The Big Question: Is there Harm Reduction in Healthcare?

Last week, my therapist (#normalizementalhealth) ended our session with a challenge. “Peter,” they said, “this week, I want you to write down everything that you think makes your life hard.”

My immediate response was, “Well, everything at the moment.” My therapist replied, “No. Be more specific.”

So I tried again. “OK fine. Maybe not everything, but many things, for sure.” After a swift shake of their head, my therapist again instructed me to get more granular.

I rolled my eyes (as I am wont to do when someone is making me do a thing I don’t particularly want to), and consented to the assignment. Then I very quickly ended the Google Meets video call for everyone so that I could not be given any other task for the week. (After I said, “Goodbye,” that is; I’m not that rude.)

Throughout the week I kept my eyes peeled for things that really made my life more challenging than it needed to be. I did my best to overlook the minor annoyances and the slight inconveniences (of which there are many). And to the surprise of no new parent, the first thing I found to add to my list related to my infant child: finding them healthcare.

There are many challenges I faced (and will likely continue to face) in providing healthcare coverage for my child. I won’t go into the sordid details in this article, but the highlights include:

1. My child is adopted, and, as the process is not finalized yet, I lack the exact documents insurers require to prove dependency;
2. I buy healthcare coverage from a Marketplace plan, and there is a lack of clarity on what I use the Marketplace versus the insurance company for; and
3. While my current plan is backed by one of the largest insurers in Illinois (and that means everyone accepts their plans), that does not mean everyone accepts all of their plans.

The short version of my story is this: my insurance plan covers my child (I think); we have our next appointment with a provider who (we’re pretty sure) accepts my Marketplace plan; and I have until November to provide my insurance plan with their required documents to prove my child is my dependent. The problem is that the adoption won’t be finalized by that date so we will still be without that proof; so we’ll see what happens then.

All of this got me thinking (again) about our healthcare system.

I consider myself a relatively savvy consumer of healthcare. So much so, in fact, that I spend my career helping various actors within our health infrastructure tackle the #wickedproblems of delivering care within our country. However, the most recent healthcare activity I had to engage in (read: buying coverage for my child) resulted in no less than three (3) not insignificantly-sized issues that will likely take me months to fully resolve.

I am privileged in that I can tackle those issues, or at least I have fallbacks (economic and social) that protect me and my family from the full potential consequences of any missteps. But what about those who don’t (of which there are many in this country)? What about those who aren’t able to take an afternoon off to call the federal government or their insurer to add a child to their plan? What decisions must some people make between addressing the need of health insurance over any other possible immediate need, such as housing, food, personal safety, employment, etc.?

This led me to thinking a little more critically about the role and function of bureaucracy.

THE PRACTICE OF BUREAUCRACY

We put a lot of bureaucracy between people and their healthcare: employment, redetermination, the ever-changing and wild world of telehealth reimbursements for providers, and the direct costs of healthcare, just to name a few. These barriers exist because:

• someone needs to hold the financial risk related to providing healthcare to disparate individuals, and we need to know how to follow the money;
• we absolutely cannot provide a publicly-funded healthcare service to someone without providing beyond a reasonable doubt that they cannot provide it for themselves (please note my sarcasm here); and
• healthcare, despite legislators, health systems, insurers, and pharmaceutical companies trying to tell us otherwise, is not a free market.

Simply put, bureaucracy functions as a mechanism not only for administering benefits, but also (fundamentally) of restricting access to, and utilization of, care.

We justify these byzantine infrastructures within and across healthcare as necessary to promote the benefit of the patient. And, while that can be true it is not a given, and enhancing the patient (or provider) experience or outcome is certainly not a natural or inevitable function of such systems. Instead a primary function (and outcome) is one of gate keeping, and protecting the financial resources and returns of the administrative entity.

This is not only true for commercial insurance (although, again, it is absolutely true for commercial insurance), as evidenced by bureaucratic requirements for Medicaid administration. Having to continuously provide proof that you are eligible for Medicaid services was found to be a contributing factor to millions losing coverage. Perceived costs of coverage prevent another group of potential patients from even seeking insurance to begin with. (And yes, cost is a bureaucratic factor.) On the provider side, bureaucratic tasks are the driving factor of burnout for 60% of providers.

The administration of health services reflects what we truly prioritize. If we really did put patients first, I suggest there would be fewer barriers to delivering and receiving care; reflecting, perhaps the harm reductionist practices we’ve already started implementing in other sectors.

WHAT’S THIS ABOUT HARM REDUCTION?

For those unfamiliar with the practice, harm reduction is “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction is also a movement for social justice built on a belief in, and response for, the rights of people who use drugs.” I know – healthcare is larger than drug use. But much like we (should have) applied lessons learned from our decades of HIV prevention and treatment to our work regarding COVID-19, so to should we more fully adopt harm reduction into our general delivery of care.

And yes, I do mean, “more fully adopt” and not “begin to adopt.” We do have components of our healthcare infrastructure that reflect some of the principles of harm reduction. For example:

• Harm Reduction Principle #5: Ensures that people who use drugs and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them. If you have ever been asked to create, facilitate, or participate on a Community or Patient Advisory Board, you are helping to embody this principle. Agencies receiving Ryan White funding are required to have Community Advisory Boards to gain input from the patients they are serving. CMS’ ACO REACH model requires both a consumer advocate on the governing body, as well as a Medicare beneficiary. Many Medicaid programs across the country require patients to sign off on their care plans.
• Harm Reduction Principle #7: Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm. There has been increased movement across our healthcare infrastructure to identify, understand, and address realities of everyday life that regularly impact a patient’s ability to engage with care. Oftentimes called “social determinants” or “social factors,” we are now making concerted effort to integrate these non-clinical aspects of our patients’ human conditions into how we help achieve and maintain health. North Carolina is piloting the use of Medicaid funds to address these factors. (And we have talked previously about the value of doing so in our Medicare Advantage populations.)
• Harm Reduction Principle #4: Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm. With all of the bureaucracy we put between people and healthcare, it is easy to become cynical and assume we do cast judgment on a person before allowing them access to what the United Nations considers a basic human right. But there are places where a person can walk in and receive care, regardless of whatever happened before passing through the doorway: community health centers. One of the fundamental principles of the community health center program is to “provide services regardless of patients’ ability to pay and charge for services on a sliding fee scale.” (Health systems may say they are similar, but they are only required to stabilize a patient, and that is a very different thing).

HARM REDUCTION AS AN INTERVENTION ON HEALTHCARE

I’ll give it to you – the correlation between Harm Reduction Principles and our healthcare industry is not an exact match; but understanding harm reduction as an intervention on our delivery of healthcare is a paradigm I argue is still worth exploring. Imagining a healthcare system where one can show up, as is, and receive care directed at their needs and delivered when and where they are most able to receive it may sound lofty. But perhaps that is only because of how the actors currently in charge of healthcare are trying to make us understand what the best practices are for delivering care.

None of us can single-handedly reform healthcare. And no single solution (despite the perpetual allure of the “silver bullet”) will address the defects of our system. But we can each take the time to reconsider how we are acting within the industry to better reduce the harm of an industry that withholds care from so many.

I put it to you: less time waiting on hold with insurance companies or collecting and recollecting certifications for eligibility may seem only one step forward for (this) man, but it would reflect a much needed leap forward for mankind.