Introduction
[00:00:01] Stacey Richter: Episode 449: "For Clinical Leaders, Payers, and Plan Sponsors, Let's Talk About Blind Spots for Getting Patients or Members Appropriate Care”
[00:00:12] Stacey Richter: Today, I speak with Dr. Marty Makary.
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.
You can listen to the episode and read the show notes with links on the episode page.
The Concept of Appropriate Care
[00:00:53] Stacey Richter: It's this idea of what is appropriate care and how good are we at ensuring that patients slash members get said appropriate care. Lots of people are of the same minds because appropriate care has come up in the show with Dr. Ben Schwartz, Dr. Spencer Dorn, Dr. Tom Lee. And if you want a blast from a couple of years past, the show with Bob Matthews and wow I could go on. Dr. Will Shrank talking about the amount of waste from so called inappropriate care.
I mean, an estimated 21 percent 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 percent of diagnostic tests, 22 percent of all medications, and 11 percent of all procedures are unnecessary slash 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.
Challenges in Delivering Appropriate Care
[00:02:34] Stacey Richter: Because in the real world, getting patients appropriate care, getting members appropriate care could be a challenge for the following four reasons that Dr. Makary sums up in the conversation that follows.
Here's reason one, it's kind of tough to get or deliver appropriate care. 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, 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 is becomes truth? In the writings of Blaise Pascal from 1670. Yes, I am a nerd, but also yes, to succeed in providing, in air quotes, 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, link in the show notes. So medical dogma and groupthink can make it difficult for patients to get appropriate care.
Number two reason it's tough to get patients appropriate care. 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.
Number three reason why getting patients appropriate care is tough. 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.
Dr. Robert Pearl 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, ie, metrics that matter for appropriate care. And yeah, by the way, RVU 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's Advice for Improving Care
[00:06:00] Stacey Richter: Dr. Makary says, first piece of advice, number one, measuring and reporting on practice patterns and appropriateness of care at the individual clinician slash physician level can help drive accountability and quality improvement. It can actually improve the level of appropriate care, which is delivered.
Number two, piece of advice, plan sponsors have an important role to play in demanding transparency around quality and cost and using the data to steer members towards 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.
Third way or piece of advice that Dr. Makary offers is that 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.
With that, here is Dr. Marty Makary. My name is Stacey Richter.
This podcast is sponsored by Aventria Health Group.
Dr. Marty Makary, welcome to Relentless Health Value. It is always such a pleasure to have you on Relentless Health Value.
[00:07:30] Marty Makary: So good to be with you, Stacey.
Discussion on Medical Dogma and Groupthink
[00:07:32] Stacey Richter: In reading your latest book, "Blind Spots", a lot of it revolved around really understanding what appropriate care is. That is a term that comes up all the time, you know, like we got to make sure that our members/patients get in air quotes appropriate care. This "appropriate" is often bandied about. What is appropriate care?
[00:07:52] Marty Makary: Well, we in medicine have a reflex to do stuff, and that reflex is not always healthy. We come out with this sort of diagnose, treat mindset, and when we see something, we go to work, and the system rewards quantity, not quality. And so we've got a system now where we're only focusing on disease.
We've got massive overtreatment, an epidemic of inappropriate care. But I wrote this book, "Blind Spots", because there is some scientific research now that's amazing. And it turns out one of those big giant blind spots is, what is the correct information about health? We have this system that has blamed patients for a long time.
And at the same time, chronic disease is going up, and we have this crazy system where you come in every few months or several months, we tell you to do something differently, throw some meds at you, and you come back and we kind of tell you that you're a bad, noncompliant patient. And the problem is that we have a public that's non-compliant.
Well, maybe we've been giving them the wrong information about so many aspects of health. We in the medical establishment got the low fat diet wrong for 60 years as the industry moved to refined carbohydrates and added sugar as obesity rates and insulin resistance and diabetes soared. We got opioids wrong for 30 years, igniting the opioid epidemic.
We got peanut allergies wrong. We got hormone replacement therapy wrong. These are not side issues. These are some of the biggest recommendations in modern medicine. We can do everything out there in the world to fix our broken healthcare system, but if we're still giving people the wrong information, we're going to continue to struggle and waste billions.
[00:09:33] Stacey Richter: Okay, so let me paraphrase what you just said. I asked you about appropriate care. And what I'm hearing you say kind of in response, you brought up just the vast amount, despite all the money that we're spending, despite people actually going to the doctors, the ones that are engaged, we still have chronic disease epically in this country.
So could you consider the care appropriate when you still have disease spiraling? And then we brought up the low fat diet. Turns out, not so much. You brought up opioids. Turns out they actually are addictive. Who knew? You brought up peanut allergies, which, you know, they're now finding that keeping the peanuts away from the kids actually causes the peanut allergy.
And then you also brought up HRTs, you know, and each of these is at least a chapter in the book. What I'm hearing you say is that what we think might be appropriate care might not be appropriate care.
[00:10:24] Marty Makary: When we use good scientific evidence and listen to patients and actually observe what's happening in this society, we can do some good. We can help a lot of people. But when we use medical dogma, when we put something out there with such absolutism, when the reality is, it's a hunch, it's the opinion of a few people without good scientific study, we can do tremendous damage. And so that's the story of the modern day peanut allergy epidemic, the opioid epidemic.
The issue with food, we're not studying food as medicine, but we need to, we're not studying the role of microplastics, which early research is telling us, hey, they can have some estrogen binding properties, may have something to do with the lowering the rate of puberty each year, we see it in society. Why aren't we talking about these giant areas, the role of seed oils, getting a lot of attention, promoting body inflammation.
So we got to focus on what matters to people, not on what isn't central to the business model of health care. And I think there's a movement now to do that.
The Role of Plan Sponsors and Health Literacy
[00:11:29] Stacey Richter: Say I'm a clinician and I want to do the right thing. I want to provide appropriate care. Like that's my goal. Or if I'm trying to buy appropriate care and figure out what actually is appropriate. There's a couple of things that are the create a bit of a flywheel here and not in the right direction.
One of them is if somebody, and this is just human nature, right? Like the loudest person in the room kind of gets listened to. So like if you have somebody who's loud, who is in a position of power, who's platformed, and they start talking about their hunch, then you may get a lot of people who are listening and just kind of like, okay, well, so and so said it, so I guess it must be true.
And it's not necessarily an evidence-based thing. So, like, you wind up getting things happening which are not appropriate, which become appropriate because everybody's doing it. And then you wind up with this kind of doom loop because the more people who hear it and do it, then it's like, well, everybody's doing it.
That's kind of one thing that winds up happening. And right now we actually have a lot of data that we didn't used to have. So in this moment in time, there's an opportunity to actually, in a data driven way, understand what appropriate care is.
[00:12:34] Marty Makary: Yeah, in the past, and by and large very much still true today, most of what we do in medicine is discretionary. That is, there's no good scientific study to tell us what to do. In the estimate of one of the chief editors of our big medical journal JAMA, he said 60%, and he told me this maybe six years ago, 60 percent of what we do in medicine is discretionary.
There's no good evidence to guide us. And so we're using our best judgment. We're using clinical wisdom and sort of deductive reasoning on health. So when you do that, you need to show some humility. You need to let people know, hey, this is what we think. There's no good studies, but this has been our practice and we've had good experience with it.
But when you put something out there with such absolutism, and the reality is, the right answer is, we don't know, you lose trust. We got a little peek of that during COVID, that was a little window into a medical establishment. But I don't write about COVID in the book, it's become too tribal and people are sick of it.
What I really talk about is this deeper medical establishment, the culture, so people can know the truth about so many of the new discoveries in medical science that relate to their everyday choices, but also the psychology of groupthink. The idea of the bandwagon mentality is one that's been around in not just all of history, but it's in every industry.
We tend to resist new ideas. We tend to hold on to what we believe simply because we heard it first, not because it's more logical. We tend to block new information or reframe it to fit what we already believe. That is cognitive dissonance. And you see it everywhere. You see it in politics and business.
And you're like, what is this resistance? These are smart people. How could they be so closed minded to something new? And this is the psychology of why we resist new ideas. It is cognitive dissonance. There's a whole literature to it. I summarize it in the book, but, we're all susceptible to it. The father of modern medicine, Claude Bernard, said “we all have our biases”.
We need to recognize that. We need to be aware of it. It's okay. They're not bad. They're intrinsic. It's part of the human condition. But we have to actively suspend those biases as we consider new information in order to be objective. And really that set the foundation of what we should be doing in medical science, that we shouldn't be tribal and we shouldn't be simply signing on to the group thing.
When I talked to the woman who wrote the guideline for the food pyramid the government issued when I did the research for "Blind Spots", I asked her, I said, can you point to me one study that shows that the low fat diet reduces heart disease? And she basically got very uncomfortable and she said, well, wait, whoa, I don't have a study for you, but are you trying to tell me that the American Heart Association was wrong, and the Surgeon General was wrong, and the American College of Cardiology wrong?
She's like, I don't think so. All these people being wrong? No way, that's impossible. And it's like, no, this is the psychology of groupthink. And when we just follow the herd mentality, we can find ourselves in a very bad place.
[00:15:44] Stacey Richter: Yeah, I did actually read "Dreamland", which is about the opioid crisis. Same story.
There was one guy wrote one paragraph that opioids aren't addictive, which was an opinion piece. It wasn't even a study, if I'm recalling this correctly. And everybody just started talking about that one paragraph, like it was a whole study, and then, you know, it's like a game of telephone. Somebody said that somebody said...
[00:16:14] Marty Makary: It was a letter in the New England Journal, one paragraph letter, where a guy just said, I saw 32,000 patients take opioids, only one became addicted.
And because the New England Journal took it, then it became "the literature", the medical science, NEJM, and as soon as you have a PDF in a medical journal, then suddenly it becomes part of the canon of medicine or something.
[00:16:37] Stacey Richter: So as everybody knows and has been said on the show many times, it takes 17 years for an idea or a clinical, someone determines that something is a clinical best practice. It takes 17 years for that to become a standard in medicine. Like the beta blockers after a heart attack is the example that everybody uses.
[00:16:54] Marty Makary: By the way, that was just proven wrong. New England Journal study just said not to start a beta blocker after heart attack. Does not improve survival. It was a quality measure for 20 years.
Another dead quality measure in the graveyard that has been retired because it was really based on bad science and dogma. Anyway, I know you didn't, that's not why you brought that up, but I understand your point.
[00:17:16] Stacey Richter: I appreciate you bringing that up because the next point that I was going to make is If I'm a primary care doctor listening right now and I'm not, but let's just say I was. And there's so many studies where, for example, every study that's in NEJM, there's always a rebuttal, like where somebody says what's wrong with it. So it's not like there is any, you know, the other thing that you hear about data is we're drowning in data and starving for wisdom.
There's so much data that's flying around. There's so many things which are, you know, what was the patient? Like, there's so many variables. I could see if I'm sitting on the other side of that, how scary I don't want to kill anybody. Give the baby peanuts. The stakes are really, really high here. So trusting a key opinion leader.
Who comes and says, I believe this, I could see how that would be maybe the most comfortable way for someone to believe something, you know, like, why do I, so somebody comes up with a new thing, which is basically go with a beta blocker thing is wrong. Like am I going to trust all of my patients lives like on that new bit of information when 10 minutes later that also could be disproven? I mean, this is a bit of a cluster here.
[00:18:31] Marty Makary: Yeah, it is and people are responding appropriately when they say, hey, you guys are all over the place and you put out things with such absolutism and then it ends up being wrong, I don't know what to believe. And then they start to distrust the profession. And mistrust of the medical profession is at an all time high.
By the way, doctors are talking about it in the medical journals right now. There's essays all over the place. People don't trust us. There was a study that just found that 42 percent of the public does not trust medical guidelines and the medical profession.
[00:19:03] Stacey Richter: So, if a doctor that's listening to the show, what's, what's your advice?
[00:19:09] Marty Makary: This new book, "Blind Spots", was really created out of these experiences where I would meet with some of my colleagues at Johns Hopkins or at national medical conferences, and I would say, hey, did you see this new study that came out at the Mayo Clinic on the microbiome? Did you hear about this new best practice in GYN surgery?
Have you heard about this latest cancer research? And they were blown away. I was blown away, and they were blown away, and I was blown away that they hadn't heard of it. It had been in the literature for a year. And so then I realized, hey, I've got clinical people that read my books and nonclinical people alike.
I try to write for both audiences. Let's talk about the latest scientific stuff that everybody needs to know so that doctors know what to put out there. And for plan sponsors, they have a huge opportunity because for a long time they've had to just, we've all had to just tolerate this broken system that's not working, that's medicating everybody, that's watching chronic diseases go up and all kinds of issues unaddressed.
Now, employers have the opportunity to create some accountability for their local health care facilities and providers. They can demand not just discounts in their networks, but also medical care to address many of these unaddressed blind spots of modern medicine, be it menopause, best practice with childbirth, cancer prevention.
There are great practices out there, and I think they have an opportunity now to help not only increase medical literacy, but healthcare literacy, try to educate people on the basics. These are things that can result in direct actions to try to usher in these big topics into discussion, especially with local hospitals and provider groups.
Because this is where it's happening right now, and it's gotta happen, otherwise if you leave it to the medical profession to fix itself, it's not, so far it's not going well.
[00:21:06] Stacey Richter: If I'm thinking like a plan sponsor, what I would be thinking to myself right now is, you know, like obviously, I'm not going to sit in my office and individually coach people, which is not at all what you're suggesting.
But like, if I know about peanut allergies, like that doesn't necessarily help anybody. I have to make sure that my members are going somewhere where they do, and that they are on top of, the consequential new science and late breaking news, which has gone through the gauntlet. It's, you know, not just like somebody just came up with it, it's somebody, there was a hypothesis, it was proven, the data shows it, it's pretty unimpeachable that like the science has moved forward.
And I think that's really important to say, because obviously, you know, go on YouTube any day of the week and you will find any number of new and exciting theories, which let's just say have not gone through the gauntlet of medical science, right? So, it has to be new, it has to be proven.
And I think if I'm a plan sponsor, I'm thinking about this in the context of I need to make sure that my plan members are going to doctors and other clinicians who are staying on top of stuff like this. And when I say that, I am implying that there's some way to measure this. Because like, how are you going to do that unless you are quantitatively or qualitatively or somehow or another figuring out where do I send my people who are moving forward with the science? How do you do that?
[00:22:32] Marty Makary: Well, first of all, when we educate employees and beneficiaries of health plans about health, when we promote health literacy, they start asking, and we saw this in one pocket of medicine, we saw it in childbirth. When women started asking, hey, can I have this delayed cord clamping that I've learned about that has good literature to support it, respected doctors for talking about it. Skin to skin time, avoiding unnecessary C-sections. Can I be a part of my birth plan instead of it just being imposed on me? Can I get a price for that service? When people start asking, the market moved and now you have OBGYN departments that have really responded to this consumer demand.
It's sort of like going to a restaurant and asking if the food is organic, or if the fish is wild caught. If enough people ask, guess what, they will respond to that demand. And now you have restaurants that boast that we offer foods that are in this healthy category. I just saw a restaurant in Austin, that says they do not use any seed oils in the restaurant.
This is responding to consumer demand out there. So we need to promote health literacy and that's what I'm trying to do with the book and that's what other groups are doing.
Measuring and Ensuring Quality in Healthcare
[00:23:46] Marty Makary: Now, in terms of measuring appropriateness, We can't measure the humility of a doctor or their listening skills in big data, but we can measure their practice patterns.
And many times, abnormal practice patterns are a flag. They're a signal in the data that something is not right. So we now have a big project called GAM, or Global Appropriateness Measures, we look at in big data, and we have access to all the Medicare data and the most of the commercial data in America, and we will look in that data to see, let's look at OB doctors in your state or nationally, and what is their C-section rate as an individual doctor? Relative to the national C-section rate in low risk deliveries. You've got to make it clinically smart. If the measure is overall C-section rates and they're just doing high risk deliveries, you're being fooled.
We have in healthcare a problem where there's no real competition. There's no insights. You're flying blind. And so, there's competition, but it's at the level of valet parking and NFL ads for a hospital. We need competition at the level of quality and price. Well, quality now, we don't have a precise tool, but we can identify that 5, 10, 20 percent of physicians in their specialty that are practicing in a way that is generally recognized to be a bad practice pattern.
They're putting in hardware during lower spine surgery at a rate so high, it's indefensibly high. You cannot justify putting in hardware that frequently in nondeformity elective lumbar procedures. Overprescribing among primary care physicians, how often they follow up a test with another test.
So we've got now the ability to look in big data for steerage, navigation, even looking at different networks and finding out how does that network perform on appropriateness of care.
Because we can do everything in healthcare to build giant hospitals and big centers. But if we're not delivering appropriate care, then I think we're going to continue to struggle in healthcare and we're not going to rebuild that trust.
[00:26:03] Stacey Richter: If we're thinking about this relative to a plan sponsor, like what do I do now? Sounds like your first piece of advice is, as health literate as you can get your employees to be, that's never gonna go wrong. I will mention Al Lewis and Quizzify, like who I think does a great job with this. Hi, Al. So teaching the employees to be health literate, I do feel like the thing that a lot of times gets forgotten is tipping points.
The market doesn't shift. Like one day, everybody in the whole entire market decides like, we're going to move, do this. We're going to shop. We're going to look for quality. How it works, always, you have early adopters who wind up starting to do something and it's those early adopters that create an early majority and then you get the majority of people shifting what they're doing.
So if only 12 percent of the high literacy patients in a certain geography creates the tipping point, it doesn't have to be absolutely everybody that has to understand what the latest is on, you know, peanut allergies. If you get 12 percent who do, you could actually get a shift that the market will respond to in the ways that you're talking about.
Because I'm certainly not sure that you had 50 percent of women across the country who were talking about having more control over their birth plan and reading some of this literature, right? Like, it was a small number, but that was enough to drive some change in certain marketplaces.
[00:27:25] Marty Makary: Stacey, I couldn't agree with you more.
You look at the food industry, when we started talking about the dangers of added sugar, only 5 percent or so of shoppers were actually looking for labels with lower sugar, but the market responded because it's a very competitive marketplace, and then they started boasting, hey, we have lower sugar. And whether or not you were shopping based on sugar, 95 percent were not.
That wasn't going to turn you away if it had lower sugar. So we do see a small group of people disrupt markets and I think that's what's also happened with health.
[00:27:58] Stacey Richter: The second point that you mentioned was actually measuring appropriateness, which is something you've been talking about a long time. I saw you probably 10 years ago on stage talking about Mohs surgery. Obviously not your first day at this rodeo.
You're talking about measuring appropriateness on maybe key metrics such as C-sections you mentioned, you mentioned putting hardware in spines. You mentioned overprescribing, PCPs who overprescribe, maybe overrefer. What are you going to do with this information, especially just given the realities that plan sponsors often face with the anti-tearing and anti-steering?
[00:28:29] Marty Makary: Our goal is to empower primary care clinics that are doing steerage to know which doctors are appropriate and inappropriate in their practice patterns among the doctors that they refer to in their community. You're told, hey, we're a great hospital, we've got a great brand. You've got quality branded at an institution level, but the reality is quality lives at the individual physician level, for the vast majority of the domain of quality.
So, it's reasonable now for people to know who should they refer to, which doctors should be in the plan, and what we're hearing from the plans is that the hospitals in particular do not like steerage to individual physicians. So we're seeing now this tension play out, and I'll tell you, the employer and plan sponsored groups are winning.
Because they're saying, look, you can say whatever catechism you have to your old principles of quality, but we want something different. We know what's happening in the community. We show them the data. Our team, this team led by Dr. Will Bruhn, he leads the GAM project that provides these insights to employer plan sponsors and hospitals.
By the way, if people are interested, it's gameasures.com. But, he'll show in a community, here's all the doctors that do C-sections in your city. Here's the range of their C-section rate in low risk deliveries, an important distinction. And you've got doctors at 70, 80 percent, and you've got doctors at 12, 11, 14 percent.
Now, if you were pregnant shopping for a doctor, wouldn't you want that information? And wouldn't you want your plan to help with your steerage? Wouldn't you want your primary care doctor to send you, especially if they're globally capitated on payments, now we've got an incentive alignment. And so we're seeing really cool stuff happen with measuring appropriateness. And we're hoping it does disrupt markets because people need to find their medical care based on quality and price, not on billboard ads and NFL ads.
[00:30:30] Stacey Richter: Well, the whole promise of transparency, you're only doing half the equation if you're only making prices transparent.
[00:30:38] Marty Makary: Exactly.
[00:30:39] Stacey Richter: Especially just given the issue where, you know, if you do actually any kind of consumer research and you say, do you want to go to get the cheapest knee replacement? You will get most of them that say, well, if my plan pays for the most expensive one, I'm going to go there.
[00:30:52] Marty Makary: Yeah, must be better. Yeah, must be better.
[00:30:54] Stacey Richter: Not, obviously people that listen to the show do understand that a lot of times actually the cheapest one is the highest quality just because they probably do a lot and they're more efficient.
And when you're more efficient, you're, yeah. So plan sponsors, make sure you're working with somebody who's measuring practice patterns because that is going to determine whether doctors are keeping up with the science, but also whether they're doing stuff because you get paid more for it, which, which I think is probably the quiet part out loud of a bit of this conversation.
It's really important to understand the old things that someone might be doing because they haven't kept up with the literature. But also, the things they may be doing because those are the most profitable. Either way, it's really important to understand that that's going on in the market. Measuring practice patterns is, generally speaking, conceived of as the best way to go about that.
And then ensuring that doctors who are referring... I mean, one of the biggest, I'm going to say, barriers to advanced primary care or direct primary care producing notably better outcomes has been that there is a dearth of data or dearth of wisdom, I'm going to put it that way, relative to specialists who are offering the best possible outcomes.
And that said, that creates a lack of incentive for specialists to really throw their backs into creating standards of care in their own practices to drive the best possible outcomes. Because if you do that and you spend all this money and all this infrastructure and you do all the things like Dr. Steve Schutzer talks about this a lot, like you can kill yourself and spend a lot of money to create the infrastructure that is necessary to drive consistently awesome patient outcomes. But if nobody notices what you're doing, then like, you're not going to get any reward for the amount of time and effort that's been placed.
So I also could see that that is music to the ears of specialists who are really trying hard in this area because, you know, if you're rewarded for having higher quality, that's an incentive.
So, for sure, measuring quality, making that information available to PCPs, I mean, honestly, I would love to see it made available just for the same exact reason that a small number of patients or a small number of a market can move the market, I would love to see this information being made available to plan members themselves or just made available because if we really are trying to transform the healthcare industry, you sort of need the quality information.
[00:33:16] Marty Makary: We've seen tremendous demand for the appropriateness scores, Dr. Will Bruhn, he's figuring all this out, but we're already seeing doctors in the community saying, hey, why am I not getting patients referred to me for childbirth?
Hey, why am I not getting spine surgery patients? I noticed a little decrease. And sometimes plan sponsors or the insurance company will just say, hey, because you're an extreme outlier here. We're not trying to measure who's 5 percent better than the next person. We're identifying extreme practice patterns that are well known ways of gaming the system in medicine.
And there's a lot of those. That was the Mohs surgery example I think we talked about years ago. And we're going to not reward people who are overbilling, over coding, over operating, over prescribing, over treating, and ordering too many tests. It's, it's a new, we're in a new area, right? We've never had this level of data before.
We've never had all the pricing data. So you can log on, search all the rheumatologists in your city, and see their performance on price and quality, looking at not just traditional complication rates, but the appropriateness of care. You know, we did a study at Hopkins, 21 percent of medical care is unnecessary according to physicians.
It was a national study of physicians. So when you have a respondent saying that one in five things is unnecessary, that is an industry in crisis. And so we can keep pouring good money after bad into this broken system. A lot of people are getting rich. A lot of people just have the goal of coming up with something that sounds good, and then they'll sell it to OptumRx overnight.
This is a game we're watching right in front of us. And a lot of people are getting rich in healthcare and it's on the backs of everyday American workers who are funding this giant broken system that is not reducing disease and it's not improving the health outcomes of our population. It's making a lot of money and it's all financed through the paycheck deduction in the everyday American worker paycheck, both for their health plan and for their Medicare excise tax.
And somebody has got to say. We're going to be their advocate. We're not going to stand for this. The system is broken. Look at the results. In any business, if you had the outcomes of what healthcare has delivered, you'd say, You failed. You failed. Now, sure, if you get shot in the chest, you want to be in East Baltimore and come to my hospital, Johns Hopkins.
And you will see an incredible tour de force of technology and clinical expertise and you will get the best care known to mankind. But if you come in with belly pain and a chronic problem that's been nagging at you, we may have no idea what, what we're doing. If you come in with a question about food and, you know, not know what to do with it. We don't, can't bill for the time we spend. We don't have research that doctors are even aware of on general body inflammation and some of these topics. So sure, there are pockets of incredible success and pride in our healthcare system, and we should be proud of that. But let's be honest, the system as a whole has failed the American people.
And this is a great opportunity for planned sponsors, for doctors, for everybody in healthcare to say, we've got to redesign the way we look at this entire payment model.
Conclusion and Final Thoughts
[00:36:46] Stacey Richter: That is probably a really amazing place to end the conversation today. I will just say, because we did start out talking about planned sponsors and clinical leaders, like lessons for clinical leaders.
I think there's a lot of lessons for clinical leaders, enlightened ones, who are trying to figure out how to do the right thing. But, you know. Even for somebody who's like, I'm going to milk the system for as long as possible. You start having databases like the ones that you're talking about, the end of that road is coming quickly, as you just said, when some of these doctors are like, wait, why am I not getting any referrals anymore? Because you're sticking all kinds of hardware and inappropriate surgeries. Like, it's a thing. We know you're doing it.
[00:37:22] Marty Makary: And we see the doctors correct once they see their data, that tells us we're on to something.
[00:37:27] Stacey Richter: Yeah, so I think that is either a shot across the bow or an interesting insight, depending on...
[00:37:34] Marty Makary: Interesting insight. I like that.
[00:37:36] Stacey Richter: Depending on who you are.
[00:37:38] Marty Makary: Right.
[00:37:39] Stacey Richter: Dr. Marty Makary, I'm sure "Blind Spots", your new book, is available wherever books are sold. We will also post gameasures.com on the website. Dr. Marty Makary, thank you so much for being on Relentless Health Value today.
[00:37:52] Marty Makary: So good to be with you, Stacey. Keep up the good work.
Hey guys, Marty Makary. I want to let you know that I love Relentless Health Value. I follow it and get the newsletter and it's great stuff.