Racial disparities in surgical care [PODCAST]

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“As a practicing surgeon for 30 years in the super-specialized field of otology, neurotology and skull base surgery, I have been privy to some of the most disturbing realities of surgical care. Often, these realities are bleaker than most people expect. One thing physicians, and the general population, need to be more aware of is the very real racial disparity in surgical care.

Are the outcomes for Black and Hispanic patients truly different than white patients when it comes to surgery? The answer is an astounding yes. Are the differences related to other factors such as socioeconomic class, insurance status, gender, income, extent of disease at presentation or other comorbidities? Even when controlling for many of these factors, racial disparities in the delivery of surgical care persist.”

Sanjay Prasad is a surgeon and founder, SurgiQuality.

He shares his story and discusses his KevinMD article, “The bleak reality of racial disparity in surgical care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Sanjay Prasad. He is a surgeon and founder of SurgiQuality. He wrote the KevinMD article “The bleak reality of racial disparity in surgical care.” Sanjay, welcome to the show.

Sanjay Prasad: Oh, thank you, Kevin. A pleasure to be on your show. Thank you.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Sanjay Prasad: Yeah. I’ve been a practicing surgeon for 30 years. Our family came to this country searching for a health care solution for a problem in the family, and I grew up and became a surgeon, helped tens of thousands of patients, and now I want to help millions more connect to the right surgeon within their network when they need it.

Kevin Pho: I’m always interested in asking physicians about what they do outside of clinical medicine. So tell me, how did you get involved in that space?

Sanjay Prasad: Well, it started with the surgery center that I started. We started bundling some of the costs associated with surgical cases, the episode of care, and then we thought about it a little bit more, and what was missing was quality. We were missing surgeon outcomes, corroborated surgeon outcomes. So we added that to the mix and created this company. It was started in 2014 by a group of surgeons that had this idea, and where we’ve come today is unbelievable. The pandemic was a big help in terms of pausing surgical care last year, but it’s a great time to reset health care as we see it today.

Kevin Pho: Now tell me about that dual role, working, of course, in a clinical setting and, of course, running a company. Tell me about how that affects your workflow and how you manage those two roles.

Sanjay Prasad: It’s very difficult, no question. I’ve got a technology team in India. I get up at three in the morning and work with them until it’s time to go, and then I’ll run off to the operating room in the morning. But it’s so exciting. I’m so passionate about this. I come up with a new idea in the middle of the night, and I’ll open my laptop. My wife, I’m driving her crazy. There’s just so much passion involved. Even at my age, 60, I still feel like there’s so much more to do.

Kevin Pho: Now, most physicians don’t have that background in business. So what was your interest in business, in terms of just running a company, and did you have any prior training before getting into it?

Sanjay Prasad: No, no prior training. I started my own private practice and had that training. I started a surgery center and worked with a number of surgeons, and technology was new to me. So I was working with a tech team, and really, I was a CTO early on. It was great. It was a great learning experience. As physicians, we’re always striving to learn more.

Kevin Pho: Now, as we reflect on both those roles, and for those other physicians who are interested in potentially getting into that health tech space, what kind of advice can you give them?

Sanjay Prasad: Well, I think it’s really important to start to understand technology. I thought I had a grasp, but I really don’t. I mean, I didn’t at the time. But, you know, how apps work, work with someone in the technology space so you can get up to speed with the cloud and HIPAA compliance. If you want to do health care IT, you just need to educate yourself and surround yourself with some smart people that’ll make you even smarter.

Kevin Pho: And how did you find these people, find these resources, or find any mentors to help guide you through this?

Sanjay Prasad: The idea really came through helping patients connect with the best surgeons, and it just evolved over time. I hired a software developer. He was outsourcing some of the stuff, and I said, “Hey, I can do that.” So I started talking to the guys in India, and next thing I know, I’m working every morning at 3 a.m. and all weekends, and it’s so exciting to see the product take shape. It’s just such an exciting time.

Kevin Pho: All right. So let’s talk more about that KevinMD article that you wrote. It’s titled “The bleak reality of racial disparity in surgical care.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Sanjay Prasad: Yeah. About six months ago, we got interested in racial disparities. I read an article by the Brigham and Women’s group. Adil Haider and his team did a meta-analysis in 2013 looking at 88 articles to that time, reviewing racial disparities, and we’re talking specifically about surgery and surgical outcomes. Much to my dismay, it was astonishing and jaw-dropping that the surgical outcomes among Black patients across an array of procedures, compared to white patients, were much poorer. In many studies, they controlled for extent of disease, they controlled for comorbidities and socioeconomic status. And what’s astonishing to me is that this article was written in 2013, yet no solution has been offered to date, and we think we’ve got some answers here.

Kevin Pho: So go into more detail about those papers. What were some of the suggested reasons why Black patients had poor surgical outcomes?

Sanjay Prasad: Some of it may be bias. Some might be discrimination and racial bias. I tend to think not. I tend to think that the health care system traps patients. And what I mean by that, well, an inner-city Black patient may in fact go see their local primary care doctor, and they have the best intentions of sending them to the best surgeon, but they don’t really know all the surgeons in the entire network. They don’t know the best one for your condition, for your surgery. And so they’re trapped. They’re trapped in their local ecosystem, if you will, and we’re trying to break through that using a personalized concierge service and a medical record distribution platform to get those patients connected to the best surgeon with the best possible outcomes, very specific to your condition, if that makes sense.

Kevin Pho: So talk a little bit more about some of your suggested solutions to the issues you bring up.

Sanjay Prasad: Well, the first thing is increased awareness. I think we as a medical community, especially the surgical community with our specialty society meetings, need to start having conversations about racial disparities across the array of procedures that are performed in our specialty. I think we’ve got to publish studies, and we’ve got to come up with possible solutions or countermeasures to alleviate some of these racial disparities. So awareness is number one.

Two, behavioral modification. Maybe Black patients, Hispanic patients, Asian patients, maybe they just don’t understand or comprehend some of the volume of information we give them when they have a condition that needs surgery. So they can have a family member there, they can record the session. There are all sorts of behavioral modifications that can certainly help.

And thirdly, of course, there’s the personalized concierge service, the record distribution platform, where your records can flow through in a very secure, safe, and HIPAA-compliant manner to multiple surgeons within your Blue Cross network or Cigna network, and then get to those surgeons that indicate their area of interest and their focus. They validate necessity, they offer alternatives to treatment, and they put in their success measures and complication measures. And voila, patients can then start to choose their surgeon. They’re empowered with tools to make well-informed decisions. It just makes a ton of sense.

Kevin Pho: So just to contrast, how are referrals being made now without a personalized concierge service? If I, as a primary care doctor, wanted to refer a patient to a surgeon, can you just generally describe how things are done now?

Sanjay Prasad: Well, as you well know, and I’m sure a lot of the listening audience knows, a lot of it’s done by habit, right? You usually have a referral sheet, or a referral nurse who has a list of orthopedic surgeons that the practice usually refers to. I think that’s all nice and fine. That’s a great start. But we can help primary care physicians tremendously, because we can help connect them to the best surgeon within the network. Stay in the network, keep your deductibles low, and the best outcomes as well.

Kevin Pho: How would that work in a typical primary care workflow?

Sanjay Prasad: A primary care doctor may see a patient. The patient has a condition, and the doctor refers the patient to a surgeon. The surgeon does a few diagnostic studies and shows a rotator cuff injury, and I think it needs to go back to the primary care doctor. This is where we can really help, because then they can work with a personalized concierge that can help upload those records to the cloud and get the information back, the outcomes measures on the various surgeons. Let the primary care doctor also be the one that helps the patient navigate the health care maze, find the right surgeon, and find the best possible outcomes. It’s really eye-opening and enlightening in terms of primary care.

Kevin Pho: Do you have a case study of a specific example where you would use some of these health technology tools to address some of the disparities that you’re describing?

Sanjay Prasad: On the disparities, I think, you know, what we’re going to do, and this is our project: When we send the records to the surgeons, we want to blind the case for race and ethnicity, and I think that’s going to be very important. But that alone will be the first step. The second step is really getting the medical records in the hands of all the surgeons in the network and having the health care system compete to take care of the patient. It’s all about value-based care, and whether we like to hear it or not, value-based care is coming very, very fast. We as physicians and surgeons can be proactive and develop and mold value-based care, or we can have the government tell us how to do it, and I think the former is much more palatable to most.

Kevin Pho: So the trend of our health care system, as you know, is that people like to keep referrals in-house, right? They want to keep it within that specific health care system, and sometimes that philosophy works against some of the things that you’re describing. So how do you reconcile those two extremes, where a lot of larger and larger medical systems want to keep their referrals within that medical system, versus what you’re describing, where you want to match that patient with the best surgeon available, whether they work for that medical system or not?

Sanjay Prasad: Yeah, there’s going to be challenges, Kevin. It’s never very easy when you have such a complex system. Yeah, there will be challenges, but I can tell you that even within a health system, you may have 30 or 40 neurosurgeons to pick from. How do you pick the right one for the pituitary tumor, you know, pituitary tumors in the sphenoid sinus, or in the sella and not suprasellar? Who’s the right one to operate on a suprasellar extension of a pituitary tumor? Those are details that primary care doctors oftentimes just don’t have the information on. And so even if you keep them in the system, it’s important.

Kevin Pho: We’re talking to Sanjay Prasad. He’s a surgeon, and he’s the founder of SurgiQuality. He wrote the KevinMD article “The bleak reality of racial disparity in surgical care.” Sanjay, give us a road map for the next year or two in terms of that mix between technology and matching a patient with the correct surgeon.

Sanjay Prasad: Well, I think the future is, we’re just kind of getting there. This whole medical record distribution platform is something new. It’s something to embrace. There will be patients who are not technology-adept as well, and we’ll have to help them all through that, but it’s going to be challenging in various ways. And surgeons really should not be afraid of this at all. Every surgeon is pretty proud of their outcomes, and now, instead of just using our relationships with primary care doctors to get patients, we’re putting our outcomes out there, and it just makes a ton of sense.

And I will say one more thing that may not be readily apparent, but what I’m advocating for is peer review of every surgical case before it’s performed. That is a great, great help in terms of reducing malpractice risk for surgeons, surgery centers, and hospitals. It just makes a ton of sense.

Kevin Pho: And when you talk about the outcomes that are now available, what specifically is more available? Is it hospitalization rate, complication rate, mortality rate? What specific outcomes do you suggest be more transparent?

Sanjay Prasad: Well, let’s talk colonoscopy, a very common procedure. What patients don’t know is the adenoma detection rate, right? My gastroenterology colleagues know more about this than I do, and I don’t want to sound like an expert, but the ADR, the adenoma detection rate, should be 20 percent or greater. That means 20 percent of the time or more, you should find an adenoma within your colonoscopic procedures. And if you don’t, if your ADR is less than 20 percent, you’re moving very quickly. You’re not diligently looking at the mucosa. So even that simple ADR over 20 percent is a tremendous measure for patients to look for in a talented gastroenterologist who’s diligently looking for adenomas.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Sanjay Prasad: Well, look, value-based care is here. It’s coming. Embrace it. The young guys are very technology-efficient and driven, and I don’t think it’s going to be an issue, but the older guys like me, we’re just going to have to get there. Value-based care is coming. Get your surgical outcomes together. Know what cases you do most commonly, know the success rates and complication measures and volumes, and please access that data and collate that data. That data is going to be gold for you in terms of getting future cases. So it’s time to do some homework.

Kevin Pho: And how can people reach you?

Sanjay Prasad: You can reach me at [email protected], info at SurgiQuality dot com, and I’m happy to talk to you. I wrote a book on the subject, “Resetting Health Care Post COVID-19 Pandemic.” It’s available at ResettingHealthcare.com. You can learn more about it there. And if any physician investors are interested, we’re in the middle of a capital raise for our company, in the middle of a Series A, so please contact me. We would be very excited to have you aboard.

Kevin Pho: Thank you so much for sharing your time and insight. Thanks again for being on the show.

Sanjay Prasad: Thank you, Kevin. Wonderful program. Thank you so much for having me on.

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