How to fix our broken health care system from the inside [PODCAST]

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We sit down with Paula Muto, a vascular surgeon, who discusses the challenges she’s faced in a health care system on the brink of collapse. From hospital closures driven by private equity to network restrictions that limit patient access, Paula shares her candid insights on how we can rebuild a better system. She advocates for banning network restrictions, restoring physician authority, and increasing financial transparency. Drawing on her years of experience, she highlights the urgent need for change and calls on fellow physicians to take the lead in transforming health care.

Paula Muto is a vascular surgeon.

She discusses the KevinMD article, “A physician’s perspective on the crisis in Massachusetts health care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Paula Muto. She’s a vascular surgeon. Today’s KevinMD article is “A physician’s perspective on the crisis in Massachusetts health care.” Paula, welcome back to the show.

Paula Muto: Oh, it’s great to be here, Kevin.

Kevin Pho: So before we talk about the article, let’s start with what led you to write this particular one in the first place.

Paula Muto: So as you know, I’m pretty talkative about what’s happening in health care, but I’m living it firsthand in Massachusetts, and I think that it’s a cautionary tale. You know, somebody had referred to me recently as being a prophet, and I said, “No, I’m more like Cassandra telling the Trojans, ‘Don’t bring that horse in.'” And so now it’s sort of coming to fruition, and I think that people have to spend this time understanding the reasons and how we got here, so we can get ourselves out of this and perhaps prevent other places from following.

Kevin Pho: All right. Coincidentally, my high school daughter is studying ancient Greece, so that metaphor certainly rings true. So talk about that article itself, and tell me about the warning signs that you’re seeing.

Paula Muto: You know, again, put it in context: Massachusetts. Steward Health Care was one of the larger consolidated groups. It was a for-profit group that came in. It started in Massachusetts out of a group of Catholic hospitals that came together, and then back in 2010, the hospital network partnered with Cbus, which is a large private equity organization. And interestingly, it was about three days after the inking of Obamacare, which sort of makes us all scratch our heads, right? Because Obamacare followed Romneycare, which was a Massachusetts-born entity, which was also created by Bain Capital. Mitt Romney and Bain Capital, four years before, had actually invested in HCA, which is now, I think, one of the biggest companies on Earth right now. I think they just, so if you go back to sort of who thought of all of this, it really did come up from that model.

So Steward Health Care expanded in the state, expanded across the country, you know, through a series of deals with leveraged debt, utilizing hospital beds actually as currency, and then sort of got caught with their pants down in some ways, you know, because that debt didn’t get paid, and it got paid out to investors, and there was actually nothing left behind to pay vendors at the hospitals. And so now the hospital network in Massachusetts had broken up. Steward filed bankruptcy, and the hospitals went to a variety of different fates, my own hospital included.

Kevin Pho: So tell us how that is directly affecting patients and the clinician staff today.

Paula Muto: When you’re living it, right, over the years, going down this slope, you kind of, every day, you see where you’re going, but you have to do your work, right? You don’t pay attention. You do your work, and you trust, and there’s a lot of trust here that your leadership will draw the line in the sand somewhere, right? At some point, they’re going to drop a line of sand, like, you know, when all else fails, we’re all going to show up and do what’s right for the patient. You know, no one’s ever going to put a profit ahead of a patient. No one’s ever going to tell us that the oxygen delivery isn’t happening. But when the oxygen delivery literally didn’t happen to the operating room, you know, how does it affect people? It’s a very scary place for physicians and nurses and patients to be, right? I mean, I think you’ve talked about this endlessly on your podcast with people. Talk about moral injury; that’s moral injury.

So in my article, I kind of reference back, to hearken to a different day when I was in training, which is, I imagine, probably the same time you were in training. I don’t know, did you train in the ’90s and, you know, ’80s and ’90s?

Kevin Pho: I finished training in 2002.

Paula Muto: Oh, so you’re a little younger than me. I finished in ’96, ’97, you know, about that, ’96. So when I was at TOS New England Medical Center, you know, our CEO actually was our chief of surgery and chief of vascular surgery. The person who ran the hospital, the one who, like, literally was in charge, was operating with me as a chief resident, right? And then he’d, like, go and answer and put out fires. Why was that important? Because, well, we were, I was a tough. Something very impressive was that they started these network restrictions, right? Harvard Pilgrim decided that no patient could go anywhere in Boston but a Harvard hospital, and you had people at New England Medical Center on cancer protocols, right? And so Tom O’Donnell, who is my mentor, went to the State House and said, “No, absolutely not. This is not safe. This is inappropriate. It’s bad patient care.” And guess what? They believed him. Why? Because he’s a doctor, and it carried a lot of weight with the legislators, and it carried a lot of weight politically, and it was just simply reversed, right?

Now our hospitals are run by, only 10 percent of the boardroom, I think, are doctors. Physicians don’t own hospitals; they’re not allowed to. Physicians aren’t even in the boardrooms, so we don’t even have that position anymore, and I think that has had a huge impact on why the Steward saga occurs. Now everyone says, “Well, Steward was run by a doctor,” but it was really run by private equity. The hospitals themselves had no physicians really involved. It was, quote, it wasn’t physician-light, other than, you know, the person in charge, Delator, was really, you know, was really private equity from the moment he stepped out of the operating room.

But the fact that we had, you know, a surgeon operating every day, running a residency program, in the thick of things, and then going and solving that problem, it was an easy problem to solve, and the communication could be instant, and the trust was there. And I’m just saying, we have lost that in a major way. It’s not just the autonomy of a doctor; we’ve lost the leadership, and so we’ve lost a voice.

Kevin Pho: So how did the evolution of that occur over the past few decades? How did physicians lose their voice in the boardroom?

Paula Muto: I think it’s economics. I mean, I think that, like, you know, we go into practice, and then you always want to be your own boss. There’s not a doctor out there that didn’t dream about just scheduling themselves, right? Except for academics. Academics is a totally different world, and I don’t put them over here, because the number of academic surgeons and doctors and physicians has remained constant for a century. There isn’t one more academic doctor out there. So let’s just put academic doctors over here.

The rest of us have always been, you know, running as small business people, essentially. We became employees again, and not for academic reasons. We became employees, and why did we make that shift happen? Well, because it got harder and harder to run a practice. We had more and more restrictions, regulations, if you weren’t part of a network. I think the networks are the problem, and I think that the state of Massachusetts should 100 percent enact a bill that bans network restrictions, because access is at a crisis level, right? Patients simply can’t get in. Massachusetts has the longest wait times to get to see a doctor in the country, and that’s a disgrace, because we train a lot of doctors, right? So to me, these network restrictions made it really hard for you to make a living, simple as that. So you had to be with other people and join the team. “If you’re not with us, you’re against us,” right?

Kevin Pho: So you mentioned that your hospital was caught up in this whole Steward saga. How is that affecting you professionally?

Paula Muto: Every day is different. We’ve lost a lot of good nurses, I’ll start with that, when the transition occurred, and doctors when the transition occurred. You know, the salaries were protected, but they forgot about people on medical leave. So people who were on maternity leave, people who were recovering from surgery, both emergency and elective, whose jobs were protected but whose benefits weren’t, were called on September 30 and told by October 1 they would have no health insurance. It was weird that the unions kind of forgot about that, but they forgot about that, and that hasn’t 100 percent been resolved. And so they either have to pay a high COBRA or, so what happened? People left. People panicked, and they said, “Well, I can’t come back. I, you know, I don’t know what’s going to happen.”

Young doctors didn’t get the kind of contracts that they wanted, so we lost some of the younger doctors. We lost talent, for sure. You know, I always think, I’ve been around so long, the more things change, the more they stay the same. But there is a very big uncertainty of what the next, and with uncertainty, you know, you’ve got people who, you know, your child is studying ancient Greece. She’s in school; you’ve got to pay for college, right? It’s like, you know, people have bills to pay, a mortgage. You know, at the end of the day, they want to make sure that they have job security.

Kevin Pho: Sure. So you mentioned that network restrictions are kind of a foundation piece in terms of leading our health care system to ruin. If we were to turn that ship around, what would be some first steps in order to make that happen?

Paula Muto: So I would love to see, at least in our state, they put a moratorium on it. In other words, if you’re a Blue Cross doctor and I’m a Blue Cross patient, there should be nothing that prevents us from connecting to care. And I think that should be, like, a public health initiative, almost. I think that will take the pressure off a lot of systems and employers as well, you know, because they struggle with this. I think that is a stroke of the pen, kind of, at the legislative or executive order level, that can be done at the state level. We won’t talk nationally; we’re just talking Massachusetts here. I think that would be incredibly important.

And the other thing is that I think we really have to ask the question: Why is it that a young doctor, newly minted, say a family practitioner from, say, BU or the health center, somebody, they graduate, why can’t they go into practice? Like, what are the economic factors that don’t allow them to be in practice? I mean, gosh, they’re educated. They are highly skilled. They have a marketable and desirable and high-demand skill, right? What prevents them from actually making a living? And I think when you look at those layers, maybe you can come up with some tax relief. You know, we give Hollywood moguls in Massachusetts tax breaks for filming a movie here. What about, like, a young doctor taking care of Medicaid patients? Like, shouldn’t that be supported, right? And it isn’t just relief for tuition and other things. It’s literally just a tax break, for God’s sake, you know, to be able to allow these people to stay in practice. Because I think the more young doctors we push into those practice places, there are more people to take care of us, and I think that will, you know, it’s an economic equation that has to be better.

And people have to ask that question. We don’t like consolidation. We don’t like Steward. Look what happened. Oh, my gosh, why? Like, what are the forces that happened that made that occur? And consolidation, of course, is the big one, because doctors simply can’t make a living on their own. And why? Barbers can, nail salon people can, you know, so why can’t we?

Kevin Pho: So let’s talk about private equity, because we were talking a little bit offline about that, and you mentioned it earlier. Private equity has been infiltrating our health care system on so many different levels, right? On private practices, on emergency departments, and of course with hospitals now. How do you turn that around? Because the end result whenever private equity takes over a health care entity, it’s universally never good. So I know that there have been congressional hearings on this. What can we do to really stem that tide and maybe reverse the trend of private equity infiltrating our health care system?

Paula Muto: So private equity is kind of here, I hate to say, here to stay. I think it’s so intricately involved in every aspect of our health care, from, you know, the pharmaceuticals we prescribe to the medication and the price of everything, and so it’s very hard to extricate. So I just want to say that from the get-go. But one of the things, I think, on the physician side is that, you know, we’re not supposed to work for corporations, right? Somehow or another, that law got pushed aside.

And when you think about private equity, and you think about, like, the health care dollar, it’s a tax dollar that comes into a system, and if it’s not reinvested in the community that it serves, because it comes out of that system and then gets siphoned off and reinvested and helps fund a Toronto teacher pension or a university endowment. I mean, think about what private equity is. It’s not you and me. It’s not our retirement plan. It’s a pension plan for, you know, private equity. People who invest in private equity are institutional investors.

So the whole question is, is the health care dollar in a community, in your community, somewhere in Massachusetts, right, say in, like, you know, in Loba, for example, where that hospital closed, the care that occurs there, should the money that is generated from that care be reinvested in that community, or reinvested far away? And I think that’s where the guardrails can come in, because that’s a tax dollar, and that’s up to the federal government and the state government to decide where those dollars can be spent. And I think that if that’s the fundamental question, if you say it must be put back in the community it serves, that’s good. That means, like, money goes in, private equity builds the community, and the money goes back into that community to maybe support the local teacher pensions in that school district, right? There are ways that you can put guardrails, I think, on private equity. I think, to the go, you’re not going to unravel, you know, the capital markets in health. Like, not easily. You’ll pull that piece of string in the whole.

And I think that’s where the reluctance comes in at the federal level, because, you know, have you noticed, have the candidates talked about health care? Relatively very little. And strangely enough, what are the two biggest issues this election? It’s the economy and the border. Now the economy is in the, we always talk about jobs overseas. What’s the number one reason why a factory sends a job overseas? Like, why is it we don’t make saline or, you know, or lidocaine in our backyard? Because health benefits are too expensive. And the number one reason why we let people come in across the border and don’t look, and we look the other way, is because we don’t owe them health benefits. So strangely enough, health care is in fact the crux, the true problem behind both the economy and the border.

Kevin Pho: Anything patients can do? Because a lot of the movement when it comes to changing congressional minds has to come from the grassroots. It has to come from patients themselves. So what can patients do to help stem the tide of private equity and the calization of health care? Are they powerless? Is there anything they can do?

Paula Muto: I, you know, I mean, going to the polls, you have no, it’s not discussed, so it’s hard for them to make a decision. Patients in this world have very few rights at this point. They’re not even at the table. Their health benefits are determined by their employers, and the employers have obligations to tell their employees now about their health plans. But I think that most of us who have a health plan feel very powerless in terms of that. So I like to think patients have a way about this, but I think it really has to come from the physicians.

I think the physicians have to offer, again, our mission’s always been about price transparency, right? Offer an alternative. Offer a way, a path forward. Be really good about knowing options. Like, “You need an MRI. Where can I send you? What’s your deductible?” That should be the first thing out of your mouth to a patient. Like, “Let’s see, you need this. How are we going to work together for you to get what you need?” You know, and I think that doctors have to have that conversation. So I think it’s more on us, Kevin, than it is on the patient to change this, because I think doctors have to lead the way. We’re the ones who, we’re a million of us, we’re 900,000 of us. But like I said, when Dr. O’Donnell went into that board, you know, went into the government, he had authority. I think together we have authority. We’re the only ones licensed to practice medicine, so ultimately, and we hold the trust of the patient. So I think it really has to come from the physicians.

Kevin Pho: We’re talking to Paula Muto. She’s a vascular surgeon. Today’s KevinMD article is “A physician’s perspective on the crisis in Massachusetts health care.” Paula, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Paula Muto: We can’t keep thinking things are too complicated, because it does affect, it’ll affect all of us. You know, I hate to say it. It’s like, “Oh, it can’t happen in my backyard.” It just did. It just did. It’s tremendously disruptive to your patients, to you, to your life, and to your colleagues, and it keeps you distracted from the good stuff. What’s the good stuff? Training residents, getting them excited about medicine, surgery, you know, and getting excited about, you know, keeping your patients healthy. I mean, it’s fun to be a doctor. We like it. So I think that we have to pay a little bit more attention to what’s going on around us. I think we have to get louder.

I think, you know, there are organizations where people get together and go to Washington, D.C. On Call in the Mall is a wonderful one. It happens two or three, a couple times a year, and they invite physicians from all over that are welcome to come. And just go to your, when we get together, we go to our local congressman with other doctors and say, “Hey, can you listen to us?” I think that’s important. People do listen. They need sound bites. They need accurate information, because the only ears they get, the only people in their ears, are industry. And so I think doctors just need to get louder and need to agree on the stuff, and I think, strangely enough, we all agree. I think this crisis has brought us all together. We don’t fight anymore, right? Primary cares and surgeons, they don’t fight anymore. So I think that’s important: getting louder and paying attention, because we have another generation we’re training, and we are obligated to change this.

Kevin Pho: Well, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Paula Muto: Thank you, Kevin.

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