A discussion on how to deliver healthcare at a lower cost for individuals, businesses, and everybody paying the bill
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US Health Policy Discussion with Susan Dentzer, Visiting Fellow at the Duke Margolis Center for Health Policy at Duke University was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best way to convert your audio to text in 2019.
Welcome to the Outcomes Rocket podcast, where we inspire collaborative thinking, improved outcomes, and business success, with today’s most successful and inspiring healthcare leaders and influencers. And now your host, Saul Marquez.
Saul Marquez:
Welcome back to the podcast. Today, I have the privilege of hosting Susan Dentzer. She’s a Visiting Fellow at the Duke Margolis Center for Health Policy at Duke University. She is one of the nation’s most respected health policy experts and thought leaders based in Washington, D.C. She works on a range of health policy issues including health system transformation and biopharmaceutical policy. She’s the editor and lead author of the book “Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care”, published in October 2018 on Amazon. Dentzer previously led the Network for Excellence in Health Innovation, a nonprofit that sought to advance innovation in healthcare. A longtime journalist, she’s been on Air Analyst, on Health Issues with PBS News Hour and a regular commentary on health policy for National Public Radio. She wrote and hosted the 2015 PBS Documentary: Reinventing American Health Care, focusing on the innovations pioneered by the Geisinger Health System and spread to the health systems across the nation. She was formerly senior policy adviser to the Robert Wood Found… Johnson Foundation and the editor in chief of the Health Policy Journal Health Affairs. So with that, I want to open up the microphone for Susan to fill in the gaps of anything that I may have missed in the intro. And let us all give her a warm welcome. Welcome, Susan.
Susan Dentzer:
Thanks so much, Saul. Good to be with you.
Susan Dentzer:
It’s a pleasure to have you on the podcast, Susan. So what is it that got you into the healthcare sphere?
Susan Dentzer:
Well, to tell you the truth, it was just a stroke of fortune. I was a writer at Newsweek Magazine. I head back in the 1980’s. I had just come off a stint as the Wall Street correspondent for Newsweek. And I was writing about general business and economics. And my editor said to me one day, you know, there are some big for profit hospital companies that are based in the south and they were trying to buy some entities in the northeast in particular. One was attempting to buy one of the Harvard affiliated hospitals and causing a great stir because at the time, as is the case now, there were laws prohibiting the corporate ownership of health care institutions in the Northeast. So it was causing quite a hubbub. And my editor said, why don’t you go do a story on this and these large for profit investor owned hospital companies. So I did. And of course, at the time, the leading one, as is now HCA.
Saul Marquez:
Yes.
Susan Dentzer:
And the different context then than it is now. Also, Humana at the time, people forget Humana was a hospital company before it decided to become an insurance company. So there were a couple of others as well. And they had established a beachhead in the south and to the to a certain degree, the west California, among other places. But they really hadn’t crept into the north and the northeast. So this was a big deal. And then HCA was attempting to buy McLean Hospital, Psychiatric Hospital in the Boston area. So I went and did a story on that. And I thought, “well, this is interesting stuff, the healthcare business.” It’s hard to believe now, but frankly, the business of healthcare wasn’t covered that much by journalists back in those days. You know, there were medical writers who covered medicine and healthcare really hadn’t become a business per say. And so I said, you know, this is interesting. There aren’t that many people writing about it. And then the other interesting timing issue was that this was just about as the government was bringing out prospective payment for hospitals in the Medicare system on the basis of what, of course, as we now know, DRG. But this was all new and it was going to happen for the first time. Hospitals had been paid by Medicare on a cost plus basis. Now we’re shifting to prospective payment and a lot of people thought the sky was going to fall, that hospitals weren’t going to be able to cope with this, that many, many hospitals would go out of business, etc cetera, et cetera. So there was this sense of doom and gloom in the hospital sector. And again, it’s hard to believe because this major event was happening, but it was getting almost no coverage. And I thought, you know, this is really a lot of interesting stuff here. And again, not that many people were covering it. And so just bit by bit, I did one story and that led to another story that led to another story. I’m pretty sure I was just completely hooked and…
Saul Marquez:
Wow.
Susan Dentzer:
Decided I was going to cover healthcare first as a business and then eventually I moved into covering health policy.
Saul Marquez:
So fascinating what what an interesting story is and amazing how things unfold to just kind of to today. And now, you know, you fast forward to all the experience you’ve had in the sector. I’m really curious from your perspective, what do you think is a hot topic that needs to be on health leaders agenda today and how are you thinking about it lately?
Susan Dentzer:
Well, I think the hot topic remains cost, cost, cost and twinned with that, affordability, affordability, affordability. It is pretty clear that for all of the wonderful things that we have accomplished in healthcare in the United States and I don’t… we should not at all understate that the sector is pricing itself out of the availability of the reach of the American public. And we have got to figure out ways to deliver healthcare at a lower rate of cost, make it much more affordable for individuals, for businesses, for everybody who’s paying the bill. Right. And that’s truly everybody. And we have to do that at an interesting and challenging time, because we also are going to have so much more ability to really intervene in disease at the cellular molecular level and really make a difference in a number of conditions. We’re seeing that now. And in the number obviously cancers, we’re seeing it in a number of other genetically based conditions, et cetera, et cetera. So our capabilities are going to become more extraordinary than ever. But at a time where healthcare is already priced out of the affordability range of much of the American public. So it really bespeaks the urgency that we have to make the system as affordable as possible so that we do have room to pay for what will clearly be some pretty expensive treatments in the years going forward. And I think that the for better for worse the sector will be and mostly for worse, but for reasons that it’s hard to turn around this battle ship of healthcare and it’s hard to get off this conveyor belt of costs always, always going up. But we have to figure out a way to do that. And that is going to require, I think, some major disruption of the way we deliver healthcare to Americans.
Saul Marquez:
Yeah. It’s definitely an issue. And you bring up some really interesting points. I mean, the capabilities are becoming more extraordinary. I mean, the guests we have on the podcast talking from artificial intelligence to t-cell therapy to but nevertheless, the pricing, you know, and you say cost and affordability. And I think it’s cute to mention those two things. So what is the the the end here? I mean, if you had to say what a potential solution looks like. What does that look like?
Susan Dentzer:
Well, I think it’s, of course, some sort of multifactorial. And we have to attack it from different ends. For one thing, we you know, we also, as we know, have a population that is to a large degree unhealthy. And we’re baking in a lot of poor health for a lot of people. And of course, as we know that it’s translating overall into declining life expectancy for Americans for the second year running. So we’ve got to invest more in the social determinants of health that will lead to better health over people’s lifetimes. So that’s a big societal project. I don’t weigh that entirely on the healthcare system by any means. So we have to do that, of course. But then when it comes to healthcare, there again we have to take a life cycle perspective. We’ve got to have the healthcare system become more of a health inducing system. Right. That really…
Saul Marquez:
Yeah.
Susan Dentzer:
Owns the responsibility to keep people as healthy as possible over their life course. So rather than and it’s a cliche, but it’s still true. We largely have a sick care system.
Saul Marquez:
Yes.
Susan Dentzer:
We have a system that responds when people decide that something is wrong and they walk in their office. And we have to turn that around and say, “no, we need a system that owns the responsibility to get into people’s lives very early and keep them as healthy as possible all along the way.” And that views as a failure in a way, people becoming sick, not exclusively because, of course, things happen. There are viruses there are… you know, things go wrong in the body, but there is a lot of sickness that we know is preventable. And to the degree that we can prevent that, our system needs to start preventing it. And then when it comes to dealing with people who are sick, whether it’s with flare ups of just short term acute illness or chronic illness, we’ve got to figure out a cheaper delivery platform than the one we have now. And when we think about it, there is so much that is in the healthcare system that doesn’t buy one single additional unit of health, but adds to a lot of the cost. And that’s a larger level. It’s big, expensive new buildings. Right.
Saul Marquez:
Yeah
Susan Dentzer:
That doesn’t buy one single unit of help, but it does add to cost. We can look at the price level and we have to look at the price level. We have to look at the fact that our system pays every aspect of the system more, even adjusted for purchasing power parity than almost any other country in the world. And we know that about 50% of the cost differential between us and, say, within a relatively generous high spending healthcare countries like Switzerland, for example, where it’s not exactly but we have a lot of starving, dying Swiss people because they don’t have good access to healthcare. They do. But if you look at the price differential between us and them, about 50% of that even is the price that is paid for anything.
Saul Marquez:
It’s a big difference.
Susan Dentzer:
And it’s a big difference. And then within the system, we have strange pricing patterns. We underpay our primary care providers in the US relative to our specialists. Other countries will pay primary care higher than we pay and they pay the specialists less. Well, primary care has an credibly important role in that first responsibility I describe, which is keeping people as healthy as possible. Why are we doing it this way? So we have to rethink a lot. And again, I think a lot of it is just debt down. It’s what is it that we’re paying for is as part of the issue. But also, what are we paying for? And in particular, what are we buying in our big package of healthcare that really doesn’t buy one single iota of health, but does add a lot to the cost. And thinking of ways to streamline that, whether it is taking more advantage of technology, more distributed care, pushing more care out of institutions where possible, bringing it closer to people in their homes and communities. I think all of that is going to be a major source of disruption in healthcare over the next few years. And it’s not going to be a moment too soon.
Saul Marquez:
Susan, I really appreciate the perspective. Definitely multifactorial. And you know, the thing is, you did such a great job of answering that. It’s not an easy question. Right? It’s a very loaded question. And the perspective that you’ve added here, I think, is insightful for a lot of the listeners. And, you know, just from an employer perspective, what are your thoughts there? You know, the folks listening are definitely many of them are sitting in the employer seat. What are your thoughts there?
Susan Dentzer:
Well, it’s interesting because, you know, not to quote myself, but if I’ve read a piece years ago when I was at U.S. News and World Report that was basically urging the employers of America to wade very, very deeply into healthcare, because as the old saying goes, “a war is too important to be left to the generals and healthcare is too important to be left to healthcare providers alone.” Not that a lot of them aren’t very good people. They many of them are, of course. But it’s just it’s a very, very complex enterprise. It’s as complex, if not more complex than running a major aerospace company or a new nuclear energy company. I mean, this is complicated stuff.
Saul Marquez:
It is.
Susan Dentzer:
And a lot of the people in healthcare went into it with clinical training, which is obviously very, very important, but not with a lot of operations training. And healthcare, as we know, has been very, very slow to move into operation science, to take advantage of health, of information technology. I mean, healthcare is 20 or 30 years behind a lot of other key sectors of the economy. That’s why we had to have the high tech law passed to still the acquisition of what kind of health records into the system. They know other industry. The US government didn’t go to the banking sector in the 1970’s and say “you people have to to it. You people have to acquire information technology.” They just did it.
Saul Marquez:
They did it, didn’t they?
Susan Dentzer:
I say sometimes sardonically they did it because the banking sector, the financial sector that was about things that really matter, money instead of just life here was…
Saul Marquez:
Something.
Susan Dentzer:
Here waited another 30 years and then it has a kind of be force fed it. And of course, that happened at a time where we we had a what in retrospect, we will view as a pretty primitive set of tools of electronic health records that, you know, we’re going to move, thankfully, rapidly beyond this. But it just tells you the quandary that we got into in healthcare, partly because healthcare was focused more on clinical care and not on operation. So what I think is the really important issue for employers now and goodness knows not every employer is going to want to do this, but we have to start bringing the same business skills that other industries have profited from and bring them in to healthcare. So it basically it’s understanding fully the supply chain in healthcare. What is it that is happening along the supply chain that is adding costs, that isn’t buying additional units of health? And how do we take that out? How do we disrupt that? And so just the same way Wal-Mart came in a couple of decades ago and disrupted retail and cut out the middleman and figured out a way to price products lower and make them more accessible for people. That’s kind of the same thing we have to do now with healthcare.
Saul Marquez:
Yeah.
Susan Dentzer:
And of course, we already see the Haven Enterprise now, as it’s…
Saul Marquez:
Yes.
Susan Dentzer:
Now been named with Amazon and Berkshire Hathaway and JP Morgan trying to do that for their employees. And that’s great. But we need basically the entire business community to be focused on doing that at the local level. So wading into this and trying to understand exactly how this industry has organized itself and then bring the tools to that industry to really make a much more efficient and cost effective supply chain.
Saul Marquez:
It’s a great call to action, Susan, and definitely I would say folks dive in. Don’t be scared if we have to get involved in our own healthcare, especially as employers. So love that call to action in the background there, Susan. What would you say is one of your proudest moments and the work you’ve done?
Susan Dentzer:
Boy, that’s hard to say, because I just think of so many different things that I’ve had the privilege actually of doing that one that were meaningful to me. I mean, all the way from covering the rollout of far as this has been on the president’s emergency plan for AIDS relief that was launched under George W. Bush that brought HIV AIDS care to tens of millions of people in poor countries around the world. And I traveled a lot in Africa to cover that.
Saul Marquez:
Wow.
Susan Dentzer:
So that was extremely it had a lot of impact on me. It’s very moving and emotional experience to see the U.S. really taking the lead on getting these what you know, it was really the US tackling what everybody said was impossible. But you will never get all these poor people around the world on these very expensive HIV AIDS drugs where we did and we did and save a lot of lives in the process. So that was quite meaningful, I think, at the other extreme now, this book that I was the lead author and editor of Health Care Without Walls really is also articulating a vision of a very different U.S. healthcare system, but not one that would be impossible to achieve. I mean the goal that we set for ourselves when we were writing that report was “let’s take everything that exists in the healthcare space today and just and fully deploy it” and say if we fully deployed everything that we already have, we don’t have to invent anything new. What could we have in the year 2025? In healthcare in America. So take telehealth and telemedicine and max out our usage of it and all the ways that we already think are appropriate. Take our ability to use all the healthcare and mobile apps that have been developed and that have been proven out in many instances. Obviously not all, but many put those into the system, make electronic health records interoperable by basically giving back ownership of those records fully to individuals having open application program interfaces so that records can be easily shared at the direction of individuals with providers all over America. Now we know we can do all of these things. We don’t have to invent anything new to do them, but we just have to do them. And so with that we said “if we did all of these things, what could healthcare look like?” And the answer is we would get care that was much closer to people in their homes and communities. Really creates the avenues for what I talked about earlier, which is ongoing engagement between healthcare providers and individuals before they are sick to try to influence the very positive health status on an ongoing basis. We know we could do that. We just have to get it done. And I think the fact that we pulled it all together into a book clearly articulated the obstacles that stand in the way. And there are many of them and things that are really obsolete that we need to hold up for scrutiny now. In this day and age, why do we have state by state, by state by state licensure of healthcare providers? When we have the ability to provide health care by virtue of telehealth across state lines. Why has regulation bake in a delivery system that we started to leave behind when we left the 20th century? These are important questions and it’s not going to be easy, but we could do that. And we have in the past adapted to this. And then the other big one is if the boat is a very important avenue of healthcare delivery in the 21st century is going to be over the Internet or over cellular or whatever, why does this country not have a plan for either universal broadband or universal 5G or both? Botswana has a plan to get to universal broadband. Where is our plan to get universal broadband? And of course, we wouldn’t… just think about doing that for healthcare. But once upon a time, this country decided that everybody needed to have access to a telephone and everybody needs to have access to electricity. And we did it. So why are we not doing that today? So, as I say, I think I feel good that we we issued that particular call to action and that we really laid out that if it is all doable, it’s just a question of us doing.
Saul Marquez:
What a wonderful summary there. And folks, an invitation to check out Susan’s book, “Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care.” You could find a link to the book in the resources page for this podcast. Just go to outcomesrocket.health and in the search bar type in Susan Dentzer. And you’ll find that the entire transcript of today’s conversation, the short notes as well as links to the book and other resources. So, Susan, it’s time for The Lightning Round. This is where we build a mini syllabus with a couple of questions and then we’ll follow that with a favorite book that you recommend. You ready?
Susan Dentzer:
Sounds great.
Saul Marquez:
All right. What’s the best way to improve healthcare outcomes?
Susan Dentzer:
Best way to improve healthcare outcomes is start with the healthiest people possible. And essentially, that means converting our system into a well care system as much as a sick care system. You’re just going to get better outcomes if people walk into any situation with as much health in their being as possible. And that’s where we’ve got to make our investment.
Saul Marquez:
Well, what is the biggest mistake or pitfall to avoid?
Susan Dentzer:
That we have to take as a given what we have now that we can’t see our way clear to shape a new future. As the old saying goes, “the best way to predict the future is to create it.” That’s what we need to do. We need to create the future.
Saul Marquez:
How do you stay relevant despite constant change?
Susan Dentzer:
Stay aware. Recognize, as William Gibson said, “the future has arrived. It’s just unevenly distributed.” Very little…
Saul Marquez:
Love it.
Susan Dentzer:
Comes about in life that we don’t see little signs of already. So stay alert to the small changes in the environment that herald bigger changes over time.
Saul Marquez:
It’s great advice. What’s one area of focus for you that drives your work?
Susan Dentzer:
Wanting to create a better world. This is not to sound immodest about it, but I really always loved Gandhi’s saying “be the change you want to see in the world” and the change I want to see in the world is healthier, happier lives for many more individuals. And how we do that in the context of a truly great country like the United States, that also faces an array of challenges. That’s my motivator.
Saul Marquez:
It’s a very worthwhile purpose there, Susan, and you’re definitely making a dent with your work. So kudos to you. I got two more for you, more on a personal note. The first one, what is your number one health habit?
Susan Dentzer:
Exercise. Staying active, going to the gym to try on a daily basis, or at least having some element of fitness in my life on a daily basis. And then of course, trying to eat us as healthily as possible.
Saul Marquez:
Nice. And what is your number one success habit?
Susan Dentzer:
I think I go back to what I said earlier, which is staying alert to change into the new and being open minded to it and willing to to try things and not view failure necessarily as silly as the enemy. I heard recently that Winston Churchill said that “success in life is going from one failure to the next with no loss of enthusiasm.” I think that’s a good, inspiring comment for those of us, too, who want to try things in life and have learned that failure can be greatly disappointing but you don’t fail unless you’ve tried something often that’s pretty challenging and that’s why would anybody give up doing that?
Saul Marquez:
Great message there. Susan, an inspiring one at that. And what would you say your favorite book for the listeners is?
Susan Dentzer:
I was an English major in college, so I have really beloved books, so I couldn’t give you one favorite one. But what I can tell you is that on a daily basis, one thing that I can’t have my day be without, frankly, is sitting down with The New York Times and The Washington Post and Wall Street Journal. I mean and I don’t want to…
Saul Marquez:
Sure.
Susan Dentzer:
Single out the Times, but the world is so interesting and things are changing so often. And being able to reflect on that and read a compelling news coverage of what’s going on in the world, read compelling analysis, even obituaries, some of the best coverage in the newspapers is obituaries where you read about people you’ve never heard about who have these amazing lives and made these amazing contributions. That’s inspiring. And it’s hard for me to imagine a day without that because we all need inspiration. And that’s a great way to get it.
Saul Marquez:
Love it and it ties really closely to your message of stay alert.
Susan Dentzer:
Absolutely. Yeah, absolutely. Fascinating, dynamic world. And we all have to be a part of it.
Saul Marquez:
Great recommendation there, Susan. So we’ve come to the end of the road here. I’ve truly enjoyed our discussion, as I’m sure the listeners are, are still wishing there was 30 more minutes left here. But I love… Susan, if you could just leave us with a closing thought and then the best place or the listeners could follow your work.
Susan Dentzer:
Well, the second one is easier to answer. Go to Dr. Google. It says my name and far more than anything that you or anybody would credibly want to know about is obviously now on the Internet. And I’m sure that things will pop up. So that’s the easy part. But just again, I would double back and say we do have this very important opportunity now to build a new future of healthcare and come back to the statement. The best way to predict the future is to create it. Let’s think about what we really want to have ahead of us, for ourselves, for our children and our grandchildren. And let’s build it now because we’ve got the tools and the capabilities to do it. And if we don’t do it, it’s on us for missing that opportunity.
Saul Marquez:
Love it Susan. And again, folks. Susan Dentzer really shared the best that she has to offer here. Take that call to action. Create your future in healthcare. Susan, just want to give you a big thanks for spending time with us today.
Susan Dentzer:
Thanks so much Saul, I really enjoyed it.
Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration, and so much more.
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