Cutting Through The Medical Money Games | Dr. Marty Makary (Author of The Price We Pay)


Guys, Supporters first
and everyone else later. I rarely get this insane
about a guest and fanboying, but today we have a guest that you guys, first of all, listening
to him is one thing, but reading his new book The Price We Pay, which I read in a day, that’s how good it was, it basically summarized everything I’ve been screaming about for years, but with amazing research
and actual bright spots, pointing our where things can be fixed, about how health care, this is not a free market. This is crony capitalism price gouging, and we need to talk about it
before we can transform it, and it means us guys, front
line health care professionals need to take a stand on this. We need to read the book
because we don’t understand how medicine as a business
has destroyed the art and the heart and the soul of it, and Dr. Marty Makary is a renowned Johns Hopkins pancreatic surgeon and has a New York Times bestselling book called Unaccountable and wrote this book and is a world-class quality researcher and coded the, actually
developed the surgical checklist that he and Gawande wrote about
that you may have heard of. He is a personal hero of mine, despite working on Fox’s The Resident, which was based on Unaccountable. We have him here today. Dr. Marty Makary, welcome
to the show brother. – Sounds like you believe in forgiveness. – I do. (laughing) I’m a man of great moral standing in terms of forgiveness. No, listen, it’s funny. We saw The Resident, and it said, Based on Unaccountable by Marty Makary, and I’m like, dude, Marty’s a good guy, (laughing) like he’s a master of quality. This show’s gonna be dope, and so we watched it live and we actually put out a
video of me reacting to it and I realize watching it back, every time I took a dump on the show it was about the drama or the
little factual inaccuracies. – Hollywood sensationalization. – Exactly. Every time I was like, yeah that’s right, yeah that’s right, yeah that happens, that was stuff based on your book. For example, Hodad, right, hands of death and destruction? – [Marty] Yeah. – [Zubin] Tell me how that
whole thing came about. (laughing) Was this your training at Hopkins? – No, I just did my fellowship at Hopkins, but in rotating in med school, (coughing) we would see these sort
of icons of the field have this internal reputation as the surgeon you want to avoid. – [Zubin] Uh huh. – So this guy had this
reputation as being called Hodad for Hands of death and destruction, even though people would
fly in from overseas and celebrities would roll in just to try and get in his practice,
and we’re kind of like, you really don’t want to
be in that operating room, and so Hodad, and then the vice versa character, the Raptor. – [Zubin] Right. – It sort of became, I think, symbolic of a lot of the doctors we work with or doctors whose ring we
kiss as you like to say, (chuckling) in training, so I think those characters, they ran with it, added
some stuff from Hollywood, and of course, every now
and then, I’ll be like, “Dude, we don’t use a knife
to place a central line,” (laughing) and they’re like, Marty just
relax a little bit, okay? Just chill out. I said, it’s a needle-based procedure. So, no I had nothing to do with doing CPR on the stomach
and other things like that. There’s a reason why my contract selling the book rights of
Unaccountable to The Resident has it that my name
will not be on the show, because they did sensationalize, but I poke fun at them,
they’ve done good stuff, talking about the drama of medicine, and it’s getting better,
the show is getting better. – That’s great, and you’re
kind of a consultant, and you kind of hang out. It’s kind of cool to be so
as connected as you are, ’cause we were talking before. We were introduced by
Dr. Peter Attia actually. – [Marty] Great guy. – Who’s a mutual colleague and friend, and he was on the show and then you had connected with me when I was out in D.C. doing a talk for AMGA, and we had lunch in a place, tell me about this place you took me to. Can you talk about it? – Peking Gourmet Inn. Yeah, it’s a favorite for politicians and George H. Bush discovered it because his nephew went there and then they could bring the motorcades
behind this strip mall. – [Zubin] Yeah. – And he could get in and out, so he just got the craving. It was great food, wasn’t it? – [Zubin] Oh, it was amazing. – So you get addicted to it, so George H. Bush, and W. also, would say in the middle of the day, “I’m hungry, let’s go
to Peking Gourmet Inn,” and Secret Service would call, roll the motorcades into the back, (laughing) and one time they actually
had no seats available, and they said, we cannot accommodate. Sorry, we just can’t ask anyone to leave, and they kept calling back. “The President says he will sit anywhere. “Any seat, he will sit anywhere!” I’m sorry, we don’t have any seats. So it’s got everyone’s
picture on the wall, it’s got bulletproof glass. – Yeah, all the Presidents
were there, bulletproof glass. I’m like dude, when was the last time I ate a hole-in-the-wall
Chinese restaurant with bulletproof glass, okay? (chuckling) – [Marty] Right. – So, we had this discussion about, it’s funny ’cause the
garbage truck is out there, which is the man trying
to silence us, Marty. (laughing) I’m just telling you. – Corporate health care interests put a garbage truck out front? – Exactly, ’cause when I
read this book I’m like, you’re gonna get murdered,
and I’m only partially joking, because what you’ve done with this book, and I think it relates back to your training with Hodad
and your experience in medical school and
kind of the hierarchy and the encouragement
of just an individual doing everything and the idea that it’s all about competition
and individualism. Well it turns out that,
that has now infused our health care system with
some of the worst practices, the most inhumane practices where you are literally reaching into somebody’s wallet and robbing from them their livelihood, their time, the time that they’re working, spending with their families. These are Walmart employees,
and we’re gouging them, and by we, I mean all of
us are complicit in this, whether we know it or not, and I think most of us don’t know it. That’s why the book was so important. What prompted you to work on this? – Well, first of all, (clearing throat) I loved your language now, because that’s what we need to do is we need to change the language. In medicine we have the most sterile, impersonal, detached language that is totally consistent with the lack of self-awareness that we promote in this indoctrination process called medical school
and residency, right. We take these highly creative people who have these very noble ambitions to help people and do good in this great heritage
of the medical profession and we beat them with this regurgitation of the Krebs cycle and this language and we don’t call a spade a spade, and even in publishing things in the medical journals they beat me down. “You cannot call it a mark-up. “You have to call it a
charge-to-cost ratio.” Well, no one gives a rip what the charge-to-cost ratio means. They wanna know it’s a
price, it’s a gouge, it’s a. Medicine has adopted a business
model of price gouging, and not everywhere but some places and it’s a disgrace to our profession, and I think we just
need to call things out, and you do that and
that’s one of the reasons I love the Z-Man and the Z-Pack and I’m a huge fan of the Z-Pack. (laughing) – You know, you’re actually a subscriber. – I am so into the Z-Pack, I have no bacteria left in my colon. (laughing) – It’s all just C. diff now. – [Marty] It’s just an empty biome. – I love it. An empty biome. So okay, let me tell
people who are watching what this book kind of is
about in a bigger sense and what I got out of it, because again I binge read it
in a day, it was that good. So what you’re talking about is the business of medicine and how we’ve ceded as health care professionals the art and the
relationship and the calling to what has now become this very big and unfathomably complex business, and through its own complexity there’s an opacity and
a lack of transparency that then allows people, whether they’re conscious of it or not, to take advantage of our patients when they are at their most vulnerable, and I would get so angry
reading these chapters and, because this is what
I’ve been screaming about for the last seven years
here in Las Vegas is, we are hurting our fellow human beings when we took an oath to help them, and it doesn’t mean that
doctors are bad people or nurses or bad people or any of this. – [Marty] Mmhmm. – It’s, we’re part of a
system that is complicit in criminal behavior, and it
starts with the fact that. – Legal criminal behavior. – Legal criminal behavior. In other words, it’s just immoral. Just because it’s a law
doesn’t mean it’s moral. We’re hurting fellow
humans and an example is, let’s just start with hospital charges. How many of us have gotten a surprise out-of-network hospital charge? How many of us have
gotten a bill from the ER for an injury that they got while hiking for $4,000 for a tetanus
shot and three stitches, with no upfront understanding
of what it was gonna cost, no clue whether it’s a quality improvement over a similar urgent
care that charges $200. – [Marty] Mmhmm. – No clue at all, and where the physicians and the nurses and the
respiratory therapists and the nutritionists,
everybody on the front lines, has no idea what it costs either? – [Marty] Yeah. – They can’t tell you, and yet this is what we do in medicine and the mark-ups that
they’re able to charge are obscene, and can you
talk about it a little bit? – Yeah, 57% of Americans (clearing throat) have received a surprise bill, and for many people it’s devastating. Did you see the movie The Big Short? – [Zubin] I did not see it directly. – You’ve heard about it. – [Zubin] But I know all about it, yeah. – Yeah, the book, so I loved that movie, and when I saw that movie I thought, “Gosh, this movie has taken a very complex “and even boring, wonky industry, “credit default swaps and
collateralized debt obligations “and wonky stuff and said, “we’re gonna break it down for you “so any person can understand it “and make it exciting,
make it a thriller,” and so that’s what I tried
to do with healthcare, because we’re in medical school taught medical literacy in residency. We’re taught medical
literacy in our practices. We’re practicing medicine with the literacy that we’ve learned, but we are never taught
healthcare literacy and that’s what I wanted to do is to explain the healthcare system, the business of medicine
so that any person can finish reading this
book and then feel like, now I understand exactly how every part of the healthcare system operates, what the money games are, and
how we can cut through it. You know, you mention
you wouldn’t be surprised if I get shot, or I
forget how you said it. – [Zubin] Murdered. – Murdered. – [Zubin] Mmhmm. – You know, I’m a cancer surgeon. I’m breaking bad news every week. I’m constantly reminded how life is short. We can continue to play the game and go through these academic games of get a promotion and publish an article in a journal that hardly anybody reads and talk to ourselves, or you can just speak
your observations to heart and call things out when you see it, and so I’ve often thought
the academic game is phony. I’m at the top of it. I’m a tenured professor at Johns Hopkins, and my senior partner is maybe one of the most famous
surgeons in the United States. There’s nowhere else to go up, and what else do you do? Do you parade around
how people need to use a certain technique in the operating room, or do you look at the data that a quarter of the public right now doesn’t trust us because of
the business of price gouging? Forget about access. It used to be that when
people got hammered with big medical bills,
society blamed them. You’re uninsured. How dare you be irresponsible
and not have insurance. Well guess who’s getting hammered
with medical bills today, the everyday hard-working
American with insurance who’s going to out-of-network providers even at in-network facilities. There’s a bait and switch going on. We’re part of it, we didn’t design it. We’re a part of it. We can change the system from within and talk to our own leaders and basically call out these practices of what I call predatory billing. – [Zubin] Hmm. – Price gouging in the
marketplace, egregious mark-ups. If we used the right language,
a mark-up is not evil. If you deliver care that’s better, and you charge twice as much, good. The market should reward that. – [Zubin] That’s capitalism, yeah. – That’s capitalism, that’s a free market, but what we have is this intense, dysfunctional game of
taking advantage of people when they’re vulnerable,
price gouging them, and then seeing how much
we can shake them down for, and we don’t do it as physicians. It’s done by the middle
industry around us. – [Zubin] Hmmmm. – Right, the re-pricing industry. I didn’t even know that existed before I started the
research for this book. – There’s a lot in this
book that I didn’t, I actually have been
studying it for a while but I think that most of the country is not gonna know that this exists, this idea that there’s a
whole cadre of hospitals that will sue working class patients for medical bills that are unpaid. Now, here’s the thing. If I don’t pay my mechanic, I expect him to sue me
to get that money back. That makes sense because it’s a fair price for services rendered and I didn’t pay. The problem with medical bills is it is not a transparent, a
competitive, or a fair price. It is a price-gouging mark-up
over what Medicare would pay because hospitals can do it. They say, well oh nobody
pays the marked up prices because people have insurance, except when they have
high-deductible plans, or they’re uninsured, and so what do these hospitals do? Often the CEO doesn’t
even know it’s happening. They’re suing their own patients. Can you talk a little bit about that, ’cause that made me so furious as a physician to see that
we’re hurting our own patients? – Yeah, and first of all, if your hospital or your practice charges two or three times the
Medicare allowable amount, then okay maybe that’s a
reasonable, fair price. We’re not saying everyone
should accept Medicare prices, but right now it’s the Wild West. If you charge five, 10, or our research even shows 23 times the
Medicare allowable amount, in a study we did of
emergency room service, emergency department services
and oncology services. Two papers, we got
hammered by the journals. Nobody wanted ’em. We finally got ’em published
in JAMA Internal Medicine and another journal,
and these two articles, they forced us to change the
language, they sterilized us. They took out all of our
passion in the article. They did what medicine does
to its own creative people and we pointed out a 23
times mark-up is egregious. A researcher published
what I consider to be the article of the decade. No one noticed this
study, but I noticed it. A cardiac surgeon called
100 heart hospitals in the United States and says, “How much does it cost for a CABG?” He fought and went through the voice menu, and they transferred
him and hung up on him, and he called back, and in the end, 51 out of 100 so hospitals
could give him a price. The price ranged from $44,000 to $450,000. He then matched the price
with the STS outcome database, which is, as you know, the most mature public quality reporting
database in medicine, and found no correlation whatsoever, and sometimes when we
take these egregious bills that hospitals produce to doctors, most of the time doctors
do the right thing or try to most of the time, right, but generally speaking, they’re
offended by these bills. They’re outraged by,
they call it despicable, but many times the doctors have, we have this knee-jerk
reaction as physicians, well that’s to make up
for the charity care. – [Zubin] Right. – It doesn’t, it’s not to make. There’s no correlation between the mark-up and the charity care. This is sort of health
business 101, right. This is the healthcare
literacy that we’re not taught, and there’s no correlation
with charity care, it’s the Wild West. I went to this hospital,
I don’t want to name it. – [Zubin] Yeah. – ‘Cause you know, the number of lawsuits that I’m probably gonna be
facing with this book are high. It’s all defamation nonsense. – [Zubin] Yeah. – Nothing legitimate. – [Zubin] Yeah, defensible. – Yeah, and nothing’s been filed yet, but I’m ready, bring it on. – [Zubin] Uh huh. – The heck, life is short. Columbus took a chance. The hospital near ski,
near Vail Mountain, okay, they charged a guy $10,000 for coming in for a few minutes to tell him you probably have altitude sickness. Does the hospital at Vail Mountain take care of so many uninsured patients that they have to
compensate on the mark-up for all of the uninsured,
homeless skiers at Vail Mountain? No, it’s just a pure
game of price gouging. – It, what’s sick about
it too, is a lot of time it’s the quote unquote
non-profit hospitals that play this game. – [Marty] Non-profit hospitals do it more. – They do it more? – So, they do it more, and so
we did a big research study of hospitals in the
state of Virginia, okay. Hospitals in the state of Virginia, most will never sue a
patient for an unpaid bill. About a third will, and then 10% will just sue the shit out of people. – [Zubin] Mmhmm. – They’ll go after them, you know. UVA for example, UVA will
sue the shit out of you. – [Zubin] Mmmmm. – An institution that
gets taxpayer funding. – [Zubin] Mmhmm. – You don’t pay a bill,
they’ll take you to this little courthouse in Virginia where me and my team go frequently, and we tell the patients going in there, “You’re not obligated to pay this bill “because there’s no legal contract.” – [Zubin] Hmm. – I can’t mow your lawn, and
I’ll tell the judge this, if they allow me to be
their ex, pro bono expert, we just did this on Friday. We do this regularly, me and my students, my team, doctors, residents,
concerned citizens, we go to these small towns in America where the hospitals are
suing the shit out of people and we offer to be a free pro bono expert. I put my name on the
case and I tell the judge I can’t mow your lawn and then charge you $50,000 without a contract. There’s no contract here. Whatever they signed
was a consent to treat. That’s when they were vulnerable. That’s not valid. You can’t sign your life away financially and by the way, where’s
the spirit of medicine? Where’s the mission of the hospital? Where’s that charter? We’ll read the charters to these judges. Here’s a hospital charter that, “We aim to be the living hands “of Jesus Christ in the community.” We, one hospital said, we are dedicated to caring for the sick and injured, to be a safe haven,
regardless of one’s race, creed, or ability to pay. That is our incredible medical heritage, and then these hospitals are
suing the shit out of people? It’s an anathema, it’s a disgrace, and it’s gotta stop and these
hospitals are paying no taxes. So every case that we go to, now in court, me and our, the Restoring Medicine group, the judges are telling
us in the courtroom, the case has been canceled. Every time the hospitals see my name on the case as the expert. – [Zubin] They back down. – They’re canceling. How are they canceling $50,000 bills? Because they know they’re egregious bills. – These fucking people,
Marty, and this is the thing. When we were sitting
down, and these are not. Let’s be very clear,
it’s not that the doctors and the nurses and the people who staff these hospitals are doing this. – [Marty] They don’t
even know it’s happening. – They don’t even know it’s happening. It’s like being part of
a financial Holocaust and not even knowing that it’s going on, but what they’re doing is they’re, first of all they’re price gouging people when they’re most vulnerable,
when they’re sick, then they’re coming after their
assets, their credit rating, all their mortgage
interests go up, everything. It destroys their life. It is a kind of financial rape that they’re inflicting on human beings that we’re there to help,
and then their mission says we’re the hands of Jesus and that. To me, the fact that nobody knows this, the fact that they back
down when you show up, the fact that when you call them and you go through the hoops and you start to haggle for your bill, what happens when that happens? When I was reading your book, I was like, oh well, I’ll tell you what. Instead of $50,000, how ’bout
you just pay us $30,000? (chuckling) That’s still 40x Medicare. Okay, then, well I’ll tell
you what, we’ll do it for 20. Oh, so you can cut it that far, that much, by me making a call,
but the little old lady who doesn’t know that just
went into medical bankruptcy? What is it, one in five Americans have? – One in five Americans have
medical debt in collections. People have liens on their
homes, now they can’t sell. One hospital CEO that I,
you know, I call the CEOs in a civil fashion and
I politely ask them, you’ve sued 20,000 people
in your community of, by census data, 28,000
people live in your town. Does that strike you as excessive? Is that consistent with
your tax-free status? And, by the way, the
for-profit hospital HCA across the town has never sued anybody. There’s no court records of them. The courthouse has converted into a taxpayer-funded collections
agency for the hospital, ruining the lives of these
people and I’ll tell you. These are at restoringmedicine.org, we’re gonna have the videos up there, because we there on Friday and one of these Virginia courthouses, these farmers, these everyday, they don’t even have
a paycheck to garnish. The hospital is trying to
legally garnish their wages and there’s places in
America where the hospital routinely goes after you in court. One CEO told me, “Well you know we’re,” they give me a different party line, “we’re happy to work with anybody. “We just want a communication
with the patient. “If they engage with us,
we’ll work with anybody.” Oh yeah? That’s not what we’re seeing. That’s not what we’re
hearing on the ground. We’re hearing they called you 50 times and there’s voice menus and the woman at the call center said,
there’s nothing I can do. One call center woman told a
patient who’s a friend of mine, if we want to charge you a million dollars for those stitches, the law says we can do it. – [Zubin] Wow. – And so we’re trying to
educate physicians, right. We did a survey asking doctors, do you know that your patients were sued? It’s a study we’re doing through Hopkins. Doctors have no idea. – [Zubin] We have no clue. – No idea. – How could we, yeah? – [Marty] And they’re
outraged when they find out. – Yeah, how would we not be? Like when I read this, I was so furious, and this is the thing. Who is, so who’s responsible for this? Who, what’s the bottom line
and what are the bright spots? What’s the solution to this? – Well, physicians have lost control of their own billing processes, so what happens is the
hospital outsources it through the CFO to sometimes
a collections agency or a law firm that comes up
to the hospital and says, hey, we’re gonna increase
your revenue cycle. Right, you change the language. Instead of calling it predatory billing, if you call it bad debt, we’re gonna reduce your bad
debt, we’re gonna help your. I met a woman whose card
literally said, from a hospital, Director of Revenue Enhancement. – [Zubin] Hmmm. – What the heck is that? – [Zubin] Hmmm. – Is that, was that a round way? – It’s exactly what the
journal guys are doing when they censor your language. – [Marty] Exactly. – It’s exactly what people try to do to me to censor my language and
say you can’t say that, you can’t say that, it’s unprofessional. – [Marty} Can’t have a heart.
– Shut the hell Up. – [Marty] Yeah. – Yeah, you can’t have
an emotional connection to a subject matter so
that people feel something and then want to change? – [Marty] Yeah. – And that’s what this book did. I mean, you can tell I’m pissed off, and I get pissed off pretty easy, ’cause I’m fairly volatile
on my neurotic scale, but the truth is when
it comes with a, also, a sense of connection to the
moral purpose or what we do, then it can actually lead to real change, and so the question is, you point some bright spots. There are hospitals that
don’t sue their patients. There are hospitals who make deals, not deals but, ’cause
this term financial aid, we give our patients financial aid, that’s an euphemism for, we’ll cut it 10% off of already 1,000% mark-up. – Yeah, we’ll cut 5% off if you agree to pay in monthly installments
for the rest of your life. – [Zubin] Right. – I mean, that’s not financial aid, right? That’s gouging. – No, that’s more financial
rape as far as I’m concerned, and again I use that word
because it’s tinged with emotion, but that’s what it feels like when someone reaches into your wallet and takes it. See, you’re working in life to make money so you can support your family, so you can spend more
time with your family. To me this is a, the
deepest type of betrayal, and that it’s coming. – [Marty] Betrayal. – From health care
professionals, it’s a betrayal and the thing is, it’s part
of a bigger game, right. So insurance companies pay the game, play the game with hospitals. It’s an escalating game. Well we’re gonna reimburse less. So, okay, we’re gonna mark it up so that we get a percentage. No one’s gonna know what
those percentages are, because we signed a non, a gag clause, because otherwise that would
lead to price transparency and people would be able to compete, and this is the take-home from this, – [Marty] Yeah. – Is this book, so people are say, “Oh, Marty Makary’s a socialist, “and he’s saying well, “we should should probably
socialize medicine “because we’re trying to take care “of poor people and rich people alike “and therefore it’s the worst idea ever.” That’s not at all what you’re saying. What you’re saying is, we’re a free capitalist
market competition country. How about we actually do that? Make it transparent, have people compete. You’ve worked with
politicians and Presidents from both parties, ’cause you’re in D.C., talking about these issues. Doesn’t matter who it is, ‘ you’ll meet with Pelosi,
you’ll meet with Trump. You’ll bring these
patients and their stories, and I think that’s what’s gonna
start to make a difference. – We just brought a bunch
of patients who had, they had the shit sued out of
them for unpaid medical bills which were massively
inflated in their small town. These are hardworking insured people. Our research shows that Walmart
is the number one employer whose employees have their wages garnished by hospitals suing in Virginia. Food service workers are a close second, U.S. postal workers,
nurses, hospital workers, I mean these people dedicate
their lives to medicine and this is what we do? They stop by the ER for
when their kid has asthma, and now they’re in court
three months later? People are listening,
good stuff is happening, doctors are rising up as
we’re getting the word out. The President, I took
patients who’d been sued to the White House twice and
had them tell their story directly to President
Trump and Secretary Azar. They listened and they
were, and I’ll tell you, say what you want, they were moved and we’ve seen several
initiatives announced from them, from the administration. This is not a partisan game. They had senators there last week to talk about bipartisan legislation. They promised it would be bipartisan. Nancy Pelosi’s office
has been very interested in all this stuff, I’ve met
with them several times. This is not, let’s not
listen to the echo chambers of the facade of cable news, that we’re a divided people by
these artificial boundaries. Those are not the real issues, right. The real issues are, are
we gonna have an industry that thrives on gouging through secrecy and through a series of money games, and I personally believe the
answer can be very simple. We need to eliminate secrecy in medicine, the secrecy of those negotiated rates, and to eliminate kickbacks, eliminate kickbacks in
the PBM pharmacy space, eliminate kickbacks in GPOs, eliminate all kickbacks in healthcare. – And I’ll tell you, we’re
gonna talk some about this, but you gotta read this book
to understand what he’s saying because nobody know what
a GPO is, what a PBM does. They are middlemen parasites
that are responsible, I’m just gonna call it like it is. They are parasites that are responsible for healthcare cost inflation
that comes back to you. Oh, my insurance covers it,
oh my employer covers it. No, guess where it’s coming from? Your future wages, the future economic growth of our country. You’re tying a leaden rope around the neck of our children with healthcare
costs, and what do we have? Some of the worst outcomes
in the developed world, which we’ll talk about
too, why that might be, but here, getting back to this, so Lisa Dubois and others in
the comments now are saying, and yet, our hospitals cut staff. Yet, we’re short staffed all the time. Yet, we don’t have the
tools to actually accomplish all these quality measures
they keep talking about, and yet, and yet, here
you have a not-for-profit making money on the back of
suing their own constituency and the air ambulance
story is a fascinating one. There was a chapter on this. Air helicopter transports
for emergency cases. It used to be, the hospitals
kind of owned the helicopter and the process and they kept
the costs basically at cost. – [Marty] And it worked. – And it worked, so if you
needed an air ambulance or helicopter transfer
to another hospital, you could get done and it was at cost. Maybe it’s $2,000, maybe
it’s $10,000, right. Then, they started to, some
business person decided, oh, there’s a profit here. Let’s take that off the hospital’s hands and turn it from a service
we give to patients when they’re at their
most vulnerable at cost to something that’s a profit center, and since they can move, they can just go wherever the profits are, and since it’s when patients
are at their most vulnerable, they can charge whatever they want, and it’s often not covered by insurance and then the patients get the bill, and here’s the best part. When these air ambulances
crash, as they do, killing nurses and doctors and paramedics, it is more often than not
the for-profit companies that this is affecting because they will throw a bird in the air
regardless of safety because it’s all about the bottom line, and I’ve heard this from
front line paramedics who are like, the company
that went down in this state, you should talk about them because they murdered these people sending them in the air for a dollar. More like $50,000. Some of the bills are
the cost of the vehicle, (laughing) of the helicopter. – Of the aircraft. – The aircraft costs this, and they’re charging
$200,000 to a patient. – [Marty] Yeah. – It’s insane. – Yeah, so private equity bought up a lot of the hospital helicopters and planted their own in
many areas of the country, and when these companies were public, many of us were looking
into the public records to find out that the gouging going on, the crazy gouging, and
guess what they did? They de-listed, they didn’t
want to have that scrutiny of being a publicly reported on company. Now, I don’t want to
mention them individually, ’cause one of my, one of
the people I met in Montana who now runs an air
ambulance brokerage group, said something like, people are getting ripped
off, or they’re overcharging, this company’s overcharging,
I don’t want to quote. – [Zubin] Sure. – The exact thing. That company, private equity-owned, sued him for defamation,
sued them for defamation. Rather than settle and get
gagged like everybody does and that’s the game lawyers play, he said no, this is immoral. I’m gonna fight this to the bitter death. – [Zubin] Wow. – Okay, and that’s the kind
of speaking up we need, and so people are afraid to speak up. How many people are speaking up about their own hospital bills? Sometimes they’re worried
about the promotion, the internal academic promotion process. Let me tell ya, once you get to the top, the full tenured at a big
academic center like Hopkins, you realize nothing’s different. There’s no prize at
the end of the rainbow. You need to speak your mind. In Boston, to deliver a baby, uncomplicated, vaginal delivery, all inclusive, epidural,
anesthesia services, that bundle costs $8,000 to $40,000 with everything in between. The Brigham and Women’s
Hospital costs $40,000 and a lot of people like to go there. One company, the women
said they like to go there because the word women is in the name of the hospital and maybe that means they’re more specialized
in labor and delivery. Well the employer said,
I would like my employees to deliver at the $8,000 hospitals because their quality is the same, they have good reputations, and I could save a lot of money because the $40,000 is
clearly price-gouging. So he offered free diapers
and wipes for a year (laughing) if you delivered at the $8,000 hospital. Well guess what? Everyone’s delivering
at the $8,000 hospital. – That’s a bright spot. – [Marty] You do see
these great innovations. – See, and what I like about
the book is actually you have, for every problem that
you get us furious about, you show a bright spot, so for the air ambulance thing, there are these brokers that will actually call around and negotiate prices and say, you know what, in a free
market what would you charge? I charge this. Well why did you charge $50,000, when you said you could do it
for $2,000 when I called you? Well, uh. If they were being honest,
this is what they would say. The patient was vulnerable. Three helicopters showed up
at the scene of the accident, all competing for this case that probably wasn’t
actually even emergent, ’cause a lot of them aren’t. – Yeah, seven helicopters
showed up at one accident scene to pick up a guy, all
trying to get the business. How insane has this? – You know, and the thing is, look. You should be able to make a living, do good in the world,
and do well financially. – [Marty] Yeah. – No one’s saying that you shouldn’t, but this is simply immoral. – [Marty] Yeah. – What’s going on, and so relating, I think relating to that, you were talking about
OB price differences. There is a chapter in the book
about the C-section thing. – [Marty] Mmhmm. – And I found it fascinating, because there’s so much variation in how many C-sections people do. For the majority of
clinicians, they’re doing an average number which is
appropriate and it ought to be, whatever 10% to 20% of
deliveries it ought to be, but then there are outliers, and you use the name Dr.
Dinner in one of them, (laughing) because he almost was 100% C-sections. Can you talk a little
bit about this variation in care amongst physicians? – Yeah, he had a, has a routine. I haven’t touched base
with him, but, recently, but he, at least according to all the residents who trained with him and the nurses who work
with him, he has a routine. He sees patients in clinic, then at a certain time in the afternoon he goes to the hospital
and any woman in labor is told a C-section might
be safer for the baby. – [Zubin] Ohhh. – Well, we doctors know
the trigger words, right. – [Zubin] Yeah, the nudge. – If we, the nudge, right. If you tell a woman in
labor anywhere in the world that a C-section might
be safer for the baby, guess what they’re gonna choose. – [Zubin] They’re gonna take
the C-section every time. – You tell a patient you’ve
got bone-on-bone in your joint, guess what they’re gonna choose? A joint replacement. You tell a cancer patient, “Yeah, we could do it laparoscopically, “but the gas might
spread the cancer cells, “but we could do it laparoscopically,” guess what they’re gonna choose, right? So we know the nudge words and we know the documentation game. Most doctors do the right
thing and I believe try to, the vast majority of the time or always, but this nudge is powerful
and you get 10 or 15% of extreme outliers playing the game or practicing from a different decade or just trying to milk the system, sometimes out of a sense of entitlement. – [Zubin] Mmm. – That they’ve been wronged by payers and Medicare for years,
now they’re getting back. – [Zubin] Right. – And they overinflate the safety of the procedures in their
minds that they do. They’ll tell you C-sections
are totally safe, so Dr. Dinner takes every
single person for a C-section. Now in healthcare, what
we do in the quality space is kind of ridiculous. We take organization level data and then feed it back to the docs, right. (laughing) We have all this data. – [Zubin] Who cares? – And then hey, look here, do better. – Look, as a hospital, we have too high a C-section rate, so you do better. – [Marty] Yeah. – Each of them rationalizes,
well I do fine. My patients are sicker. (laughing) Like, of course they have C-sections, this and this and this, but, so what’s the answer? – Imagine you’re a flight attendant and someone comes up to you. – I imagine that often, Marty. (laughing) It’s one of these weird fantasies I have, like, okay I’m a flight
attendant, and I’m on Spirit, and I’m trying to elevate the game. How do I make that happen? – Well, let’s imagine,
and this is a big stretch for your imagination, I’m sure, but imagine a rude flight
attendant out there. I know this is a huge stretch. – [Zubin] It’s a stretch. – If that rude flight attendant is told by their supervisor at, say, United, United has no rude flight
attendants but imagine they do, you, we as an organization
are below the mean on our quality metrics as United Airlines, relative to other companies. Here’s the data, and try to do better. Is that actionable for that individual? No, right, but if you tell that
individual flight attendant, you’re in the outer two percentile of flight attendants in
your customer surveys. We’re gonna look at this
data again in six months. There’s no action right now, but this is where you stand
relative to your peers, is that data actionable? Yes, because it’s specific to the practice and to the individual, so in
medicine we’ve been doing that. We’ve been watching, and
I highlight this OB chair who shares individual C-section rates for uncomplicated pregnancies
with individual physicians. In one example, the one doc who had an extreme outlier rate said well, of course, my patients are sicker, even though they’re randomly
assigned call nights. (snickering) – [Zubin] Right, right. – And on Friday, his
C-section was 57%, so. – [Zubin] The weekend syndrome. – Yes. – Yeah. – [Marty] So it’s the power of data. – Now here’s an important point. Now a lot of physicians
will push back and say, well this data, these
metrics are bullshit, but this is why you design the metrics with the physicians first. – [Marty] Yeah, we have
them define the metrics. – Yeah, you define it. – Yeah. – And then, just say here’s your data. – [Marty] Yeah. – Here’s your data, and
then you can decide, ’cause we’re pretty competitive and we actually generally
want to do the right thing. If you tell me, oh I’m doing too many, I’m referring too many
patients to cardiology when I could manage it
myself, I’m an outlier. I’m gonna go, I don’t want
to be that kind of outlier. I want to be the good outlier. – [Marty] That’s right. – And I’m gonna look at my practice. – [Marty] Right. – And you’re seeing that evidence in practice and outcomes, right? – Yeah, and in this national
Improving Wisely collaborative, which was originally funded by the Robert Wood Johnson Foundation and now we’ve got other
grants to support it. – [Zubin] And we’ll put
links to all this, yeah. – Okay, improvingwisely.org. What we’ve done is we’ve gone to the doctors with this model. You tell me if you like
this or not as a physician. We tell them, we ask them
a question, one question. Tell us about an area
of inappropriate care in your field where there are
measurable practice patterns, and then define the measure for us, help us come up with the
inclusion, the exclusion. We’re not trying to
evaluate individual cases because we know everybody’s different, medicine is an art, and
we don’t want the hammer to come down because you
deviated on one patient. That’s the stuff that
drives us crazy as doctors. – Right, drives us nuts,
it’s the quality measure. They don’t measure
quality, the measurement industrial complex, all
these things, terms of use. – [Marty] It’s the
pre-authorization nonsense. – Yep. – [Marty] It’s the
peer-to-peer, it’s the stuff that drives us freakin’ bananas, right. – Makes us insane, yeah. Health 2.0, yeah. – Yeah, exactly. Let’s let doctors be doctors, practice medicine embracing
variation, it’s an art, but you tell us what the boundaries of reasonable variation are, right. – [Zubin] Right. – 30% C-section rate may be the ceiling. – [Zubin] Yeah. – That’s what they’re telling us? – [Zubin] Mmhmm. – If you’re over 30, which by the way is like 15% of GYN’s, of OB docs. – [Zubin] Are over 30%? – Over 30 in uncomplicated
vaginal deliveries, right, then can we share that
data with the outliers and let them see where they
stand relative to peers and let them auto-correct or help them, not punish, but can we help them? – And you gave a great example in the book about Mohs surgery. – [Marty] Mohs surgery. – And Mohs surgery is done in stages. – [Marty] Yeah. – And you can often do
it in one or two stages. If you’re going into three and four, you’re probably an outlier
in most of the cases. Now, when you actually fed
that Dear Doctor letter saying, Hey, guess what? You’re a bit of an outlier,
you’re doing it three stages. You get paid more when you do
it in multiple stages, right. – Yeah. – But it’s more, it’s more time, it’s more cost, all these other things. When you fed that back,
you got messages back saying thank you for this information. I’m gonna look at my practice pattern, or here are the reasons for this, but it’s good to have this data. No one’s ever told me this. We have no ability to understand our own care variation
relative to our peers ’cause we don’t have the data, and if the data’s defined
by some bureaucrat, we’re not gonna listen to it anyways ’cause it’s bullshit data. So it has to be defined
by us and our peer group and maybe our medical organization that represents our specialty, but it cannot be defined
by some bureaucrat. – The doctors liked receiving that data. Now, granted there was a cover letter. It wasn’t, hey, Marty’s
showing you where you stand. (chuckling) – [Zubin] Yeah, right. – It’s a cover letter from the professional association that says, as a courtesy we’re letting
you know where you stand. This data is confidential,
it’s peer-to-peer, and it’s intended to be, to help, and if you want educational
resources, let us know. Okay, that cover letter, that was page one and page two was the
report with the bell curve and where you stand on stages per case. That two page letter that cost $150,000 for the data analysis and the mailing to half of U.S. Mohs surgeons
saved Medicare $18 million in the first year and a half. Now you tell me where you have
an intervention in healthcare where for $150,000 you’re saving $18 million and the doctors
are sending emails in, thank you, we like this, can you show us where we stand next year? – And that is an example of a bright spot, so that’s a solution to our problems. We complain a lot, but you actually are developing solutions, which I think is what distinguishes this book out separately,
and relating to that, because one of the big themes of the book is something I’m very passionate about, which is over-treatment. So, just because we
can do things to people doesn’t mean we should, and the fee-for-service
business of medicine incentivizes us to do things to people, not necessarily for them, and that doesn’t mean we’re bad people. You know, Robbie Pearl
in his book Mistreated talks about these cardiac
surgeons who are doing all these procedures because
that’s how they’re conditioned. They think they’re actually
doing the right thing and it’s backed up by the fact that they’re making money doing it. So they are gonna convince
their unconscious elephant that this is the right thing to do. They’re not doing anything
maliciously, and then we do it. We do more, we do more, we do more. No evidence that it helps,
maybe evidence that it harms, and what ends up happening,
we crank up the costs and patients thank us for doing it. There are vein claudication
screenings in churches in the poorest parts of our inner cities that are then getting people to come into these vein clinics
to do PTCA on veins. Can you talk a little bit about that, ’cause that was outrageous? – Yeah, sure, and I
reluctantly but I did decide to open the book with the
story of me visiting a church where we found doctors
there with ultrasound probes over-screening people for
peripheral vascular procedures, despite a U.S. Preventive
Services Task Force guideline that no one should be screened for peripheral vascular disease, recruiting them to their surgery centers, predominantly in the
African-American churches and predominantly in
Prince Georges County, which is the African-American
suburb of Washington, D.C. Four surgery centers, by the way, called out by a very
impressive cardiologist who refused anonymity
when I offered it to him. – [Zubin] Oh, I saw that, yeah. – And his name is in there. He said four of these centers, within two miles of my
office are doing these things all days long with little or no science. Most of it is bogus. Most of it is predatory,
if we can reuse the term, predatory screening in American churches. My students, when, you know, millennials are social justice-minded. – [Zubin] Yeah. – And when they heard
that I’d gone to a church after doing this interview
with this cardiologist, they said, look, we’re going with you. We’re gonna show up,
just like they show up at the courthouses now to
help defend these patients. They’re showing up at the churches, and they’re meeting with pastors. I met with one pastor and told them, these doctors coming in,
they’re not providing free healthcare as you may think of it or screenings consistent with guidelines. These are predatory screenings. This represents over-screening. – [Zubin] Call it what it is. – Call it what it is. – Predatory screenings. So you see it all the time. You see it all the time,
and then the question is, this is not a victimless crime. They’re gonna get charged for it, you’re gonna crank up fees, and then you may have complications, and now you’ve injured someone who should never have been
screened in the first place and we will rationalize it as, no we’re actually catching something that wouldn’t have been caught. These are non-compliant patients that would never otherwise be seen, so let’s get them in the
churches where they are and we can help their symptoms. – You know, we were hoping to do an Improving Wisely
project showing doctors who do these peripheral
vascular procedures, how frequently they’re
doing them for claudication and certain indications,
relative to their peers, because we’ve mathematically figured out how to identify these people, docs who do too much in the data. – [Zubin] Mmm. – I was really hoping that
a professional society would step up to the plate and say, we’re gonna do the
Improving Wisely project. We’re gonna notify the outliers. We’re gonna write that cover letter, like the Mohs college did and so many other societies have done, but it’s incredibly frustrating when you can, in the data,
see the names of the outliers, and we can do that only
because I lobbied Congress, testified in front of them, fought with CMS and
all these policymakers, that we deserve the
Medicare data in real time. Forget about de-identifying physicians. We deserve all of this data without all the hoops so we can study it. How are we supposed to
address the opioid epidemic when we can’t see the data on opioids that Medicare has locked up? So they gave us the data. They said, okay Marty,
here’s all the data. It’s this mechanism where we
access the Medicare servers. – [Zubin] Wow. – And now we’re looking at these names of egregious practice
patterns around measures that the experts in that specialty told us there’s a lot of abuse, and so we’re looking at these egregious peripheral
vascular procedure rates, and honestly, I don’t know
what to do with this data. I’m thinking about just sending a Certified Mail letter
with the names saying, we have serious concerns
about the public health and let it sit on the desk of the American Academy of
you name it, and so we’ve. – What a moral conflict to have, to have this data and be unable to publicly do something about it when you know these guys are committing, I mean this is harming people. – Now that we can measure
egregious practice patterns. – [Zubin] Yeah. – With broad consensus
from the specialists, do we have a duty to do something? – Do we have a duty, right. I mean, I think we have to. The problem is, again,
between getting sued, between violating the law,
because it’s all set up to be as un-transparent as possible, and this is all we’re saying is sunlight is the best disinfectant. If we open the doors and say, you know what, we could actually practice at the top of our game,
the top of our training, do what our calling is, and make a living, that’s really quite good. – [Marty] Yeah. – Why shouldn’t we, that should
be what we’re searching for. – When we rein in the outliers, and I don’t call them bad doctors, I call them doctors who need help, there’s more money for the rest of us because 15% of outliers
that are massively overdoing things in ways that peers tell us, they’re sucking up all the
money out of the system, so there’s lower
reimbursements for inliers. – [Zubin] For everyone, for inliers. – And there’s precedent, I’m optimistic because we’ve seen these associations like the Mohs college step up. The paper just came out
in JAMA Dermatology. The chair of the American
Medical Association board wrote an editorial saying physician level peer-to-peer physician-created metrics are the future because it’s individual data that’s actionable. – [Zubin] Mmm. – So I’m optimistic. If an association told us,
we’re overwhelmed by this, I’d understand, but there’s precedent now by these groups that
have had bold leadership, so I would, I know you have a
lot of physicians that listen. I’d encourage physicians out there to go to their professional association and say we want to do an Improving
Wisely-type project and push your associations. You know, for a long time
a lot of the associations were only pushing for more doctor pay. We can do a lot better, right. Instead of just being worried about what every dues-paying
member of the society thinks, they can actually take a bold step and address these
outlier practice patterns using data and the
precedent that’s been set. – See, that’s where I
think our leadership is, in these organizations is frustrated. They’re like, ah, our
reimbursements are dropping, everybody’s pushing on us,
Health 2.0’s destroying us, there’s all these quality metrics and Press Ganey and patient satisfaction, all these other things
that are pushing on us. We feel it at every level, and yet there are solutions here that take the best of quality science, which you’ve dedicated a good
part of your life to doing, and actually apply in a way where we actually get paid, we reduce waste, and we improve outcomes
and everybody feels like they’re living their actual calling instead of struggling in
the business of medicine. You know, you said something
earlier where you said, a lot of doctors justify this by saying, I’m owed this because I’ve been screwed by every single person in this system, so if I want to do a vein
stripping or something, I’m gonna do a vein stripping. It’s the only way I can
keep my practice open. (chuckling) – We hear, we actually hear that. – [Zubin] Yeah. – Every now and then, we’ll realize in trying to get a consensus
as to what to measure, we realize we’re talking to an outlier, and they’re not evil people. They’re telling us that it’s safe, I’ve been cheated by the
system, what’s the harm, and you realize the moral injury as you so brilliantly talk about over time creates this entitlement and this robotic approach and, I had a case once where I did a vascular, we might hear, and I discovered
a cancer while doing it. Well, that doesn’t, that’s
not how we practice medicine is that you did a random MRI once on a normal person,
discovered a cancer, so now everyone in the world
should get an MRI, right? So we see these patterns of moral injury where we’ve become sterilized, we’ve become androgynous,
we’ve become robots, and there’s this entitlement that sets in and I don’t blame the doc. I blame the freakin’ Krebs cycle that we pounded into them for eight times they had to memorize
every step and produce it. (laughing) – Pyruvate, okay? That’s all I’m gonna say. – [Marty] Know that in
the trauma bay, right? – Yeah, in a trauma bay. Get me an amp of pyruvate, stat! (laughing) You nailed it, and I think the way that our medical education, the end of the book you talk about this, and it was very powerful. It actually made me a little weird, like reading it I was like, uh, this hurts, I can’t read this, because what it said was, in our medical education
we teach ourselves Latin. We encourage four, sort of, biases. We encourage a competitive bias, in other words you have to
compete your way to the top. You talked about your own rise to the top of academic medicine and when you get there you’re like, huh. You know, one of my mentors, and he wasn’t an intentional mentor, was a hospitalist, a
private practice hospitalist in Honolulu, and I did a rotation there at Queens Medical Center when
I was a second year resident. – [Marty] Yeah, Queens. – Yeah, in fact I’m gonna,
I can’t announce that yet, but they, what ended up happening was, he was the hospitalist attending
and I was a second year, and I was struggling
through my day, and he said, “Zuben, listen. “I’ve been doing this for 15
years now as a hospitalist. “I’m gonna give you some advice. “One day, you’re gonna make
all the money you need. “You really don’t need
more, and you’re gonna say, “Kay, I don’t need more money. “The second thing you’re gonna look at is “all your struggles and everything you did “and all this energy you put in “through medical school and training. “You’re gonna look at your life and go, “This is it? “This is the apex? “Like, what are we doing this for? “And then you’re gonna wake up and realize “it’s because I get to be with people “when they’re at their most vulnerable.” – [Marty] Mmhmm. – “And make a difference,” and they let me be with him, and I never forgot that,
and in the darkest parts of my moral injury I would feel that and your description of,
this is moral injury. The end stage of it is sometimes a shutting down and us saying, I’m gonna do this stuff
because I’m owed it now. – [Marty] Mmhmm. – ‘Cause it’s the only way I can survive. – [Marty] Mmhmm. – So I don’t think we can, you cannot be angry and hate these people. You can be angry and hate a system that creates these people. – [Marty] Yeah. – And the system. – And if anything, doctors, I think, right now are the heroes of healthcare. Doctors are the ones
who are winning it back. Doctors are the ones who are calling out their own hospitals
and who are calling out insurance companies and middlemen, and you’re seeing this
entire redesign of healthcare where people are going
direct to the doctors and the doctor groups. – And this is where the
interview pivots to the positive. So, I didn’t even realize, now physicians, nurses, front
line healthcare professionals are leading a disruptive revolution, and they’re working with
self-funded employers. What that means is the employers aren’t working directly with insurance companies. They are paying the
medical bills themselves, whether it’s Amazon or whether it’s a small company in your town, they’re taking on this cost and therefore they’re free to innovate. They’re free to cut out
middlemen if they want to. They’re free to go direct to
primary care physicians and go, you take care of our patients. You find us the best specialist, you create a good guys
network that we trust, and we’ll send our patients to you and if our patients tell us
they’re getting good care, we’re gonna go back to you and
we’re all gonna save money. You’re gonna make money, and no one’s gonna intend to make money, but by doing the right thing we’re actually gonna do well financially, and it’s happening, and then I realize you wrote a whole chapter on
our organization, Iora Health. – [Marty] Yeah. – Our co-partners in building Turntable, and you described, it’s primary care. Rushika Fernandopulle is
their CEO, remarkable guy. You went to Phoenix, and I was there when that practice opened. I went there with the board,
I was on the board of Iora. – [Marty] Oh yeah? – And you describe in that whole chapter, and I won’t kill the chapter because it’s in the kind of talks I do too, that, oh, what happens if we
give you a bunch of money to just take care of a
population of patients, of Medicare patients? And we say, you’re not
doing fee-for-service, you’re not billing, you
don’t have to document, you do what is best for the patient, and if it works we’ll do it again, and maybe we’ll even give you some of this money that you saved, and what does that mean? That means intensive primary care, focusing on prevention, cutting out over-screening
and over-treatment, finding a network of specialists
who do the right thing, who are willing to get peer feedback and who are willing to practice in a way that is in the best
interest of their patients. In doing that they take the responsibility for the successes and the failures in that population across
the continuum of care. If they get admitted that means, hmm, was it something
we could have prevented, or is it something necessary? If it’s something necessary, let’s have the health
coach go to the hospital, talk to the ER doc, go this
is who this patient is. Just so you know, we’re
gonna be sitting here watching and listening, and guess what? You can have a facility because you’ve gotten rid of all the billers, and now you have more space to do yoga, (laughing) and meditation, and do
teaching cooking classes, and this kind of thing
and the health coaches take a lot of stuff off our plate, like motivational interviewing and looking at shopping
lists and doing home visits and getting into the
real emotional backstory of what’s driving this patient’s problem, and when I read that chapter I’m like yeah, yeah, yeah, that’s it. That’s what we’ve been doing at Turntable, that’s what we talk about
when we talk about Health 3.0, that’s a damn bright spot
and it’s led by clinicians and the fact that you put it
in this book means so much. It really means a lot,
because it means there’s hope. – You’ve done a tremendous
job pioneering some of this new redesign of
healthcare and Rushika, and I’m a big fan of so many doctor innovators who have tried to say the current system is completely broken, let’s start from scratch, and Iora’s one. There’s so many I. – [Zubin] There are a lot, yeah. – There’s a lot and so I was privileged to spend time with the Iora staff. ChenMed, Oak Street, I mean, ChenMed’s very impressive, I think. – [Zubin] Very good, yeah. – So, I believe that
doctors are not lazy people. (chuckling) We just don’t want to spend our time on things that don’t matter, and if you think about our workflow, a tremendous amount of that stuff can be done by highly
attentive, eager human beings. They don’t have to have a degree, they don’t have to have a formal education and have studied Latin
and the Krebs cycle. It could be a high school student. It could be a kinesiology
major from college, right. If I need to do wound care in the clinic, I can take any eager body
with the right attitude and train them exactly how
they could be extremely helpful and that’s what Iora’s doing, right. They’re a team. – That’s exactly right. It’s a team, and these
health coaches, the nurses, the licensed clinical social worker, they call them nurse innovators, the one who leads the clinic. You have physicians in
a, and the thing is, going back to your medical school rant, I was struck because you said
we have a competitive bias, so we all compete and
that’s what we’re about. The second thing was an autonomy bias. It’s one doc against the world, and it’s our judgment that rules and it’s, that’s the third bias
which is the hierarchy bias, that we’re trained in a hierarchy, therefore we perpetuate a
hierarchy on our nurses. Did they ever train you
how to talk to nurses? – I had no training in
any communication skills. I mean, breaking bad news, something I gotta do now every week, I mean, I’m still learning
how to do it effectively. – 1,000%, but what do they train us? The Krebs cycle. – [Marty] The Krebs cycle. – And they train us how to
compete against each other and do really well on MCAT and O. Chem and those kind of things, those are the people
they accept to school. – [Marty] Yeah. – And then they throw another bias, a non-creativity bias. In other words, the more creative and out of the box you are, the more you’re gonna get
stomped in medical school. – My chief resident on day
one of internship gave me, I met with a couple people on my team and the second-year resident told me, oh here’s how you get a nutrition consult and here’s how you fill out the TPN forms. Third-year resident,
here’s how you order blood, and the chief resident, when I met him, he just handed me a pack of Surgilube. (laughing) And no words, and it had
so many meanings, right. Layers and layers of meanings. – Layers and layers
and layers of meanings. That’s our training. – [Marty] That’s sort of
the kiss the ring mentality. – Yeah. – That you talk about. – I was told by a top clinician at UCSF, Damania, you speak and then think. (laughing) I’d like you to reverse that. Better yet, just think. Non-creativity bias, I
think, is so damaging because the innovators,
the creative types, the people like Rushika Fernandopulle, who we were talking about, Iora’s founder, he is an out-of-the-box creative. Imagine how he must have
suffered in medical school, and how, I know I suffered and
I’m not even that creative, but it was beaten out of me by the end and it took me 10 years
to reconnect with it. It would come out in these weird ways, but now we’re seeing that
passion start to arise. Now you gave an example of,
Jefferson Medical College? – Yeah. – [Zubin] And how they’re
screening differently now? – Yeah. – [Zubin] They’re screening
on emotional intelligence. – Yeah. – Now, you know that our
generation is sitting there going, God, yeah, they’re gonna
drop in the rankings. (laughing) Like, that’s gonna be a
shitty medical school. I remember I was at UCSF
and someone was complaining, oh, they’re screening
for social activities and all these things. That’s gonna be the end of this school, (laughing) and that’s how we were conditioned. – [Marty] Yeah. – Yeah. – Oh yeah, I love the old
school surgeons that talk about, “The kids don’t know anatomy anymore.” Well, you know what, you learn
it as you study the cases. – [Zubin] Right. – Before you do the operations
and on your rotation. What’s the limit of how much knowledge we have to stuff in the minds
of these creative people? Does every medical student need to know how to refract people for eyeglasses? I mean, in surgical training, we’re spending time
learning prostate surgery. – [Zubin] Right. – I’m a, does a cardiac surgeon need to spend a month learning prostate? What if they spent a month learning effective communication
and self-awareness, and middlemen of health
care and the kickbacks and the schemes and the
stuff you talk about? – That’s the thing. If everybody had to
read this as a textbook, we would transform medicine
in a generation less. In 10 years, it would be transformed, because they’d be so outraged, and they’d have the idealism
of youth to go into that instead of the cynicism of age where that’s never gonna happen,
it’s never gonna happen. – Well, thanks. I tried to basically create a book that is as comprehensive as a short read can be on the business of medicine to complement what we learn as medical literacy, complement it with healthcare literacy, and I think in the end it’s both a very, for me, an eye-opening experience learning about the
middlemen, the kickbacks, the pricing failures, and
the inappropriate care, which is in sum the reason for
our healthcare cost crisis, not the stuff they talk
about in Washington, D.C. Washington, D.C., the
politicians, they’re talking about different ways to fund the
broken healthcare system. We’re talking about how to fix
the broken healthcare system. – That’s right. That is so important. People are like, how we
gonna fix healthcare? How we gonna fund healthcare? Forget about how you’re gonna fund it. You’re funding a steaming turd of lack of transparency, price gouging, (chuckling) and immorality. You want to fund that
with Medicare for all? Go ahead and ruin everything. Here’s when you do Medicare for all, when you get the system right first, then you can cover
everybody however you like, because it’s gonna be
cheaper, more effective, more egalitarian, more
fair, and everybody, whether you’re a conservative
or whether you’re a liberal, it’s gonna hit you in your moral palate that that system is good and right now, it hits
everybody in their moral palate that this system is horrible and we don’t even know the depths until you read a book
like this and you go, wait, it’s even worse than I thought, but you know what, it’s
even better than I thought, because there are actionable
things we can fix. It’s not this mysterious,
why is it not working? No, here’s the reasons it’s not working. We’re smart enough to
get into medical school, to be a nurse, to be a pharmacist. I think we’re smart enough
to fix these problems, and the first step is
realizing this is a business. Let’s make it a calling again, and we can still do financially well while doing good for patients, and that’s what I love about this. – You know, a pothole is not a political issue in a community. It’s a competence issue, right. – [Zubin] Mmm. – It’s a corruption issue, and it’s the same with healthcare. We’ve been misled by this
sort of right vs. left, and throwing more money at it while there’s certainly things that need more funding like mental health. – [Zubin] Right, prevention. – Overall, prevention. It is not, it’s a distracting argument. How much more money do you want to throw at this broken system? Some of this egregious stuff, and the reason I opened with this sort of inappropriate predatory screening in churches that was leading to all this downstream unnecessary care is to show, if you just pour billions
more into Medicare, you’re just continuing
to fuel that very system. – [Zubin] Yes. – And I believe healthcare’s a right. I think everyone should have, there’s so much consensus in medicine. We don’t even need to be talking
about some of this stuff. We need to be talking about what people are not talking about, and I think for me,
the most exciting thing are the people who are fixing healthcare and have already fixed
healthcare on a small scale, the Iora’s, the Oak Street,
the direct-to-employer, the innovative patient steering that the Boston company did to get doctors now who are saying, hey why aren’t patients
coming to me anymore? Oh, my hospital is charging 40
grand for labor and delivery. – [Zubin] Holy crap. – And South Shore is charging eight grand. Lemme talk to hospital administration. What’s going on? Why are we overcharging? And actually, a lot of this exciting direct-to-employer stuff that I get into, the one of the few remaining barriers is that the insurance companies
who manage the networks, that is, an employer will
often rent the network of an insurance company
to get their discounts, the insurance companies
come back to them and say, employer, don’t you dare
create price competition and feed the market based
on quality and price, which is the definition of value, because our contracts, if you’re gonna use our negotiated discounts
in our network, forbid it. – [Zubin] Yeah. – Why do they forbid it? ‘Cause the hospitals
told them, no steering. – [Zubin] Yeah. – And that, so it’s. – [Zubin] Opaque, yeah. – Exactly, so I mean,
once we break that down, and right now, the policymakers
are totally interested in this subject, the
secret negotiated prices. – It is our chance to pounce. This is the chance to actually
make meaningful change, because in the end you have
entrenched legacy players, you have a lot of people who resist this. This is why I started this interview saying you’re gonna get murdered, (laughing) and I was joking, but the truth is there are a lot of people
who are gonna be angry because when your livelihood depends on the truths of a system being true, new truths you will
resist any chance you get. It’s a natural human tendency and I know because I went
through this transition when I left my job where it
was a fee-for-service thing and we were indoctrinated a
certain way and I came here. I was like, no this can’t be right. Wait a minute, am I? Now my livelihood depends
on finding an answer, working, standing on
the shoulders of giants like Rushika and others who’ve worked, given up and sacrificed to do this, and they’re entrepreneurs. This is not some Communist
manifesto, right, ’cause I know, I can hear the, half my fans are conservative,
half my fans are liberal, another half are in the middle, and the truth is this is the
apex of American competition, ingenuity, and free market value is an open, fair, transparent system that’s driven by a higher moral purpose. That’s America. Nowhere else in the world, we are still the shining beacon. I mean, you’re an Egyptian immigrant. I’m, my parents are from India. They came here for this opportunity to do something magical. Why are we squandering it? We need to stand up and take it. – If I get murdered, by the way, all my passwords are ZDoggNumberOne. (laughing) – [Zubin] I’m glad to know that. I will access all your accounts, get the data out. Actually that’s very important. You need to give people, in
the event that you’re murdered, the passwords so that
they can get the data out, because if something happens to you, I cannot live with myself
if this doesn’t continue so I’ll do my best to
continue to evangelize, and we’ve spoken now for
about an hour and 10 minutes. – Well keep up the good work. I mean, I’ve been, as a subscriber myself, been following a lot of the comments, and it’s, you’ve engaged a real impressive group of individuals who have said, Look, we want to do more than just be on this treadmill
that we’re told to be on. We know there’s something
bigger out there, and we know there’s a
better way to design it, and it’s amazing. If we just ask doctors and nurses and everybody involved in the
care coordination of patients, how can we do this better,
they have the answers. They’ll tell ya. It’s just nobody’s asking them. – I tell ya. Hey, you know what? Our hope is give them a mouthpiece. Give them this platform. You’re right, our audience is amazing because it’s all of us. It’s all the healthcare professionals who’ve sacrificed so much
and they come together because they say, you know what? We need to have a voice and do it better, and they don’t all agree
and all healthcare is local, just like all politics is local. That’s great, that’s beautiful. That’s the diversity and the variety. That’s normal care variation, right, not unexplained outliers. So, I’ve never been so excited. I’m so excited for this book. Everyone should buy,
you can order it soon, pre-order it now. Go out, get it, and Dr. Marty Makary, what a privilege and an honor it’s been to have you on the show. – Great to be with you, Zubin. – Brother, brother, stay safe. (laughing) I’m gonna get you a bodyguard. I’m gonna get you Logan. All right, Z-Pack, we out. Peace!




Comments
  1. Without fail, when i talk to friends, family or patients who arent in medical field and show distrust in doctors the fear/anger is based on feeling they are commodities. That they are being scammed in some way. Primary way ive heard the trust has been broken. Super sad as doctors are just as frustrated if not more with price gouging. Thank you for taking time to address this.

  2. I am loving this video, ive preordered the book. My question as a nurse is how do we get on board so there is transparency to how we are staffed, why when nurses leave for whatever reason they arent replaced by new hires either ever or 6 mos to a year. Reason were given is cost saving, hospital in trouble, be a team player. Being the tyoe that makes up nurses of course we want to help out,

  3. You are both heroes; please keep your voices strong and continue to speak truth to power. I am an occupational therapist and have the same experience even at the level of rehabilitation. And don't even get me started about SNF. Thank you.

  4. Lol literally just finished listening to him talking to Peter Attia for 3hours lmao! Must watch this one too for some added Zdogg spice

  5. When is the last time you ate at a restaurant, paid your check, only to receive by the mail bills from the chef, busboy, dishwasher, and doorman ?

  6. Thank you. My heart rate has been 80% of max for an hour and a half. Now I don't have to do my cardio today.

  7. Circa 2010. As a medical student my wife went to an obgyn at the university medical center and our university insurance paid for everything except the thyroid test, which WAS medically indicated, but which the insurance decided not to cover. A single tsh was billed at $414. I proposed that the charge seemed excessive compared to reasonable and customary… they informed me that they would not reduce the bill… and would make sure that i did not receive my degree until i paid.

  8. Sorry guys. In the USA, there is no conservative free market plan plan/model for health care. Germany can make it work by regulating private insurance companies like utilities. In the USA the insurance companies will fight tooth and nail to deregulate. That's why we are stuck debating Medicare for all.

  9. You could start by getting the MBAs out of hospital adminitstration and the health provider networks. The financial mindset is Mars, while doctors and nurses are Venus. Two different mindsets, two different goals.

  10. Save a life, kill your local hospital administrator and lawyer. You two are doing amazing work, please don't ever quit, we're in desperate need of it, these people are taking us by the thousands to the slaughterhouse

  11. As a frequent flier patient, when it comes to over treatment, trust your patients to trust you. Especially with younger patients who are chronically ill, we probably come in wanting to know if what is wrong is normal or if we should be worried. If you tell us it's a normal connection to our conditions, we usually trust you. We don't need excess testing or added medications. I don't enjoy that I now have needle scars like a heroin addict.
    Everytime I go into the doctor, even just to get my Ritalin perscription, if I make any complaints- their immediate react will always be to look at the list of medications I haven't tried and think of tests that will placate me.
    They don't do it for money or anything nefarious, they really mean good for me. But it's not what I want. I just want communication. communication communication communication. communication.

    I went into the ER last year for a horrible headache, so bad I was in and out of consciousness. I was worried it was related to a metal plates in my head that I had put in as a kid- the pain was concentrated mostly around them (which is the whole left half of my skull). The Doc explained that it was almost certainly just my migraines, that were getting worse from stress. He then asked if I wanted a referral to a Neurosurgeon and Opiods. He was shocked when I said I just wanted Neurology. He was surprised that I trusted him. Probably not that flat, but he auto- assumed that I would want to dig deeper.
    He seemed quite happy when I took the perscription for ibuprofen and went on my way.
    I was back in for chest pains two weeks later (my mother died of a heart attack at 38, so it was a serious worry). Again, this doctor was surprised when I nodded being told that it was inflamation of my rib cage courtesy of Fibromyalgia, and indigestion from the Ibuprofen- even more surprised when I was fine not being persciribed anything. I've tried and had nasty side effects to pretty much all pain meds but Opiods, and I don't want to touch those with my family history of addiction. And they upset my tummy, so it wouldn't have helped the indigestion.

    Interesting but unrelated, I'm with a new Neurologist who has persciribed me Ajovy for my migraines. It's actually working amazing, just gave myself my fourth dose yesterday. I cried, but it's worth it. And medicare actually covers it, since I've failed on every other treatment.

    P.S. Your channel makes me really respect my team, and I am so proud to say that my local healthcare network follows your healthcare 3.0. I'd bet the people in charge here are fans.

  12. ZDogg, this may be off topic of this incident report, but could you do a report on the state of the American Board of Medical Specialties and the law suits against it? It is part of the idea of egregious gouging of the medical system, in this case physicians themselves. I view it as part of the overall control mechanism of the medical system and forcing compliance of physicians to play the game.

  13. Refusel to except payments on bills hurts the poor, its also poor shaming, my moms refusing to see her doctor because of this. I got health issues to & i avoid the er because apparently if your poor, fat, ugly, take meds for multiple invisible illnesses its we cant find nothing wrong, one time when i was leaving the ER i heard someone refure to me as a drug seeking hyperchondriact. I went home had an asthma attack that caused me to black out when it was over i refused to go back to ER because i figured if I wasn't wheezing or coughing i must be faking. I stared going back in 2012 but after injuring my knee in 2018 im not going back again especially after reading the reviews for the ER of a local hospital, people being denied care & called druggies, one person went to another hospital & found out she had brain bleed, another women had dead fetus inside her & they refused to remove it claming abortion. It was dead… This is why i dont trust & hate doctors. Sorry nothing against you but i had to share my feelings.

  14. Im on medicaid & Medicare if a hospital or doctor ever did that to me when i only get $800 a month from ssi that would be the last time i speak to a doctor or go the er. Hospitals in Africa hold patients hostage till they pay up.

  15. Yeah medical field price gouge the hell out of its patients nothing like getting charged $4000 for 1 or 2 bags of fluids a shot of muscle relaxers, weak pain meds(heck if you are charging me that much give me the dang good stuff for my pain) and anti-nausea meds! I bet they upcharge cause the doc banged her head on the light while in the room with me lol pfft fixing the opioid crisis my butt I'd run the risk of overdosing before I ever go back to that expensive ER!

  16. I think it's a governmental issue; could taxes pay for reduce cost? If I had to pay 6k for a treatment I'd just call it a day

  17. Im glad you guys recognize that there is a problem but are completely off the mark the problem is capitalism because capitalism is inherently crony. The means of production in this case the healthcare system should be owned by the people who invest their labor into that healthcare system nurses, doctors etc. it should not be owned by shareholders and billioniares whose labor is not invested into these facilities. In short the working class nurses and doctors should own the means of production NOT capitalists, capitalists being people who do not invest labor but make money from mere ownership.

  18. My aunt had to have a double lung transplant to live. She will owe that hospital for the rest of her life. On top of all this debate, the non-profit hospitals don't want competition to come in either, they'll do anything to convince the community that we don't need more hospitals in the area. If anything we need another one of their hospitals. I feel like i shouldn't have to travel hours away to get healthcare that i can afford.

  19. This is fantastic! I work for Intermountain Healthcare in Utah. Our new system President & CEO Marc Harrison, is obsessed with fulfilling the call of delivering the highest quality healthcare to all at the lowest possible cost. I am a Department Nurse Manager. Part of our yearly goals every year is to reduce usage and cost on our departments any way we can to help reduce the cost to our community. Under his lead the system has started Civica RX which is a drug company created to produce some of the medications that the pharmaceutical companies are price gouging on. They produce it and supply it at a drastically lower cost to hospitals to deliver to patients at a significant lower cost. This is only one innovative ways he is leading our system to change the mindset of what healthcare should be and how much it should cost. ZDoggMD…you should do a piece on how flipping amazing this system is and what we are doing to decrease our patients cost.

  20. This is probably one of the best podcasts I have ever heard. I literally got goosebumps several times during this interview! I posted it on my LinkedIn account. I would work for any organization with this vision and these values! Thank you Drs. for honoring your oath and your vocation. Hats off to you for your fearlessness!

  21. This is important. Pull the blinders back on the hidden financial practices going on behand healthcare today. Shine the light of truth on what is going on. Transparency is so important for a true renewal of healthcare. Kudos to you. More of this pkease.

  22. OMG – not until the end does it come up that this talk is all about being AGAINST Medicare for all…I was waiting for the other shoe to drop here. Earlier in the talk you slipped in NO DOCUMENTATION and just outcomes and now here it is NO MEDICARE FOR ALL until we get the system right. So disappointing Zdogg/Makary. THE FIRST STEP IN FIXING THIS SYSTEM IS ALL DOCUMENTATION IN ONE PLACE so the analysis can be done – NOT NO DOCUMENTATION AT ALL. Medicare for all puts all the documentation in one place. No documentation?!? I thought the argument you guys always put forth was SCIENCE, what does the "science" say. Where is the science in NO DOCUMENTATION AT ALL – the entire system judged by what the patient's employer thinks?!? Have you been reading the news?!? Employers have skewed the power balance and reward scale so much half the population with full time jobs is on food stamps. I thought this talk had value at first but it seems to be another angle on the same crap we already have – perhaps worse. now I have to suffer though the whole thing AGAIN just to make sure I am not being unfair to you….unfair the medical industry – after they destroyed my daughter in front of my face, taking down a young beautiful woman in MONTHS in horrific agonizing terrifying and cruel manner, which is what prompted my desire to understand the "industry" – i'll delete this comment if I've been unfair – because I actually like you for some reason even though I dont always agree with you. UPDATE: yep minute 56:40 new paradigm DOCTORS DONT HAVE TO DOCUMENT – so I heard right. But I do think maybe i've been a little unfair – both of you I think really care about the issue of unnecessary care and overbillings and are really helping to break down that wall. HOWEVER the capitated model is just as ruthless – because in that model, in combination with MICRA cap laws (limiting the payouts for killing patients to an amount so LOW that no lawyer will take the case) is creating incentives for deaths of patient that have experienced NON-LETHAL HARM and it also makes the entire STORY OF HARM COMPLETELY DISAPPEAR so there is no learning or system improvements either – insuring others will be harmed in the same manner. And from personal experience watching one of these deaths – the cruelty used to achieve that goal to get out of these liabilities via death has NO LIMIT. Doing the right thing in health care means releasing the control of the data to the patients that are suffering the consequences of this profiteering scheme. A person should at least have some say in and full knowledge of what is being done to them IN REAL TIME. And to fix the BROKEN PROTOCOLS (that Robbie denies exist) we need all the data out of the hands of those that are profiteering from the secrecy of this data control and the data has to all be in one place so no profiteer gets to enjoy secrecy and full impunity from the law or repercussions. MEDICARE FOR ALL INSTANTLY GETS ALL DATA IN ONE PLACE AND RIDS PATIENTS OF THE LIFE & FAMILY EVISERATION OF PRICE GOUGING – medicare for all is the fastest means to those ends.

  23. OMG….there is SOOOOOOOOO much I could say about this broadcast Z….what an amazing hour with Dr. Marty!!! I feel like I want to buy a few cases of his book just to give to the docs, RNs and residents at my work. Having witnessed so much of this as a lab rat, it is so disheartening to see that vibrant life is being sucked out of the medical profession. I see so much unnecessary lab testing being done by residents who have either never been taught or fail to use critical thinking in the treatment of patients. The residency program at my work place could be so much improved if the leadership of the program WOULD BE WILLING to engage with those of us who have been in the field frontline. I cant tell you how many residents DO NOT KNOW how to order labs or dont know what tests are in the panels they order or just outright don't have a clue as to why they are even ordering such labs. What's worse is I have only seen it happen twice where an attending has called out their resident on why they ordered what they did. Neither times was the resident able to give an answer….how sad. It's like they are just throwing anything at the wall to see what sticks in terms of results and disgnosis.

    There IS NO COMMUNICATION between docs/ nurses to the pt most times because when I show up to the pts room to draw labs they are asking me… in much frustration I might add…why they are being poked AGAIN. All they know is we keep taking blood samples but nobody is telling them results or why they need to have frequent blood work done in the first place. As a phleb, I cant tell them anything about results… I tell them they need to talk to the doctor of which they quickly retort, " I HAVE YET TO SEE ONE!!" ..and the patient has been in the hospital three days already. I realize some patients fail to remember the doc visiting so that isn't always the case but the point is more how much I hear that.

    At the end of your talk with Dr. Marty he's states that nobody is asking for the input of frontline workers or else things would probably change at a quicker rate. Well unfortunately, I have to respectfully disagree with him at least concerning where I work. The hospital annually issues an "employee engagement survey" of which every employee is all but harassed into completing. It asks for ways to improve all the areas of the care we provide. I personally end up writing what could be considered full letters on things I see yet nothing ever changes…. I still see the hospital operate understaffed, many units without charge RNs or sufficient CNAs, constant waste of resources in areas that can easily rectified. In the lab we are continually dealing with being forced to work with garbage supplies that have intentionally replaced quality supplies for the sake of saving money, yet the hospital will overlook the egregious waste of money in other areas. IT'S UNBELIEVABLE!! I dont know why they waste money and our time on the stupid survey if they really dont listen and make quality and valuable changes.

    It says something when even the doctors think the way the hospital runs is a joke as well as the quality of residents hitting the market. I talked with one doc a couple weeks ago and asked them what their opinion was on the education of the residents and their ability to truly provide quality care to the public. The response was not good…. this doc is mystified at how incompetent their residents are with just the basics of care. I was told that if many of the residents they work with had to do a residency program where they did theirs, the residents would be kicked out of the program within weeks of starting. This doc is also frustrated at how the hospital has a mission statement that is in such conflict with its actual practice …you can't be the best provider of care when you refuse to invest in those who provide the actual care…it just cant happen.

    I believe TurnTable health/Healthcare 3.0 and Dr. Marty along with others of us who are invested in seeing a better future for our profession come to pass will be the only reason that someday future generations will have the benefit of experiencing. This healthcare system is criminal and needs to be dumped, taking with it all the garbage practitioners who are without conscience and dont care other than to make money.

    Rant complete…………for now!!

  24. How about talking about the American Urological Association's predatory screening of prostate cancer with the PSA test which leads to overdiagnosis and overtreatment. The CDC proposed obtaining informated consent for the PSA but the AUA successfully lobbied against it. Men are being unnecessarily screened for PC with a PSA and suffering increased morbidity and mortality. The AUA's response to criticism is to launch an attack on the USPSTF and lobby to place a urologist on the USPSTF committee.

  25. Medicare for all would solve this problem. ZDogg dismisses Medicare for All because doctors compensation will fall under Medicare for All. Zdogg would never want to leave his McMansion and live in the same kinds of housing that his patients live in everyday.

  26. ZDogg – You've GOT to watch the Big Short! He's right and this movie is the perfect example of how to tell this story.

  27. Also – Check out the Rosetta people who are working with major employers who are paying all direct medical costs for their employees. These employers are a key to solving the price gouging medical system. (self-insured employers) .

  28. This is exactly what I'm talking about, when I tell people it isn't just one part of medicine and healthcare that's broken! This is a big part of it, but so many people just want to take a one facet approach and it's a multifaceted problem! Thank you Dr. Makary and ZDogg, for helping shed light on the real problems with the healthcare system!

  29. Great interview until "Highly attentive, eager, able body high school students" doing wound care. In other words, nurses are too expensive.

  30. This is shocking to me what hospitals will do. I fought an out of network bill to the death and won that fight. Medicare isn’t a standard though and typically doesn’t cover overhead. I think it’s important to also focus on how insurance companies have hurt doctors by reducing reimbursements by putting physicians against each other. There is no standard and this is a large problem. What does quality care cost? Market people will say what it will bear – we can’t bear the current conditions long. Can’t wait to read the book!

  31. Good article
    https://www.washingtonpost.com/health/uva-has-ruined-us-health-system-sues-thousands-of-patients-seizing-paychecks-and-putting-liens-on-homes/2019/09/09/5eb23306-c807-11e9-be05-f76ac4ec618c_story.html
    I especially love their claim that they provided $322 million in charitable care – but when the inflated prices are taken into account it’s $88 million, $83.7 million of which they were reimbursed. Not sure providing $3 million in true charitable care is something to be bragging about.

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