Building Health 3.0 will mean taking bright spots and applying them to our larger healthcare non-system, while cutting out huge amounts of waste.

Dr. Vivian Lee, MD, PhD, MBA is a physician, scientist, and leader who’s spent much of her career implementing real change that improves real outcomes AND saves money. She’s currently the President of Health Platforms at Verily Life Sciences (an Alphabet company). Her new book The Long Fix concisely outlines a long term strategy to transform healthcare.

This is a fantastic conversation with practical strategies and teaching. Order her book (release date 5/26/20) here!

Follow Dr. Lee on Twitter here.

– Hey, what’s up Z-Pac? Welcome to The ZDoggMD Show. I’m your host, Dr. Z, ZDoggMD if you’re nasty. Okay, today I have a really cool guest that I’ve been waiting to get on the show. Her name is Dr. Vivian Lee. So she is one of those, you know, at UCSF we used to call them gunners. She’s done pretty much everything. So she was the Chief Scientific Officer at NYU then went on to head University of Utah Health and be dean of their medical school, did amazing work there as a leader, she’s a radiologist, very accomplished, even in that space as a leader, as a quality improvement person and now is the president of health platforms at Verily, which, if you don’t know what that is it’s the Alphabet owned Google thing that’s trying to transform healthcare from that side. And she joins us today because she’s written a book that I read with great interest called “The Long Fix.” And there are a lot of books about healthcare, about how to fix healthcare, and most of those books make you feel really bad about our current system and they spend a lot of time complaining about it, and you never get solutions. This book almost to a page is about solution, solution, solution, solution, bright spot, bright spot, bright spot, and I read it just going “Yeah, yeah, yeah, yeah,” and only partially because Iora Health, our partners at Turntable were mentioned as well. So welcome Vivian to the show, I’m super excited to talk to you.

– It is so great to be with you, thank you.

– The last time we hung out was at U of U when I did a talk for the medical students there and you actually showed up to my talk, which was I was like, “Oh my God” cause you were famous back then.

– Are you kidding? You are such a star. What are you talking about? And saying that I’ve done everything, how many music videos have I made? How many followers, subscribers do I have on YouTube? Just saying.

– You know what, I’m glad you see that as a valuable metric because you know if we’re talking about transforming healthcare we got to measure the right things and I think YouTube views are crucial to the transformation.

– You are influencing, that’s influence.

– Now speaking of influence, so I was reading your book and I have all these questions for you because a lot of the stuff you talk about is stuff we talk about on our show when we talk about building health 3.0, which is a healthcare system that takes the science of quality improvement, which you’re passionate about, which you’ve actually had experience with it at the University of Utah and other places, and apply it to the human relationship that’s the core of this, while elevating and respecting the experience of the caregivers, which you talk about as well. So, what was it that prompted you to write this book? Because it seems like you’re passionate about the same thing. Yeah, you know, this is the book that after 27-some years on the front lines and even serving as the dean and the CO, as you mentioned, it’s the book that I always wish I could have read before I got into medicine. Because in medical school and training we learned a lot about how to care for people, we don’t really understand how it really works. But we certainly are never taught the business of healthcare. So I really, really wanted to know that, I wanted to write a book for that generation just so they could really understand. And then what I really wanted to do is what you just said, which is to share the bright spots across the country to give people a sense of optimism that actually healthcare is a solvable problem and to show them that there are fantastic examples like Iora, you know, where patients, and Turntable, where patients can spend a lot of time with their clinicians, where it’s really all about achieving health. And when we align the interests of the providers, or the clinicians, with the payers and with the patients, we can just do so, so much better. So when we started, when I started collecting these stories together, I actually just found myself being able to weave them together and arriving at what I call an action plan for the country, and a plan for actually fixing our healthcare system, and I have to say that if the COVID crisis is teaching us anything, it’s really that there’s just an incredibly urgent need to make maybe the long fix into a slightly less long, maybe shorter fix, I hope.

– I think, I think you kind of nailed it in that COVID is a crisis that we cannot let go to waste because now is the chance to truly disrupt what’s been happening. So everything you talk about in the book and each chapter kind of goes through a different part of it which I think is very helpful, and at the end you say okay to patients this is what you need to do to solve this particular problem, for providers, this is what you need to do, for payers like insurance companies, etc., this is what you need to do, and for policymakers is what you need to do, and I really like that organization because it actually gives you action items at the end of each chapter, and then at the end of the book it’s a summary of the kind of long fix. Like okay here’s how we deal with pharmaceuticals, here’s how we deal with actually paying for outcomes, which is one of the central premises of your book actually which I care passionately about. In a fee for service, right, it’s a pay per widget kind of thing. You’re incentivized to do things to people, not necessarily for people, and I have the saying that I’ve stole from someone that says humans are only as good as their incentives and if you screw the incentives up, you get the system that you incentivized. And right now our system is totally backwards incentivized because again, it’s so lucrative to do a spine surgery and not lucrative to prevent the spine surgery from needing to happen. Hit me with what’s your main way you think that we can transition to a value base, and this is a big question of value based thing where you’re paying for outcomes?

– Yeah, so that’s really the single most important point. And I think it’s the biggest lever, as you’ve also landed on, in terms of what we can really do to change. And the metaphor that I use when I’m sometimes trying to explain it to people who are right in hardcore health care, and health policy, and thinking about it all the time is it’s like we’re on this big jumbo jet trying to try to get towards that destination of better health, better outcomes, lower cost. And we are flying into the headwinds of capitalism, it’s where every other part of our industry and our economy in this country, capitalism is really supposed to be incentivizing competition and innovation to drive to better value. But in fact what we’re doing with the way in which our healthcare system is structured with fee for service is we’re just incentivizing doing more procedures, doing more imaging studies, doing more surgeries and so on, regardless of whether they achieve better health, and what we need to do in changing our payment models, is to get that capitalism into our tailwinds. And the way in which I talked about the relationships, so one of the real challenges is with a fee for service model we are all incentivized to do more. Now that’s not to say as you know, and as I know, that also physicians or clinicians are over-treating, or intentionally over diagnosing, but just the fact of the matter is the system is set up to reward that. So what happens is, we’re doing more, we’re being incentivized to do that, and so therefore we have the insurance industry, which is set up to be the controller, or the part that is intended to prevent that over utilization, so what do they do? They put in prior authorization, they do denials. and so we go back and forth, we order an MRI, they deny it, we have fill in more paperwork, and so we end up hitting 8% of all healthcare costs just on administration, 8%. When European countries, other OECD nations is 3%. That’s a huge amount of waste, and as you and I know that is a huge contributor to the burnout and, you know, all the suffering on the frontlines. And then when we can resolve it we get to the surprise billing, right? So it falls in the lap of the patients, and that’s why we end up with balance billing, and surprise billing. So the examples that I talk about are the ones that you really know the best in terms of Iora Health, Chenmed, all of these Medicare Advantage models where the payers have decided to contract with physician groups, as you know better than anyone, to allow them to have the autonomy to decide to work very closely with their patients to decide, you know, how best can we keep you healthy, and the models in which they’re using now, paying, getting paid a fixed amount of money per patient, per year to keep them healthy and out of the hospital allow them to design these delivery systems that are so much better for the patients, and actually so much more resilient in times of COVID and keeping them out of the hospital allowing them longer time with their physicians, on site pharmacy, shuttle services to and from clinic, tai chi, yoga classes, even bingo and domino nights, you know, just to address some of the loneliness, and social isolation. And as a result, as you know, with Iora Health, we actually see significant reductions in overall cost of care, so it creates a win, win, win. I think the biggest challenge, I mean I think there we’re seeing that in primary care there really are terrific models, but we definitely need more adoption and we need more sharing of those lessons from places like Iora Health. And the challenge is really, I think, on the hospital side. How do we really move that same model into hospital based care.

– Oh, you know, there’s so much in what you said. I mean that that’s a four hour discussion you and I can have just on what you just said. The distortions of capitalism that lead us to fly into this headwind instead of a tailwind are all incentive driven and it was, none of it was intentional. The employer, and you talk about this in the book, the employer based health care system that resulted from our World War II wage restrictions and things like that, so employers got around it by offering benefits that were tax advantage that then grew into an insurance industry, and an employer based insurance industry that then disintermediates the consumer, there’s no price transparency. Then you have this push and pull, like you said, in a fee for service world where the insurance companies have to say no, the caregivers have to push to get more pay, and then you have inflated charge master fees which are these artificial things. So if we set the fee here then we can discount it, unless you’re uninsured, in which case you have to pay the full amount. And you get these surprise bills. Nobody knows what the cost of care was. And one of the, so there’s so much here, one of the things I want to talk about, and don’t let me forget is talking about how do we actually motivate physicians to change in a way that doesn’t burn them out. Because you talk about lean, and you talk about quality measures, and you talk about outcomes, but then physicians feel that as, oh that’s more boxes I have to click in a thing, I have no sense of autonomy, no sense of purpose, no sense of mastery. And those three things are required of high level workers. Like an assembly line, you just, if you pay them more they’ll do better. But this isn’t an assembly line, right? So we have to talk about how can we shift the culture in healthcare. One of the things you said about Medicare Advantage that makes it such a compelling financial incentive model is they say here’s some money, do the right thing for patients, if you do well, your outcomes are good, we’ll come back as an insurer and also you might be able to keep some of that money and use it then to improve your processes more, and you have all the autonomy in the world to go do this in a way that achieves real outcomes. We’re not gonna tell you how to do that. You are smart people, and you can find mastery by getting really good at it, you can find autonomy by finding ways you can figure out to give better care, and you have a sense of purpose. I’m actually helping patients and doing well financially, oh my gosh, everything’s aligned, and now capitalism and care are actually aligned, and you can tell the people who are like this shouldn’t be about money to go well, but this is America and there’s capitalism so we can actually make it so that people can make a living doing good for patients if you design it right.

– That’s exactly right. And they’re using all of their, you know, that ability to use their brain power. I mean most kids when they get into medical school, they’re pretty bright. They’re pretty driven. And if you unleash them and say okay help us, help us make the healthcare system better, it’s so liberating and empowering. So when we were at the University of Utah, one of our challenges was really to focus on how do we improve patient satisfaction. How do we reduce cost of care and keep quality up, right? On the patient satisfaction side, we started by providing patient feedback back to the providers, back to the clinicians, and they could just read it in the privacy of their own offices, and over time we made it more and more transparent, and then finally we actually posted them online, but only after people really improved a lot. And in the course of doing that, in the beginning it was just pretty straightforward, how do we actually train our staff and receptionist, how do we keep on time with our appointments, but then as people started to get, really get on top of this and really be receptive to the feedback, and then start to think about the patient as the center of the universe, and apply some of that creative talent they really had but that’s been mostly untapped, mostly untapped, right? We started coming up with some really creative ideas. There was a clinic that we opened from, and we opened it just after I started there, and the team started thinking about what they can really do, really invent. So they said hey, you know what, we have all these young families in our community, and they’ve got kids in tow, and so on, let’s put an on site childcare. So you come in with your kids or your grandkids, you drop them off, a couple of hours, you go and get seen, you get your prescriptions filled and so on. We actually had to make a rule of it, you cannot leave the premises in no more than four hours because there was an Apple store right across the way. So, a little bit tempting, you know? So people loved that. We had home baby visits, newborn visits. So you know you have a newborn, you have to bring the baby in, I don’t know about you but I had my babies all in New York City, always in the middle of winter, you’re schlepping them in in the rain and cold. You show up in a waiting room full of kids with runny noses and things, right? Really not good way to bring care. And so we actually had a nurse, and a pediatrician, hop in their little Prius, drive over to the patient’s homes, you know in the community right there, and visit with them, and be able to check on them, how are feeding, how are we nursing? Remember, don’t shake the baby. You know, people are able to come up with better ways of delivering care when they had some good feedback, and they also had some autonomy on how to really do that.

– And you nailed it. It’s funny cause you told the story about pappy hour that Iroa had done. Where they said, okay, we have a low rate of cervical cancer screening in this particular population that we’re taking care of. By the way, Rushika, their CEO who’s a friend and was a partner in Turntable, has this saying that you know, you don’t, it’s not a practice, it’s nothing, you’re taking care of, you’re responsible for a group of people, they’re your family in a way and they have a voice in how you care for them. And so he listened and said, oh, it would be really interesting if we had this like fun thing with some drinks and some snacks and stuff we call it, pappy hour and you come and you get your pap and it’s not–

– And candles, candles.

– [Dr. Z] Candles.

– Candles, with a spa like experience, yeah.

– Very, very important, we’re talking about patient experience, right? But it’s also provider experience because they’re experiencing the kind of fun of like hanging out with patients, and doing this thing, and we did that at that Turntable as well. And what they found is a whole huge uptake in paps, finding early cancers and treating them, some actually required chemotherapy, you tell the story in the book, and what did that do? Great outcomes for the women that would have, might have died, had not been caught early, terrible outcome for the employers bottom line in the short run because the employer was the insurer paying for their care. You’ve now discovered a cancer that you have to treat, so in the short run the cost went up. In the long run, you saved a life, but since most employees turnover so fast they’re not with that employer for so long, so the employer just invested in somebody who’s going to go away, and that’s the sad disconnect between the financial reality and the actual outcome. So we have to make sure we try to align those, and giving physicians autonomy to do the right thing, is a key component of that because they’re competitive, they’re passionate, and they want autonomy, and I remember when they took my autonomy away, that’s when I realized my days were numbered, and I said this is it, and I found that all my autonomy was given to the, you know, having to document it in the EHR and feeling like a data entry clerk, instead of actually getting to spend time with patients, having freedom to practice within certain guidelines to achieve outcomes. Instead it was like, no, the guidelines are the outcome, it’s not the actual outcome. So I put a lot there, I’m just, I get rambley about this stuff.

– I think you’re totally right about that, and I think one of the lessons that we learned after working on patient satisfaction was around reducing cost of care. So cost of care is like the holy grail of most of health care, right? We can’t tackle the cost of care, that’s too hard, and all the alignment of incentives and all those issues, but actually, when we had this really great system of tapping into and really engaging our frontline providers, and we said okay guys, payment models are starting to change, right, Medicaid for us in Utah became completely capitated like just overnight, and so all of a sudden that woman that came into our emergency room 52 times the previous year on Medicaid and we just charged Medicaid 52 times, now all of a sudden we were gonna get paid a fixed amount of money, and we really did not want to see her in our emergency department that many times. We also knew the bundled payments were coming forward, and so I was on the system started thinking, oh geez, you know, it only makes sense that we need to manage our costs better, right? We know that this fee for service gravy train is really coming to its end pretty soon. And so when we engage the physicians about that, we said okay guys and gals, what can we do? They said, okay, well, you know, we manage patient satisfaction pretty well. Show us the cost data. I actually had a dinner with all the chairs, all the departmental chairs, and I remember the chair of pediatrics looked right at me, right across the table, and he said, “You know, Vivian, you keep talking about cost. “If you and your bureaucrats,” I knew that’s what he was thinking, but he didn’t say it, he was like, “if you and your guys could just show us “what it actually costs for us to provide care “I bet we could get it under control.” That’s what he actually said to me. He actually laid down this charge. So, the very next day I call this emergency meeting of all these finance people and IT people and accounting people, and department administrators and I said, “Guys, is it really true we can figure out our cost?” And they said, well you know we have costs, of course we’ve got financial statements and here’s what we spend on labor and here’s what we spend on supplies, and I said, no, no, no, Dr. So and So said when he’s caring for one of these pediatric patients, let’s say you know a kid with pneumonia, who doesn’t know how much it cost us just to take care of that patient with pneumonia. Is that really true? And I looked at the surgeons like you don’t know how much it cost for you to do a hip replacement? And they said, no idea. And then they looked at me and they said you’re an MR radiologist, do you know how much it costs to do an MRI? I said, no, I have no idea. So then all of a sudden we started saying okay, let’s figure out what does it cost us. Not what are we going to bill somebody, but what does it really cost us? I mean, you go down the road to Jiffy Lube, or you go down to LL Bean, and you ask them how much does it cost for you to do a tune up, cause they know how they price it and they know their margin. We don’t know it in healthcare. So when we started working on that and giving the cost data to physicians, and we showed them just how much variation there was, you know, the orthopedic surgeons, all thankfully had very good outcomes for hip and knee replacements. But when it came to cost, just the hip prosthesis alone, threefold difference in cost, even though they all turn out pretty well. The surgeons had no idea. No idea. And now they can exercise that autonomy and actually really start to tackle costs.

– And this is business 101, right Vivian? Like you know what your costs are so you can set prices in a way that it has a tiny profit margin, but is optimizable. And one of the things I learned from your book that I had never thought about is what is the cost per hour for, say, a radiologist? And if you actually know what your, so 60%, roughly of costs in healthcare are personnel based, so they’re staff. And so, if you can control and understand those costs, and optimize them, then you can understand that okay it costs so much per hour to have a radiologist work. So are you going to have that radiologist spend a ton of time trying to track down clinicians to give them results, or do something like that? What a waste of a highly paid per hour professional. How about this, instead hire somebody who’s got less pay per hour but is really good at doing that to offload some of that so that radiologists can then do more efficient work in what they’re trained to do, which that high level intuitive medicine that’s going to take forever to replace with a computer because it’s just that hard. So that was something that opened my eyes when I read your book because we don’t even know what it costs, how are we supposed to have price transparency, and save money, if we don’t even know what we’re saving? So instead we cut blindly and say, “You know what, we’re just going “to lower nursing staffing ratios.” Well, that’s gonna end badly. How about just stop having them stare at the computer the whole time and figure out a way to make it more efficient, and have nurses aides help, and have this and that. So what are your thoughts on this? Having done this for a living.

– So you know one of the conversations that I remember early on having this with Bob Kaplan at the Harvard Business School.

– [Dr. Z] Smart guy.

– Who has done this kind of cost accounting work in every other industry. And then maybe 15 years ago, Mike Porter brought him into healthcare. He thought he pretty much solved cost accounting. You know, he worked with manufacturing, worked with technologies, worked with all these different industries along his career. And when he came into healthcare it just blew his mind. He said, “You have these high end trained “17 years post high school people “and they’re running around looking for a piece of paper, “or they’re calling up a pharmacy “trying to clarify a dose, “or they’re trying to, “and they’re doing things that just “any anyone who has a little bit “of training could actually do it.” And this lesson is not only important financially, it’s just back to what you originally were saying about autonomy, mastery, and purpose. How many of us went into healthcare in order to type more data points into a EHR? Or cut and paste another history and physical in from somewhere, or run around trying to find somebody’s creatine level. Or dig up some old x-rays from, you know, three weeks ago across town, I mean, it’s so frustrating as well. So we hear a lot of people talk about top of license. We really want people practicing at top of license for their own fulfillment, but when you look at the finances of it, it just makes so much economic sense. So these are the opportunities, when people throw their hands up about, oh, you know, health care and tractable problem, 18% of GDP, still have 10% of the population uninsured. I say no, actually, you know what, there’s a lot of waste in the system. There are a lot of inefficiencies in the system. And when we start to set up the economic models to try to really call out that waste, not even the economic models, but also the management models, where we really engage people like you, right? Instead of putting you on that little treadmill, we say, “Zubin, come help us think “about how to make this healthcare system “smarter and better for patients.” All of a sudden, boom, you know, you can see this this radical transformation that’s just better for everybody.

– Yeah, you nailed it. The most disheartening thing about my job as a hospitalist was having to track down stuff, find records, do this stuff it made me feel like a data entry clerk. I’m like wow I’ve sacrificed my 20s, I care so much about this high level craft, I’m stressed, not because I’m, you know, worried about the medicine, I’m stressed because I can’t connect the dots for these patients. And, but there are people who can. And so the best days I had as a clinician were the ones where there was a team around me, everybody practicing like you said, top of their license, and everything’s firing on all cylinders, and I’m doing my part at the top of my game. You know, when we were at Turntable Health, what we used to do is we would say, you don’t need a medical degree to do a lot of what we do in primary care that is so important to patients, developing a relationship, connecting the dots, teaching you how to ride the bus so that you’re not lonely and you’re an elder, helping you look at your shopping list of food to see what it is you’re eating and giving you advice, developed doing this blocking and tackling. So we wouldn’t hire health coaches to do that that were drawn from the community, that spoke the language of the patient, that could form those connections, and that freed the doctor to do that high level, intuitive medicine that only they can do. And I think that was so important because then what you’re doing is you’re looking at your costs and going, why is the doctor doing all this when they’re best freed to do this, and you can take somebody else and do it. What that does, it doesn’t eliminate jobs, it actually grows the pie overall, grows the efficiency, improves the bottom line, and outcomes for patients.

– That’s right. And what we need to do is to start to see how those models that have been so successful in Iora can really translate into the hospital setting, and I think we’re already talking about some really great examples of that. And right now is a perfect time for us to be exploring that and be pushing more aggressively on it, because we’re seeing with COVID that the Ioras of the world are actually faring pretty well because the payment model, instead of being fee for service, when the clinic shuts down, you shut down, you furlough doctors and nurses, April numbers just came out, almost one and a half million health care workers laid off. That’s a disaster. That’s heartbreaking, especially when people are on the frontlines so courageous every day facing COVID. So we’re seeing that the Medicare Advantage model, because it’s being, because the medical groups are being paid a fixed amount every month, I’ve heard it called the subscription model of care, you know, you kind of get paid your subscription every month.

– [Dr. Z] Like a gym.

– Yeah, those practice, like a gym, those practices are actually really flourishing while hospitals are really struggling. I read a quarter of rural hospitals are likely to close. So this is a good time when systems are paying a lot of attention to how they are being paid and wanting to create more resilient models and saying okay, you know what, now, how can we pay you in a way that’s going to be a little bit more like Medicare Advantage and a little bit, maybe more like our VA system, and our military health system, where you have an annual budget of some sort, it’s fair, it reflects the population that you have to care for, and so you have that security of revenue, and you know that if there’s a downturn, if there’s any kind of a crisis, or even mini crisis, you’re not going to have to layoff patients and then be reactive afterwards. I think this is a really good time to revisit that.

– I agree I think we need to look at those models that create anti-fragility. So you know, right now our model is completely fragile, it got hit with COVID and it shattered. And like you said, a million healthcare workers out of work. This is exactly the time you don’t want that, so that’s a fragile system. You know, you could make a resilient system where it actually resists that stress, or you could actually make an anti-fragile system where every time there’s a stress the system itself is designed to grow more powerful, stronger in reaction to that, like a bone that’s broken and you get that healing, you know, scar, it actually gets more powerful because you have systems of self iteration and improvement that are kind of recursive and that means you treat your people as creative partners in this you lead you don’t manage, right? And that was something that always struck me about you, is when especially when reading this book is like this is about leadership, this is about showing people this can be done. Here are some bright spots. I’m not going to micromanage all these things. Like one thing I want to talk about, I really want to get into this patient satisfaction thing. So, if you tell nurses in my audience that patient satisfaction, or ER docs, patient satisfaction, they think H-caps, which you talk about in your book as the series of edicts from above that say these are the things you have to meet and so on and so forth, they don’t think about the more dynamic way of thinking about the patient experience that then reflects on how well did you care for them, they think about on giving them opioids, and I’m treating it like a hotel, and they’re getting a turkey sandwich. And you actually do a really good job of distinguishing that in the book. It’s like, that’s not, that is not productive, but what is productive is thinking about what it’s like as a patient in the system and how your care, and your attention to communication, is not only going to give them a better experience, but it’s also going to be something that you can get competitive about and compete with your peers in a way that elevates everybody, and on top of that, actually improves your chances of not getting sued, because you have a beautiful, open, and communicative relationship with your patients, and you used to publish, at the request of the docs, like publish all the reviews that patients gave, not just like how the commercial entities will be like okay, only the angriest people go on the line and go “This guy didn’t listen to me at all.” It’s like no, everybody gets surveyed in a timely way, you know, kind of at the point of care so that they can, you can actually get better.

– It was a pancreatic surgeon who actually pushed us to post all those scores online, because she, we had been collecting the data, we had been feeding it back to them, including the scores and the comments, and then gradually we made it more and more transparent. So everybody knew how they were doing, as you said, definitely tapped into competition. Who does not want to be in at least the top half, if not the top 10 percentile, right? I mean you’re pre-med. Once a pre-med, always a pre-med. She actually was told by a friend, “Go online, just Google yourself.” And when she Googled herself, she found some of those commercial websites where anybody can go on and login, and say something about you.

– Vitals, or yeah, whatever,

– And she read some things that weren’t particularly flattering. She was pretty skeptical of whether they were even real patients, you know, might have been disgruntled somebody, who knows what. And she said, you know what, you guys have hundreds of patient satisfaction scores and comments on me over the last couple of years, just post them online. I want to go head to head with these guys. You know this was a point of pride. This was a point of pride. She said, “I know mine aren’t all perfect, “but at least they are true, “at least these are real patients.” And so we said okay, hmm, let’s just talk about that with your other 1200 physician colleagues, see how they feel about it. Discussed it for a few months, actually. And by that point because we had already been working on it a lot, we had good performance overall. So we said, okay, we’re going to try it, it’ll be a little experiment. We’ll post our patient satisfaction scores online. The five yellow stars, plus all the comments, and see what happens. And the response was unbelievable. Because if you think about it from a consumer, if you go online and you’re looking for a rheumatologist for your mom or a new pediatrician, or a new dermatologist, and you Google, and you come up with some doctors names, and some of them have ratings and some of them have none, even if the ones that have ratings aren’t perfect, as long as they’re not bad, you definitely go to the ones that have ratings, right? I mean how do you, think about how you buy stuff. So we just found enormous demand. I mean it was just, it was incredible, on our web traffic, our call center, for the physicians it was this huge boom for business. Actually it was almost, we actually had to build whole new clinics as a result of having to do that. And then one of my favorite things that happened was, maybe a year or so later, one of the senior surgeons was in my office, we were just having a nice chat, and I said, “How’s it going?” And he had been sort of equivocal about this idea of posting his scores online, just in total candor, and he said, “Well, you know what? “This weekend, my son called me up from out of town, “and he said, Dad, you know, I was searching you online, “I just came across your scores “and you know what Dad, “I read what those patients said about you, “you’re a pretty good doctor.” And he just had this big grin on his face like it was the proudest moment of his life. So, you know, when you do it right, you’re really tapping into that competitive, like I want to be the best, but I want to be the best at something really important, which is making my patients healthy and happy about their care. And so that was a really fantastic experience.

– That is really such a beautiful story. And you know what’s interesting that people don’t realize is, when you do it that way, because of the number of reviews and the juice that, say, University of Utah has on Google, because it’s all aggregated there when people search, the first hit is going to be your set of reviews. Not, or one of these other commercial companies that you have no recourse when patients aren’t even the patients and so on. So, I think it’s a way to fight misinformation online, it’s a way to reclaim our professional integrity, away for some healthy competition, and a way to again, incentivize, because we’re no better than our incentives. Incentivize people to actually improve. Now, again, I think the way, there’s a difference between management and leading right? Which so many hospital administrators want to manage their patient satisfaction scores by goading, and threatening, and over measuring, and just putting it in a way where people actually feel now disempowered, they don’t have autonomy, they don’t have purpose, they don’t have any chance of mastery because they feel like it’s out of their control. They just have to, you know, kiss butt, or give the patient what they want, and that’s the opposite.

– Over prescribe, you know, those kinds of concerns.

– [Dr. Z] All those things, all those things.

– Opposite, opposite of what you want.

– Opposite of that. Now, speaking of over-prescribing, the one interesting, one of the interesting parts of this book was when you start talking about pharmaceuticals, and I learned quite a bit here. So one of the interesting things I learned is that physicians actually get a percentage of infused medications pegged to the cost of the medication. So, if you work, if you’re an oncologist, and you infuse an expensive chemotherapeutic or biological, you can take up to 4% of that list price as a fee. And that’s a kind of perverse incentive because then they’re incentivized to give the more expensive drug whether or not it’s better, did I understand that wrong?

– That’s my understanding of how it works.

– And when you see Natural News and others going viral on Facebook saying the medical industrial complex is in it for money and they want to poison you, that’s the seed of that conspiracy, which is incorrect, but that’s the seat because the perception is well, yeah these guys can make a lot of money. So these are kind of policy issues that you can change. You can say, “Well no, maybe it should be “a flat fee they get to administer the drug “and oversee it and all the costs associated with that,” Because you should know your cost, what they are, so you can then price it correctly. And instead of these kind of things, so these are distortions in incentives that can cause behavior that isn’t aligned with good patient care.

– That’s right, that’s right. And I think that once you, once you make, one of the things you said earlier is transparency. And I just think it’s really important that we’re really transparent about the flow of money. We need to be really transparent about that, and I think that people respect that, and they respond to that. When we were working on, on the trying to reduce the costs of care and really drive quality, one of the things I think, as you’ve heard in our whole discussion is, we wanted to be really transparent with our physicians, and we wanted to be really transparent with our patients. A couple of things that actually in response to the earlier question, when we were talking about giving people some autonomy as to how they could respond to patient satisfaction, we actually applied the same thing to the quality side. So the quality metrics for most physicians are also kind of checklist items, right? You talked about frustrations as being a hospital, so you would have experienced that completely. And so we said to our physicians, “Okay guys, we’re going to come up with “this perfect care index,” actually it was their name, “and this will be our scorecard “for how we’re providing care.” And, you know, we do want to get paid, it’s important to get reimbursed, so we do need to include some of those required checklist items, and they’re important, we don’t want to hospital acquired infections, of course, and so on, those are important. But let’s give you a lot of latitude to put forward some ideas of your own about how we could actually drive better care. That was a pivotal moment of our discussion because now all of a sudden instead of beating people down, you’re saying hey you guys are pretty smart, you guys are seeing things, what should we do? When the orthopedic surgeons had that opportunity, they said you know what, we want to get patients up and out of bed on the day of surgery because we know that makes them better. We actually want our patients cared for on orthopedic wards, not in general surgeon wards. That’s been a fight that they’ve been having forever. Once we gave them the chance to measure how often was it happening, they actually found that about a third of the patients were not getting up out of bed the day of surgery. Those patients tended to have longer stays in the hospital, more complications, after we discharge them they had a higher likelihood of having to come back and get re-admitted. So we discovered, we looked at those patients what was happening, they were getting operated on at the end of the day. They were the last case of the day, by the time they hit the wards, nurses, the nurses were there, the physical therapists had gone home. And so they weren’t getting up and out of bed the day of surgery. So all we needed to do was to shift a few of the physical therapists to slightly later shifts. Come in at noon, leave at eight. All of a sudden now everybody is getting up and out of bed the day of surgery. Now everybody’s doing better. Reduced the cost of care, better outcomes for our physicians, for our patients, and our physicians were the ones that figured that out. And so they got an enormous amount of satisfaction out of that. So that’s another example of that autonomy.

– I think that you have nailed what will change the culture of medicine which is giving it back to the frontline and saying here’s a problem to solve, figure it out in a way that works for you. When I was at Stormont Vail Health System in Kansas City, they had these interdisciplinary morning rounds for their hospitalist medicine team that I’ve never seen anything like it. It was beautiful. All the teams got together and they figure out okay here’s a problem we’re having, we’re having overuse of this antibiotic which really isn’t indicated for a first line treatment of sepsis or whatever, and so what can we do? Well here’s the pharmacist weighing in, here’s, okay well this is going to be our agenda item, we’re going to try to figure out a way that we can change it, is it a thing in Epic that we change, is it a way that we just keep educating each other, what is it, let’s figure it out. That’s how you improve care. And they had their purpose which is we’re just going to make it better, cost as little as possible, do the most good in the world, keep it sustainable for us. So it’s kind of like a quadruple aim, right? Good cost, good outcomes, good experience, good provider experience, and it was beautiful to see because it was, again, clinician led, but their administrators, who were all former clinicians or current clinicians, were actually leading instead of just, you know, tisk, tisk, tisk, tisk. It really does work. Now we only have a few minutes left so I want to make sure, you know, unless you have, because I think you have a hard out in a few minutes. I want to make sure we talk about the big elephant in the room, which is well, we know that we could save a butt ton of money if we cut out a lot of the administrative stuff. Why not single payer? Why not VA style system? Why not a Germany or Swiss style system of private insurers all competing with government mandates of universal coverage? Because I think you said in the book this, we all want everyone to be covered, where we disagree is we don’t want people freeloading or, sort of, there’s a good way to put this which is there’s a sense of fairness. So you want to do your part, whether it’s as a patient being co-accountable with your caregiver, if you can afford it paying something towards your care, but then making sure we cover everybody for stuff that really is essential. So what are your thoughts on this because it’s the last few chapters of the book where you bring it all together?

– Yeah, you know, it’s a great question, I think it is really one of the most difficult questions of our times because we inherited a healthcare system that we know probably isn’t how we would’ve designed it. So as a result we’ve now grown into a system that’s about a fifth of the U.S. economy and there are a lot of vested interests in keeping the status quo, or keeping it close to the status quo. So while I believe that maybe if we had started all over again we’d be designing it differently I think from a practical perspective, looking at where we are now, we should be thinking about what our priorities are in terms of what change can we likely achieve. And I think first and foremost, before we start upsetting, kind of whether the hospitals are all private or owned by the government, which I think is just too enormous a hurdle, I think we can get to the point where all Americans have access to health insurance and healthcare. That would be my first priority. And universal healthcare or access to healthcare, as you just alluded to, is mired in some political, a bit of a political quagmire, mostly as I believe, around whether people should pay or whether it should be free. But we’re seeing that there are opportunities to reach kind of a compromise where there is some mean spaced payment. I think that’s fair, it just has to be very carefully monitored so that it is not, isn’t an artificial or an inappropriate, or an equitable barrier to care, which I think is most people’s concern is, and a very justifiable concern. I think that has to be the top priority, and the way in which we get there, because I think that is fundamentally the question is if we’re spending 18% of the GDP now to cover 92% of Americans, let’s say 90 to 92% of Americans, then how could we possibly afford to cover the remaining eight to 10? And the answer there is many of the points we’ve talked about, many of the points that are in the book, we need to create a more efficient, less wasteful, fewer administrative burdens and waste system, because the amount that we can recover from the system can more than cover the opportunities to insure everybody, or to provide care for everybody. One area that we didn’t really talk about, I think, is the untapped potential around really engaging people as patients. And this idea that I came across, really, in the research for my book of co-producing health. I really, really loved that idea. And it came about, Victor Fuchs, an economist from Stanford coined the term, I think, where we’re changing, when he was talking about changing from an industrial economy to a service economy in the fact that in a service economy instead of just having goods thrown over to us we’re actually co-producing that service together. Whether it’s, for example, in education, where we attend PTA, conferences, and help our kids with homework. In healthcare, we really are mostly co-producing health. Of course, in intensive care unit, it’s mostly the physicians that are doing it, and the nurses, but for the most part, as you know, it’s really what we eat, you know, what we drink, how we sleep, exercise, and so on. And the newest, the developments around COVID with telehealth and the newer technologies like home blood glucose monitors, or other devices that actually can measure blood pressure, you know, other home based monitoring, but even more so I think it’s the mindset that we need to equip our patients with the ability to care for themselves and to co-produce their own health. There is everything that we talked about in terms of tapping into the capability of physicians and unleashing that into solving healthcare. I think a whole order of magnitude more powerful will be when we really tap into patients and their ability to influence their own health and health outcomes. And if we can do a little bit of both, we’re gonna be more than able to cover health for everybody, healthcare for everybody.

– And I think that’s why it’s so well done in your book that in every chapter you have a thing for patients, doctors, payers, policymakers. Because we’re all in this game together, co-producing health. I really like that actually. I mean it sounds slightly wonky, but it’s so true.

– It is wonky.

– [Dr. Z] But you know, everything we do in medicine is wonky.

– You need to come up with a better phrase for me. You know what I mean? I’m actually waiting for you to do the co-production video. Will you a co-production music video for me? Work on that a little bit. Yeah, I think there’s some potential there.

– You down with OPP somehow has to be involved, you know, other people’s health. I’m just gonna use the word synergy because I saw it on TV once. And I think that just answers every question. No, but it’s true. Actually, communication is a big part of this, actually all the joking aside, the words you choose, and how you express this is what is going to help start to shift the policy, which is why I’m glad that this book has been written, and I see the stack of books behind you. “The Price We Pay,” by Marty Makary who is a regular on the show, good friend. Again, it’s like a cabal of people that are all coming from different angles, but seem to converge on the ideas of what needs to happen. And it’s gonna take collaboration among all sectors of this to fix this huge part of the economy, and it’s along fix, like you say, it’s not a magic thing. Anyone who tells you there’s a magic answer is trying to sell you something. And the sense I get is, no, we gotta chip away at it, but first we have to be open and available to each other to say, you know what, okay, I see your angle on it, here’s the other angle, let’s try to come together and come up with a solution. Instead of, you know, I fall into this trap of villainizing administrators, or villainizing insurance companies, or sometimes villainizing doctors because they’re misbehaving. The truth is we’re all, we all have our part to play, and when I go out and do talks it is so clear to me that everybody is in this to try to improve the system, they just sometimes feel powerless, that’s all it is. So one thing, you have a huge chapter in this book that was very important to me on employers and healthcare. They’re like 56% or something of our health insurance is provided by employers. They are so important to this, yet they’ve kind of historically been awol. Tell me what your thinking is on how employers are gonna modulate this.

– Well I, you’re completely right about that. Over half of Americans have their healthcare through their employers. And we know that employers could have enormous impact, market power, whatever you wanna call it, in terms of really driving better healthcare. And right now is a perfect time to be talking about that because we’re in this COVID crisis. These employers are facing huge economic pressures, and the one thing we know, the one certainty about 2021 is healthcare premiums are gonna go up. They’re gonna go up because there’s a lot of uncertainty right now in the market, we’re worried about the rebound, we don’t know what COVID’s gonna do next year. And when those premiums go up, those employers, I’m worried that it could be the tipping point for them. So this is the time for employers, sit down, ask for the information about all that money that they’re spending. On average, healthcare costs $15,000 per employee per year those employers are having to cover. So they need to sit down, look at the data, understand how they can work with other employers, work with the healthcare systems that are caring for their employees, and really try to develop a better strategy. I’ve got 10 points in my employer action plan chapter. Really good time for those folks to sit down and try to tackle that.

– That is a great teaser for the book because when I read that section I was like that is a whole book in itself, and you really summarized it beautifully. Okay, here’s the pitch guys, cause I have to just give this pitch on behalf of Vivian’s book because I read quite a few books on healthcare, and I gotta say, like, if you just read this, and I read it in a day, if you just read this, you will get an excellent overview of quickly what’s wrong, but more importantly, what we can do to right it, which means that you can then become an influencer in your own right with your own teams, whether you’re a leader, whether you work in an organization, you can start to influence the conversation. It’s not black and white politics. It’s this beautiful, slightly complex, but understandable nuance, whether it’s pharmaceuticals, employer pay, whether it’s the insurance system, whether it’s what we can learn from VA and military systems and what we can discard, how we can be better clinicians, patient satisfaction, all of that is in here, and it’s available, I think for pre-order, right Vivian? I’ll put a link in, it’s coming out on Tuesday.

– That’s right, out on Tuesday.

– But I’m gonna get this show out like ASAP because I think people need to see this, and I would love you guys, Z-Pac, if you check out this book. This is one of those high recommendations from me. Okay, you really need to do it. Dr. Lee, man, so Verily, are you gonna change the world now through Googleation? What’s going on there?

– Hey, stay tuned. Some good action happening. Good action.

– I love it, that’s a nice teaser. Thank you so much for spending your precious time with me. I hope you’re staying safe during all this, and staying, I know you’re staying busy.

– You too, thank you. It’s been so much fun. Keep up all the great work.

– All right, thank you, thanks so much. Hey, Z-Pac, man, if you like what the message was here, check out the book, please share this episode, leave a comment, tell us your stories. Argue with us if you think something’s not right, but I bet if you read the book you’d see that your argument is actually discussed because it’s that, it’s that good. We want more leaders like Dr. Lee and others to kind of lead us into Health 3.0. So we want to encourage that, again, by sharing this video. If you become a supporter of the show that’s even better, but you don’t have to. I love you guys, and we out, peace.

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