Ep 12: Affordability in the Price We Pay

with Marty Makary, M.D., M.P.H.

June 3, 2021

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Marty Makary, M.D., M.P.H.
Surgical Oncologist and Professor, Johns Hopkins School of Medicine and Bloomberg School of Public Health

Dr. Marty Makary is a New York Times bestselling author and leading voice for transparency in health care. He is the recipient of the 2020 Business Book of the Year Award for The Price We Pay. A professor at the Johns Hopkins Bloomberg School of Public Health, he has published over 250 scientific articles on the re-design of health care, medical innovation, and vulnerable populations. Dr. Makary has been elected to the National Academy of Medicine and is Editor-in-Chief of Medpage Today. He has written for The Wall Street Journal, The New York Times, and USA Today and is a frequent medical commentator. 

Clinically, Dr. Makary practices pancreas surgery and has pioneered novel operations at Johns Hopkins.  He is the recipient of the Nobility in Science Award from the National Pancreas Foundation and has been a visiting professor at over 20 medical schools.

Dr. Makary was the lead author of the original publications on the surgery checklist and later served in leadership roles at the World Health Organization. Dr. Makary is the chairman of the African Mission Healthcare medical advisory board and leads several health care collaboratives. His current research focuses on the underlying causes of disease and relationship-based medicine.

His book Unaccountable turned into the T.V. series “The Resident” and his newest bestselling book of The Price We Pay was has been described by Don Berwick as “a deep dive into the real issues driving up the price of health care” and by Steve Forbes as “A must-read for every American”.  He speaks nationally and internationally on the appropriateness of care, lifestyle choices that influence health outcomes, employee health benefits design, and health care costs.

Dr. Makary is a graduate of Bucknell, Thomas Jefferson and Harvard University.  He completed his surgical training at Georgetown University and his fellowship at Johns Hopkins Hospital.

People are looking for quality that is going to move into a new area called 'Appropriateness of Care' because a lot of good practice lacks a randomized control trial.

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Gary Bisbee  0:06  

Healthcare leadership is hard work, but what if you could learn from the most brilliant and influential minds in healthcare and beyond? What would you ask them? Would you ask about politics, policy, or maybe leadership? On The Gary Bisbee Show, I’ll do just that. You’ll hear from healthcare’s most successful leaders and those experts who they listen to, as together we’ll explore how the healthcare economy is transforming.

 

Several months ago, Dr. Marty Makary wrote op-ed pieces in the Wall Street Journal that predicted that the US would reach herd immunity in April or May of this year. Curiously, many governmental and establishment figures did not pick up on Marty’s findings. In this conversation, we explored the reasons for Marty’s successful prediction and why many experts were silent on it. Dr. Marty Makary is a surgeon and professor at the John Hopkins School of Medicine. Marty is an accomplished author. His most recent book—The Price We Pay, being introduced in softcover early in June—is a collection of fascinating stories that emphasize the importance of solving the affordability gaps in US healthcare. We dug into the affordability crisis with Marty and engaged with him about how healthcare in the US can become more equitable and affordable.

 

Good morning, Marty, and welcome.

 

Marty Makary, M.D., M.P.H.  1:39  

Good morning, Gary. Good to see you again.

 

Gary Bisbee  1:41  

Great to have you at the microphone. I’d like to kick off with two congratulations. One, of course, is the softcover of The Price We Pay is basically now available and included a look back to COVID. It was originally published right before COVID in 2019. Secondly, tell us about the Business Book of the Year award. That’s awesome.

 

Marty Makary, M.D., M.P.H.  2:05  

Thanks, Gary. I was really excited about that. The journalism Association awarded the book the Business Book of the Year award, so I’m excited about this second edition. It’s updated for COVID and it’s in paperback, so it’s also cheaper.

 

Gary Bisbee  2:17  

For those of us that have the hard copy, we might want to buy the soft copy just for the COVID update. I’m sure your publisher views it that way.

 

Marty Makary, M.D., M.P.H.  2:25  

They’ll be excited about that.

 

Gary Bisbee  2:27  

The second congratulations is referencing your point about herd immunity. You wrote an op-ed piece in The Wall Street Journal in February followed up by one in March making a point that if you add those with vaccinations and natural immunity, you were approaching herd immunity, or would at least in April/May timeframe. Today, the CDC, of course, issued the guidelines that said those of us who are vaccinated don’t need masks inside or outside or worry about social distancing. You call that the question there. How do you think about this idea of herd immunity? What is it and why is it important?

 

Marty Makary, M.D., M.P.H.  3:12  

The big deal is that natural immunity is real. It works and it’s been blown off by our public health officials. When you talk about calculations to high herd immunity levels and you ignore the fact that half of the unvaccinated people have natural immunity, that’s a big omission, and it changes the path to herd immunity a lot and it changes the timeframe. What we saw with the CDC guidance saying, “Hey, all of a sudden vaccinated people can take off their masks indoors or anywhere,” it came out of nowhere it came out of the blue because they were responding to public perception that, hey, the community risk is extremely low among vaccinated people and there’s not a lot of infection out there. Cases have plummeted faster than the CDC anticipated, so they responded to public perception, issuing that guidance that really was based on data three months ago. By the way, I wasn’t the only one saying we were going to see herd immunity late spring. There were a couple of us all of whom had some public platform, but really just felt like the message being broadcast from on high was missing natural immunity and that it was roughly half of the population. All of us after that article came out where I suggested we’ll hit herd immunity in late spring in time for a normal summer. Remember, that was a time when people were cooped up and depressed. There was a lot of pent-up giddiness and that excitement translated into a misinterpretation that herd immunity means eradication. Of course, I said in the article that it absolutely does not mean that. I said the infection will be around for many, many decades, so we quickly switch to the term “population immunity” to avoid the stigma of the word “herd” and we’ve seen population immunity really kick in since then.

 

Gary Bisbee  5:00  

“Population immunity” is a good term. We’ll start using that, but what about the natural immunity from the standpoint that the powers that be really haven’t addressed that? You don’t hear that as a cause or condition to get us to population immunity. Why do you think that is?

 

Marty Makary, M.D., M.P.H.  5:17  

I’ve actually had personal conversations with Dr. Fauci about this and have been poking a lot of the national figures saying, “Hey, talk about natural immunity.” The seroprevalence study from California confirmed that it’s about half the population 45% of La residents back in February. I mean, since then, there’s been a lot of a lot more natural immunity. What they’ve told me is, “We don’t have good data.” Of course, it doesn’t fit the beautiful randomized control trial model, because you can’t randomize a population of natural immunity. And there’s this sort of far-reaching hypothesis that natural immunity could drop off. Like it’s dropping off a cliff. But my response has been “open your eyes.” We are not seeing reinfections after 15 months of this Coronavirus being around. That tells you that natural immunity is working. If there were reinfections, we’d be talking about them. By the way, the few rare times we see them, they’re very mild cases. Even in the Danish study, it was 6/10 of 1%. At a time when there was a lot of infection. Now there’s a lot less infection.

 

Gary Bisbee  6:26  

We’re at the point where we have at least maybe 55% of the adult population has been vaccinated. I think we’re at 85 or 90% of the 65 and older being vaccinated so if you add in natural immunity, the population immunity is starting to approach 80 or 90%. Is that the way you look at that?

 

Marty Makary, M.D., M.P.H.  6:46  

Yeah, it changes everything. If you recognize the power of natural immunity, then all of a sudden the path to high population immunity is a lot different. It no longer requires vaccinating every kid vaccine mandates and coaxing and demonizing those who are hesitant. Some Americans have been hesitant for good reason. They’ve got natural immunity from prior infection. Let’s respect their decision and stop ostracizing them. If we want to help the hesitancy problem. I can tell you as a doctor, you win more bees with honey than fire. And if we can just make vaccines more available on a walk-up basis where it’s convenient and easy. We saw a very slow pivot to walk up as soon as we had a surplus. That’s how you really help address that hesitancy issue.

 

Gary Bisbee  7:34  

I agree. I think this whole idea of retail vaccinations is the key is just going door to door if you need to, why don’t we turn to The Price We Pay? And you started a course with unaccountable So what was the thinking behind starting without accountability and then moving The Price We Pay? Why did you embark upon writing The Price We Pay?

 

Marty Makary, M.D., M.P.H.  7:57  

The reason to write a book is if you feel that there is a message out there that really needs to be told that is not currently being told. As a resident, I saw wide variations in the quality of care at the best institutions in the country. I had the privilege of going to school at Harvard, and I’m at John Hopkins, Georgetown, a lot of these great institutions. Even in rotations at other universities, you see common themes, and that is that the standardization of care is vastly underappreciated, under-recognized, under adhered to, and so unaccountable. It was really just a bunch of stories from residency. After I felt like I had shared my perspective on variations in quality, the problem of variation in price was getting to be a big issue. More and more businesses were getting crushed with healthcare costs. I wanted to sort of do what The Big Short did. That book and movie did something amazing. In the world of storytelling and writing, it’s really an art form. That is how do you take a very complex, wonky, and even boring subject and make it exciting, make it a storybook and simplify the topic so anybody can understand it so you can democratize health policy. I basically tried to explain that the reason health care costs are so high is number one, the price of care. We’ve talked about the price of services rather than the healthcare costs. It’s more relatable variations in the appropriateness of care, overtreatment. overmedicating over operating, and then finally care coordination. I was privileged to be able to tell the story of a lot of disruptors in each of those spaces in the book The Price We Pay.

 

Gary Bisbee  9:42  

The Big Short became a movie are we looking at a potential movie here for The Price We Pay?

 

Marty Makary, M.D., M.P.H.  9:47  

No. I don’t know if you know, but I sold the book on accountable rights to the TV series, The Resident. When I watch it, I cringe because some of this stuff is thinking that’s not How we actually do it in the hospital. Amy Holmes has done a great job trying to tell the public about some of these issues of quality and pricing failures in healthcare to the public to empower people. She’s done a great job with that show.

 

Gary Bisbee  10:14  

The Price We Pay included listening to her, you just have story after story in the book, it’s fascinating to work through them. He didn’t really use the term affordability. But let me put that term on the table. It’s certainly suggested by the title and many of these stories. How do you look at affordability these days?

 

Marty Makary, M.D., M.P.H.  10:34  

First of all, the public has a right to be angry right now. That was my number one take-home message from this two-year listening tour when 48% of all federal spending is going to health care and its many hidden forums. And I mean that that’s not I miss speaking, we have a paper out on our restoringmedicine.org website under reports. We have I’ve got a piece in USA Today. That explains it’s not just Medicare and Medicaid. It’s half of the social security checks. Now we’re going to healthcare co-pays deductibles non covered services. It’s 15% of the Defense Department’s budget goes to health care for their own system. And that’s separate from the VA which is almost 5%. The interest on the debt is interest on health care spending. So almost half of federal spending is going to healthcare, American families are paying $20,000 a year on private health insurance. On top of that, they say, “Oh, my employer is paying part. I’m paying par—” No. They’re paying all of it. It’s coming from the same pool of money of wages and benefits. And then they get a bill for $4,000 and told this is not covered people have a right to be angry right now. I learned that we have good people in health care at every level. This is not a system we designed. This is a system our generation inherited, and it’s an entirely broken system. We have good people working in a bad system. I’ve seen the disruptors on the price transparency front on the direct contracting front, hospitals innovating insurance companies using new models, and doctors saying, “Hey, look. Our current system of practicing healthcare is broken. We don’t like it. The patients don’t like it. Why are we doing it?” As Rushika Fernandopulle told me, this old model of you come in to see us as doctors, we tell you to exercise more, eat better, and then come back in a year and we tell you, “You bad non-compliant patient” and throw meds at you. Look at the clinics that are now treating diabetes with cooking classes instead of just insulin and treating back pain with ice and physical therapy more than surgery and opioids and treating loneliness with communities and treating cancer by talking about environmental exposures and health and food as medicine and treating chronic disease instead of just throwing pills at people. That’s the exciting revolution in healthcare that I really loved learning about and sharing in that book.

 

Gary Bisbee  12:52  

Those are private sector initiatives that have probably fallen in the social determinants of health category with all of the spendings on the part of the government half the government spending being healthcare-related, or directly healthcare-related. What role is the government ought to be playing in changing the incentive structure and moving toward both more social determinants and perhaps even more of a managed care model? What do you think the solution is here?

 

Marty Makary, M.D., M.P.H.  13:20  

I’m sure have more insights on this than I do and knowing all the wisdom that you have from healthcare, but I’ll share with you my observation. Affordability is an access path and it is matter of fact, it’s the number one way to increase access and tear down barriers that we see with social determinants of health. We can keep throwing good money after bad into this system. I opened the book by showing how doctors just around the US Capitol Building within miles are putting unnecessary stents in plaques that don’t meet the criteria. But they know how to game the system. Medicare’s paying for all of it to show that we can keep throwing money into the system. Or we can start to get wise about using what I call appropriateness measures. That’s a big project now that my team and I are doing how do we identify practice patterns of appropriateness, and maybe replace pre-authorization with gold carding providers that fall within those boundaries of normal variation, practice variation is good and healthy, within boundaries. It turns out that when you talk to experts, the docs will tell you in that narrow specialty is a pattern that’s outside of the boundaries of reason, that it’s a pattern that’s indefensible. It’s a pattern that’s a byproduct of our fee-for-service system.

 

Gary Bisbee  14:41  

Relating standards to appropriateness is the right way to do it. I can remember 10 or 15 years ago, there was a lot of discussion about appropriateness, but it was without standards. Then it was interpreted as not really best practices. So I love watching You’re doing love that project like to stay in touch with it. What do you think about managed care as a model? Is that something that we could put our arms around and think that that’s going to help?

 

Marty Makary, M.D., M.P.H.  15:13  

Managed care came with the promise that if we kind of police care, it’ll save money. And that savings will be greater than the cost of policing. The real-world laboratory conclusion of that experiment is that it didn’t deliver the savings that it promised to deliver because it’s hard to know what the unregulated practice variation would be, but an entire infrastructure that set up and it burdens us as doctors, as a matter of fact, that drives us crazy sometimes, and especially those of us who are just subspecialists at tertiary medical centers. There’s a role for it, but it’s got to be done better. What we’re doing with a new project, called Global appropriateness measures is developing practice patterns of appropriateness, and making those algorithms available. What we’re seeing is that organizations are saying, “Hey, we want to know which physicians are way overboard in terms of their C-section rate or rates of doing spine surgery without prior physical therapy or conservative therapy.” Those appropriateness measures are things I wrote about in the book, The Price We Pay, there’s a lot of frustration with quality measurement, and that’s the other half of the value equation, the field is stagnant, we spent $16 billion just collecting these measures each year, people are frustrated, I’m frustrated because my surgical infection rate and readmission rate does not capture the quality of my surgical skill or clinical judgment. People are looking for quality that is going to move into a new area called appropriateness of care. That’s the crisis we’re in, we have a crisis of appropriateness. It’s not going to be evidence-based like we’ve painted ourselves in a corner to define because a lot of good practice lacks a randomized control trial. That’s the reality, you’re never going to do a study of a doc with a c section rate of 62% and compare them to doctors with a C-section rate of 20%. That study would be unethical. We have to sometimes say, “Hey, evidence can be defined differently and it can use clinical wisdom when there’s a consensus among specialists.”

 

Gary Bisbee  17:22  

Let’s go back to appropriateness. What kind of support do you have in the field among your physician colleagues or leaders of the health systems for appropriateness measures?

 

Marty Makary, M.D., M.P.H.  17:35  

There’s been a lot of enthusiasm across the board, but one of the sad stories is that the hospital systems that are using the appropriateness measures are the ones that share risk financially. Now, that’s great, and I love it, but that’s where we’re seeing the appropriateness measures get adopted broadly into practice. And I wish it were those on the fee for service side as well. I wish it didn’t rely on the financial motive of sharing risk to say, “Hey, we want to look under the hood and understand which pediatric surgeon is doing too many umbilical hernia repairs in young kids when the kids should be waiting till age five.” Again, the idea of appropriateness measurement is that we have to get off of the all-or-nothing clinical pathway and look at patterns in big data.

 

Gary Bisbee  18:24  

We’re going to be looking for progress in your appropriate in this study, so good job and keep up that good work. Why don’t we turn to you personally? At what point did you decide medicine was going to be your future?

 

Marty Makary, M.D., M.P.H.  18:40  

My dad is a hematologist. And I grew up in Danville, where Geisinger is amazing how Geisinger has been a force nationally. And I’m proud to be a part of that little tiny town in Central Pennsylvania that’s like, three hours from any international airport, and have no movie theater growing up. But when you go to the grocery store and you see somebody at random give your dad a hug and start breaking down in tears saying, “Thank you for caring for my dad when he passed away” or “thank you for giving me my life back.” How can you not be attracted to that? I became really proud of my dad in the community. He was respected. He’s retired now, but that’s something where I felt this intrinsic desire to be a part of because I saw it up front and personally.

 

Gary Bisbee  19:27  

You’re also interested in politics. You certainly are playing in that space. When did that interest develop?

 

Marty Makary, M.D., M.P.H.  19:34  

I try to pride myself in being independent but I look I go on cable news a fair bit. I go on Fox News a fair bit, which sometimes those who know I go on fox news to do medical commentaries don’t like me because it’s Fox and then those who watch fox hear my independent nonloyalty to a specific narrative, and they don’t like me. So it’s a very lonely place sometimes, but I like it. I’ve enjoyed advising political leaders at the highest level. The cool thing is that they value an academics independent perspective because stakeholders are all pushing an agenda as they should they should be voicing their concerns, and they see an academic sometimes as tell us the way it really should be. Staying politically independent has really helped my credibility and also opened a lot of doors in DC where people from both sides of the aisle will say, “Give is a big idea. We want to champion some big idea.” It’s been really cool.

 

Gary Bisbee  20:31  

When do you write and you’re so busy, so much going on? When do you actually have time to write?

 

Marty Makary, M.D., M.P.H.  20:37  

I actually am in a hotel room right now traveling. I try to write on planes, nights and weekends. The medical school asked me to give a lecture to the medical students at Hopkins on work/life balance. I was like, “You got the wrong dude. I’m sorry, find somebody else.”

 

Gary Bisbee  21:00  

Do you enjoy writing?

 

Marty Makary, M.D., M.P.H.  21:02  

I do. I enjoy sort of the art of taking a complex subject and making it consumable and digestible to both healthcare professionals and experts and the lay public alike. It’s an art form that many of my friends have mastered tool Gawande and others. And I’ve always admired that. Again, the reason to write is to say something that you feel needs to be said that’s not being said. Natural immunity was one of those things where I felt like, “I can’t believe we’re ignoring the fact that half the population is immune on top of those getting vaccinated,” and it does. They’re not mutually exclusive. We can still encourage everyone to get vaccinated, so I do enjoy writing. Of course, 45% of the population is going to hate your guts the second something comes to print.

 

Gary Bisbee  21:45  

It is an art form to be able to write about these complex topics and make it understandable for everybody, which you’re terrifically good at. So keep writing. And speaking of that, what’s the next book?

 

Marty Makary, M.D., M.P.H.  21:57  

I’m really interested in the microbiome and how it relates to health. So much of health is really inflammation comes down to inflammation. When we talk about health in 100 years, I think we’re going to be talking about what’s your level of inflammation, and it’s measurable to some degree. We have some crude tests now, like highly selective c reactive protein. But inflammation is why people die of heart attacks, the blood vessel wall gets inflamed, and that’s when the cholesterol moves in, and the lipids move in. It’s implicated in cancer. It’s why we have a whole host of diseases we never had before. Ulcerative colitis, Crohn’s, irritable bowel are common. They didn’t exist before 1920. Why is that? Maybe the advent of antibiotics, which screws up your microbiome. Now antibiotics save lives. I’ve seen that, but when not indicated—and studies from the CDC show that up to 70% are not indicated—it screws up your microbiome process. Food added sugar, bottle feeding instead of breastfeeding when somebody can breastfeed, even C-section versus vaginal delivery and not washing a baby immediately upon delivery. All these things influence the microbiome. We don’t talk about it. The science just hasn’t caught up. I think it’s the big frontier in healthcare. As somebody who has a background in gastrointestinal medicine, and gi surgery, it’s been something that’s always fascinated me. I think it’s the future and it relates to food as medicine, which is also something I’m passionate about.

 

Gary Bisbee  23:32  

We’ll be looking for that one. Marty, thank you so much. This has just been a terrific interview. I’m sorry you had to do it in a hotel room, but you do do a lot of traveling. Thanks again, Marty.

 

Marty Makary, M.D., M.P.H.  23:43  

Great to see you, Gary.

 

Gary Bisbee  23:46  

New episodes will debut every Thursday. Join me in conversations to gain advice and wisdom from CEOs, presidents, and healthcare experts. Health care leadership is hard work, but it becomes more manageable as we learn from the remarkable lives and careers of our guests. I’ll see you there.

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