Podcast Episode Transcript: Lessons from organized crime for improving health care

With L. Gordon Moore, MD

Gordon Moore: Welcome to 3M’s Inside Angle Podcast. This is your host, Gordon Moore. With me today is Dr. John Wasson, a colleague, with whom I’ve worked in the past at the Institute for Healthcare Improvements in all sorts of interesting work around out-patient settings. Welcome Dr. Wasson.

Dr. John Wasson: Thanks, Gordon, nice to be here.

Gordon: John, tell me what’s the work that you’re into now, and then I want to get into an article that you published recently.

Dr. Wasson: Well, the work I’m into now, so to speak, is what I’ve been into for four decades, at least of research if not more, and that is trying to make the patient the key part of our healthcare system. Fortunately, over that period of time, technology has advanced enough that it’s really quite easy to do. So we’ve had continued development of our HowsYourHealth.org website supporting that type of interaction.

Gordon: That’s where our conversation is going to go today, because you’ve done so much work in thinking about what really matters to people and where there’s a gap between what matters to the people and how we think as clinicians and how the healthcare delivery system serves that. You wrote an article recently with a pretty interesting title: What do organized crime and health care have in common? That’s something I’d like to follow up on. Where did that come from?

Dr. Wasson: Well, years ago during medical school, and actually during college, I worked as a maître d’ at a resort that catered to a fair number of well-known figures from organized crime. Being a young guy, I observed what they did and kept track of some of them over time.

Gordon: That sounds like a really interesting job. Tell me more.

Dr. Wasson: Well, it was an interesting job as far as those jobs we all take part in during high school or college and medical school, but the most interesting thing was a character that I met named Tony who exemplified in many ways a story that’s applicable to healthcare and it was that story that I told in the article.

Gordon: Tell me more about Tony.

Dr. Wasson: Well, Tony was a fascinating guy. He was what was called in the media, “A new breed of labor leader”. He was head of the International Longshoreman’s Union. He was very articulate and handsome. He lectured at famous Ivy League institutions. He was being considered for Secretary of Labor of the United States. He also happened to be a member of the Gambino family.

Gordon: Oh my. Now, help me understand how this pertains to health care.

Dr. Wasson: The way it pertains to health care is Tony’s story. He was eventually indicted and found guilty on all 20 counts for money laundering, extortion, tax evasion, and sentenced to 20 years, but he only served three. There is a message in there. The three messages that come from organized crime are the following: first, when you observe people like Tony, they make it pretty much their business not to damage the host. In other words, they know they’re doing parasitic work: they’re extorting, they’re doing things like that, but they know not to do too much to damage the host.

Secondly, as Tony’s sentence and time served indicates, he’s sentenced to 20 years and only serves three. How is that? Well, he watched his reputation. The third point, whether we like it or not, organized crime when they get into trouble they adapt aggressively and quickly.

Gordon: I think I sense where you’re going with this. We’ve got: “Don’t damage the host, watch your reputation, and adapt.” Is that how you pivot this to healthcare?

Dr. Wasson: Exactly. If you think of healthcare, first of all, we’re damaging the host badly. We’re now 20%, or one out of every five dollars of GDP, are going toward healthcare and that’s money that could be spent on infrastructure and other good works in the United States—and people are noticing that.

Secondly, in terms of reputation, the number of stories I documented in the article called Insights from organized crime for disorganized healthcare. In that article, I reviewed the Wall Street Journal and New York Times for multiple decades and documented the incredible increase in stories and amounts of money that those newspapers are attributing to corruption. In order words, we’re damaging our reputation.

Most importantly, is our inability to adapt to the 21st Century; we are still structured using yields from the 20th Century, educational patterns from the 20th Century. Technologies: our EMRs are for billing in the 20th Century, etcetera. Those were the lessons that I wanted to extract from Tony’s story and move from there.

Gordon: You mentioned corruption, that’s a pretty strong word. I know that there’s a great deal of waste in healthcare. Are you equating corruption with waste?

Dr. Wasson: Well, it’s estimated that about a third of US healthcare dollars is waste and of that the estimates are that a third of that is corruption. So it’s not me estimating it, it’s actually out there. If you go online, you see sadly just all types of stories. You just say, “Who is doing that?” In the old days we could have said, “Well, there are a few rotten apples.” But now it seems that the whole tree is rotten.

Gordon: Give me an example or two of corruption that you saw in these articles.

Dr. Wasson: Well, I would say there are many. First of all, we all know the opioid crisis right now. I mean, that’s a perfect example of corruption up and down the tree everywhere in healthcare. That’s the most recent bad example, but there was another recently exposed in New York State, where six very prestigious hospitals were playing with Cayman Island accounts, going back and forth in a form of extracting money from insurance companies and then kicking back. It was very convoluted and these were six very prestigious hospitals.

Gordon: Let me come back then to your point about adapting. You described how organized crime can adapt to change and yet in healthcare we’re using 20th Century tools. Tell me more about that. How can we adapt?

Dr. Wasson: Well, in the article, I used two examples to illustrate adaption. One is in the technical area and the other is in the area that you and I have spent our lives, which some people call the cognitive area of healthcare primary care, etcetera. In other words, not doing technical stuff, but doing interaction and trying to improve outcomes by management. Regarding the technical story, an example that stands right out is Mohs surgery.

Mohs surgery is the type of surgery that’s done for skin cancers that could cause problems if they’re not taken out completely. Those are called, for example, squamous cell cancers or basal cell cancers, particularly on the face. Well a Mohs surgeon takes the scalpel, removes them, and looks under the microscope to make sure that all the cancer cells have been removed. Now, that’s not something that sounds terribly complicated, does it? Yet, a Mohs surgeon has had 13 years of training to hold the scalpel and look under a microscope, when for example, nowadays, artificial intelligence is better at looking in the microscope and diagnosing cancers than a pathologist.

Just think of that as one example of an incredible waste of resources training that person who now probably has a fair amount of debt after 13 years of education and wants and needs to be paid well to pay back his or her debt. Society is going to pay for that. We should be changing our whole educational system in that direction.

Gordon: That’s pretty challenging. I think that sort of one of the stories you hear about across in the US in terms of people who’ve been trained one way but then the economy and the world moves in a different—and now they’re skills are no longer necessary.

Dr. Wasson: Yeah, you got to adapt aggressively or you become, you know, stuck in the past.

Gordon: John, you’ve talked about adapting on the technical side, but what about the cognitive side? Should we be adapting and if so how?

Dr. Wasson: The cognitive side is where we have spent a lot of time trying to think about the adaptions that make the most sense and are feasible quickly. Clearly, medical education and training is going to change dramatically in the near future. You look at the younger generation and you ask them, “Well, who’s you doctor?” They may very well point to their smartphone and so there’s been a lot of attention, correct attention I think, toward the use of technology to change care.

Let’s start with our old pattern. Our old pattern is to see a patient in the office, talk to them, hopefully get on the same page with what matters to them, which unfortunately, if you look across the country, there’s huge variation. We’re non-standardized. How you talk to a patient and find out what matters to them maybe very different that what I would find out. So that variation can result in very different treatments.

In addition to that type of variation, there’s a crazy variation of when you or I might bring them back for a revisit. We’ve found again and again that you might be a “bring him back in two months” kind-of-doctor and I might be “bring him back in six months”. There is no rhyme or reason to that and yet it makes a big difference in monies spent.

Over the years, for example, we showed that if you substituted telephone house-calls for face-to-face revisits, you actually improved the outcomes, but our payment mechanisms are still based on face-to-face visits. So we’re in this cycle of not being able to adapt when we know a lot of the stuff we’re doing is crazy. So revisits, we could be doing a lot more telephone outreach or smartphone outreach and places are doing that more and more that can get around the payment game, such as Kaiser Permanente.

In addition to that, there’s a “get on the same page” issue, I alluded to and it’s in that area that we’ve spend a fair amount of time doing research. I think we’ve come up with some very useful tools for doing that.

Gordon: You know it’s interesting, I remember the study you published in 1992, I think—way back—talking about how you could double the time between face-to-face visits, putting some calls in between just to check up on somebody, and it resulted in lots of satisfaction, fewer bad events like: hospitalization and ED visits; and the decrease in prescribing rate, which was kind of interesting. The sense that I remember from that article was that maybe all those things are lanes—maybe I prescribe less and it’s actually better for people, because I’m less likely to trip them into polypharmacy and the consequences of that.

Yet you identified the key challenge. We don’t get paid that way. You published this article in the 1990s and here we are in 2019 and I still hear what I talk about different ways of doing work. Colleagues will say, “Yeah, that’s nice I’d like to do that, but we can’t get paid that way.” Why is it that we have such an incapacity to change the payment system, at the same time there’s such a gross understanding of recognition that the system is not working?

Dr. Wasson: Yeah, that’s the key isn’t it? Change is difficult, particularly when you’re set up as healthcare is with corporate structures, all types of people employed in different activities, and you’re talking jobs in the end of the game, or sunk costs in the way that the computers are set up, etcetera, etcetera. So it’s tough, but adaption is going to have to happen because it also was tough for Chicago taxi cabs to think about doing something different.

Uber came in and the ballgame was over. The same with Sears, thinking, “Oh heck, we have a good monopoly” and Amazon comes along. That type of pressure is going to build especially when you’re damaging the host as much as we are. We have that reputational problem. That’s why the article is a call to say, “Let’s start thinking about these alternatives, to speak very specifically about that.”

When you think about quality of care, there are much better ways to do that simply and more efficiently and improve patient outcomes, but it’s going to be hard for us to move in that direction, I agree.

Gordon: Both of the models you raised are coming from the outside, an innovator steps in and basically says, “Enough of you all, I’m going to do it a different way and whatever happens to you it’s on you.” You think that’s what it’s going to take in health care?

Dr. Wasson: I think it is happening in healthcare and a lot of that, unfortunately, is going to fragment further and raise costs as well. Economists look at healthcare problems right now and say, “Look, it’s all about pricing.” It’s like a game of Monopoly, in which healthcare has monopoly position and has get out of jail free cards, like Tony, and in addition to that can, you know, can gouge on prices. Everybody is doing a bit of that. We’re all part of the problem. So I agree with you, it’s tough but there are some simple solutions that I listed in the article.

Number one, regarding the simplest which is reputation; there are many, many websites online that you can look at and call in corrupt practices. We should be doing that aggressively, rather than waiting for it to appear in the paper. Every dollar we save in that area is potentially a dollar that is going to help society and possibly help those changes that are going to be painful.

Gordon: You mean having like a whistleblower or reporting site or something like that?

Dr. Wasson: Yeah, those exist. Actually, there’s some physician groups now that make their money being whistleblowers. They go around looking for all the corruption and take a slice of the action from the Justice Department when they report it. You know, it’s sad, it’s a sad commentary, but it’s something that we can do.

Secondly, in terms of changing the way we deliver technical and non-technical care; in the technical area, that is definitely “cruising for a bruising” to use the terminology of the gangs back in the fifties. For example, in some countries now, iPhones are being used instead of dermatologists at the public health level. In that type of technical interference, shall we say in the prerogatives of the past, could result in dramatic changes. A Mohs surgeon won’t be needed anymore.

The cognitive area is the tough one and we’ve come up with simple techniques—that we can talk about in a separate section—about getting on the same page with patients, but there are very easy ways to standardize and those can be done again without a lot of highly-trained clinical input. So changes will come both from within and without. I’m hoping clinicians will become part of the solutions instead of part of the problem.

Gordon: Are there any examples inside or coming at healthcare that you would point to and say, “Here’s a group or an approach that’s getting it right”?

Dr. Wasson: Well, bits and pieces. If you go around the world, as I mentioned, there are some countries that are saying, “Look, I know you’re not happy with artificial intelligence replacing radiologists, replacing dermatologists, replacing pathologists, and others soon to be named, but we’re going to endorse that because that’s better for our society.” That’s one example.

I mentioned the Kaiser outreach use of phones, that’s a win all the way around, definitely for the patients who don’t have to go through finding a babysitter, taking a trip, waiting in a waiting room, etcetera, etcetera—so that’s beginning to spread more and more. Outside of Kaiser, of course, CMS or Medicare and others are toying with that, but the issue is: how do they make sure there isn’t some fraud? Change is coming, but there are a lot of fixed costs and fixed ways we’ve done business.

Gordon: As I think about this, the degree to which an entity or actor has fixed cost is probably inversely related to their willingness to change—willingness, I want to use that forgivingly in a sense of it’s just more and more challenging the more I have invested in the current process.

Dr. Wasson: Absolutely and that’s how it always is with change; the more invested you are in the status quo—in every sense of the word invested—the less likely you are to want to change. Ultimately, we have to ask ourselves, who are we serving? As clinicians, we’re serving patients. As public health workers, we’re serving people. In both those situations, the mantra we should, and often do follow, is “first do no harm”. That is what we are supposedly about. As I’ve mentioned, the harms are we’re damaging the host, we’re damaging our own reputation, and we’re not adapting in any way; and that’s causing a lot of unnecessary hospitalizations, etcetera, etcetera. We should be aggressively at that.

Unfortunately, there’s a third group at the table. Unlike MD or MPH, they might have an MBA. I don’t mean to point fingers, but it’s a different mindset, because instead of “do no harm” as the mantra, a corporate mindset has “maximize profit” as the mindset. Don’t get caught doing bad stuff, but let the law determine what’s allowable or not and not the first “let’s do no harm.”

That’s an important twist, particularly since healthcare has become so much more corporate and that’s probably why a lot of what’s happening now is so difficult to change. We now are dealing with corporate healthcare and the mindset is let’s—even though we’ve got sunk costs, we got to pay the bills. We all heard the classic statement “no margin, no mission”. That’s a business aphorism, whereas, for healthcare workers and public healthcare workers, it’s “first do no harm”.

Gordon: What do you think about the mergers and acquisitions and the coming together of different healthcare entities into ever larger groups?

Dr. Wasson: Well, they’re very clearly corporatization. I don’t have anything else to add to that, except that it’s fixing the status quo. Now, whether the corporations will adapt depends on how much pressure is put on them by shareholders.

Gordon: I just had the sense that the larger the entity, the more fixed cost is being concentrated, the less willing that entity would be to fundamental change. Also, in addition to that, I have this sense that the larger the entity, the more work has to go into coordinating work across that entity; therefore, there’s an increase in the cost of care delivery, the larger the group becomes just because they have to have meetings and they have to have managers and they have to have people who report up and down and the up and down gets bigger and wider.

I’ve always wondered about this quote/unquote “economy of scale in healthcare” when healthcare is working with individuals and working with people and the corporatization and the increase in size being two factors that have been working strongly against actual care—not intentionally. I don’t think it was anybody’s intent to do that, but certainly I sense that that’s some of the main driver of the outcomes we’re seeing today. Do you think I’m off-base on that?

Dr. Wasson: Well, you’re politically in one camp. As you know, there are two ways to view it. Corporatization or business aspects of healthcare do argue that, “Look, efficiency is what it’s all about and we are much better at efficiency than healthcare providers are. Therefore, we can drive the cost down and the value up”—value being quality divided by cost. So that’s the business argument for conglomeration, the economy is a scale you alluded to, etcetera.

Unfortunately, the increase of 6,000 percent in administrators supports your argument that that just isn’t working. The increase in the healthcare budget, of hundreds and hundreds of percent, also indicates that the efficiencies are not happening. That is not a good argument in favor of corporatization.

Ultimately, the biggest problem is corporatization takes us back to the Monopoly game, which I might add was invented in 1904, and at that time there was also a huge concentration of wealth. I think we’re having the same concentration aspects in healthcare, but that’s a political discussion.

I’m more frontline practical on all this, which is to say, “Okay, let’s report corruption. Let’s clean that up, let’s clean up our own house. Let’s minimize non-standard care. Let’s look at aspects that cut out craziness and revisit interval inability to be on the same page with patients so that there is huge variation in what Gordon Moore does versus John Wasson does for the same patient. Let’s focus on that type of stuff at the grassroots and build from there up a better system, rather than point fingers at the front office or the insurance company, etcetera, etcetera, which is what is out there is the standard operating procedure right now.”

Gordon: I want to leave our listeners with a sense of hope. Where I go with that is the impression that I have in almost every conversation with professional colleagues that they’re deeply interested in “first do no harm”; in other words, the professional ethic and values and are looking, sometimes desperately, for ways to get out of complicated, unhelpful, disabling systems that get between them and the patients that they want to serve.

The interest is there, the passion is there. It may be covered with layers of cynicism, but in some examples that we’ve both seen across the country when some of those barriers are removed or they have hope and a little bit of resource to chase an ideal, that’s worked well. I hope that gives people a sense that this can get better. We can do this. We need to change policies, payment, and measurement. Your article is helpful. It’s incredibly challenging, but I think it’s challenging in the right way.

Dr. Wasson: Well, thanks, and again, the right way, I hope, is let’s think from the bottom up. That’s where we have our greatest strength. Ultimately, a medical student commented on a blog, KevinMD.com, about this type of article on corruption in healthcare and said, “Look, I know what’s out there. I’m going forward knowing that I’m going to try and do a little something to make it better.” That’s again your positive note. If every medical student took that on, that would be a better system in the long run.

Gordon: That’s an excellent message of hope on which we can wrap. Dr. John Wasson, thank you so much.

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