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Join us for an insightful conversation with nephrologist and physician executive, David W. Moskowitz, as he shares his transformative views on the U.S. health care system. Drawing from his time as a Marshall Scholar and extensive experience in patient care, David discusses the challenges of national health services, the shortcomings of Medicare as the single payer for dialysis, and the importance of prioritizing quality to lower costs and alleviate suffering. He proposes a reimagined Public Health Service (PHS) to address the needs of 50 million un- and underinsured Americans while maintaining a balanced public-private sector system.
David W. Moskowitz is a nephrologist and physician executive.
He discusses the KevinMD article, “Health care reform requires better access and quality: dialysis as an example.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome David Moskowitz. He’s a nephrologist and physician executive. Today’s KevinMD article is “Health care reform requires better access and quality: dialysis as an example.” David, welcome to the show.
David W. Moskowitz: Thanks so much for having me.
Kevin Pho: Let’s start by briefly sharing your story and journey.
David W. Moskowitz: So, I trained to be an academic physician. I went to good schools. I did biochemistry twice, once at Harvard and once at Oxford on a Marshall Scholarship. I went back to Harvard-MIT. I went to Barnes for residency in medicine. I was going to be a membrane biochemist, and nutrition seemed the closest thing, but when I came to apply for a GI fellowship at WashU, I was tired of moving around, and only renal was available. So that became my organ, because you have to subspecialize to be an academic.
Renal patients are interesting because my other interest has always been primary care and outpatient internal medicine, not so much hospital-based. The thing about dialysis patients is that they’re too sick for anybody to touch them, so you wind up being the primary care provider for your dialysis patients, and that was fine with me. The two things that I was interested in as a nephrologist were acute renal failure and chronic renal failure, and about thirty years ago, I found out a way to avoid both and was promptly fired. Instead of becoming a division director of nephrology somewhere or a department of medicine chairman, I have been living in the desert for the last thirty years.
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Kevin Pho: All right. So you wrote your KevinMD article, “Health care reform requires better access and quality: dialysis as an example.” So for those who have to read your article, tell us what it’s about.
David W. Moskowitz: Well, in brief, there should be no more dialysis. It should be obsolete by now, based on the protocols that I published in one form or another in 2002. And yet dialysis goes on, a $200 billion a year industry. Acute renal failure still hasn’t been solved, according to the NIDDK. There are still workshops and grants being issued.
And this is in the information age, the age of instant news. All you can conclude is either I’m a doofus and a liar, which I don’t think I am, because I graduated summa at Harvard, first-class honors at Oxford, and cum laude at HST, or that my 4,000 patients I made up, including one who’s been off dialysis now for almost seven years, who was told to go on the machine seven years ago in San Antonio, Alice Slow, who’s happy to have her name known. So either I’m lying or health care is being anti-innovative.
I think the latter, and I think in the case of dialysis, and perhaps the rest of human disease, health care has become too satisfied with the lucrative $4.7 trillion a year status quo in the U.S. alone. So the point of my article was that you can’t count on health care to innovate anymore. At a time when science is revolutionizing medicine, when genomics finally lets you know exactly what’s wrong with every single patient that you see, science is hamstringing you in terms of what you can do for your patient. I mean, this is like perfect managed care, and it fits in with all the frustrations that physicians have been feeling for the last thirty years.
So if you want health care reform, not only do you have to have greater access, which is Obamacare, but you also have to emphasize quality and quality improvement. You can’t have one without the other. It’s just not fair; it’s not just. The current system we have is basically manure, and increasing access is just spreading manure. We have to get to a QI system.
The proposal I had was to order people in the public sector, and I’m picking on the VA now, since they have the highest responsibility to their patients, the veterans who sacrifice their lives for the good of the country. The VA refused to adopt my anti-dialysis protocols. So since they failed miserably to innovate and save patients, I want to give the VA back to the Public Health Service, which was created by Congress in 1789. I want to keep the VA doctors there because they’re the foundation of academic medicine; they’re all great investigators. But I want to order the reconstituted PHS. I want the surgeon general to be responsible for his or her job to improve clinical outcomes, which currently nobody in health care has the responsibility to do.
Kevin Pho: So tell me, when you said that innovation is being held back today by most medical entities, what are the forces that are holding innovation back?
David W. Moskowitz: Well, let’s take dialysis. Every single nephrologist makes his money or her money on dialysis in one way or another. So academics, if they don’t have a robust dialysis program, don’t bring money into their division. Private practitioners, of course, don’t get to go on vacations and buy fancy cars if they don’t have a stable of fifty dialysis patients. And in fact, chronic kidney disease patients are just loss leaders when they’re in the clinic. You don’t make any money from them as a nephrologist until they actually go on dialysis, and then they bring in a hundred grand a year for the two or three years that they manage to stay alive.
So dialysis is a stopgap, a horrible quality of life, but all of academic medicine, all of hospital profits depend on it. It is the most lucrative pillar of hospital-based medicine that there is. Half a million dialysis patients bring in as much as all the cardiac patients in the country. So you can’t get rid of your crown jewel. And nonprofits don’t want to go the way of the March of Dimes. When polio was solved, it’s now a shadow of its former self, used to be huge. And they all make six-figure salaries, the C-suite executives of nonprofits.
So the NKF, the professional societies, the ASN, the ISN, none of them have wanted to publicize the fact that dialysis is preventable. Medicare, single payer for dialysis since the beginning, since ’72, didn’t want to cut 7 percent of its budget. No bureaucrat wants to. It’s not their money; it’s not their lives, but it is their salaries. And as Upton Sinclair famously said about a century ago, “Don’t expect a man to understand what you’re saying when his salary depends on his not understanding it.” That has basically been my experience over the last thirty years: Absolutely no nephrology authority, no health care authority, nobody in charge of a health plan wants to kill the golden goose.
Kevin Pho: So you’re saying because of how lucrative dialysis is, there’s no financial incentive to innovate and get people off dialysis, purely because of the financial benefit it brings to medical institutions.
David W. Moskowitz: There is no financial incentive to prevent any disease in medicine. And so in addition to the scientific revolution, which has been ready to happen now, thanks to genomics, for thirty years, there has to be a moral revolution. There has to be public education that the system is crooked. Like was said about the military-industrial complex back in the ’30s, it’s a racket. Health care is a racket and has nothing to do with public health anymore. In the ’50s it did, when I was a kid. I mean, polio really was defeated, joyously, based on very little data from Jonas S. But now you have to have forty million patient-years of experience before anybody will even listen to your new protocol. It’s absurd. Nobody has the money for that, and so we wind up with the status quo year after year.
Kevin Pho: So you talk about reconstituting the Public Health Service that you said was formed back in the 1700s. For those who aren’t familiar with the Public Health Service, tell us a little bit about what that is and its history.
David W. Moskowitz: Well, the Public Health Service, PHS, is one of the few untarnished government institutions left. In the 20th century, they had TB hospitals until streptomycin was invented in the ’50s. And in fact, in 1921, after World War I, the PHS gave fifty-seven hospitals to the nent VA to care for all these veterans of World War I that were lying on the roadside. So it wasn’t a gift; it was a loan, and it needs to be repaid now that the Army has become an army of one and there’s no longer a draft.
In Taiwan, they took their veterans health service and turned it into a public health service for the entire country, and I think that’s what needs to happen in the U.S. The veterans I spoke to in St. Louis (I was there eleven years) said they’d much rather give the VA back to the PHS than have it dismantled piece by piece, which was happening before the first Gulf War. There just aren’t enough wars and American soldiers to keep the whole system going.
Kevin Pho: So tell us how a reimagined Public Health Service, how would that encourage innovation and perhaps divorce the status quo from the financial incentives that are holding innovation back?
David W. Moskowitz: Well, the beauty about the public sector is that you’re on a salary, which in the private sector you’re not. You eat what you kill, literally. So if you don’t have a lot of patients coming in the door, you don’t make much money. In the public sector, you’re on a salary, and in fact, the incentive in the public sector is to see as few people as possible and make as much money on your salary as possible. It’s precisely the opposite of the private sector.
And so the VA is known for its laziness. The private sector hustles and does unnecessary procedures and tests to make more money, and the public sector has a tradition of being lazy and having patients die in the parking lot because they can’t get an appointment soon enough. So you have to do something. Forget about the private sector; it’s incorrigible, and politically it’s untouchable because we live in a capitalist society, and business rules and will rule even more after this election.
But you can manipulate the public sector, and what you do is, instead of just letting people exist on a salary with no real demands on them, you demand that they actually do as much as they can to improve patient outcomes. And the VA is already very good at doing clinically focused research, unlike the NIH, whose mantra is mechanism. The VA actually has patients and enrolls them in trials, and every grant has to be clinically focused. So the way going forward really has already been indicated by VA researchers, and what they need to do is make their grants less like the NIH, less mechanistic, and more clinical outcomes-related. And fortunately, genomics lets you do that.
Kevin Pho: So in terms of transitioning the VA back to the Public Health Service, how’s that going to potentially impact veterans’ care in your proposal?
David W. Moskowitz: Well, veterans would be essentially the most valued patients, the MVPs of this new system, and they would benefit most from innovation. For example, thirty years ago, I worked out how to avoid dialysis. Veterans are still dying on dialysis, a modality that should have become obsolete if the VA had actually done its job and agreed to innovate. Instead, they’re being pied for belonging to an anti-innovative administration, who really does view them as their own private property.
So what you do: Put me in charge. Make me the surgeon general, and I’ll crack the whip. I’ll make sure that every grant is going to benefit patients, that every grant is focused on improving outcomes, not on diddling around with mechanism in some model system or other that’s probably irrelevant to the human system. And we’ll start recording outcomes, like how many diabetics seen by physician X go on dialysis at the end of the year versus physician Y. And then I’m going to ask physician X, if he or she has better outcomes than everybody else by a few standard deviations, “Please teach the rest of us what you’re doing,” so that we learn from each other and we become a learning machine, which currently physicians are not doing for each other.
Kevin Pho: Now, with the advent of some value-based care concepts in the private sector, do you feel that we’re moving toward the trend where quality measures are dictating how much physicians are paid or influencing how physicians are paid?
David W. Moskowitz: I think not. Number one, this is coming from Medicare, and Medicare has never even measured outcomes, let alone tried to improve them. What passes for quality in the managed care environment, the Medicare environment, are HEDIS measures, which have never been shown to actually be associated with outcomes. So you’re supposed to get an eye exam for diabetics. Now you’re supposed to give people with normal lipids who happen to be diabetics, they all have to be on a peanut dose of statin, like 10 milligrams of Lipitor, because that’s a HEDIS measure. And if you don’t meet your HEDIS measures, you don’t get five stars as the managed care plan, and if you don’t get five stars, it means that you can only recruit patients twice a year instead of every day of the year.
Anyway, I think Medicare has no idea how to improve outcomes because they don’t. And I think value-based care, the ACO system that Medicare implemented a few years ago, none of the things that Medicare has done to try to improve outcomes has ever worked. ACOs don’t save Medicare a penny. I approached all the ACOs with preventing dialysis. None of them were interested, because you get 40 percent of the savings for the year or two that you’re saving, but after three years, Medicare assumes that you’re going to keep on doing that, and you lose all your forty grand a year from the hundred grand a year dialysis cost that you’re saving. So ACOs have never adopted any kind of prevention measure.
I think Medicare is just doomed to be idiotic and focus on computers and not patients, and so that’s why I would leave it alone. I would leave the private sector alone, and I would just focus on the reconstituted PHS. I would publish the outcomes improvements, and then the rest of the world, the rest of the U.S. American health care system, would have to match, or else people would vote with their feet and all go to the smelly PHS. And that wouldn’t be such a bad idea, to have a national health system that actually focused on quality improvement, unlike the national health services of other countries.
Kevin Pho: We’re talking to David Moskowitz. He’s a nephrologist and physician executive. Today’s KevinMD article is “Health care reform requires better access and quality: dialysis as an example.” David, let’s end with some take-home messages for the KevinMD audience.
David W. Moskowitz: Well, I don’t know how many hours we have left, but I’ll just tell you one example of how genomics personally impacted me. I developed calcification of my aortic valve, to my gross surprise, and my alk phos had always been high, 300 or so. The most I could establish was my gamma GT was normal; the alk phos was coming from bone. But I never understood why; I never paid much attention.
I get my whole genome sequenced by Nebula, a very good firm, and I find out that of the two genes for Paget’s disease, I’m homozygous mutated for one and heterozygously mutated for the other. So I have Paget’s disease, which a CT scan for my new aortic valve, my TAVR, went down to my pelvis and detected: Paget’s in my right hemipelvis. All of a sudden, now I have an understanding of why my valve calcified, even though there’s no connection between Paget’s and valve calcification in the medical literature.
So what I’m saying is that whole genome sequencing is going to become de rigueur for primary care, and primary care internists are going to have to interpret the whole genome sequence for each of their patients. That’s going to revolutionize prevention and health care and improve longevity quite a bit. I’m very excited about the future.
Kevin Pho: David, thank you so much for sharing your perspective and insight. Thanks for coming on the show.
David W. Moskowitz: My greatest pleasure.
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