From Our CEO: Is Health Care Upside Down?

Patient-Centered Care Becoming Difficult to Achieve as Complexity Evolves

 As free-market forces adjust in response to federal influences toward value-based care, an ongoing challenge becomes how physician leadership supports the industry in maintaining focus.

As I wrote this column, a major merger in the industry was announced that caught our attention and caused a shake of my head — a major pharmacy chain was buying a major health insurance company. Yes, we are all quite aware that merger/acquisition activity in our industry is at an all-time high. And while I am not generally an alarmist, nor politically motivated in my commentaries, this particular acquisition, from my perspective, seemed to be different from what I would have expected. A reverse order of acquisition, if you will.

peter angood

Peter Angood

According to language of the Dec. 3, 2017, news release:

“CVS Health, a company at the forefront of changing the health care landscape, and Aetna, one of the nation's leading diversified health care benefits companies, today announced the execution of a definitive merger agreement under which CVS Health will acquire all outstanding shares of Aetna. …

“This transaction fills an unmet need in the current health care system and presents a unique opportunity to redefine access to high-quality care in lower cost, local settings whether in the community, at home, or through digital tools. …

“This is a natural evolution for both companies as they seek to put the consumer at the center of health care delivery. CVS Health has steadily become an integrated health care company, and Aetna has moved beyond being a traditional insurer to focus more on consumer well-being.”

The language of the announcement initially sounds altruistic and seemingly patient-centered — but is it? As you reread the statement, however, you will recognize there is only mention of consumers, and not patients.



CVS HEALTH: CVS Health is a pharmacy innovation company helping people on their path to better health. Through its 9,700 retail locations, more than 1,100 walk-in medical clinics, a leading pharmacy benefits manager with nearly 90 million plan members, a dedicated senior pharmacy care business serving more than one million patients per year, expanding specialty pharmacy services, and a leading stand-alone Medicare Part D prescription drug plan, the company enables people, businesses and communities to manage health in more affordable and effective ways. (Source:

AETNA: Aetna is one of the nation's leading diversified health care benefits companies, serving an estimated 44.6 million, at September 30, 2017, people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers' compensation administrative services and health information technology products and services. (Source:

CVS Health President and Chief Executive Officer Larry J. Merlo further stated:

“This combination brings together the expertise of two great companies to remake the consumer health care experience. … [We] look forward to working with the talented people at Aetna to position the combined company as America's front door to quality health care, integrating more closely the work of doctors, pharmacists, other health care professionals and health benefits companies to create a platform that is easier to use and less expensive for consumers.”

In the same release, comments from Aetna CEO Mark Bertolini similarly were oriented to consumers. Another phrase from the release stated:

“… capabilities developed following this transaction will directly benefit clients of both companies and enable them to better manage their health care costs.”

Again, no patients, or even people, are mentioned in these phrases.

To be fair, there is a segment in the news release that occasionally mentions the word “patient” when describing “benefits for consumers,” but the preponderance of language is focused on the financial aspects of the deal and “benefits to shareholders.” As I delved deeper into the news of this acquisition, I noticed even the rhetorical language used within the descriptions of their respective companies (see Table 1) created another moment of pause in my thinking.

It was a wake-up call for physician leadership.

A Big Flipping Deal

Certainly, the sheer size of these companies alone is able to create significant influence, but is it the correct influence? How far have we drifted as an industry from physician leadership as the primary driver for patient-centered care? And with this example of the free market at work, have we become upside down in our thinking on where the influences for patient-centered care are best generated?

Drawing a comparison between being upside down in the financial markets and the physician workforce’s influence on patient-centered care might be a stretch, but the fundamental concept is not far off. Doing what is best for patients, and doing so in a caring, compassion-ate fashion with open communication, is what physicians value as a highest priority. This value also is a core asset within health care.

upside down (adj.) — A situation in which one owes more on a loan used to pay for an asset than that asset's current market value. ... Negative equity is most common after the burst of an asset bubble. One with negative equity is said to be upside down in the loan.

I do not believe the asset bubble of physician leadership in health care, nor the attendant physician influence on patient-centered care, has (or is about to) burst. In fact, I believe strongly that the opposite is the scenario we are facing. There is an ongoing demand in the marketplace for strong physician leadership, and our association is continuing to build the programs, products and services that will be more readily needed in the marketplace.

Yes, mergers/acquisitions such as CVS-Aetna will catch our attention. But, still, there was language in the news release excerpts in this column that asserts the importance of physicians.

As stated, the deal “… positions the combined company as America's front door to quality health care, integrating more closely the work of doctors, pharmacists, other health care professionals … .” The recognition that physicians, working in an interprofessional, team-based environment, potentially can come together in a new platform represented by this acquisition is intriguing. But only time will reveal the successes or failures of the new company — and its influence on health care delivery.

The critical issue in my mind is that we all continue to promulgate the importance of physician leadership — at all levels of the delivery system — and that we also continue to work closely with the various sectors of our industry to further promote the benefits of patient-centered care and shared decision-making with patients. If we do not continue to pursue this aspect of health care, then we run the risk of an excess of nonclinical influences pressuring the core of health care in a potentially negative fashion — and end up “upside down.”

What Are We Doing?

Our clinical workforces already struggle enough as it is with anxieties, frustration and burnout that often are related to the complexity of delivery systems. Beyond addressing the issues related to workforce fatigue, system complexity and eventual burnout, being able to help our workforces remain focused toward a higher purpose will help support better morale as well. As physician leaders, providing this ongoing focus on the essential components of the industry is an important endeavor for us all as we continually help others to achieve improved professional satisfaction.


Sirsasana, or headstand, is a yoga pose purported to have numerous health benefits. It is known as a cooling posture, meaning that it helps you to draw your attention inward. If done properly, it is said to be healing and has the following health benefits:

  1. Relieves stress.
  2. Increases focus.
  3. Improves blood flow to the eyes.
  4. Increases blood flow to the head and scalp.
  5. Strengthens shoulders and arms.
  6. Improves digestion.
  7. Helps to flush out the adrenal glands.
  8. Decreases fluid buildup in legs, ankles and feet.
  9. Develops strength in the core muscles.
  10. Stimulates the lymphatic system.


While I occasionally practice yoga in my advancing age and enjoy its many benefits, being upside down is not one of them. As someone who expertly knows biology and physiology, expounding (somewhat tongue-in-cheek) upon a Top 10 list for being upside down (see Table 2) provides me with a chuckle. A purpose of the metaphor is, however, that if we are not careful, the dominant influences on true patient-centered care gradually will slip from the purview of physicians and other concerned clinical disciplines. A net result is that our industry becomes further upside down with its priorities, the messages become convoluted (like in the Top 10 list), and our clinical workforce becomes more disgruntled with an eroding influence in light of decreasing clarity of purpose.

As physicians, we must continually seek how to optimize patient-centered care in the face of ever-increasing complexity. We also must continue to seek how our role as the natural, intended leaders in the health care system can be further leveraged in the face of competing priorities as set by free-market economies. Proactively helping others, as physician leaders, to stay focused on true patient-centered care is a critical component of our professional responsibility — in fact, it has been a professional responsibility since our beginnings.

I encourage all of us to continue seeking deeper levels of understanding and to generate influence at all levels to which we are individually comfortable. As physician leaders, let us get more engaged, stay engaged and help others to become engaged. Creating a broader level of positive change in health care — and society — is within our reach.

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