System. Shes interviewed by david blumenthal, president of the commonwealth fund. Host hello. It is a pleasure to be here with you. I want to congratulate you on an incredibly readable in a thorough review of our problems in the Healthcare System and proposals for a solution. I have a ton of questions for you based on my background in the physician as a policy analyst and of course, also as an occasional patient. But first, i would like to ask a couple of question for context. The first one is why did you write this book and why did you write it al . Guest i worked on a series for the new york times. My first stop in that it was actually at the Commonwealth Club to learn a little bit more about the Healthcare System andd how it had gotten so very expensive. Then during that series, we solicited in love stories through social media. At the end of the series two years later, i had a kind of wow of patient stories and people that were smart just havent been able to make the system work. Which nobody seems to like right mow. And by understanding that, you can we get to a better place. We have seen so many efforts that reform. Everyone agrees it needs to be reformed but as we see on the hill today, we are still arguing. As you mentioned, you are a physician and i am a physician. We both went to Harvard Medical School and traineded in internal medicine. You went on to become a journalist. How did that come about . Guest i dont want to say by accident but i love writing and i did a lot of freelance writing on the side and in the early 90s i was working in an emergency room in new york and i felt the Health System wasnt working for people who were poor or uninsured. It was largely working well for people like me who had good insurance. There was something called the Clinton Health repoform and the times asked if i could like to write about it. I thought i would be a journalist for a few years, that will pass and i will go back to being a physician and it didnt and i didnt and here i am 20 wreerz years talking about the same issue. The system has spiralled out of control without Getting Better results were patients. Host before we get into the substance, one of the special things about your book is the way you ground it in stories. Stories about doctors, stories about patients, hospital administrators, you have lots and lots of stories. They are all very detailed. How did you get all those stories . What caused you to take that approach for this book . This is something i learned from years of journalism. My first story was about bone Marrow Transplant stories. I realized it became a mission to write about how whatever i wrote about affected real people. Even when i covered Climate Change i would get a nice family who has been impacted by Climate Change. I have read a lot of Health Policy book and stories and read the stories about the Million Dollar bone Marrow Transplants and i think the way most readers see those is they say that is really terrible or i dont think the policy, that story is heartbreaking but i hope i dont get that kind of cancer or i hope i dont insist on everything at the end of life. What i tried to do in the book is make the connection between acronyms and the things that go in washington and this is an issue that plays out on our wallets, bodies, in our living rooms and kitchen. The people in the bock, i was fortunate in the age of social media, most of the people came to me and said i want to share my story. They were tremendous volunteers and vehicles making readers and helping readers to understand this is about you. Also, they are great characters. I often feel like i want to have dinner party or club of everyone in the bock because they were fun, interesting, thoughtful people to talk to. I hope as readers read their stories they are compelling and 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 a Health Policy wonk but most people dont an appetite for. Host and doctors are about their patients stories. Guest one thing that truck me at the end, like many of us who watched Health Reform i repeated the phrase a hundred times about we are looking for patient centered Evidence Based care and at some point i stepped back when researching the book and thought wait a second, what other kind of health care could there be . This is about patients. If it is not patientcentered and Evidence Base it is terrible care. What i learned in researching the history is too often the finances are on the front burner and the patient centered and evidence are on the become burner and that is the shift i would like to see. Host sure. So, you said about this book, organizing it in a doctorally way. You started talking about describing the problem and what we call taking a history of the present element and office and diagnose and then offer therapy and those are the way doctors go about organizing their interaction with patients and their problems. I would like to take a viewer through those three segments if you will. Maybe you could start by describing the problem. What is the american sickness that presents itself to you . I was an er doctor so the chief complaint is high prices. It is high unfordable prices and unfordable health care. I dont think anyone, republican, democrat, libertarian, independent, would disagree with that. Host how did we get to those high prices . What is the diagnose, if you will . Guest this is where the history of present illness has to fool itself out. I think what i realize as i was digging into that is this is kind of a classic case of, you know, the road to hell is paved with good intention. Each step of the way over thealist decades you see to new decade come in that was a good the last idea and then it gets preverted as how p perverted how can we make money off this a lot of peoplet got Health Insurance and that is not to say Health Insurance is a bad thing. That was partly because health care was getting more expensive. There are historic reasons that i dont want to go in but we end up with people alet of people medicare or employerbased insurance. For those who were lucky, your employee paid your premium and you had little in the way out of of pocket cost. What happens if you are entrepreneurial and business minded under that setup it feels like nobody is paying. So in my dads day, an office visit would cost 10. Once it feels like no one is paying it becomes 100 or 200 and then around the 80s and 90s Business People start coming into the health care and say what could you charge for that . When it was just the physician in this office, or her office, he was thinking what is reasonable for health care . When the Business People start coming in and sometimes it is as bold and direct as consultants from mckenzie being hired by hospitals and the consultants come in and they are not medical people. They dont know the best treatment were your liver failure or your phenomena. They are thinking how can we squeeze more money out of the system and make it more efficient. And the answer over and over again is the easy answer you just bill differently. You do the same thing you have been doing all ong but you can charge more because it feels like nobody is paying. You suddenly see charges coming in which were 200 may be 2,000 and then you see layers of administrators and va coming in. Many of the ceos were pormer chief physicians, medical people without much business training, and hospitals were not very efficient. But somehow the kind of we ran over a boundary where business became primary and the Business People became primary and the medicine secondary. They get resentful and they think here i am doing all this work. I am doing this surgery. I am seeing the patients and i am looking at this layer of 20 administrators with mbas who are all making a million a year. I want more. Not all physicians do it but many get in the entrepreneurial spirit and many are angry 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 start being compared with fellow physicians and 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 and so once again, i think you see the values of business which are efficiency, revenue generation, revenue maximize, and our my infection rates low. Hospitals know more about the rbu and billing cycle than they know about if infection rates. I was pretty shocked this week when i saw that centers for surgeries have widely varying in the complication rates. And the centers know what the complications rates are, patients cant know them. Now, that seems crazy to me. If we are asked to be a good consumer we kind of deserve that information and it is our health afterall. Lets mover on to talking about what you are already beginning, i think, to deal with and that is the treatment, the solution to some of these problems. As you pointed out, some of them are valuebased. You had a lot of suggestions. One of things that i think is special about your book the extent to which you spend time prescribing things for the system and people. Can you say a few lines about how you think you ask go about reversing the problems you described. I think if we wait for a solution from washington we may be waiting for a very long time. I want to say i think the Affordable Care act i always have to say it did really important thing for our health care in that it covered people with preexisting conditions at a reasonable cost which is in the balance, it covered 20 more million people, it put an emphasis on value and what is good for patients back in the bullseye, and i think it changed the notion of should government think of this as its responsibility to get good, Affordable Health care. I think many patients are at a Tipping Point where they cant afford this anymore. I hear from people spending 2030 of their income on health care. More than food, more than housing. They are not going on summer have vacations. I tragically hear from people who are leaving the u. S. Because there is someone in the book who has type one diabetes. She is a grad student and only looking for jobs outside the u. S. Because even with good insurance she is worried she will not be able to afford her disease and i think that is not just an american sickness that is an american tragedy. What i do with the book and aim to do is help people understand there are solutions. There are step by Step Solutions as we see the Health Care System got to be where it is in a kind of step wise fashion. Likewise, we can start reeling it back in a step wise fashion. Part of that is what individuals can do. So, Little Things that they sound silly maybe but they do work. I became the bill trouble shooter for everyone in the newsroom fe new york times. I ivise used a lot of these thing and gotten a lot of bills reversed and reduced and muigated. One thing i feel people and you i seen patients, you know how this works, it is uncomfortable for doctors when patients do this but when i go see my physician when he says maybe we should get some blood tests, i feel okay and not because i am a former physician, but because i am a patient and i believe it is pai right to say, well why . Because as you and i both know when doctors are ordering test, the test are a long check sheet and you are just going down the sheet. I think the question now should be why . How is it going to change my care . That requires a lot little mind shift. My mom knows to the doctor and she said i like her but she didnt even order a blood test. As patients we have to say maybe the answer is to wait and not jump in all the time. But when it is time to jump in, then i say to my physician the computer is programmed to send my blood test order to the hospital lab. No, can you please send it to lap corp or quest, the two commercial labs i know in my network because lab core and quest may charge 10 for the same lab test a hospital would charge 500 or 1,000 and we know they are both putting tubes of blood into a machine that spits out numbers. Likewise, i think we can say to our physicians if i need an xray of my knee which of the dozen centers will boo a good xray at a reasonable cost. We know most doctors dont have that information. But i think the more patients ask the more they will have that information. It will send a message we care and we paying for that. V with my 5,000 deductible plan. It matters to me. Host so this is an important theme of your book. You do put a lot of the burden of containing and cost reducing prices and also deciding what you are going to get and where you will get it on the consumer. I was struck by the recommendation people review the papers they were asked to sign without looking at them to make sure they are not being referred do doctors and hospitals who will thought be paid by their Insurance Company because they are out of network as i said. I had the 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 or lab tests saying i dont want you to dothese and these things because they are not covered. It it is a burden to put on patients but this is where we find ourselves. This isnt the ultimate solution but the alternative is like someone in the book being lulled in on the stretcher for an emergency and the Business Manager comes through saying we need your credit card before we can proceed with your surgery and she said i am naked and i dont have my wallet and the Business Manager said do you know someone we can call and get a credit card number so we can proceed. There are lots of parts of medical care that are not emergency situations. Yes, it is unfair and yes, it is a burden. But if we tont take the steps the system doesnt eform. The ultimate goal isnt to write in. If you go to an innetwork and you run Hospital Systems and that is extra work. The goal isnt to say this was the final answer but to push the providers who were not paying attention to do so. It is unfortunate this has fallen into the patients lap and on the back of sick people who should not pea thinking about how they are healing and into the the laps of doctors who should just be thinking about what is the right thing to do. But physicians spend a lot of time dealing with the system. I have to fill out paperwork and do preauthorization for a drug that is a hundred years old unless they start walking i think that is going to get worse and worse. Host and this relationship between nurses and patient patients and physicians and patients has been based on trust. That is an important part of the therapeutic and healing relationship. None of those even those trained in medicine are in a position to make positions about our own care. What is left of trust in our Health Care System . I hope it isnt lost anyone who reads the book can see many of the best sources are physicians who are distressed and want to keep that connection with their patients. I think it has been diluted. Some of that may be needed and it not realistic to think you could spend an hour with the patient but this kind of notion that doing things more efficient will result in good care. One example that is minor but telling. So much has been replaced with technology. Telemedicine, we will give avenue everyone an ipad and it will be better. Electronic records. All of those things could be useful tools but they have been used as a substitute for that face to face interaction which is so crucial to trust. I was just hearing about a program to give patients in hospice ipads. Home hospice ipads. That is kind of great at some level if it is used for certain things but instead of a nurse coming by and holding someones hand and talking to them which is what a lot of people need in home hospice that is just diluted everything that is so precious to me about health care and what patients really want. It shouldnt be the primary goal of health care. As you and i are speaking the house of representatives is deeply engaged in the future of the Affordable Care act and government and policy at the National Level and underlying that discussion is a big philosophical question about whether health care is a market good and whether it should be ruled by Market Forces or some other mechanisms. As i read your book, i sometimes felt like we could solve our Health Care Problems through free market sources. I think what we have seen as the answer is probably not. At the beginning of the become, i put somewhat tongue and cheek rules of the dysfunctional Health Care Market where if you think of health care as a business proposition, that the market will solve, you get to crazy places like, you know, a life time of treatment is pr preferable to a cure. I am not saying for a second anyone thinks that but that is where market force puts you. Type one diabetes is a wonderful example of this. It is a chronic illness which great treatments now, better insulin, pumps, monitors, peoples lives are much, much better than they were 2030 years ago but that has come at a huge price. If someone came along tomorrow and said we can cure diabetes with a cheap, old drug what would happen in the industry with tens of billions . There is an example i bring up in the book, a researcher at mass general who is working with very old vaccine to see if that will cure type one diabetes. It may or may not; right . It is early stages. But she cant get pharma funding which is who we