{"id":16849,"date":"2025-03-28T15:44:26","date_gmt":"2025-03-28T19:44:26","guid":{"rendered":"https:\/\/www.uri.edu\/magazine\/?p=16849"},"modified":"2025-03-28T15:44:27","modified_gmt":"2025-03-28T19:44:27","slug":"its-complicated","status":"publish","type":"post","link":"https:\/\/www.uri.edu\/magazine\/issues\/spring-2025\/its-complicated\/","title":{"rendered":"It’s Complicated"},"content":{"rendered":"
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Navigating Health Care.<\/h1>\n\n\n\n

It’s Complicated.<\/p>\n\n<\/p><\/div><\/div><\/div><\/section>\n\n\n

If you\u2019ve had to find a primary-care provider or pay a medical bill lately, you know that accessing and paying for health care can be very difficult. But why? What are the biggest problems? And how can we get the care we need in such a system?<\/span><\/p>\n\n\n\n

By Patrick Luce \u201999<\/em><\/p>\n\n\n\n

When the CEO of one of the largest health insurance companies in the United States was gunned down on a midtown Manhattan sidewalk in December, the public reacted with anger and exasperation, not a surprising response to such a brazen attack.

What was surprising was the target of that public ire.

In this case, the vitriol normally reserved for the perpetrator was largely directed at the victim, UnitedHealthcare CEO Brian Thompson, and all he represented: the most expensive health-care system in the world\u2014a for-profit system that is complicated and inaccessible to many; a system that, ultimately, leaves many behind.

The universal right to health care is ingrained in many industrialized nations, but that is not the case in the U.S. More than 70 percent of U.S. adults feel the health-care system fails to meet their needs, according to a 2023 Harris Poll conducted with the American Academy of Physician Associates. The poll found 54 percent of Americans think the health-care system is going in the wrong direction, more than 25 percent feel it is completely broken, and 26 percent grade the system with a D or F, while just 10 percent give it an A. Those from traditionally underserved communities have a worse view. U.S. News & World Report<\/em>\u2019s State of Equity in America conference found that 75 percent of Black Americans believe their race negatively affects the care they receive.

More than a quarter of people polled cited cost and poor access to care and insurance as the key problems in the U.S. system. Even those with insurance say it\u2019s difficult to get treatment, largely due to a shortage of primary-care providers. One-third say the health-care system does not meet their needs because it takes too long to get an appointment.

These problems add up to a worldwide ranking that is dead last among the top 10 wealthiest nations, according to a survey by the Commonwealth Fund, an international organization that promotes equitable health-care systems. Of the five categories measured in the survey, the U.S. ranks last in access to care and health outcomes, and ninth in equity and administrative efficiency. The American system performed well in just one category\u2014care process\u2014ranking second, largely due to its emphasis on preventative services like mammograms and vaccinations.

\u201cEspecially concerning is the U.S. record on health outcomes, particularly in relation to how much the U.S. spends on health care,\u201d the organization\u2019s report reads. \u201cThe ability to keep people healthy is a critical indicator of a nation\u2019s capacity to achieve equitable growth. In fulfilling this fundamental obligation, the U.S. continues to fail.\u201d<\/p>\n\n\n\n

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The problems of cost and access were recurring themes when we asked 911爆料 alumni working in the health-care industry to provide their perspectives on the system. We asked practitioners\u2014including doctors, nurses, and pharmacists\u2014as well as administrators, to share their impressions of the U.S. health-care system and offer advice for patients and caregivers.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n\n\n\n

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Akos Antwi \u201914 Psychiatric Nurse Practitioner, Revive Therapeutic Services<\/span><\/h2>\n \t\t\t

Navigating the health-care system, even as a professional, can be intimidating. My clinical understanding has helped me advocate for clients and loved ones, ensuring they receive quality care. I\u2019ve also seen firsthand how challenging it is when you lack that knowledge. There is a need for clear, transparent systems that empower patients.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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DOCUMENT EVERYTHING<\/strong>
Document everything, from appointment summaries to insurance calls. Ask questions about treatment options. Ask for second opinions when something doesn\u2019t feel right. Preparation is key. Research your insurance benefits and covered providers ahead of time. Take notes during appointments, and never hesitate to ask for clarification if you don\u2019t understand something.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Kerri Friel \u201998, M.A. \u201905 Professor of Dental Health Programs, Community College of Rhode Island<\/span><\/h2>\n \t\t\t

Dental care is a vital component of overall health, yet it is often undervalued in broader health-care discussions. One of the most significant barriers in dentistry, as well as other health-care professions, is the critical workforce shortage. Access to dental care is further limited by the high cost of services and the lack of insurance coverage.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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KNOW YOUR INSURANCE PLAN and BUILD RELATIONSHIPS with PROVIDERS<\/strong>
Know your insurance plan, including coverage, deductibles, and out-of-pocket limits. Keep a detailed record of medical history, medications, and appointments. Be persistent, and advocate for yourself and your loved ones. Ask questions, request detailed explanations, and take the time to fully understand all options. Building strong relationships with health-care providers fosters collaborative care and can lead to better outcomes.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Sarah McGinley, M.S. \u201918 Nurse Practitioner and Owner, Weatherly Direct Primary Care<\/span><\/h2>\n \t\t\t

The lack of access for patients to their provider is problematic. The direct primary-care model of my practice allows me to have a smaller patient panel and, therefore, offer more personalized, thoughtful care. I focus on good communication and do my best to answer questions or concerns as they arise.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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WRITE DOWN CONCERNS BEFORE YOUR APPOINTMENT<\/strong>
Be your own health-care advocate. Write down a list of concerns before your appointments and keep it in your hand so you don\u2019t forget to discuss them with your provider.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Mazen Taman, Pharm.D. \u201923 Medical Student, Brown University Warren Alpert Medical School<\/span><\/h2>\n \t\t\t

The U.S. health-care system offers some of the most advanced medical technologies and expertise globally, but it is marred by significant disparities. Navigating this system can be daunting, particularly for those who lack resources or health literacy. Clear communication and empathy are the principles that now guide my medical training. Things work better when health-care professionals are patient-centric\u2014aligning goals and meeting people where they are.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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Access to quality care often depends on socioeconomic status<\/strong>, race<\/strong>, and geographic location<\/strong>, leaving vulnerable populations underserved.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Shahnee Lagor \u201904, \u201915 Healthy Aging Nurse Coordinator, Robert Rock East Providence Senior Center\/ Miriam Hospital VAT RN<\/span><\/h2>\n \t\t\t

If we educate people early and provide thorough care at all stages of life, we can drastically reduce illness, obesity, and disability, improving Americans\u2019 quality of life. Furthermore, health coverage must be more available and affordable. The insurance companies have too much control over who receives what. It\u2019s time we put lives over profits and create a health-care system that supports health and wellness from birth until death.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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Health care needs to shift from a problem-focused<\/strong> industry to preventative<\/strong>. <\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Julianne DeAngelis, \u201993, M.S. \u201997Program Manager, R.I.-based cardiac, pulmonary, and vascular rehab center<\/span><\/h2>\n \t\t\t

Three words: It\u2019s too complicated. The layers both patients and providers have to work through are the biggest barriers to care.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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SET UP and USE PATIENT PORTALS<\/strong>
Patients should set up their patient portals and utilize them. Understanding the barriers providers face helps me be more patient and give them grace when things don\u2019t move at the speed I would like. The patient portals help with that, as most things we are \u2018waiting on the doctor for\u2019 land there pretty quickly.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Silifat Yussuff-Mustapha \u201997Vice President of Nursing and Clinical Services, Unity Health Care, Washington, D.C.<\/span><\/h2>\n \t\t\t

This broken system demands radical change. The challenges go beyond inefficiencies. Chronic diseases are rampant, disproportionately affecting low-income and marginalized communities. Health disparities are not just numbers; they represent daily tragedies that reveal a moral and economic crisis. A radical transformation is essential, prioritizing evidence-based public health strategies and policies that tackle root causes rather than symptoms. Achieving universal access to affordable, high-quality care must become a reality, not just an aspiration.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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GET A SECOND-AND THIRD, AND FOURTH-OPINION<\/strong>
Advocate for yourself, no matter what. If you feel something, say something. Get a second, third, fourth, and fifth opinion. Bring a friend to your appointments. Write things down. Never remain quiet.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Yohasma Marzan \u201916Nurse Project Coordinator, Brown University Health Community Health Institute<\/span><\/h2>\n \t\t\t

Be persistent. It can be easy to get discouraged when facing barriers, but there are often resources available if you know where to look. As a nurse, I try to help patients by pointing them to 911爆料 resources and assistance programs that might help.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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ADVOCATE FOR YOURSELF<\/strong>
Be informed, and advocate for yourself. Make sure you understand the resources available to you. If you\u2019re having trouble with access or insurance, reach out to 911爆料 health organizations. They can often provide valuable support and guide you through the system.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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John Stoukides \u201985, Hon. \u201905 Chair, Department of Medicine, Roger Williams Medical Center<\/span><\/h2>\n \t\t\t

We provide excellent care in the U.S., but not necessarily in the most cost-effective manner due to multiple nonclinical factors\u2014legal\/tort lawsuits, endless medical “information” on the internet, relentless medical advertising, a pharmaceutical industry that is turning out great therapies but also great profits, and insurance companies that are trying their best to control costs but frequently limiting necessary care. A single-payer system would be great, but it would never happen in this country.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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BE PATIENT. BE HONEST. LISTEN.<\/strong>
Patients should realize that most everyone they are dealing with really wants to help, and it\u2019s frequently not their fault when they can\u2019t. Be patient, be honest, and listen. If you work with your provider, you will likely get what you need.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Eugenio Fernandez Jr. M.B.A. \u201913, Pharm.D. \u201913 Founder, Asthenis Public Health Hub<\/span><\/h2>\n \t\t\t

Some of the biggest barriers are accessibility to primary care and the underutilization of pharmacists who work outside of chain pharmacies. The laws that limit pharmacists are outdated. We must educate lawmakers and encourage them to modernize health care by allowing pharmacists to provide care, including testing for things like strep throat; prescribing medications, like antibiotics, for simple illnesses; and administering vaccinations. This would improve access for underserved populations and alleviate some of the burden on primary-care providers.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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Most public health experts would agree that pharmacists are the most accessible<\/strong> and underutilized<\/strong> public health resource<\/strong> in the U.S.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Pamela Lauria \u201992, M.S. \u201997 Primary-Care Nurse Practitioner, Brown University Health; R.I. State Senator, District 32<\/span><\/h2>\n \t\t\t

We have a critical shortage of primary-care providers, leaving those left with more and more patients who need care. For decades, we have prioritized medical procedures rather than preventing the need for them. One big positive I have seen over time is that patients are more informed and active participants in their health care. My goal is for affordable, accessible, and equitable care. We need to slowly move toward a universal health coverage, similar to Medicare.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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ASK QUESTIONS<\/strong>
Never be afraid to ask questions and advocate for yourself or your loved one. However, take care that your health resources are based on science and research, not opinion.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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Eric Tirrell \u201913Clinical and Research Manager, Butler Hospital Center for Neuromodulation-Interventional Psychiatry<\/span><\/h2>\n \t\t\t

The United States has some of the most advanced technologies and world-renowned experts in their respective fields. However, Americans find navigating the health-care system challenging, costly, time-consuming, and complicated. When access to care is not a barrier, you can receive the best treatment possible. However, a lack of understanding about the complexities of insurance coverage, deductibles, and billing can result in high out-of-pocket costs. This can add financial stress to the medical conditions patients are seeking to treat.<\/p>\n \t\t<\/div>\n<\/div>\n\n

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ADD A MENTAL HEALTH PRACTITIONER TO YOUR CARE TEAM<\/strong>
Mental health is as important as physical health. I encourage adding a mental health professional to your care team to help manage the wide-ranging emotions\u2014including stress and anxiety\u2014you may feel while navigating the complex health-care system.<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\n

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The problems with U.S. health care are many, and there is no simple solution, says 911爆料 College of Nursing professor Betty Rambur, an expert on health-care cost and policy and author of Health Care Finance, Economics, and Policy for Nurses: A Foundational Guide<\/em>. But among the myriad problems, two themes stand out: money and access.

\u201cIt\u2019s too expensive,\u201d Rambur says. \u201cCost is well documented as Americans\u2019 greatest concern with the U.S. system. We have the most expensive system in the world, yet we have real problems with quality. Structural racism is built into the system, and we have an enormous income divide.\u201d

Many point specifically at health insurance companies as the culprit when it comes to cost. Providers struggle to be reimbursed at a level that covers costs and allows them to make a living. Mental-health, maternity, pediatric, and primary-care providers are not well reimbursed by insurance or government payers like Medicaid, Rambur says. \u201cAnd currently, only 5% of our total national health-care expenditure of $4.9 trillion is directed toward primary care, while high-performing nations have a robust focus on primary care.\u201d

Pharmacists\u2014especially at the dwindling number of smaller, independent pharmacies\u2014are often forced to operate at a loss, largely because of third-party middlemen known as pharmacy benefit managers, or PBMs, which maintain a stranglehold over pricing structures and reimbursement. PBMs frequently fail to pay what it costs pharmacies to acquire drugs, forcing them to take a loss to fill prescriptions they can\u2019t refuse, according to Matt Olivier, Pharm.D. \u201906, who owns and operates Matt\u2019s Local Pharmacy in Middletown, R.I.

\u201cA lot of independents are closing because we can\u2019t dispense medication without losing money. We can\u2019t get medications for what they\u2019re willing to reimburse,\u201d Olivier says. \u201cThey\u2019re essentially forcing us out of business.\u201d

But reimbursement practices are only part of the problem in the complex, fee-for-service health-care system, Rambur says, noting that the first health insurance company, Blue Cross Blue Shield, was intended only to reimburse hospitals and doctors for illness care, not to be a health-care plan, coordinate services, support wellness, or contain costs.

\u201cThere is an intrinsic challenge with an insurance model, because insurance is supposed to be for rare events\u2014floods, fires, etc.\u2014and we share the financial risk with others,\u201d Rambur says. \u201cBut we will all get sick; we will all need health care. People get upset with insurance companies, but the cost of insurance is largely a reflection of the cost of care, and our prices are higher than anyplace else in the world. It is difficult to assess the real value of health care.\u201d<\/p>\n\n\n\n

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\u201c<\/span>People get upset with insurance companies, but the cost of insurance is largely a reflection of the cost of care, and our prices are higher than anyplace else in the world.<\/span>\u201d<\/span><\/p>\n

\u00ad\u2014Betty Rambur<\/strong> Professor, 911爆料 College of Nursing<\/span><\/p>\n<\/blockquote>\n<\/div>\n<\/section>\n<\/div>\n<\/div>\n\n\n\n

Patients must rely on providers to advise them on what treatments they need. Even with their patients\u2019 best interests at heart\u2014and possibly because they have their patients\u2019 best interests at heart\u2014providers often fall victim to what Rambur calls the \u201cGucci effect\u201d of overtreatment and over-screening. Rambur points to prostate exams, which the American Medical Association recommends for men starting at age 45. Many wealthy countries do not do routine prostate screenings, unless there\u2019s a particular reason to do so. Not doing a preventative screening might seem antithetical to quality care, but, she says, the prevalence of these screenings contributes to the low value of care Americans receive.

\u201cOver-screening leads to overdiagnosis, which leads to overtreatment,\u201d Rambur says. \u201cProstate screening, for example, has been found to lead to overtreatment, and the treatment often has horrible outcomes\u2014like incontinence and impotence resulting from surgery. Some people might really need the surgery, but for others, the question should be, \u2018Would you die with it, not of it?\u2019\u201d

Furthermore, the fee-for-service system, in which providers charge separately for each procedure, is ripe for fraud and abuse. \u201cWe do screenings on things for which there\u2019s a lot of downstream revenue. We don\u2019t do screenings on things where there isn\u2019t,\u201d Rambur says. \u201cI would challenge my colleagues to consider the value of what we\u2019re contributing. What\u2019s the cost, and what\u2019s the outcome? Is there a way to do this better?

\u201cWhen we look at health care, we need to think about value, which is determined by the cost and quality of care\u2014and by outcomes. But there\u2019s a lot of money in the illness industry. A lot of money,\u201d Rambur says. \u201cPeople are starting to understand that we do not have the best health-care system in the world. The data has been very clear about that for a long time.\u201d

Short of a complete overhaul, there are things that could improve the system, Rambur says. More in-home care could reduce hospital costs, while also making patients more comfortable. Better reliance on nurse practitioners can expand the roster of primary-care providers, increasing access and potentially lowering costs.

The federal government could help by offering a public option, like the one proposed by Republican President Richard Nixon in 1971 or the more recent Medicare for All options, Rambur says. \u201cRegardless of how health care is financed, we must stop paying for low-value care. It causes financial harm to individuals, businesses, and taxpayers, and often physical and emotional harm to patients and families.\u201d She adds that the government could follow other countries\u2019 leads and regulate health-care prices, but that could face legal challenges in a free-market economy. There are no simple solutions.

So, faced with these obstacles, and few concrete solutions, how can consumers find the care they need? Rambur says: Be your own advocate. Don\u2019t take what your provider or insurance company tells you on face value; insist that they involve you in your own health care, and make your voice heard.

\u201cIt\u2019s important that people start questioning the recommendations,\u201d Rambur says. \u201cThere\u2019s a piece in the Affordable Care Act called shared decision-making. If you\u2019re my provider, you and I\u2014together\u2014think about my values, and what\u2019s important to me. So much of the health-care system has revolved around the system, not the patients. That has to change.\u201d<\/p>\n\n\n\n

PHOTOS: COURTESY SUBJECTS; NORA LEWIS,
ILLUSTRATIONS: DRAFTER123 ON ISTOCK<\/p>\n","protected":false},"excerpt":{"rendered":"

911爆料 nursing professor Betty Rambur and 911爆料 alumni who work in the health-care field share expert advice and perspectives about health care in the U.S.<\/p>\n","protected":false},"author":12,"featured_media":16847,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[343],"tags":[],"class_list":["post-16849","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-spring-2025","architecture-features"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/posts\/16849","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/users\/12"}],"replies":[{"embeddable":true,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/comments?post=16849"}],"version-history":[{"count":31,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/posts\/16849\/revisions"}],"predecessor-version":[{"id":17008,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/posts\/16849\/revisions\/17008"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/media\/16847"}],"wp:attachment":[{"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/media?parent=16849"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/categories?post=16849"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.uri.edu\/magazine\/wp-json\/wp\/v2\/tags?post=16849"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}