'Missed desires'
“This lonely afternoon of memories
And missed desires, while the wintry rain
(Unspeakable, the distance in the mind!)
Runs on the standing windows and away.’’
—From {Putting Up} “Storm Windows,’’ by Howard Nemerov (1920-1991). A Pulitzer Prize-winning poet, he taught at various colleges, including Bennington College, in Vermont.
Elisabeth Rosenthal/ Emmarie Huetteman: He got tested for COVID-19; then came a flood of medical bills
By March 5, Andrew Cencini, a computer-science professor at Vermont’s Bennington College, had been having bouts of fever, malaise and a bit of difficulty breathing for a couple of weeks. Just before falling ill, he had traveled to New York City, helped with computers at a local prison and gone out on multiple calls as a volunteer firefighter.
So with COVID-19 cases rising across the country, he called his doctor for direction. He was advised to come to the doctor’s group practice, where staff took swabs for flu and other viruses as he sat in his truck. The results came back negative.
In an isolation room, the doctors put Andrew Cencini on an IV drip, did a chest X-ray and took the swabs.
— Photo courtesy of Andrew Cencini
By March 9, he reported to his doctor that he was feeling better but still had some cough and a low-grade fever. Within minutes, he got a call from the heads of a hospital emergency room and infectious-disease department where he lives in upstate New York: He should come right away to the ER for newly available coronavirus testing. Though they offered to send an ambulance, he felt fine and drove the hourlong trip.
In an isolation room, the doctors put him on an IV drip, did a chest X-ray and took the swabs.
Now back at work remotely, he faces a mounting array of bills. His patient responsibility, according to his insurer, is close to $2,000, and he fears there may be more bills to come.
“I was under the assumption that all that would be covered,” said Cencini, who makes $54,000 a year. “I could have chosen not to do all this, and put countless others at risk. But I was trying to do the right thing.”
The new $2 trillion coronavirus aid package allocates well over $100 billion to what Senate Minority Leader Chuck Schumer of New York called “a Marshall Plan” for hospitals and medical needs.
But no one is doing much to similarly rescue patients from the related financial stress. And they desperately need protection from the kind of bills patients like Cencini are likely to incur in a system that freely charges for every bit of care it dispenses.
On March 18, President Trump signed a law intended to ensure that Americans could be tested for the coronavirus free, whether they have insurance or not. (He had also announced that health insurers have agreed to waive patient copayments for treatment of COVID-19, the disease caused by the virus.) But their published policies vary widely and leave countless ways for patients to get stuck.
Although insurers had indeed agreed to cover the full cost of diagnostic coronavirus tests, that may well prove illusory: Cencini’s test was free, but his visit to the ER to get it was not.
As might be expected in a country where the price of a knee X-ray can vary by a factor of well over 10, labs so far are charging between about $51 (the Medicare reimbursement rate) and more than $100 for the test. How much will insurers cover?
Those testing laboratories want to be paid — and now. Last week, the American Clinical Laboratory Association, an industry group, complained that they were being overlooked in the coronavirus package.
“Collectively, these labs have completed over 234,000 tests to date, and nearly quadrupled our daily test capacity over the past week,” Julie Khani, president of the ACLA, said in a statement. “They are still waiting for reimbursement for tests performed. In many cases, labs are receiving specimens with incomplete or no insurance information, and are burdened with absorbing the cost.”
There are few provisions in the relief packages to ensure that patients will be protected from large medical bills related to testing, evaluation or treatment — especially since so much of it is taking place in a financial high-risk setting for patients: the emergency room.
In a study last year, about 1 in 6 visits to an emergency room or stays in a hospital had at least one out-of-network charge, increasing the risk of patients’ receiving surprise medical bills, many demanding payment from patients.
That is in large part because many in-network emergency rooms are staffed by doctors who work for private companies, which are not in the same networks. In a Texas study, more than 30 percent of ER physician services were out-of-network — and most of those services were delivered at in-network hospitals.
The doctor who saw Cencini works with Emergency Care Services of New York, which provides physicians on contract to hospitals and works with some but not all insurers. It is affiliated with TeamHealth, a medical staffing business owned by the private equity firm Blackstone that has come under fire for generating surprise bills.
Some senators had wanted to put a provision in legislation passed in response to the coronavirus to protect patients from surprise out-of-network billing — either a broad clause or one specifically related to coronavirus care. Lobbyists for hospitals, physician staffing firms and air ambulances apparently helped ensure it stayed out of the final version. They played what a person familiar with the negotiations, who spoke on the condition of anonymity, called “the COVID card”: “How could you possibly ask us to deal with surprise billing when we’re trying to battle this pandemic?”
Even without an ER visit, there are perilous billing risks. Not all hospitals and labs are capable of performing the test. And what if my in-network doctor sends my coronavirus test to an out-of-network lab? Before the pandemic, the Kaiser Health News-NPR “Bill of the Month” project produced a feature about Alexa Kasdan, a New Yorker with a head cold, whose throat swab was sent to an out-of-network lab that billed more than $28,000 for testing.
Even patients who do not contract the coronavirus are at a higher risk of incurring a surprise medical bill during the current crisis, when an unrelated health emergency could land you in an unfamiliar, out-of-network hospital because your hospital is too full of COVID-19 patients.
The coronavirus bills passed so far — and those on the table — offer inadequate protection from a system primed to bill patients for all kinds of costs. The Families First Coronavirus Response Act, passed last month, says the test and its related charges will be covered with no patient charge only to the extent that they are related to administering the test or evaluating whether a patient needs it.
That leaves hospital billers and coders wide berth. Cencini went to the ER to get a test, as he was instructed to do. When he called to protest his $1,622.52 bill for hospital charges (his insurer’s discounted rate from over $2,500 in the hospital’s billed charges), a patient representative confirmed that the ER visit and other services performed would be “eligible for cost-sharing” (in his case, all of it, since he had not met his deductible).
Last weekend he was notified that the physician charge from Emergency Care Services of New York was $1,166. Though “covered” by his insurance, he owes another $321 for that, bringing his out-of-pocket costs to nearly $2,000.
By the way, his test came back negative.
When he got off the phone with his insurer, his blood was “at the boiling point,” he told us. “My retirement account is tanking and I’m expected to pay for this?”
The coronavirus aid package provides a stimulus payment of $1,200 per person for most adults. Thanks to the billing proclivities of the American health care system, that will not fully offset Cencini’s medical bills.
Elisabeth Rosenthal: erosenthal@kff.org, @rosenthalhealth
Emmarie Huetteman: ehuetteman@kff.org, @emmarieDC
On the Bennington College campus on a dreary day
Karen Gross: Do American colleges now need co-presidents?
The Everett Mansion at Southern Vermont College, in the beautiful college town of Bennington, also site of a Revolutionary War battle. See more information below.
From the New England Board of Higher Education (nebhe.org):
Harvard University recently appointed a new president, Lawrence Bacow. He’s a well-known, highly regarded leader, having spent the better part of his adult life in educational administration. He’s been president of Tufts University and chancellor of the Massachusetts Institute of Technology; he also served on the Harvard Corporation, Harvard’s governing board, prior to being considered a presidential candidate. And the announcements have been clear: Even at Harvard, he has many real challenges ahead of him.
Few question the difficulties of being a college or university president in today’s era: The issues about, the needed skills are abundant and the stresses and strains real. Perhaps that is why there is even a recent book with the frightening title: Presidencies Derailed.
When I left (voluntarily) the small college I led for eight plus years (longer than the average tenure in such posts), I was and still am asked if I would consider another presidency. Until very recently, I always said “one and done.” While that is a demeaning term in collegiate athletics, I did not see anything negative in saying “one presidency is enough.” It is a lifestyle, not a job.
To be clear, Larry Bacow also apparently said, as he was leaving Tufts University, that he was one and done, reportedly using those very words. Yes, people can change their minds for sure.
But make no mistake about this: The work of college and university presidencies is getting harder not easier with the passage of time. The challenges are wide-ranging from fundraising and “friendraising” to quests for academic excellence and its quality measurement, from developing a healthy culture on campus without sexual assault and harassment to access and financial support for students who are not from wealthy families or elite high schools and prep schools. Add to all this, the problems that arise in athletics, running an art (and other) museums (and their collections), dealing with deferred maintenance and wrestling with the parameters of free speech.
And, we have a federal government that is challenging the role and importance of a college degree, a government that is also forcing us to re-think institutional finance due to changes in the tax laws that impact many while reflecting deeply on notions of truth and power as well as civility, cooperation and collaboration. Not all states are exactly higher education aficionados either.
Two heads are better than one?
A higher-education recruiter recently approached me regarding a college presidency (name and place deleted in the interests of privacy). I don’t know what possessed me to say what I said but I repeat it here: “I would not do another presidency unless it is constructed as a co-presidency.” I later added that, as an alternative, I would need to bring a senior team with me in the absence of a co-presidency, something that is antithetic to academic culture at most institutions.
Having said what I said, I needed to back it up in writing—which I have done. And the idea, which I will flesh out a bit more here, has most assuredly not met with universal approval. Indeed, some comments have been downright demeaning—suggesting that co-presidencies would replicate the good cop/bad cop aspects of parenting and thus lead to institutional disaster. Others were kinder, suggesting the idea was good but impossible, suggesting that finding co-presidents who worked well together would be like finding a celestial match. And to be clear, I don’t know any angels.
Let me start, in support of co-presidencies, with these observations. Educational administrative structure does not work well in many instances. We are not altogether clear on the role of provosts and deans, as debated in a recent piece in Insider Higher Ed. There are many openings for presidencies, some with awfully quick exits; just look at the Comings and Goings appearing in our emails on Wednesday of each week and produced by NEJHE. And there are searches, although rarely disclosed, that fail to find leaders who meet the criteria of trustees, faculty, staff and students. And presidents are staying in their roles for shorter time periods. Indeed, half the presidents report that they plan to serve for less than five years.
Don’t underestimate the price institutions pay—literally and figuratively—for failed presidencies and failed searches. The rush of recent resignations of longer-serving presidents is also not exactly a sign of leadership good health. And calls for resignation, even if not realized immediately, are institutionally disruptive.
So, why not consider a solution that has been tried outside academe. For example, co-presidencies are increasingly common in business. In late 2017, Apollo Global Management LP became the most recent example. Decades ago now, the Graduate School of Education at Harvard had co-academic deans. And within the academic sphere, there are several instances of interim co-presidents.
Risks and benefits
I could detail the risks of co-presidencies but people surely can imagine those with little effort. What’s harder is to see the benefits and demonstrate that in some situations, a co-presidency makes extraordinary sense. And those critiquing my idea misstate that I mean for co-presidencies to be appointed at every institution. Wrong. That is not what I am saying; nor would such appointment necessarily work. Knowing when they might work within an institution’s needs, culture, structure, challenges and history is key.
Instead of thinking about co-presidents like parents or conductors of an orchestra (a common analogy used when thinking about leadership generally and leading an educational institution with its multiple interests in particular), first think of airline pilots.
On every flight (virtually), there are co-pilots. Yes, there is a captain but his/her partner is called a co-pilot. They are a team that may have not even met before a particular flight. They know their tasks; they work together; they problem-solve together; they communicate; they collaborate. They each can do the other’s job to a tee. They are responsible for the lives of hundreds of people—together. And if there were a sudden need for an immediate decision and no time to discuss how to act (a rarity I assume), I cannot imagine most pilots bickering for long given that their own lives are at stake in addition to the lives of others; I assume one pilot makes the needed choice. Egos are, as a generalizable matter, in check—and I assume pilots have no shortage of ego strength.
Now consider surgical teams—two humans as opposed to a human surgeon and a robotic president (something even I am not suggesting at colleges and universities). Yes, there used to be a lead-surgeon in most surgeries, but in many of today’s complex medical situations, different established surgeons work together on different body parts and body systems as co-surgeons.
Surgeons may fight on television and perhaps in an occasional OR suite. But if I were to guess, good surgeons learn to work together and prefer working with fellow surgeons and anesthesiologists and nurses they know. Recent studies suggest some noticeable benefits of co-surgeries (with two attending physicians not one lead surgeon and one resident) although the literature is still not robust.
Decisions large and small
While some pilot and surgeon decisions are grand in size and impact, it is not as if every decision has massive consequences. Small decisions are delegated all the time on campuses. The big strategic decisions are usually ones that require both time and reflection and often require input from the board, among other groups; two people can do that as well or perhaps better than one person. And if there is an emergency or a disaster and an immediate decision must be decided, perhaps the co-presidents could agree with the board ahead of time as to who makes that call or the responsible person could change from month to month or year to year.
And if there were to be consideration of co-presidents, they would have to be interviewed both together and separately. I can see interview teams asking each possible co-president to discuss the strengths and weaknesses of his/her counterpart. And there would need to be opportunities to see them engaging with each other and with others including faculty, staff and students. Trustees too.
So, how would one come up with individuals who could be co-presidents? I think we’d need to change the paradigm for how presidents are identified and selected. I also think there would have to be a movement, a shift, in how the hiring is done, a response to the realities of the jobs that college/university presidents face.
A search
I can think of a half dozen people right now with whom I would and could happily serve as a co-president were I ever to consider another presidency (another issue altogether). To be fair, two of the people I think of have retired, but the point is I could have been a co-president with them. I do not think I am alone as an educator in being able to identify a handful of people with whom I could work well and intimately, without ego problems and with enormous sharing, communication and institutional benefit.
Here are three examples:
I can think of a current provost who wants to be a president who has real expertise in admissions, financial aid and diversity. He is younger than I am; I have known him for decades. We have worked on projects together (not in the same institution). He has served as a House Master in a campus dorm (with his wife and two children). He is thoughtful and innovative; he has a degree in Divinity. He has skills related to student life and admissions—and I can see us working on overall policy but then overseeing different areas of life within and outside a college’s walls.
There is a CFO, with whom I have worked in the Northeast, who would make an excellent co-president. He is multitalented and has served at many institutions, including in times of crisis. He also understands accreditation—both regional and programmatic, and he is decent and hard-working and thoughtful and careful. He sees problems before they actually are problems. He values teamwork.
Finally, and don’t worry because I see the risks here: there is my life partner, with whom I could easily be a co-president. He and I have very similar values and a desire to make the world a better place. We are both a product of the 1960s and you could call us both advocates and activists. But his experience in the working world (although he has taught and written including a major book in his field) is in government and technology. He has worked in several federal government agencies; he gets how institutions and processes work; he gets which technology is literally on the cusp. He cares about data and the role of big data. He understands cybersecurity and interoperability. He is smart and funny and fun and sociable.
And, none of these individuals would be scared to voice their views if they differed from my own. They all have.
My point is this: no one person in this day and age can have all the skills it takes to be a college or university president. The list is simply too long and too diverse. My shortcomings are plentiful. And, while a leader can surround him or herself with excellent talent and a sensation senior leadership team, ideally in areas in which the leader is not as strong, there is a value to considering a different model: co-leadership.
Widening the pool
Co-presidencies would, I think, widen the pool of candidates. We need that and it would foster diversity in all ways—age, race, skills, ethnicity, experience. Next, they would send a loud and clear message about collaboration and cooperation and the busting of silos. An academic could partner with a government or business official. A financially savvy person could partner with someone with vast expertise in student life. It is about putting one’s ego in the right place and giving glory to another and accepting blame. It is fundamentally about some of the very skills we want students to acquire: problem-solving, teamwork and decency.
I think a co-presidency would set an example. It models risk-taking and out-of-the-box approaches in real time. It shows the capacity to try new ideas and explore new territory thoughtfully and with deep regard for the risks and benefits. And it highlights the real world: the complexity of problems we face and the need to ask for and get help—not as a sign of weakness but as a sign of strength.
Co-presidencies are not toys of the moment; there are rich examples and case studies that can be evaluated. I see co-presidencies at this moment in time as enabling key educational institutions in American culture to be lead with expertise, grace, equanimity, talent and collaboration. And it is reflective of how many decisions are needed and how many are ones that can be shared.
And perhaps, just perhaps, there are added upsides to co-presidencies that we do not yet know about or cannot anticipate. I, for one, believe those positive possibilities exist.
Karen Gross is senior counsel with Finn Partners, former president of Southern Vermont College and author of Breakaway Learners: Strategies for Post-Secondary Success with At-Risk Students. This piece on co-presidencies is based on a similar article by Gross published in the Aspen Journal of Ideas.
Southern Vermont College was founded in 1926 in downtown Bennington as St. Joseph Business School. In 1962, it became an accredited junior college, St. Joseph College, awarding associate degrees in business and secretarial science.
In 1974, the school moved to its current location, on the Everett Estate in Bennington, and became Southern Vermont College, a nonsectarian liberal arts college.
The 27-room Everett Mansion, listed (along with most of the campus) on the National Register of Historic Places, is the college's primary administrative and academic building. It was built 1911–14 for Edward H. Everett, a rich businessman from Cleveland, and is a distinctive combination of Beaux Arts and Norman Revival styles, designed by George Oakley Totten. It has the library, theater, Center for Teaching and Learning, Burgdorff Gallery, eight classrooms, plus administrative offices. From 1977 to 1994, the theater was the residence for the regionally acclaimed Oldcastle Theater Company.nning
Bennington is also the home of Bennington College, founded as a woman's college in 1932 but co-ed since 1969 -- and still a rather arty place and definitely a bastion of progressivism.