Cutting Through The Money Games (& Restoring Medicine To Its Mission)

– Guys, supporters first and everyone else later. I rarely get this insane about a guest and fanboying, but today we have a guest that you guys, first of all, listening to him is one thing, but reading his new book The Price We Pay, which I read in a day, that’s how good it was, it basically summarized everything I’ve been screaming about for years, but with amazing research and actual bright spots, pointing our where things can be fixed, about how health care, this is not a free market. This is crony capitalism price gouging, and we need to talk about it before we can transform it, and it means us guys, front line health care professionals need to take a stand on this. We need to read the book because we don’t understand how medicine as a business has destroyed the art and the heart and the soul of it, and Dr. Marty Makary is a renowned Johns Hopkins pancreatic surgeon and has a New York Times bestselling book called Unaccountable and wrote this book and is a world-class quality researcher and coded the, actually developed the surgical checklist that he and Gawande wrote about that you may have heard of. He is a personal hero of mine, despite working on Fox’s The Resident, which was based on Unaccountable. We have him here today. Dr. Marty Makary, welcome to the show brother.

– Sounds like you believe in forgiveness.

– I do. I’m a man of great moral standing in terms of forgiveness. No, listen, it’s funny. We saw The Resident, and it said, Based on Unaccountable by Marty Makary, and I’m like, dude, Marty’s a good guy, like he’s a master of quality. This show’s gonna be dope, and so we watched it live and we actually put out a video of me reacting to it and I realize watching it back, every time I took a dump on the show it was about the drama or the little factual inaccuracies.

– Hollywood sensationalization.

– Exactly. Every time I was like, yeah that’s right, yeah that’s right, yeah that happens, that was stuff based on your book. For example, Hodad, right, hands of death and destruction?

– [Marty] Yeah.

– [Zubin] Tell me how that whole thing came about. Was this your training at Hopkins?

– No, I just did my fellowship at Hopkins, but in rotating in med school, we would see these sort of icons of the field have this internal reputation as the surgeon you want to avoid.

– [Zubin] Uh huh.

– So this guy had this reputation as being called Hodad for Hands of death and destruction, even though people would fly in from overseas and celebrities would roll in just to try and get in his practice, and we’re kind of like, you really don’t want to be in that operating room, and so Hodad, and then the vice versa character, the Raptor.

– [Zubin] Right.

– It sort of became, I think, symbolic of a lot of the doctors we work with or doctors whose ring we kiss as you like to say, in training, so I think those characters, they ran with it, added some stuff from Hollywood, and of course, every now and then, I’ll be like, “Dude, we don’t use a knife to place a central line,” and they’re like, Marty just relax a little bit, okay? Just chill out. I said, it’s a needle-based procedure. So, no I had nothing to do with doing CPR on the stomach and other things like that. There’s a reason why my contract selling the book rights of Unaccountable to The Resident has it that my name will not be on the show, because they did sensationalize, but I poke fun at them, they’ve done good stuff, talking about the drama of medicine, and it’s getting better, the show is getting better.

– That’s great, and you’re kind of a consultant, and you kind of hang out. It’s kind of cool to be so as connected as you are, ’cause we were talking before. We were introduced by Dr. Peter Attia actually.

– [Marty] Great guy.

– Who’s a mutual colleague and friend, and he was on the show and then you had connected with me when I was out in D.C. doing a talk for AMGA, and we had lunch in a place, tell me about this place you took me to. Can you talk about it?

– Peking Gourmet Inn. Yeah, it’s a favorite for politicians and George H. Bush discovered it because his nephew went there and then they could bring the motorcades behind this strip mall.

– [Zubin] Yeah.

– And he could get in and out, so he just got the craving. It was great food, wasn’t it?

– [Zubin] Oh, it was amazing.

– So you get addicted to it, so George H. Bush, and W. also, would say in the middle of the day, “I’m hungry, let’s go to Peking Gourmet Inn,” and Secret Service would call, roll the motorcades into the back, and one time they actually had no seats available, and they said, we cannot accommodate. Sorry, we just can’t ask anyone to leave, and they kept calling back. “The President says he will sit anywhere. “Any seat, he will sit anywhere!” I’m sorry, we don’t have any seats. So it’s got everyone’s picture on the wall, it’s got bulletproof glass.

– Yeah, all the Presidents were there, bulletproof glass. I’m like dude, when was the last time I ate a hole-in-the-wall Chinese restaurant with bulletproof glass, okay?

– [Marty] Right.

– So, we had this discussion about, it’s funny ’cause the garbage truck is out there, which is the man trying to silence us, Marty. I’m just telling you.

– Corporate health care interests put a garbage truck out front?

– Exactly, ’cause when I read this book I’m like, you’re gonna get murdered, and I’m only partially joking, because what you’ve done with this book, and I think it relates back to your training with Hodad and your experience in medical school and kind of the hierarchy and the encouragement of just an individual doing everything and the idea that it’s all about competition and individualism. Well it turns out that, that has now infused our health care system with some of the worst practices, the most inhumane practices where you are literally reaching into somebody’s wallet and robbing from them their livelihood, their time, the time that they’re working, spending with their families. These are Walmart employees, and we’re gouging them, and by we, I mean all of us are complicit in this, whether we know it or not, and I think most of us don’t know it. That’s why the book was so important. What prompted you to work on this?

– Well, first of all, I loved your language now, because that’s what we need to do is we need to change the language. In medicine we have the most sterile, impersonal, detached language that is totally consistent with the lack of self-awareness that we promote in this indoctrination process called medical school and residency, right. We take these highly creative people who have these very noble ambitions to help people and do good in this great heritage of the medical profession and we beat them with this regurgitation of the Krebs cycle and this language and we don’t call a spade a spade, and even in publishing things in the medical journals they beat me down. “You cannot call it a mark-up. “You have to call it a charge-to-cost ratio.” Well, no one gives a rip what the charge-to-cost ratio means. They wanna know it’s a price, it’s a gouge, it’s a. Medicine has adopted a business model of price gouging, and not everywhere but some places and it’s a disgrace to our profession, and I think we just need to call things out, and you do that and that’s one of the reasons I love the Z-Man and the Z-Pack and I’m a huge fan of the Z-Pack.

– You know, you’re actually a subscriber.

– I am so into the Z-Pack, I have no bacteria left in my colon.

– It’s all just C. diff now.

– [Marty] It’s just an empty biome.

– I love it. An empty biome. So okay, let me tell people who are watching what this book kind of is about in a bigger sense and what I got out of it, because again I binge read it in a day, it was that good. So what you’re talking about is the business of medicine and how we’ve ceded as health care professionals the art and the relationship and the calling to what has now become this very big and unfathomably complex business, and through its own complexity there’s an opacity and a lack of transparency that then allows people, whether they’re conscious of it or not, to take advantage of our patients when they are at their most vulnerable, and I would get so angry reading these chapters and, because this is what I’ve been screaming about for the last seven years here in Las Vegas is, we are hurting our fellow human beings when we took an oath to help them, and it doesn’t mean that doctors are bad people or nurses or bad people or any of this.

– [Marty] Mmhmm.

– It’s, we’re part of a system that is complicit in criminal behavior, and it starts with the fact that.

– Legal criminal behavior.

– Legal criminal behavior. In other words, it’s just immoral. Just because it’s a law doesn’t mean it’s moral. We’re hurting fellow humans and an example is, let’s just start with hospital charges. How many of us have gotten a surprise out-of-network hospital charge? How many of us have gotten a bill from the ER for an injury that they got while hiking for $4,000 for a tetanus shot and three stitches, with no upfront understanding of what it was gonna cost, no clue whether it’s a quality improvement over a similar urgent care that charges $200.

– [Marty] Mmhmm.

– No clue at all, and where the physicians and the nurses and the respiratory therapists and the nutritionists, everybody on the front lines, has no idea what it costs either?

– [Marty] Yeah.

– They can’t tell you, and yet this is what we do in medicine and the mark-ups that they’re able to charge are obscene, and can you talk about it a little bit?

– Yeah, 57% of Americans have received a surprise bill, and for many people it’s devastating. Did you see the movie The Big Short?

– [Zubin] I did not see it directly.

– You’ve heard about it.

– [Zubin] But I know all about it, yeah.

– Yeah, the book, so I loved that movie, and when I saw that movie I thought, “Gosh, this movie has taken a very complex “and even boring, wonky industry, “credit default swaps and collateralized debt obligations “and wonky stuff and said, “we’re gonna break it down for you “so any person can understand it “and make it exciting, make it a thriller,” and so that’s what I tried to do with healthcare, because we’re in medical school taught medical literacy in residency. We’re taught medical literacy in our practices. We’re practicing medicine with the literacy that we’ve learned, but we are never taught healthcare literacy and that’s what I wanted to do is to explain the healthcare system, the business of medicine so that any person can finish reading this book and then feel like, now I understand exactly how every part of the healthcare system operates, what the money games are, and how we can cut through it. You know, you mention you wouldn’t be surprised if I get shot, or I forget how you said it.

– [Zubin] Murdered.

– Murdered.

– [Zubin] Mmhmm.

– You know, I’m a cancer surgeon. I’m breaking bad news every week. I’m constantly reminded how life is short. We can continue to play the game and go through these academic games of get a promotion and publish an article in a journal that hardly anybody reads and talk to ourselves, or you can just speak your observations to heart and call things out when you see it, and so I’ve often thought the academic game is phony. I’m at the top of it. I’m a tenured professor at Johns Hopkins, and my senior partner is maybe one of the most famous surgeons in the United States. There’s nowhere else to go up, and what else do you do? Do you parade around how people need to use a certain technique in the operating room, or do you look at the data that a quarter of the public right now doesn’t trust us because of the business of price gouging? Forget about access. It used to be that when people got hammered with big medical bills, society blamed them. You’re uninsured. How dare you be irresponsible and not have insurance. Well guess who’s getting hammered with medical bills today, the everyday hard-working American with insurance who’s going to out-of-network providers even at in-network facilities. There’s a bait and switch going on. We’re part of it, we didn’t design it. We’re a part of it. We can change the system from within and talk to our own leaders and basically call out these practices of what I call predatory billing.

– [Zubin] Hmm.

– Price gouging in the marketplace, egregious mark-ups. If we used the right language, a mark-up is not evil. If you deliver care that’s better, and you charge twice as much, good. The market should reward that.

– [Zubin] That’s capitalism, yeah.

– That’s capitalism, that’s a free market, but what we have is this intense, dysfunctional game of taking advantage of people when they’re vulnerable, price gouging them, and then seeing how much we can shake them down for, and we don’t do it as physicians. It’s done by the middle industry around us.

– [Zubin] Hmmmm.

– Right, the re-pricing industry. I didn’t even know that existed before I started the research for this book.

– There’s a lot in this book that I didn’t, I actually have been studying it for a while but I think that most of the country is not gonna know that this exists, this idea that there’s a whole cadre of hospitals that will sue working class patients for medical bills that are unpaid. Now, here’s the thing. If I don’t pay my mechanic, I expect him to sue me to get that money back. That makes sense because it’s a fair price for services rendered and I didn’t pay. The problem with medical bills is it is not a transparent, a competitive, or a fair price. It is a price-gouging mark-up over what Medicare would pay because hospitals can do it. They say, well oh nobody pays the marked up prices because people have insurance, except when they have high-deductible plans, or they’re uninsured, and so what do these hospitals do? Often the CEO doesn’t even know it’s happening. They’re suing their own patients. Can you talk a little bit about that, ’cause that made me so furious as a physician to see that we’re hurting our own patients?

– Yeah, and first of all, if your hospital or your practice charges two or three times the Medicare allowable amount, then okay maybe that’s a reasonable, fair price. We’re not saying everyone should accept Medicare prices, but right now it’s the Wild West. If you charge five, 10, or our research even shows 23 times the Medicare allowable amount, in a study we did of emergency room service, emergency department services and oncology services. Two papers, we got hammered by the journals. Nobody wanted ’em. We finally got ’em published in JAMA Internal Medicine and another journal, and these two articles, they forced us to change the language, they sterilized us. They took out all of our passion in the article. They did what medicine does to its own creative people and we pointed out a 23 times mark-up is egregious. A researcher published what I consider to be the article of the decade. No one noticed this study, but I noticed it. A cardiac surgeon called 100 heart hospitals in the United States and says, “How much does it cost for a CABG?” He fought and went through the voice menu, and they transferred him and hung up on him, and he called back, and in the end, 51 out of 100 so hospitals could give him a price. The price ranged from $44,000 to $450,000. He then matched the price with the STS outcome database, which is, as you know, the most mature public quality reporting database in medicine, and found no correlation whatsoever, and sometimes when we take these egregious bills that hospitals produce to doctors, most of the time doctors do the right thing or try to most of the time, right, but generally speaking, they’re offended by these bills. They’re outraged by, they call it despicable, but many times the doctors have, we have this knee-jerk reaction as physicians, well that’s to make up for the charity care.

– [Zubin] Right.

– It doesn’t, it’s not to make. There’s no correlation between the mark-up and the charity care. This is sort of health business 101, right. This is the healthcare literacy that we’re not taught, and there’s no correlation with charity care, it’s the Wild West. I went to this hospital, I don’t want to name it.

– [Zubin] Yeah.

– ‘Cause you know, the number of lawsuits that I’m probably gonna be facing with this book are high. It’s all defamation nonsense.

– [Zubin] Yeah.

– Nothing legitimate.

– [Zubin] Yeah, defensible.

– Yeah, and nothing’s been filed yet, but I’m ready, bring it on.

– [Zubin] Uh huh.

– The heck, life is short. Columbus took a chance. The hospital near ski, near Vail Mountain, okay, they charged a guy $10,000 for coming in for a few minutes to tell him you probably have altitude sickness. Does the hospital at Vail Mountain take care of so many uninsured patients that they have to compensate on the mark-up for all of the uninsured, homeless skiers at Vail Mountain? No, it’s just a pure game of price gouging.

– It, what’s sick about it too, is a lot of time it’s the quote unquote non-profit hospitals that play this game.

– [Marty] Non-profit hospitals do it more.

– They do it more?

– So, they do it more, and so we did a big research study of hospitals in the state of Virginia, okay. Hospitals in the state of Virginia, most will never sue a patient for an unpaid bill. About a third will, and then 10% will just sue the shit out of people.

– [Zubin] Mmhmm.

– They’ll go after them, you know. UVA for example, UVA will sue the shit out of you.

– [Zubin] Mmmmm.

– An institution that gets taxpayer funding.

– [Zubin] Mmhmm.

– You don’t pay a bill, they’ll take you to this little courthouse in Virginia where me and my team go frequently, and we tell the patients going in there, “You’re not obligated to pay this bill “because there’s no legal contract.”

– [Zubin] Hmm.

– I can’t mow your lawn, and I’ll tell the judge this, if they allow me to be their ex, pro bono expert, we just did this on Friday. We do this regularly, me and my students, my team, doctors, residents, concerned citizens, we go to these small towns in America where the hospitals are suing the shit out of people and we offer to be a free pro bono expert. I put my name on the case and I tell the judge I can’t mow your lawn and then charge you $50,000 without a contract. There’s no contract here. Whatever they signed was a consent to treat. That’s when they were vulnerable. That’s not valid. You can’t sign your life away financially and by the way, where’s the spirit of medicine? Where’s the mission of the hospital? Where’s that charter? We’ll read the charters to these judges. Here’s a hospital charter that, “We aim to be the living hands “of Jesus Christ in the community.” We, one hospital said, we are dedicated to caring for the sick and injured, to be a safe haven, regardless of one’s race, creed, or ability to pay. That is our incredible medical heritage, and then these hospitals are suing the shit out of people? It’s an anathema, it’s a disgrace, and it’s gotta stop and these hospitals are paying no taxes. So every case that we go to, now in court, me and our, the Restoring Medicine group, the judges are telling us in the courtroom, the case has been canceled. Every time the hospitals see my name on the case as the expert.

– [Zubin] They back down.

– They’re canceling. How are they canceling $50,000 bills? Because they know they’re egregious bills.

– These fucking people, Marty, and this is the thing. When we were sitting down, and these are not. Let’s be very clear, it’s not that the doctors and the nurses and the people who staff these hospitals are doing this.

– [Marty] They don’t even know it’s happening.

– They don’t even know it’s happening. It’s like being part of a financial Holocaust and not even knowing that it’s going on, but what they’re doing is they’re, first of all they’re price gouging people when they’re most vulnerable, when they’re sick, then they’re coming after their assets, their credit rating, all their mortgage interests go up, everything. It destroys their life. It is a kind of financial rape that they’re inflicting on human beings that we’re there to help, and then their mission says we’re the hands of Jesus and that. To me, the fact that nobody knows this, the fact that they back down when you show up, the fact that when you call them and you go through the hoops and you start to haggle for your bill, what happens when that happens? When I was reading your book, I was like, oh well, I’ll tell you what. Instead of $50,000, how ’bout you just pay us $30,000? That’s still 40x Medicare. Okay, then, well I’ll tell you what, we’ll do it for 20. Oh, so you can cut it that far, that much, by me making a call, but the little old lady who doesn’t know that just went into medical bankruptcy? What is it, one in five Americans have?

– One in five Americans have medical debt in collections. People have liens on their homes, now they can’t sell. One hospital CEO that I, you know, I call the CEOs in a civil fashion and I politely ask them, you’ve sued 20,000 people in your community of, by census data, 28,000 people live in your town. Does that strike you as excessive? Is that consistent with your tax-free status? And, by the way, the for-profit hospital HCA across the town has never sued anybody. There’s no court records of them. The courthouse has converted into a taxpayer-funded collections agency for the hospital, ruining the lives of these people and I’ll tell you. These are at restoringmedicine.org, we’re gonna have the videos up there, because we there on Friday and one of these Virginia courthouses, these farmers, these everyday, they don’t even have a paycheck to garnish. The hospital is trying to legally garnish their wages and there’s places in America where the hospital routinely goes after you in court. One CEO told me, “Well you know we’re,” they give me a different party line, “we’re happy to work with anybody. “We just want a communication with the patient. “If they engage with us, we’ll work with anybody.” Oh yeah? That’s not what we’re seeing. That’s not what we’re hearing on the ground. We’re hearing they called you 50 times and there’s voice menus and the woman at the call center said, there’s nothing I can do. One call center woman told a patient who’s a friend of mine, if we want to charge you a million dollars for those stitches, the law says we can do it.

– [Zubin] Wow.

– And so we’re trying to educate physicians, right. We did a survey asking doctors, do you know that your patients were sued? It’s a study we’re doing through Hopkins. Doctors have no idea.

– [Zubin] We have no clue.

– No idea.

– How could we, yeah?

– [Marty] And they’re outraged when they find out.

– Yeah, how would we not be? Like when I read this, I was so furious, and this is the thing. Who is, so who’s responsible for this? Who, what’s the bottom line and what are the bright spots? What’s the solution to this?

– Well, physicians have lost control of their own billing processes, so what happens is the hospital outsources it through the CFO to sometimes a collections agency or a law firm that comes up to the hospital and says, hey, we’re gonna increase your revenue cycle. Right, you change the language. Instead of calling it predatory billing, if you call it bad debt, we’re gonna reduce your bad debt, we’re gonna help your. I met a woman whose card literally said, from a hospital, Director of Revenue Enhancement.

– [Zubin] Hmmm.

– What the heck is that?

– [Zubin] Hmmm.

– Is that, was that a round way?

– It’s exactly what the journal guys are doing when they censor your language.

– [Marty] Exactly.

– It’s exactly what people try to do to me to censor my language and say you can’t say that, you can’t say that, it’s unprofessional.

– [Marty} Can’t have a heart.

– Shut the hell Up.

– [Marty] Yeah.

– Yeah, you can’t have an emotional connection to a subject matter so that people feel something and then want to change?

– [Marty] Yeah.

– And that’s what this book did. I mean, you can tell I’m pissed off, and I get pissed off pretty easy, ’cause I’m fairly volatile on my neurotic scale, but the truth is when it comes with a, also, a sense of connection to the moral purpose or what we do, then it can actually lead to real change, and so the question is, you point some bright spots. There are hospitals that don’t sue their patients. There are hospitals who make deals, not deals but, ’cause this term financial aid, we give our patients financial aid, that’s an euphemism for, we’ll cut it 10% off of already 1,000% mark-up.

– Yeah, we’ll cut 5% off if you agree to pay in monthly installments for the rest of your life.

– [Zubin] Right.

– I mean, that’s not financial aid, right? That’s gouging.

– No, that’s more financial rape as far as I’m concerned, and again I use that word because it’s tinged with emotion, but that’s what it feels like when someone reaches into your wallet and takes it. See, you’re working in life to make money so you can support your family, so you can spend more time with your family. To me this is a, the deepest type of betrayal, and that it’s coming.

– [Marty] Betrayal.

– From health care professionals, it’s a betrayal and the thing is, it’s part of a bigger game, right. So insurance companies pay the game, play the game with hospitals. It’s an escalating game. Well we’re gonna reimburse less. So, okay, we’re gonna mark it up so that we get a percentage. No one’s gonna know what those percentages are, because we signed a non, a gag clause, because otherwise that would lead to price transparency and people would be able to compete, and this is the take-home from this,

– [Marty] Yeah.

– Is this book, so people are say, “Oh, Marty Makary’s a socialist, “and he’s saying well, “we should should probably socialize medicine “because we’re trying to take care “of poor people and rich people alike “and therefore it’s the worst idea ever.” That’s not at all what you’re saying. What you’re saying is, we’re a free capitalist market competition country. How about we actually do that? Make it transparent, have people compete. You’ve worked with politicians and Presidents from both parties, ’cause you’re in D.C., talking about these issues. Doesn’t matter who it is, ‘ you’ll meet with Pelosi, you’ll meet with Trump. You’ll bring these patients and their stories, and I think that’s what’s gonna start to make a difference.

– We just brought a bunch of patients who had, they had the shit sued out of them for unpaid medical bills which were massively inflated in their small town. These are hardworking insured people. Our research shows that Walmart is the number one employer whose employees have their wages garnished by hospitals suing in Virginia. Food service workers are a close second, U.S. postal workers, nurses, hospital workers, I mean these people dedicate their lives to medicine and this is what we do? They stop by the ER for when their kid has asthma, and now they’re in court three months later? People are listening, good stuff is happening, doctors are rising up as we’re getting the word out. The President, I took patients who’d been sued to the White House twice and had them tell their story directly to President Trump and Secretary Azar. They listened and they were, and I’ll tell you, say what you want, they were moved and we’ve seen several initiatives announced from them, from the administration. This is not a partisan game. They had senators there last week to talk about bipartisan legislation. They promised it would be bipartisan. Nancy Pelosi’s office has been very interested in all this stuff, I’ve met with them several times. This is not, let’s not listen to the echo chambers of the facade of cable news, that we’re a divided people by these artificial boundaries. Those are not the real issues, right. The real issues are, are we gonna have an industry that thrives on gouging through secrecy and through a series of money games, and I personally believe the answer can be very simple. We need to eliminate secrecy in medicine, the secrecy of those negotiated rates, and to eliminate kickbacks, eliminate kickbacks in the PBM pharmacy space, eliminate kickbacks in GPOs, eliminate all kickbacks in healthcare.

– And I’ll tell you, we’re gonna talk some about this, but you gotta read this book to understand what he’s saying because nobody know what a GPO is, what a PBM does. They are middlemen parasites that are responsible, I’m just gonna call it like it is. They are parasites that are responsible for healthcare cost inflation that comes back to you. Oh, my insurance covers it, oh my employer covers it. No, guess where it’s coming from? Your future wages, the future economic growth of our country. You’re tying a leaden rope around the neck of our children with healthcare costs, and what do we have? Some of the worst outcomes in the developed world, which we’ll talk about too, why that might be, but here, getting back to this, so Lisa Dubois and others in the comments now are saying, and yet, our hospitals cut staff. Yet, we’re short staffed all the time. Yet, we don’t have the tools to actually accomplish all these quality measures they keep talking about, and yet, and yet, here you have a not-for-profit making money on the back of suing their own constituency and the air ambulance story is a fascinating one. There was a chapter on this. Air helicopter transports for emergency cases. It used to be, the hospitals kind of owned the helicopter and the process and they kept the costs basically at cost.

– [Marty] And it worked.

– And it worked, so if you needed an air ambulance or helicopter transfer to another hospital, you could get done and it was at cost. Maybe it’s $2,000, maybe it’s $10,000, right. Then, they started to, some business person decided, oh, there’s a profit here. Let’s take that off the hospital’s hands and turn it from a service we give to patients when they’re at their most vulnerable at cost to something that’s a profit center, and since they can move, they can just go wherever the profits are, and since it’s when patients are at their most vulnerable, they can charge whatever they want, and it’s often not covered by insurance and then the patients get the bill, and here’s the best part. When these air ambulances crash, as they do, killing nurses and doctors and paramedics, it is more often than not the for-profit companies that this is affecting because they will throw a bird in the air regardless of safety because it’s all about the bottom line, and I’ve heard this from front line paramedics who are like, the company that went down in this state, you should talk about them because they murdered these people sending them in the air for a dollar. More like $50,000. Some of the bills are the cost of the vehicle, of the helicopter.

– Of the aircraft.

– The aircraft costs this, and they’re charging $200,000 to a patient.

– [Marty] Yeah.

– It’s insane.

– Yeah, so private equity bought up a lot of the hospital helicopters and planted their own in many areas of the country, and when these companies were public, many of us were looking into the public records to find out that the gouging going on, the crazy gouging, and guess what they did? They de-listed, they didn’t want to have that scrutiny of being a publicly reported on company. Now, I don’t want to mention them individually, ’cause one of my, one of the people I met in Montana who now runs an air ambulance brokerage group, said something like, people are getting ripped off, or they’re overcharging, this company’s overcharging, I don’t want to quote.

– [Zubin] Sure.

– The exact thing. That company, private equity-owned, sued him for defamation, sued them for defamation. Rather than settle and get gagged like everybody does and that’s the game lawyers play, he said no, this is immoral. I’m gonna fight this to the bitter death.

– [Zubin] Wow.

– Okay, and that’s the kind of speaking up we need, and so people are afraid to speak up. How many people are speaking up about their own hospital bills? Sometimes they’re worried about the promotion, the internal academic promotion process. Let me tell ya, once you get to the top, the full tenured at a big academic center like Hopkins, you realize nothing’s different. There’s no prize at the end of the rainbow. You need to speak your mind. In Boston, to deliver a baby, uncomplicated, vaginal delivery, all inclusive, epidural, anesthesia services, that bundle costs $8,000 to $40,000 with everything in between. The Brigham and Women’s Hospital costs $40,000 and a lot of people like to go there. One company, the women said they like to go there because the word women is in the name of the hospital and maybe that means they’re more specialized in labor and delivery. Well the employer said, I would like my employees to deliver at the $8,000 hospitals because their quality is the same, they have good reputations, and I could save a lot of money because the $40,000 is clearly price-gouging. So he offered free diapers and wipes for a year if you delivered at the $8,000 hospital. Well guess what? Everyone’s delivering at the $8,000 hospital.

– That’s a bright spot.

– [Marty] You do see these great innovations.

– See, and what I like about the book is actually you have, for every problem that you get us furious about, you show a bright spot, so for the air ambulance thing, there are these brokers that will actually call around and negotiate prices and say, you know what, in a free market what would you charge? I charge this. Well why did you charge $50,000, when you said you could do it for $2,000 when I called you? Well, uh. If they were being honest, this is what they would say. The patient was vulnerable. Three helicopters showed up at the scene of the accident, all competing for this case that probably wasn’t actually even emergent, ’cause a lot of them aren’t.

– Yeah, seven helicopters showed up at one accident scene to pick up a guy, all trying to get the business. How insane has this?

– You know, and the thing is, look. You should be able to make a living, do good in the world, and do well financially.

– [Marty] Yeah.

– No one’s saying that you shouldn’t, but this is simply immoral.

– [Marty] Yeah.

– What’s going on, and so relating, I think relating to that, you were talking about OB price differences. There is a chapter in the book about the C-section thing.

– [Marty] Mmhmm.

– And I found it fascinating, because there’s so much variation in how many C-sections people do. For the majority of clinicians, they’re doing an average number which is appropriate and it ought to be, whatever 10% to 20% of deliveries it ought to be, but then there are outliers, and you use the name Dr. Dinner in one of them, because he almost was 100% C-sections. Can you talk a little bit about this variation in care amongst physicians?

– Yeah, he had a, has a routine. I haven’t touched base with him, but, recently, but he, at least according to all the residents who trained with him and the nurses who work with him, he has a routine. He sees patients in clinic, then at a certain time in the afternoon he goes to the hospital and any woman in labor is told a C-section might be safer for the baby.

– [Zubin] Ohhh.

– Well, we doctors know the trigger words, right.

– [Zubin] Yeah, the nudge.

– If we, the nudge, right. If you tell a woman in labor anywhere in the world that a C-section might be safer for the baby, guess what they’re gonna choose.

– [Zubin] They’re gonna take the C-section every time.

– You tell a patient you’ve got bone-on-bone in your joint, guess what they’re gonna choose? A joint replacement. You tell a cancer patient, “Yeah, we could do it laparoscopically, “but the gas might spread the cancer cells, “but we could do it laparoscopically,” guess what they’re gonna choose, right? So we know the nudge words and we know the documentation game. Most doctors do the right thing and I believe try to, the vast majority of the time or always, but this nudge is powerful and you get 10 or 15% of extreme outliers playing the game or practicing from a different decade or just trying to milk the system, sometimes out of a sense of entitlement.

– [Zubin] Mmm.

– That they’ve been wronged by payers and Medicare for years, now they’re getting back.

– [Zubin] Right.

– And they overinflate the safety of the procedures in their minds that they do. They’ll tell you C-sections are totally safe, so Dr. Dinner takes every single person for a C-section. Now in healthcare, what we do in the quality space is kind of ridiculous. We take organization level data and then feed it back to the docs, right. We have all this data.

– [Zubin] Who cares?

– And then hey, look here, do better.

– Look, as a hospital, we have too high a C-section rate, so you do better.

– [Marty] Yeah.

– Each of them rationalizes, well I do fine. My patients are sicker. Like, of course they have C-sections, this and this and this, but, so what’s the answer?

– Imagine you’re a flight attendant and someone comes up to you.

– I imagine that often, Marty. It’s one of these weird fantasies I have, like, okay I’m a flight attendant, and I’m on Spirit, and I’m trying to elevate the game. How do I make that happen?

– Well, let’s imagine, and this is a big stretch for your imagination, I’m sure, but imagine a rude flight attendant out there. I know this is a huge stretch.

– [Zubin] It’s a stretch.

– If that rude flight attendant is told by their supervisor at, say, United, United has no rude flight attendants but imagine they do, you, we as an organization are below the mean on our quality metrics as United Airlines, relative to other companies. Here’s the data, and try to do better. Is that actionable for that individual? No, right, but if you tell that individual flight attendant, you’re in the outer two percentile of flight attendants in your customer surveys. We’re gonna look at this data again in six months. There’s no action right now, but this is where you stand relative to your peers, is that data actionable? Yes, because it’s specific to the practice and to the individual, so in medicine we’ve been doing that. We’ve been watching, and I highlight this OB chair who shares individual C-section rates for uncomplicated pregnancies with individual physicians. In one example, the one doc who had an extreme outlier rate said well, of course, my patients are sicker, even though they’re randomly assigned call nights.

– [Zubin] Right, right.

– And on Friday, his C-section was 57%, so.

– [Zubin] The weekend syndrome.

– Yes.

– Yeah.

– [Marty] So it’s the power of data.

– Now here’s an important point. Now a lot of physicians will push back and say, well this data, these metrics are bullshit, but this is why you design the metrics with the physicians first.

– [Marty] Yeah, we have them define the metrics.

– Yeah, you define it.

– Yeah.

– And then, just say here’s your data.

– [Marty] Yeah.

– Here’s your data, and then you can decide, ’cause we’re pretty competitive and we actually generally want to do the right thing. If you tell me, oh I’m doing too many, I’m referring too many patients to cardiology when I could manage it myself, I’m an outlier. I’m gonna go, I don’t want to be that kind of outlier. I want to be the good outlier.

– [Marty] That’s right.

– And I’m gonna look at my practice.

– [Marty] Right.

– And you’re seeing that evidence in practice and outcomes, right?

– Yeah, and in this national Improving Wisely collaborative, which was originally funded by the Robert Wood Johnson Foundation and now we’ve got other grants to support it.

– [Zubin] And we’ll put links to all this, yeah.

– Okay, improvingwisely.org. What we’ve done is we’ve gone to the doctors with this model. You tell me if you like this or not as a physician. We tell them, we ask them a question, one question. Tell us about an area of inappropriate care in your field where there are measurable practice patterns, and then define the measure for us, help us come up with the inclusion, the exclusion. We’re not trying to evaluate individual cases because we know everybody’s different, medicine is an art, and we don’t want the hammer to come down because you deviated on one patient. That’s the stuff that drives us crazy as doctors.

– Right, drives us nuts, it’s the quality measure. They don’t measure quality, the measurement industrial complex, all these things, terms of use.

– [Marty] It’s the pre-authorization nonsense.

– Yep.

– [Marty] It’s the peer-to-peer, it’s the stuff that drives us freakin’ bananas, right.

– Makes us insane, yeah. Health 2.0, yeah.

– Yeah, exactly. Let’s let doctors be doctors, practice medicine embracing variation, it’s an art, but you tell us what the boundaries of reasonable variation are, right.

– [Zubin] Right.

– 30% C-section rate may be the ceiling.

– [Zubin] Yeah.

– That’s what they’re telling us?

– [Zubin] Mmhmm.

– If you’re over 30, which by the way is like 15% of GYN’s, of OB docs.

– [Zubin] Are over 30%?

– Over 30 in uncomplicated vaginal deliveries, right, then can we share that data with the outliers and let them see where they stand relative to peers and let them auto-correct or help them, not punish, but can we help them?

– And you gave a great example in the book about Mohs surgery.

– [Marty] Mohs surgery.

– And Mohs surgery is done in stages.

– [Marty] Yeah.

– And you can often do it in one or two stages. If you’re going into three and four, you’re probably an outlier in most of the cases. Now, when you actually fed that Dear Doctor letter saying, Hey, guess what? You’re a bit of an outlier, you’re doing it three stages. You get paid more when you do it in multiple stages, right.

– Yeah.

– But it’s more, it’s more time, it’s more cost, all these other things. When you fed that back, you got messages back saying thank you for this information. I’m gonna look at my practice pattern, or here are the reasons for this, but it’s good to have this data. No one’s ever told me this. We have no ability to understand our own care variation relative to our peers ’cause we don’t have the data, and if the data’s defined by some bureaucrat, we’re not gonna listen to it anyways ’cause it’s bullshit data. So it has to be defined by us and our peer group and maybe our medical organization that represents our specialty, but it cannot be defined by some bureaucrat.

– The doctors liked receiving that data. Now, granted there was a cover letter. It wasn’t, hey, Marty’s showing you where you stand.

– [Zubin] Yeah, right.

– It’s a cover letter from the professional association that says, as a courtesy we’re letting you know where you stand. This data is confidential, it’s peer-to-peer, and it’s intended to be, to help, and if you want educational resources, let us know. Okay, that cover letter, that was page one and page two was the report with the bell curve and where you stand on stages per case. That two page letter that cost $150,000 for the data analysis and the mailing to half of U.S. Mohs surgeons saved Medicare $18 million in the first year and a half. Now you tell me where you have an intervention in healthcare where for $150,000 you’re saving $18 million and the doctors are sending emails in, thank you, we like this, can you show us where we stand next year?

– And that is an example of a bright spot, so that’s a solution to our problems. We complain a lot, but you actually are developing solutions, which I think is what distinguishes this book out separately, and relating to that, because one of the big themes of the book is something I’m very passionate about, which is over-treatment. So, just because we can do things to people doesn’t mean we should, and the fee-for-service business of medicine incentivizes us to do things to people, not necessarily for them, and that doesn’t mean we’re bad people. You know, Robbie Pearl in his book Mistreated talks about these cardiac surgeons who are doing all these procedures because that’s how they’re conditioned. They think they’re actually doing the right thing and it’s backed up by the fact that they’re making money doing it. So they are gonna convince their unconscious elephant that this is the right thing to do. They’re not doing anything maliciously, and then we do it. We do more, we do more, we do more. No evidence that it helps, maybe evidence that it harms, and what ends up happening, we crank up the costs and patients thank us for doing it. There are vein claudication screenings in churches in the poorest parts of our inner cities that are then getting people to come into these vein clinics to do PTCA on veins. Can you talk a little bit about that, ’cause that was outrageous?

– Yeah, sure, and I reluctantly but I did decide to open the book with the story of me visiting a church where we found doctors there with ultrasound probes over-screening people for peripheral vascular procedures, despite a U.S. Preventive Services Task Force guideline that no one should be screened for peripheral vascular disease, recruiting them to their surgery centers, predominantly in the African-American churches and predominantly in Prince Georges County, which is the African-American suburb of Washington, D.C. Four surgery centers, by the way, called out by a very impressive cardiologist who refused anonymity when I offered it to him.

– [Zubin] Oh, I saw that, yeah.

– And his name is in there. He said four of these centers, within two miles of my office are doing these things all days long with little or no science. Most of it is bogus. Most of it is predatory, if we can reuse the term, predatory screening in American churches. My students, when, you know, millennials are social justice-minded.

– [Zubin] Yeah.

– And when they heard that I’d gone to a church after doing this interview with this cardiologist, they said, look, we’re going with you. We’re gonna show up, just like they show up at the courthouses now to help defend these patients. They’re showing up at the churches, and they’re meeting with pastors. I met with one pastor and told them, these doctors coming in, they’re not providing free healthcare as you may think of it or screenings consistent with guidelines. These are predatory screenings. This represents over-screening.

– [Zubin] Call it what it is.

– Call it what it is.

– Predatory screenings. So you see it all the time. You see it all the time, and then the question is, this is not a victimless crime. They’re gonna get charged for it, you’re gonna crank up fees, and then you may have complications, and now you’ve injured someone who should never have been screened in the first place and we will rationalize it as, no we’re actually catching something that wouldn’t have been caught. These are non-compliant patients that would never otherwise be seen, so let’s get them in the churches where they are and we can help their symptoms.

– You know, we were hoping to do an Improving Wisely project showing doctors who do these peripheral vascular procedures, how frequently they’re doing them for claudication and certain indications, relative to their peers, because we’ve mathematically figured out how to identify these people, docs who do too much in the data.

– [Zubin] Mmm.

– I was really hoping that a professional society would step up to the plate and say, we’re gonna do the Improving Wisely project. We’re gonna notify the outliers. We’re gonna write that cover letter, like the Mohs college did and so many other societies have done, but it’s incredibly frustrating when you can, in the data, see the names of the outliers, and we can do that only because I lobbied Congress, testified in front of them, fought with CMS and all these policymakers, that we deserve the Medicare data in real time. Forget about de-identifying physicians. We deserve all of this data without all the hoops so we can study it. How are we supposed to address the opioid epidemic when we can’t see the data on opioids that Medicare has locked up? So they gave us the data. They said, okay Marty, here’s all the data. It’s this mechanism where we access the Medicare servers.

– [Zubin] Wow.

– And now we’re looking at these names of egregious practice patterns around measures that the experts in that specialty told us there’s a lot of abuse, and so we’re looking at these egregious peripheral vascular procedure rates, and honestly, I don’t know what to do with this data. I’m thinking about just sending a Certified Mail letter with the names saying, we have serious concerns about the public health and let it sit on the desk of the American Academy of you name it, and so we’ve.

– What a moral conflict to have, to have this data and be unable to publicly do something about it when you know these guys are committing, I mean this is harming people.

– Now that we can measure egregious practice patterns.

– [Zubin] Yeah.

– With broad consensus from the specialists, do we have a duty to do something?

– Do we have a duty, right. I mean, I think we have to. The problem is, again, between getting sued, between violating the law, because it’s all set up to be as un-transparent as possible, and this is all we’re saying is sunlight is the best disinfectant. If we open the doors and say, you know what, we could actually practice at the top of our game, the top of our training, do what our calling is, and make a living, that’s really quite good.

– [Marty] Yeah.

– Why shouldn’t we, that should be what we’re searching for.

– When we rein in the outliers, and I don’t call them bad doctors, I call them doctors who need help, there’s more money for the rest of us because 15% of outliers that are massively overdoing things in ways that peers tell us, they’re sucking up all the money out of the system, so there’s lower reimbursements for inliers.

– [Zubin] For everyone, for inliers.

– And there’s precedent, I’m optimistic because we’ve seen these associations like the Mohs college step up. The paper just came out in JAMA Dermatology. The chair of the American Medical Association board wrote an editorial saying physician level peer-to-peer physician-created metrics are the future because it’s individual data that’s actionable.

– [Zubin] Mmm.

– So I’m optimistic. If an association told us, we’re overwhelmed by this, I’d understand, but there’s precedent now by these groups that have had bold leadership, so I would, I know you have a lot of physicians that listen. I’d encourage physicians out there to go to their professional association and say we want to do an Improving Wisely-type project and push your associations. You know, for a long time a lot of the associations were only pushing for more doctor pay. We can do a lot better, right. Instead of just being worried about what every dues-paying member of the society thinks, they can actually take a bold step and address these outlier practice patterns using data and the precedent that’s been set.

– See, that’s where I think our leadership is, in these organizations is frustrated. They’re like, ah, our reimbursements are dropping, everybody’s pushing on us, Health 2.0’s destroying us, there’s all these quality metrics and Press Ganey and patient satisfaction, all these other things that are pushing on us. We feel it at every level, and yet there are solutions here that take the best of quality science, which you’ve dedicated a good part of your life to doing, and actually apply in a way where we actually get paid, we reduce waste, and we improve outcomes and everybody feels like they’re living their actual calling instead of struggling in the business of medicine. You know, you said something earlier where you said, a lot of doctors justify this by saying, I’m owed this because I’ve been screwed by every single person in this system, so if I want to do a vein stripping or something, I’m gonna do a vein stripping. It’s the only way I can keep my practice open.

– We hear, we actually hear that.

– [Zubin] Yeah.

– Every now and then, we’ll realize in trying to get a consensus as to what to measure, we realize we’re talking to an outlier, and they’re not evil people. They’re telling us that it’s safe, I’ve been cheated by the system, what’s the harm, and you realize the moral injury as you so brilliantly talk about over time creates this entitlement and this robotic approach and, I had a case once where I did a vascular, we might hear, and I discovered a cancer while doing it. Well, that doesn’t, that’s not how we practice medicine is that you did a random MRI once on a normal person, discovered a cancer, so now everyone in the world should get an MRI, right? So we see these patterns of moral injury where we’ve become sterilized, we’ve become androgynous, we’ve become robots, and there’s this entitlement that sets in and I don’t blame the doc. I blame the freakin’ Krebs cycle that we pounded into them for eight times they had to memorize every step and produce it.

– Pyruvate, okay? That’s all I’m gonna say.

– [Marty] Know that in the trauma bay, right?

– Yeah, in a trauma bay. Get me an amp of pyruvate, stat! You nailed it, and I think the way that our medical education, the end of the book you talk about this, and it was very powerful. It actually made me a little weird, like reading it I was like, uh, this hurts, I can’t read this, because what it said was, in our medical education we teach ourselves Latin. We encourage four, sort of, biases. We encourage a competitive bias, in other words you have to compete your way to the top. You talked about your own rise to the top of academic medicine and when you get there you’re like, huh. You know, one of my mentors, and he wasn’t an intentional mentor, was a hospitalist, a private practice hospitalist in Honolulu, and I did a rotation there at Queens Medical Center when I was a second year resident.

– [Marty] Yeah, Queens.

– Yeah, in fact I’m gonna, I can’t announce that yet, but they, what ended up happening was, he was the hospitalist attending and I was a second year, and I was struggling through my day, and he said, “Zuben, listen. “I’ve been doing this for 15 years now as a hospitalist. “I’m gonna give you some advice. “One day, you’re gonna make all the money you need. “You really don’t need more, and you’re gonna say, “Kay, I don’t need more money. “The second thing you’re gonna look at is “all your struggles and everything you did “and all this energy you put in “through medical school and training. “You’re gonna look at your life and go, “This is it? “This is the apex? “Like, what are we doing this for? “And then you’re gonna wake up and realize “it’s because I get to be with people “when they’re at their most vulnerable.”

– [Marty] Mmhmm.

– “And make a difference,” and they let me be with him, and I never forgot that, and in the darkest parts of my moral injury I would feel that and your description of, this is moral injury. The end stage of it is sometimes a shutting down and us saying, I’m gonna do this stuff because I’m owed it now.

– [Marty] Mmhmm.

– ‘Cause it’s the only way I can survive.

– [Marty] Mmhmm.

– So I don’t think we can, you cannot be angry and hate these people. You can be angry and hate a system that creates these people.

– [Marty] Yeah.

– And the system.

– And if anything, doctors, I think, right now are the heroes of healthcare. Doctors are the ones who are winning it back. Doctors are the ones who are calling out their own hospitals and who are calling out insurance companies and middlemen, and you’re seeing this entire redesign of healthcare where people are going direct to the doctors and the doctor groups.

– And this is where the interview pivots to the positive. So, I didn’t even realize, now physicians, nurses, front line healthcare professionals are leading a disruptive revolution, and they’re working with self-funded employers. What that means is the employers aren’t working directly with insurance companies. They are paying the medical bills themselves, whether it’s Amazon or whether it’s a small company in your town, they’re taking on this cost and therefore they’re free to innovate. They’re free to cut out middlemen if they want to. They’re free to go direct to primary care physicians and go, you take care of our patients. You find us the best specialist, you create a good guys network that we trust, and we’ll send our patients to you and if our patients tell us they’re getting good care, we’re gonna go back to you and we’re all gonna save money. You’re gonna make money, and no one’s gonna intend to make money, but by doing the right thing we’re actually gonna do well financially, and it’s happening, and then I realize you wrote a whole chapter on our organization, Iora Health.

– [Marty] Yeah.

– Our co-partners in building Turntable, and you described, it’s primary care. Rushika Fernandopulle is their CEO, remarkable guy. You went to Phoenix, and I was there when that practice opened. I went there with the board, I was on the board of Iora.

– [Marty] Oh yeah?

– And you describe in that whole chapter, and I won’t kill the chapter because it’s in the kind of talks I do too, that, oh, what happens if we give you a bunch of money to just take care of a population of patients, of Medicare patients? And we say, you’re not doing fee-for-service, you’re not billing, you don’t have to document, you do what is best for the patient, and if it works we’ll do it again, and maybe we’ll even give you some of this money that you saved, and what does that mean? That means intensive primary care, focusing on prevention, cutting out over-screening and over-treatment, finding a network of specialists who do the right thing, who are willing to get peer feedback and who are willing to practice in a way that is in the best interest of their patients. In doing that they take the responsibility for the successes and the failures in that population across the continuum of care. If they get admitted that means, hmm, was it something we could have prevented, or is it something necessary? If it’s something necessary, let’s have the health coach go to the hospital, talk to the ER doc, go this is who this patient is. Just so you know, we’re gonna be sitting here watching and listening, and guess what? You can have a facility because you’ve gotten rid of all the billers, and now you have more space to do yoga, and meditation, and do teaching cooking classes, and this kind of thing and the health coaches take a lot of stuff off our plate, like motivational interviewing and looking at shopping lists and doing home visits and getting into the real emotional backstory of what’s driving this patient’s problem, and when I read that chapter I’m like yeah, yeah, yeah, that’s it. That’s what we’ve been doing at Turntable, that’s what we talk about when we talk about Health 3.0, that’s a damn bright spot and it’s led by clinicians and the fact that you put it in this book means so much. It really means a lot, because it means there’s hope.

– You’ve done a tremendous job pioneering some of this new redesign of healthcare and Rushika, and I’m a big fan of so many doctor innovators who have tried to say the current system is completely broken, let’s start from scratch, and Iora’s one. There’s so many I.

– [Zubin] There are a lot, yeah.

– There’s a lot and so I was privileged to spend time with the Iora staff. ChenMed, Oak Street, I mean, ChenMed’s very impressive, I think.

– [Zubin] Very good, yeah.

– So, I believe that doctors are not lazy people. We just don’t want to spend our time on things that don’t matter, and if you think about our workflow, a tremendous amount of that stuff can be done by highly attentive, eager human beings. They don’t have to have a degree, they don’t have to have a formal education and have studied Latin and the Krebs cycle. It could be a high school student. It could be a kinesiology major from college, right. If I need to do wound care in the clinic, I can take any eager body with the right attitude and train them exactly how they could be extremely helpful and that’s what Iora’s doing, right. They’re a team.

– That’s exactly right. It’s a team, and these health coaches, the nurses, the licensed clinical social worker, they call them nurse innovators, the one who leads the clinic. You have physicians in a, and the thing is, going back to your medical school rant, I was struck because you said we have a competitive bias, so we all compete and that’s what we’re about. The second thing was an autonomy bias. It’s one doc against the world, and it’s our judgment that rules and it’s, that’s the third bias which is the hierarchy bias, that we’re trained in a hierarchy, therefore we perpetuate a hierarchy on our nurses. Did they ever train you how to talk to nurses?

– I had no training in any communication skills. I mean, breaking bad news, something I gotta do now every week, I mean, I’m still learning how to do it effectively.

– 1,000%, but what do they train us? The Krebs cycle.

– [Marty] The Krebs cycle.

– And they train us how to compete against each other and do really well on MCAT and O. Chem and those kind of things, those are the people they accept to school.

– [Marty] Yeah.

– And then they throw another bias, a non-creativity bias. In other words, the more creative and out of the box you are, the more you’re gonna get stomped in medical school.

– My chief resident on day one of internship gave me, I met with a couple people on my team and the second-year resident told me, oh here’s how you get a nutrition consult and here’s how you fill out the TPN forms. Third-year resident, here’s how you order blood, and the chief resident, when I met him, he just handed me a pack of Surgilube. And no words, and it had so many meanings, right. Layers and layers of meanings.

– Layers and layers and layers of meanings. That’s our training.

– [Marty] That’s sort of the kiss the ring mentality.

– Yeah.

– That you talk about.

– I was told by a top clinician at UCSF, Damania, you speak and then think. I’d like you to reverse that. Better yet, just think. Non-creativity bias, I think, is so damaging because the innovators, the creative types, the people like Rushika Fernandopulle, who we were talking about, Iora’s founder, he is an out-of-the-box creative. Imagine how he must have suffered in medical school, and how, I know I suffered and I’m not even that creative, but it was beaten out of me by the end and it took me 10 years to reconnect with it. It would come out in these weird ways, but now we’re seeing that passion start to arise. Now you gave an example of, Jefferson Medical College?

– Yeah.

– [Zubin] And how they’re screening differently now?

– Yeah.

– [Zubin] They’re screening on emotional intelligence.

– Yeah.

– Now, you know that our generation is sitting there going, God, yeah, they’re gonna drop in the rankings. Like, that’s gonna be a shitty medical school. I remember I was at UCSF and someone was complaining, oh, they’re screening for social activities and all these things. That’s gonna be the end of this school, and that’s how we were conditioned.

– [Marty] Yeah.

– Yeah.

– Oh yeah, I love the old school surgeons that talk about, “The kids don’t know anatomy anymore.” Well, you know what, you learn it as you study the cases.

– [Zubin] Right.

– Before you do the operations and on your rotation. What’s the limit of how much knowledge we have to stuff in the minds of these creative people? Does every medical student need to know how to refract people for eyeglasses? I mean, in surgical training, we’re spending time learning prostate surgery.

– [Zubin] Right.

– I’m a, does a cardiac surgeon need to spend a month learning prostate? What if they spent a month learning effective communication and self-awareness, and middlemen of health care and the kickbacks and the schemes and the stuff you talk about?

– That’s the thing. If everybody had to read this as a textbook, we would transform medicine in a generation less. In 10 years, it would be transformed, because they’d be so outraged, and they’d have the idealism of youth to go into that instead of the cynicism of age where that’s never gonna happen, it’s never gonna happen.

– Well, thanks. I tried to basically create a book that is as comprehensive as a short read can be on the business of medicine to complement what we learn as medical literacy, complement it with healthcare literacy, and I think in the end it’s both a very, for me, an eye-opening experience learning about the middlemen, the kickbacks, the pricing failures, and the inappropriate care, which is in sum the reason for our healthcare cost crisis, not the stuff they talk about in Washington, D.C. Washington, D.C., the politicians, they’re talking about different ways to fund the broken healthcare system. We’re talking about how to fix the broken healthcare system.

– That’s right. That is so important. People are like, how we gonna fix healthcare? How we gonna fund healthcare? Forget about how you’re gonna fund it. You’re funding a steaming turd of lack of transparency, price gouging, and immorality. You want to fund that with Medicare for all? Go ahead and ruin everything. Here’s when you do Medicare for all, when you get the system right first, then you can cover everybody however you like, because it’s gonna be cheaper, more effective, more egalitarian, more fair, and everybody, whether you’re a conservative or whether you’re a liberal, it’s gonna hit you in your moral palate that that system is good and right now, it hits everybody in their moral palate that this system is horrible and we don’t even know the depths until you read a book like this and you go, wait, it’s even worse than I thought, but you know what, it’s even better than I thought, because there are actionable things we can fix. It’s not this mysterious, why is it not working? No, here’s the reasons it’s not working. We’re smart enough to get into medical school, to be a nurse, to be a pharmacist. I think we’re smart enough to fix these problems, and the first step is realizing this is a business. Let’s make it a calling again, and we can still do financially well while doing good for patients, and that’s what I love about this.

– You know, a pothole is not a political issue in a community. It’s a competence issue, right.

– [Zubin] Mmm.

– It’s a corruption issue, and it’s the same with healthcare. We’ve been misled by this sort of right vs. left, and throwing more money at it while there’s certainly things that need more funding like mental health.

– [Zubin] Right, prevention.

– Overall, prevention. It is not, it’s a distracting argument. How much more money do you want to throw at this broken system? Some of this egregious stuff, and the reason I opened with this sort of inappropriate predatory screening in churches that was leading to all this downstream unnecessary care is to show, if you just pour billions more into Medicare, you’re just continuing to fuel that very system.

– [Zubin] Yes.

– And I believe healthcare’s a right. I think everyone should have, there’s so much consensus in medicine. We don’t even need to be talking about some of this stuff. We need to be talking about what people are not talking about, and I think for me, the most exciting thing are the people who are fixing healthcare and have already fixed healthcare on a small scale, the Iora’s, the Oak Street, the direct-to-employer, the innovative patient steering that the Boston company did to get doctors now who are saying, hey why aren’t patients coming to me anymore? Oh, my hospital is charging 40 grand for labor and delivery.

– [Zubin] Holy crap.

– And South Shore is charging eight grand. Lemme talk to hospital administration. What’s going on? Why are we overcharging? And actually, a lot of this exciting direct-to-employer stuff that I get into, the one of the few remaining barriers is that the insurance companies who manage the networks, that is, an employer will often rent the network of an insurance company to get their discounts, the insurance companies come back to them and say, employer, don’t you dare create price competition and feed the market based on quality and price, which is the definition of value, because our contracts, if you’re gonna use our negotiated discounts in our network, forbid it.

– [Zubin] Yeah.

– Why do they forbid it? ‘Cause the hospitals told them, no steering.

– [Zubin] Yeah.

– And that, so it’s.

– [Zubin] Opaque, yeah.

– Exactly, so I mean, once we break that down, and right now, the policymakers are totally interested in this subject, the secret negotiated prices.

– It is our chance to pounce. This is the chance to actually make meaningful change, because in the end you have entrenched legacy players, you have a lot of people who resist this. This is why I started this interview saying you’re gonna get murdered, and I was joking, but the truth is there are a lot of people who are gonna be angry because when your livelihood depends on the truths of a system being true, new truths you will resist any chance you get. It’s a natural human tendency and I know because I went through this transition when I left my job where it was a fee-for-service thing and we were indoctrinated a certain way and I came here. I was like, no this can’t be right. Wait a minute, am I? Now my livelihood depends on finding an answer, working, standing on the shoulders of giants like Rushika and others who’ve worked, given up and sacrificed to do this, and they’re entrepreneurs. This is not some Communist manifesto, right, ’cause I know, I can hear the, half my fans are conservative, half my fans are liberal, another half are in the middle, and the truth is this is the apex of American competition, ingenuity, and free market value is an open, fair, transparent system that’s driven by a higher moral purpose. That’s America. Nowhere else in the world, we are still the shining beacon. I mean, you’re an Egyptian immigrant. I’m, my parents are from India. They came here for this opportunity to do something magical. Why are we squandering it? We need to stand up and take it.

– If I get murdered, by the way, all my passwords are ZDoggNumberOne.

– [Zubin] I’m glad to know that. I will access all your accounts, get the data out. Actually that’s very important. You need to give people, in the event that you’re murdered, the passwords so that they can get the data out, because if something happens to you, I cannot live with myself if this doesn’t continue so I’ll do my best to continue to evangelize, and we’ve spoken now for about an hour and 10 minutes.

– Well keep up the good work. I mean, I’ve been, as a subscriber myself, been following a lot of the comments, and it’s, you’ve engaged a real impressive group of individuals who have said, Look, we want to do more than just be on this treadmill that we’re told to be on. We know there’s something bigger out there, and we know there’s a better way to design it, and it’s amazing. If we just ask doctors and nurses and everybody involved in the care coordination of patients, how can we do this better, they have the answers. They’ll tell ya. It’s just nobody’s asking them.

– I tell ya. Hey, you know what? Our hope is give them a mouthpiece. Give them this platform. You’re right, our audience is amazing because it’s all of us. It’s all the healthcare professionals who’ve sacrificed so much and they come together because they say, you know what? We need to have a voice and do it better, and they don’t all agree and all healthcare is local, just like all politics is local. That’s great, that’s beautiful. That’s the diversity and the variety. That’s normal care variation, right, not unexplained outliers. So, I’ve never been so excited. I’m so excited for this book. Everyone should buy, you can order it soon, pre-order it now. Go out, get it, and Dr. Marty Makary, what a privilege and an honor it’s been to have you on the show.

– Great to be with you, Zubin.

– Brother, brother, stay safe. I’m gonna get you a bodyguard. I’m gonna get you Logan. All right, Z-Pack, we out. Peace!