Dr. Robert Pearl: His book offers a prescription to cure wait ails American medicine
By Patt Morrison
July 5, 2017 FiDA highlight
Dr. Robert Pearl has spent his life in medicine — most recently 18 years as executive director and CEO of Kaiser Permanente’s medical group in California, and president and CEO of its mid-Atlantic group. But it was the death of his father, and a simple medical miscommunication, that prompted him to look long and hard at an American medical system that doesn’t always deliver bang for its billions of bucks. In his book, “Mistreated, Why We Think We’re Getting Good Health Care — And Why We’re Usually Wrong,” Pearl lays out his four ways though the morass of American medical practice: integrated, not fractured care; a flat-fee capitated payment system instead of pay-per-treatment; embracing mobile and video medical technology; and most of all, care that’s led by doctors themselves.
Let me take a classic American playground taunt and turn it around: The line is, if you’re so smart, why aren’t you rich? So if the United States is so rich, and so smart, why aren’t we healthier?
This is exactly why I wrote “Mistreated,” because we spend 50% more than any other nation on the globe and our results are in the lower half. And the reason is because the American healthcare system is broken. It most closely reflects a 19th century cottage industry. It’s fragmented, with doctors scattered across most communities, hospitals in every town.
It’s paid on a piecemeal basis; we call it fee-for-service. It uses technology from the last century. You’d never bank someplace where you couldn’t access information on your account 24/7, but if you want to get your radiology results, your laboratory results, you’d have to call the doctor’s office between 9 and 5 Monday through Friday, or go there. You can’t use video; all the modern tools are not available.
You say our results as a country are in the lower half. Can you get specific?
We’re last in the world [among the 20 most industrialized nations] when it comes to life expectancy. A girl in Seoul, [South] Korea, being born now has on average a life expectancy of 90. The same girl in the United States, 83 — seven years fewer.
We’re second to last in terms of childhood mortality.
Colon cancer — half the colon cancer deaths in the United States are preventable with proper screening, and I don’t necessarily mean a colonoscopy. It’s called a FIT test, which is basically done in the privacy of a bathroom once a year, five minutes, no bowel prep required, you can do it every year for 10 years. It’s just as good as a colonoscopy, and yet across this nation, it’s done 50 to 60% of the time. The best medical groups do it 90% of the time.
What other industry, what business can you think of that would function like American medicine today?
— Robert Pearl
Americans are dying unnecessarily. Half a million people die every year from either failures of prevention, or from medical errors, like my father, or from avoidable complications of chronic illness that simply were not addressed.
We value intervention over prevention; we value the newest advance over the things that are tried and true.
You make a distinction between malpractice and mistreatment, which can simply result from haste or error.
You’re right. I think most physicians are dedicated, smart, hard-working, knowledgeable. That is not the big problem. I’ll give you an example, again my father. He was someone who had tremendous energy. He slept four hours a night, until one day he got tired. And he had to have his spleen taken out because he had hemolytic anemia.
Now, he spent half his time in New York and half his time in Florida. His doctors in New York knew he needed to have the vaccine, the pneumococcal vaccine, to prevent the complications that often follow removal of the spleen. The doctors in Florida knew that he had to have that same exact vaccine, but they each thought the other had given it.
And that’s the system. That’s the lack of an integrated, comprehensive electronic health record. If he had had that, he would have gotten the vaccine. He didn’t die because of malpractice. He died because of a broken system.
If you were able to wave your magic stethoscope and redesign the American healthcare system, what of it would you keep and what of it would you jettison?
What I would jettison or replace is the fragmented fee-for-service, out-of-date technology, lack of leadership that we have today. I’d replace it with an integrated system with the physicians and hospitals working together as one, paid in a prepaid or capitated way, using the most modern electronic health records along with the most modern and mobile devices, things like video, secured email. And I’d put it all inside a leadership structure with physicians.
And I would have multiple groups competing to provide the best value, making information available and transparent for patients so they can make the best choice for themselves and their families.
The main thing, though, that I would keep, and I’m afraid we’re losing it, is all of the mission-driven, wonderful spirit of American medicine that’s been handed down through five millennia. I think we’re seeing right now that physicians are spending almost half of their day hunched over a computer, trying to document things for a billing system rather than looking at the patients, being able to communicate or other things. We’re asking physicians to squeeze more and more into every day with less and less time.
I think we’re reaching a breaking point where one of two things will happen: If we don’t address the concerns and transform American medicine, what we’re going to see is we’re going to devolve into a two-tier system. Not the two-tier system of today, with the poor and everyone else, but the middle class and the Medicare patients not able to get access, similar to the Medicaid patient of today.
Or we’re going to see disruption. I think if we don’t do something about American medicine, the system will simply disintegrate, dissolve, and we’ll run the risk of being disrupted, as Kodak learned.
What’s the resistance to adding technology, when technology seems to be one of the great drivers in American healthcare?
Today what you’re describing, the ability to get paid to do a video visit, for most physicians doesn’t exist. It could happen. It’s just that it doesn’t exist. And I think part of why it doesn’t exist is that insurance companies are concerned that doctors will just generate more and more and more visits whether they’re needed or not, in order to be able to bill for them.
I was struck by your point in the book that the medical system is driven by fear, and it’s not necessarily the patient’s fear of pain or death.
What happens is that in part of our brain, the reward center and the fear center, we call it lighting up, because it activates, and within fractions of a nanosecond, the perceptual side changes. And so medicine is filled with reward and fear.
The problem is that in American medicine, that same brain process leads doctors and patients to do things that don’t make sense when you look at it through the lens of objective reality. As an example: I live in Silicon Valley, and between San Jose and San Francisco, there’s 10 hospitals doing heart surgery, three of which do 200 or 300 cases a year.
That means there’s at least 65 days a year when the team’s going to be there and available, with nothing to do. It’s hard to imagine you’re going to get great results when you’re doing less than one case a day. And similarly, the cost is going to be much higher.
Take the hospital administrators, and put them in one of my classes at the Stanford graduate school of business. They’ll immediately say, bring the three together, close two of the services and have one service that does 800 or 900 a year, a much higher volume service. But what they know is they’ll lose their jobs. They know the hospitals will lose their revenue. Fear of loss — how powerful losses are compared to gains.
I talk about sepsis, which is an infection that is now the leading cause of death among hospitalized patients, a systemic infection, the same problem that my father died from. The fear there is that, what we know is that half the people who come through the hospital with sepsis are very, very sick. Everyone in the United States knows how to treat them.
But a woman named Diane Craig, one of my associates at Kaiser Santa Clara, found that half of these patients looked very sick coming in. But she also found that the other half — they were sick, because otherwise they would not be at a hospital — but they were not nearly as sick. They were often younger people, sometimes with a kidney infection or maybe a mild kind of pneumonia, and then they progress rapidly over the next couple of days, [into] that intermediate zone [where] no one quite knows what to do. And if you treat all the people in the intermediate zone, you’re going to save lots of lives.
What’s the problem? Because the intervention requires doing very aggressive treatment, and the physician is worried because some patients who might have lived will actually be harmed. And in the mind of a doctor, not all deaths are the same. I hate to say it that way. The ones they cause are far worse than the ones they could have avoided.
And so there’s an imbalance. So rather than aggressively treating the patient, they just put them in the hospital, put them on some antibiotics, and they call a consultation. It’s now no longer on their hands.
It’s not that the doctor intentionally wants to harm anyone, it’s just their fear of being the one to cause the problem.
Again, it’s how our brains change perception. Those things that we cause, the problems we cause, the deaths we cause, are significantly greater in magnitude than the ones we otherwise could have saved. It’s also why we see intervention as being so much more valuable than prevention.
You saw some of these things first-hand when your father fell ill and died.
My dad survived the first acute episode he had, but he never overcame the complications. My brother and I got called; my dad had had a bleed into his brain in Florida. We got on an airplane and we flew there. When we arrived, there were a lot of doctors at the door. There was the [ears, nose and throat] doctor who wanted to do the tracheostomy, the [gastrointestinal] doctor who wanted to put the feeding tube in place, the neurosurgeon who wanted to take a piece of bone from his skull to let his brain expand. And we looked at the X-rays — we’re both physicians — and we said no, he’s not going to get better. It’s not what he wants.
The next two and a half days he was in the hospital, we never saw a physician. There’s no [current procedural terminology] code for how doctors bill for compassion. Doctors in the fee-for-service world don’t get paid for coming by and comforting a family in its time of greatest grief.
The system is making the lives of patients worse.
And I want to add one piece: It’s making the lives of doctors worse. What we see today is one in every three doctors reports being depressed. Over half of physicians say they would not tell their children to enter into medicine. There are over 400 physician suicides every year.
And the reason is, medicine is becoming less and less fulfilling. And yet somehow, because of the context, ask most Americans and they will tell you the medical care in the United States is the best in the world, even if it’s a little expensive. The data says exactly the opposite.
How do your suggestions work when, as you pointed out in your book, about 50% of medical care costs go to 5% of people?
If you look at the 50% that go to 5% of people, you have really three groups within it: one group of people who just have a terrible, unexpected problem. A baby is born very, very premature. But the reality is, they’re not going to have another baby born premature next year.
There are some people who have severe disease, and the problem in that group is that we missed the opportunity 20 or 30 years before to actually prevent them from developing those kinds of diseases.
But the places that most people look are individuals with chronic disease, multiple chronic diseases. And that’s where I think the approach I’m describing will make the biggest difference. All these patients are seeing physicians. It’s just that when they see the physicians, the system is not focusing in a way to get that best outcome. And what do I mean by that? People often have five or six doctors. Well, are those doctors working together as one, or are they all duplicating the same kinds of things? Are the computer systems they’re using coordinated with each other? Or does everyone basically have an office-based system?
Is there a leadership structure? Doctors are not going to follow hospitals or insurance executives — they don’t trust ’em. But they will follow physicians who are well-trained, whom they know and whom they respect.
What other industry, what business can you think of that would function like American medicine today? Try to think of a business where you wouldn’t have coordination between the people who design the products, the people servicing the products, the people selling the products, where you wouldn’t have modern 21st century computing systems so that everyone has information not just to do the care at the time, but to be able to analyze it in order to improve performance.
It just doesn’t exist in most of American medicine today.
I believe that change can best happen through the businesses of this nation, that if the businesses said, in a certain number of years — let’s say five years from now — we’re not going to purchase insurance from any organization, from any doctor, from any hospital that is not integrated, where the care is not coordinated among primary care, specialty care, inpatient care, outpatient care, where it’s not paid on a capitated or prepaid basis, where they don’t have the most modern electronic health records — I believe the American healthcare system would respond and would improve.
If we’re able to accomplish that, then my dad’s death will have served a purpose, because the result will be hundreds of thousands of patients who live who otherwise would die.