Innovation and Disruption

Atul Gawande: A World of Promise

July 27, 2018 2:36 pm

During my years running a health research institute, I welcomed new staffers with a thick packet of New Yorker articles. Not just any New Yorker stories, but a selection of articles written by Atul Gawande, MD, MPH. Far better than any textbook, the collection remains one of the best—and certainly the most enjoyable—discourses on the many failings of our nation’s healthcare system.

Memorable reads such as “Finding Medicine’s Hotspots,” “The Coach in the Operating Room,” and “What Big Medicine Can Learn from the Cheesecake Factory” illuminate how and why we spend more than $3 trillion as a country and have fair to middling results. The perverse incentives, the lack of transparency, the egos and agendas—it’s all there in the Gawande collection. So too are many of the most promising, and often, elegantly simple, solutions. Gawande has even given us a roadmap for dying well, in his breathtaking book Being Mortal.

So the decision by Warren Buffet, Jeff Bezos, and Jamie Dimon (“the Big Three”) to put this Renaissance man in charge of their effort to rescue health care is, in many respects, inspiring.

Gawande is not your ordinary ink-stained wretch of a writer carping from the sidelines. He has logged the hours in the operating room and at the bedside to speak as a true peer to clinicians who look askance at laypeople intent on “transforming” their industry. He also is a bona fide entrepreneur, founding Lifebox, a not-for-profit that brings safer surgery to the developing world, and Ariadne Labs, a research center that tests and implements health system innovations such as surgical checklists. And he has enough scars from the Clinton administration’s failed health reform effort to know that significant change requires superb political acumen—and a thick skin.

Yet even a rock star such as Gawande could easily become overwhelmed by an effort to turn our inefficient, impersonal, nonsystem of acute care into a high-performing, customer friendly, ecosystem of health and well-being.

It is true he’ll be leveraging the buying power of the Big Three’s more than one million employees. But spread out over perhaps all 50 states plus the District of Columbia, that purchasing power quickly dilutes.

Nevertheless, I have high hopes for the yet-to-be-named new enterprise, especially if Gawande narrows the focus to themes that have dominated his career—what I call, “getting our money’s worth.” In one form or another, whether assessing which patients to devote time and resources to (“Finding Medicine’s Hotspots”) to eliminating waste (“America’s Epidemic of Unnecessary Care”), Gawande is one of the earliest and most eloquent proponents of high-value care. Put another way: Here’s hoping Gawande can lead us on a mission to slash the swaths of dangerous, unnecessary, inappropriate, duplicative, unproven, or low-value care delivered—and paid for—every single day.

In one recent survey conducted by Johns Hopkins researcher Martin Makary, MD, MPH, and colleagues, physicians estimated 20 percent of medical care is unnecessary. And they put prescription medications at the top of the list.

Consider the fact that more than 47,000 head scans were administered to patients with uncomplicated headaches in Minnesota in 2014. Those scans, which expose patients to harmful radiation, cost $22 million.

Medicare spends $2.4 billion to $6.5 billion annually on services that do not improve health, according to the Medicare Payment Advisory Commission. The estimates vary, but suffice it to say low-value care is costing the United States between $200 billion and $750 billion a year.

Of course, those figures don’t include the cost of complications and errors, not to mention lost productivity. Nor do the numbers capture the human toll, the anxiety of false positives, the pain and discomfort of tests and procedures, or the unpleasant side effects. This is not a data issue. We are nearly drowning in evidence that we, as a society, are purchasing tests, treatments, devices, and procedures that, at best, do nothing to improve our health and that all too frequently violate the Hippocratic oath, “First, do no harm.”

All of this is not news to Gawande. And that is precisely the point. Perhaps he, with the Big Three behind him, will be able to convince consumers and clinicians that in health care, less is often better. This means no more antibiotics for the common cold. No more prostate screenings in men over 75. Next to zero early, elective inductions. Fewer heart stents, lower back scans, and lab tests. A lot less opioid prescribing. The lists are seemingly endless, many of them crafted by Gawande himself.

We are not talking about denying necessary medical care. In fact, just the opposite. The goal must be the right care for the right patient at the right time. Money must flow to proven interventions, including prevention and nonmedical supports such as housing and food.

Of course, saying no to physicians and their tests and scans and surgeries feels counterintuitive, even a bit scary. We’ll need Gawande’s skill as a communicator—a credible physician who speaks in plain English—to help navigate the cultural and emotional minefields of reducing low-value care.And let’s not forget the $3 trillion healthcare sector, employing millions of Americans, is backed by powerful societies, companies, and trade groups, including my own association. We will need someone of Gawande’s stature to convince industry leaders to join him in this effort to give Americans the healthcare system they deserve and pay for.

Despite the hurdles, Gawande won’t be alone if he pursues this path. Efforts such as “Choosing Wisely” and the United Kingdom’s “Do not do” database provide the evidence needed to start targeting wasteful interventions. The Lown Institute works to address the harm and waste caused by unnecessary medicine and is a leading voice in the “Less is More” movement. It conducted the first nationwide survey to ask physicians in a range of specialties about overtreatment. And in Utah, Intermountain Healthcare and SelectHealth teamed up to entirely eliminate elective inductions prior to 39 weeks, thereby drastically reducing infections, premature births, and time and money spent in the NICU.

Makary, who like Gawande, created one of the first medical checklists, has shifted the dialogue to focus on “appropriateness.” Working with Oliver Wyman, he developed an approach called “Practicing Wisely,” which presents data to physicians tracking their performance relative to peers and the appropriate clinical guidelines.

In the coming weeks and months, Gawande will encounter a barrage of suggested problems to solve. Given his background, if he were to make even a small dent in our mountains of low-value care, he would have scored a tremendous victory not only for his three new bosses, but also for the nation as a whole.


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