Q&A with Martin A. Makary, MD, MPH

FAIR Health’s new Policy Advisor, Dr. Martin (Marty) Makary, is a pioneering surgeon at Johns Hopkins Hospital and a prominent researcher whose work has influenced the healthcare system at both the patient and policy levels. Dr. Makary is Chief of the Johns Hopkins Islet Transplant Surgery Center and a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. He has published more than 250 scientific articles on topics such as vulnerable populations, the appropriateness of care, quality metrics and payment reform. Dr. Makary is the creator of the Surgery Checklist and led a World Health Organization workgroup with Dr. Atul Gawande to create global measures of surgical quality. He is currently the Executive Director of Improving Wisely, an initiative to lower healthcare costs in the United States.

Dr. Makary has been elected to the National Academy of Medicine and was named by Becker’s Hospital Review as one of the “40 Smartest People in Health Care.” He is a New York Times best-selling author who recently published The Price We Pay: What Broke American Health Care—and How to Fix It. Dr. Makary recently spoke with FAIR Health Access about his work to promote transparency and his optimism about the future of healthcare in the United States.

FAIR Health Access: Your father was a physician and your grandfather was a pharmacist. To what extent did your family’s background in healthcare influence your decision to pursue a career in medicine and public health?

Marty Makary: Anyone who grows up observing a physician interact with a community cannot help but admire the incredible public trust in the medical profession. In my father I witnessed that deep bond and how it was grounded in the pure goal of helping others. I was inspired by the sacred heritage embodied in a common oath to advocate for people when they are vulnerable. I also was attracted to the fact that the medical profession allowed one to quickly form a deep relationship with people at a time of need.

I’m often reminded of that great public trust. Being a doctor is the best job in the world. In no other profession will people trust you to put a knife to their skin within minutes of meeting you or tell you secrets they have never told their spouses. As much as I have enjoyed the national platform to advocate for issues that are important to the medical profession, caring for surgical patients is the highlight of my job.

FHA: The Price We Pay is a call for restoring medicine to its mission. What inspired you to write the book? What did you learn during the course of your research for the book?

MM: I loved the movie The Big Short because it took a wonky, complex subject—the financial services industry—and explained it with a series of easy-to-understand and sometimes funny stories. In doing so, the movie created financial literacy and even ignited a movement for change among everyday Americans. This is what I sought to do in The Price We Pay.

Sadly, most Americans learn about healthcare from sound-bite grenades that reflect highly opinionated, uninformed views. There is also a lot of spin from the special interests. But I’m convinced that if healthcare’s problems could be explained in simple terms, there would be broad consensus on the solutions. The Price We Pay pieces together my clinical experiences with investigative journalism. Under the mentorship of a seasoned healthcare journalist, I traveled to 22 cities over two years to interview every kind of healthcare stakeholder—executives, frontline clinicians, insurers, brokers, pharmacists, hospital leaders and patients—in an attempt to answer the question: How can we stop the healthcare cost crisis from destroying the country?

I sought to clearly present the problems of healthcare and what we all can do to address them. We doctors are taught medical literacy—anatomy, disease—but we are never taught healthcare literacy, i.e., the business of medicine. Ultimately, I identified three fundamental root drivers of our healthcare cost crisis: pricing failures, avoidable care and middlemen. I also had the privilege of spending time with the many innovators who are disrupting healthcare and, in some cases, have already fixed healthcare on a small scale in different pockets around the country—approaches that beg to be scaled nationally. These are the stories I loved telling in the book. For example, I visited several relationship-based clinics, which pay doctors on a globally capitated level and take on downstream risk; this incentivizes them to send patients to high-value providers and coordinate care so that no one falls through the cracks. Many are treating early diabetes with cooking classes and tackling disease using food as medicine. I watched doctors treat back pain with ice and ibuprofen instead of surgery and opioids. One clinic eliminated all billing and even converted the billing room and staff to patient care coordination. I was deeply inspired. These clinics have reduced hospitalizations, readmissions and healthcare costs. The question is, can we scale these successful models?

After finishing my research for the book, I became optimistic about the future of healthcare—not because we’re on the brink of a government fix, but because demand for more honesty and transparency is now moving markets.

FHA: How serious is the cost crisis in healthcare today?

MM: Healthcare now accounts for nearly half of all federal spending, according to a new study from my research group. Tax dollars don’t just go to Medicare and Medicaid. Nearly half of Social Security payments are being used for healthcare copays, deductibles and uncovered services. The military has its own healthcare system and there is the Veterans Health Administration system. Add to that the tax dollars going to insurance for the nine million federal workers, former workers and their families. In addition, interest on the national debt is, in part, interest on the healthcare spending debt. All in all, nearly half of federal spending goes to healthcare in all its hidden forms. In addition, there are private health insurance premiums and out-of-pocket costs, which now typically reach $3,000 per household annually. That’s a lot of money. Our country’s bloated $3.5 trillion annual healthcare spend now threatens all other national priorities, including education, infrastructure and even the expansion of healthcare benefits. It’s time we cut the waste.

FHA: What are the most significant challenges currently facing the healthcare system? What opportunities exist for improving healthcare in the United States?

MM: In addition to the three underlying root issues of the healthcare crisis, special interests pose another challenge. Few healthcare experts are not beholden to one of the special interests and can truly offer an honest critique of healthcare’s problems and meaningful solutions. A lot of energy is spent on problems that represent a small fraction of the preventable harm and avoidable costs in healthcare. For instance, both the Surgery Checklist and the intervention bundle to reduce ICU infections and central line infections are important interventions that came from my research group and that have been widely adopted. But these interventions simply address a small fraction of preventable harms; they are not silver bullets that will fix the healthcare system.

Undertreatment and overtreatment are both problems in medicine, but overtreatment has reached endemic levels. Medicine has adopted a mentality of reflexively treating patients, which naturally comes from a confluence of factors: an education that emphasizes rote memorization of thousands of diagnosis-treatment pairs, the pressures of corporate medicine to see patients quickly, and a consumerist culture. In a national study conducted by my research group at Johns Hopkins of over 2,100 randomly selected physicians in the United States, physicians said that, on average, 21 percent of all care is unnecessary. Frontline clinicians in medicine are telling us that we have a “crisis of appropriateness” in healthcare. The opioid epidemic is a crisis of just one medication. There are other crises among other less deadly medications. For example, many antibiotics are overused at the same time that a Hopkins study found that one in five intravenous antibiotics results in a complication. Fortunately, there are many bright spots now in addressing overtreatment.

FHA: You lead the Improving Wisely program, which is designed to reduce unnecessary care and lower healthcare costs. What was the basis for the initiative? How is the program working to achieve high-value care?

MM: The Choosing Wisely program helped raise awareness about unnecessary healthcare procedures. Improving Wisely is a data-driven next step aimed at driving physician behavior change. The goal is to create actionable data. In healthcare we collect a ton of data, but often look at it and say, now what do we do with all these data?

Improving Wisely partners with physician groups to develop measures of appropriateness. As a part of the program, we create physician-specific reports, which are sent to doctors by their professional societies. The goal is to recognize doctors with appropriate practice patterns so that the work of quality improvement can be directed to those who need help. It has had tremendous success and received a lot of support from physician groups because it is a confidential, peer-to-peer, benchmarked quality improvement program that allows doctors in a specialty to define practice pattern measures. In The Price We Pay, I describe the project with the American College of Mohs Surgery and the decrease in unnecessary surgery. By informing doctors on where they stood on the overuse metric with a “Dear Doctor” letter from the specialty society, the program, which cost $150,000 for the data analysis and letter mailings, resulted in over $27 million in savings to the Centers for Medicare & Medicaid Services.

We are living in a new era of medicine. New science is showing us that we can be more precise in our medical interventions, and therefore more appropriate in customizing patients’ care. In my field of gastrointestinal (GI) surgery, the indications for a colon operation for diverticulitis narrow each year in the medical literature. Traditional quality measures are limited in their actionability. They also have one big Achilles’ heel: they are triggered by doing something, like an operation. The real question is, did the patient need surgery? By developing practice pattern measures using intervention rates, we can finally measure appropriateness and use physician consensus to define boundaries of reasonable variation versus outlier patterns.

FHA: The national healthcare debate has focused largely on controlling costs and increasing coverage. What other issues should be given greater attention in the public forum?

MM: Policy makers debate how to fund the broken healthcare system, but we really need to talk about how to fix the broken healthcare system. We need to ask how we can spend our healthcare dollars wisely. We also need to zoom out and look at the macro-level factors that influence disease. As a GI surgeon, over the last few years I have increasingly come to appreciate the role of healthy food and the state of one’s microbiome. We now recognize that many conditions that we treat with surgery, such as ulcerative colitis and Crohn’s disease, are the direct result of a microbiome that has been altered into disequilibrium by bad food, antibiotic overuse and other factors. Many doctors are now asking important questions: Can we talk about the role of food in medicine? Can we consider meditation a first-line treatment for borderline hypertension? Can we identify and treat loneliness—one of the biggest public health epidemics that the medical field is not talking about despite its impact on one’s physiologic reserves? Can we treat loneliness with communities? And can we talk about the role of chronic poor sleep in causing some types of Alzheimer’s—a disease on the rise—instead of simply pushing for a drug to treat it? In my view, these issues need to take center stage in our scientific discussions.

FHA: You share FAIR Health’s commitment to transparency in the healthcare system. How has the current healthcare landscape made cost transparency a critical element in the national conversation on costs? What is the future of healthcare cost transparency?

MM: I can’t imagine that anyone in the United States would like to purchase an airline ticket online with no price listed and instead get a surprise bill after the flight. Would it be okay if the airlines argued that they can’t give passengers a price before the flight because they didn’t know whether the flight would be delayed or rerouted? If airlines worked without showing prices and then stories loomed of astronomically high bills, we’d all conclude that a lack of price transparency was enabling price gouging.

The healthcare system has good people, but the system we have inherited focuses on delivering care and not pricing the care ahead of time. No one is suggesting that we surgeons give patients a price in a trauma situation, but most of medical care is elective and shoppable. Everyday Americans are asking for honest prices and we need to respond. Research has shown us that the variation in pricing for healthcare procedures is not associated with quality, is rarely associated with charity care and creates an inefficient, wasteful marketplace. One of the bright spots in healthcare is a group of providers that offers a price menu for services. This kind of innovation can help restore the public trust in the medical profession.

I believe there are no villains in healthcare. We have good people working in a tough system—a system we all inherited and don’t love, but it’s the system we work with. Historically, hospitals have been busy dealing with regulatory requirements and a changing healthcare environment. Hospitals simply have not had the time, resources or energy to calculate how individual services should be priced relative to their true costs. But given how the current pricing system is eroding the public trust in American hospitals, transparency’s time has come.

FHA: FAIR Health has continued to lead as a source of independent and objective price and utilization information. How are claims data valuable in addressing the system’s current challenges? Looking to the future, how would you predict FAIR Health’s role will evolve?

MM: FAIR Health is committed to delivering transparency in healthcare—and the more transparency the better, given today’s high cost of market inefficiencies. Over recent years, FAIR Health has democratized its data, making easy-to-use tools available to patients trying to navigate their care. The medical community is also learning a tremendous amount of information about trends from the data. These insights are informing a range of efforts, from addressing the opioid epidemic to trends in telemedicine. We will continue to learn more from patterns and signals in big data in a way that will help us figure out what patients want and how we can deliver higher-quality care.