Speaker 1 00:00:00 We've got work to do on our health care system. And I, I think we have the tools and I think we have the will, but we have to really manage that.

Speaker 2 00:00:20 Welcome to Off the Chart, A Business of Medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Littrell. I'm the assistant editor of Medical Economics, and I'd like to thank you for joining us today. This week, we're taking a step back to look at the bigger picture, what's broken in the U.S. health care system and what can we do to fix it? Medical Economics managing editor Todd Shryock sat down with Dr. Marschall Runge, dean of the University of Michigan Medical School and the author of The Great Health Care Disruption, to uncover what's behind the dysfunction and what it will take to build a health care system that works better for physicians and patients. So thank you again to Dr. Runge for joining us. And now let's get into the conversation.

Speaker 3 00:01:06 I'm here with Dr. Marschall Runge, dean of the University of Michigan Medical School and CEO of Michigan Medicine, to talk about health care disruption. Doc, thanks for joining me today.

Speaker 1 00:01:17 My pleasure. Todd, it's good to look forward to speaking with you.

Speaker 3 00:01:20 So if you talk to patients, they'll talk about how it can take months to get an appointment. Drug prices are rising. They fight with their insurance company over coverage they don't understand, and sometimes they just skip coverage rather than fight the system. Sometimes it feels like everything's just falling apart in health care. You know what's happening out there?

Speaker 1 00:01:42 Well, I think that health care in the United States needs. It. Just needs. We need to look at how to improve, health care, especially from sort of a consumer standpoint. And you know that that involves getting appointments properly. That involves, understanding your insurance and your insurance working for you instead of feeling like it's an antagonistic relationship. because we have great, great specialty care. And if I was, had a very complicated problem, there's nowhere I'd rather be than in the United States, but access.

Speaker 1 00:02:18 Otherwise, it can be very challenging, as you know.

Speaker 3 00:02:22 So we heard a lot about how, you know, the big retailers, Walmart and others were going to jump in and fix all these, these inefficiencies. And Madison, well, they kind of jumped in and went, oh, this is way more complicated than we thought and jump back out again. Like, what happened? Why didn't that work?

Speaker 1 00:02:42 Well, I don't know all the factors, but I know a few of them. So, from a just from a medical standpoint, it's a, it's a challenge when you have, if you have a regular doctor of primary care physician. And then you go to one of these other places, like a Walmart or an Amazon and, you get care there and there's no connection between the two. So electronic medical records in the United States, I'd say, have met part of what their mandate was, but they haven't met the part that all medical records will be connected. So first of all, it leads to some fragmentation.

Speaker 1 00:03:18 But I think what Walmart and others, and I'll mention Amazon in particular have discovered is that it's very expensive to deliver high quality primary care because of the way that, reimbursement works in the United States, both from commercial insurance and from Medicare and Medicaid and other government funders. So, Walmart has, you know, jumped in and then jumped out. The idea was you get a lot of traffic in a store. so why wouldn't people come there for their medical care? And some, some pharmacies have used that approach. CVS, for example, with Minit Clinic, which has been somewhat more successful, but they're also looking at that model. The one that was most interest to me was Amazon. Amazon bought a company called One Medical. Which is a terrific company that delivers high quality primary care. And that does work pretty well. But what I understand from, publicly available information is that Amazon has found this to be a big loss for them. And I think part of the part of the business model was always also thinking that they could capture the income from pharmaceuticals.

Speaker 1 00:04:26 So you come there, you go to Walmart, you go to Amazon, you have an appointment, you need a medication, you can fill it right there. But I think that also has not turned out to be a profitable business model. So from a business model standpoint, I think that hasn't worked. And I'd have to say from a consumer standpoint, from a patient standpoint, it works. It has positives. So it does offer 24 over seven access, which I think is great. but. But then there is this disconnect. And if if you can. I can imagine myself if I called into one of the 24 seven lines and I forgot about something important in my medical history and I'm feeling sick, I'm hurting. I call in and I forget something that could have an adverse impact on my health care. Or the next time I see my primary care physician or specialist, I forget aspects of that Amazon encounter. There's no connection there between the medical records and so. So I think when I last looked, which was several months ago, there were 90 new startups in healthcare that involved using AI and AI driven technologies to try to solve some of these problems.

Speaker 1 00:05:34 I'd say that, you know, at the end of the day, I'm sure some of those will survive and will be helpful, but I think there are a lot that won't survive because it's a tough area. People, people don't realize. I'll stop my, my, soliloquy here in a moment, but I think people don't realize how complicated healthcare is. It seems like we ought to be able to fix that, just like you can fix a consumer product. And we know that that works because people order now most of what they order online, rather than going to a mall or a store.

Speaker 3 00:06:08 I hear a lot about primary care, how it's the key to really keeping people healthy, to build those relationships so the doc understands the patient. The patient feels comfortable talking to. The doctor has that really strong relationship, but yet it seems like that's the hardest part to solve. We pay primary care physicians less than specialists. But yeah, we're trying to keep everybody healthy. What? How do we fix primary care what's happening there?

Speaker 1 00:06:38 Well, I think there there are a number of levels of problems.

Speaker 1 00:06:43 I am a big believer in primary care. Now, this has come from a specialist. I'm a cardiologist, but I think primary care and preventive health management can be a salvation for the economics that we look at in terms of the cost of health care in the United States. So if you compare and I think this is commonly known, if you compare the cost of health care in the United States to that in other similar countries, we are by far the most expensive, over $12,000 per person per year. where many are in the range of three, 4 or $5000 per person per year. And I think part of that expense is because people don't get preventive health care. And by the time they end up going to a hospital or an emergency room, which can be extremely expensive, they're sicker than they would be otherwise. But when you take all that and then look at the number of primary care physicians, the number of primary care physicians per capita in the United States is very, very low compared to all those same countries.

Speaker 1 00:07:45 So that tells you tells me right away that our problem is we don't have. Part of our problem is we don't have enough primary care physicians. there are other health care providers who provide great primary care nurse practitioners, physician's assistants, etc. but we don't have enough of those either. So there's there's a shortfall. I think the pandemic was difficult, and really a lot of health care providers in all areas, got burned out and many of them left. but we can easily predict today that unless we change something dramatically, we won't have enough primary care providers now. Why don't more people go into primary care? I'll tell you in at Michigan Medicine, University of Michigan Medical School, about a quarter of our class is very interested in primary care. When they start medical school, by the time they finish, if we get up to 10%, that that's a really good year. And I think part of it is they see how hard primary care physicians are having to work. they see, that they're struggling financially.

Speaker 1 00:08:47 So they are, as you said, family medicine, pediatrics in a big way. General internal medicine. They're the lowest paid physicians. And when you look at it, really some of what they do is most important for our health as well as for the health of the United States. So I think I think there are all those challenges. And on top of that, with electronic medical records, the paperwork for all healthcare providers has increased dramatically. Now, that is an area where I think I have to has some potential. And if you'd like to hear my thoughts on that, I'd be happy to share them. But I think it's a whole step stepping ladder of, challenges that we haven't we haven't dealt with in the United States.

Speaker 4 00:09:30 Say, Keith, this is all well and good, but what if someone is looking for more clinical information? Oh.

Speaker 5 00:09:36 Then they want to check out our sister site, Patient Care Online. Com the leading clinical resource for primary care physicians. Again, that's patient care online.

Speaker 5 00:09:45 Com.

Speaker 3 00:09:49 Let's let's talk about AI. There's new tools coming out all the time. You mentioned the number of startups and they all sound great. And a lot of doctors are already using AI with their note taking and reporting. A lot of time savings there. You know, is AI a miracle cure for everything that ails medicine? What what are your thoughts on AI?

Speaker 1 00:10:09 I wish it was Todd and I, and I'm really very positive about AI, but I think it's I like like all things in its initial foray. It's overblown. And the thought is that we can fix everything. And at least today, we don't have the tools to fix everything. You did mention that, physicians, other health care providers are using AI in their encounters with patients. And so if if you're my doctor and we're talking having this conversation, if AI is turned on, its called ambient AI and there are several providers that I not just does a transcript. It records everything, but it it provides a really high quality medical note.

Speaker 1 00:10:51 We're using this now at Michigan Medicine, and every doctor I talked to there are about 1000 doctors using it right now says thank you. this has saved me an hour or two every single day, but not having to fill out all those notes. And I think it's easy to imagine that I can play a similar role for patients. So now you call in, you want to get an appointment. They put you on hold. They call this doctor, that doctor. they're the times don't work with your schedule. and there's some modules out there with AI that work extremely well for that scheduling process. The other thing that AI is, is already showing is that it helps efficiency. I'll give you one example. Methodist hospital has a, facility in Cypress, Texas. that I was just, there not too long ago. And they have sort of an AI enhanced hospital. And what they found is that it improves efficiency as well. And the example one of the examples is that, in surgery, I can, look at every different surgeon, recognize what happens when that surgeon is put it's last his or her last stitch in and how long it is until they get to the recovery room.

Speaker 1 00:12:08 And that enables two things. It enables the room to be turned over much more quickly. And and it's really eye based because it might be different for your last stitch versus my last stitch. But I think even more importantly, it, enables, health care providers, the nurses or whoever's running the post-surgical area to tell the families, your loved one will be there in approximately 15 minutes or 20 minutes where the usual one. I don't know if you've had friends or family who are getting surgery. It's usually, well, we don't know it. We'll let you know when we know more. So it's I think it can be helpful for patients, but also for efficiency. Now where I think and in imaging I think it's powerful. So in radiology or histopathology or dermatology, what I right now is really exceptionally good is at is recognizing normal. So if you think about a Cat scan or an MRI, you may have 30 or 40 images. So if it can tell the radiologist, don't worry about anything except for images 13 through 15, that makes the radiologist much more, able to spend a lot of time on those particular images and saves them time.

Speaker 1 00:13:25 I don't believe that we are anywhere close to AI being a healthcare provider. Some people are trying to push that. You'll see lots of advertisements about it. all I know is I don't want an AI bot to be my health care provider, in part because, although I can emulate, human connection, it's just not human connection. It can emulate empathy. But it's not empathy. It, you know, it tells you back what it thinks you want to hear, which may sound good, but may or may not be good advice. So I, I, I, I'm hopeful in the next 5 or 10 years we'll have much more meaningful impact from AI, but I think it's making a difference already.

Speaker 3 00:14:06 When it comes to equity. You know, our rural hospitals are already struggling to stay open, and all these AI tools are fantastic, but they're also not free. Do you have concerns about we're going to end up in a have and have not medical system where the big city or the research centers have all these great technology tools, and the rural hospitals and rural practices do not.

Speaker 1 00:14:31 A really good point again. Todd. So we we do have, inequity, inequity in access to health care inequity and access to the level of health care. And it's both in rural areas, but also in areas with low socioeconomic status where there aren't as many physicians practicing there, not as many health care providers or the facilities just don't have the breadth of what is needed. So I I'll tell you what I believe. I believe that the United States would be much, much better off. It's a it's a political hot point. But if we had some level of health care that is available to everybody, it doesn't have to be the blue plate special. It doesn't have to be what we might get out of our commercial insurance. But health care to the level that if you go to a health care facility, you're going to be able to get health care and appropriate health care. People criticize government programs a lot, but the VA system, while it has its detractors, does a great job with veterans.

Speaker 1 00:15:34 There are a number of different kinds of, of health care facilities that the federal government supports. And if you look at these countries that I mentioned earlier, whose expenses are much less than the United States. It's partly about primary care, but it's partly about how primary care is provided with a sort of basal health care. and, there are several examples that are brought up. Some of the northern European countries, Denmark, Sweden, Switzerland. they're they're touted for they have this government health care. But when you really dig into it, it turns out that half or more of the people, citizens in those countries have purchased supplemental health care. So if you want extra health care, you can you can get it if you're okay with, sometimes the weights or other problems that are inherent in a system that's providing care for a large, large number of people. if you're okay with that, then I think that's fine. So that. But that's a step we have never been able to, achieve in the United States.

Speaker 1 00:16:37 I remember back in the, in the late 80s, early 90s, it was going to be, HMOs, health maintenance organizations. That didn't work out too well. then it was going to be universal health. Universal health, where everybody had all of their health care. And it imagined something like the UK or Canada. But, you don't have to read very deeply to find that those health care programs are, you know, they're sort of B-minus level. And many people in those countries, and they have huge waiting lists. Many people in those countries do have supplemental private health care insurance. So, it's a pity that we have these big, political arguments. it's more about ideology. And I've always hoped that, we'd have people that had a better understanding of health care itself and what it involves trying to form these new policies.

Speaker 3 00:17:31 Yeah, it's funny you mention HMOs because I've heard a lot about capitation coming back around again. It's like we're coming full circle there.

Speaker 1 00:17:39 Yeah, yeah. And in HMOs, I think that ran a whole lot of primary care physicians out of business, because in the HMO model of the early 90s, the primary care physician was the one who had to tell the person, the patient, no, you don't qualify for that Cat scan, or you don't qualify for that surgery or you don't qualify for that hip replacement.

Speaker 1 00:18:01 And that put the doctors in those primary care doctors really in a difficult position. now, some of that still exists with particularly with commercial insurance companies, where they have a medical director who denies things. so again, we, we, I think we can learn from other countries about how to better manage, health prevention. I am, as I said, I'm repeating myself. But I think if we really focus on health, rather than just, getting in the system, people will be healthier, actually. I'll tell you. I'll say give you one other bit of information. The, if you look at healthy average life expectancy. So that's not just average life expectancy, how long you live, but how long you live as you're healthy and you're still able to think and do many things you'd like to do. the United States, as of today, ranks 60th. That's six zero in the world. So there are 59 countries that have a longer, healthy life, healthy average life expectancy than the United States.

Speaker 1 00:19:07 And, there's a, a group at the University of Washington in Seattle, that does a lot of really people look to for these predictions. The predictions are if we don't change something, it by 2050 will be 110 110th or 120th. So, and you don't have to look very far. Obesity is rampant. Diabetes, which goes along with obesity, is rampant. and it has multisystem problems. So we've got work to do on our health care system. And I, I think we have the tools and I think we have the will. but we have to have to really manage that.

Speaker 6 00:19:55 Hey there folks, my name is Keith Reynolds. I'm the editor of Physicians Practice. And this is the P2 management minute. I'm not sure if it's time to add staff. Check these three metrics. Number one, rising wait times, longer lobby waits and clogged phone lines. Scream over capacity. Check. Median in office. Wait in the third next available appointment every month. Two straight quarters of increases. Time to hire or redeploy a scheduler or medical assistant.

Speaker 6 00:20:17 Number two chronic overtime FLSA rules make overtime a hidden tax pull payroll every cycle. If overtime tops 10% of total hours for three pay periods in a row, run the math. A full timer often costs less than time and a half. Number three labor costs per visit divide total count by total visits each quarter if the ratio climbs while volumes flat. Offload clerical tasks to support staff or software so clinicians can see more patients and restore margin. Watch weights, overtime and cost per visit. Your trio of hiring signals for more bite sized practice tips and tricks, make sure you visit Physician's Practice. Com thanks for watching and I'll see you tomorrow on the P2 Management Minute.

Speaker 3 00:21:04 Like you wrote an entire book on on healthcare disruption and and possible solutions. When you were putting that together, was there anything that that surprised you?

Speaker 1 00:21:15 Well, I have to say, even though I was I knew about it, I was surprised how, behind the game. We are in primary care. on the other hand, I wasn't so surprised on this, but I think some people will be.

Speaker 1 00:21:31 the power of development of new approaches in healthcare that the United States has, the. We feed the rest of the world. So, I'll give you two examples. one of these weight loss drugs, so-called weight loss drugs, bound to others, that were initially developed for diabetes. Then it turned out that the people who were taking these drugs lost weight in a way that has not been. That's much better than anything that was present before. but what is also turned out is it wasn't just because of the approach that they thought would work with diabetes, which was delaying stomach emptying. it turns out that these drugs, interfere with a pathway, a neural pathway that when you, when you do something that is sort of addictive, you get this surge of dopamine and then it makes you want to do that more and more and more. So you can think about eating that way. You can think about cigarette smoking, about alcohol, about gambling, about all kinds of things. And, these drugs are now, proven to work in those areas and are, FDA approved in several of those areas.

Speaker 1 00:22:44 So, and, and it'll be more so, you know, that kind of ability to develop those drugs and test them. And then the last comment I'll make about drug development has to do with genetic therapies. and the the big successes today are that, in children who have an inherited, lethal mutation, that those can be repaired. And there are several examples. They're fairly rare, several examples where, that child can live a normal life rather than either living 3 or 4 years or ten years and requiring an enormous amount of health care, not really ever having a normal life. Trouble with all these things is they're expensive and the weight loss drugs are expensive. Everybody knows that these RNA therapies are expensive. And another one of my thoughts about that I mentioned in the in the book is about the the the federal government has enormous purchasing power. And so if the federal government decided and this is one of the proposals, that it will, make all medications less expensive, but if it decided it wanted to buy in bulk, these weight loss drugs, instead of it costing $100 a month, it'd probably cost $250 a month.

Speaker 1 00:23:58 You know, unaffordable amount of money. Not not for everyone, but at least for insurance companies, which now a lot of insurance companies are saying we just won't pay for that anymore.

Speaker 3 00:24:08 Like, we've had a wide ranging discussion of of lots of things happening in medicine. Is there anything else that you would like to to mention that we haven't talked about.

Speaker 1 00:24:16 Well, one last topic. So in the last chapter in the book, I talk about, aging and healthy aging. And, as you probably know, there are lots of people writing about aging these days and all the things you can do for aging. There's a person named, Brian Johnson who's very well known, who has a website called, well, blogging on the name of it, but if you look up that name, Brian, with a Y, you can see all the he he's doing spending $2 million a year trying to reverse aging on himself. But, but the truth is, when you look at all these approaches, there are 4 or 5 common features that seem so simple, but we don't always do them.

Speaker 1 00:25:03 I don't always do them. So one is sleep. So having regular sleep, going to bed about the same time, waking up at the same time, Tailoring that to how much sleep each person needs, which can be a little bit different. It could be seven, eight, nine hours of sleep. So sleep is one of the most powerful determinants of health. fitness. In one of the books written by a person named Eric Topol. It says fitness is not optional. Fitness, fitness. An exercise is not optional. You know, I wish I had, embraced that a lot of years ago. But but fitness, community, having friends, family, to keep active with, is another. And there are two or 2 or 3 other ones that are things that we can do. They don't cost any money. but they're hard to do. But if we could embrace that and, and actually in some countries, they have set up and avoiding these high calorie junk foods that we are so addictive to us.

Speaker 1 00:26:02 In other countries, they have figured out ways to enhance those, by federal regulations. For example, in Singapore, which has great health. They charge a lot of tax on junk food, and then they take that money from the junk food tax, and they apply it to healthy foods so that healthy foods are are inexpensive in those countries. And there are there are many approaches like that. But I think we need to figure out which ones of those that we can individually control and that we can, get help in terms of government regulation.

Speaker 3 00:26:43 And one more question for you, doc. How concerned are you about the prevalence of misinformation in medicine that's out there? We seem to have gone from, hey, let's see what doctor thinks to I'm going to see what Facebook thinks. Like, how concerned are you about all the misinformation that's out there?

Speaker 1 00:27:03 well, nobody I've, I've done some of these interviews. Nobody has asked me that question. So thank you for asking. I am very concerned about it because I think that's a lot of, you can put whatever you want on Facebook or on Twitter or on, TikTok, wherever you want to.

Speaker 1 00:27:21 And people have gotten so engaged with social media that they and many of the people who speak sound very authoritative. And, so, so I think that has been very destructive in terms of health because, for example, the, a lot of the debate about vaccinations has been through those kinds of medias. so one of the thoughts I have, that is that we could if we could reinstitute health as a part of the curriculum. K through 12, it used to be a bigger part of the curriculum and talk about all things, all kinds of things in health. Now it's kind of scrunched into a little box. I think if we can do that, as kids are growing up, there. Their brains just soak up information, and there are several studies that show that they then take that home and say, well, wait a minute, wait a minute. I learned in school today that I should be getting some exercise every day, or I should be not eating junk food and sitting in front of the TV or sitting in front of the computer.

Speaker 1 00:28:25 So, I think that, we need some more sources of truth that can be out there and can be, part of the dialogue, because we have many sources of untruth that people are plug in on the internet.

Speaker 3 00:28:46 Great talk. Fascinating conversation. Thank you for taking the time today.

Speaker 1 00:28:50 Thank you. I really enjoyed speaking with you, Tom.

Speaker 2 00:29:07 Once again, that was a conversation between medical Economics managing editor Todd Shryock and Dr. Marschall Runge, dean of the University of Michigan Medical School and the author of The Great Health Care Disruption. My name is Austin Littrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show, and as you please, subscribe so you don't miss the next episode. You can find us by searching off the chart wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice published delivered straight to your email six days of the week, subscribe to our newsletters at Medical Economics and Physicians Practice.

Speaker 2 00:29:39 Com. Off the chart, a business and medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds and produced by Austin Littrell. Medical economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Thank you.