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Don't wait for Atul Gawande

Amazon, Berkshire Hathaway and JPMorgan Chase appoint Dr. Atul Gawande as Chief Executive Officer of their newly-formed company to address U.S. employee healthcare

Business Wire, June 20, 2018

Amazon, Berkshire Hathaway and JPMorgan Chase announced today the next step in their partnership on U.S. employee healthcare with the appointment of Dr. Atul Gawande as its Chief Executive Officer, effective July 9. The new company will be headquartered in Boston and will operate as an independent entity that is free from profit-making incentives and constraints.

Atul is a globally-renowned surgeon, writer and public health innovator. He practices general and endocrine surgery at Brigham and Women’s Hospital and is Professor at the Harvard T.H. Chan School of Public Health and Harvard Medical School. He is founding executive director of the health systems innovation center, Ariadne Labs. He also is a staff writer for The New Yorker magazine, has written four New York Times bestsellers: Complications, Better, The Checklist Manifesto, and Being Mortal, and has received numerous awards for his contributions to science and healthcare.

“I’m thrilled to be named CEO of this healthcare initiative,” said Atul, “I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world. Now I have the backing of these remarkable organizations to pursue this mission with even greater impact for more than a million people, and in doing so incubate better models of care for all. This work will take time but must be done. The system is broken, and better is possible.”

https://www.businesswire.com...

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Ariadne Labs founder Atul Gawande transitions to chairman and becomes CEO of new health care organization

Ariadne Labs

Ariadne Labs founder and Executive Director Dr. Atul Gawande has been named the CEO of the new Amazon, JPMorgan Chase, Berkshire Hathaway nonprofit health care organization and will transition to a new role as chairman of Ariadne Labs. He will remain a practicing surgeon at Brigham and Women’s Hospital and a professor at Harvard T.H. Chan School of Public Health and Harvard Medical School.

Ariadne Labs was founded in 2012 by Gawande and a team of leaders to find solutions to some of the most complex problems in health care, including life-threatening errors in surgery, maternal and neonatal mortality, failures in end-of-life care, and fragmented and ineffective primary health care systems. Leveraging a network of expertise across the Harvard-Brigham system, Ariadne Labs’ designs, tests, and spreads simple solutions to address failures in health care delivery worldwide.

Among Ariadne Labs innovations:

* The Surgical Safety Checklist

* OR Crisis Checklists

* The Safe Childbirth Checklist,

* The Delivery Decisions Team Birth Project

* The Serious Illness Conversation Guide

* The Primary Health Care Vital Signs

https://www.ariadnelabs.org...

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Promise unrealized: A birth checklist fails to reduce deaths in rural India

By Casey Ross
STAT, December 13, 2017

It was supposed to be a breakthrough moment in global health.

Atul Gawande, the physician and writer, was applying a simple tool he championed — the checklist — to improve birth outcomes in a rural part of India with some of the world’s highest infant mortality rates.

But his closely watched study, the BetterBirth Trial, has produced a disappointing result: Despite increased adherence to best practices, outcomes for babies and mothers did not improve with the use of a checklist and coaching on its implementation, according to data published Wednesday in the New England Journal of Medicine.

https://www.statnews.com...

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Head of New U.S. Corporate Health Plan Cites Surgery as Biggest Cost

By Reuters
The New York Times, June 21, 2018

"We are screaming right now about pharmaceutical costs ... and that is just 10 percent" of total U.S. healthcare spending, Gawande said, noting how patients faced with a $200 drug co-pay see that as standing between them and their health.

But with surgery the single biggest healthcare cost, he outlined ways he has worked with hospitals to standardize procedures, resulting in lower costs and better results for patients.

"We need to act through data tracking ... to see when treatments are benefiting and when they are not," Gawande said.

https://www.nytimes.com...

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Health insurers support CEO pick to head Amazon-Berkshire-JPMorgan venture

By Greg Slabodkin
Health Data Management, June 21, 2018

America’s Health Insurance Plans, the national trade association representing insurers, gave its support for the selection of Atul Gawande, MD, as the chief executive officer to lead a new healthcare venture started by Amazon, Berkshire Hathaway and JPMorgan Chase.

“To Amazon, Berkshire Hathaway and JPMorgan Chase, here’s what we say—bring it on,” Matt Eyles, president and CEO of AHIP, told Wednesday’s opening session of its annual conference held in San Diego. “We are welcoming new voices that challenge us to think differently about healthcare.”

Atul Gawande contends that the objective of modern care is not to “rescue” patients from “catastrophic” health episodes—but an ongoing process that takes into account patients’ physical, cognitive and emotional life goals that clinicians never ask them about.

“To measure and manage that over time is going to be highly technologically enabled in order to make that possible,” Gawande said on Thursday at the 2018 AHIP Institute & Expo in San Diego. “We need to act through the data, tracking you with your life on how you’re doing against those goals, and when our treatments are benefitting and when they’re not.”

https://www.healthdatamanagement.com...

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Quote of the Day Comment:

By Don McCanne, M.D.
May 22, 2015

On "Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?"

By Atul Gawande
The New Yorker, May 11, 2015

Yesterday’s Quote of the Day discussed the harm done by our health care reform agenda that overemphasizes attacking overutilization while neglecting more compelling goals of reform. Atul Gawande has been one of the more credible and outspoken voices in raising the alarm on overutilization, especially with his widely referenced 2009 New Yorker article on the excessive use of health care services in McAllen, Texas. But where does Dr. Gawande stand when he is faced with health care utilization questions regarding his own patients?

In his current New Yorker article, “Overkill,” he describes the overtesting and overdiagnosis of thyroid carcinoma, which, in turn, results in overtreatment - all manifestations of overutilization of health care. For his own patient with a very small thyroid nodule, he recommended leaving it alone - a recommendation that is well supported in the medical literature.

Yet, apparently because the patient wanted something done, he elected to remove her thyroid gland. She did turn out to have a microcarcinoma, but he reports that it “was not a danger to her life, and would almost certainly never have bothered her.” She manifested two common problems of overutilization: 1) a post-operative complication (hemorrhage requiring a second operation), and 2) significant costs that were unnecessary but added to the very high costs of health care paid by all of us through taxes or insurance premiums.

Thus Dr. Gawande is himself an overutilizer while preaching the evils of overutilization.

http://www.pnhp.org...

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Is Health Care a Right?

By Atul Gawande
The New Yorker, October 2, 2017

Few want the system we have, but many fear losing what we’ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?

https://www.newyorker.com...

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Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

By Russell Mokhiber
Common Dreams, February 10, 2015

As for (Gawande’s) opposition to single payer, he remains steadfast.

In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.

“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations - because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”

Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”

“Patients do not care what their insurance plan is - just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service - eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”

“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”

“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”

“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.

http://www.pnhp.org...

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Comment:

By Don McCanne, M.D.

Warren Buffett, Jeff Bezos and Jamie Dimon are receiving praise for having selected Atul Gawande as the CEO of their joint effort to improve employee health care in the United States. Based on his writing and speaking eloquence, on the surface he seems like a good choice. Some have hopes that he may revolutionize health care for all of us. So how realistic are the prospects?

Perhaps Gawande's most noted contribution was an article in The New Yorker describing overutilization of health care in McAllen, Texas. In response, the health care community in McAllen did a self-assessment and found that the largest difference was in home health care, and they made appropriate reductions, bringing them into line with other communities. Gawande is being given credit for reducing excess care throughout the United States, but our experience with accountable care organizations shows that little change has taken place. Regions with greater needs may well represent a normal distribution under the bell curve rather than inappropriate overutilization.

Ironically, in another article in The New Yorker Gawande describes having removed a thyroid lesion in a patient even though he had recommended that it be left alone. The fact that even Gawande can be an overutilizer indicates how difficult it is to reduce care that may be of lesser value or even detrimental, as it was in his case since complications occurred.

Gawande is also praised for his advocacy of checklists. I'm not sure why he is given so much credit for them when I've used them my entire medical career, and I graduated from medical school before he was born. Be that as it may, but the experience with BetterBirth checklists in India, which he championed, proved to be disappointing. Don't get me wrong. Checklists are a very good idea. It's just that he seems to have overstated his role when he says, "I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world."

And I won't even go into his Cheesecake Factory analogy.

He now seems to want to concentrate on data tracking, "to see when treatments are benefiting and when they are not." This certainly seems to be a good idea - basic research - but it is a slow and arduous process of evaluation of minutiae. There doesn't seem to be any earth shattering transformation in this approach, even though continuing research is certainly beneficial.

In another more recent article in The New Yorker he discussed whether people believe that health care is a right. Since views on this are divisive, it is no wonder that he concluded with a question: "Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)?" That certainly muddles the question.

The health-care-as-a-right article might represent a slight moderation of his more negative views expressed in a 2015 article from The New Yorker wherein he was quite dismissive of single payer. David Himmelstein explained then why he shouldn't be.

Gawande says that he is data oriented. Well, we have plenty of data for him. Instead of merely dabbling with the health care system, he should take up the cause seriously and emphatically support a well designed, single payer national health program - an improved Medicare for all. That will do more good for the one million employees of Berkshire Hathaway, Amazon, and JPMorgan Chase than any amount of tweaking that he could accomplish within our current, dysfunctional system.

Above all, don't wait to see what little bit Atul Gawande can do for us. Move forward immediately with all the forces you can muster to help bring health care justice to us all.

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