How Author Malcolm Gladwell Would Fix Healthcare

Neil Chesanow


September 30, 2015

Malcolm Gladwell on Fixing the US Healthcare Mess

In a recent Medscape video, Medscape Editor-in-Chief Eric J. Topol, MD, spoke with New Yorker journalist Malcolm Gladwell, author of such bestselling books as Blink, The Tipping Point, What the Dog Saw, and David and Goliath, on his recommendations for fixing the healthcare mess the United States finds itself in today. That Gladwell is neither a physician nor a member of the healthcare industry, but rather a keen observer on the outside looking in, was precisely why his famed out-of-the-box perspective was sought.

Among his insights:

On the price of drugs:

"I remember a piece I did recently for the New Yorker. I was talking about the Sovaldi® (sofosbuvir) controversy—a great drug (for the treatment of hepatitis C infection).... It's a disease that costs a lot of money to treat in a chronic way. And people objected to the prices for Sovaldi."

"My point was that you can't have it both ways. If you want pharma to produce first-class drugs, when they hit a home run, you have to let them charge home-run prices. At the same time, when they don't hit a home run, you have to stand up and say, 'You can't charge home-run prices.' We can't have a blanket objection to expensive treatments or care of any kind.... When it is not warranted, we are going to stop wasting our money. That is what I want to see—some correlation between what we pay and what we get back."

On electronic medical records (EMRs):

"I recently gave a talk at the California Medical Association in Los Angeles—just a group of doctors. What is so striking when you talk to ordinary, front-line doctors is how frustrated and unhappy they are in the present day with the way that their workloads have shifted, how their status in society has changed, and the way that EMRs have been conceived and pushed on them so that their own interests are last... They have not been a hit, and I don't think the public understands. For example, 90% of the public thinks that doctors would welcome innovation and assumes that EMRs made doctors' lives easier, when, in fact, the opposite is true."

On changing medical practice:

"I always use my 85-year-old mother as an example. What does my mother want from the medical profession?... What she really wants is an individual physician in her life who knows her well, who listens to her, whom she trusts, and with whom she can periodically have extended conversations.... It matters less to her that she has access to world-class, cutting-edge technology because she is 85.... She needs a system that allows that physician to spend 25 minutes with my mother when she needs 25 minutes, which is not every time she goes. Maybe it is just twice a year, but right now we have a system where finding 25 minutes twice a year is really hard."

"So we can change who we select for medicine all we want, but unless we change the nature of medical practice, it is pointless. We are just going to have brilliantly gifted doctors capable of having these kinds of discussions who are forced into a system where they have got to run patients through an electronic treadmill."

On fixing the healthcare mess:

"At the present time, I am most encouraged by the notion that there ought to be, at the bottom end of healthcare—the simplest, most routine end—a cash economy. Rather than expanding insurance, we ought to be restricting insurance. Let's use insurance for the things that insurance is best for, and insurance is best for catastrophic events—unexpected, big-ticket things that no one could plan for or anticipate. And for the stuff that is predictable and manageable, let's use the market to handle that because that is what the market is good at."

"There is a surprising move toward these very high-deductible plans. Although I am scarcely typical, I have opted for a very high-deductible plan for precisely this reason. Is there some way that we can subsidize and help people deal with a cash economy and use healthcare savings accounts? There are all kinds of ideas out there, and I wonder whether at least experimentation with this might not be the right way to go. That might curb some of the worst overtreatment instincts that people have."

While dozens of doctors, nurses, and other healthcare professionals responded to various topics in Dr Topol's interview with Malcolm Gladwell, by far the greatest number focused on Gladwell's conviction that health insurance should be reserved for catastrophic events; that the simplest, most routine care should be paid for in good old-fashioned cash; and that what patients like his 85-year-old mother really want isn't the latest technology but a doctor whom they know and trust, and who can spend sufficient time with them when they need it.

"As a concierge physician who limits his practice to a few hundred patients per doctor and continues to use paper charts, I am encouraged by Mr Gladwell's comments," a family physician and geriatrician wrote. "We have every technical electronic bell and whistle. We use electronic prescriptions. We provide all of our patients with a flash drive containing their medical records. We are able to spend the 30 minutes per routine visit Mr Gladwell's mother deserves and much longer times when needed. In addition, we care for our patients in the hospital and nursing home, as well as those who are homebound."

"I agree that patients putting more 'skin in the game' would help decrease health care expenditures and reduce unnecessary testing and treatment," commented an internist. "However, what about those who are on a fixed income? Or those who are unable to afford concierge doctors? Or those who can't put money into a health savings account because they are working a minimum wage job and struggling to afford food, housing, etc.? The United States currently rations healthcare based on ability to pay. Wouldn't this just make it worse? Wouldn't this discourage people from using preventive care? Wouldn't we end up paying more (and patients suffering more) when they show up in the emergency department with advanced illnesses?"

"The exact opposite is true," a family physician countered. "Obamacare has increased premiums and deductibles, in addition to requiring special interest inclusions in every plan. Do you actually practice in the real world? The Affordable Care Act has not been affordable or efficient."

"A cash economy at the lower end of healthcare is exemplified by copays, which have been shown, time and again, to disproportionately burden the poor, discourage appropriate use of preventive and early intervention services, and do nothing to contain costs," a family doctor observed. "If we have learned anything, it is that market economics apply very poorly to healthcare. Nowhere is this more clear than in the predatory tactics of rich pharmaceutical companies, which are dictating that we devote huge sums to lining their pockets. If ever there was an industry in need of nationalization, Big Pharma is it."

"Yesterday I spent 20 minutes in the emergency department in a failed attempt to persuade a dialysis patient in need of admission to remain in the hospital," an emergency physician wrote. "His reason for leaving? The failure of his nephrologist to explain the rationale behind the constant changes in his dialysis run time and the doctor's insistence on taking off so much fluid that he would feel terrible for the next 2 days. The patient didn't blame the doctor. He simply could no longer tolerate the system's failure to allow sufficient time for someone to listen to him and take his personal wishes into account. More time and less technology? Amen to that!"

"It is important to understand the domination of the insurance cartel—middlemen, really—who benefit by underpaying doctors and overcharging patients," a gastroenterologist opined. "Take THEM out of the equation and billions will be put back into care, not insurance, which actually deprives patients of comprehensive care."

"Direct primary care is a model of primary care that is growing in interest and in practice—and it addresses many of the issues brought up here," a family physician remarked. "The change is already happening at a grassroots level among individual practitioners as healthcare data show cost savings as these doctors deliver high-quality care."

"Things have gotten so bad for patients and doctors—and so good for insurance companies and hospitals—that we are primed for disruptive change," a urologist was convinced. "We are at the precipice of a 'tipping point.' I think either the government will take over healthcare or offer a parallel basic system like the Department of Veterans Affairs, or something totally unexpected will sprout up—like what Uber did to the taxicab industry. I can't wait because otherwise health insurance will continue to cost as much as the public will tolerate, while doctors will continue to be pressed to the breaking point."

"In America, we treat—we don't prevent," a pediatrician lamented. "We treat—even if futile or unnecessary. We treat—we don't educate. We treat—even if there is nothing to treat. Treating makes money—good old capitalism at work. The ONLY way to fix this mess is to take the profit motive out of medical care."

"This seemed to be a wide-ranging as opposed to an in-depth interview on how to 'fix' the US healthcare mess," commented on otolaryngologist. "High-deductible policies, for example, are an enormous, unsurmountable hurdle to workers somewhere between expanded Medicaid eligibility and average family income. For those of us in the higher tiers of income, the high-deductible plans pose relatively little disincentive to purchasing healthcare. The bottom line: a wrongheaded, simplistic recommendation. I don't think erecting economic hurdles to healthcare is anything but a class warfare tool, but I do agree that we need to find ways to drive


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