Cure sometimes, heal often, comfort always.

15th Century Health Care Aphorism

The other day my father called me and said, “You’re never going to believe this!” I’m easily surprised, so it was a shock to me that my stoic father, who seemed to be unfazed by anything, would be outraged. “Guess how much your Aunt paid for a single night of staying in the hospital?”

If your first response, like mine, was, “Do you mean the list price or how much she actually owed?”, then you’re probably really into American healthcare and all of its pricing trials and tribulations. This week’s read: “The Price We Pay: What Broke American Health Care and How to Fix It” by Marty Makary, MD, is going to provide you with a lot of great anecdotes and easily cite-able data, but it’s not going to radically change your viewpoint or understanding of the situation. The good doctor, an incredible writer and deep thinker, provides a sweeping narrative about the broad strokes of what is wrong with American healthcare. I will focus most here on his prescriptions for success and why I think they are flawed or sound, plus share my take on what’s to be done.

By the way, the answer to my father’s question was $17,000 (list price). Given my past experiences with inpatient bills for childbirth, I thought my Aunt got the deal of a century.

Solution #1: Create the Tesla of Healthcare

Dr. Makary poses the reader a question: “Do you like buying a car?” For most people the answer is clearly no. Salesmen are impossible to haggle with, want to slip you into some car on the lot that you don’t want, and change the terms at the last minute. As someone who has gotten into it in the middle of a showroom floor, I can attest that the experience is awful.

By contrast, go and buy a Tesla (no, not the stock, it’s too expensive now anyway). Teslas cannot be bought in a showroom. They don’t have salespeople harassing customers and independent dealers selling service warranties. Instead, an online portal allows potential Tesla owners to customize cars and have them delivered directly to their homes. The showrooms are just that: showrooms. Places to test drive cars and fall in love with the brand.

To Dr. Makary, this model is clearly working for Tesla and should be replicated by the healthcare industry. He cites as a model company Iora Health, a Direct Primary Care (DPC) regional Medicare Advantage-focused insurer. As he relates:

Iora’s founder and CEO, Dr. Rushika Fernandopulle, a Harvard-trained primary care doctor, didn’t like what he was seeing in the health care industry: the assembly line method of seeing complex patients, rushing them through the exam rooms, ordering large swaths of tests, then chasing down insurance companies for payment… At the core of the model is time. Iora carves out a lot of time for each patient… They coordinate care and strive to achieve the best health outcomes.

I want to be absolutely clear: I believe this is the correct model of health care. Not only does it belie the shift in narrative (changing from “insuring downsides” to “providing care”), study after study shows the increasing importance of considering Social Determinants of Health (SDOH) in creating a healthy population. Therefore, the entire picture should and must be taken into account in any future vision of primary care.

“Your zip code can affect you more than your genetic code. For example, for people living in the Chicago Loop, life expectancy is about 83 years. On the other hand,those living 3 train stops south of downtown, in Washington Park,have a life expectancy of only 69 years. The gap in life expectancy between these two neighborhoods is larger than the life expectancy gap between the U.S. and Honduras.” – Healthbox, Root Causes of Health Report

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However, the industry has not yet proven that DPC will result in better, more efficient care across all populations. Companies like Iora Health have started by selling Medicare Advantage plans which, much like Tesla[1], cater to wealthy individuals with choice and time on their hands. DPC has been challenged in rolling out to lower-income populations and the 150 million Americans who get insurance through their employers, although companies like Wal-Mart and CVS/Aetna are starting to show promise in reinventing primary care.

Solution #2: Price Transparency

The second solution Dr. Makary puts forth is transparency. As Justice Louis Brandeis famously remarked, sunlight is in fact the best disinfectant[2]. And on this again, I agree with Dr. Makary[3]. He highlights a company named Healthcare Bluebook that aims to bring exactly this level of insight to the everyday patient experience. It’s also worth highlighting, in my opinion, some of the great state and local efforts like New Hampshire Health Cost.

I wrote about this topic in relation to a personal experience in a previous post entitled “Price Transparency: Healthcare’s Silver Bullet?” Briefly restating my counter-argument to Makary here: yes, transparency will absolutely help consumers comparison shop when there is an elective procedure that needs to happen eventually and there is time on the patient’s side (e.g., childbirth, knee/hip replacement). But as I learned firsthand, when there is an emergency and/or emotions are involved (e.g., ER visit, cancer, pediatric anything), sometimes price is not the problem. The lack of time combined with the indirection of a provider -> hospital -> insurance -> patient loop means that choices are not actually being made with rationality in mind. In this case, price transparency would do very little toward creating an Econ 101 competitive market with maximum consumer/producer surplus. The Atlantic said it better than I could, when describing a $94,000 prostate operation to prolong a terminal cancer patient’s life by two weeks:

The problem with these straightforward economic calculations is that they involve real human beings who have friends and relatives. That 94-year-old cancer patient, after all, may have loving children or grandchildren at the bedside; hardly anybody is willing to let Grandpa die just to save money for the overall health-care system.

T.R. Reid, “How We Spend $3,400,000,000,000”

Solution #3: Eliminate the Kickbacks and Middlemen

This is a bit of a catch-all, so I want to get a few specific players lumped in here. Dr. Makary (as many doctors do) feels that insurance brokers, pharmaceutical benefit managers (PBMs), and wellness consultants (among others), provide very little (or no) added value to patients and payers while at the same time massively inflating the cost of healthcare.

Let me start with the last one first: wellness. As Dr. Makary puts it:

America’s love affair with workplace “wellness” is costly and dangerous… We all should eat sensibly, exercise, stop smoking, moderate our alcohol consumption, drop excess weight… That’s not what I’m talk about. Today’s wellness movement is a $6 billion industry run amok… There’s an army of companies and consultants who can’t wait to get their hands on American workers.

Most of the author’s proof to back this up relies on a survey study done by Tufts Medical Center that evaluated over 2,000 wellness programs and concluded evidence for any positive impact was limited and inconsistent. And while this is compelling, I was not persuaded by the rest of his “anecdata”. For instance, he recalls berating a wellness consultant for promoting a low-fat diet, touting the controversial book Good Calories, Bad Calories as the bible for how every diet should be. To me, this smacks of arrogance, as recent work by researchers (shown in the incredible documentary Game Changers) is showing evidence that a high-fat, animal-based diet may actually be contraindicated by the fossil record and our evolved anatomy. Perhaps money being spent on the wellness industry is fueling research and evaluation of different diets, even if they come to conclusions Dr. Makary disagrees with. Plus, I would make the argument that the wellness industry (especially the burgeoning Wearables category) will be vital to a consumer-driven health care system that goes beyond the four walls of the traditional hospital.

Now how about insurance brokers and PBMs? How do these middlemen inflate the cost of healthcare? Well, as the argument goes, middlemen seek to enrich themselves by having their clients select the most expensive options, collecting high fees, and calling themselves “Value-Added” without actually adding any value. In fact, this is the exact same criticism that the Trump administration leveled at PBMs (and then later withdrew).

According to the National Health Expenditures Account (NHEA) Table 04, the 2018 Net Cost of Health Insurance[4] was $258.5 billion (7.6% of NHEA). This is no small amount. By contrast, retail sales of pharmaceuticals totaled $335 billion for the year. Unfortunately, we don’t know how much of that subset is fees/rebates going from the premiums paid to insurers back down to “value-added middlemen”. Without this knowledge, it’s unclear what the true cost – or true benefit – of all of these middlemen is, no matter how morally repugnant their job may be.

By the way, many have argued that we should just remove that line item from the NHEA entirely with nationalized medicine! That’s a valid argument, but not in line with Dr. Makary’s calls for price transparency reform and direct primary care which only are needed in competitive, privatized systems. For privatized systems, the answer is probably “smarter regulation”. But beware, even the best-intentioned regulation like limiting profits creates its own problems.

Thad’s Solution: Yes, And… Focus!

I have talked at length in this review about all of the things that Dr. Makary has laid out and where I agree or disagree with them. But what if I were king for a day? Don’t oppose, propose!

So here it is: combine direct primary care, price transparency and kickback/middleman regulation to create a privatized system where high-cost populations can be more efficiently. Target Americans 55 and older who spend $1.9T on healthcare every year (56% of all health spend for 29% of the U.S. population). Aggressively manage diabetes, kidney disease, and other cost sinkholes. Use taxation sticks and carrots to actually drive behavioral change.

My only problem really with Dr. Makary’s solutions are that they are too broad-brush in their application. Remember the “Willie Sutton Rule”: look where the money is.

Sidenote: we could easily make this bipartisan: Medicare-for-All-who-want-it and the abolition of federal debt. Given that federal health entitlements account for 29.4% of the U.S. Budget, it turns out that better caring for our nation’s most vulnerable is actually sound fiscal policy. Who knew.

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Living Outside the Beltway. On the next installment, I am going to talk about “Beyond Peace”, Richard Nixon’s final book before he died. Given the impeachment saga in Washington and the upcoming Iowa caucuses, I thought a politics-themed review was in order!

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About “Executive Book Report”. This is a passion project brought to you by Thaddeus Diamond, a Computer Science and MBA grad currently working in the Kansas City area.

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[1] Not to be the party pooper, but Tesla still has barely turned a profit. In addition, the Model 3 retails at $39,990 with zero customization or packages, more than 10% higher than the average full-size sedan competitor.

[2] I don’t think Justice Brandeis ever had bleach.

[3] Although I will say I find Dr. Makary’s argument a little suspect because he himself admits that price transparency wouldn’t help in End of Life care. Specifically, he calls out that his Improving Wisely project helped predict overtreatment based on the proportion of oncology patients in a physician’s care dying while on chemotherapy and/or radiation. If 10% or 20% were dying on chemo or radiation, that’s probably normal, but 80% to 100% might suggest poor discretion on the part of the oncologist. According to the National Cancer Institute, the initial treatment of cancers in 2018 was $46.6B nationwide (1.37% of U.S. NHEA).

[4] “Net cost of health insurance is calculated as the difference between CY incurred premiums earned and benefits paid for private health insurance.  This includes administrative costs, and in some cases, additions to reserves, rate credits and dividends, premium taxes, and plan profits or losses.  Also included in this category is the difference between premiums earned and benefits paid for the private health insurance companies that insure the enrollees of the following programs: Medicare, Medicaid, Children’s Health Insurance Program, and workers’ compensation (health portion only).”

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Dylan Thomas (1951)

Global life expectancy has risen from less than 50.0 years circa 1900 to 72.0 years today largely due to improvements in nutrition and public health. In the 1950s, people over 80 were only 1% of the U.S. population. Today that has quadrupled to 4%. China has more than 100 million elderly people.

The global aging crisis is real, and here. Global prosperity has inverted our traditional population distribution from a bell curve to a pyramid. As a result, the specter of old age is causing global governments to shore up their safety nets, revamp their policies on immigration, and make systemic changes to how we treat the dead and dying. Dr. Atul Gawande, in his sweeping opus Being Mortal, does no less than narrate and propose solutions for the entire issue. In his own words:

This is a book about the modern experience of mortality–about what it’s like to be creatures who age and die, how medicine has changed the experience and how it hasn’t, where our ideas about how to deal with our finitude have got the reality wrong… neither I nor my patients find our current state tolerable. But I have also found it unclear what the answers should be, or even whether any adequate ones are possible.

Though modest, his book is actually a stunning piece of work, and instantly became one of my favorites. Weaving data from demographic, medical, and popular sources with personally touching narratives of his patients and family, Being Mortal tackles the weightiest of all topics and leaves the reader incredibly satisfied.

When discussing this book, it is important to take it in three sections. First, the overarching narrative around “how we age and die”. Dr. Gawande charts the evolution of societies from Pre-Industrial to Developing to Industrial, and the mirror evolution that our treatment of the elderly takes. Second, Dr. Gawande tells a lengthy, complex narrative about his first exposure to caring for a loved one: the death of his grandmother-in-law due to natural mental and physical decline. Finally, Dr. Gawande closes with a very touching (yes, I cried!) discussion of his father’s struggle with, and eventual death from, a rare form of invasive spinal cancer.

The Practice of Aging – Dr. Felix Silverstone

Throughout the first half of the book, Dr. Gawande uses the narrative of Dr. Felix Silverstone, an eminent geriatrician experiencing his own physical and cognitive decline, to talk about the history of aging.

Societies pass through three stages: Pre-Industrial, Developing, and Industrial. In the Pre-Industrial phase (e.g., America before the Civil War, China before accession to the WTO, India in Dr. Gawande’s grandfather’s time), families care for the elderly. A relative lack of geographic mobility, combined with a human predilection to respect the elderly, leads tight-knit kin groups to care for their elders through their final declines. The Farewell, an upcoming movie starring the hilarious Awkwafina, actually touches on the Chinese tradition of surrounding family members in their final days.

Old age is a continuous series of losses. – Dr. Felix Silverstone

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Economic development radically changes this familiar formula. As the wealth of a nation increases, the mobility of its citizenry tends to increase as well, leading to families dispersing geographically. In addition, reduced infant mortality rates actually lead to the average number of offspring declining. This combination leaves the elderly either partially or entirely alone late in life. In turn-of-the-20th century America, in the wake of the Gilded Age, 2/3 of United States poorhouse residents were elderly. In India today, a similar situation exists (which Dr. Gawande describes as “straight out of Oliver Twist”).

The moral outrage of these conditions in a fully developed society (in combination with surplus wealth from a now-mature economy) leads to the emergence of social safety net programs like Social Security (1935), Medicare (1965) and the ability for people to die in their homes again. In the U.S., a clear majority of deaths occurred in the home at the turn of the century. Although this figure dropped to 17% by 1980, since cementing our status as a fully Industrialized nation in the 1990s this number has steadily climbed.

The job of any doctor, [Dr.] Bludau later told me, is to… [provide] as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself. And if it doesn’t… well, that isn’t really a medical problem, is it?

Trying to Age Alone at Home – Alice Hobson

To explore how a society undergoes the shift from Developing to Industrialized, the author relates the story of his own grandmother-in-law, Alice Hobson. Born on a farm in a rural Pennsylvania town, Alice had a quintessential 20th century American life, marrying a civil engineer named Rich, and raising two children in Arlington, VA. Sadly, Rich preceded Alice in death due to a sudden heart attack in 1965. At 56, Alice was a widow.

Alice was a strong, self-sufficient woman. For years after Rich’s death, she lived on her own in the same neighborhood as her children. As the author recalls, “she mowed the lawn and knew how to fix the plumbing”. However, the writing was on the wall. In 1992 at the age of 86, Alice began having falls and experiencing visible confusion. Her family worried: was it really safe for her to live at home anymore?

I asked [Felix Silverstone, the former senior geriatrician at Parker Jewish Institute] whether gerontologists have discerned any particular, reproducible pathway to aging. “No,” he said. “We just fall apart.”

With nothing clearly medically “wrong” with Alice, the family had few options. Alice wished to remain in her own home, but it was clear she was unable to. She despised leisure-focused “retirement communities” like those Del Webb pioneered in the 1960’s. After searching with her son Jim, Alice ultimately chose to use the proceeds of selling her home to secure a spot in Longwood House–a pseudonymous senior-living facility that had private units combined with a Skilled Nursing Facility (SNF) ward for residents who could no longer live on their own.

Unfortunately, when Dr. Gawande visited her a few weeks later, “she [didn’t] feel at all happy or adjusted.” Rather than feeling that Longwood had provided care and amenities for her to continue living, Alice ultimately felt that Longwood had completely replaced her life. “She never got used to being there or accepted it”. After falls in her own living room forced her into the SNF ward of Longwood, Alice became dejected. She remarked to her son Jim, “I’m ready” and passed on quietly during the night.

Decline on Your Own Terms – Dr. Atmaram Gawande

The final section of Being Mortal is devoted to the moving story of the author’s own father, Dr. Atmaram (“Ram”) Gawande. In 2006, after experiencing neck pain and hand numbness that won’t subside, Ram gets an MRI and is presented with startling news. A slow-growing tumor has invaded his spinal canal and is beginning to compress all of the major nerves that control his bodily functions. Consultations with leading neuro-oncology surgeons present Ram with an option: open the spinal canal, remove as much of the tumor as possible, and create space for the tumor to grow without causing total paralysis.

“My father came to his end never having to sacrifice his loyalties or who he was, and for that I am grateful. He was clear about his wishes even for after his death.” – Dr. Atul Gawande, Being Mortal.

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The possibility of undergoing such a drastic procedure frightens Ram, who then begings to ask probing questions: “Do you use a microscope? How do you cut through the tumor? How do you cauterize the blood vessels?” The first consultation – at Dr. Gawande’s own institution no less – is with a surgeon who quickly becomes peeved. After deciding that this was not the man to cut him open, Ram visits with a Cleveland Clinic neurosurgeon named Edward Benzel. Dr. Benzel answers all Ram’s questions and then presents an alternative: what if we keep an eye on the situation without surgery? When you decide it’s time to have the surgery, we’ll schedule you right away. Ram and Dr. Gawande are both incredibly relieved, and agree to follow this course of action. A year later, a repeat MRI shows the tumor has grown significantly, but Ram’s quality of life had hardly been impacted at all. No surgery is on the horizon, and life moves on.

But the good run does not continue forever. Although avoiding surgery had allowed Ram to maintain his quality of life, in 2009 his symptoms begin to change. He retires from his practice, but continues to delay surgery. By 2010, Ram struggles to walk, and Dr. Gawande sits him and his wife, Sushila, down for a talk. Using tactics he had learned from palliative care expert Susan Block, he begins:

“I’m worried.” [Atul Began]. “What are your fears if you should become paralyzed?”

“That I will become a burden to your mother and be unable to take care of myself.”

“If you could still eat chocolate ice cream and watch football on television, would that be enough for you?”

“That wouldn’t be good enough for me at all. Being with people and interacting with them is what I care about most. I can’t accept a life of complete physical paralysis, of needing total care.”

“Your advancing quadriplegia will mean twenty-four hour care, a ventilator, and a feeding tube. It sounds like you don’t want that?”

“Never. Let me die instead.”

(Paraphrase)

With this framework in place, Ram finally undergoes the spinal cord decompression surgery. It is a success, and seven hours later, his spinal column had been opened, small bits of the tumor removed, and general decompression performed. Ram would stave off full-blown paralysis.

But not for long. Unfortunately for Ram, oncological specialists press him to take a course of radiation and chemotherapy over the next several months, leading to severe side effects and frustrations (especially for Sushila, Ram’s primary caretaker). Finally resigned to his fate, and understanding that even the state-of-the-art treatments will not extend his expected lifespan beyond 3 years, Ram makes the decision to enlist home hospice care.

Dr. Gawande (being the elitist Bostonian he is), fully expects the Appalachian nurse from hospice to be completely incompetent. Instead, she is concise, direct, and caring. She sets an action plan in place, provides Ram with support to live his final days, and actually improves his quality of life.

Together, the family and caretakers string together good days, good weeks even, but troubles remain. Struggles walking, talking, writing, and even using the bathroom plague Ram. Dr. Gawande comes to Ohio to stay with his father full-time, along with his sister (who is able to introduce her father to her future husband). Finally, Ram’s time comes. The author writes:

[At the end], he asked for the grandchildren. They were not there, so I showed him pictures on my iPad. His eyes went wide, and his smile was huge. He looked at every picture in detail. Then he descended back into unconsciousness… [Finally], we went to him. My mother took his hand. And we listened, each of us silent. No more breaths came.”

Concluding

How do we conclude our lives? What is the “right” answer? The book’s epilogue includes a touching (and funny) tribute to Dr. Gawande’s father, describing how after Ram’s death, the family travels along the Ganges river to spread his cremated ashes, as per Indian tradition:

The Ganges might have been sacred to one of the world’s largest religions, but to me, the doctor, it was more notable as one of the world’s most polluted rivers, thanks in part to all the incompletely cremated bodies that had been thrown into it. Knowing that I’d have to take those little sips of river water, I had looked up the bacterial counts on a web site beforehand and premedicated myself with the appropriate antibiotics. (Even so, I developed a Giardia infection, having forgotten to consider the possibility of parasites.)

But for the rest of us, Dr. Gawande has no single prescription. The path forward it seems is for us to move toward a post-Industrialized state where we can use creative, non-institutional forms of medicine to improve our quality of life in the final years. He cites a study by Dr. Chad Boult, a geriatrician with the University of Minnesota, that found that simply having a team of geriatric nurses and doctors see high-risk patients over the age of 70 resulted in a 25% reduction in disability, 50% reduction in depression and actual cost savings by reducing home health service utilization by 40%. Although mortality rates among the control and treatment groups were equivalent, there can be little doubt this points to the possibility of reducing costs and improving outcomes in tandem. Marching toward the Triple Aim through innovative medical treatments and more compassionate care is as good a solution as any.

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Next Time: War Plan Orange by Edward S. Miller

Next time: we go to war! I will be reviewing War Plan Orange by Edward S. Miller, a fantastic treatise on the process of planning a war against Japan in the pre-World War II era. If you liked this, don’t forget to sign up below to get this analysis delivered straight to your inbox!