by Marty Makary
What we need is a grassroots change to put the patient back at the center of health care. We need to tackle the problem of inappropriate medical care. These are self-inflicted wounds.
Medicine has a tremendous heritage of solving problems. Medical science and clinical wisdom are now addressing the issue of what we call low-value care: medical care with little to no benefit and significant risks of harm. One of the leading medical journals, JAMA Internal Medicine, now has a regular section titled “Less Is More.” An alliance of 90 medical centers has just formed the High Value Practice Academic Alliance, started by my colleague Pam Johnson, a radiologist at Johns Hopkins who decided to do something about all the unnecessary CT scans, ultrasounds, and MRIs she saw being ordered.8 Finally, after decades downplaying the magnitude of the problem, conversations to address unnecessary care are more common at our national medical conferences. I believe a solution is in sight.
To get at these drivers of cost, hospitals and insurers need to partner with the grassroots groundswell of doctors who are writing, speaking, and fighting for more appropriate medical care in the United States. Together, they need to call for a reversal of payment models that incentivize quantity over quality.
For years, health care reform in Washington, D.C., has asked the question: How do we pay for health care? But the real question is: How do we fix the health care system? Addressing the epidemic of too much medical care (which doctors believe represents 21% of all medical care delivered) is a practical solution.9 My own medical experiences have reminded me that the problem is not just administrative waste, it’s clinical waste as well that’s driving up health care costs for everyone.
Overtreatment is not just a side issue in medicine. It is the root cause of some of our greatest public health crises. Consider the antibiotic resistance problem, a leading public health concern of the World Health Organization. Consider the opioid crisis. It’s essentially a public health crisis stemming from overprescribing. Consider the health care cost crisis. It is fueled by the 21% of medical care that doctors believe is unnecessary. Consider the antimicrobial resistance crisis. It is essentially a result of the overuse of antibiotics both in medicine and in animal food production.10 These public health crises are all manifestations of the problem of too much medical care.
Korea’s Thyroid Cancer Epidemic
A few years ago, South Korea found itself in the middle of a thyroid cancer epidemic. Starting around 2000, Korean doctors were finding an alarming number of cancerous tumors on the thyroid, a gland in the neck that makes hormones to regulate the body. The rate of thyroid cancer rose at an alarming rate, with yearly increases. Between 1992 and 2011, the Korean thyroid cancer rate increased by a factor of 15, making it the worst in the world for the disease.11
Thyroid cancer is easy to treat if caught early. And the Korean medical industry responded to the crisis with full force. Hospitals expanded thyroid clinics, hired surgeons, and invested in surgical robots to perform operations to remove tumors. The rate of thyroid surgery skyrocketed more than tenfold. About 4,000 Korean patients underwent surgery for thyroid cancer in 2001. By 2012, about 44,000 Koreans had undergone the same operation. Thyroid cancer cases consumed valuable resources, and the economic burden of thyroid cancer in South Korea increased sevenfold, from $257 million in 2000 to $1.7 billion in 2010. Korean surgeons got very good at the operation. I remember watching teaching videos from Korea showing elegant and creative ways to remove the thyroid gland, or parts of it, through an incision in the armpit. We often joked that the reason Korean surgeons were the slickest in the world at minimally invasive thyroid surgery was that there were no obese people in Korea.
When you look back a few years later, you would think everyone would celebrate the Korean medical community’s response to the crisis. But instead, medical journals recount it as a tragic cautionary tale. About 90% of the cancer cases identified during the “epidemic” were actually overdiagnoses. Research published in the New England Journal of Medicine found that a third of all adults normally harbor small papillary thyroid cancers, and the vast majority won’t ever produce symptoms. The tumors are so common, and often so harmless, that most would be better considered a “variant” of normal rather than a deadly disease.
What caused the Korean epidemic wasn’t an increase in cases of dangerous thyroid cancer. The rate grew so fast because the medical community started widespread screening of patients who had nothing wrong with them. The screening identified a lot of cases that probably wouldn’t have caused any problems. And identifying those cases led to treatment.
Looking back, we can see several telltale signs that the Korean cancer epidemic was not real. During the spike in thyroid cancer cases there was no corresponding increase in mortality. In 2011, more than 40,000 Koreans were diagnosed with thyroid cancer, but fewer than 400 died—a similar figure to previous years. In addition, the median tumor size of the tumors that were surgically removed got much smaller over time: from 20 millimeters in 1999 to 9 millimeters in 2008.12 Tumors of 9 millimeters are too small for patients or doctors to notice at high rates, a study in the BMJ said. “It is not possible that so many tumors of less than 20 mm were detected clinically.”
A group of Korean doctors first raised the alarm that overdiagnosis may be to blame for the apparent outbreak of thyroid cancer.13 In 2014, eight Korean doctors formed the Physician Coalition for Prevention of Overdiagnosis of Thyroid Cancer. The coalition wrote an open letter to the public that flagged screening with ultrasonography as the possible culprit for the spike in diagnoses. That led to media coverage, and in the next year, thyroid cancer operations dropped by 35% in South Korea.14
Korea isn’t the only country that’s had a thyroid cancer “epidemic.” It’s estimated that 50 to 90% of thyroid cancers in women in high-income countries could be overdiagnoses, according to a 2016 report by the International Agency for Research on Cancer in collaboration with the Aviano National Cancer Institute in Italy.15 Korea was the most extreme example. An estimated 70 to 80% of women in Australia, France, Italy, and the United States with the diagnosis were misdiagnosed, according to the report. “More than half a million people are estimated to have been overdiagnosed with thyroid cancer in the 12 countries studied,” the IARC director said in a press release. He called the overdiagnosis problem a “serious public health concern.”
Global Public Health
The overuse of medical services represents one of the greatest public health issues of the modern world. We don’t often think of the appropriateness issue in health care the way we think of Ebola or Zika. Yet new research, and my own personal conversations with many physicians overseas, seems to indicate that more people are harmed from unnecessary care or poor-quality care than from Ebola and Zika combined. In 2017, the Lancet produced a special issue on overuse called “Right Care.” It defined overuse as “the provision of medical services that are more likely to cause harm than good.”16
There’s a continuum of overuse. At one end are tests and treatments that are beneficial when used on the right patient. At the other end of the continuum are services that are entirely futile or even so risky they should never be delivered. Some examples of overtreatment around the world cited in the Lancet series were unnecessary procedures performed at a rate of 26% of knee replacements in Spain, 49% of upper endoscopies in Switzerland, 55% of cardiac interventions and one third of hysterectomies performed in women younger than 35 performed in India, and 20% of hysterectomies performed in Taiwan. Fifty-five percent of Thai children with acute diarrhea inappropriately received antibiotics.
On medical travels throughout the world, I’ve asked physicians to tell me about the burden of unnecessary medical care. They don’t hold back. A general surgeon from Sudan told me of a patient who was told by another surgeon that she needed a mastectomy of both her breasts for a small lump in one breast that was never biopsied. Not only that, the woman was told she needed to have the surgery within 24 hours to prevent the cancer from spread
ing. Of course, the recommendation was bogus, and the tight time frame was nothing more than a technique to manipulate patients into having surgery and not getting another opinion so the surgeon doesn’t lose business.
A pediatrician in North Africa told me a child was taken for heart surgery and only had the skin cut open, then immediately sewn shut at the time of surgery. The parents were told by the surgeon that a heart operation had been performed. Another surgeon told me of a doctor who, while doing a colon operation, removed a kidney to transplant into another patient without asking the patient. The scandal of inappropriate medical care can sometimes be criminal.
One of the surgeons I became fond of in Egypt, Dr. Sami, demonstrated to me how he takes the surgical specimen out to the waiting room and shows it to the family. I couldn’t believe what he was doing. My patients back home would probably vomit and give me one star in all the online reviews. In the Middle East, he explained, some families ask to see the specimen with their own eyes to be sure that the operation was actually performed.
Adam Elshaug, professor of health policy at the University of Sydney in Australia, was a contributor to the Lancet special issue on overuse. When he was asked in a Q&A with the Commonwealth Fund whether the problem of overuse is as bad as we’ve been led to believe, he said, “It might be worse. Evidence suggests that the world’s various health care systems are becoming even less efficient. We’re moving in the wrong direction.”
As we address the challenges of global public health, we should remember that it’s not just too little care that is the problem. In some areas, the problem is also too much medical care. If overtreatment were a disease, it would rank as one of the leading public health threats across the world. The appropriateness in medicine problem exists in the United States but may be many times worse in some of the poor countries I visited. The crisis of appropriateness in medicine is a global public health issue.
PART III
Redesigning Health Care
CHAPTER 11
Starting from Scratch
Walking into a car dealership puts a knot in the pit of my stomach. I feel cheapened by the whole experience. I know that I will have to haggle with the salesperson, as the sticker price is never the real price. I will endure the silly playacting (“Let me see what my manager can do”). Even if I walk out with a good deal, I leave feeling ambushed, frazzled.
But one day, while walking through a mall, I stumbled upon a Tesla showroom and took notice. Maybe it was the sight of a beautiful electric car glistening under LED lighting. Or perhaps it was the music coming from its powerful sound system serenading me through the vehicle’s open doors that drew me in. I was hypnotized. I strolled around a car and sat in the driver’s seat. A few young Tesla reps were on hand, fielding questions from prospective customers. But there was no pressure, no games. The experience was completely different than visiting the average car dealership.
I asked a few basic questions about how fast the car charges and how many miles it would go on a single charge. Blown away by this modern showroom concept, I asked the sales rep if he was paid on a commission. He said “no.” I liked that—the pressure was off. Maybe his incentives might actually be aligned with mine.
A few months later, walking around San Diego, I saw another Tesla on display. This car wasn’t in a mall; it was on a street corner downtown that had a lot of foot traffic. A Tesla representative had parked the car there, opened all the doors, blasted some great tunes, and encouraged people to sit inside. Again, I took a look, sat in the driver’s seat, and asked questions, all while feeling zero pressure to purchase the vehicle. I learned I could schedule a test drive in which a Tesla rep would drive a car to my house and let me take it for a spin. That’s great service.
I did the test drive and fell in love with the smooth ride, the safety features, and the fact that it had essentially no maintenance to worry about. A Tesla has few parts. No engine, hence no spark plugs, no belts, no oil to change, no emissions inspection. I researched it for a couple more weeks and then returned to the Tesla store in the mall where I first saw the car. I walked up to the sales rep who had helped me the first time.
“I’ve done my research and I’d like to go ahead and buy one,” I told him.
“That’s great!” He stood there, looking at me with a big smile.
The pause continued long enough to become awkward. Finally I asked, “Well, how do I order the car?” I had allotted two hours that day to be at the store doing paperwork and didn’t want to waste time.
“Just go to Tesla.com,” the rep relied. “You can buy it there.”
I went home, logged on to the site, clicked on the model I wanted, and selected a few options. I entered my credit card information for the deposit. Within five minutes, I had purchased the car. It was as easy as buying an airline ticket. The experience represented a milestone, a complete change from how I’d bought cars in the past. Gone were the days of haggling. I had just enjoyed the most streamlined, honest, and consumer-centered car buying experience I could imagine.
Now I understood how Tesla is disrupting the century-old system of going to a car dealership and playing hardball in the negotiation spin cycle. When I picked up my Tesla, I got a one-hour orientation on how to use it. The Tesla rep gave me a 24-hour customer service number to call anytime. I learned that in the event of a repair, a service technician will come to my house if the job is small enough. Tesla has created an experience centered on the customer, rather than sticking with a system entrenched in outmoded practices.
It’s no wonder that when Tesla announced their all-electric mass market car, the $35,000 Model 3, they instantly got half a million preorders. People nationwide lined up outside Tesla stores early the morning before they opened, all to order a car that didn’t yet exist. It made automotive history.
Do you see long lines of people waiting outside other car dealerships early in the morning before they open to buy a car they’ve never seen? I don’t. In fact, locally, I witnessed one of the most generous political donors in state politics, the Virginia Automotive Dealers Association, sue Tesla to keep them from opening a store in Richmond,1 which was one fight in an ongoing battle against Tesla in the state capitol.2
Tesla’s market cap surpassed that of Ford. All the while, do you know how much money Tesla has spent on advertising? Nothing. Zero dollars. Tesla has won people over with their intense focus on the consumer—a strategy common to disrupters of entrenched billion-dollar industries.
What would happen if someone redesigned medical care so that it was laser-focused on the patient?
That’s precisely what Iora Health is doing. Iora’s founder and CEO, Dr. Rushika Fernandopulle, a Harvard-trained primary care doctor, didn’t like what he was seeing in the health care industry: the assembly line method of seeing complex patients, rushing them through the exam rooms, ordering large swaths of tests, then chasing down insurance companies for payment. I met up with Dr. Fernandopulle at a conference to learn more about his new model. Hearing him describe the problems of modern primary care struck a chord with me. I told him that’s why I had gone into surgery. He chuckled. We agreed that the current model exasperates patients and burns out doctors. After doing it for years, he finally said “No, thanks.” He left a distinguished career as executive director of the Harvard Interfaculty Program for Health Systems Improvement to take a chance on a completely redesigned model of primary care.
Fernandopulle and his colleagues began with the mission of restoring humanity to medicine through what they call “relationship-based” care. Together with nurses, social workers, nutritionists, and other experts, they sought to find the most effective way to engage patients on a deep level. At the core of the model is time. Iora carves out a lot of time for each patient. They want to see you, talk to your other doctors on your behalf, and teach lifestyle changes to avoid unnecessary dependence on medication. Rejecting the high-throughput, high-billing model of health care, they try to understand a patient’s social
and economic conditions—what we call the “social determinants of health.” They coordinate care and strive to achieve the best health outcomes. Depending on the situation, they’ll make house calls, send a Lyft car to take a patient to a cooking class for diabetics, or do whatever they determine is needed to get and stay healthy. And they do all this at no out-of-pocket cost to the patient.
It’s a reimagined way of taking care of a population. When Dr. Fernandopulle opened the first clinic in 2010, little did he and his team know that starting with a clean slate would allow them to create one of the most exciting disruptions in health care today.
“We had the advantage of starting completely from scratch,” Fernandopulle said, describing their approach. Fernandopulle, born in Sri Lanka, named the clinic after the iora, a small bird native to Sri Lanka known for its bright colors and loud whistle.
As Fernandopulle explained the Iora model, I thought it made perfect sense, but seemed too good to be true. Iora is based in Boston, Massachusetts, but has locations in about a half dozen states. I asked Dr. Fernandopulle if I could travel to Phoenix to visit one of their health centers.
Days later, I walked into an immaculate facility, the Iora clinic on Indian School Road, and was greeted by the local clinic supervisor, Sarah Cabou.
Good People Attract Good People
It was 7:00 A.M., but Sarah Cabou, who is also a nurse, began to give me a quick tour of the facility before the daily morning “huddle.” Cabou came to work at Iora because she was frustrated with jobs she had in the traditional fee-for-service health care system. In her previous jobs, she saw patients on medications they didn’t need because no one took the time to fully explain things to them. She saw patients fail to get the care they needed because they couldn’t navigate the system. She also saw how corporate medicine was all too often penny wise and pound foolish, failing to address underlying problems that actually made people sick. Cabou has an MBA and an MHA (master’s in hospital administration), but it didn’t take an advanced education to see that the fast throughput and billing model of primary care was badly broken. She saw patients fall through the cracks and incur high costs because the system was too fragmented, too rigid, and too hard to navigate.