EP449: For Clinical Leaders, Payers, and Plan Sponsors, Let’s Talk About Blind Spots for Getting Patients or Members Appropriate Care, With Marty Makary, MD, MPH

Relentless Health Value™

So, I had a chance to read Dr. Marty Makary’s new book, which is called Blind Spots; and here’s why I wanted to get him to come back on Relentless Health Value and talk to you, people of the healthcare industry. It’s because of something that he said on page 127 and which I’ve been mulling over for probably years, actually.

For a full transcript of this episode, click here.

If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.

It’s this idea of what is appropriate care and how good are we at ensuring that patients/members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Ben Schwartz, MD, MBA (EP434); John Lee, MD (EP438); Spencer Dorn, MD, MPH, MHA (EP446); Tom Lee, MD (EP445). And if you want a blast from a couple of years past, the show with Bob Matthews (EP315) and, wow, I could go on … Will Shrank, MD (EP413) talking about the amount of waste from so-called inappropriate care.

I mean, an estimated 21% of all medical care is potentially unnecessary. And unnecessary is, of course, one category of things that are not appropriate. This is according to a national survey of physicians: 25% of diagnostic tests, 22% of all medications, and 11% of all procedures are unnecessary/inappropriate. This is billions of wasted dollars doing stuff that shouldn’t be done, and it’s not appropriate care.

But think about this: How many visions for how to fix healthcare and how to reduce waste depend upon a broad-stroke assumption that we will materially ensure that patients are getting best-practice (ie, appropriate) care? That we cut down on over-medicalization and surgeries on the back end and add appropriate preventative stuff and optimal medical therapy to the front end?

Okay … great. Now let’s head out into the real world, which is what the conversation is about today with Dr. Marty Makary, this intersection between knowing the best science available and getting a critical mass of patients, getting care informed by this best science available. Because in the real world, getting patients appropriate care, getting members appropriate care could be a challenge for the following three reasons that Dr. Makary sums up in the conversation that follows.

1. Medical dogma and groupthink can lead to incorrect health recommendations that are slow to change, even in the face of new scientific evidence. There’s this cognitive dissonance. I mean, think about the whole fear of peanut allergies and, therefore, avoiding peanuts thing actually resulted in a lot of peanut allergies.

There’s the C-section rates, HRTs (hormone replacement therapies), fat-free diets with margarine. Lots of examples of science learning new stuff, but the standard of care is well behind.

But speaking of medical dogma, to not be dogmatic requires a degree of openness and humility. And openness and humility might be a hard thing for doctors, maybe in particular. It’s kind of the curse of experts to be overconfident in their expertise. But it’s also just a hard thing for humans to be open and have some humility. I mean, when habit becomes automatic, it also takes on a veneer of being correct and true.

You know where I just read this, that habit becomes truth? In the writings of Blaise Pascal from 1670. Yes, I am a nerd, but also yes, to succeed in providing “appropriate care,” a doctor is fighting against human instinct that clearly goes back a ways. Also, Daniel Kahneman, of course, won a Nobel Prize proving this point of Blaise Pascal’s. So, yeah … there’s also that System 1 thinking, if that rings a bell. So, medical dogma and groupthink can make it difficult for patients to get appropriate care.

2. Delivering appropriate care is impacted not just by the clinical aspects of what’s going on but also business, legal, and financial incentives that creep in. Obviously, there’s incentive to treat sickness, not prevent it, in this country; and it’s why it’s said we have a sick care industry here, not a healthcare industry. Along these lines, there’s this term “administrative harm” that I’ve been hearing about lately; and any patient getting harmed administratively is not getting appropriate care or not getting it in a timely fashion, kind of by definition, and for reasons that fall into the second category of how getting patients appropriate care gets stymied by financial business or legal forces.

3. What’s not measured tends to not get managed, and what doesn’t get managed tends to not improve a whole lot. But measuring the appropriateness of care is hard. It requires looking at practice patterns, outcomes, and the nuance of each clinical situation, not just broad utilization metrics.

Robert Pearl, MD, talked about this also in episode 412. Dr. Pearl in that episode said pretty crisply actually that being a good leader of clinicians requires reporting back on how everybody’s doing re: metrics that matter for appropriate care. And yeah, by the way, RVU (relative value unit) reporting is not that, at least in isolation. We’re talking about reporting back on patient outcomes as a result of the care that docs are rendering with those RVUs.

So, what is Dr. Marty Makary’s advice here? Dr. Makary says:

1. Measuring and reporting on practice patterns and appropriateness of care at the individual clinician/physician level can help drive accountability and quality improvement. It can actually improve the level of appropriate care which is delivered.

2. Plan sponsors have an important role to play in demanding transparency around quality and cost and using the data to steer members toward higher-performing providers providing more appropriate care.

Cynthia Fisher, by the way, talks about this in an upcoming show. This is just, though, how a functioning market works. The customer makes demands and holds their service providers accountable. And by service providers, I mean carriers and care delivery organizations are held to account. If the customer doesn’t make demands and we leave it to the sellers to perform however well they want at whatever price they want to charge, then yeah … I mean, you get what you get, and you pay a lot for it.

3. Improving health literacy among patients and plan members can really empower some to demand higher-quality, more appropriate care from their providers. And if some make demands for appropriate care, this actually can move the market. This is the whole thing with tipping points.

Also mentioned in this episode are Johns Hopkins Medicine; Benjamin Schwartz, MD, MBA; John Lee, MD; Spencer Dorn, MD, MPH, MHA; Tom X. Lee, MD; Bob Matthews; William Shrank, MD; Ishani Ganguli, MD, MPH; Robert Pearl, MD; Cynthia Fisher; Al Lewis; Will Bruhn, MD; Global Appropriateness Measures (GAM); and Steve Schutzer, MD.

You can learn more in Blind Spots and at gameasures.com. You can also connect with Dr. Makary on LinkedIn.

Martin “Marty” Makary, MD, MPH, is professor at the Johns Hopkins University School of Medicine and the author of two New York Times best-selling books. Dr. Makary served in leadership at the World Health Organization and is a member of the National Academy of Medicine. A public policy researcher, he leads a Johns Hopkins initiative on the “redesign of healthcare” to make healthcare more reliable, more appropriate, and more affordable, especially for vulnerable populations.

He is the recipient of the 2020 Business Book of the Year Award for his book, The Price We Pay, about the high cost of healthcare and the grassroots movement to increase transparency. For his work on this topic, Dr. Makary was invited to be one of the architects of the recent federal hospital price transparency rule, which requires every US hospital to post cash prices for common shoppable services and requires insurance companies to disclose their secret discounts.

His prior book, Unaccountable, was turned into the popular TV show, The Resident, which just completed production after six seasons. His newest book, Blind Spots, challenges conventional medical dogma to educate people about their health.

Clinically, Dr. Makary is the chief of islet transplant surgery at Johns Hopkins and is the recipient of the Nobility in Science Award from the National Pancreas Foundation. He has been a visiting professor at over 25 medical schools and has published over 250 peer-reviewed scientific articles on the appropriateness of care, the evaluation of new medical interventions, and healthcare costs. He was the first editor in chief of Medpage Today and is currently on the editorial board of Sensible Medicine. He writes for the Wall Street Journal and the Washington Post and is a frequent medical commentator on television.

Dr. Makary is a graduate of Bucknell University, Jefferson Medical College, and the Harvard School of Public Health. He completed a surgical residency at Georgetown University and his subspecialty training at Johns Hopkins.

07:32 What is appropriate care?

10:19 Why what we think might be appropriate care might not be appropriate care.

10:34 Why is medical dogma damaging to appropriate care?

12:45 Why we need less absolutism in medical practice.

13:37 How is groupthink prevalent in medicine?

14:02 Why do we resist new ideas?

17:43 How do providers figure out what to believe and what not to believe?

20:59 “If you leave it to the medical profession to fix itself … so far, it’s not going well.”

22:33 How does supporting health literacy affect appropriate care?

30:23 “People need to find their care based on quality and price.”

34:28 What proportion of medical care is deemed unnecessary right now?

You can learn more in Blind Spots and at gameasures.com. You can also connect with Dr. Makary on LinkedIn.

@MartyMakary discusses blind spots in #appropriatecare on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation #vbc

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Shawn Gremminger (Part 2), Shawn Gremminger (Part 1), Elizabeth Mitchell (Summer Shorts 9), Dr Will Shrank (Encore! EP413), Dr Amy Scanlan (Encore! EP402), Ashleigh Gunter, Dr Spencer Dorn, Dr Tom Lee, Paul Holmes (Encore! EP397), Ann Kempski, Marshall Allen (tribute)