Costs and got provided guidance to consumers. Shes interviewed by doctor david blumenthal, president of the Commonwealth Fund. Its a pleasure to be here with you. I want to congratulate you on an incredibly readable review of our Healthcare System and proposals. I have a ton of questions based on my background as a physician and of course as a id like to ask a couple questions for context and why did you write this book and why did you write it now . I had worked for a couple years on a series with the New York Times. I first got the necessaries from the Commonwealth Fund to learn a little bit more about our Healthcare System and it had gotten expensive and then during that series we solicited a lot of stories through social media and at the end of the series 2 years later i had this bank of kind of patient stories, people who were smart and for the most part the New York Times reader just hadnt been able to make the system work so that was one aspect to another aspect was in the newspaper series you take off little parts of the system and examine them one by one and as so often happens as a newspaper reporter by the time youre finished you realize that you just kind of scratched the surface and i felt like i needed to know in that series we show how prices have gotten high and looked at some of the factors but i really wanted to understand the evolution about process because as a physician, who trained in the 80s and as someone whos in that decision i knew healthcare have always been that way. Guest i dont want to say by accident but i always loved both writing and medicine. My family has a lot of physicians in it and id always done a lot of free lance writing on the side. The irony of this book and my career is in the early 90s i was working in an emergency room in new york and in an emergency room at that time i felt the Health System already wasnt working very well for people who were poor or uninsured. It was largely working pretty well for people like me, who had good insurance. So there was something in the early 90s call the Clinton Health reform plan, and the times asked me if would like to write about that, and i assumed i will come, be a journalist for a few years, write about that. And then that will pass, ill can go back to being a physician, and of course it didnt, and i didnt, and here i am, more than 20 years later talking about the same issues or steroids. The system has kind of spiraled out of control, especially in terms of its costs and prices, and as we all know, without Getting Better results for patients. Host so, before we get into the substance theres a lot of substance to talk about one thing that is very special about your book ive read a lot of books about the Healthcare System is the way you ground it in stories, stories about doctors, stories about patients, stories about hospital administrators. You have lots and lots of stores, all very detailed. How did you get all those stories . How did you what caused you to take that approach . Guest well, yeah. This is something id learned from my years of journalism. Obviously my first story was about bone marrow transplants and i realized from that moment on it kind of became a mission, whatever i was writing about, to understand how it affected real people. So, even when i was covering climate change, i would get a nice family who had been impacted by climate change. So i think thats so important. Id read a lot of Health Policy books and stories and i also read the stories about the Million Dollar bone marrow transplant, and i them the way most readers see those is they say, wow, thats really terrible, or i dont understand the policy. Thatster is heartbreaking but i hope i dont get that kind of cancer or hope i dont insist of everything the end of life. What i tried to do in the series, and again with the book, is to make that connection between all these kind of acronyms and obscure debates going on in washington and how it affects you on the ground. This is really an issue that plays out on our wallets our bodies in our living rooms and our kitchens, and so the people in the book i mean i was very fortunate in this age of social media, most of those people came to me and said, i want to share my story. And they were tremendous volunteers and vehicles for making readers and happening readers helping readers to understand this is about you, and theyre great characters. I often feel like i want to have a kind of dinner party or club of everyone in the book because they were fun, interesting, thoughtful people, who talk to, and i hopes as readers read their stories, theyre are compelling stories actor little kafkaesque and absurd but they drive the narrative in a way i hope will get people to understand a lot more about the kind of backend policy and economics without suffering through the kind of diagrams and the charts. Raid because im a Health Policy wonk but most people dont have an appetite for. Host of course, doctors are about their patients stories, arent they . Guest in the end, one of the things that really, like, struck me as i was researching the book, is like many of white house have watched health reform, i repeated the phrase, 100 times, about were looking for patient centered, evidencebased care. And then at some point i step back when i started researching the book and thought, wait a second. What other kind of health care could there be . This is about patients and if its not patientcentered and evidencebased, then its terrible care, and i think what i learned in researching the history is that too often the finances are on the front burner and the Patients Center and Evidence Base is on the back burner average thats the shift id like to say. Host you organized this book in a very doctorly way and started by talking about the problem, describing the problem, what we in medicine call taking a history, the history of the present illness and then went on to offer some diagnoses and then went on to offer therapies and those are the way doctors organize their interaction with patients and their problems. Id like to take our viewers through the three segments. And maybe you can start by describing the problem. What is the american sickness that is presenting itself to you. Guest i think i was a new york doctor so the chief complaint, as we said, was its high prices. Its high prices and Unaffordable Health care. Dont think anybody, republican, democrat, independent, libertarian, would disif a free with that. Disagree with that. Host how did we get to these high prices . Whats the diagnosis . Guest well, this is where the kind of history of present illness kind of has to spool 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. So at each step of the way in the history over the least decades, you see a new idea come in that was a good idea, and then it somehow gets kind of perverted as a kind of how can we make money from this . So i think people have often said the problem is the middle of the last center a lot of people got Health Insurance. That is not to say that Health Insurance is a bad thing. We need it. That was because health care was get more expensive, historical reasons which i dont want to good into here. So we end up with a lot of people on medicare or employerbased insurance. For those of us who have been lucky enough to have Health Insurance, in those days your Employer Paid your premiums and you had very little in the way of out of pocket costs. So what happens if youre kind of entrepreneurial in businessminded under that setup . Nobody is paying. So in my dads day, an office visit would cost 10. Once it feels like nobody is paying, maybe that becomes 100 and maybe 200. And then at some point i would say around the 80s and 90s, Business People start coming in to health care and saying, what will the market bear . What could you charge for that . And then when it was just the physician and his office he was still homecoming 0 her office what does this mean for patients . What is reasonable for health care . When the Business People start coming in sometimes its as direct as consultants from delight mckenzie being hired by hospitals and consultants come in and they not medical people. Dont know what is the best treatment for your liver failure or your pneumonia. Theyre thinking, how can be squeeze more money out of this system and make more efficient . And the answer they come up with over and over again, which is kind of these answer for squeezing more money out, just bill differently. Do the exact same thing you have been doing, but you can charge a lot more for it because it feels like nobody is paying, so suddenly you see charges come in, which are what was 200, may be 2,000 and then layers of administrators and mbas a come in. When we were in hospitals, many of the ceos were former chief physicians, 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 the kind of we went over a boundary where business became primary and the Business People became primary and the medicine became secondary. And what you see at that point is many of the physicians this where is it moves to the physician question say, they get resentful and understandably so. They think, here i am doing all this work, doing this surgery and seeing the patients and im looking at this layer of 20 administrators with mbas who are all making a Million Dollars a year. I want more. And not all physicians do it but many get into the entrepreneurial spirit, others get angry and resentful theyre being judge not by how well they take care of patients but by how much revenue the generate, how much money they generate from the hospital and they start being compared with their fellow physicians, and again, this is the logic of business. Who is generating more revenue, and maybe youll get a bone fuss if you ben news if you bonus if you generate revenue. And you see the value of business which is efficiency, revenue generation, revenue max jimmization, and push out, can i extend time with i patient . Can i understand the problems . Aim being sensitive to his or her needs . Are my infection rates low . Hospitals know much more about their rbus and billing cycles than infection rates. Was shocked this week when i saw that centers of excellence for bariatric surgery have widely varying rates in their complication rates, and even though the certifying organization for those complication rates for those centers know what the complication rates are, patients cant know them. Now, that seems crazy to me if were asked to be a good consumer. We kind of deserve that information. And its our health, after all. So, anyway lets move on. To talking about when youre already beginning to deal with and that is the treatment, the solution to some of these problems. As you have pointed out, some of them are valuebased. You have a lot of suggestions. One thing that i think very special about your book is the extent to which you spend time on prescribing things for people and for the system. So could you say just a top few top lines about how you think we should go about reversing the problems you have described. Guest well, i think if we wait for a solution to come from washington, we may be waiting for a very long time. I want to say that i think the Affordable Care act i always have to say it didert important things for our health care in that it covered people with preexisting conditions as a reasonable cost, which is in the balance again. It covered 20 more million people. It put an emphasis on value. Put that kind of whats good for patients kind of back in the bulls eye, and it also kind of i think an important way changed the notion of should government think of this as its responsibility to help people get good, Affordable Health care . And i think you ask why now . I think its a crucial time because i think many patients are kind of at a Tipping Point where they really just cant afford this anymore. So i hear from people who are spending 2030 of the Household Income on health care. The preinsurance and minor medical bills, thats more than food, more than housing, not going on summer vacations, having trouble sends kids to college im tragically hear from people who are leaving the u. S. Because they have an illness like theres someone the book who has type 1 diabetes. She is a grad student and only looking for jobs outside the u. S. Because even with good insurance, she is worried she wont be able to afford her disease. And i think that is not just an american sickness. Its an american tragedy. Thats really sad. What i do with the book and aim to do is to help people understand that if there are solutions, theyre stepbystep solutions as we see the Healthcare System got be writ is in a kind of stepwise fashion, and likewise, we can start reeling it back in a sevenwise fashion and stepwise fashion and part another that is what individuals can do. Little things they found silly but they work. Ive used them. Became the bill troubleshooter for everyone in the newsroom the New York Times. And so i have used these things and got an lot of bills reversed, reduced, and negated. So, one thing i tell people you have seen patients, you know his works. Its 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 about saying not because im a former physician but because im a patient and i believe its my right to say, well, why . As we both know, often when doctors are ordering tests, in my era of training there was a, why dont we just order these tests . The tests of will onbe a long check sheet and youre just going down, check, check, check. I think the question now should be, why . How is it going to change my care . That requires a little bit of mind shift in terms of patients. I like to say my mom goes to the doctor and shell call me and say, i saw my doctor and i really liked her but she didnt even order a blood test. And we want as patients we have to kind of say, maybe the answer is to wait. Maybe the answer isnt to jump in all the time. But when its time to jump in, then i say to my physician, whews whose computer is now programmed to send my test to the hospital lab. No please send it to the two commercial lab is know in my network because lab core and quest may charge ten dollars for the exact same lab test that a hospital would charge 500 or a thousand dollars for and you and i both know that theyre both putting tubes of blood into a machine which spits out numbers. So, likewise, think we can say to tower to our physician if i need an xray of my knee, which are the dozens of xray centers within a mile radius of this office do an xray at a reasonable price witch know that most doctors dont have that information now, but i think the more patients ask, the more they will have that information, and i think sadly those of us who run into medicine didnt go into it to, like, be bean counters or to think about bills, but that is the position were in now to advocate for patients. I would say, its kind of the doctors responsibility to know which xray centers are good value now and to say to the one who is charging a thousand dollars for a 100 stray, xray, saying im not going to refer parents because youre representing off my patients. Not a work for doctors but not only will that that save money but will send a message to the centers that are overcharging that, hey, were going act like this is a market now and we care and price matters and, p. S. , now we are raying for that with my 5,000 deductible plan, it matters to me. This is an important theme of your book, you do put a lot of burden of containing costs, reducing prices, and also of deciding what youre going to get and where youre go to get it on the consumer. Was struck by the recommendation you made that people actually review the papers they are asked to sign, which of course they sign without looking at them, to make sure that theyre not being referred to doctors and hospitals who are not going to be paid by their Insurance Company because theyre out of network. I had the picture of a patient on a stretcher, you know, clutching his chest and having to go through that paperwork, or running down the list of drug prices the hospital or the lab tests and saying issue dont want you to do these and these and these things because theyre not covered or you see the point im making. Guest yes. Host fair and railistic. Guest 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 a. L. Tentative right now is ick the alternative right now, nasa book, somebody being rolled in on a stretcher for an emergency appendectomy and the Business Manager comes in in a gown, saying we need your credit card before we can proceed with the surgery. Im naked and i dont have my wallet and the Business Manager says, well, do you have someone you know who we can call and get a credit car number so we can proceed . That is the alternative now. So its not like of course in an emergency you cant do the things but a lot of parts of our medical care are not emergencies so, where to be yes, its unfair and a burden but if we dont take these steps, then the system wont respond, and the ultimate goal, of course, is not to have to go through those forms and write in as i do, you know, i will pay anything my insurance doesnt cover so long as its in my insurance network, but the ultimate goal is to prod hospitals to respond to us and to say, okay, if you go to an innetwork hospital, its our job to ensure that the er doctors, the radiologist, the pathologists, the new yearsolist is all in our network. The goal of the prodding is not to say this is the final answer but to say to push all the providers who are not