Don’t Wait for the Government to Fix Healthcare

ZDoggMD and MedPage Today Editor-in-Chief Marty Makary, MD, MPH, talk about overhauling healthcare with diversity, price transparency, and why you should get involved.

Following is a rough transcript (note that errors are possible):

ZDoggMD: Guys, Zubin, Dr. Marty Makary

Makary: Great to be with ya.

ZDoggMD: back again. Marty’s a hot shot, wrote a book, came out on paper book. Paper book? This is a paperback.

Makary: Good start.

ZDoggMD: Yeah, yo, I keeps it real. “The Price we Pay: What Broke American Health Care “and How to Fix It,” and I had you on two years ago, when the thing came out in a hardcover.

Makary: That was fun, I’ve watched it five times.

ZDoggMD: Dude, I have it on repeat too. When I’m rolling with my kids, I’m like, Let’s listen to basically how angry you can get, understanding how we’ve financially assaulted patients who are, in fact, us.

Makary: I no longer go and buy Ben & Jerry’s when I had a rough day at work, to engage in emotional eating, I now just watch our videos.

ZDoggMD: There’s a whole branch of therapy devoted to that, Marty.

Makary: I am proud to be here. Great to see you again, Zubin. By the way, my preferred pronouns are member of the Z-Pac/ZDoggMD Tribe.

ZDoggMD: That’s the only pronouns that I will allow my children to list on their Zoom for school. Dude, so speaking of pronouns, there’s a lot of pronouns in here. You tell stories of people, and the fact that it’s in paperback means that the Z-Pac needs to go buy this book on paperback today, that it’s out, so that we can rocket it to the New York Times Bestseller List, and the reason that matters is that that will give it a viral boost, and the reason that matters is, in this book, when I first read it, and it’s been updated now and it’s got post-COVID stuff, it’s got some things that happened since the book came out.

Makary: Some good follow-up.

ZDoggMD: It really is. It led to this activism, where doctors and patients actually made a difference. This intractable system that no one can fix, it’s starting to shift, because, first, sunlight’s the best disinfectant. You shine a light on everything that… Patients get these ridiculous surprise bills. They then go bankrupt when a hospital system, whose motto is doing the Lord’s work, like maybe a not-for-profit Catholic group, is suing their own patients, throwing them into bankruptcy.

Makary: It’s nuts. We can do stuff, and good stuff is happening, and I’m proud to report, since we first did that conversation on this topic, we are shutting down this practice of predatory billing in America, and when I say we, it is really not me. It is the giant group of people out there, that read the book, that have heard our stuff, that have seen our paper in JAMA, and have said, “This isn’t right. “It’s violating the great public trust “in the medical profession. “We’re offended by it.”

We should be offended by it. 64% of Americans say they have avoided or delayed care for fear of the bill. It’s affecting access, and these are things we can prevent. We’ve lost control of billing, as healthcare clinicians, but these are our institutions engaging in price gouging and predatory billing, and we have a say. If we are aware of it, we can have a say, and good stuff is happening.

We’ve asked a lot of hospital CEOs, “Can you stop the practice of suing people “who can’t afford to pay your bill?” And of the one-third of hospitals that do do this stuff, most of them are saying, “OK, yeah, I get it. “I understand.” Now, a couple of them are tough and they won’t do anything, but that’s when we unleash. We get other people to call. We talk to the doctors and say, “Hey, these are your patients.” And we, one time, resorted to calling the donors of the hospital, and that shut it down. That shut it down at UVA.

ZDoggMD: That’s where you did it. So this is the thing. In the book you wrote about how patients will get these inflated Chargemaster bills, and in the book, you detail the money games that hospitals have to play, in order to get reimbursed by insurance. It’s this lack… It’s completely opaque world of subterfuge, where it’s like if I bill the insurance this ridiculously inflated rate, they’ll pay this much of it, so let’s keep racking up those prices,

Makary: Crazy gain.

ZDoggMD: the rack rate, and then what happens is when their patient comes that’s uninsured, or worse, under-insured, they have insurance but they have these high deductibles, whatever,

Makary: High deductibles.

ZDoggMD: they’re on the hook for that full Chargemaster, they get sued by the hospital when they can’t pay, because of course they can’t pay and they never agreed to that price up front. It’s not like they got an estimate at a mechanic for a tire rotation. It was like, “No, your appendectomy is now $30,000. “Oh, and by the way, “no one knew that you could get the same appendectomy “down the street for $2,000, “but there’s no way to shop these prices.” So you brought that to light. You said, “Well, OK, this is what’s happening,” and then you didn’t stop. You actually went and you went to courthouses and started… Tell me what you did there.

Makary: So myself and my friends that are in this with me, we have offered to defend any patient who is sued by a medical center, pro bono, as their expert. We’re not lawyers, but we’re experts, and when we show up there, you can better believe that it’s a different court proceeding. When we approach the bench with the patient and say, “Your honor, there’s no agreement here. “You can’t just show up and mow someone’s lawn “and charge them $5,000. “There’s got to be an agreement. “Where’s the agreement on the price?” Now, many times, these people are begging for a price. They just want to know, is this going to clean me out? A lot of this stuff is elective. 60% of medical care is shoppable. They’re asking us for a price and our hospitals cannot give it to them. This is the most basic piece of information, and so we win 100% of the time.

ZDoggMD: Wow.

Makary: We win every freaking case that we go and defend a patient at.

ZDoggMD: You’re like a Perry Mason MD, my friend. It’s pretty impressive.

Makary: We’re getting the hospitals to just cancel a practice altogether, and so we’re going to keep winning.

ZDoggMD: ‘Cause how much revenue does it really generate for a hospital?

Makary: Half of a CEO salary, that’s how much revenue, assuming all these people generates, and we published that in JAMA.

ZDoggMD: That makes me slightly want to vomit projectile right into the camera.

Makary: Well, I asked one of the CEOs, “Do you think you can get by on 1 million a year?” We’ve got to have an honest conversation about this stuff. It’s price gouging, is what it is.

ZDoggMD: You said something that’s super important, you point this out in the book. Healthcare could be shoppable, but we can’t shop, because they cannot and will not give you a price. So can I tell a story? So my daughter needed an MRI done, and I’ve told this story vaguely before, so I’ll leave some of the details out, but suffice to say, she needed an MRI. I have a high deductible plan, so it’s like $6,500 deductible, family deductible, so I’m on the hook for at least that much. So my skin’s in the game. To me, that’s money I don’t necessarily need to spend if it’s not necessary, and I will haggle, believe me, ’cause I’m Indian, I will haggle, and I’m a doctor, so I think, oh, I know what’s up. So I go to my usual multi-specialty group, that, actually, you’ve mentioned before, that’s part of a larger organization that is known to price gouge. They are known to do this. They’re known to inflate rates on labs and all of this, and in fact, they were sued by the state of California for this. We’ll leave them unnamed.

Makary: Yeah, I would never name it. I would never name Sutter Health.

ZDoggMD: No, I wouldn’t do that either. That would be wrong. So not naming Sutter Health, we could say that I went to this unnamed project–

Makary: The irony is there are great doctors there. That’s the big irony.

ZDoggMD: Oh, the best. That’s why I went there. These are my colleagues. That’s where I used to work, and so I knew. I was like, OK, this is going to be an issue, so before I got the MR, the doctor ordered it, the pediatrician ordered it, she was fantastic, I called the billing department and I said, “Hey, this is Dr. Damania.” I pulled the whole doctor thing, and I said, “I’m about to get my kid this thing, “curious how much it costs “and if there’s any discounts available, “or if we pay cash, because I have a high deductible plan.”

Makary: You have a coupon for 50% off.

ZDoggMD: Basically, that’s what I want. “I have a Groupon. “Me and my friends are all getting MRIs, “and we were wondering…” And she said, “Oh, great, doc. “What’s the CPT code for the scan you’re getting?” And I was like, “OK, let’s pretend I’m a patient, “’cause I don’t know CPT codes.” She goes, “Oh, OK, so what’s the scan?” And I was, “Oh, it’s this, that and the other thing.” She goes, “OK.” So she takes some time. She was actually very helpful. She took some time. She looked up the CPT code. She said, “OK, it’s this. “All right, and I can’t promise that this is what it is, “because they may add things. “They may change things. “It’s going to be 1800 bucks for this MRI.”

And I was like, all right, OK, no surprise. It’s this place. It’s going to cost a lot. So I said, “OK, does that include physician’s fees and all that?” “I don’t know.” “OK, so let me understand then. “If I pay cash, what will the discount be? “Will I get a discount?” She goes, “Oh, yeah, absolutely, we really encourage that.” “OK, what’s the discount?” “30% off.” “OK, so it’s still 1500 bucks or whatever. “OK, great, well, let me ask a question. “When do I need to make that decision?” “You need to do it before the procedure “and before the insurance is billed, “because once the insurance is billed, “we can’t give you the cash discount.”

“OK, so then, let me ask the third question. “What will the insurance discount be?” Because a lot of times insurance companies negotiate discounted rates, that they then would say, “OK, so Zubin, “you’re going to have to pay this much “towards your deductible “because the insurance negotiated rate for that MRI “was only $1,000, but you’re on the hook for the thousand, “’cause of the high deductible that you chose.” And she said, “We can’t tell you that, “because those rates are not disclosed publicly.” And I said, “Oh.”

Makary: Because if they were, there would be competition. There would be a free market around those discounts.

ZDoggMD: And we know we live in America, where we talk about free market medicine, but this is not the free market. This is obfuscated. So at this point, I said, “So you’re telling me I need to make a decision now “with information I don’t have “about what the insurance discount would be, and by the way, “if I make the decision to pay your cash rate, “that cash payment that I made to you “does not apply towards my deductible, “so that if I incur more medical expenses, “then I’m going to have to pay them.” So this is very complicated, and look, I did math, I’m a doctor, I couldn’t do the math

Makary: I did calculus III in high school. I cannot develop a model that’s going to figure out whether or not I should pay this cash discount, and what would happen if you didn’t ask for a discount?

ZDoggMD: If you didn’t ask for a discount, you’re simply not gonna get it, you’re gonna get the rack rate charged to you.

Makary: And collections.

ZDoggMD: It’s gonna go to collections, it’s gonna go to court, and I’m going to be medically bankrupt if I’m–

Makary: What a joke.

ZDoggMD: It’s worse than a joke.

Makary: It’s embarrassing. It’s a disgrace.

ZDoggMD: It’s a moral injury the country suffers. We’re the only country… What is this? 1800s Victorian England, where you end up in paupers’ prison because, oh, it looks like Billy got an appendix blown out. Well, now he’s in paupers’ prison, because his whole family couldn’t pay the bill, and now she’s sold herself into white slavery. You’re like, wait, wait, where did this come from? How about we have clear prices? People don’t go into bankruptcy because their mechanic gave them an estimate in advance and they couldn’t pay for the car. It’s like they sell the car, they make a decision.

Makary: Imagine you went to a travel website and there were no prices, and the airlines argued what hospitals argued. “Oh, we don’t know the price. “We don’t know what our true cost is going to be. “The plane could have a delay or a cancellation “or it could crash. “That would cost us a lot of money, “even though it’s our fault, you could consume a beverage. “We can’t give you a price.” No, there are smart people… Arguably, we might have smarter people in medicine, America’s university medical centers,

ZDoggMD: It’s arguable. It’s arguable, yeah.

Makary: supposed to be the bastion of medical scientific genius. They build models of predictable risk and they price it into a shoppable price for that service, like the MRI, and you go on the travel website and you look at different prices and you shop. Imagine if there were no prices. You would get gouged by every airline and the public would hate the airline industry. Sound familiar? We are losing the public trust with these money games, and it’s up to us, physicians, nurses, everyone who works in a hospital, to say, “These are our services. “How dare you gouge somebody “and put them in wage garnishment at the local courthouse?” And so we’re going to keep fighting. We’re going to keep winning. We’re going to shut it down.

ZDoggMD: OK, so you do you do that for the court houses and things like that. You’ve stopped… I’ll just show this graph, so this is in the update. This is why the paperback, even if you have the hard cover, this is why this is important. There’s a whole afterword here about stuff that’s happened. Look at this graph, dudes. I feel like Nickelback. Look at this here graph. Every time I do, it makes me go, wow, Marty.

Makary: A number of lawsuits, yeah.

ZDoggMD: And I showed this on a previous show, so here’s the number of lawsuits before the book. Here’s where, the line, the vertical line is, where the book came into being, and this is the number of lawsuits against patients after the book.

Makary: We’re shutting it down. It’s going to come out in JAMA, that graph. JAMA’s probably going to be upset that we released it here in the updated book today but–

ZDoggMD: You know what?

Makary: You know what, they’ll get over it. They’ll get over it.

ZDoggMD: I understand they’re really good at handling controversy. Remember the dude who was like, “Racism isn’t a thing.”

Makary: Yeah, right. I think they might add a third minority member to their editorial board. So they have 49 editors, two of them were African-American. New England Journal… I don’t know why I’m talking about this now.

ZDoggMD: No, it’s important.

Makary: They have 51 editors at the New England Journal of freaking Medicine, one African-American. Doesn’t somebody say, “Hey, you know what? “Maybe diversity changes our perspective “on what the important issues are. “After all, we are the gatekeeper “of the entire healthcare system of the world. “Maybe it would be important to have some diversity.” Not just race. How about age diversity? How about people from different specialties, AKA non cardiologists, on the board. Just an idea.

ZDoggMD: I love it, dude. I love it.

Makary: But anyway, JAMA is publishing that, unless they’re going to watch this and maybe cancel the publication.

ZDoggMD: Oh, in which case, then you’re welcome, Marty, you just lost a publication. I will say this. So your activism, again, ’cause we always feel powerless, all you did was incredibly and meticulously research, like a bulldog, this subject, wrote a book, that was a result of years of work, and then evangelize it for the last couple of years, since this has been happening, and it’s changed actual lives, and actually, my issue, where I was like how do I even estimate a price here? What do I do? What did you do about that? You went and lobbied Congress and stuff and got something done.

Makary: First of all, we can get stuff done. We, in healthcare, even though we’re seeing patients at the bedside, we can get stuff done, and seeing patients increases our credibility, because we’re respected in the community.

ZDoggMD: Oh, you are. They look at me as a rapping clown man.

Makary: No, I still think the sort of person that goes into nursing school, the sort of person that has many career options and says, “I want to be a doctor,” that person is different from their peers, and they are highly respected for what they do. You see it every day. People trust us to put a knife to their skin within a second of meeting them, just because they’re at the hospital.

ZDoggMD: No, that’s me on the street. Honestly, people will come up. I’m like, “Hey, buddy, can I have your wallet?” And the knife is to the skin and he trusts me implicitly. No, no, no, no, you’re absolutely right.

Makary: But we can get stuff done. So we went to the policymakers, and I’ll tell you exactly who we went to, even though we might get canceled or this will generate some comments.

ZDoggMD: What else is new?

Makary: We went to Nancy Pelosi and we went to her staff. We went to Secretary Azar and we went to the CMS administrator, Seema Verma. They all said, “I get it, I get it. “This is wrong.” We posted videos of the patients, because CEOs are like, “No, we have liberal financial aid policies. “Anybody qualifies. “They just don’t return our calls.” Not true. Listen to the patient stories.

OK, one of my students, Michael Boctor, is a filmmaker. He’s a medical student. He was a filmmaker. He said, “Marty, I want to create videos “to share their stories with the world,” and we put them up at restoringmedicine.org, and we played those little two minute video clips of patients telling their story of a predatory and unfair billing system in medicine that shut them out and put them into this paupers’ court, garnished their wages from Walmart, and we played that to Nancy Pelosi and the White House and all kinds of folks, and they said, “You know what? “We’re going to do something,” and so we got the Price Transparency Executive Order passed and signed by the president with bipartisan support, and that also requires that hospitals create a price estimator, so you put in your insurance information and you figure out what they’re going to pay, what you pay and what the price of the service is. Mayo Clinic had done it already, and we said, “This is the model. “If Mayo can do it, every hospital can do it.” So it’s taking effect. Some hospitals are not complying with the law and they’re paying the $300 a day fine instead.

ZDoggMD: That’s like a mosquito bite for them though.

Makary: It’s nothing. We can do something. We work for these hospitals. We can create public accountability around this practice.

ZDoggMD: And you have, ’cause now you have this price estimator, which would have helped me dramatically.

Makary: When there’s transparent pricing, there’s no gouging. ‘Cause it’s the sunlight that disinfects price gouging.

ZDoggMD: Yeah, you can make a choice actually, heaven forbid. What’s interesting is that I think everybody agrees this is a problem. So here’s a question. This was the follow-up, and this is tough, because it’s such a complex web, who’s ultimately to blame for the obfuscation going on here? Is it the hospitals that don’t want to do this? Is it the insurance companies for negotiating these things and playing these games? What is it?

Makary: I think we’ve got good people in healthcare, honestly, but we’re working in a bad system, and it’s a system that we didn’t design, it’s a system we inherited and it’s a broken system, and the games are getting worse because of the trickle down orders from the top line management in hospitals. It’s like increase revenue, increased revenue, so it gets outsourced to the CFO, who outsources billing to another firm, who outsources it to a third party, who outsources it to a lawyer, who’s beating people down for these prices and gouging people. I think we’ve become disconnected. We’ve lost control of billing as physicians.

ZDoggMD: Yeah, we have nothing to do with it now. It’s crazy.

Makary: And we can take it back.

ZDoggMD: Yeah, and the book really talks about some bright spot ways to do this. By the way, what was the deal with Henry in the book? You had a story. It was really quite powerful.

Makary: Well, similar to your situation, where he was told his dad needed a CABG, very standardized procedure in the United States, and he was told by the hospital it’s going to be $150,000, because it was clear that he had means. He flew in from overseas and they knew he had means, so they just threw out there, $150,000 for the CABG. He didn’t know if that was a reasonable price. He was happy to pay a fair price, but just had no idea. Is it normally a million? Is it normally 20,000? They call a family friend in France, and the doctor, who is a cardiac surgeon with great outcomes, well-known and does the same procedure, says, “We do it at our hospital for $15,000. “If you want to have it done here, “you can fly in and get it done. “That is our hospital price. “If you want to get it done there, “that’s a good hospital too. “I don’t know about their pricing.” So he then tells the hospital administrator, who’s now starting to harass him, like, “Do you want it done here? “We can lock in that price.”

ZDoggMD: Oh my gosh.

Makary: Like some car dealership.

ZDoggMD: Like a car dealership, yeah.

Makary: And he says, “Well, we hear it’s $15,000 elsewhere. “We might have it done there,” and the hospital says, “OK, how about $50,000?” And he was like, “I don’t know. “I don’t feel comfortable with this.” And the guy goes, “OK, what did you hear? “What was the other price?” “15,000.” “25,000 if you pay in cash.”

ZDoggMD: Oh my God.

Makary: He was so turned off, by not only the hospital, but by the American healthcare system, that he said, “I just don’t trust them. “I’m going to go elsewhere.”

ZDoggMD: I would never… Are you kidding me? To treat somebody… A situation like that as like a used car salesman. How desperate for revenue are you? Pretty desperate, because, like you said, it’s the trickle down message from above, the revenue is what matters, and we do good for people because we make a ton of money, so we can build more wings and get another yacht.

Makary: And if it’s that much better, maybe the market enables them to charge that much more, but there’s no difference in outcomes.

ZDoggMD: And you talk about that in the book.

Makary: Yeah, the Society of Thoracic Surgeons has an independent registry of heart surgery outcomes, and guess what? No association between price and quality or price and charity care. Every place perceives that they’re the best quality, and every place perceives they do more charity care than the next, but good stuff is happening. We’ve got Sesame Care now, an online pricing platform, David Goldhill as well.

ZDoggMD: Yeah, David Goldhill, yeah, yeah.

Makary: So good stuff is happening.

ZDoggMD: Yeah, so again, like you said, you’ve got to shine a light on it, when you use sunlight, it disinfects and then people go, “Wait, there’s solutions here.” Actually, since this is America, the solutions are often entrepreneurial, like what David is doing, like what ChenMed is doing. So ChenMed’s interesting, because if you’re looking at solutions, it’s like, well, we do all this unnecessary care, there’s all this care variation, we don’t develop relationships, we don’t focus on those important things, your team has been working on this for some time, tell me what the research your team has been doing, and then we can talk about ChenMed.

Makary: Yeah, I don’t know what to call the research our team is doing, but I love it, and I would say it’s about the redesign of healthcare, and there’s no specialty for it, but it’s beautiful, because it allows you to take a step back and ask, hey, maybe we should be treating more patients with diabetes with cooking classes than just throwing insulin at them. Maybe we can get people to a better place. Maybe we should talk about food as medicine. Maybe we should talk about low inflammatory foods as one of the treatments that we otherwise recommend for patients with certain conditions. Maybe we should just not talk about obesity in terms of what you should eat. Maybe we can talk about school lunches, instead of just bariatric surgery. Maybe we can talk about access to medical care, in terms of how we can better use physician assistants and nurse practitioners and a team-based approach.

These are the things we’re interested in. How can we study cancer, so it’s not just about memorizing the chemo protocols, it’s about understanding the environmental exposures that cause cancer, something we haven’t really studied. Loneliness, one of the greatest epidemics. It predated COVID and it’s magnified and it affects your physiologic reserves, and it’s rampant among seniors.

ChenMed is creating communities. It’s beautiful. This is the sort of stuff we’re interested in. Social justice, addressing human rights issues by making medical arguments, not just political arguments, talking about the cost of healthcare by talking about the appropriateness of care in every specialty, not just one specialty, rebuilding the public trust in hospitals by getting to honesty with pricing, these are the issues that we’re passionate about. I don’t know what you call it. Maybe it’s healthcare 3.0 in the way that you talk about it. We call it the redesign of healthcare. A lot of old-fashioned docs will tell you it’s just great bedside medicine.

ZDoggMD: It’s just great medicine. Everything you said is exactly what we’ve been banging on for all this time, and that’s where the ChenMeds, the Iora Healths, Iora was our partner at Turntable, full disclosure, it’s this idea that, oh, wait, hold on, you can have team-based care that focuses on prevention and relationship with patient, that’s technology enabled, so you have good tech, that’s not just a billing platform for your EHR, it’s actually a frickin’ care device, get the patient involved in their care, put skin in the game, teach them how to cook, teach them how to shop for food in a supermarket, in the periphery, where the food is fresh, instead of all that processed garbage in the center, teach them basic nutrition, teach yourself basic nutrition, which we’re not taught in medical school

Makary: Yeah, never once talked about added sugar in med school.

ZDoggMD: Nothing, it wasn’t a thing, and if we do that, then what happens is you actually bend the cost curve, you bend the happiness curve, because patients feel heard, and you feel like you’re actually part of a calling, instead of clicking boxes. Right here we talk about the algorithm of the checklist and all that, all that’s great. If you can actually treat the unique patient in front of you and prevent a case of diabetes, oh my gosh, it’s amazing.

Makary: And it takes time. You cannot do it in 10 minute visits. This is what I love in your talk, when I’ve heard you speak, is you’ve got to get off the treadmill, because doctors and nurses and people in America who are billing are told that the way we’re gonna get better, the way we’re gonna get out of this hole in healthcare, is you work harder. OK, that’s the solution. Work harder, and then we’ll increase the billing, and things will be better. Well, guess what? That’s the wrong message.

ZDoggMD: It’s the wrong answer.

Makary: It’s the wrong path.

ZDoggMD: Yeah, patients know it. You don’t think patients accommodate. They message me, “Doc, I love you.” This is the thing. They’re projecting onto me their vision of the perfect doctor, someone who makes eye contact, someone who spends more than five minutes talking about something with them, someone who doesn’t stare at the computer the whole time, and they say, “My doctor just seems stressed. “They’ve got so many patients. “They’re running late. “They’re harried. “I could tell they care, but they don’t have time, “and they’ve got all these notes, “and sometimes they’ll let something slip, like, man, “my kid’s little league game’s today, “but I don’t know if I’m going to make it.” That’s insane.

If you could spend 30 minutes with a patient and then have a team around you that actualizes the rest of the care network together, like a health coach, that can get in their head, that really gets into the emotion, the why, of what’s driving this patient, or a PA that can do the stuff that they’re so good at doing and they’re so flexible at doing, as part of a team, and you huddle every day, and you talk about patients that aren’t coming in, like, “How am I going to keep so-and-so out of the hospital?” They could be like, “Oh, text him. “Let him know. “See what’s going on. “See what he’s eating. “See if he’s still stressed.” And the loneliness thing means that we better, as a society, start looking at blue zones, where people live to 100 on average. They’re just doing so much better. Why is it? Because they have a sense of community, a sense of connection, a sense of purpose. It’s not just, “Oh, we have a pill to help you live to 100.” There’s no such thing. The pill is called love. It’s called community. It’s called connection. It’s called purpose. It’s called walking.

Makary: It’s amazing. It’s beautiful. I visited ChenMed and Iora and a bunch of these clinics, and I had the privilege of telling their story in this book, “The Price We Pay.”

ZDoggMD: I love the chapters there. They were near and dear to me, man.

Makary: I loved being there. There is no emoji to describe how excited I was to be there.

ZDoggMD: Yeah, they haven’t invented it yet.

Makary: I feel like I finally discovered medicine the way it was meant to be practiced, and it was this incredible experience, and actually, I went back to ChenMed, I did a lot of describing of Iora, but ChenMed is just as wonderful, just as incredible of a vision, and I spent time there, and this clinic… By the way, it’s not one clinic. It’s 60 clinics in 20 states now. People are hungry for this stuff, for spending time with folks, to have their outcomes measured on a population level: how well these people are doing, how healthy they are, instead of just how much did you bill? The doctors and the nurses love it, because they’re off the billing treadmill. They’re not on the hamster wheel. They can spend as much time as they need. They can send a car to pick you up or take you to a specialist visit. They can do whatever it takes to keep you healthy. They have classes on high blood pressure management and cooking and stress and yoga, whatever it takes to get you healthy. It’s like your Turntable thing. It’s beautiful.

ZDoggMD: Dude, and it’s all story driven. This is the thing is how do you quantify this? Well, talk to people, listen to their narrative and watch what they experienced. Oh, there was a patient at one of the Iora clinics that was noncompliant with dialysis, which, as you and I know, that’s not a great thing, and would miss them and just was miserable and depressed. Well, what’s going on? “Well, I sit in dialysis. “I have nothing to do. “My family’s not there. “I’m alone for three hours,” and they were jumping out of their skin. They just couldn’t take it.

So the clinic huddled in the morning and said, “Well, what can we do for this person?” “Oh, there’s a $100 iPod. “We get a capitated rate to take care of a population. “Let’s spend some of that and get a little iPod “and fill it with music and audio books “and give it to this patient. “Now, when they go…” And this is a poor patient. It’s not a patient who is affluent and can just go on bestbuy.com and get this thing. Gave it to the patient, patient now looks forward to dialysis, because it’s their time to catch up on their books and their music and all of that, and it’s simple stuff like that. This is the thing. You talk about the problems in the book, but who cares? We can talk about problems for ever, and it’s important to shine the light on it. That’s all great. This is the part of the book that matters.

Let me see if I can get it to focus, redesigning healthcare, redesigning healthcare. This is the part, where then you get into bright spots. You’re talking about starting from scratch. You’re talking about real healthcare disruption, a healthcare blue book. Oh, if air ambulances give you these surprise bills for hundreds of thousands of dollars, well, here’s a company that’s fixing that. Here’s what we can actually do. How do you buy health insurance in a transparent way? How do you deal with pharmacy hieroglyphics? What’s going on with equipment in our fetish with technology? Does it actually help? Are we over-treating patients? Here’s how we fix it. Overwellnessed. That’s a great chapter. That’s a great chapter. Dude, what you’ve done here, As someone who’s been in this space now for a while, when I first read the book, I’m like, finally, it’s all in one thing, and we did that interview, and actually, the book did really well and it’s changing the actual system.

Makary: People are hungry for this. I think they’re hungry for the redesign of healthcare. I’m not talking about the book. I’m talking about… You come in pigeonholed and you’re interested in a topic and you’re given this diagnosis, treatment, diagnosis, treatment, pairing of everything, and it’s frustrating, because you know that you’re not addressing the underlying causes that are bringing people to care, and you can. You’re an expert, you’re an authority, you’re respected in the community, but you want to be out there, and we cage you inside the building, and it’s like you’ve got to–

ZDoggMD: It’s true. How many times have you gone to a colleague and gone, “Oh, it’s a really nice day,” and they’re like, “Oh, I wouldn’t know. “I’ve been in here all day.” I could go to a patient’s home. I could sit outside with a patient and do Tai Chi. There’s so many things you could do, if you actually empowered that as an engine of it. It’s inevitable. It’s the next emergent, but it needs a catalyst.

Makary: And with ChenMed, which is, I think, one of the great laboratories of healthcare, where they’ve totally redesigned healthcare, look at what happened. They’re value based, in other words, they’re paid on a lump sum by Medicare Advantage, so they don’t have to bill for every little thing they do.

ZDoggMD: Which frees up a lot of bureaucracy. You’re not clicking boxes.

Makary: Maybe some people like billing for every single thing they do. Good for them.

ZDoggMD: It may work for dermatology. It may work for plastic surgery. It doesn’t work for primary care.

Makary: Exactly. It may work for radiology, but when you’re talking about relationships… the hard part about chronic disease is not telling people what to do, it’s helping them do it. They want a hand, and when you’re able to enter into a relationship, work with a team, get them a navigator or a coach or somebody who can help with accountability, get you out to the gym, like a workout partner would get you out to the gym, just provide some support and friendship, guess what? Virta and other companies are showing you get much better outcomes.

So here’s what they did with this value-based model. COVID hits. They hear there’s a virus in Italy and China that’s about to come to the US that targets seniors. OK, they’ve got all seniors. Most of them are from minority groups and have chronic diseases. They go out into the sickest, poorest communities in America.

ZDoggMD: Of elders, yeah.

Makary: Yes, they hear about this virus about to hit the U.S. They put their pickup vans that they use… they identified transportation as one of the big barriers to primary care and specialty care, so they pick people up. “We’ll take care of that. “We just want to get you to a great state of health.” They have all these vans. They put them in reverse, said, “Stay at home right now. “Don’t come in. “We’re trying to understand COVID. “We’re going to deliver your medications and food.” They didn’t have to wait for telemedicine to be approved by CMS. They could turn it on overnight and they did.

ZDoggMD: Because they’re paid to do the right thing for the population they’re caring for. You do well financially by doing good for patients, and when you align those incentives, every single other stupid money game falls away. That’s what we did at Iora. That’s what they do at ChenMed. Just get paid to do the right thing for patients. So what do the doctors get to do? The right thing for patients.

Makary: They work very hard.

ZDoggMD: But it’s with a passion and a purpose that they felt was not even possible in the 30, 40 patient treadmill with primary care, where, as a hospitalist then, I’m seeing all the failures of that. Everybody’s coming in and it’s just going to be a wheel, hamster wheel, coming back in, discharge, no real change, not addressing root cause, still loneliness, isolation, despair, social determinants, completely unaddressed, and then we wonder why we spend 3.2 trillion and 20% of our GDP and get the worst outcomes in the developing world, ’cause we’re doing it all backwards, but we know how to do it.

Makary: Yeah, it’s amazing when you see it, and so we’re basically seeing a generation reject the current healthcare system and build their own healthcare system, and direct primary care–

ZDoggMD: Real disruption. Direct primary care’s a good example of that.

Makary: They’re following right after the lead of the Ioras and ChenMeds. They’re not doing Medicare Advantage. They’re working with employers and working with individuals, and I know you and I, I think, both spoke at the Hint healthcare conference, all these people doing very creative ideas, you can’t do in this fee for service treadmill billing model system.

ZDoggMD: Yeah, yeah, yeah, and there’s no reason the large integrated health systems can’t do this. They can internally disrupt themselves. There’s no reason that Geisinger or Kaiser can’t do this kind of care. In fact, there’s every reason to, because all their skin is actually in the game, because they’re both the insurance product and the clinical arm.

Makary: And that’s cool when you have alignment like that. So Ohio State Medical Center basically said, “Look, we’re going to give up “on trying to do primary care. ChenMed, you do it for us. You take over. You’ve got the model down.” They’ve been playing catch up at these large centers, large organizations have trouble being agile.

ZDoggMD: And it’s the same with Iora, large insurers partner with Iora and go, “We need you to keep our Medicare Advantage population safe “and healthy, and that way we all actually make money,” because with Medicare Advantage, you get a chunk of cash, hey, don’t spend it all in one place, do the right thing, and by the way, if your patients are sicker, it’s going to cost you more. So now you’re aligned to actually keep them well, and then you get to keep some savings. That’s huge, and the patients have an experience that’s like they’re not being nickel and dimed. You already know what you’re paying for, primary care, it’s like, oh, it’s like a gym membership, or less. Like I just pay my insurance premium and it’s covered, no copays.

See, once you pull copays away from primary care, I understand the reason of copays, it’s to deny care, it’s to prevent unnecessary care, but what if any contact with your primary care is a relationship building activity? Well, then you kick the copay away, and now you have a seamless relationship with your patient, so you see them when they’re well, you see them when they’re sick, you see them whenever. They come in for a yoga class. They come in for a cooking class. That’s what we used to do at Turntable.

Makary: What would it be like if you came to visit me in DC and I charged a copay?

ZDoggMD: I believe you do sometimes, yeah.

ZDoggMD: No, we eliminated copays at my health, but it affects the relationship.

ZDoggMD: I’m not gonna go, and you’re gonna be like, well, this guy’s thrown up a barrier.

Makary: Yeah, it’s just gonna create some weirdness, right? That’s what we’re doing with patients right now.

ZDoggMD: Right, right, and this is the problem. The money games are so entrenched, so when our insurance partner that would play ball with us, Nevada Health CO-OP, because they were new and not for profit, and they were like, “Oh, we have some funding. Let’s do something unique.” And then, “OK, Turntable Health, great. We’ll pay you a capitated flat fee, you take care of these patients and keep them out of trouble and you don’t have to charge a copay.” OK, when they went under, the only way our clinic would survive is to get another large partner like that, because we needed enough patients to keep the lights on. This is what happened.

You go to UnitedHealth. “Hey, this is what we did with these guys. “You want to do the same thing?” “Oh yeah, sure, except you’ve got to charge a copay, because, I mean, utilization, “and also we’re only going to give you X, because we don’t pay that much for primary care. “That’s dumb. “The going rate is $18 per month per patient. “Oh, and also you could just supplement it by doing fee for service Botox or something, right?” And they literally told me this.

Makary: CoolSculpting.

ZDoggMD: Yeah, yeah, CoolSculpting, exactly, yeah, exactly. I’m going to do some Reiki, just throw some Reiki in there, just for fun, and we would do that, we would do that stuff. We would do yoga and acupuncture and things like that, just because it was all just part of the thing, if the patients benefited, and we’d do it in groups, because there’s a group dynamic, really, it’s more. If the stuff is all placebo, great. If it works as a placebo and you’re not lying to patients and giving them magical thinking, great, and they got something out of it, because they were worked together. The social isolation that’s driving so much of this despair, you can alleviate it. Our waiting room was like a community frickin’ center.

Makary: Yeah, Iora does a great job with that, and ChenMed too.They tell you, “We want to see you. “We want you to come in. “Come in every month. “We love you.” Love is one of their three values.

ZDoggMD: That’s awesome.

Makary: Love, passion and accountability.

ZDoggMD: Nice.

Makary: And it’s everywhere. It’s obvious. It’s on the walls everywhere you go. It’s beautiful. People feel loved. They come in. They’re greeted by their front desk staff there. The doctors will come out between patients and just socialize with them if they’re not there for an appointment. They’re creating communities, they learn together about chronic diseases and they’re winning. They’re slashing healthcare costs and people are happier, with an NPS score of 90 plus. You don’t see that in healthcare. Typically it’s like 15.

ZDoggMD: 15, yeah, our Turntable score’s like 90 plus. That means a net promoter score, like how likely are you to recommend this clinic to family and friends? It’s absurd. The average healthcare entity scores a 35%. That’s the best you’ll get, not even average. It just tells you what we’re willing to compromise in this country, crappy care and, oh, here’s the thing, so people will say, “Oh, as a doctor or as a nurse, I don’t have time to do that touchy, feely, squishy stuff. I’ve got stuff to do.” What stuff, what’s the stuff that you’re doing? Let’s think about that. You’re filling out a note so that the clinic can get paid. You’re paying a biller, who’s totally unnecessary, in a world where you don’t bill like that. All this stuff that you can strip away, it’s a subtractive process, then it allows you to actually just take care of another human being, as a human being, and feel that passion, and that’s how our staff was.

Makary: Imagine that. In the plastic surgery board exams, they are asked, “What is the billing code for certain procedures?”

ZDoggMD: Oh my God.

Makary: It is part of the board examination.

ZDoggMD: Wow, really?

Makary: That’s how far we’ve come. That’s how pathetic the system is. This fee for service treadmill, where we waste so much brain real estate on this useless nonsense, in a game that we manufactured, that the AMA is promoting, because they are licensing fee on every CPT code.

ZDoggMD: CPT code. That’s how they make their money. People don’t realize that.

Makary: That’s right. You think you’re going to see an article in one of the big journals saying, “Hey, we need to just use plain English for our billings?” Not in JAMA.

ZDoggMD: Yeah, because CPTs pay for all that. They pay for the huge building in downtown Chicago–

Makary: Beautiful building.

ZDoggMD: Yeah, and then they’re lobbying to resist any kind of change, and of course, doctors are on board, at least the doctors that are part of the AMA, the three of them that are still part of the AMA, because medical culture says this is how it’s always been and this is how it can be and another world is threatening to our sense of status and so on, and we’re getting nickeled and dimed by administrators, so we need this organization to push back. How about this? Make all that irrelevant. Reinvent healthcare the way you know it’s supposed to be done and just get paid to do the right thing, and everything just clicks, and here’s the best part. People are, “Well, it sounds to me, Marty and ZDogg, that the only answer for what ails us then, since this is medical bankruptcy, is a single-payer, because if we have single-payer, then there’s no more medical bankruptcies.” Right, but what are you paying for? If you’re paying for the same crap, the same garbage fee for service mill, is that going to solve the problem? Do you think the Europeans have solved the problem? Have the Canadians solved that problem of care? No, it’s just who’s paying it. Now, we’re all paying for it. So you can have single-payer, that’s great, but pay for something that’s good. Fix that first.

Makary: I opened the book with the story of patients getting recruited for peripheral vascular stents at local churches in Washington, DC.

ZDoggMD: Oh, that was heartbreaking, dude.

Makary: And the point was, the point I started with that story, even though no one’s told me that’s the best story in the book, everyone loves chapter three and Carlsbad and some other parts, but the reason I started with that story is that in the end it shows it’s all funded by Medicare, all of those unnecessary… The millions and millions of dollars wasted in Washington, DC, on unnecessary procedures

ZDoggMD: We’re paying for it.

Makary: we’re paying for it. You think if you give Medicare to everybody, you’ve fixed healthcare? No, you’ve cut out middlemen you’ve cut some of the middlemen out, and you’ve now empowered another problem, and so let’s not be fooled by the politicians that make it sound–

ZDoggMD: So easy.

Makary: The problem is how we finance healthcare. No, we don’t need to just talk about how we finance healthcare. We need to talk about how we fix it, two totally different things.

ZDoggMD: And by the way, you’re a professor of… You’re in the Public Health Department, you’re in the Department of Medicine as a surgeon and you’re in the business school, so you span all this world, and that’s exactly right. You talk about payment and you talk about the care, and when we were doing Turntable, we were having to deal with both. OK, so what’s our payment model? Just pay us to do the right thing, a flat fee, and let us handle that, the rest. That way we don’t have to spend our time spinning wheels, trying to please a bean counter. We just do the right thing, and then you can measure those outcomes that matter.

Makary: Let’s stop waiting for the government to fix healthcare. People here that were interested, my team and I are interested in the redesign of healthcare, and they think, oh, OK, is this single-payer or is this lowering the Medicare eligibility? No, no, we’re not waiting for the government. We’re talking about on the ground. We, doctors, nurses, changing the way that we deliver healthcare, suggesting new payment arrangements to the people we get paid from, but we fix it, not wait for other people to fix it.

ZDoggMD: Hello, amen, preach, preach, Marty Makary. You and I are aligned on this, and this is not to say that you and I are like, “Well, no, we shouldn’t have every person in this country getting good healthcare.” No, that’s exactly what we can do. We have to help build it. Actually, we have to drive it.

Makary: We’ve been tricked into thinking that healthcare is a partisan issue, where you either support one piece of legislation or a form, or you don’t, and the parties are laughing at all of us in the country, who are in this cat fight of, do you support this or not support this? We saw it with the ACA, the Obamacare. Are you for Obamacare? That’s not gonna save us. With those, they’re talking about different ways to pay for healthcare, not how to fix healthcare.

ZDoggMD: How to fix it, right.

Makary: Tim Shu is a medical student of mine, and he quickly got it. He was like, “Hey, I like this redesign of healthcare.” Not macro, micro, on the ground.

ZDoggMD: Micro, ground up. See, our healthcare system is an emergent property of us. It’s like you have all these people doing this care. Now, this is the macro system. If the emergent property comes from a culture that’s defunct, it doesn’t work in the 21st century, that’s still cowboy thinking. That’s still doesn’t believe in science, in methodology that improves care, that doesn’t believe that the human relationship is primary, and that’s driven by a fee-for-service incentive. What will emerge is a f’d up system that’s then codified by government payments like Medicare, which by the way, people are like, “The U.S. has a free healthcare system.” Medicare prices are set by fee art by a committee that’s mostly run by specialists.

Makary: Yeah, price-fixing.

ZDoggMD: It’s price-fixing. The communist party in Soviet Russia couldn’t have fixed prices more efficiently than Medicare does, because all the other insurance companies peg the price to that. That’s not freedom.

Makary: It’s not a sustainable solution. Tim Shu, he was a medical student who graduated. This kid’s a genius. OK, this kid’s a true genius, and Tim joined our research team, which is half research, half advocacy, ’cause we believe firmly… We’re not writing stuff to present at a doctor’s conference. Oh, isn’t that interesting?

ZDoggMD: I’d like to show you my next 12 slides. Please advance the slide please.

Makary: Right, please advance the slide.

ZDoggMD: That’s my favorite. They don’t even have the tenacity to hold the damn clicker in their own hand. Next slide please. Get control of your slides, man. Anyway, sorry, Tim Shu.

Makary: You’ve been traumatized by PowerPoint also.

ZDoggMD: I am a victim of an ACE, an Adverse Conference Experience.

Makary: I wrote into my living will that if I’m in a vegetative state, they are supposed to play a PowerPoint presentation on the ceiling of the ICU to knock me off, ’cause that will officially knock me off.

ZDoggMD: That’s like basically IV morphine at an intolerable dose. Oh my God.

Makary: It’s high-dose potassium.

ZDoggMD: Oh, it is, man, it’ll just stop your heart right away out of boredom. So Tim Shu.

Makary: So Tim is a true genius. He joins my team. Every now and then, he’ll say something like… I’ll be talking, citing studies in our research meetings, and I’ll say something like according to this study in 2006, and he’ll say, “Marty, by the way, that was 2005.” I’m like holy smoke, he’s right. The guy’s a genius, and I pulled him aside once and I was like, “Tim, I saw your resume, pretty darn impressive. Vanderbilt, magna cum laude.” I don’t even know what that means.

ZDoggMD: I don’t either, but I saw it on the Jeffersons once. George Jefferson was like, “I’m graduating magna cum lordy.”

Makary: It’s some distinction. I take it it’s good. Then he decides to go to Oxford for two years after college, before he starts Hopkins Medical School, and he gets a degree, a master’s degree in advanced mathematics.

ZDoggMD: Oh, just as a side project.

Makary: Yeah, it’s a little side project. I’m like, “Tim, people are taking calculus VI in high school, AP. Just out of curiosity, not an insult, why did you decide to do a master’s in advanced math before med school?” And he says, “I just wanted to bone up on my math.”

ZDoggMD: So this is what we’re dealing with here.

Makary: He’s a genius. The guy’s a true genius. So Tim does our initial paper, that set off these races of toxic price gouging. It’s six years ago, seven years ago, on emergency room markups, that was the paper, and there was a lot of anger about it. “How dare you,” and all this. “Insurance companies are screwing us. “Now, this team is saying that there’s markups. “It’s not our fault.” The classic finger pointing–

ZDoggMD: Anger, bargaining.

Makary: Yeah, exactly. We’re looking at a system that’s broken and we’re saying, “Why is the price marked up 23 times “the Medicare allowable amount? “That’s not the fair price, the Medicare price.” But it’s the wild west, and so Tim goes down to the billing department, meets with a friend of mine, because he’s trying to understand, how does somebody figure out to mark it up 23 times? Is it deliberate? Is it software? It turns out they program in the margin they need, based on their payer collection rate, into a software program, and it jacks up the bills.

ZDoggMD: It’s like Chargemaster software light. Yeah, there’s the free version and the paid version.

Makary: And Tim is like a programmer and this math genius and a genius in general, and he goes down and spends hours trying to understand this, and he basically tells me, “Marty, I cannot interpret the bills. It’s so confusing, and the way the markup is calculated is almost not understandable.”

ZDoggMD: Wow.

Makary: This guy’s a genius. He can’t figure it out.

ZDoggMD: You know what’s funny? I was wondering where all this genius talk was going, ’cause I was like, Marty, if you liked him so much, why don’t you just marry him? OK, but now I realize why, because you’re painting a picture of a guy who’s more than competent, the most competent person you can find to figure this out, and he can’t figure it out, and this has been told time and time again.

It’s a tale as old as time, a song is old as rhyme, Beauty and the Beast. I don’t know where that came from in my head, but the thing is, it is an archetype, that even the smartest humans can not figure out where the hell these prices come from, and so how can Betty, who works at Walmart as a greeter, ever have a hope of not getting sued and end up in court for a bill that made no sense to her, that she has no idea how to fight, for something that was never disclosed to her, that she had no opportunity or capacity to research, because we don’t give people the tools, the resources and the autonomy to do that? That’s the moral heart of this book. We can’t accept it, morally, ethically, as humans, we can’t.

People talk about, “Well, how can you live in the US, “where you don’t have a universal health care,” and all of this? Yeah, it’s not a question of what human rights are and all of this. It’s a question of what kind of society do we want to build and do we want a society where Betty goes bankrupt, so we can pay half the CEO’s salary?

Makary: Healthcare in January two years ago became the largest business in the United States by dollars.

ZDoggMD: Really?

Makary: Yeah, the largest industry in the United States.

ZDoggMD: You told me this once. It’s not that we spend 20% of our GDP on healthcare. It’s more than that. Why is that?

Makary: Yeah, next time you hear… If we change the lexicon, we can fix healthcare, just by engaging the public, and that’s what I try to do with this book. It’s a little bit of the business of healthcare 101, like “The Big Short” was. Instead of saying, “Oh, I didn’t have to pay Medicare paid.” No, we paid through our tax dollars. Instead of saying, “I didn’t have to pay my employer paid.” Guess what?

ZDoggMD: You’re paying through wages.

Makary: Through your wages and benefits pool. If we can change the lexicon in healthcare to recognize that of all federal spending, 48% of it goes to healthcare, in it’s many hidden forms. Let me show you how. 25% goes to Medicare and Medicaid.

ZDoggMD: Of all federal spending?

Makary: Of all federal spending, and then another big area is social security. It’s like 24% of federal spending. A Kaiser study found that half of all social security cheques are used for healthcare expenses, uncovered services, copays and deductibles amongst seniors. Remember, half of people don’t live like us. Half of Americans live paycheck to paycheck.

ZDoggMD: You mean half people don’t live on the street like me? ‘Cause I don’t know how you’re living, Marty Makary, Mr. Hopkins surgeon.

Makary: By the way, it’s great visiting you out here, but when I get to the airport, why is it that the mayor has to announce that they are the mayor of that city?

ZDoggMD: Oh, I love that.

Makary: What is that?

ZDoggMD: “I’m Betsy Josh Evans, the mayor of Orlando. Welcome to our wonderful city. While you’re here, make sure to eat at Joe’s, an amazing cafe that shows the vibrancy of the Orlando community.”

Makary: Yeah, I don’t need to know–

ZDoggMD: Do they do it in San Francisco too? They did it in SFO? ‘Cause I know we’re dead inside. Our mayor is just like, “Yeah, whatever, live here or don’t. We’re San Francisco, bitch.” That’s how our mayor is, but these other cities, you land in there, you’re on the tram, going from the airport to the parking, and it’s just like, “Welcome to sunny Duluth, Minnesota, home of the Duluth Pickles.” It’s like, “Oh, was that the sports team?”

Makary: It was in Atlanta, now that I’ve come to think of it.

ZDoggMD: Oh, Atlanta, yeah.

Makary: I was connecting at Atlanta.

ZDoggMD: I remember, Atlanta’s airport is so big, that you’re going to be assaulted by that for hours.

Makary: In Orlando, they have that tram,

ZDoggMD: Little tram, yeah.

Makary: That takes you 50 yards. You have to wait 15 minutes to take this tram to go 50 yards.

ZDoggMD: You’re basically crossing an alligator infested s