Clinical Innovators | Improving Care Through Technology, Policy, and Philanthropy: An Interview with David Blumenthal, MD

By Katlyn Nemani, MD

David Blumenthal, MD, is president of the Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy issues. Dr. Blumenthal is formerly the Samuel O. Thier Professor of Medicine at Harvard Medical School and Chief Health Information and Innovation Officer at Partners Healthcare System in Boston. From 2009 to 2011, he served as the National Coordinator for Health Information Technology, where he succeeded in putting in place one of the largest publicly funded infrastructure investments the nation has ever made. Previously, Dr. Blumenthal was a practicing primary care physician, director of the Institute for Health Policy, and professor of medicine and health policy at Massachusetts General Hospital/Partners Healthcare System and Harvard Medical School. Dr. Blumenthal received his undergraduate, medical, and public policy degrees from Harvard University and completed his residency in internal medicine at Massachusetts General Hospital.

You have had a professional career that has ranged from primary care clinical practice to government service to health policy research, and now, to leadership of an important health care philanthropy. What has motivated your extraordinary career?
This is a very kind characterization of my career, but whatever I have accomplished was motivated by a series of influences. First, my father, who fled Germany as a teenager in the 1930s to the safety of the United States, instilled in my brother and me a deep appreciation for the value of public service, the capacity of government to be a force for good, and a deep gratitude for what the United States offers immigrants forced to find refuge in another land.

Second, I grew to political awareness during the presidency of John F. Kennedy, who inspired many in my generation to find ways to be of service and convinced many at the time that work in government could be a noble calling. Such attitudes are not fashionable now, but I still believe in their fundamental importance.

How did you begin your path to government service?
I was a government major as a Harvard undergraduate, and when I went to medical school, I always knew that I wanted to seek opportunities to work on public policy issues. During medical school, I took an extra year to get a Master of Public Policy degree at Harvard’s Kennedy School of Government. Exposed at a graduate level to the disciplines of economics, political science, management, statistics, decision science, and quantitative analysis, I became interested as well in academics, so intellectual curiosity led me, when opportunities later arose, to conduct research at the Kennedy School and later at Massachusetts General Hospital (MGH), and Harvard Medical School. As a primary care physician at MGH, I was fortunate to find a professional home at an eminent academic institution that valued primary care and the other work I did on health care policy. A long-time love of writing also helped me feel at home in the world of academics.

As time went on, I had the opportunity to serve in a variety of roles that I regarded as public service of one type or another: primary care practice, nonprofit health care management, academics at the Kennedy School of Government and Harvard Medical School, and government service in both the executive and legislative branches of the federal government. My current role in health care philanthropy is simply a natural extension of these past involvements.

As president of the Commonwealth Fund, you serve as an important advocate for health care reform. What do you see as the greatest threats to achieving that reform?
The greatest threat to successful health reform is the unprecedented politicization of the Affordable Care Act (ACA) and everything related to it. In particular, the identification of the ACA with a single president, his legacy, and his party has made it the centerpiece of partisan warfare at a fraught time in American politics. Clausewitz said that war is the continuation of politics by other means. The debate over the ACA has become the continuation of the 2012 election by other means.

The facts around the ACA and its implementation have become weapons in this partisan warfare, and are obscured by the fog of political combat. And it is impossible to make the technical corrections that would normally occur after passage to correct flaws that are inevitable in legislation of this complexity. If the ACA succeeds, it will do so under the most adverse political circumstances imaginable.

The Commonwealth Fund frequently considers American health care policy in a global context, providing important international comparisons. What do you see as special about the United States health care context?
Cross-national comparisons conducted by the Fund highlight the many ways in which our system lags other countries in the developed world. Our report, Mirror, Mirror, compares the health systems in 11 industrialized countries, and we have repeatedly found that the US system ranks last on composite measures of quality, efficiency, and access to services. These reports have exploded the myth that we have “the best health system in the world.” We spend at least double the amount on health care per person of any other developed nation, and we perform less well on measures of health and longevity, a finding also documented by the Institute of Medicine.

We are unlikely to ever import wholesale the systemic approaches of other countries.  But their examples serve as concrete, real proof that we can and should do better. Perhaps the most important way to start improving our system and lifting our lagging performance is through improving access to care.  The United States certainly has some of the best physicians, hospitals, and health systems in the world. But those valuable resources are not available to every American. And, in fact, too many people in this country do not have access to health care at all. Recent reforms are beginning to make inroads into this problem. Commonwealth Fund surveys have demonstrated that between October 2013 and April 2014, 9.5 million uninsured Americans gained health insurance, mostly because of provisions of the Affordable Care Act.

You are one of the leading scholars on health care policy and the presidency. Why was President Obama able to achieve what none of his predecessors could?
For a full answer to this question, I refer readers to the preface of the paperback edition of my book (with co-author James Morone), Heart of Power:  Health and Politics in the Oval Office. This volume recounts efforts by presidents from Franklin D. Roosevelt to George W. Bush to manage issues of health care coverage and access. President Obama and his team benefited enormously from lessons learned from the few successes (such as the passage of Medicare and Medicaid during the presidency of Lyndon Johnson) and many failures (such as the Nixon, Carter, and Clinton national health plans) of his predecessors. If “right” means things that make the difference between success and failure in passing national health reform, there are a few things that Obama did right.

First off, he cared passionately about it and made it his first domestic policy priority. He risked his presidency and his legacy for health care reform. He acted quickly and early in his first term, when his political capital was greatest. He laid out strong, clear principles for what kind of plan he would accept, but left the drafting to Congress, so that it would own the result. Within the administration, he left the policy details to his expert staff, and concentrated on the politics of passage, which is the key contribution a president can make.

Perhaps most importantly, he didn’t give up. When the bill’s prospects looked darkest, right after the election of Republican Scott Brown ended the Democrats’ filibuster-proof majority in the Senate, he pressed on. He was willing to lose rather than surrender. Eventually, House Speaker Nancy Pelosi and Senator Majority Leader Harry Reid found a way to get around the filibuster.

Let’s talk about your role in health care reform as the National Coordinator of Health Information Technology from 2009–2011. What is the role of health information technology in supporting our nation’s health care reform efforts?  Is the one necessary for the other?
Health IT is necessary, but not sufficient, to ensure that our health care system achieves its full potential. To get the best out of health IT, we need to reward its best and highest uses. Put another way, if we reward the wrong thing, we shouldn’t expect health IT to produce the things we want and value. If our payment system encourages upcoding, health IT has the capacity to facilitate that. If the payment system rewards volume, not quality, then the quality advantages of health IT will go unappreciated, and its negative effects on throughput will be resented. If the health system rewards improving patient outcomes and efficiency, then health IT can provide invaluable assistance in achieving these goals.

You have often spoke about your hope and vision that clinicians would one day be “delighted” to use their electronic medical records. Are we there yet?
We are not there yet, but we are making progress. Surveys already show that the great majority of physicians see the value of current electronic medical records, even though they wish they were easier to use. Under pressure from users, vendors will improve the usability of records over time and will increasingly adapt them to more user-friendly devices, such as iPads and iPhones. This is an ongoing process, comparable to the maturation of the PC itself from a clunky, large desk top to the light and usable devices and software that we now enjoy. I am also confident that a new generation of young health professionals will find the electronic world much easier to navigate than my generation has.

Katlyn Nemani, MD, is from Tufts University School of Medicine in Boston.

Keywords: Health Policy, Medical Informatics, Electronic Health Records, Federal Government, Developed Countries, Investments, Medicare, United States, Health Care Reform, Health Services Accessibility, Medicaid, Physicians, Primary Care, Reward, Patient Protection and Affordable Care Act, Universities, Institute of Medicine (U.S.), Financial Management, Internship and Residency, Medically Uninsured, Schools, Medical, Emigrants and Immigrants, Internal Medicine, Primary Health Care, Hospitals, General

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