doctors in the outpatient setting, who may, or may not coordinate care with each other, and we call it fragmented when no single doctor accounts for, let's say, a majority of visits.

This is a particular problem for older adults, 65 and older, with Medicare insurance, because they may see many providers. If they have 10 visits in a given year, 10 outpatient visits, but every visit is with a different provider, let's say, or the most frequently seen provider only accounts for two, or three visits, it would seem to make sense that no doctor is really coordinating care.

Now let me be absolutely clear, so, I am not misunderstood. I use the word fragmentation of care to refer to a pattern of care. And I will repeat the definition, a patient has many visits with different providers, and no single provider has a majority of visits.

So, for a 10-visit pattern, there is nobody who has five, or more visits. That's, typically, what I mean by fragmentation. The way fragmentation can cause harm is through lack of communication among those doctors. And so, if we see a pattern where no provider has the majority of visits, we are concerned that that pattern puts people at risk for gaps in communication. It does not prove that there is no communication. It just means that there is a high risk of having more gaps.

My team and I have studied this with qualitative interviews of doctors and patients, we have done large-scale national surveys, we have analyzed claims data, which are the billing data of the services that Medicare pays for. We have measured this in a lot of ways, and what we have found is that fragmentation is extremely common, and it is potentially harmful. And patients recognize it, providers recognize it.

Yet there does not seem to be a lot of focus on how to solve this problem. And so, that is the area of research that I am currently working on, both trying to understand the causes of it, the consequences, how we measure it, and what we can do about it.

Sacopulos: Does fragmentation result in delay of care?

Kern: What do you mean by delay of care?

Sacopulos: Well, I am thinking that if someone were coordinating, care might be smoother, more sequential, and quicker than if it is left to the patient to try to coordinate with multiple different providers on their own. Is that fair?

Kern: Well, I am not sure that I have data to suggest that it delays care, per se, but I do have a project that I am working on now with funding from the National Institute on Aging. I have a grant, the type of grant is called an R01 mechanism, which will study whether fragmentation of care is associated with delays in the diagnosis of dementia, because it's possible that if your care is very diffusely spread across many doctors, that no single doctor is seeing you often enough to notice a change in cognitive status.

We also want to learn from this research whether the distribution of types of doctors you are seeing impacts the timing of a dementia diagnosis. So, that research is just getting underway, and I will have to get back to you with the results, which are not available yet, but we are doing a lot of work to try to understand how fragmentation impacts patients. We have some data so far, but there is more to learn.

Sacopulos: We will stay tuned for that. Can you speak to fragmentation of healthcare with respect to socioeconomics? Is it worse, or better in different socioeconomic brackets?

Kern: A very good question, and I do have data to use to try to help me answer that question. So, some people who I have discussed this with say, "Lisa, you should pick a different word other than fragmented, because fragmented has a negative connotation."

And I have tried to come up with other words like diffusion of care, but fragmented really does capture what a lot of patients are familiar with. So, I have used that, but I do want to clarify that it is not necessarily harmful.

I say that, because I went to do a study looking at socio demographics and fragmentation to try to understand exactly ... I have done a couple of studies. One study I did looked at whether fragmentation was different in Medicare, Medicaid, and commercially insured populations. People with Medicare, low-income individuals, so, that addresses some of the socioeconomic questions that you are asking.

So, we looked in one big county region, which presumably had the same set of doctors, was there more fragmentation in Medicaid? We also thought maybe there would be more fragmentation in Medicare, because other people thought, "Well, fragmentation must be just a proxy for severity of illness." Right? Sicker people have more doctors. That is what they thought.

So, I said, "All right. Well, let's test those hypotheses." It turned out that all three insurance types had the same extent of fragmentation. It was prevalent in Medicare, Medicaid, and commercially insured patients. It was virtually identical, and that was surprising to us, because we were expecting it to be higher in one group, or the other.

So far, our best interpretation was that fragmentation is just so baked into the way American healthcare is delivered that it is really not about how sick patients are. It is more about getting care here in this country.

Another study that we did that tried to look at that, I thought, initially, that if healthcare fragmentation were a bad thing, that we would expect to find it to be more common in Black Medicare beneficiaries than white, and in lower income people than in higher income, and lower education than higher education.

But it turned out, again, this is why being a scientist is so much fun, you learn from ... Even when your hypotheses are rejected, you learn what the truth might be.

So, what we found is that if you try to look at associations between these characteristics, meaning race, education, and income, and fragmentation, the income and education fall away. They are not independent predictors. But race was an independent predictor.

But it was the opposite direction of what I expected. I expected Black Medicare beneficiaries to have more fragmentation, and it was the opposite. It was less. And I sat on those results for a long time because I could not understand it.

And what we, ultimately, did is we dove deeper to see, "Well, who are they seeing? Why is it fragmented?" And it turned out that the Black Medicare beneficiaries had just as much primary care as white Medicare beneficiaries, but they were seeing fewer specialists.

And then it started to make sense as, "Oh, maybe the Black Medicare beneficiaries are not having access to the specialty care that they do need." So, at some point, there is either too much fragmentation, or not enough fragmentation. It can happen both ways. There has to be some sweet spot in the middle where you are seeing just the specialists you need, but not too many.

So, I don't know if that answer makes sense, but I think we've seen that there are some systematic differences in which segments of the population have fragmented care, and which don't, but it is more common in my work to find the conclusion that nothing actually predicts fragmentation other than the United States healthcare system.

There was another paper we did that looked at not only Medicare beneficiary level, I think we looked at something like 60 different possible predictors for fragmentation, and nothing showed up. It was just common for everybody.

And I will add one more thing, and then pause there, which is that we have found, though, that even if fragmentation is less common for, let's say, Black Medicare beneficiaries, when it does happen, it can be more harmful.

So, we have found that, for example, fragmentation is an independent predictor of emergency department visits. If you have highly fragmented care, you are more likely to land in the emergency room, even if we hold everything else constant, if we hold the chronic diseases that you have constant, all of that, it's an extra predictor probably because maybe your doctors are prescribing medications that don't go together, maybe they're not talking to each other about how best to manage things, and each doctor thinks the other person is in charge of doing it, and it goes unmanaged.

But we saw that that association between fragmentation, and emergency department visits happened for the whole study population we were looking at, but if you divided people into the Black Medicare beneficiaries and white Medicare beneficiaries, the magnitude of that association was much greater for the Black Medicare beneficiaries.

They were much more vulnerable to landing in the emergency room if they faced fragmented care. So, the situation is complicated, but so is American healthcare. So, I am not totally surprised, but there is still a lot of work that we can do to understand that, and improve this.

Sacopulos: Amen to that. Now it seems, to me, from what you just said that there is a bit of leaving the patient out of the equation, or maybe the patient's just not part of the equation if it is an across-the-board problem. Does that mean that solutions to fragmentation cannot rely upon patients?

Kern: No. I think solutions have to engage patients, and I have been writing about that in my work. We did a national survey of more than 7000 people, 65 and older, and we found that more than a third of them, 38% to be exact, 38% of this sample of 7000 people said, in various ways that we asked about it, "My doctors are not talking to each other." 38%. And this is what keeps me up at night.

Why is that okay? It is not okay. That is unacceptable. It is unacceptable. We should not have a healthcare system that leaves 38% of people thinking that their doctors are not talking to each other. Communication is critical in medicine. If you make decisions in medicine based on incomplete information, you are very likely to cause problems.

So, what I have been trying to propose is to say, "Well, gee, in the past, some other investigators have looked at ratings of patients, ratings of communication as a general marker of satisfaction. Are you satisfied with your care? Do you think your doctors are talking to each other?" And they will use it for some kind of scoreboard for a health system, or a practice to say, "Oh, we're doing well, or not well on these measures."

We need to use that feedback in real time to fix it. Don't just use it as a survey measure and go away. Say, "If your doctors aren't communicating with each other, tell us what is not being discussed that needs to be resolved. Is your cardiologist talking to your geriatrician? Is your neurologist talking to your urologist?" People need to be talking.

And so, I am trying to draw attention actually to the fact that patients and their caregivers, their family members, they are usually the first ones to know that fragmentation happens. They are also the first ones to recognize being at risk for harm from fragmentation, if two doctors are prescribing medications, and they have not discussed whether those medications go with each other, or not.

So, I think patients are a key part of future solutions.

Sacopulos: Well, what about patient records? Because it seems to me that fragmentation also is in the records. Right? And maybe that is what you are getting at by communication, that one provider cannot see his, or her colleagues' records, if they are on a different system.

Right now, we have a system where the records are kept by provider, but it does not seem to me that that naturally has to follow. The patients could themselves have control over their records. Would that assist with the harms of fragmentation?

Kern: You touched upon so many really important things. You are right. Right now, the way health records work is that they are visible to the providers. So, a provider inside one health system can see visits to other providers inside the same health system.

Sometimes they can access records in another health system, if, and only if that other health system uses the same vendor for their EHR as the first system, but right now even the most popular EHR vendor only accounts for about a third of the country. So, it is very common for people to get healthcare outside of their health system, and that care to be in a different medical record.

So, the problem you mentioned is very valid, which is also why I think that the payers have an opportunity to help with this problem. So, we talked about the patients being a key factor, but the payer is also no faster than the provider that it's happening, because if we have a patient at our health system who also gets care at another health system, the payer knows that, because they're sent the bills. The payer gets the bills in real time, and the payers might have a role to play in this solution.

Then you asked if it would make sense for patients to hold their own records. People have tried that. It has not worked very well yet. There was one organization about 20 years ago that tried to give patients the equivalent of their records on a USB drive thing, and they needed doctors to have certain USB readers in their office, and nobody would install the readers. And so, that initiative failed.

There have been other initiatives, bigger initiatives by Microsoft and Google Vault to put your medical records in. All those efforts have largely failed.

Healthcare is really complicated, and the other big part of my job is teaching master's students, if I can comment on that for a second, because I think it is related.

Sacopulos: Please.

Kern: So, I do teach medical students, but I also teach master's students in both the Weill Cornell graduate school of biomedical sciences, and Cornell Tech, which is an interdisciplinary graduate school part of Cornell University that brings together computer scientists and business leaders.

And one of the possible majors at Cornell Tech is health. So, you could want to get a job in the health sector, and leverage your skills in computer science and business, but many of those people do not have backgrounds in clinical care.

And so, I teach a course on healthcare organization and delivery to help educate the computer scientists who might be able to help us fix some of these problems, not just what I'm interested in, but what lots of doctors are interested in, and bridge those gaps, help translate back and forth between the language of clinical medicine, and the language of healthcare delivery, and engage non-clinicians in helping us to solve some of these problems.

Sacopulos: So, essentially, informatics for medicine. Is that fair to say?

Kern: Yes. Absolutely.

Sacopulos: You touched on third-party payers and how they often times have information globally faster than individual providers of a patient. And it seems, to me, that there is a lot of anger with third-party payers these days. And a really shocking turn of events, as you will recall about six months ago, an executive with one of the larger third-party payers in the United States was gunned down in New York City.

As shocking as that was, to me, the more shocking thing happened next, which was a large public support for the alleged murderer. It seems, to me, that that is a window into people's anger with third-party payers. And does that really speak against their use for resolving problems with fragmentation and patients' trust in their third-party payers?

Kern: I am guessing that some of the patient anger is about denial of payment for certain healthcare services, which is not the focus of my work. But what I do in my job is I teach medical students, and graduate students about the history of American healthcare, and how we got here in terms of being a multi-payer country.

I teach them that no one quite intentionally designed our system this way. In other countries, they have a Minister of Health, they have a centralized government that says, "Okay. This is the size of our population. This is, therefore, how many doctors we need, what the size of the budget is," I am not saying that is better, or worse than what we have. I am just saying it is different.

We don't have that. We have a very decentralized non-system, and the evolution of private payers in this country is longer than the evolution of the public payers. Right? We have had private payers in this country since the 1930s. We have only had Medicare and Medicaid since the 1960s.

I cannot speak to, specifically, the circumstances, but I can say that we don't talk enough about how our healthcare system is designed or not designed. Right? No one seems to know the history of how health systems came to be, how health insurance is delivered the way that it is, and I think we need more national conversations about that.

I will say that something else I teach my students is that sometimes the health insurance debate gets boiled down into what I think is a false dichotomy. You can say ... Well, some people debate whether healthcare is a right, or a privilege. I think that dichotomy gets us nowhere. Some people will always say it is a right, and some people will always say it is a privilege, and the debate stops there.

I would rather reframe it as what kind of country do you want to live in? Right? How can we design healthcare, so that it delivers what we want? Which path is going to get us there? Whether that means that we have ... There are all kinds of policy options that can flow from that premise. Right? But it opens up the dialog to say, "Let's start over." Not literally, we cannot literally start over, but let us, as an exercise, imagine what kind of ... Or how do we want to pay doctors? How do we want to think through how many different healthcare organizations we have? Who should communicate with whom? Whose responsibility is it to communicate in the first place?

And really recognize that what we are living in is a human-made system. This is not biology. This is designed by people. And that means it can be changed. So, I think we need more dialog about more awareness about the fact that the way healthcare is designed in our country is somewhat a historical artifact. This is just the way it evolved. Maybe we need more deliberate restructuring based on how we think it should go.

Sacopulos: Well, asking those kinds of questions and addressing those issues are, clearly, what make you a physician leader, and why we need other physician leaders at the forefront of these discussions.

Our time is drawing to a close, and based on what you just said, I would like you to talk about whether, or not you are optimistic about healthcare delivery in the future for our country, and where you see us going.

Kern: Well, I think I try to channel my energy into teaching students, both medical students and computer science, business students, because, clearly, what we've done so far isn't reaching all of the goals that I think the American people want, and I think that we need more conversations like this across disciplines to discuss how we want to shape healthcare, more discussions that remove false dichotomies, more discussions about what kind of country do we want, and how can we shape the policy to achieve those goals?

I think there are a lot of new things on the horizon that we do not quite know what to do with yet, like AI in medicine, and all of that. That is going to be another huge hurdle, and I think that is also another great example of where we need interdisciplinary dialog. We need conversations between the computer scientists and the clinicians about how we are going to handle artificial intelligence, and when we are going to use it, and how.

So, I think interdisciplinary conversations are really critical for the future of medicine.

Sacopulos: Well said. My guest has been Lisa Kern. Dr. Kern, thank you so much for your time, and your leadership on some very important issues for our country. Thank you.

Kern: Thank you for having me.

Listen to this episode of SoundPractice .