Money Games in Healthcare and How To Solve them
This week I am talking to Marty Makary, MD, MPH, (@MartyMakary) Professor Johns Hopkins School of Medicine & Bloomberg School of Public Health Editor of Medpage, and author of The Price We Pay – What Broke American Healthcare – and How to Fix It (released Jun 8, 2021) and Unaccountable which is the basis of Fox’s medical drama The Resident, and an impressive minimally invasive medical practice that included pioneering the first laparoscopic Whipple’s procedure carried out in Johns Hopkins.
We dive into the US healthcare system that continues to fail our citizens and was subject to an extensive nationwide tour that offered eye-opening insights into the lives of people struggling to work and to navigate the healthcare system. Marty boils down the three primary drivers of why healthcare costs so much in the US:
- Pricing Failures (that facilitate price gouging, and predatory billing)
- Appropriateness of Care
- Care Coordination
The good news is there is plenty of positive change happening in healthcare with alternative approaches and practices that are changing the way we think about wellness and care, such as treating diabetic patients with cooking classes instead of insulin, and back pain with phsycian therapy instead of surgery and opioids.
We dive into the failures of the Pandemic response in the US that included the inability of the NIH to pivot any of the billions of dollars of available budget towards COVID19 related research and science and how the US response compared to other countries failed to capitalize on science and knowledge quickly leaving many finding workarounds and alternative methods to communicate
Listen in to hear Marty discuss the failure of leadership and the flawed vaccination strategy based on a rationing system that was misapplied and hear what he has to say when summarizing what we learnt from the Pandemic and how this compares to current and future health crisis that will continue to challenge our world and what we should be doing to rectify this.
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
And today I’m delighted to be joined by Dr. Marty Makary. He is a professor of Johns Hopkins School of Medicine and Public Health. Marcy, thanks for joining me today. Great to be with your neck. So there’s lots going on, we’ve got lots to talk about. I know you’re well known to many folks, thanks to multiple books, lots of experiences. But if you would just briefly give us a quick outline of your career history and some of the highlights and I know there’s a lot in there. So if you could skip.
Marty Makary
Well, I’m interested Nick, in the big issues that need to be discussed that are not being discussed, the areas of medicine, which are not getting research funding from the NIH and other traditional sources. So that’s the culture of medicine. It’s why medicine costs so much. It’s how we train young doctors and nurses. It’s the out of control practice of Monopoly pricing and price gouging and predatory billing. And it’s discussing the appropriateness of care how we doctors deal with uncertainty when we get a lab test result. And I think one of the fun parts of my job is we’ve been able to pivot really quickly to the opioid epidemic and to COVID. And really, that’s what a good research team should be able to do is respond quickly to a health emergency.
Nick van Terheyden
Alright, so your pathway to this you started out you’re a surgeon, laparoscopic surgeon, you’ve done some pretty incredible things. Those people that know what a Whipple is, you’ve done it laparoscopically, which is just an astounding Feat. You got into public health and you know, started this whole research. Tell us a little bit about that journey, because that from a standpoint of experience driving your sort of activities. What What got you into that?
Marty Makary
Well, I think as physicians, Nick, you’ve seen this through your career, there are things that should offend us, right? Things that are not right. ways in which people who were otherwise vulnerable and helpless succumb to an ugly, complex system, despite good people working in that system. And when you see the system, have people fall through the cracks. When you see the machine go awry, when you see the rudder in the wrong direction. I think we’re taught in our training not deliberately, but subconsciously, to internalize it or to comment, we comment to each other in our echo chambers. You see this all the time when in doctors conferences, right, we go and talk about the way it should be with payment reformer malpractice, and we’re talking in our own echo chambers. And so the big opportunity that I found is to translate research into advocacy. And that’s been the exciting thing. And having the vantage point of being a practicing physician, I think really helps inform that. For me, you know, a lot of our great research ideas come from my own experiences, operating, seeing patients, barriers in the system and talking to doctors, I get the privilege of traveling around the country, meeting with doctors and hospital leaders all the time. I learn. I mean, they’re telling me about their struggles. They’re telling me about, you know, Carty therapy. And it’s amazing, amazing promise and yet how difficult it is to get payers to pay for it. This is the Learning Lab of research, I think. So that’s been a little bit of my background.
Nick van Terheyden
So yeah, I know as part of your sort of research. For the price, we pay the original version, you went on a pre extensive tour that provided you insights that you don’t get on on average sort of experience. Tell us a little bit about some of the highlights or the lowlights, I want to call them those experiences and some of the things that you found in that research.
Marty Makary
Well, I had a blast doing it, I’m not gonna lie. I basically was on a mission. And I think I was just at that point in my career, where I could do this, and I wanted to do it. And so what I wanted to do is get an answer to the question, why does health care cost so much? And how do we address it? Now, if you talk to 10 doctors or 10, hospital administrators, they’re going to give you 10 different answers. If you talk to pharma, they’re going to blame pbms. If you talk to insurance companies are going to blame providers. And there’s this massive blame game where the so called experts point their fingers to everybody except themselves. And so we’ve got this oligarchy, almost talking about a problem where really every stakeholder in healthcare is getting rich. every stakeholder in healthcare is getting very rich right now, except for one, the patient and that those patients are represented by Employers and employer groups and some health plans. I wanted to get to the bottom of the question, why does health care cost so much? And finally, you know, when you feel like there’s a topic and medicine, you don’t really have a grip on and you just want to do a deep dive, like you want to just understand what’s the bottom line with hormone replacement therapy. I mean, then you read all the papers and you leave feeling great. That’s how I left about health care costs. I talked to hospital leaders, doctors, nurses, pharma, big hospitals, small hospitals, remember, academics is like 20%, of medical care in the United States. And yet we have this perspective all the time from the large institutions, most cares delivered in communities. And so I went out to those communities. And what I found is that the bottom line is that the big drivers of healthcare are number one, pricing failures, that enabled price gouging and predatory billing. Number two, the appropriateness of care issue. And number three, care coordination. And I learned of these sort of heroes, disrupting each of those areas in a way that left me feeling so optimistic about the future of healthcare. So that was a little bit of that journey. Yeah,
Nick van Terheyden
I you know, it’s interesting, you say optimistic, because I have to say, I read this. And, you know, the, there’s more than one book that sort of talks to some of these problems. And each and every time I feel like we continue to talk about it, but we don’t manage to move the needle, right in power, because of the folks that you describe in your discussion about this, which is the special interest groups, the lobbyists who are all pointing fingers elsewhere and have a vested interest, you really see an opportunity to help fix this, except for the sort of ones these where we shine the spotlight.
Marty Makary
I do take a look at I’m laughing because I relate there were days on this two year research tour that I documented in the book where I wanted to go out and buy a Ben and Jerry’s and engage in emotional eating at the end of the day, because it was so depressing. You feel like there’s no hope, you know, these mass consolidation in healthcare that nobody seems to be paying attention to that’s resulting in, you know, leverage unfair leverage in the marketplace. And there are things that are really discouraging, no doubt, there’s no doubt and you’re right. A lot of people are talking and it’s hot air, right? You have these conferences and people come together, and they talk about social determinants of health, and nothing comes out of it. And it’s like, give me a break. Like, what are we going to actually do? But I discovered Chen med and I era and Oak Street and landmark and DPC, an employer groups that are saying, hey, maybe we can treat more diabetes with cooking classes than just throwing insulin at folks. And if you unbound if you unbound us from the chain of the billing throughput models health care where we code in, we’re obsessed with documentation and coding, and it detracts from us. And just release us to spend more time with people and use a care team as sort of extensions of our of ourselves. It’s beautiful. I saw back pain treated with physical therapy more aggressively and ice instead of just surgery and opioids. I saw loneliness treated as a medical condition. It’s rampant, it’s epidemic. And it’s been magnified during COVID. researchers who are saying look, we want to study the environmental exposures that cause cancer, not just new chemo drugs that we give to people. And I learned this beautiful movement to get at the underlying causes of care that’s enabled by global capitation or or global payment. And by the way, COVID was a test of that, right? Because the globally capitated programs, the value programs thrived during COVID, they went and picked up seniors delivered food took meds, and the fee for service world went starving because the money the money. Flow stopped, and they immediately rushed Congress just give us more money like an addict almost. And so you saw this beautiful example of value based health care play out.
Nick van Terheyden
So if I can I want to pull on that thread a little bit. So if we shift it, let’s suppose we shifted almost everything to value based care. Do you think that changes enough of the drivers throughout the system and I’ll give you one example where I struggle with this or I see, you know, resistance through the lobby and, you know, the vested interest for the folks getting paid or reimbursed, and specifically physicians who come into this with good intentions but you know, end up being stuck in a system. They have to pay their bills and more importantly have to pay The fees that it costs them to go through that training which are not insubstantial in the marketplace. We do we do we have to throw everything out, or is there a real gradual, incremental change that we can make to stop these improvements to really change to a better more positive healthcare system?
Marty Makary
I think both. And look, I get it, doctors I found are getting hammered right now. They’re getting crushed, increasing overhead, shortage of nurses and medical assistants, increasing malpractice premiums, declining reimbursement, and they’re getting crushed right now. And so what you’re seeing is a group of doctors, partly driven by excitement and partly fed up with the medicine that they’ve been burnt out from, say, I want to start from scratch, I want to redesign care, let’s just focus on what would be the ideal way to deliver care. And I met emergency room doctors that do house calls, because if they can come up with a really good phone triage system, they can figure out what’s going to spare you an expensive ER visit and everyone wins, everybody wins. And so you learn about these innovators, and I left very optimistic. I just thought, Gosh, we’re seeing more transparency with pricing, with quality with primary care with physician referrals, steering patients, one of the great holy grails of health economics is can we steer patients to high quality specialists? Right now? It’s kind of, oh, that’s my golf buddy down the hall, I’ll send you to him. Insurance companies don’t do it well, right. They do it they, they it’s very clunky. Nobody’s gonna go to the doctor the insurance company tells you to see right. But if a doctor in a primary care clinic or an urgent care emergency room says, you know, here’s some doctors we recommend close to your home. And these doctors are pre screened with good medical quality, good appropriateness, scores, and good billing quality, where they have fair and honest billing practices, then you you’re moving markets.
Nick van Terheyden
Alright, for those of you just joining, I’m Dr. Nick the incrementalist today I’m talking to Dr. Marty Makary. He’s a professor in the Johns Hopkins School of Medicine and Public Health, we were just talking about some of the expos a in your original book, the price we pay new edition, it’s out. Exciting sort of additions to that, you know, certainly those of you that haven’t read it, I would encourage you, if you don’t read it and get angry like I did, then I’m not sure what’s wrong. Ultimately, I think you’ve really followed through. And importantly, we’ve seen this spotlight or amplification of all of these problems with COVID-19. Tell us a little bit about the update and some of the latest insights that you’ve added to the book.
Marty Makary
Well, thanks. I’m really excited about the paper book and the paperback and it is out today, I included in there a COVID section because I think it’s important to look back on COVID and recognize what we got right and wrong. You know, our entire healthcare system was unable to pivot quickly. You had some hospitals able to build an expand, but otherwise, we’re dealing with, you know, building permits that had to be issued from the city during a health crisis to build on your own property, you know, like an expansion of your hospital. We learned a lot of lessons. But I think one thing that I’m most struck by is how we spend $40 billion at the NIH. And we could not pivot one dime of that money to study the most basic research questions early in the pandemic. How does it spread? Do masks work? When are you most contagious? How many people are asymptomatic? The NIH in its rigidity and leadership was unable to pivot a dime of their $40 billion? To answer those questions in any sort of timely fashion. We had doctors at the bedside wanting to know the answers that we had some of us going on cable news and other media outlets trying to answer questions from the public using a smattering of information that we collected from Italy in Wuhan. And it’s you look back and you realize we’ve got to be able to pivot and by the way, it’s not just a viral pandemic. It’s a mass shooting. It’s a hurricane a tornado. It’s another pandemic, which has already set in which is antimicrobial resistance. By the way, it killed about 1/6 the number of people COVID killed in the same year, and it’s increasing each year. COVID is going down, it’s increasing each year. So this these are things that are avoidable with antimicrobial resistance that has to do with the food we choose at the grocery store and whether or not we prescribe antibiotics when people really don’t need them, and we don’t think they need them. So there are many things we can learn, I think from the pandemic. And, you know, as a side note, I had called for focusing on first doses and for us not to start vaccinating. With vaccinating people already immune with natural immunity. I thought that was ridiculous that we actually get this life saving scarce resource. And in the early months of December and January, are giving it to people already immune with net with circulating antibodies. And I just had this big, big beef with the medical establishment argument where they argued, Oh, we don’t know about natural immunity, we can’t say for sure. Well, guess what those antibodies are lasting and the immune protection is long term, we’ve learned that we’ve had more data on natural immunity than vaccinated immunity. And of course, as I saw the medical establishment, ignoring natural immunity, which by the way, by mid spring was half the population. I saw how that was driving cases down and predicted by April or May, we would see a significant plummeting in cases and getting back to a normal life by summer. And in fact, that’s exactly what happened.
Nick van Terheyden
So you bring out the fact that we were unable to pivot, we couldn’t even share information. I don’t know if you were but I was part of a whatsapp group and a Google Doc that essentially shared clinical information worldwide. Those were the two platforms that were used for sharing this information. I mean, a total tragedy, we’ve shown this spotlight, what have we learned? And what are we going to do better? As a result of the insights? Let’s hope I mean, I, we still have to action, some of these insights. But what do we need to do better? And what do you think we’re going to do better as a result of that?
Marty Makary
Well, I think our old methods of communicating as physicians, Nick failed us publishing in medical journals commentaries, we publish the largest study of COVID risk factors ever done. It was an all US Medicare beneficiaries, sat in peer review for six months during the pandemic, and ultimately was resubmitted and went on the preprint server Finally, but you know, we can’t wait nine months during a pandemic, for a basic logistic regression analysis of risk factors. So we’re decided to bypass the journals. I’m the editor of medpage. Today, as you know, there’s two big trade publications for doctors medpage today, and medscape. And we decided, you know what, let’s just go ahead and share stuff with the world like you’re describing with the WhatsApp community, we saw doctors at Mount Sinai in the ICU say, Hey, you know what, we’re not seeing issues with lung elasticity. This is not a compliance issue with the lungs, we may not need to ventilate as aggressively as a result. And here’s a protocol we’re using. And it went viral, where were the journals, the journals, our funding mechanisms, the NIH, the study section, committee process, all of that stuff was unable to pivot quickly. And I think we’re recognizing more and more now that we got to find other ways to share. And actually some of us doctors, were actually having these debates in the mainstream media, we were having them on cable news, and the Wall Street Journal in the New York Times. And that’s good, right? That’s good when I had realized universal masking was very important after talking to doctors in Wuhan, China. And doing a lot of research on it early on early in the very beginning of the pandemic, when we were first having that surge. In New York, I put an article in The New York Times The first article in a mainstream publication calling for universal masking, I took a lot of heat for that I took a look at for that. What was the other option, go to the journals and do it long peer review. So I think we need to figure out ways we could communicate and share ideas quicker and more freely.
Nick van Terheyden
So you describe that, and I can only sympathize. I know the level of sort of vitriol that seems to exist when we have countering opinions. You know, good healthy debate is an essential part of science. As I look at it, and I think about other countries, and let’s pick the UK, because I obviously have a tinge of an accent and I know you at least have some association with both Liverpool supporters. I’m just going to declare it to be the case. But they took a different strategy with the vaccinations. That said we were going to spread it out. We’re just going to give the first of the doses and actually proved out. Do we have more to learn from other countries? And can we bring that into the United States is the better sharing of information do you think now?
Marty Makary
Yeah, absolutely. And, you know, I wrote a piece in The Wall Street Journal titled, UK vaccination. Put us to Shame. And it’s true, you know, they chose to go with the single focusing on first dose strategy. And they won. They were, they had the same number of vaccines per capita. And they reached a high degree of population wide immunity much sooner than the United States just by focusing on the first dose. And we were having these debates. And I was debating with Fauci and others that you know what the immune protection, if you look at the data is pretty good after the first dose, you’re not going to really lose anything by waiting 12 weeks for the second dose? Well, you know, they had this far reaching hypothesis that the antibodies could, quote unquote, fall off a cliff after two. But literally, that was what Fauci told me. Now, look, I respect him and I communicated to him directly. I told him, Look, I have enormous respect for you. This is a professional sort of debate, we should be having these debates, right? We should it shouldn’t. You don’t want to just listen to one point of view when you’re dealing with a topic of such gravity. UK Got it? Right. The data came in, you know, as it was a philosophical theoretical debate early on, then the data came in UK got it right. It turns out a study found that even with the Pfizer vaccine that’s just came out a few weeks ago, if you wait 12 weeks to get the Pfizer vaccine from the first dose, you know, spaced them out by 12 weeks, the antibody responses 3.5 times greater. And so there’s a lot we can learn. And we can still learn, they’re still struggling overseas in some countries around the world with the pandemic. So these are some basic ways in which we should learn from our mistakes, not to immunize when you’re so we’re good at developing things and inventing things. We’re not good at the science of rationing. As a matter of fact, our leaders are very uncomfortable with the idea of rationing. Right? The FDA is uncomfortable with our public health officials. And it turns out that’s its own science is how do you ration wisely. And so, you know, that is another lesson learned.
Nick van Terheyden
So I, unfortunately, we’re almost out of time, before we close out. And, you know, to your point of rationing, I think people have this somewhat distorted view of healthcare, that it’s unlimited for everybody it can’t possibly be, we have to ration it, in some form, get the maximum benefit. I think that’s what you’re talking about. In the closing couple of minutes. Tell us what you’re excited about as a result of this. I mean, I always try and find the silver linings. I know, that’s a terrible thing to say about this dreadful pandemic. But ultimately, we have to find the positives. What have we learned that’s gonna benefit us? And how do you see the future unfolding as a result of this?
Marty Makary
Okay, I want to say something, Nick, and maybe this is I shouldn’t say this. But what the heck, life is short. And I don’t want this misconstrued. But COVID was a mild pandemic in the world of pandemics. Okay, that was it was significant, and terrible, and tragic. But about 400,000 Kids died the year before from malaria. rotavirus at one point was the number one killer in the world. Now, I’m not downplaying COVID. I’m saying that, imagine the case fatality rate was closer to five or 10%, as we were worried initially when we were sounding the alarm. Right. So this is where we have, we can now learn in the country, are you the United States is then oddly complacent about the number of seasonal flu deaths each year. 80,000 81,000 people died four years prior to COVID. In that one year from flu, I think one of the silver linings is we’re going to take infection control seriously. I don’t think it’s going to be acceptable to show up to work and have, you know, a hacking cough and be sneezing and slobbering sitting right next to somebody anymore. I mean, that is something that we just downplayed. And so I think we’re going to learn a lot of great things. And we’re going to save many more lives. Look at the number of live saved from seasonal flu this year. I think we’re going to see that year to year and I hope we can learn lessons we can apply to the antimicrobial resistance epidemic, which is growing and real and projected by the who to claim more than 10 million lives per year by 2050. This is not a fast pandemic like COVID Amr is a slow pandemic, and I just did a TED talk on this. This is something that we need to address early on. And so I think there’s a lot of good also, you know, on the positive side, one of the other things that keeps me so upbeat is we’re seeing so much on the transparency front, price, transparency, quality transparency, we have a big initiative, you’re creating quality measures of the appropriateness of care through global appropriateness measures or ga measures calm a lot of use of these appropriateness measures, especially as an alternative to pre authorization so we can Gold Card physicians. Lots of good So, you know, websites are popping up now with price transparency, we got the executive order passed on a bipartisan basis for disclosing those secret discounts that the insurance companies have. So lots of good stuff is happening. I’m really optimistic. And the thing that gets me most excited as the young generation students, residents, doctors, nurses, you know, for millennials, social, social justice is a generational value. And it’s exciting, it’s invigorating.
Nick van Terheyden
Fantastic. Well, unfortunately, as usual, we’ve run out of time. I agree with you, 100%. I think, you know, the opportunities are bound for us to really benefit from the insights to really make a difference, you know, apply some of the technologies that we’ve advanced at record pace, albeit still not as fast as it should be. For those of you listening, even if you read the price, we pay, you need to read the updated version. It’s got updated stories, and results as a result of the incredible focus that you’ve applied to the various communities and challenges. So I would encourage you to read it just remains for me to thank you for joining me today. Marcy. It’s been a great pleasure,
Marty Makary
Nick, great to be with you. As always, thanks for having me.
