Profile — April 2016
Tex Med. 2016;112(4):43-49.
By Amy Lynn Sorrel
As co-developer of a lifesaving surgical checklist now used in hospitals worldwide, Marty A. Makary, MD, has seen firsthand how physician leadership and innovation can help transform patient care. The Johns Hopkins Bloomberg School of Public Health professor, surgeon, and author also has witnessed a health care system characterized by high costs, persistent rates of preventable harm, and patients who aren't given options for their care. The key to improving health care outcomes and reducing cost, he says, is greater transparency, and the time is ripe for physicians to lead the charge.
Texas Medicine spoke to Dr. Makary for a preview of his upcoming keynote address during the General Session of the Texas Medical Association's annual policymaking and educational meeting, TexMed 2016, April 29–30 in Dallas.
Texas Medicine: The title of your speech is intriguing: "Art, Assassination, and America: How Transparency Disrupts an Industry." Can you explain where it comes from?
Dr. Makary: I like history, and I like to talk about the great heritage of American medicine, the fact that there were five doctors who were signers of the U.S. Constitution and the Declaration of Independence who had prominent roles in society and were respected leaders. I go through the assassination attempt of one of the U.S. presidents and how it wasn't the bullet that killed the president. It was the medical care he experienced. There were two doctors: One had the correct treatment, the other had a flawed treatment, and they fought over who was right, and the guy who had the wrong treatment won.
Texas Medicine: How does transparency tie into what you describe as the heritage of American medicine?
Dr. Makary: Not only as a country, but as a profession, we have a tremendous heritage in teamwork and transparency. In fact, some of the hallmark characteristics of American medicine over a century ago became learning from our mistakes, teaching those around us, working with nurses as colleagues and team members, and honest dialogue with patients. Also, we have a strong heritage in this country of physicians leading the way, tracing back to the signers of the Declaration of Independence and the U.S. Constitution who were prominent physicians. Physicians were and continue to be some of the most respected members of a community. While we may not have a lot of power today, we do have tremendous authority on the subject. There's an opportunity for the future to be different and better in health care and for a more patient-centered, physician-led marketplace.
Texas Medicine: What led you to become an advocate for transparency? Why is this an important issue for physicians to pay attention to?
Dr. Makary: My interest in the subject really came from my own practice doing complex pancreas surgery at a tertiary center where many cases are high-risk. I became a firm believer that transparency done properly can be a common-sense tool to reduce unnecessary variation in health care, and when done poorly can unfairly hurt the doctors who take on high-risk cases. In watching the field of quality metrics develop, I did what many doctors did: stick up for their patients in arguing that any efforts to improve health care have to use the clinical wisdom of practicing clinicians. What I've found is, when our input is solicited, great things can be done. And when external metrics are imposed without good clinical guidance, we can create perverse incentives that are counterproductive and can even make health care disparities worse.
Right now, we are at a time when we as a medical community can propose our solutions in a way that brings people together. Health care costs have been absolutely unsustainable, and despite promises over a few decades and many different well-intended efforts, we've not seen them go down. Instead, we've seen them go the other direction at an accelerating speed. And while medicine has and will be a great profession, the patients we serve are under increasing financial duress with crushing premiums and high deductibles. I've had the opportunity to visit many hospitals around the world and within the United States, and I've learned that many of the issues we struggle with are common issues, and there are some new threats to health care that we are all concerned about: corporate medicine, erosions of physician liberty. And many of us are concerned that our input is not being solicited in the restructuring of health care.
Texas Medicine: How can transparency help solve some of those problems, with doctors as advocates?
Dr. Makary: Some of the metrics in health care have been incomplete, and what we've been able to do is speak up about the issue and try to work on more mature metrics. For example, patient satisfaction is an important aspect of medical care that should be measured, but it turns out if that's the only measure that patients are using to choose their doctors, we create an incentive to game the system. What happens is, doctors who give antibiotics liberally to patients or parents [with that] expectation get rewarded, and doctors who practice sound medicine and use appropriate and judicious criteria for antibiotic use are punished. It's not that patient satisfaction is irrelevant. It's one piece of a broader picture of excellent patient care. In my experience at policy meetings and gatherings with leaders in health care, there can sometimes be an enthusiasm to measure health care that outpaces the appropriateness of the measure, or the comprehensiveness of the measure, or the maturity of the measure.
Choosing Wisely is a great initiative of physician-level efforts to raise awareness about appropriateness because, collectively, we as a community have a problem with appropriateness. It turns out that in our medical education, appropriateness is not front and center. What's front and center is a litany of memorization when what's important are issues we get little attention on in our training: how to communicate with our patients, how to work as a team, how to deal with outliers, and what are the appropriate thresholds to intervene in a practice where every patient is different.
Those are the real, pressing challenges in our discipline, and it turns out for many reasons, including a consumerist culture, a malpractice climate, and perverse financial incentives, massive variation around best practices is endemic, and medical errors at both the individual and health system levels collectively rank as the third leading cause of death in the United States. We're seeing now a more direct, transparent, consumer-based health care marketplace like we've never seen before. As health care costs become completely unsustainable, patients are unfortunately left bearing the costs themselves, and for the first time ever I'm having patients ask me when I tell them they need a [computerized tomography] scan or an operation, how much will that cost, or are there alternatives, or do I have to do it now?
We've never in most specialties addressed these issues, and we're seeing a lot of interest now at the physician level in addressing issues of quality. In the past, we haven't had a way to measure quality at the granular level. Now that we can look at a specific area of waste and identify the extreme 1 percent of outliers, the question is, what should we do about it? My efforts have focused on responding with the answer that we should share the data with providers in a confidential fashion that's nonpunitive, but actionable. And we are seeing physician associations provide resources to help.
Texas Medicine: Describe some of the trends you characterize as "disruptive innovation" and how physicians might be affected.
Dr. Makary: We are in the middle of these issues because we are the interface with our patients, and they look to us. And there are some new things in health care that are happening that influence how we interact with the marketplace.
One big trend is sharing medical data directly with patients. In many hospitals now, patients can access doctors' notes, so we're changing the way we write these notes so they can be understood by both a colleague and by the patients, and we're sometimes getting corrected so the notes are better. We're seeing metrics that are applied to us as physicians now becoming public information, and the question is, what metrics are coming, and how can we prepare for them? We're seeing medical practices exploding on social media. What should our response be? Should we participate? Should we advertise our services on social media and talk about them? And what's the limit? At what point is interacting with patients risky using social media, or at what point is it a great way to tell what you can offer them?
On the pricing level, there's a demand for drug price transparency; there's a demand for procedure price transparency; there's a demand for hospital accuracy when it comes to offering estimates around services. Patients are saying, "I know I need a hip operation or I need to deliver a baby, and if I go in and have everything done and it goes as smoothly as could be expected, why can't I know that price ahead of time, and why can't I understand the bill afterwards?" Well, it turns out doctors don't generate hospital bills, but we are swimming in the middle of it. A trend now is that patients are responding to doctors who are listing standardized fees that build in the price of complications.
One question is, what should be the future of our relationship with payers? In 20 years, will we even have payers, or will employers go directly to doctors' groups and hospital systems to say, "Will you take care of our [employees] if we pay for the services from our cash reserves? We don't need an insurance company." We're actually seeing a surge of more self-insured employers in the country, and that's a change for us as physicians. Whether it's good or bad, it's a change that we need to adapt to, and we can learn from those who've come up with innovative ways to adapt, or to use it as an opportunity to come up with better care.
Texas Medicine: Do you have some examples of how transparency has led to patient safety innovations, for instance?
Dr. Makary: It's an issue for which we have not had great forums, historically. When I have been involved in mistakes that have had terrible consequences for patients, there have not been good opportunities to share those experiences and to learn from them and to teach others. That's changing because there's an ethical foundation within doctors that says, "This is the right thing to do for us to learn as a community." Before, many of these issues were discussed in doctors' lounges or in small circles, and any public discussion was met with a strong deny-and-defend approach by the hospital's legal office. Now, we are realizing that not talking about it is part of the problem, and so it's doctors who are taking the lead on this.
The other thing I like to talk about is great hospital cultures, and how we can learn from those units, departments, centers about what makes a great, safe, high-quality workplace and high levels of workplace satisfaction. There's a study we just completed where hospitals with a great workplace culture had lower complications after surgery than hospitals with a poor workplace culture. While many doctors have suspected the culture at work influences how well our patients do, it's now becoming a science where there's data supporting the observation.
Texas Medicine: What are the biggest barriers to transparency in health care?
Dr. Makary: We all agree as doctors we are not trying to provide the cheapest care possible. What we are trying to do is provide the highest quality care possible at a reasonable price, and that equation is different from price transparency. Really, what we are interested in as doctors is value transparency: What are you getting — the care delivered at some of our best hospitals is the best care in the world — and at what price? People are willing to pay for quality. The goal is to change the conversation to value, and in order to have a conversation around value instead of just cost, we have to measure outcomes, which hardly anybody is doing.
The few people doing it — Medicare, payers, states requiring public reporting — are only capturing a small fraction of outcomes in health care, probably less than 1 percent. We don't have comprehensive metrics, and that's where I'm working with doctors on a national campaign [Improving Wisely, a Robert Wood Johnson Foundation project] to create ways to measure physician quality in a way that physicians endorse and author and own. That's been our response to the quality discussion, which has not really moved the needle when it comes to real-time events, rates of preventable harm. U.S. hospitals are as messy as they were 10 years ago with rates of preventable harm persisting, despite some small pockets of success. We still have a big problem, and in order to address it, we need to measure it fairly.
Texas Medicine: How would you rate physician engagement on this? What's at stake?
Dr. Makary: A lot is happening. People are frustrated. Physician engagement is at an all-time high, mainly because regulatory burdens and other hassles are at an all-time high. Patients are frustrated with costs, and we have the most engaged patient population we've ever had in U.S. history. For those reasons, a whole new health care system is being constructed.
There will be tremendous overhaul in health care, but it will not come from the government. It will come from technology organizations and applications and startup companies partnering with innovative health systems that want to do things really differently. If doctors are at the forefront of that change, it will be good for patients. If they are not at the forefront, there will be inefficient endeavors with multiple iterations until we realize that sound physician guidance is the best ingredient in changing any health care marketplace.
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Like it or not, physicians are business people, too. Mark G. Dotzour, PhD, will look into the crystal ball that is today's economy and share his visions for the upcoming year at the General Session of the Texas Medical Association's annual policymaking and educational meeting, TexMed 2016, April 29–30 in Dallas.
Population growth, inflation, and interest rates may not be subjects physicians studied in medical school. But the chief economist and director of research for the Real Estate Center at Texas A&M University in College Station says those and other economic factors can have a big impact on decisions physicians have to make, just like any other investor borrowing money or buying real estate to sustain or expand their businesses.
Dr. Dotzour also will demystify the turmoil in the declining stock market and discuss the outlook for job growth and oil and gas revenues in Texas — factors the House of Medicine knows all too well can have implications for the state budget. He's done his homework to know, too, that in the past, the Federal Reserve System has not been shy about raising interest rates in an election year.
The goal of his presentation, Dr. Dotzour says, is to decipher the complex economic environment so physicians can walk away confident in their business plans personally and professionally.
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