A Visit with Dr. Elisabeth Rosenthal

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In January 2020, Cambia Grove Utah was honored to host Elisabeth Rosenthal in Salt Lake City, Utah to kick off our first ever Under the Aspens fireside chat series. This post follows up on the conversation to explore more closely the barriers facing health care transformation. 

Maura Little: Elisabeth - first, thank you for joining us here in Utah.  It’s great to have you here. During the fireside chat you mentioned that “over the last 25 years we’ve let finance define innovation.” How is this exemplified and how do we steer innovation to a place that is more patient-centered and financially sustainable?

Elisabeth Rosenthal: Innovation is often now defined as something that makes health care more “efficient.” Which is first and foremost a business value. Not that it’s bad in medicine. But health care is both a business, a science and a hands-on art, in a way. Telemedicine is a great efficiency tool for things that are straightforward and simple – like renewing a prescription or a patient questions about mild-moderate back pain. But it’s not good medicine for many other things, where it’s far preferable to have a medical professional in the room. Like diagnosing whether a person has pneumonia or asthma (you have to listen to the lungs) or hospice care. People who are in hospice deserve human contact and many for-profit services are almost entirely remote – modeled on IKEA assembly. Sure, the latter examples are good for revenue generation, but they’re bad medicine. Also, it makes me crazy that telemedicine is often charged at exorbitant rates. When my daughter needed to renew a prescription with a physician, that 3-minute phone call was billed at $250. Ten years ago, a doctor would have renewed that prescription for free. 

My plea is always to have doctors and nurses at the table who can weigh in if the innovations are good for medicine or just good for profits. Lots of things that are bad medicine can generate revenue. And people in the profession have to stand up again that trend. 

Maura: Great insights. To follow up, if business incentives have been the predominant factor in moving innovation forward, how do we instead get towards value and outcomes as a driving metric?  

Elisabeth: First I think that we need far more transparency in health care generally – both on pricing for patients and on quality. But that’s a precondition to any kind of health reform. But my takeaway after writing my book is that any metric can and will be gamed for profit. And metrics are again primarily written with a business in mind. I’ve not seen any quality metric that includes: “Did you spend at least 15 minutes talking with a new patient about his problems?” That’s really important for good care! That’s why I’m perhaps a bit more optimistic about bundles or capitation for many common medical situations. And the payments need to be set scientifically – which is why that transparency now is so important. I’m a big admirer of the economist James Robinson’s work at Berkeley who helped CalPERS figure out how much to offer as a reference price for hip replacement. How much does/should it really cost to do an average high-quality hernia repair, all-included? That’s knowable and we should know it. 

Maura: As we look forward, what are the biggest barriers you see in driving this much needed innovation? 

Elisabeth: That all parts of the medical system are now fighting to keep their part of the $3.6 trillion health care spend. Few people are thinking of the common good. So, they all point to the other guy as being overpaid and wasteful.

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It’s a circular firing squad.

The truth is, in different measures, all part of our medical system will have to change their ways. And most will be paid less. A young doctor coming out of family practice residency at 30 makes $200,000. That’s not bad…

Maura: During the Under the Aspens conversation, Jennifer Napier Peirce asked how do we get started making these big changes and ‘what can be done to improve the health care system?’ You noted that patient accountability is a large part of any fixes. And you say that this is “not a left or right issue, but rather a consumer and pocketbook issue.”  

Can you expand upon this especially in the context of the 2020 election?  

Elisabeth: I think patients can and should be more activist on this issue – they say health care is a number one voting issue. But they do not feel empowered to change anything at the local/personal level. So, my first lesson is that everyone can and should do more. Some ideas: 

  • Refuse to sign a consent form that says I’ll pay whatever my insurer doesn’t cover (I add: “so long as it’s in my insurance network.”) 
  • Ask for itemized bills and refuse to pay for crazy charges 
  • When you go to a doctor, insist that x-rays and blood work go to in-network facilities 
  • Force your doctor to lean on his/her network of referrals so that they join networks and charge competitive prices 
  • Demand estimates for procedures in writing and insist that providers stick to them
These are basic pocketbook issues, and we should all demand that the medical system respond at least as responsibly as an auto repair shop.

So, the first answer is don’t just wait for Washington to solve our health system. I hope they do. But in the 2020 election, all Democrats are proposing either Medicare for All or some variant of public option combined with preserving the Affordable Care Act (ACA). As a journalist, I can’t state an opinion about which I prefer. But I can say that I think all systems could work, if they are well designed with health care as the goal. And there are options we’re not considering: Germany relies on a private system, but it has a price schedule, like a utility. It has many insurers, but they have to be non-profit.   

Maura: One of the topics we have yet to cover in this conversation is the infrastructure needed to help innovation succeed.  In our work we see one common infrastructure questions, access to data, is a continual challenge for innovators to be successful. How do you view the new interoperability measures being pushed for at the U.S. Department of Health and Human Services impacting the need for data to ‘fuel’ innovation? 

Elisabeth

Too much data is sequestered in companies or silos because data is money in our system. That had to end.

I think data should be in the hands of each patient – they should decide how it’s used. Also, health care institutions, public or private, shouldn’t be able to sell my data. I’m happy to have my data used to cure a rare cancer or help treat a disease. BUT I want to knowledge of that to be in the public domain and not used to produce a drug that no mortal can afford. Perhaps if we had some better way to control drug prices, I’d be more comfortable with my data ending up in the hands of drug manufacturers. I do think the US needs a way to regulate or control drug pricing – I think that should be the first/next frontier for politicians. And there is a lot of activity there. But whether it will result in legislation, who knows?

Maura: In our work we see that another challenge to innovation is that players working to innovate in health care typically miss one another. As an example, innovators sometimes solve problems that don’t exist, and heath care systems sometimes don’t know the problem’s they are trying to solve. What do you make of this disconnect and what solutions should we all seek? 

Elisabeth: Well, I think this comes down to the distorted way the business of medicine functions. Entrepreneurs are now playing to VC investors, rather than to doctors and patients. I get 10-20 emails a day from some young company selling an “innovative” idea. Most of them are, frankly, pretty useless and awful from a medical perspective. There may be a good narrative behind the innovation if you don’t know much about treating patients. Many of these “innovations” would be (and are) ultimately rejected in any national health system because they don’t really add care value – just revenue. And too many of the “innovations” I hear about are just adding new layers to any already overly complex system. When Electronic Health Records (EHRs) didn’t deliver as promised, a new industry of EHR consultants grew up to troubleshoot flawed EHRs. That's Nuts. We need to get the basics right, but after-the-fact there's not money to be made in that!

Maura: Elisabeth, thank you for joining us in person in Utah and joining us virtually here.  Your insights have been incredibly valuable for me, my team and the community of innovators we are serving who work every day to try and make the health care system more person focused and economically sustainable.

What I have taken from our time together is that we should stop looking towards another to solve our problems. Rather, we need to look towards ourselves to ask what we can do to make the health care system work better.  There is a role for each of us to play, whether we are part of the 5 Points of Health Care™ an entrepreneur or a community member. We must all look to fall in love with the problems, not the solutions, and find a way to work together to be more productive.  As Elisabeth says, there are business interests at stake but for innovation to work, you must also look at the problem through the lens of health care also being a science and an art.  

Elisabeth notes that we are all accountable and we need to all be part of next steps working towards a better health care system.  Thank you again to Elisabeth Rosenthal for taking the time to join us at Cambia Grove and for all your work in shedding a light on the possibilities to transform the system.

 

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