My first stop in the series was at the Commonwealth Fund to learn more about health care and how it got so expensive. We solicited a lot of patient stories through social media and at the end of the series i had this bank of woe of patient stories, people who were smart for the most port New York Times readers who had not been able to make the system work. By there time you are finished, you realized you just scratched the service. I felt like i needed to know because it shows how prices had gotten as a physician to tried in the 80, i knew health care had not always been this way. I wanted to understand how did we get to this system which literally nobody seems to like right now. And by understanding that how can we get to a better place. We have seen so many efforts reform and everybody agrees to needs to be reformed but as see see on the hill today we are still arguing. As you mentioned, you are a physician i am a physician. We went to the same medical school. Harvard medical school. We both trained in internal medicine and you went on to be a journalist. I always loved writing and medicine. I always did a lot of free lance wri writing on the side. In an early 90s i was working in an emergency room in new york and i felt the Health System already wasnt working very well for people who were poor or uninsured. It was working well for people like me who had good insurance. The times asked if i would like to come write and i assumed i would go and write a few years, that will pass and i will go back to being a physician and of course it did want and i didnt and here i am talking about the same issues but also this system has spiralled out of control and without Getting Better results for patients. Before we get into the su substance and there is a lot of substance, one thing about that is special about the book is the way you grounded it in stories. Stories about doctors, patients, hospital administrators. You have lots and lots of detailed stories. How did you get all those stories . What caused you to take that approach for this book . My first story way back then was about bone marrow transplants and my editor said this is an interesting story but there is not a patient here. When i would write about climate change, i would get a nice family impacted by climate change. I think that is so important. I have read a lot of Health Policy books and stories and also read the stories about the Million Dollar bone marrow transplants. And i think readers say that is terrible or i dont understand the policy. That story is heartbreaking but i hope i dont get that kind of cancer or insist on everything at the end of life. Where write about how it affecs you on the ground. The people in the book, i was fortunate in this age of social media that most of those team came to me and said i want to share my story and they were tremendous vaut volunteers for helping readers this is about you. And also they had great character. I often field like i want a dinner party or club with everyone in the book. They were fun, interesting thoughtful people to talk to. I hope as readers read their stories, they are compelling and a bit kind of absurd but i think they drive the narrative in a way that i hope will get people to understand a lot more about the kind of back end policy and economics without suffering through the kind of diagrams and the charts that are you know, i read because i am kind of a Health Policy wonk but most people dont have an appetite for. And doctors are about their patients stories. In the end, one thing that really struck me is like many of us who watched health reform, i repeated the phrase, you know, a hundred times about we are looking for Patient Center evidence based care. At some point, i stepped back with researching the book and thought wait a second what other kind of health care could there be . Guest i think i was in er daca so the chief complaint they got was its high prices and Unaffordable Health care. I dont think anyone republican democrat independent for libertarians would disagree with that. Host how did we get to those high prices . What is the diagnosis . Guest this is where the history of present illness has to pull itself out and i think what i realized as i was digging into that is this is kind of a classic case of the road to hell is paved with good intentions. You see a new idea come and that was a good idea and then it somehow gets kind of as a kind of how can we make money from this . So i think people have often said the problem is you know both the middle of the last century a lot of people got Health Insurance. That is not to say that Health Insurance is a bad thing. We need Health Insurance and that was partly because health care was getting more expensive. There were lots of historical reasons which i dont want to go into here so we ended up with a lot of people on medicare or employerbased insurance. For those of us who have been lucky enough to have Health Insurance for longtime do we know in those days your employer pay for premium and you had very little in the way of outofpocket costs. What happens if you are an entrepreneurial or business minded under that product . In my dads day and Office Visits would cost 10 up. Maybe that becomes 100 maybe 200 and then at some point i would say around the 80s and 90s Business People started coming into health care and saying you know what is the market there . What could you charge for that and then when it was just a physician and his office he was still thinking what does this mean for patience and what is reasonable for health care . When the Business People start coming in and sometimes this is all done as direct from deloitte mckinzy being hired by hospitals and the consultants come in and they are not medical people. They dont know what is the best treatment for liver failure for your pneumonia. They are thinking how can we squeeze more money out of the system and make it more efficient . The answer they come up with over and over again which is kind of the easy answer for squeezing more money out of us you just do the same thing you been doing all along but you can charge a lot more. Suddenly you see these charges come and which are well worth what was 200 maybe 2000 and then administrators. When you and i were in hospitals many of the ceos were former chief physicians. They were medical people. They didnt have much Business Training and of course as a result hospitals were not very efficient. They could have used a little dose of efficiency but somehow we went over a boundary where business became primary and the Business People became primary and the medicine became secondary. What you see at that point is many physicians and this is where it moves to the physicians question say they get resentful and understandably so. They think here i am doing all this work im doing the surgery and seeing the patients and im looking at this layer of 20 administrators with mbas who are all making 1 million a year. I want more and not all physicians do it but many get into the aunt muriel spirit. Others get kind of angry and resentful that they are being judged not by how well they take care of their patients but how much revenue they generate, how much money they are generating from the hospital and they are compared with their fellow physicians. This is the logic of business. Who is generating more revenue and maybe you will get a bonus if you generate a lot of revenue once again i think the values of business which are efficiency revenue generation, revenue maximization kind of push out those oldtime values of can i spend time with my patient pecks can i understand the problem . Am i being sensitive to his or her needs . Are my infection rates low . Hospitals often know much more about their billing cycle than they know about infection rates. This is an example, i was shocked this week when i saw centers of excellence for bariatric surgery have widely varying rates and their complication rates and even though the certifying organization for the complication rates, for those centers will know what the complication rates are well patients dont know them. That seems crazy to me were. If we are asked to be a good consumer we kind of dessert that information and its our help after all. Post a list move on to talking about what you are all ready beginning i think to deal with and that is the treatment, the solution for some of these problems. As you pointed out some of them are valuebased. Youve had a lot of suggestions. One of the things i think is very special about your book is the extent to which you spend time on prescribing things for people and for the system. Could you say pretoplines about how you think we should go about reversing the problem . Guest well, i think if we wait for a solution to come from washington we may be waiting or a very long time. I want to say that i think the Affordable Care at, it did really important things for health care and that it covers people with preexisting conditions at a reasonable cost which is in the balance again. It covers 21 million people. It puts an emphasis on value and whats good for patients back in the bullseye and it also i think in important ways change the notion of should government take of this as a possibility to help people get good Affordable Health care . I think think you asked why he now comets at a time because many patients are at a Tipping Point where they can afford this anymore. I hear from people who are spending 20 or 30 of their Household Income on health care on minor medical bills, more than food, more than their housing. They are not going on summer vacations. They are having trouble sending their kids to college. I tragically hear from people who are leaving the u. S. Because they have an illness. Or someone in the book who has type i diabetes. Shes a grad student and shes only looking for jobs outside of the u. S. Because even with good insurance shes worried she wont be able to afford her disease. Thats not just an american sickness, its an american tragedy. So i guess what i do with the book and what i aim to do is to help people understand that there are solutions. There are stepbystep solutions the Health Care System got to be where it is in a stepwise fashion and likewise we can start reeling back in the stepwise fashion. Part of that is what individuals can do so little things. They sound kind of silly maybe but they do work. I became a troubleshooter for everyone in the newsroom of the news york times and so ive used a lot of these and gotten a lot of bills were first, reduced and negated. One thing i tell people and you have seen patients and you know how this works. Its uncomfortable for doctors and patients do this but when i go see my physician, when he says the maybe we should get some blood tests i feel okay about saying and not because im a former physician but it has im a patient and i believe its my right to say why . As you and i both know often when doctors are ordering tests and my training there was a wildly distorted these tests and the tests will often be a long check sheet and you are just going down check, check to the question now should be wise. Hows it going to change my care . That requires a little bit of a mind shift in terms of patience. I like to say my mom goes to the daca and she will call me and say i saw my doctor and i really liked her but she didnt even order a blood test. As patients we have to say maybe the answers to wait. Maybe the answer isnt to jump in all the time but when its time to jump and then i say to my physician, whose computer is now programmed to send my blood test order to the hospital lab, can you please send it two for two commercial labs i know are in my network because of they may charge 10 for the exact same lap test for the hospital will charge 500 or 1000 toward a new and i both know they are both and blood into a machine which spits out numbers. Likewise i think we should say to our physicians, if i need an xray of my knee, which of the dozens of xrays are within a mile radius of his office and will do the xray at a reasonable price. You and i both know that doctors dont have that information but i think the more patients ask the more they will have that information and sadly those of us who went into medicine didnt go into it will to think about bills but thats the position we are in now to advocate for patients. I would say that doctors responsibility is to know which xray centers are good value and to say to the ones who are charging a thousand dollars for a 100dollar xray im not going to refer patients anymore because i dont want you lifting off my patients. A lot of work for patience and a lot of work for doctors but not only will that save save money was in individual cases but it will send a message to the centers that are overcharging that hey we are going to act if this is a market and price matters. Now we are paid for that. With my 5000dollar deductible plan it matters. Host this is an important theme in your book. You do put a lot of burden and containing the cost of reducing prices and also in deciding what you are going to get in where you are going to get it on the consumer. I was struck by that, the recommendation made that people actually review the papers that they are asked to sign and sign without looking at them to make sure they are not being referred to doctors and hospitals who arent paid by their Insurance Company and they are out of network as you say. I have a picture of a patient on a stretcher clutching his chest and having to go through that paperwork or running down the list of drug prices at that hospital for the lab tests and saying i dont want you to do these things because they are not covered. You see the point im making. They are unrealistic. It is a big unfair burden to put on patients but its the situation that we find ourselves in. Of course i dont think this is the ultimate solution but the alternative right now is like someone in the book who is being rolled in on a stretcher for an emergency appendectomy. An addictive manager comes to her while shes in a gown and says we need your credit card before we can proceed with the surgery and shes like, will im naked and i dont have my wallet the Business Manager says do you have someone you know who we can call and get a credit card number so we can see . Thats an alternative now so its not like in an emergency you cant do these things but there are lots of parts of our medical care that are not emergencies so yes its unfair and yes its a burden that i think if we dont take these steps then the system wont respond in the ultimate goal of worse is not to have to go through those who, i will pay anything my insurance doesnt cover so long its its in my Insurance Network but the ultimate goal is to ask hospitals to respond to us and say okay a few good and Network Hospital but its our job to ensure that the er doctor their radiologists in the pathologists, the anesthesiologist are all in your network too. Thats extra work for them. The hospital knows which anesthesiologist are in my Insurance Network and i dont. I think the goal of this prodding is not to say this is the final answer but to say, to push all the providers who are not paying attention to this to do so. Its unfortunate that this has fallen into the patients lap and ruled on the backs of people who should be thinking about how they are feeling and also into the laps of doctors who should just be thinking about what is the right thing to do. As we all know position spend a lot of time dealing with this outofcontrol system feeling helpless as patients. The have to fill out all the paperwork and i have to do preauthorizations for a drug that is 100 years old. Unless we Start Talking i think its going to get worse and worse. Host this relationship between physicians and patients and nurses and patients and clinicians and patients clinicians and patients they are all part of this very complicated system. Traditionally its been based on a certain level of trust. Its an important part of the therapeutic relationship and important part of the healing relationship and none of this even those of us who who are in medicine are in a position to make decisions about our own care when we are in the midst of an illness. So what is left of trust in our Health Care System and have we lost your truth of wave something that is always an important part of the relationship between clinicians and their patients . Guest i hope its not lost your retreat simply because as anyone who reads the book and see many of the best our physicians who are equally distressed to desperately want to keep a connection with their patient. I think its been severely diluted and some of that may have been needed. Maybe it was so inefficient that its not realistic to think this day and age you can spend an hour with the patient. The kind of notion that it will result in good care. One example that is pretty minor but i think its really telling. Telemedicine, will just give everyone an ipod and it will be better. All those things are in Electronic Medical records, all of those things can be really useful fools but too often they have kind have been used as a substitute for bread that will face to face interaction which is so told to trust. I was in my office and Kaiser Health news about giving everyone hospice ipads. That is great at some level if its used for certain kinds of things but if its used instead of a nurse coming by and holding someones hand and talking to them which is what a lot of people need at hospice benyette its just diluted everything is so precious to me about health care and what most physicians and patients really want. So efficiency, thats a business method. Health care could have been a lot more efficient than it was 30 years ago but it shouldnt the primary goal of health care. Lets go as you and i are speaking the house of representatives is deeply engaged with in the future of the affordable hair at the end Health Care Gove