Podcast Episode Transcript: Health care pricing: Why it’s time to consider big changes

With L. Gordon Moore, MD

Gordon Moore: Welcome to 3M’s Inside Angle Podcast. I’m your host, Dr. Gordon Moore, and with me today is Dr. Marty Makary. Dr. Makary is a New York Times bestselling author of ‘The Price We Pay’, which has been described as a deep dive into the real issues driving up the price of health care by Don Berwick, and a must read for every American, by Steve Forbes. A professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health and a professor of surgery at the Johns Hopkins University School of Medicine.

Dr. Makary is a member of the National Academy of Medicine and a leading voice for physicians, writing for the Wall Street Journal, New York Times, USA Today, and is a frequent medical commentator on Fox News. He has served in leadership roles at the World Health Organization and has published over 250 scientific articles on organizational culture, vulnerable populations, and health care costs. His current research focuses on the appropriateness of medical care, health care costs, and innovative models of relationship-based care.

He serves as the executive director of Improving Wisely, a national collaborative to reduce unnecessary care and serves as editor-in-chief of medpagetoday.com. His previous books include: Mamma Maggie, and Unaccountable, which was adapted for the TV hit series, ‘The Resident’. He’s a graduate of Bucknell, Thomas Jefferson, and Harvard University; and completed his surgical training at Georgetown University and subspecialty training at Johns Hopkins.

Welcome Dr. Makary.

Dr. Marty Makary: Great to be with you, Gordon. We’re doing this, it sounds like.

Gordon: We are. This is terrific. I’ve got to say, I’ve heard you speak before and it’s really exciting in hearing about the work that you’re doing. I’d like you to tell me about what inspired ‘The Price We Pay’ and how did that come about?

Dr. Makary: Well, I think that you write a book if you feel that there is a message out there that needs to be told that is not currently being told. For me, that message was, “Why does health care cost so much? Why has it resulted in the United States losing its competitive advantage in manufacturing and so many businesses? Why is it crushing homes and households and families; and why are wages really burdened by this once expense that businesses just can’t seem to understand?”

So I wanted to do a deep dive. Everybody has their perspective on the problem. Everyone has got their personal experience or their opinions. We’re a country of very opinionated people, right? It’s not that we’re bad people. It’s that it’s fueled by social media and shouting and talking with authority about topics that people have no idea—they have no expertise on—but it’s, you know, fueled by this kind of Twitter and social media world.

I wanted to take a step back from all of the research and all of the wonky policy stuff and just listen—something that we don’t do very much of anymore—and listen to everybody. Listen to the small hospital CEO, and the big pharma executive, and the nurse on the frontlines of a hospital, and a case manager, and the folks running pre-authorization at an insurance company. Talk to everybody, get their takes, and come up with a very simple business of medicine 101 kind of book. A book that anyone could read and feel like after you read it, now I understand exactly how the system works.

There’s no textbook for it because it’s got so many things. And everyone has got their own biases. We have these implicit biases we don’t understand. If you ask an OB doctor, why does health care cost so much? He’ll you malpractice insurance. If you talk to a primary care doctor, they’ll tell you because it’s lack of care coordination—because of a lack of a medical home. Talk to an orthopedic surgeon, they’ll tell you it’s the lack of dedicated teams or the reliance on fee‑for‑service, rather than value. Talk to a cardiologist, they’ll tell you it’s readmissions from heart failure.

Everybody has their own vantage point and everybody is correct. It’s just somebody needs to take a look globally. So I personally, Gordon, was just blown away by the book, “The Big Short”—if you saw that movie?

Gordon: Oh, yeah.

Dr. Makary: I just thought, man, if somebody could put together the business of medicine, explain health care, and all of its nuances, and the reasons why health care costs are going up, in a way that anyone can understand, even at a sixth-grade reading level with stories and experiences and things that made it all make sense, you could de-code what credit default swaps—how they were decoded in “The Big Short”—and make it actually exciting; and that was the goal of the book.

Gordon: What’s the credit default swap in health care?

Dr. Makary: I would say it’s the negotiated rate, what I call the game, or the system that we’ve inherited. By the way, nobody came up with system who’s in health care today. This is a game we inherited—marking up prices and then offering selective and secret discounts, so that the actual sticker price is meaningless. If you actually get a kind soul who has quoted that actual price, you feel embarrassed and want to just cut it down because you realize it was never intended to be a price that anyone pays.

That whole system: the billing, coding, appeals, customer service, bad debt collections, process—a game that starts with negotiating these discounts—is what I call “the game.” People don’t like it. We all play it. It doesn’t make sense. It’s not patient-centered and it’s being completely disrupted right now by a bunch of innovators. That was the great privilege of writing this book is, telling the story of the great innovators of health care.

Gordon: I’m curious about the disruption that’s happening there. Give me an example of some?

Dr. Makary: Well, I’m a part of one company called Sesame Care. If you Google Sesame Care, you’ll see the Sesame website is, basically, becoming like the Kayak of health care, where you can go on there, look up a procedure or a service or a consultation that you need, get a price—and the quality metrics are maturing—and we’re starting to actually create open and honest market places and this is being fueled by the high-deductible marketplace.

Deductibles are not coming down next year, guaranteed. The deductible for the average American is not coming down any time soon. So that means they’re basically paying for their own care. Now all of a sudden, those real prices get rewarded in the marketplace if they’re really honest and fair.

MDsave is doing something similar. We’re going to see a couple of these big search sites become the online marketplaces for the next generation here. So that’s an exciting thing going on. The relationship-based clinics I fell in love with and was privileged to tell their story. There’s just so much cool stuff like that where you have people in the industry saying, we can do this much better.

Gordon: I want to chase both of these; they’re interesting to me, but I’m thinking about publishing a rate. So when I set up my family medicine practice back in the day, I asked my old office manager, “I got to set up a fee schedule, what do I do?” She said, “Well, you look around. You say, this insurer pays X and this insurer pays X times 1.5, and they’re going to give you whatever you ask for, or their negotiated rate, whichever is less. So you want to find the fattest payment from the fattest payer and set your fee schedule with that. Then they’re going to give you whatever the discounted rate is. I was like, “That’s just so weird.”

Then I think about that piece of complexity. So then, I’m going to nuance what am I getting paid from the different insurers. If I’m a patient seeking care, my insurance company has a negotiated rate. Maybe my employer has negotiated a special rate for a certain kind of thing. Maybe I have a certain out-of-pocket co-pay, and maybe the procedure is negotiated a certain way. How does at Sesame Care anybody adjudicate all that information to give me my out-of-pocket costs?

Dr. Makary: Well, when you go to a restaurant and say, “Can I see the menu?” They don’t ask you, who’s your employer? If they did, you’d say, “Wait a minute. I’m looking at a menu that could be half or three times the price of the next table, but I’m not allowed to see their menu? What kind of free market is this?” So you realize that creating some degree of transparency makes sense. That is why you have hospitals and clinics and surgery centers now saying, “MDsave, you want a price for your online platform? Sesame Care, you want a price for your online platform? I’m going to give you a price and it turns out to be 30 to 40 percent less than what they gladly accept from an insurance company.

Why? Because they are getting paid in cash up front. They’ve eliminated claims, appeals forms, claims processing, paying the licensing fee to the AMA Code Book for using their codes, customer service, collections, bad debt; all of that. They don’t even have to negotiate contracts for that price because it’s a fair honest price and the market is hungry for it.

If you went to buy an airplane ticket on Expedia and there were no prices and instead it said simply, “American Airlines will bill you after the flight.” That’s is the absurdity of American health care for elective shoppable services—which by the way, is 60 percent of medical services.

Look, I’m a surgeon. If you get shot in the chest, we’re going to take care of you. We’re not going to give you a price and we shouldn’t. I’ve got to focus on taking care of you. But most of health care is elective or scheduled, or there is an opportunity for people to be informed when they make their choices.

So if the airline simply sent you a bill after the flight, guess what, the public would lose trust in the airline industry. They would despise some airline companies—you could argue more than they already do. They could argue, these are not predictable flights. We don’t know if there’s going to be a delay or cancellation. Or the pilot may experience turbulence and have to bill more RVUs when they land the plane and spend 30 minutes coding. You’d say, “Look, this is a crazy system. Let’s redesign it.”

The pilots don’t like it. The people on the planes don’t like this system. Let’s come up with a way where the airlines build in the predictable risk into a flight, including the risk of a crash, you name it. Risk of a cancellation; all risks are built into that price and they give you an honest and fair price. I’m a surgeon, we can do that with standard gallbladder surgery. We can do that with hysterectomies and breast biopsies. These are ways in which it is embarrassingly simple how we can provide real value in the marketplace right now.

Gordon: One of the complexities I think about then—if I put my population health hat on that I can look at, let’s say, somebody who needs a gallbladder surgery. I’m not a surgeon, so you got to tell me. There’s the relatively young healthy person and there’s the frail sick person who has vascular conditions, diabetes, etc, etc. Is that the same surgery? Is that the same complexity?

Dr. Makary: Yeah. So those are things that we can categorize, right? We can basically create a simple system of stratifying cases without hyper-stratifying them. We don’t need to stratify that price by every last detail of your flu shot at birth when you have a surgery as an adult, right? But, we do that. The ICD-10 book has got stuff on there that is not in the ICD-9 book and it’s just getting so out of control.

Can we let the market work as it has in plastic surgery, in cataract surgery in some places, in many places in the world? Lasix eye surgery, IVF treatments, these are sectors of health care that have already moved to transparent pricing where the price globally has come down year-to-year as the rest of health care has had their prices outpace inflation year-to-year.

Gordon: I’m a consumer now; I’ve got price transparency. You’re the surgeon; you’ve got some way of adjusting for a handful of reasonable factors about how complex it’s going to be to do the surgery on me. But how do I know you’re a good surgeon? How do I know that I’m going to get good care?

Dr. Makary: If there is one television for sale in your town and it’s for $500, your brain thinks do I buy it or not? If there’s two televisions for sale, one is for $500 and the other is for $575, your brain will automatically ask, “Well, what are the differences? What’s the warranty? What’s the specs? What’s the technical difference? Can you tell a difference from looking at the TV? What are the experienced ratings of those who bought that TV over the last few years?”

Price transparency ushers in quality transparency. The fundamental problem with quality transparency and the reason it has stagnant for so long, is that it has not had that impetus, or the push, from those who are shopping for care. If you think that price transparency alone is the silver bullet, I’ve got news for that person. It’s not. If you think it’s as simple as publishing your hospital compare quality scores next to it, it’s not that simple.

What we are seeing right now is a complete launch of a new field of patient-centered outcome measures, patient-reported outcomes, which research now finds is as reliable as outcomes independently abstracted by an independent clinical nurse reviewer. I mean, why is it that all quality measures are triggered by doing something? I, as a surgeon, have to operate and then that triggers the outcomes of that patient. It looks at the consequences of that operation. But those consequences: the infection rate, the readmission rate—you name it—are all triggered—that is the collection or search for those consequences begins with doing the operation. If there is no operation, those quality measures are never triggered.

So as we say in surgery—there’s an old saying, if you operate on patients that don’t need surgery, you have great outcomes, because everyone seems to be doing well. The question is, “Can we measure appropriateness?” The real question is not, “What are the outcomes after doing something”—that’s part of it. The real question is—and the question the patients are interested in is, “What are the outcomes for people who present to you as a doctor with that clinical scenario?”

So we have developed incredible questions that we are asking people that have a high-capture rate. They are questions like, “What is your activity of daily living relative to your activity before the procedure or before you presented to that doctor?” We ask outcome questions a good three and six months out because, you know what, in the first couple weeks sometimes you can’t tell; and we surgeons say, “Give it time.”

We’re asking questions like, “Would you recommend this particular doctor to a friend who is in the same clinical situation you were in? Do you believe that you were diagnosed and treated appropriately?” Now, we don’t want to consume risk-driven culture in quality measurement, but there are outliers relative to peer physicians who do the same type of care, those are things that are measurable. So we’ve been developing appropriateness measures.

By the way, can we value things that are not interventions or are different types of interventions? Can we start talking about the benefits of physical therapy and ice for back pain, instead of just surgery and opioids? Can we talk about cooking classes for those with diabetes? Can we talk about counseling people and addressing their sleep as recognizing that poor sleep is a disorder just like other medical conditions; and that poor sleep contributes to high blood pressure instead of simply throwing medications at people with high blood pressure?

Can we talk about food as medicine? Can we talk about high and low inflammatory foods for people with inflammatory conditions? Can we talk about the holistic care of the patient? That is something that has been almost completely forgotten in the modern world of quality measures.

Gordon: So as you think about those other interventions and you broaden the scope to capture things that are not currently measured, how would you track and understand do these have an impact; is it good for a person to receive those things?

Dr. Makary: First of all, a lot of stuff in health care is measurable, but the field has not matured yet. There are other things in health care where we’ve already developed appropriateness measures—me and my team—and we are using that in the field today. A lot of organizations out there in the country are using our appropriateness measures now. I talk about them in the book, The Price We Pay. Let me give you one example. What we do to develop appropriateness measures by way of background, Gordon, is we meet with specialists who are doctors practicing in a very narrow area of medicine.

We talk to hand surgeons. We talk to doctors who specialize in the inner canal of the ear. We talk to neurosurgeons that specialize in spine surgery, and we ask them, “Tell me if there’s an area of overuse in your field that can be measured with claims data?” Sometimes they don’t have an answer. Other times, we sort of nudge them by saying, “Is there a practice group in your region that is doing things they shouldn’t be doing?” And then unload. It’s just like it all comes out. “Yeah, they’re doing follow-up colonoscopies within six months of most of their patients.” We write all this down. We take it back to our shop and we basically create appropriateness measures.

When we met with the skin cancer surgeons that do a very elegant operation called Mohs surgery, they told us about a practice pattern of taking too many sections of tissue when removing the cancer. Rather than removing it in the minimum number of sections necessary, they take basically excess numbers of sections, sometimes cutting right through the cancer because they get paid per section removed. It’s a perverse incentive in the system.

First of all, most doctors do the right thing, or all of us try to. But those outliers are very expensive. Sometimes they’re high-volume doctors and they’re affecting a lot of people. So we’ve measured, in the medical claims data, “What is your average number of sections per skin cancer when you do this operation over the course of a year?” We are not going to ding somebody for having a complex case or a couple complex cases. Let’s look over the course of a year at your average number of blocks or sections per case. Then we go back to the experts and say, “What is the threshold of what would be considered too much?”

If you saw a number that was somebody’s average, at what point do you say, ‘Look, that’s really hard to justify. That raises a serious flag. There should be a closer review.’ They say that’s around 2.3 sections per cancer. If you as a doctor average more than 2.3 sections per cancer, that’s an average—practice pattern average—that’s a flag. Well, guess what, there’s a group of surgeons in the United States that are not only over it, they are way over that threshold.

So we did a national project where we took half of the surgeons in the country that do that procedure, sent them a simple, friendly, cover letter with a report on it showing them their performance, their average number of sections per case, relative to all the other surgeons in that specialty nation-wide. Guess what happened to the high outliers? They reduced their behavior, their overuse—the patterns of overuse.

Gordon: Why? Why would they do that?

Dr. Makary: Well, one, I think we’re very competitive as doctors to be very honest. I don’t think anyone wants to be an outlier. I think there is some degree of, “Oh, my gosh. My peers are all performing in this group and I’m a poor outlier. I’m doing way more.” We used very statistical language saying that you are using more stages per case than 99.4 percent of all Mohs surgeons in the country. I think people don’t want to be outliers.

When we shared this back with them, there may have bene a sense of, “Oh my gosh, if CMS or some regulatory body or reimbursing body sees this, I could be penalized and maybe there is that sort of implicit sense of, hey, this is a warning. This is a shot across the bow that I need to get my act together.”

Well, 83 percent of the outliers reduced their pattern of overuse immediately. It’s been sustained now for two years. It’s saved Medicare over $20 million. We published this study. It’s incredible the power of data transparency and actionable data that captures appropriateness of care, not just the consequences after the care.

Gordon: That’s interesting. It rings a bell. I have to go look up the source, but I remember hearing that in criminal or marginal behavior, the probability of being caught, or capture, has a greater impact on the behavior than the stiffness of the punishment. Capital punishment, is that going to charge the Mohs surgeon? I don’t know. But like all of a sudden somebody is noticing and they’re getting a letter, I’m guessing that’s why you have to use claims data, because you have access to that—whether or not somebody wants you to—obviously, within reasonably parameter and PHI and all that stuff.

Dr. Makary: Yeah. We used real-time Medicare data, which I have access to the Medicare servers. We did this as a part of quality and improvement collaborative. By the way, our cover letter was very friendly. It was actually signed by the respected leaders in the field, saying, “As a courtesy, we are letting you know where you stand around this appropriateness measure that we’ve developed with Johns Hopkins.”

Now, around the same time, someone over the anti-fraud, what they call the CPI division of Medicare—it’s the Center for Program Integrity. That’s where the fraud, waste, and abuse stuff falls under Medicare—they had sent a letter unbeknownst to us, around the same time, to doctors who prescribed way too much Seroquel—something that should be prescribed very sparingly in older Americans. They simply showed them, this is how much Seroquel you’re prescribing relative to your peers nationally.

Their letter was not friendly, Gordon. It was nasty. It threatened an audit. It threatened all kinds of stuff. It was nasty. Guess what kind of improvement they saw? The same; they saw the same improvement. Whether or not the letter was friendly or nasty, there was a change in behavior immediately and it was sustained, saving folks a lot of harm and money.

Gordon: I like staying on the side of civility. Let’s take the high road. I think that’s good. This is what you’re doing with the Improving Wisely. You’ve got a bunch of measures. Tell me more about that.

Dr. Makary: We’re using appropriateness measures in several different capacities. One of those capacities we partner with physicians specialty organizations. It gives them the opportunity to rally around it, to help provide some gravitas. We work with physician groups. I work with some payers. I work with hospital organizations; all kinds of health care organizations. Everyone right now is hungry for some meaningful quality measure beyond the standard infection rate, readmission rate, HEDIS measures.

They have a role and they have a value, but at a certain point, you really just can’t capture much more variation. We know there’s tremendous variation. For example, we developed a measure that looked at how often a procedure is parsed into two days when it really should be done on the same day. Like, you need and upper and lower endoscopy.

You have a resection of a skin lesion and then you come back on a separate day to have it closed. These are things that normally should be parsed out five, ten percent of the time in somebody’s practice, or less. But there are some doctors that parse them out into two days, 50, 90, 100 percent of the time in a high-volume practice. It’s their standard routine. It’s very measurable. It’s not on the preauthorization radar because sometimes you have to do it that way. But we can look at patterns.

We thought, “Can we instead of creating this narrow guideline, the path that is essentially quality measure in the spirit of most quality measures that ‘always do, or never do.” By the way, we doctors hate that—telling us we should always do or never do? If there’s really strong evidence, okay fine. But you know what, not even every patient reads the textbook of that evidence and sometimes there’s still exceptions.

So the ‘always do, never do’ often just means a lot of barriers, a lot of hurdles for those of us that are busy doctors who are doing innovative cutting-edge thing. But instead, can we look at patterns and concerning patterns defined by a clinical consensus of peers. Nobody has done that work—to get a consensus among doctors in a narrow field about what pattern is too frequent.

So that is work right now that’s been highly-valued in the marketplace to say, ‘What C-section rate is too high if we include twins and triplet deliveries?’ We’re not going to exclude everything, let’s talk about a heterogeneous practice mix. ‘What level is too high? Forty-seven percent?’ Guess what, you’re never going to have a randomized control trial to tell you that a C-section rate above 47 percent is too high. There should be a trial, right? We have to listen to clinical wisdom and use clinical consensus.

We have been intoxicated with this narrow view of quality as defined as quote/unquote “evidence-based defining evidence in a very narrow way as supported by a level 1 study, which is a randomized control trial.” You know what? There is great evidence that lives in the wisdom of practicing physicians presented in consensus and it complements the randomized control trials; it doesn’t negate it or supersede it.

I think that right now is an exciting area, because you will never have a randomized controlled trial that tell you that a parachute works out of an airplane, nor should there be. That is not a question designed to be answered with a randomized control trial. It turns out a lot of health care is like that.

Gordon: I also think about the transaction cost of measuring discrete processes that are occurring minute-to-minute between patient and the clinician in practices. It’s exhausting. I’m reflecting back to your comment about you’re looking for patterns not pre-auth. You developed these appropriateness measures. What’s the risk of these being turned into prior authorization hurdle that doctors have to go through?

Dr. Makary: Well, prior authorization is sort of a necessary thing that, unfortunately, we have to do in parts of health care because there is some, unfortunately, abuse among a small number of physicians in most specialties and it’s driven by the things that we’re well aware of—the fee-for-service lure. We don’t want physicians ordering CAT scans every day on somebody, so there needs to be some guardrails around what is reimbursed. Otherwise, we’re just creating this system that promotes fraud. I describe that in the book ‘The Price We Pay’ with these vascular procedures putting stents in people’s legs, trying to convince patients that they have some symptoms.

Well, you can convince almost any 70-year-old or older individual that they have some leg pain. You spend enough time with them, you will convince them that they have some leg pain. Then to tell them, “Oh, we found a little narrowing here in the femoral artery”—which is long. It’s not like a coronary artery. You’re more likely to find some plaque. “Oh, and we opened it up with stent.” This is the kind of overkill, fraud, abuse that we need some safeguards against.

So rather than say, “Hey, you did it in this one person, now you have to go through this massive system of preauthorization.” Instead, could we say, “Let’s look at your pattern? You are an inlier, you’re not an outlier, and therefore we’re going to gold card you. We trust you. You do what you think is best in patients. We’re going to revisit this in a year.” You do these spot checks in the data around practice patterns and it turns out its much more efficient; the payers like it; the doctors like it, and so you’ve got a system that is a much more value-based system that way.

Gordon: That makes a lot of sense. Again, I just think about the extraordinary burden on practicing clinicians responding to discrete data calls they have to pull out of their EMR; and you talked about doing this from administrative data, so I like that a lot. If you’re happy with that, I’d like to shift to modern times and COVID and what’s happening; and about your piece where you talked about re‑opening. I want to hear about that.

Dr. Makary: First of all, the COVID journey has been really fascinating for me. It’s been a real sort of journey in a sense that I’m not an infectious diseases doctor, but I have a faculty appointment at the Johns Hopkins School of Public Health; and I talk to a lot of my colleagues. As I talk to virologists and epidemiologists and infectious diseases doctors in January and February—I follow Dr. Scott Gottlieb, the former FDA Commissioner, very closely. I respect his judgment tremendously. He’s one of the people I learn from in reading the stuff that he puts out.

I would read the data that he would share about what’s happening in Wuhan, China, and then soon after in Italy. I would take it back to the infectious diseases experts and ask them, “Is this a very real threat that the Harvard epidemiologist, Dr. Marc Lipschitz, is suggesting it might be? And if so, why don’t we just start contingency planning?” They all, basically, said, “You know, Marty, you’re right, but we don’t have the platform.”

So I decided to write an article that ended up going viral and it said why I’m very concerned. Basically, I describe this complete disconnect between public opinion, including some of the federal agencies, and the experts; and how I became educated on this. Then, I, along with a couple other folks, went to the mayor of Austin and begged him to postpone South by Southwest, which was supposed to take place in late March, assembling almost quarter million people from around the world in Austin, Texas, where I spend a fair amount of time. I’m like, “No, this is a bad idea. What’s happening in Italy could happen here.”

We went to the mayor of New Orleans about Mardi Gras, and the NCAA, begging them to postpone the tournament. I started staying, “Why are we doing this? Where are some of the experts in this thing?” I realized the media just was not giving them airtime. They had very strong feelings about this. They believed we needed contingency planning. I couldn’t believe it. So I, basically, went to the TV networks. I’ve been going on different media platforms ever since I worked on the World Health Organization surgery checklist project, and haven’t written some books. I’ve been on the media a fair bit.

So I said the reason to go on the media, is if you believe there is a message, again, that is not being told, that needs to be told—and right now there’s a strong message I believe that’s not being told: our experts believe we need contingency planning. Contingency planning around non-essential travel, non‑essential business activities, public gatherings, preparing to potentially close schools in March or April.

I said, “Stop getting these political pundits to go on TV. We’re stick of it.” By the way, I’m kind of sick of it even without COVID. “I don’t want to hear all their opinions. You have all elected politicians and Republican and Democratic strategists—really, honestly, we don’t want to hear their opinion on COVID-19. We want to hear from the experts. Let me tell you what the experts are telling me.”

So I wrote that piece that went viral. I went on CNBC, basically, pleading with them to get the word out, sound the alarm, tell people to develop contingency planning. I urged businesses on CNBC to transition into the delivery business for restaurants and other businesses. To plan on curbside, retail transition strategies, and non-essential activities. So I went on this little crusade. It turns out some of these things, like the CNBC appearance, which ended up getting titled in the world of getting forwarded around, it titled ‘What happened in Wuhan could happen in the US’.

Then the country, basically, ultimately, sort of got it—some of the country. Places went into what we recommended, which was kind of a stay-at-home order. We didn’t know what we were dealing with. We didn’t know if it would be worse here than it was in Italy. So around that that, I felt like we’ve peaked now in terms of hospital capacity or the number of hospitalization. Now it’s time to talk about re-opening.

So I wrote a piece in the New York Times that was basically titled, ‘We need to Reopen Carefully.’ I called for—at the time it was a foreign concept; a lot of people laughed at it; I took a lot of arrows, but I called but universal masking. A lot of debate. And for two months—it’s been, I think, almost three months since I wrote that New York Times op-ed, calling for universal masking. It’s almost as if it went from having five percent public support to 80-85 percent public support. So that’s been my journey on this. I didn’t plan to be at the center of COVID, but I think using the general principles I used in research and that is, listen to the experts who know what they’re talking about.

I felt a moral obligation to speak up and I’m glad I did. Now I go on Fox News frequently. I feel privileged to be able to have that platform to tell people what I believe is the truth and that is, when you take this virus seriously, lives are saved. When you don’t and you blow it off with all kinds of unscientific ideas, then people get hurt. So that’s the message that I think we need to stay on.

Gordon: Dr. Marty Makary, thank you so much for your time. I hope folks listening will look for your stuff in the Wall Street Journal, New York Times, USA Today; will go out and grab a copy of ‘The Price We Pay’ and read it up. Then we can engage in lots of fun conversations. It was a terrific read and a terrific conversation.

Dr. Makary: My pleasure.

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