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Join vascular surgeon Paula Muto as she dives into the complexities of the health care system in this episode. Drawing parallels to the excitement and challenges of an escape room experience, Paula examines the intricacies of health care reform, accountability, and transparency. From the role of insurers to the impact on individuals and families, she sheds light on systemic issues and offers thought-provoking solutions.

Paula Muto is a vascular surgeon.

She discusses the KevinMD article, “Panic button: Escaping the broken health care escape room.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Paula Muto. She’s a vascular surgeon, and today’s KevinMD article is “Panic button: Escaping the broken health care escape room.” Paula, welcome back to the show.

Paula Muto: Thank you, Kevin. Thanks for having me again.

Kevin Pho: Paula’s been on multiple times. Go to KevinMD.com/podcast to search her name and prior episodes and hear her story. But today let’s jump right into your most recent KevinMD article, “Panic button: Escaping the broken health care escape room.” Now, for those who didn’t get a chance to read this one, what’s this one about?

Paula Muto: So all of us, or many of us, have done escape rooms. They’re very popular these days, for team building, families do it, they do it for team spirit and so forth, and cohesion. And so the concept of an escape room is, you go into this impossibly strange place and you put all your brains and your power together, work together, to solve the clues.

So I think it’s very much like the health care system. We have so many smart people, policy makers, physicians, writers, health care gurus, we have so many smart people trying to fix the system, but we can’t fix it. We can’t fix it.

So the question is, are we in an escape room without an algorithm or a clue to get out? Somebody actually, when I published this paper, said, you know, maybe someone’s inside the room with us that’s sabotaging us. But I actually think it’s the former. I think we really have to ask ourselves, we’re trying so hard to fix a system that may be unfixable. And that’s what the article is about. And it comes in the wake of a major health system in my state, and the hospital that I work at, and it’s a national health system, that declared bankruptcy four days ago.

Kevin Pho: All right. So let’s extend the analogy. You have all the players in this health care escape room. You have the physicians, the administrators, the policy makers, and the patients. Tell us about some of the puzzles that they need to solve to potentially escape these rooms, from your perspective.

Paula Muto: So I think that you always look backwards to see, how did we get where we are, and what step along the way could we have done differently, or do we need to repair, to get to the next level?

And I think that it was built this way from the beginning. When you look back at the origin of the Affordable Care Act and the way physicians were written out of the equation. Many people don’t know, but from a business perspective, physicians were not allowed to own or operate a clinic, surgery center, multi specialty group. It sort of set the stage for the fact that we needed to have a business partner if we were going to do anything at scale. So it’s sort of like, from the beginning, pushed the doctors out of the equation.

And then you kind of built the system where you have the insurers who are controlling the price of the medications we prescribe, they control the price of the admission to the hospital, they control the price of literally everything. And it’s a fantastic positive feedback loop, right? As long as you keep fueling it, and you have government tax subsidy fueling all of it, you can create an amazing business model for health care. But it forgets the fact that you forgot about the delivery.

So I think that we have a system now that’s on a positive feedback loop, and it’s really hard to get off of this without really taking down, or understanding, or putting limitations on the insurers, putting limitations on how the tax dollars are spent. And I think to do that you have to understand it.

Kevin Pho: So the fact that it’s very difficult for physicians to operate independent clinics, surgery centers, things like that, what are some of the downstream effects of how that potentially affects patients?

Paula Muto: So if you think about just, take a practice like even my practice. Right here, I have a vein center and I’m an independent practitioner. So now I have a payer mix, always the same. My patients now have high deductible plans, because their employers used to pay everything, now they pay less. Now I have to chase my patient down. And the insurers have been behaving badly. You have, like, Change Healthcare, you have all these things that happen.

So now you come in, I do your surgery, I get pre-approval, I get authorization, I do it, I hire the equipment, the personnel and everything else and do it, I take care of you, and then I now don’t get paid, for all variety of reasons. Or the patient can’t pay it. So now I can’t do the next case, and I can’t do the next case, and I have to make my payroll, I have to pay my malpractice, I have to do all this. And I’m like, oh my gosh, this equation is getting so hard.

Then someone comes my way and says, hey, we understand that, Dr. M, why don’t we just, we’ll buy you, and we’ll buy Dr. Doe, we’ll buy Dr. Jones, and we’ll put you all together, and we’ll group together, and we can create this entity. Now, I would say, like, maybe I can combine with other doctors and do the same thing, except that again the Affordable Care Act limits you, sort of, 49 percent.

OK, so now we’re all together. And next thing you know, you sold to, say, a private equity backer. They have capital. You’re like, this is great, they’re paying for everything. And then they say, well, you need to buy all of your equipment from here, not here. You have to see your patients starting at this time and not that time. You’re not allowed to do two procedures in the patient, even though the poor patient’s there, you opened the catheter, you can do it, no, we’re going to get paid better if you do it twice.

So next thing you know, your practice, your clinical decision making, is being driven by a revenue model.

And this is sort of how it happens. It happens innocently enough, that you can’t pay your bills, and then next thing you know you’re employed, and next thing you know you’re enabling this system. And so I think that’s sort of how we got here. And I think a lot of it is because we’ve kind of given in to this model that the insurers have dictated to us through all of these other tentacles. And that’s why I think the entire system is rigged.

Kevin Pho: Yeah, it sounds like physicians today, they started with giving up a lot of their control. They’re disempowered, right? And not only can they not have these independent surgery centers or vein clinics, that makes it very difficult, but fewer and fewer physicians are even in private practice. They’re in some type of employed model, and they give up that control. And if that employed model gets sold to, say, private equity, it further disempowers physicians. So it sounds like, like you said, that feedback loop takes away more power from the physicians.

Paula Muto: I think so. And the interesting part of this is, they talk about corporatization in medicine, like, we’re in this corporate model where we don’t answer to our patient, we answer to our boss. But now the New England Journal had an article, financialization. It’s not corporatization, financialization.

What does that mean? It means that you’re not answering to your boss, you’re answering to a stockholder. In other words, the entity itself has a value that is being bought and sold far from where you are. So that your business, your service, the success of your practice, could fuel a Toronto teachers’ pension.

Just think about the concept. A health care dollar comes into your hospital or your practice, and it doesn’t get reinvested in your team, in your community, that may be a poor community. You might be able to reinvest it so that the next patient’s free, because the next patient needs it badly but can’t afford it. But you can’t balance that anymore, because that money that comes into your practice is now immediately sent up the ladder and out into a private equity investment.

And people think, oh, it’s buying a yacht. It’s not buying a yacht. It’s fueling college endowments, it’s fueling bus driver pensions. And I think the question is, do we want the health care dollar reinvested that way, or reinvested in the community they serve?

And I think that if you read the front page of the Wall Street Journal today, a very nice article by Melanie Evans, about a poor person who wants her daughter to get her tonsils out, and the surgery center is asking for payment up front. I completely understand that, but here’s a woman who works, who has a health plan, the child needs an operation she’s going to get once in her lifetime, and she can’t afford it. Something really doesn’t make sense there.

Because maybe in the old days, that surgery center knew that that Blue Cross patient that came in was already paid, so that that second patient that came in that had limited means could be done at a different price. We always had that give and take, because the money was reinvested. The money was reinvested in the community it served. Now that extra Blue Cross payment is going off to fund something else.

And I think that’s where the issue is, the reappropriation of the health care dollar. And the health care dollar is limited, it is precious, it is tax subsidized, and it should not be reinvested except in health care, in delivery of health care.

Kevin Pho: Let’s talk about potential paths forward, right, to solve some of these puzzles, to escape that proverbial escape room. You mentioned about physicians banding together, but realistically, you know how difficult that is, because physicians, they’re kind of siloed, we don’t have a lot of business training. And our adversaries, let’s use this analogy, our adversaries, they’re kind of trained all their lives in business and finance. So what hope do physicians have to escape this system, because we’re already, as you said, so far in the weeds, so far in the trenches of the financialization of health care?

Paula Muto: So they always say doctors make bad business people, but I’m going to say the corollary, business people practice bad medicine. And we know that now. So what they’re doing isn’t working. So that’s the first thing. And everybody understands, it’s not even a debate anymore. Outcomes are bad, costs are high, and at the end of the day the people who are purchasing the medical care are not happy. The employers, the patients, they’re not happy.

So I think that what we need to do is, doctors cannot unionize, or have not. Although I will say that I think the first doctor union is going to occur in Massachusetts, not through the Steward thing, but the MGB merger is wreaking havoc once again. Consolidators, business people. I mean, if you look at the board of MGB now, it’s a football franchise owner, it’s a construction person, and it’s an investor. How are they qualified to make safety decisions on patient care?

Kevin Pho: Yeah, and just to explain for those listeners who may not be from the local area, when you say MGB, you’re talking about the Massachusetts General Hospital and Brigham and Women’s Hospital merger that is causing all sorts of havoc.

Paula Muto: Right. And they’ve been merged through the Partners network anyways, but they’re just sort of bringing it to another level. And you can say, you know, these are giant nonprofits, and they behave in the same playbook as the for-profits, I mean, at this point.

But the concept of putting all these services together, doctors can’t do their job. You talk about it all the time on your program, people really honestly talking about burnout and moral injury. It really has come to that point where you are asking permission to transfuse a bleeding patient, because we have to make sure that transfusion is not just covered, is it economically a good decision, is it going to make us money? It’s not even that, it used to be, is it covered? Now it’s just, is it going to be profitable? And I think that’s just not morally correct, ethically correct, and medically unsound.

So I think that the union issue is interesting. It sort of saddens me a little bit to think that doctors have to be labor in a hospital, and that the leadership of the hospital is in opposition. Like, why would you go to a place where the doctor and the hospital are in opposition to each other? It sort of doesn’t make any sense.

But I do think that we’re coming off that bell curve. I don’t know what’s going to happen to the 11,000 Steward employees, if Steward can’t land on its feet in Boston, whether those doctors are going to try to go independent. I think it would be fantastic.

I think in the short term what could be done is supporting independent doctors, either with tax incentives. I think that there is support at the highest levels in Washington over anti-consolidation. People don’t like consolidators.

I think that in the short term also, all network restrictions should be banned. If you are a qualified physician and you take Blue Cross, you can take a Blue Cross patient from anywhere on Earth. End of story. No more network restrictions, because that limits access, and it also causes a lot of cost at the point of care for both the patient and the doctor. And I think banning network restrictions in this emergency, when you don’t have access, is a really important measure, and I think that lawmakers can do that.

I think long term, the whole system should just be eliminated to a single currency. We should have a currency. I mean, you think about, you travel through Europe in the old days, you’d go to France and have a franc, and then you translate your dollar into a lira and then into a deutsche mark. Think of all the cost. That’s exactly like our health system. We have all these different players with different currencies.

But when Europe went to the euro, economically it was really a good idea, saved billions of dollars, because then everybody knew what their token was worth. So that, you know, that operation’s 100 tokens, your employer pays 50 of it, my employer pays 75 of it, we know the cost of it, it’s standardized.

Standardizing the health care dollar on a currency, I think, goes a long way to making it so that when you go see your primary care doctor, you whip out your insurance card, it has a computer chip, and you go ka-ching, just like Toast. You just pay for it, the transaction’s instant, the doctor’s paid, the fee is made, everything is done. And we’ve eliminated this constant transfer of data, where that can’t be protected, and it’s costing a lot, and it’s this whole complex, we just don’t need it anymore.

So I think we need more independent doctors. I think it’s the natural course of events right now. To have that happen, we just have to figure out how to support them economically, to go back to work for patients again.

Kevin Pho: So I think there’s a little bit of a tension here that you bring up, right? Because you’re clearly a proponent for independent doctors, but in order to bring the entire health care system to that proverbial single currency that you say, I think the only entity that has the power to do that would be the government, right? So there’s that tension of having government control, to have elements of a single payer system where you could have a single administrative bureau rather than all these silos, but that is clearly in tension with the independent physicians. So what do you think about that?

Paula Muto: So first of all, the federal government already has their hands in health care. That’s what the Affordable Care Act did. But the health care dollar by the federal government is given to middlemen. So 48 percent of the federal budget, 75 percent of the health dollar is to middlemen. 48 percent of the federal budget is health care. And a recent study said 69 percent of the revenue from private insurers is actually tax subsidized.

So let’s just say Medicare for all would be 80 percent. We’re at 69 percent, Kevin. We’re there. So the whole concept of, the government pays, we already passed that threshold.

OK, what we have to ask now is how that money is spent and who do we pay. And the currency concept isn’t a single payer, it’s a single payment. It’s just standardizing the bloody system, so that you can’t have 15,000 different dialects and languages and currencies. That just confuses people and confuses providers, it confuses doctors, it confuses patients. And there’s a cottage industry built around those token exchanges, and you can’t secure that data.

So the government can decide that the health care dollar is this, and what it can be spent on. Because the government has already decided that health care dollar, they’ve already given it away, but they’re giving it to insurance, Medicare Advantage. That’s their solution to Medicare, keep everybody permanently 64 and give your Medicare dollar that you’ve earned your entire life away.

I actually did the math on this, and I said, what would you need your entire life from age zero to 95? And these are actuarial insurance tables. And you know how much money you’d actually need? Wow. That includes the kid in the NICU to the healthy person. That’s all you need: $875,000.

And if you work every day from the age of 20, 21 years old, and you’re putting away your Medicare 2.7 percent, and you put it in the stock market at 10 percent, you take 3 percent out for inflation, you have about $600,000 by the time you hit 65, which will more than happily carry you through all of your health care expenses.

So when we look at the math and see the finiteness of medicine, suddenly the mystery should disappear. There’s plenty in the system today. It’s just, 75 percent of it is not paid to patient care, and the government is in control of that.

Kevin Pho: We’re talking to Paula Muto. She’s a vascular surgeon. Today’s KevinMD article is “Panic button: Escaping the broken health care escape room.” Paula, as always, we’ll end with your take-home messages that you want to leave with the KevinMD audience.

Paula Muto: So I think that I’d like to just say, doctors need to not give up. We need to ask the questions. I think that we are the ones who have to get out of that escape room, because we provide the service, and at the end of the day the patients will listen to us first. And you cannot forget that.

Even when your day is terrible and you feel like you’re getting beaten up by all the suits around you telling you what to do, at the end of the day you know that you’re going to do what’s best for your patient, and your patient will go along.

Kevin Pho: Paula, as always, thank you so much for coming back on the show and sharing your perspective and insight.

Paula Muto: Thank you.