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On Point Live! With Atul Gawande: The Future Of American Healthcare

Superstar surgeon and medical thinker, writer Atul Gawande on the future of American health and healthcare.

We are well into Obamacare now, and still fighting over it.  Well into panic over healthcare costs, and still struggling to really bring them down.  Well-schooled in how we ought to eat, exercise, live – and still overweight and pushing up the diabetes numbers.  Celebrated surgeon, writer, thinker Dr. Atul Gawande is watching it all.  Thinking it through.  When he’s not in the OR, he’s at the keyboard, helping shape the American conversation on health and healthcare.  This hour, in a special edition of On Point:  On Point Live! – with Dr. Atul Gawande.

– Tom Ashbrook

Guests

Atul Gawande, surgeon, writer and public health researcher. General and endocrine surgeon at Brigham and Women’s Hospital in Boston. Professor at the Harvard School of Public Health and Harvard Medical School. Author of “Complications: A Surgeon’s Notes on An Imperfect Science,”  “Better: A Surgeon’s Notes on Performance” and “The Checklist Manifesto: How To Get Things Right.” (@atul_gawande)

From Tom’s Reading List

Forbes: Surgeons Know Bad Surgeons When They See Them – “All surgical procedures carry risks, after all. Even in the best of hands, the procedure Dave Weindel received – gastric bypass – carries a high risk of complications. Some surgeons have higher complication rates than others, but it is often difficult to tell whether this is because some are more skilled or because some surgeons operate on “riskier” patients – those with other medical problems that increase the chances that something will go wrong.”

New Yorker: Big Med — “Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. ”

Croakey: Twitter and health policy research – time to get together? — “There is some good company out there in the Twitterverse and some great examples of how to use it effectively. But university-based researchers described social media as being incompatible with research, of high risk professionally, of uncertain efficacy, and – this might be important – an unfamiliar technology that they did not know how to use.”

Morris And The East Coast Performs

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  • brettearle

    With regards to Forbes Magazine’s comment above:

    It is not possible to observe, and analyze a study–of the secondary and primary illnesses, suffered by a patient—to see general trends, among surgeons, over time, of success rates….according to type of surgery and patient?

  • creaker

    We have a healthcare system based on profit – and in that respect, we have the best healthcare in the world if it’s looked at only in terms of the amount of money we spend on it.

  • stillin

    My 89 year old neighbor and good friend, went to Canada for her dental teeth…it would have been 5,000 here on the US side of the border, it was 1G on the Canadian side. People who are watching their very, very hard earned money get stolen out from under them, are wising up, and wising up quickly. Out of the country operations in Latin American and China are not unheard of now either…even with the airfare costs ….it is much cheaper and comparable sometimes BETTER than what the US offers regionally.

    • brettearle

      Are these patients researching evidence-based outcomes–before they temporarily leave the country for Health Care?

  • brettearle

    Surprising that the reduction of the rate of increase of Health Care costs can already be seen tangibly–in part, according to Gawande, because of ACA.

  • brettearle

    VNA can handle the monitoring of the proper use of Insulin Needles.

    VNA referrals are handled easily by PCPs.

    Are we suppose to believe that this has never occurred to PCPs, VNAs, and Health Managers?

  • Dia Bubalo Kleitsch

    Having recently left the field of social work (specifically the chronically mentally ill), I have experienced first hand, how shrinking budgets and not wanting to pay those educated to provide basic education about dealing with conditions/problems experienced in daily life by these populations causes much greater costs to care for them in crisis.

    • brettearle

      Could NAMI be helpful in this regard?

      • Dia Bubalo Kleitsch

        NAMI gives help mostly in the form of support and referral directly to those in need, if it could raise the funds to lobby in Washington to increase awareness of the need for consistent funding at a level that actually meets the needs of the mentally ill, that would be a great help.

  • ChevSm

    I do appreciate and agree with most of Dr. Gawande’s writing but I do think he’s a bit of a hypocrite when we discusses health care cost being that he works at the highest cost hospital (BWH) in highest cost state (MA).

    It would be refreshing to hear him speak about the high cost of care at Partners hospitals vs. other hospitals in MA.

    http://www.mass.gov/chia/docs/r/hospital-profiles/2012/massachusetts-hospital-profiles-report-fy12.pdf

    • brettearle

      High cost of care is sometimes partially associated with the best trained specialists and the best Hospitals and the best state-of-the-art research..

      BWH is one of those hospitals and has those kinds of MD specialists as well as, often, state-of-the-art research.

      • ChevSm

        I do agree that it’s partially associated but the problem I have is that we shouldn’t see enormously different costs b/t research hospitals (Partners Healthcare) and other local hospitals for simple common procedures (ex: reading an MRI, colonoscopy, etc.). At some point a colonoscopy is a colonoscopy. One shouldn’t cost twice as much just b/c you’re having it at a “state-of-the-art research hospital”.

      • hopeful61

        Also, if you are buying insurance on the open market as I have been, it will cost you more to get care at the best Boston hospitals. Blue Cross calls these “tiered plans” or “Hospital Choice Cost Sharing” and if you want to go to the Brigham or MGH, you have to pay more than if you went to a suburban hospital. So what this means is the people with the most money will get the best care at the best Boston hospitals. (Medicaid may be excluded, I am not sure.)

        Rationing, anyone?

        • brettearle

          Your point does suggest an unfair distribution of services.

          But I think it’s an exaggeration to believe it has reached the point–or will reach the point–of pure rationing.

          What’s more, state health insurance coverage, in MA, does not preclude access to a place like B & W.

    • http://neilblanchard.blogspot.com/ Neil Blanchard

      I think the reason that healthcare is so expensive is that we allow profits to be made – by the insurance companies, and by hospitals, etc.

      • brettearle

        The profits still gouge.

        Read the TIME magazine article from, maybe, 2 years ago.

        It’s a landmark article.

        “On Point” had a show on it.

      • ChevSm

        I agree but it’s not the only reason. The most expensive (cost per patient) large hospitals in MA are non-profit.

  • creaker

    Capitalism is the wrong model for healthcare. Imagine you are running an Apple store, you want people spending lots of money and coming back again and again – if you had a salesperson who got customers the least they needed at the lowest cost and set up those customers so they rarely or never needed to come back and buy more at the store, you’d probably fire them. But that’s the model healthcare should be following.

  • http://neilblanchard.blogspot.com/ Neil Blanchard

    Much of the “diet problems” can be laid at the feet of factory food.

    • brettearle

      It takes discipline to get around that.

      But it can be done.

      • hennorama

        brettearle — Discipline? Ack! Run away, run away!

      • http://neilblanchard.blogspot.com/ Neil Blanchard

        It takes learning how to cook good food.

        • hennorama

          Neil Blanchard — it begins even earlier, with learning what good food is, then how to obtain it, followed by actually buying it.

        • brettearle

          The Irony, of course, is that `good food’ often costs more….

          • http://neilblanchard.blogspot.com/ Neil Blanchard

            Actually, whole food (lower case!) is often less expensive. Potatoes instead of potato chips, tap water instead of sugar drinks, eggs and rice and flour etc. instead of frozen dinners.

            Avoiding sugar, and excessive salt and fats by eating something homemade is the point I am trying to make.

          • brettearle

            Well, Neil, you’re going to have to take me on a tour, of where you go.

            Because, anytime I go to a well-stocked Health foods store or chain, I’m paying anywhere from a 20%-40% markup.

            Please advise…

          • http://neilblanchard.blogspot.com/ Neil Blanchard

            Farmers market is a good place to start.

            The fact that crappy food is so cheap is the problem.

          • brettearle

            Just went to one yesterday.

            The markup was somewhat less. But it was there.

            Also, I’m in a place where the FM is supposed to be reasonably well-stocked with variety. But it isn’t.

            The Region is in a choice location in which to live–where there are Organic Foodie Elitists.

          • tbphkm33

            You are absolutely right – if you know how to cook, you can feed yourself for a lot less than those who buy processed foods. Plus, eat a heck of a lot healthier.

          • brettearle

            Potatoes v Potatoes is the issue.

            Not Potatoes v Potato Chips.

            You obviously know that.

        • TFRX

          And time, also. There’s something counteractual to that when someone has to patch together one income out of 2 to 2 1/2 half-time jobs.

  • brettearle

    MDs do not always acknowledge side effects, from prescribed medications, in their patients.

  • hennorama

    Dr. Gawande is pointing to the difference between “health care,” which is largely absent in our medical systems, and “sick care,” which is the predominant reality of our medical systems.

    We need more of the former, which will eventually lead to less of the latter.

    • brettearle

      Problem is, the patient has to take notable responsibility to carry out prevention strategy.

      • hennorama

        brettearle — dammit! Is there a “responsibility pill” we can take?

        • brettearle

          You SOB

          Why didn’t I think of that?

          • hennorama

            brettearle — I’m guessing here, but I perhaps it’s due to your complete lack of responsibility.

          • brettearle

            Why didn’t I think of that?

          • hennorama

            See above.

          • brettearle

            Forum Alert!

            Encoded Acronyms might appear soon.

            Forum Alert!

        • creaker

          If you buy a product, you get a warranty – usually there’s a clause written about abusing the products voids the warranty. But for many products you can pay extra and get repair/replacement coverage for just about everything. Health insurance already does this for things like smoking – maybe it should be further expanded?

          • brettearle

            It’s a good point.

            But, once again, it brings up Outside Intrusion as a political issue.

  • brettearle

    Even if we’re sick, do we want moment-to-moment monitoring?

    Some Libertarians would likely prefer a fatal Myocardial Infarction.

  • Bill Frank

    Are we heading to a point where all physicians are simply employees? Where the pressure is to simply follow the corporate model? Pay salaried physicians less and less, and the “system” keeping the profits?

    • hennorama

      Bill Frank — perhaps.

      Vertical integration has been going on for some time, with insurers and hospitals purchasing physician groups, in an effort to ensure that they have enough providers for their patients. There is then the inevitable process of standardization of care through quality control systems, and regular feedback.

      To some extent, physicians are trading in the management and financial headaches they experienced as independent providers, for the security of regular employment, as well as the advantages provide by organizations with far greater resources.

      OTOH, there are also some providers who are going the other way, to the concierge model. They are rather few and far between, however.

  • levigirl

    I love this guest

    • brettearle

      Because?

      • levigirl

        smart & compassionate and actually has an idea how to fix this mess

        • brettearle

          He needs to Turn On his colleagues–i.e., to get as passionate about the salient issues as he does..

          Big Time.

  • becky karadin

    Health in the US will continue to decline until employers stop 40 + hour work weeks and allow individuals more vacation time to relax and enjoy life.

    • brettearle

      Often times, people (though not all) who relax and enjoy life, eventually follow a lifestyle of lassitude–which leads to worsening health problems.

    • pennyroyal

      the stress and fear of a catastrophic illness wiping out family finances is intense these days. My sister, an RN, is recovering from stage III cancer. The hospital paid her healthcare insurance for that year, $30,000. She’s paid well but it will take a long time to just break even meanwhile paying for current insurance costs and money just to live. If she has a recurrence, she’ll be financially devastated. And at age 60, how long can she keep up the pace and stress of a job, where the other nurses are complaining to management about the intense pressures on them.

  • Bruce94

    Thanks, OnPoint, for a thoughtful discussion and a guest whose expertise and knowledge on this critical topic stand in obvious contrast to the demagoguery of another MD you’ve had on the show not too long ago —the Good Doktor, Ben Carson.

    Unlike Dr. Carson, Dr. Gawande’s offered many valuable insights that hopefully the DC politicians and bureaucrats alike will heed as the ACA is fully implemented and the hysterical opposition from ultra-conservatives like Dr. Carson melts away as millions of Americans continue to sign up, receive the benefits and see through the shameless scare tactics of the GOP.

    The first part of the discussion reminded of the critique that came out in the early 70’s—Barbara Ehrenreich’s “The American Health Empire: Power, Profits and Politics” which delved into some of the monopolistic forces in the healthcare market that lead to information asymmetry, restrict entry into the medical profession itself, and reduce price competition as well as supply resulting in escalating costs. That’s right, I’ve been following the evolution of universal healthcare in the U.S. for over 40 years, and it’s gratifying finally to see that it may actually come to fruition in my lifetime.

    Dr. Gawande correctly identified rising costs as the main culprit in our healthcare system that threatens to undermine the ACA. He then went on to describe how the traditional fee-for-service model exacerbates the problem of rising costs implying that a new paradigm like “capitation” will be required to provide the incentives necessary for keeping patients well and reducing costs (i.e. rewarding value vs volume of services). However, he didn’t specify how the ACA might help in the interim until such a revamping of incentives can be accomplished. Here are a few reforms in the new law which are expected to bend the medical cost curve downward and, according to the CBO and JCT, to actually reduce the Fed. budget deficit over the next 10 years:

    –mandated wellness care which will reduce demand for and consumption of medical resources by keeping patients healthier

    –limiting reimbursement of providers for readmits or tests and procedures that are repeated due to preventable errors

    –eliminating subsidies to private insurance companies for Medicare Advantage since actuarial date show no difference in health status and outcomes among patients enrolled in Regular Medicare vs Medicare Advantage Plans

    –information sharing enabled by electronic records and data systems that reduce duplication of expensive tests and procedures

    –standardization of insurance forms and procedures which could provide surprisingly large cost savings

    –further development of evidence-based medicine which utilizes data-bases including double-blind trials and other comparative effectiveness studies that could dramatically improve the quality of healthcare and reduce its cost

    • brettearle

      Well-done.

      Dr. Gawande made the point that he could already point to a decrease in the increased rate of Health Care costs–as the result of ACA.

      Although, I did not hear an explanation as to how he arrived at that conclusion.

      • Bruce94

        I didn’t either. It may be worth listening to again to catch the gist of his assertion.

  • Elizabeth Babb

    I found myself in considerable disagreement with the medical views
    expressed by today’s and other medical guests on the On Point
    programs.

    First, the medical community does not distinguish between damaged
    healthy and sick conditions. Damaged healthy (including such newly identified conditions as hemorrhagic stroke) are treated without regard to letting and encouraging the body to restore its natural systems. Not only doctors who prescribe., but people who formulate medicines are unaware of cause and effect in a patient’s history and how it should affect treatment.

    Second, current trends toward self-measurement (self-administered
    blood pressure, diabetic level, etc.) and computerized hospital records that a patient is allowed to see – such records mean that the horrible inaccuracies common in official records come to light. The state of “computerization” in hospitals seems comparable to that common in industry 30 years ago. If doctors and others spend a lot of time on data entry, it is a reflection of their horribly naiive procedures.

    Third, an advantage of forcing medical people to have their
    records viewable by patients means that medical people must be more
    precise and more honest in their documentation, not easily hiding snaffoos, using way-off records

  • http://flustercucked.blogspot.com/ Frank TheUnderemployedProfessi

    Perhaps it’s time to question the entire economic structure of our health care system from using insurance companies as middle men to the training of physicians. Consider the following comparison:

    U.S. Health Care:

    * 17+% (18%?) of GDP spent on health care.
    * Tens of millions of Americans uninsured or under-insured.
    * A populace terrified of losing employment (and thus health insurance)
    * Hundreds of thousands of medical cost-induced bankruptcies every year.
    * Businesses burdened by health care costs.
    * Wealthy health insurance executives and a thriving yacht industry.

    Evil Socialized Medicine: (Warning–this stuff is evil !!!)

    * 12% (sometimes less) GDP spent on health care.
    * 100% of the populace insured.
    * A more contented populace.
    * Zero medical bankruptcies.
    * Businesses that don’t have to worry about insurance issues.

    * Far fewer wealthy insurance company executives (if any) and hospital execs. However, the yacht industry is suffering.

    Is it possible that we could learn something from how other nations do it? Essential viewing and reading:

    http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

    http://www.forbes.com/2009/07/02/health-care-costs-opinions-columnists-reform.html

  • ConcernedCitizen

    Atul Gawande promotes the Internet as a way to connect a person’s health records with her prescriptions and insurance records, interacting with each other and with a smartphone or other personal digital device. He also wants open source applications for this purpose, making it easy for any programmer to make changes in the system. This means also that one’s location, heartbeats, sleep patterns, medications etc. will always be accessable to anyone who can enter the system. This leads to the conclusion that vulnerable people will be even easier targets for identity theft, ripped-off bank accounts and credit cards, intensive marketing endeavors and government intrusion.

  • eat_swim_read

    Tom, Tom, Tom – I am Boomer Chick. You read my pre-submitted question at the top of the show and let the doctor blow right past it to a long ‘answer’ about home health visits for a very ill diabetic.
    I wanted to know about the 30 mil. of us who are *still* uninsured – and also why dr. pay and non-profit hospital earnings are seemingly off-limits.
    Softball handling of this guest.
    Yawn.

    • tbphkm33

      The elephant in the room answer is that the for-profit medical system in the US makes more money when you and the other 30 million seek treatment late. When it is more difficult and costs more to treat you. Bottom line, it is for profit, big business. Why pick the apples early, making only make 15 cents per apple, when you can wait till that apple is worth a whole dollar?

      In the crony capitalism of the United States, you are worth more sick and close to death, than just doing routine checkups.

      • brettearle

        tb–

        Not EVERYone is in the Medical Business for the money.

        You ought to know better than that.

        Your cynicism would be healthier if it weren’t so exaggerated.

        There are plenty of medical professionals who are committed to Healing.

        And while what you say has, unquestionably, notable significance, I think that you are overstating it.

        Purse strings may control things, in many ways.

        But too many people also want to help.

        C’Mon….

        Stop being so progressively Left, all the time.

        I am a Lefty, too, but I clean my Prism, every once in a while.

  • donny_t

    1) measles are on the rise not due to people avoiding vaccinations, but because of the vaccination itself (anyone who doesn’t believe me, do some research – vaccinations have been linked to the spread of the disease it’s meant to cure)
    2) the number one reason why blood pressure is on the rise is NOT because people don’t take their medication, it’s because doctors have not been trained in diet and nutrition which is an easy fix for high blood pressure

    • brettearle

      Diet and Nutrition are NOT necessarily an easy fix for Hypertension.

      Hypertension can be congenital.

      And it is so often related to Heart Disease that we would be looking at many unnecessary deaths–if hypertensive drugs were not taken–regardless of whether cholesterol and high fat foods are eliminated.

      It is NOT true, what you say.

      Obviously diet and nutrition can often help significantly.

      But nothing is a panacea.

      • donny_t

        Even high risk patients can be cured without drugs. You’d be surprised. Do a little research into natural cures. Heart disease, cancer, MS, ASD and more all are treatable with diet and substances found in nature. And therein lies the problem. There’s no money to be made on things we can’t patent. No return equals no research. It’s to the point where we’re being sold sickness. We’re treating the symptom and not the cause, and in a lot of cases even perpetuating it.

        • pennyroyal

          my husband has Parkinson’s Disease and all the alternative treatments, like gobs and gobs of coconut oil wouldn’t help as much as the ongoing intelligent care of a good neurologist and her due diligence when, in conversation with her, we discuss his medication regimen. Nothing can substitute for that close partnership, carefully nurtured by both parties.

        • brettearle

          Of course, natural remedy is important.

          Of course it is.

          But for you to see Alipathic medicine as a disease, in itself, is adolescent, destructive, radically zealous, and fool-hardy.

          • donny_t

            That’s clearly your own assumption because I never stated that.

            My point is: compare our medical industry’s effort on both approaches. Our research, spending and approbation is clearly on drugs not actual health because we should be more focused on things like cleaner food, cleaner environment, and healthier activities. We should be educating people on things like how sugar effects the body, gmo’s, toxins in the environment, etc. A visit to the doctor should be so rare, that the medical industry would be 1/3 of the size it is now. See the conflict of interest? We’re a nation that has the best health care in the world yet we’re one of the sickest.

          • brettearle

            You make declarations about money and patents and “being sold sickness”–with regard to the practice of medicine.

            Then you walk away from your claim by suggesting that you don’t think medicine is fool-hardy, etc.

            You can’t have it both ways.

            You don’t know what you’re doing.

    • ExcellentNews

      But of course. A vial of dewdrops collected upon a full moon from the flowers of Persinifloria Magica, and steeped with toad eggs, will cure measles AND hypertension…

  • ChaiseKerswellmmy

    Peyton . true that Jessica `s blurb is shocking, last
    monday I got a gorgeous Peugeot 205 GTi after having earned $6860 this past 4
    weeks an would you believe ten-k this past-month . with-out a doubt this is the
    easiest-job I’ve ever had . I actually started six months/ago and pretty much
    immediately started to bring in minimum $84… p/h . Read More Here F­i­s­c­a­l­p­o­s­t­.­C­O­M­

    • tbphkm33

      Please help by flagging this spam.

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