tul Gawande has yet to speak out about his plans for leading the new Amazon-JPMorgan-Berkshire Hathaway health care organization, but his past speeches and writings provide some clues to what he might do in the job.
Here are five key points about Gawande’s views:
He has thoughts about how to reduce health care costs. Lots of thoughts.
The purported goal of the new venture is to decrease health care costs for employees of the three corporate giants, though when it was announced, JPMorgan CEO Jamie Dimon said it could “create solutions that benefit … potentially all Americans.” (It should be noted that Dimon later tried to reassure spooked health care companies that the company’s purpose was really only for the three founding firms, as the Wall Street Journal reported.)
But whatever the enterprise’s reach, Gawande has been a student of screwed-up health care expenditures for years. Perhaps his most famous New Yorker piece is his 2009 story looking at the wide divergence in Medicare expenditures (often tied to the quantity of care people were given) and how more spending did not lead to better quality.
Gawande’s been critical of the fee-for-service payment system and its perverse incentives for clinicians to provide more care. Instead, he’s called for doctors and hospitals to team up “to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.” He more recently wrote an adulatory piece headlined “The heroism of incremental care,” all about how tiny, regular interventions could lead to better outcomes than grand, rare, lifesaving interventions.
“We’re all specialists now, even the primary care physicians,” he said in a 2012 TED Talk. “Everyone just has a piece of the care. But holding onto that structure we built around the daring, independence, self-sufficiency of each of those people has become a disaster.”
He added: “We want the best drugs, the best technologies, the best specialists, but we don’t think too much about how it all comes together. It’s a terrible design strategy actually.”
More coordinated care could lead to cost savings as well as better results, according to Gawande.
Checklists could be one way to curb medical errors — and cut costs
To emphasize smarter, more efficient care, Gawande has placed a big bet on checklists. In his book “The Checklist Manifesto,” Gawande says the medical field can take a page from the playbook of pilots, who tick off items on a step-by-step list for everything from takeoff to taxiing.
His argument: The everyday duties of health care providers can get so complicated, it’s nearly impossible for competent physicians to completely avoid mistakes. Checklists, while not a cure-all, can make surgery, emergency care, and intensive care unit medicine safer and more effective.
“Good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation,” he wrote in a 2007 essay published in the New Yorker.
The 19-item checklist — which asks surgical staff to pause before anesthesia begins, before an incision is made, and before the patient leaves the operating room — aims to curb errors and adverse events and boost communication in the operating room. The World Health Organization adopted the checklist as a global standard of care in 2008. And in 2009, a study published in the New England Journal of Medicine found the checklist cut the rates of death and complications after non-cardiac surgeries in eight hospitals in as many countries.
It’s critical to rethink how we approach end-of-life care
Gawande, like others in the field, has pointed to overuse of medicine as a key factor in soaring health care costs. He’s grappled, in particular, with how spending plays out at the end of a patient’s life. In his book “Being Mortal,” Gawande makes the case against the idea of treating a patient at all costs — even when it’s clear a treatment likely won’t benefit them.
“Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery,” Gawande wrote in a 2010 piece for the New Yorker. “But, ultimately, death comes, and no one is good at knowing when to stop.”
There’s nothing wrong with searching for a way to help patients with a terminal illness beat the odds of their prognosis — unless doctors haven’t prepared the patients for the far more likely outcome, Gawande says. And more often than not, that’s what happens. The physician says we’ve created a “multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets,” and haven’t adequately prepared patients for the “near-certainty that those tickets will not win.”
To begin to address that issue, Gawande says the medical community — and society as a whole — needs to rethink end-of-life care. Gawande argues against treating patients at the end of their lives at all costs. The question isn’t whether we can afford end-of-life care — it’s how we can change the health care system so that patients with terminal illnesses can achieve what matters most to them. It’ll be interesting to see how, if at all, Gawande, tries to implement those kinds of changes in his new position.
Expanding coverage, including through the government, is a top goal
Some of Gawande’s ideas reportedly caught the eye of President Obama as his administration was working on what became the Affordable Care Act, and Gawande (who in the early 1990s worked on President Clinton’s health care plan) did not take kindly to Republicans’ recent attempts to dismantle the law. As Gawande sees it, expanding insurance led to improved access to care and better health. He took particular offense at moves to cut Medicaid spending and the Medicaid expansion.
In his arguments, he tied health coverage to his support for smarter incremental care. “Conservatives often take a narrow view of the value of health insurance: they focus on catastrophic events such as emergencies and sudden, high-cost illnesses,” he wrote. “But the path of life isn’t one of steady health punctuated by brief crises. Most of us accumulate costly, often chronic health issues as we age. These issues can often be delayed, managed, and controlled if we have good health care — and can’t be if we don’t.”
But, but, but: What seem like slam-dunk ideas to improve quality don’t always pan out
When Gawande and Ariadne Labs’ checklist strategy was tested to see whether it improved birth outcomes in a rural part of India with some of the world’s highest infant mortality rates, it didn’t work. Mothers and their babies didn’t see benefits when clinics used the checklist: The rates of stillbirths and deaths for mothers and babies remained the same.
“Sometimes when you put evidence-based practices into the world, the world is stronger than those practices,” a health expert told STAT when the data were released.
If there’s any “world” that is resistant to change, it could be the entrenched health care system, with its tangled-ball-of-yarn collection of stakeholders (hospitals, insurers, clinician groups, drug makers, pharmacy benefit managers, and so on).
In a note to friends and colleagues Wednesday announcing his new position, Gawande wrote that he intended to “develop high-impact collaborations across the health care sector.” We’ll see if those can create meaningful change.