Experiencing Canada’s healthcare system firsthand gave Dr. Michael Apkon an interesting vantage point from which to assess the U.S. model. Apkon served as CEO of the Hospital for Sick Children in Toronto from January 2014 until the fall of 2018 when he returned to the U.S. to become CEO of Tufts Medical Center and Floating Hospital for Children. He previously served as chief medical officer at Children’s Hospital of Philadelphia and executive director of Yale New Haven Children’s Hospital in Connecticut. He recently spoke about the differences between the two nations’ healthcare models with Modern Healthcare Managing Editor Matthew Weinstock. The following is an edited transcript.
MH: You heard about the Tufts job in an interesting way, right?
Apkon: I did. I learned that the opportunity had been created from my daughter, who at the time was a first-year medical student at Tufts School of Medicine. She read about the former CEO moving to a role at (Wellforce, Tufts’ parent organization) in the Tufts Daily. She texted me from the classroom asking whether I had any interest in coming back to Boston.
MH: What was it like when you got that text?
Apkon: We shared a laugh.
I wasn’t necessarily actively looking for another opportunity. It kind of sat on the shelf for a few weeks or even a few months until the recruiting firm reached out to me.
MH: Being back in the U.S. delivery system for a year, has anything surprised you?
Apkon: In terms of the organization, I wouldn’t say I was surprised, but I was pleased to learn more about the role the medical center plays in delivering some of the most complex care in New England. We have the highest case mix index of any hospital in New England despite being one of the smaller academic medical centers. In terms of the broader system, I was surprised how little has changed over the last five years despite a two-decade dialogue around the conversion from volume to value.
MH: In terms of the national debate, what does your experience in Canada tell you about where the U.S. is and where we need to go?
Apkon: Going to Canada, my orientation was very much built around the role of the marketplace and driving innovative approaches to care and using the competitive environment to try to fuel the development of better systems.
As a provider, I was skeptical of the role that government could or should play in driving the evolution of the healthcare system. Having been in Canada, I had the experience of working in a system that, for all intents and purposes, has a single payer; where people have universal coverage, with the exception of recent immigrants. And there is minimal if any financial burden for people who need care from physicians, hospitals or other associated services—imaging, laboratory, that kind of thing. What I saw was the impact that has on the ease of the access, the quality of the outcomes and the social justice of the system.
Before I went to Toronto, I was the chief medical officer at the Children’s Hospital of Philadelphia. Our hospital provided advanced pediatric care. At the time, I think we had 13 community hospitals where we did all the neonatology and emergency care. It was not rare to be in a situation where our neonatologists in an outlying hospital were caring for a newborn with, for example, congenital heart disease who needed major surgery … but we could not accept a patient because they didn’t have insurance that we accepted or the out-of-network costs to families would be prohibitively expensive.
The moral distress that creates when you know you’re the best place to care for a child and those barriers are there because of the way the system is constructed, those were issues that I never faced in Ontario. In fact, if a child was born in Nova Scotia or Manitoba or British Columbia, and (the parents) felt that the surgeons at the Hospital for Sick Children in Toronto were the best to do their baby’s cardiac surgery, we would find a way to get them there and they would get their care without a copay, without a bill, without any real questions asked. That was independent of where you were on the socioeconomic scale.
MH: Some form of single payer is probably unlikely here over the next few years, but the debate over affordability and access are looming large. How does your experience inform how you advocate for change?
Apkon: I don’t believe that a single-payer system is the only option. And I don’t believe that there’s an easy path to a single-payer system in our country anyway. There are a lot of people employed; there’s a lot of capital invested in healthcare. There are a lot of large companies with political capital, a lot of provider organizations with a lot of political capital. The interest in preserving the status quo is very significant. We have to recognize that. We have to figure out what it is we’re trying to achieve. And we have to be realistic about the role of the architecture of our system in creating some of the undesirable effects that we see.
What I came to appreciate in Canada … is that there are things that markets are just not built to do. They’re not built to provide care to people who can’t pay.
The fiduciary responsibility for the insurance companies is to create a return for their investors. The fiduciary responsibility for a hospital CEO or a physician practice CEO is to ensure sustainability of the organization, which means addressing the bottom line. It doesn’t matter whether you’re a not-for-profit or a for-profit entity. There is a certain amount of margin that you have to make and it’s not easy to make that margin in the face of escalating labor, pharmacy and other supply costs.
MH: Short of wholesale change, are there things that U.S. providers can do to address these issues?
Apkon: We are doing things that help, but if the providers are honest about it, we’re working more at the margin than in the middle.
We have two accountable care organizations where we have integrated the risk. And I do think that those integrated settings … have the inherent motivation to do things differently. So the Kaisers, the Geisingers, those of us with ACOs are motivated, but the truth is between two ACOs we have 100,000 covered lives out of half a million or more people that we touch every year.
It’s a small population. And the administrative complexity makes it difficult to build systems because it’s not easy to pull out those 100,000 people who are in two different ACOs, one administered by Medicare and the other by Medicaid, and figure out how to treat them and manage them in different ways, and to do it within the ground rules that have been set up within the ACOs.
MH: How do market dynamics influence your ability to home in on social determinants?
Apkon: There’s a similar issue with the social determinants, because who is going to invest in addressing the social determinants of poverty, homelessness, educational barriers? Markets really are not built to do that. What you see very clearly is the best predictor of overall health of a population is not healthcare spending, it’s the combined healthcare and social-care spending.
MH: But increasingly, the industry is being asked to address these issues.
Apkon: They’re taking it on at the margin, right? So they’re taking it on for the patients they care for where they might be able to mitigate future costs. And that’s a good thing.
We’re doing some of that too. We’re partnering with the homeless shelters and we’re partnering with organizations like community servings that do medical prescribed meals. We’re doing a lot of those activities—intensive case management that’s working to try to address social determinants and transportation services. It’s reactive though. What I saw in Canada is a much greater degree of integration in the thinking between the healthcare and the social-care systems because they both came out of the same budget.
MH: Along those lines, Massachusetts Gov. Charlie Baker last month introduced legislation that would boost spending on addiction services, behavioral health, primary care. What are your thoughts on that bill?
Apkon: I applaud Gov. Baker and the Legislature for considering a bill that raises spending in primary care, mental health, addiction services. All those are very much needed. And I think it is a testament about the importance of those issues, but also a recognition that the market won’t take care of it on its own.
It’s not that people aren’t doing the right thing. Organizations like ours, like the insurance companies, again, what is their fiduciary responsibility? It’s not that we’re financial driven; the fiduciary responsibility is social impact through care delivery. But the only way we can do that is to be sustainable. So finances, whether you’re for-profit or not-for-profit, end up being a critical success factor. And there is only so much charity care that an organization can do. Now it does beg the question, what’s a reasonable margin?
I don’t want to come across as totally negative about (the U.S.) system. What I think is really important is that the quality of care at the bedside, whether that’s in primary care or in hospitals or in the home, has never been better. Our capability in medicine has never been better. I also think the level of innovation that we’re seeing … has never been greater. The amount of capital going into fueling new approaches has never been greater. So this is a good news story in general.