SAN DIEGO - Atul Gawande, MD, addressed a range of topics concerning the direction healthcare needs to move at America's Health Insurance Plans Institute & Expo Thursday.
Gawande took the AHIP stage a day after Amazon, Berkshire Hathaway and JPMorgan Chase announced that he will take the helm at their venture, an independent entity free from profit-making incentives based in Boston.
It's "the day after the venture was announced," Gawande said. "It will take on greater significance. I'm delighted that's true."
Susan Denzer, CEO of the Network for Excellence in Health Innovation at AHIP, asked about his future plans.
"At this point I can only think about this new job I'm taking on," Gawande answered. "I can only say it's a long target … over the next decade it will be a gradual progress, it won't be instant solutions."
The exact nature of the new healthcare company has yet to be announced, but Gawande confirmed that the venture will be an insurer for the million-plus employees of Amazon and partners.
"I feel incredibly lucky in this role," Gawande said. "I will get a million new patients."
While he didn't say more than that, Gawande also illuminated some of the issues healthcare is currently struggling with and said caregivers need to ask more questions of patients.
Gawande, who among his many titles as surgeon, public health researcher and author, said when he thinks about what he wants to accomplish on the writing side, he thinks about connections, "understanding the aspirations of how lives should go, and the reality."
The reality is that care, especially end-of-life care and how physicians treat serious and life-limiting illnesses does not always fulfill or align with the patient's desire for quality of life at the end of life.
Unnecessary tests and treatments waste about 30 percent of healthcare spending, and these interventions often do more harm than good. An estimated 45 percent of Medicare patients get EKGs, CT Scans, MRIs, have a stent placed or receive other procedures without good reason, Gawande said.
Physicians offer options to patients, but don't always ask what the individual wants to achieve by treatment. Doctors must be more than technicians, he said.
"The goal of the healthcare system is not survival at all costs," he said. "The goal is a good life as you define it. We've never even asked what that means."
Patients need to be asked, Gawande said, what they consider worthwhile living, what are the tradeoffs they're willing to make for more time, what is their minimum quality of life?
When Gawande asked this question of one patient, the reply was, eating chocolate ice cream and the ability to watch football.
Gawande reported his own experience with his mother at a rural hospital in Ohio where he grew up. His mother was a pediatrician; his father a surgeon. His mother had a fainting episode and the ambulance took her to the emergency room where physicians performed an ultrasound for a carotid artery.
They found nothing and put her on a helicopter to a larger hospital. At 11 p.m., laid out flat in the ER, a doctor finally asked her what exactly happened with the fainting episode. It turned out she had started on an increased dose of blood pressure medicine that morning, went for a walk and felt faint.
"She was dehydrated," Gawande said. "It took all of that to figure it out."
Another person he called the father of his friend Bruce fainted, but this individual had end stage renal disease and was on dialysis. His artery was 99 percent blocked. The physician said they needed to do surgery to clean out the artery and do a cardiac bypass operation.
"Here's a guy who's on the edge of not being independent anymore," Gawande said.
They wanted to do two procedures to address future problems.
"The benefit is in years to come. You don't need AI to determine the benefit, it's 15 years before he a sees benefit. None of it was discussed."
Bruce's father came out of surgery with a stroke, paralyzed one side of his body and was unable to speak. The man died six months later in a facility.
Bruce's dad never got the right care for a chronically ill person, said Gawande, who interviewed 200 people with serious conditions and their family members.
None had been asked what they wanted to achieve.
"It's shocking to me we've not understood it," he said. "People have priorities besides just living longer. We need to learn what their priorities are for life, we have to ask them. But we don't ask."
Where this model has been deployed, when physicians do ask, it reduces cost and actually increases life expectancy, he said.
Healthcare has the education and the science. It now needs a better delivery system.
"Precision medicine has to be matched by precision delivery," he said. "We're still in a stage of primitive thinking in how we create delivery."
After five years of work in South Carolina using this approach, physicians have reduced the death rate by 22 percent.
At Dana Farber in Boston, more than 90 percent of clinicians now ask questions of chronically ill patients months, not weeks prior to end of life.
"When we ask, what is the goal of our care, we still don't have an answer to that," he said. "What is our goal when health and independence isn't possible anymore?"
Having health insurance has been found to help the health of patients and has shown a 5 percent reduction in mortality over five years.
There cannot be exclusions for pre-existing conditions and coverage can't just be catastrophic care.
There's been enormous amount of investment in discoveries, but only now is healthcare looking at the social environment of isolation, food insecurity and the other social determinants of health.
"The genetic code is not as powerful as your zip code," Gawande said.
In Boston, when investments were made in housing rather than in shelter beds, treatment improved for chronic conditions and that, in turn, reduced costs.
"We will come to a place where we can generate scalable solutions to change the practice of medicine," Gawande said. "It's a long road. It's cleary possible."