Dr. Robert Pearl is the visionary former CEO of Kaiser-Permanente Medical Group and a passionate advocate of putting the "health" back into modern American healthcare.
In a candid conversation, Dr. Pearl dissects the fragmented, fee-for-service model that keeps healthcare stuck in the 19th century. He helps unravel the cultural complexities within medicine that not only impede physician satisfaction but also jeopardize patient safety.
Dr. Pearl believes technology will be the linchpin of personalized healthcare. He explains how advancements in AI herald a paradigm shift in modern healthcare. According to him, AI could use personal health data to tailor patient care like never before.
He's acutely aware that without addressing the current healthcare system's inefficiencies, these innovations may not reach their full potential.
He proposes systemic reforms that could marry technology with healthcare, bringing about a quality, accessible, and affordable healthcare system that we've long aspired to achieve.
Dr. Pearl asks provocative questions about the economic motivations behind our current healthcare model even as he casts a vision for more sustainable practices like capitation. What will happen as titans like Amazon step into the healthcare arena? We wrap the conversation with a look ahead, not just at the obstacles, but at the transformative solutions poised to reshape our healthcare landscape.
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Website: RobertPearlMD.com
Chances are, you wouldn't be listening to this podcast if you didn't need to change your life and get healthier.
So take action right now. Book a call with Dr. Ovadia's team.
One small step in the right direction is all it takes to get started.
How to connect with Stay Off My Operating Table:
Twitter:
Learn more:
Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings
Dr. Robert Pearl is the visionary former CEO of Kaiser-Permanente Medical Group and a passionate advocate of putting the "health" back into modern American healthcare.
In a candid conversation, Dr. Pearl dissects the fragmented, fee-for-service model that keeps healthcare stuck in the 19th century. He helps unravel the cultural complexities within medicine that not only impede physician satisfaction but also jeopardize patient safety.
Dr. Pearl believes technology will be the linchpin of personalized healthcare. He explains how advancements in AI herald a paradigm shift in modern healthcare. According to him, AI could use personal health data to tailor patient care like never before.
He's acutely aware that without addressing the current healthcare system's inefficiencies, these innovations may not reach their full potential.
He proposes systemic reforms that could marry technology with healthcare, bringing about a quality, accessible, and affordable healthcare system that we've long aspired to achieve.
Dr. Pearl asks provocative questions about the economic motivations behind our current healthcare model even as he casts a vision for more sustainable practices like capitation. What will happen as titans like Amazon step into the healthcare arena? We wrap the conversation with a look ahead, not just at the obstacles, but at the transformative solutions poised to reshape our healthcare landscape.
===========
Website: RobertPearlMD.com
Chances are, you wouldn't be listening to this podcast if you didn't need to change your life and get healthier.
So take action right now. Book a call with Dr. Ovadia's team.
One small step in the right direction is all it takes to get started.
How to connect with Stay Off My Operating Table:
Twitter:
Learn more:
Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings
All right, we are live. Welcome. It's the Stay Off my Operating Table podcast with Dr Philip Ovedia and we've got a cool one coming up here. I know that because we were chatting before we started recording and I'm really interested to hear this, but my job is to pass the baton to you, Phil. Who are we talking to today?
Speaker 2:Yeah, thanks, jack. It should be a great conversation today. Really honored to have Dr Robert Pearl with us today. Dr Pearl has been named as one of the 50 most influential physician leaders in healthcare and he's the former CEO of the Permanente Medical Group, which is the nation's largest medical group. Author of two great books, mis-treated and Uncairing and we also will be getting into he has another upcoming book that we'll talk about as well, and really excited to have this conversation with Dr Pearl about the healthcare system. You know what some of its failings are and maybe what we can do to help start to improve that. But before we get into all of that, I'm going to turn it over to Dr Pearl to give usa little bit more of his background and maybe talk about your journey from the sort of you know practicing physician to healthcare administrator to really be being a influential force in the healthcare system today.
Speaker 3:Heart to know exactly where to begin. But I was a medical student at Yale and I decided that I was interested in heart surgery actually like yourself and went to Stanford because the head of the department there, norman Shumway, was the pioneer to the first heart transplant and created a lot of the operations I wanted to learn from him. While I was there, I had the opportunity to rotate on plastic surgery and take a mission trip to Mexico where I had the privilege to watch repair of cleft, lip and cleft palate and immense joy that it brings to families, and I decided to switch from heart surgery, which I loved at the time. But there's something that I thought would be even more fulfilling, which would be reconstructive plastic surgery, which is what I specialized in when I finished my well, I was the chief resident in plastic surgery. My plan had been to go to South America and operate and show the cleft lip and cleft palate to continue the mission work that I had done during my residency. And about six months before I graduated, the surgeon at Kaiser Permanente and Santa Clara died of tragic plane crash, and I tell people that serendipity is a major part of a life journey, and it was for me. They asked me whether I had come for six months and I said what can I lose? I have the rest of my life ahead of me and I fell in love with the system of healthcare that was integrated and paid differently, with a lot of collaboration, cooperation.
Speaker 3:When I was there my first year, I was asked to take over the role as head of the operating room committee and I assume this was because I had such great credential jail in Stanford, because I was so smart. No, everyone else had said no to the job. It was an impossible job and they figured only the guy who just came here would be foolish enough to say yes. And that was again my path into leadership had the chance to become the system position chief of that facility. I had the chance to go to the Stanford Graduate School of Business and a lot of opportunities, and then the CEO role became available.
Speaker 3:The current CEO at the time was stepping down. The organization was in trouble. There were only two days of cash on hand, three days in California to stay in business. So I had to borrow a day of cash just to meet regulatory requirements and I didn't really want the job to CEO.
Speaker 3:I was so happy as a clinician with a half-time administrative job and a half-time clinical role, although I had a full-time clinical accountability but did it in half of the time that was otherwise allocated. But two people that I asked to step forward said they didn't want to do it. The job was just going to be too demanding, too tough, and I felt that if I didn't step forward at that time that I would be left behind, that I'd have to probably leave the organization because I didn't like where the other candidates were going, and so I put my hat in the ring. It's a process that is first done at the physician level and at the board level, and I was selected for CEO, which I did for 18 years, and then since then I've moved on to my third career as author, professor in Stanford Business and Medical School, keynote speaker, consultant, and I'm enjoying it just as much. My three careers have all been very rewarding as a clinician, as the CEO and now in my current role as, hopefully, a leader of health care for the entire nation.
Speaker 2:Where do?
Speaker 1:we go with that.
Speaker 2:Yeah, so many places and awesome career trajectory. And, by the way, I share your story of being named, you know, head of the OR committee as a young surgeon just coming into practice and, like you said, it's usually because everyone else in front of you has said no, but you don't recognize it at the time that they're certainly young and dumb to know that it's, it's not an honor.
Speaker 2:So I guess I'd like to start, you know, with your your more recent book, uncairing, and in it you kind of lay out how the physician culture and the health care system kind of conspire to to injure physicians, which therefore injures patients essentially. And you know, one of the things that I've said on this show and elsewhere is that the current health care system is working great for everyone except the patients and the physicians. And so let's kind of start with your perspective, as you know very much in the system and leading the system, what your perspective is on the current, I guess, state of the health care system, the current issues that we need to address.
Speaker 3:I see the current health care system as most similar to a 19th century cottage industry. It's fragmented, with physicians scattered across facilities unconnected with each other. It has it's paid on a piecemeal basis. We call it fee-for-service the more you do, the more you get paid. Whether it does any good or not doesn't really matter. In fact, often if you have a complication, you get paid twice, once we're creating the complication and once we're trying to address it. It uses technology left over from the last century, although more accurately from the century before that. The most common way that doctors exchange vital patient information is through the fax machine an 1834 invention and there is no effective leadership structure. A lot of people with big titles, but if someone wants to change health care, transform it, there's no one with that role, that responsibility, with that opportunity to make a difference. That sits in place. I agree with you completely that everyone's doing great, except for the doctor and the patient. The upcoming book that you mentioned earlier, chatgpt-md, will look at the issue of generative AI, but it's subtitled how doctors and patients can reclaim control of medicine, because that has left them completely over the past two decades, and the results are predictable, compared to the other 12 pure nations of the world.
Speaker 3:We are last in longevity. We have the highest maternal mortality, double the second worst nation, the highest infant mortality, the highest costs. We spend $13,000 per American on health care. Switzerland is around 10,000, germany around 9,000, everyone else is half. And yet the outcomes we get lag other places. The longevity of Americans today is no better than two decades ago and yet the costs are dramatically higher. And none of this is a lack of education, a lack of dedication, a lack of commitment on behalf of the clinicians. It's just simply all of the hurdles and barriers that have been put in front of them. And people most negatively impacted are the patients, the physicians burnout is rampant at 60%, but for patients we have 250,000 misdiagnoses, 250,000 people dying every year from medical errors, 400,000 from misdiagnoses and far more from chronic disease. We can and we need to do much better as a nation. I give the clinicians an A for effort and I give the system an F for outcomes.
Speaker 2:Yeah, I think that's a great summary. The statistics that you cited certainly I'm familiar with them, but many in our audience those will be kind of shocking. And the fact that our longevity is not only the worst amongst developed nations but has actually been decreasing over the past five years, even before the effects of COVID, are really, I think, telling and shocking. But it's also an interesting dichotomy that we have, because in a lot of ways the US is still seen as the mecca of medicine. When wealthy people from other countries need high-level care, oftentimes they're coming to the US for that, and yet we kind of fail at the basics.
Speaker 2:And I think we've gotten to a place where we have become so focused on taking care of very sick people and trying to optimize that that we've lost a focus on how do we keep people from getting sick in the first place. And I think if we shifted more focus towards that, it helps a lot of these problems. One of the reasons that physicians, I think, are getting so burnt out is because they're just overwhelmed with these sick people who aren't getting better and most physicians are. They went into medicine because they want to help people get better and that's becoming more and more difficult in the healthcare system. What kind of thoughts do you have on that?
Speaker 3:What you're describing is the crisis that we have with chronic disease. So if you go back, I'll say 50 years into the future, why did patients come to the physician for care? They had a broken bone that needed setting. They had pneumonia that required an antibiotic. Possibly they had a heart attack that would require time in the hospital to recover and resuscitation, should they experience a fatal type arrhythmia. Most often these problems could get treated and the patient would then resume their normal health and not need a whole lot more care until the next acute episode occurred.
Speaker 3:Today we have a totally different situation. What we have today is an epidemic of chronic disease. So diabetes, hypertension, asthma, a range of problems and when you have a chronic disease, most often you require care every year for the rest of your life. I think a lot of the burnout that physicians have today is this shift in disease. If you compare the United States to other nations, you might think that the high burnout rate in our country is the worst in the world by far, but it's not. We're actually in the middle of the pack Of four nations, below five nations if you look at the 10 most industrialized countries, because everywhere the chronic disease epidemic is impacting the demands on clinicians and making it that much harder to provide care, and simply, demand is exceeding supply.
Speaker 3:Because we've not innovated, we've not found technology that makes our lives easier. What do we like to use technologically and this is part of the culture operative robots. Operative robots take the surgeon longer to do the case, they cost more money and the outcomes have never been shown to be significantly better. We have not put in place a single technology that makes the job of the doctor easier or the clinical results dramatically better, and the electronic health record is certainly one of the biggest problems. Let's now spend more time staring at that screen than they do looking at patients.
Speaker 2:On the technology front, you just laid out that we've introduced all of these advanced technologies that really haven't had a great impact. We're still using very outdated technologies on a lot of other fronts. Like you mentioned, the fax machine, the beeper we saw the struggle although this is finally getting better to introduce telemedicine and telehealth has really been a struggle to get that adopted within the system. It sounds like your new book is going to focus on another technological advance. I guess getting into that a little bit. Why do we think that technological advance is going to be different? First of all, is it going to be accepted by the medical community, or the barriers to technological advancement at a systemic level going to get in the way of that? How can AI help the doctors and the patients ultimately with improving this quagmire we're in?
Speaker 3:The answer requires 250 pages, which is why I wrote the book as I say. I wrote it with ChatGPT. Chatgpt is a co-author, of which I started by uploading 1.2 million words that I had published, and combined that with various instructions about language and style. As you would with a co-author went back and forth many iterations for every single chapter. It's called PROMPS, the information you put in to help drive the answers or the types of answers you're looking for. To summarize relatively quickly, what we've seen across history is that positive technology has expanded knowledge the printing press that made books available. You had the internet that made information available from your computer, the iPhone, information in your pocket but none of this really has expanded expertise for patients. All the technology has been introduced as focused on clinicians but not very much on patients. If you have a problem and you go to Google and you go to a link or a series of links, you'll get a lot of information about diabetes or hypertension or cancer various types but you really can't do anything with that information because it's not specific to you. This is where generative AI is so different than other forms of AI. One of my hopes is that we'll stop labeling everything AI. That's like saying computer, it's a very generic term. You had early on what's called rule-based AI. Experts would put in algorithms into a computer system that could use those PROMPS to help you come up with the answers, but they were never as good as the individuals who put them in place because they had to be overly simplified. Then you got into what's called narrow AI. This is where researchers would take 5,000 mammograms, 10,000 mammograms, 5,000 of which showed cancer, 5,000 of which didn't. They'd use deep learning neural nets to be able to compare the two and come up with a variety of ways 30, 40, 50 ways that they differed, unlike humans that use heuristics, a few rules of thumb, maybe four or five. The applications are better than fellowship-trained radiologists at being able to interpret these studies, but they're narrow. The application for mammograms can't be used for pneumonia or certainly not for brain aneurysm or any other type of radiologic procedure.
Speaker 3:Gender of AI is completely different. It begins and I love the letters GPT, because it's actually going to be PTG. It's pre-trained on the entirety of the internet, all the textbooks, all the journal articles, all the information publicly available. Then, after being pre-trained, then it's given parameters. These are ways that they can use the information, medical knowledge that's more recent is more important than other information ones from high-impact journals that are peer-reviewed or better than ones from journals that are not Then it uses that to generate an answer to any question.
Speaker 3:It's interesting that very recently, openai the makers of chat GPT said that they were going to allow two things to be done Number one, plugins, and number two, memory inside the AI application. What does this mean? This means that you can now connect wearable devices, wearable monitors of patients, home monitors EHRs, for that matter into the system through plugins, which is difficult to do prior to this time. You also can have it remember all of your medical information, your personal preferences, a lot of other things about your life that are vital to your healthcare deciding process. Now, if we go back to chat GPT, it can do a lot of things besides language processing. It can help you to paint in the style of a Picasso or a Rembrandt, even though you've never had an art course. You're actually what you create looks relatively expert. It may not be quite as good as the famous painters, but it's incredibly better than anything else that's currently available by a factor of 10 or 100. Now you can create songs in the style of Drake. That sounds just like Drake. Even though you don't play an instrument, you can program computers equally well to many of the current programmers that exist right now.
Speaker 3:Patients will be able to use this technology to be able to manage their chronic diseases, to know every day how they're doing, for these diseases impact patients all the time. As a doctor, you change your medication. Then what do we say? Come back in four months. No, you want to know how you're doing in four weeks. If it's not doing well, you need to make a change that occurs.
Speaker 3:It will allow hospitals at home to have monitoring of individuals they were always aware of how they're doing and then connect them with telemedicine Into clinical experts should there be a deviation. This is going to move from knowledge to expertise. It's going to move from the sole domain of the clinician into the empowered patient working with the clinician. To answer your question about what happens if clinicians don't like it, the answer is that patients will have other opportunities to use this information because it will empower them to know their diagnoses In the middle of the night, if something should arise, to recognize whether it's serious enough that they should drive to the ER or wait till the morning, when it can be better handled than a doctor's office and to be able to not only prevent chronic disease but avoid the complications, the heart attacks, the strokes, the kidney failures that come along, that lower quality and raise price. We have to get to a point of higher quality, easier, more convenient access and greater affordability. I believe that generative AI, chat, gpt will allow that to happen.
Speaker 1:You mentioned earlier that there were these barriers that prevented medical professionals from delivering on the promise. It seems to me that there's a process, obviously, that's kind of broken. No, not kind of broken, there's a process that's terribly broken. It appears to me that the process is an intentional outcome of the system that's been put in place. I'll jump to the punchline.
Speaker 1:I don't see how the introduction of this type of artificial intelligence monitoring that you're talking about is going to make a lick of difference, as long as the system we have in place is in charge of decision making, deciding what is valid medical, what is valid healthcare and what isn't, as long as patients are not actually the customers of the company, of the organization that pays the bills. I'm all in on what you're talking about in terms of AI helping with much better diagnosis, faster responses. That all makes sense, but that's all processed stuff. That's not system stuff. The system to me looks I don't see it as as fixable. I see it as we've got to clear the whole thing out and get back to and I apologize for the rant, but you talked about this 19th century model of I can't remember the phrase you used.
Speaker 3:Cottage industry.
Speaker 1:Cottage industry. What appears to me that the problem with the system is that we don't have these cottage industries. In terms of a system, I have completely agreed with you. In terms of the processes, it's cottage industry type process. In my lifetime I've watched the system that delivers healthcare deteriorate directly as a consequence of centralization of decision-making authority and of paying authority. And the result as in any kind of human endeavor, where there's a concentration of power, there's a concentration of psychopaths. Now, I realize that's a controversial statement, but we'll live with it. How do we? You know what I've said enough Can you address that? I think the system is the problem and the processes are just until the system's fixed. We're putting a bandaid on a bleeding artery, to try to use an actual medical metaphor.
Speaker 3:I think you're raising a really important chicken and egg phenomenon, and I think that's how I would put it and what I mean by that. I go back to when I was first selected as the CEO in Kaiser Permanente. I was invited to give a talk at the Oregon Health Sciences Building and at the end of my talk I had about 30 minutes before I had to go to the airport, so I decided to just walk around and look at all the stuff on the walls. I always find that very interesting to go to different academic places, and there I saw a sign big letters across the top quality service cost, and below, in small letters, it said pick any two. That was the mentality of the 20th century, because it's also the best that we could do. The idea of moving to what's called value-based care is not new. As I said, it's almost 100 years old, but we never had the tool to accomplish it. So chat, gpt or anything.
Speaker 1:Hold on, slow down, slow down, just a minute, so value what were the three?
Speaker 3:Value-based care.
Speaker 1:Value-based care. No, the three words that you were looking at.
Speaker 3:Well, quality service cost.
Speaker 1:Quality service, cost Pick two. We had the same joke in software development you can have it fast, you can have it cheap, Anyway.
Speaker 3:So by the way, you maybe don't have it both now, with chat, gpt doing a lot of the programming and software development. But let's skip all software development at the time being and stay in medicine.
Speaker 1:Yeah, let's stay in health care.
Speaker 3:So what I'm saying within all of that is we didn't have the tool to accomplish it and, from my perspective, what value-based care is? We're going to make care more affordable by raising quality and making care more convenient. That's the antithesis of what most people think. Most people think to raise quality, you need more dollars.
Speaker 1:Okay, that makes sense.
Speaker 3:Bride more service, not only I'm going to keep people healthier, because if we can eliminate 30% heart attack, strokes, cancer what's going to happen to health care costs? They're going to come down dramatically. What's going to happen to men and doctors? It's going to get relieved, so that problem really becomes. Doing that, and what you describe is exactly right.
Speaker 3:What happened about 20 years ago is hospitals realize that if they can solidate and they form monopolies in geographic areas, they can just raise their prices. Drug companies said if we get Congress to pass very liberal patent opportunities, we can just raise our prices, which is what they've done. Insurers have come up with the same. Well, insurers have been faced now with this pressure and what they've said is yeah, we want to sell our products and to do that we need to raise costs, and to do that we need to put restrictions in place, and it's those restrictions that are getting in the way of the doctor and the patient. It's those restrictions prior authorization, need to document everything.
Speaker 3:It's not being done because there's psychopaths. Some of them may be, but it's not that all of them are psychopaths. They're logical. How are you going to rein in costs when doctors are paid on a fee-for-service basis? It's not possible. Charlie Munger says tell me your incentives and I'll tell you the outcomes you're going to get. Pay someone based upon the volume created and get a lot of volume. Pay people lines of code and get lots of lines of code. And it's not negative, intentional, it's just the way humans evolve. So that's the underlying challenge.
Speaker 1:Okay, now, all right, I'm on board. Now I get it. I understand what you're saying. Let's talk about another challenge that your hopeful, optimistic view of the future faces, and I wanted to preface this by saying I am always in favor of hopeful optimism, because people who are optimistic just have better outcomes period. So I'm bringing up these, what I see as problems, because I want to find ways around them. Cancer is a multi-billion-dollar business. Heart disease is a multi-billion-dollar business. The two biggest killers of human beings in the United States are humongous money generators.
Speaker 1:We have seen over the last I'll pick a number of years, just I'll pick a random number, let's say, since 2020, for example, behavior by pharmaceutical companies that would indicate that they're far more interested in creating lifelong customers for their products, that they are protected from being sued for lack of quality control. And these are the people, these are the organizations, these are the industries that derive the major decision-making, and we all know what I'm talking about. The question is how do we do an end-run so that we can actually get past? I'm going to give an example that is very, very common.
Speaker 1:I constantly hear people refuse to go to an alternative type of health care provider who has proven results because my insurance won't cover it. The problem is not the insurance. The problem is between the ears of the people, who think that somebody else is responsible for their health. I can't tell you how many people I've said look, is it cheaper to pay for this out of your pocket or to be sick? Which one is it? So these are the systemic issues that I want to harness, exactly what you're talking about. How do we do that? How do we make an end-run around the people whose very business model depends on Americans getting and staying sick?
Speaker 3:Let me connect the last question and this question with the transition from A to C through B. First part of my optimism is that we are an economically dire times. We see the projected cost of health care between now and 2031, which is only seven years away going up by $3 trillion. That's a 75% increase in health care costs for the same system of today. We see 50% of people in the United States having medical debt, being unable to pay their bills. Today we see the United States having a deficit that is massive and growing At some point soon. I don't think we can keep doing what we're doing. You can't keep raising out-of-pocket expenses for patients. You can't keep having higher deductibles. You can't keep putting in more restrictive care without compromising outcomes. I think we're getting to an endpoint, so something is going to have to change.
Speaker 3:I teach, as I said, the Stanford Graduate School of Business. I used to believe that things would change for the right things to do. I used to believe that if it would save lives, america would do it. I had been disappointed, so now I say okay, it will happen when, economically, there's a driver around it. That's why I see us coming today. Now it could come from inside medicine. It could be doctors demanding that insurers move to capitation, which is a single payment to take care of a population of patients, and then, when they avoid heart attack, strokes and cancer, they and the patients benefit as a result of that. I hope it does come from that, because I think that would be the best health system. But I also want to point out that there's another force sitting on the edge about, or the process of invading into, healthcare, and that's the retail giants Amazon, cvs and Walmart, three of the nation's four largest companies. If you look at what they've done over the past 12 months Amazon actually, a little bit earlier, bought Pillpacks. Now it's pharmacy that can be delivered with drones very soon, you have. They acquired one medical, one of the leading primary care organizations in the United States. They already are now offering services to self-funded insurers, which is half of the commercial market, meaning people under the age of 65. Cvs acquired Etna Insurance Company. They have a pharmacy. They bought Oak Street, again another very leading primary care group. They bought Signify, a home health group. Walmart signed a 10-year deal with UnitedHealthcare which, by the way, employs 90,000 doctors, to say nothing about the ones they contract with. United has 10 million people in Medicare Advantage the capitated form of Medicare and Walmart's in the process of negotiating with another medical group called ChenMed, which is one of the large primary care groups.
Speaker 3:I see these as having a short-term, middle-term and long-term agenda. Short-term, they're going to acquire a lot of pieces. They're doing it, they have the capital to accomplishing it. Mid-term, they're going to start providing the care, finding specialists that consult to the primary care, finding centers of excellence. And long-term, what are they going to do? Take everything over. We're not going to lea well, we'll lead it meaning those inside health care if we decide to do so and have the courage to accomplish it. But if we don't, it's going to happen. This is the classic Clay Christiansen model of disruptive change. An industry is so inefficient that everyone benefits from the inefficiency. Exactly what you're describing A health care organization that benefits from sickness, someone from the outside and these companies no retail.
Speaker 1:They know the cost, they're used to operating on razor-thin margins. Yeah, that's.
Speaker 3:Well, I don't know if it's razor-thin margins, but they've certainly been able to find the best products at the right price and negotiate aggressively around it. For the people listening who are clinicians, I can guarantee you that what they will do will be better for patients than what exists today. I can't guarantee that for the providers of care.
Speaker 2:So you know, kind of zeroing in on that and bringing it to a topic that's near and dear to our hearts here on this podcast, you know, if we look at something like nutrition in the food that we eat, and clearly it has a major impact on our health and clearly you know, the more processed your diet is, the worse the health outcomes are.
Speaker 2:And yet we have a you know. So it should be pretty obvious. You shouldn't need AI to tell you that. You know, if we got people to eat real food, we would solve a lot of these chronic health problems, bring down costs. This has been demonstrated by, you know, companies like Verda Health and others, and yet you know it doesn't get, it's making no headway. And you know again, you sort of have the food industry who isn't solving for people's health, and so they're not, you know, solving for the same problem that we are trying to in healthcare. Yet they have an outsized influence on healthcare, you know, intentionally or not. So you know, I guess, how, when we look at a problem like that, you know, how do we start to change that, where these forces outside the healthcare system that aren't trying to solve for the same issue or having this influence on our health?
Speaker 3:Well, I love it. When I was in Kaiser Permanente, the leaders of called lifestyle medicine, and particularly around improving diet, were the cardiovascular people. So when someone inside medicine recognizes the power, even though it will negatively hurt their work because patients won't have the heart attacks and the strokes and the diabetes as a consequence of that, I just love all that from happening. But the question really becomes you know, as a clinician, we ask what's the diagnosis? You know, do people really want to be heavy? I don't think so. Do people really want to be out of shape? I don't think so. I think that it's just hard to do so if the problem isn't desire, but it's actually the ability to accomplish it. That's why I have a lot of optimism again around generative AI. It can create menus that are using the best ingredients, the freshest food. It can give you shopping lists and it can give you ways to prepare, cook it most efficiently. You can have 15 minute meals or three hour meals, depending upon whatever you want. It's this ability of generative AI to personalize it. Now I want to point out there are people in society who have to work two jobs, who struggle to survive every day, and they just may not be able to accomplish it, no matter what they do. There's a lot of other people who they can take a half hour away from TV and go out for a run or for a walk or some other kind of exercise. They could find ways to at least three or four nights a week to cook a very different diet. They can shop differently and I think that if we give them the help they will, that's going to be a lot better than some of the GLP-1 drugs that are out there right now which will have to be taken for the rest of their life. But I think we have to start with the fact. It's just hard to do. If there was a pill people could take, they would take it every day. I have no doubt about that. It's just hard to build lifestyle change. But I will tell people who might be listening in and watching in if you do it, you feel so much better that you don't want to go back. It takes 30 days or so to really make it a consistent habit.
Speaker 3:I'm a runner. I run every day. If I don't run I suffer. It's so different than it was the first day I went out for a run. We're getting it around the track. One time was a tough deal to accomplish. I think the same thing around food. Just say I'm not going to buy that white bread. It's a better opportunity to get the bread that I need for my family. I think some of it is educational, but a lot of it is just giving people the tools to make it easier the society. Today, time is the most precious element. I'm hoping that chat GP2 will allow that to happen for more and more individuals and families.
Speaker 2:Circling back on the clinician perspective on this, here we are. Like I said, 60% of physicians currently in the US are facing burnout and probably worse in other places, other systems. Like you said, some of these clinicians might be listening to what you're saying and reading this book and thinking, well, if the AI is this good, will I be needed anymore? If I'm a non-proceduralist, I might be sitting there getting pretty worried about, well, all of the algorithm can do it better than I can. What's my future?
Speaker 3:Well, first, the procedures should not be so sanguine.
Speaker 2:Exactly Because they're coming for us too.
Speaker 3:Well, only because anything that's done through a monitor and you can think about all the things that we do through a monitor, whether it's laparoscopic surgery, whether it's going to be angiograms of the heart, potentially even valve insertion percutaneously, anything that's done for an operative robot, anything that's done through a monitor, chatgp can learn. With ChatGPT as a large language processing module. What it does is it predicts the next step. If it observes 10,000 of the US's best clinicians, it can learn exactly what to do. An image on the screen leads either to that catheter being advanced or pulled back or twisted, and it can duplicate that action. Now we're not talking five years, when this technology is going to be 30 times better than today, at the rate that it's improving. We're talking 10 years, when it's 1,000 times better, but at some point in the future it may be able to do that. But leaving all that aside, I believe there's always going to be a role for the clinician, because I think that people are always going to want to have individuals, human beings, that they can relate to, have a relationship with and care about. In the same way that I don't think robots are going to replace patients, even on Valentine's Day, replace people even on Valentine's Day. I think we want humans in our life.
Speaker 3:The problem right now is, as clinicians, we don't have the time to give people what they want. The fact that we only, as an example, control hypertension 60% of the time. The best organizations are able to do it 90%. Why do we do this 60%? We know what to do. It's almost algorithmic. We just don't have the time to accomplish it. The same with diabetes. The same with cancer prevention, early diagnosis we know the things, we just don't do the job because we don't have the time. What I see is this technology won't replace 20% of physicians, but it will replace 20% of what physicians do. If clinicians are awarded based upon value and outcomes, they can actually care for far fewer patients in their office every day, spend more time with each and yet financially come out ahead of the process. People who are not clinicians may not know is that what doctors have paid per unit has gone down for the past 20 years by Medicare. We're 23% less than we were back 20 years ago.
Speaker 1:Is that in real dollars or inflation?
Speaker 3:In inflation, it's credit dollars Okay, which is still bad, but by the way, the past last year and this year is actually in real dollars. It's reduced per unit in real dollars because what the federal government recognizes is that when they reduce the dollars per unit, more units are done. The costs, in their mind, go up. But all that's happening is that people are running faster and faster on this treadmill, less and less time with patients. The average visitor is now down to 17 minutes. The average physician is forced to interrupt the patient after 11 seconds because there's this constant pressure.
Speaker 3:What happens when you're always cutting corners? You go home at the end of the day feel like you can do your best job. You feel unfulfilled. What is that called Burnout? Burnout is a result of the speed at which we are forced to go.
Speaker 3:If this was an industry where we had way too many doctors who had not enough care to deliver, I'd be worried. This is the opposite. 71,000 physicians left medicine last year. We are short dramatically, particularly in primary care. We do not have the resources that are needed and we can't afford to have the number of people that would be necessary in a broken system. The best solution if chat GPT can help patients to do 20% of what we do in the office. All of a sudden everything goes back into equilibrium. Physicians have more time, patients get better care, the problems that can be solved easily, safely, at home, reliably, are accomplished and we're back into an equilibrium. We have to start looking for the next advance, but at least we will be back at time zero, where today we are at our breath and far behind where we should be.
Speaker 1:I'm thinking through implementation. Let's assume we've got at least three major private they're not really private, they're all publicly owned Three major publicly owned retail organizations who employ physicians. Is it clear that in that model that the retailers who employ the physicians have the incentive to pay that way, to pay the way you're describing, to pay for results, to pay for health rather than just sheer volume? This is just sheer ignorance on my part. It's not skepticism, it's just I don't understand the model.
Speaker 3:And if the incentives are there, the first change is on the economics of paying capitation versus fee-for-service.
Speaker 1:Right.
Speaker 3:The capitated model. How you do best is by keeping people healthy.
Speaker 1:Sure, obviously. What's the incentive to go for the retailers to use that model?
Speaker 3:Because that's how they're going to be paid by the self-funded businesses. That's how they're paid by Medicare Advantage. They are capitated. Right now in the insurance world, what happens is the insurer is often capitated through Medicare Advantage, but they have the choice to pay fee-for-service because they don't have a delivery system. Now you're combining an insurance-capable organization with a delivery system and now they have that ability to do so. I'm not sure that in quotes you'll get paid by it.
Speaker 1:This is a system process problem that I wasn't aware of. What you're saying is that the capitation systems are currently in place. For what did you say? 50% of the insured under 65?
Speaker 3:No, no no, it's 50% of the Medicare. So everyone over the age of 65 has Medicare. They have two choices.
Speaker 3:Traditional Medicare is fee for service. Medicare Advantage is a capitated form. Traditional Medicare you got any doctor you want, bills are submitted and the government pays them. Capitated Medicare the payment goes to the insurance company and then they have to find a way to deliver the care. They can't capitate doctors because you can't capitate a doctor who has 20% of the person's practice. So they pay fee for service, which means that all the incentives remain wrong.
Speaker 1:So they put these effective forces to keep it down.
Speaker 3:Now you have a company taking the insurance, the capitated payment, and I think they're going to probably not directly employ the physicians through Amazon or Walmart, but they're actually going to do it through those medical groups. They acquired one medical, oak Street or Chen Med or through United Health, 90,000 doctors because they can organize them, they have a common computer system, they can collaborate, they can cooperate, they can create all the systems. In Kaiser Permanente we were able to achieve 90% hypertension control. We were able to achieve higher levels of blood lipid control. As a result of all that, we had 30% fewer heart attacks and strokes and other preventable diseases because we were an integrated structure paid in a capitated kind of way. I think that's the model that people are going Up to now. They could do better just by raising the rates. They could do better by putting high deductibles in the pocket. They had other opportunities that were better.
Speaker 3:My observation is those days are over and that's why I think that this evolution will happen. But the problem for most insurers they don't know how to do it because they've got to do it across the entire United States. That's almost impossible. These companies I just mentioned, they're everywhere, they have sites, they have retail clinics, they have opportunities. Now they're going to have to shape it in a way and figure it out. None of this is easy. You're transforming one in five GDP dollars. This is 20% of the US economy, the biggest economy in the world. This is not going to happen in six months, but what I'm seeing is the forces are lining up to drive in that direction and if they're successful, just imagine if you were a the largest company in the world. Walmart, in terms of revenue, has about $600 million of revenue. If they can capture 10% of a $4.5 trillion business, which is what healthcare is today, that's $450 million almost double billion dollars.
Speaker 3:They'll almost double their revenue If they can find a way to lower costs by 20%. They can lower premiums to patients by 10% and maximize their profits by almost 50%. Those are numbers that have. I'm the CEO of these companies. I'm drooling over that opportunity that exists.
Speaker 1:All right, so what's going to prevent?
Speaker 2:Because one of the other ways that you can maximize profits in a capitated system, if you're administering the system, is just by denying care. Essentially and like you alluded to earlier in the talk, you can in this conversation you can put barriers to care without outright refusing. You just put these processes that become so onerous that no one will bother going through it anymore. So what prevents them from going in that direction and kind of framing this in? When we look at some systems that have tried to do this the NHS over in the UK, the Canadian healthcare system what you see is you end up with everyone's got insurance, no one has to pay out of pocket for things, yet they just can't get care because the waiting lists are so long and there aren't enough clinicians to deliver the care. And we see the NHS especially at a crisis point now because of their inability to deliver care even though it's freely available.
Speaker 3:So you're asking two questions. First, in terms of why they would do it because all the restrictions just don't work. That's what the insurers are doing today. They don't work for two reasons. Number one there is a legal system that ultimately will force people to do the right thing, as people take the complaints forward and bring them to the courts and make them happen. We may see that around various expensive medications that are coming up we'll have to see how that plays through but also because it will ruin their brand.
Speaker 3:When you think of Amazon, you don't think of cheap. You think of getting a product delivery. You think of broad choice, transparency, information, the product delivered in one to two days and getting what you deserve. And if you can't, you can send it back. Where do you find that in medicine today? Walmart those of us in the upper socioeconomic extent, if you would is cheap, but that's not the way it looks to the people in the lower half, and I had the chance to listen to the CEO of Walmart talking about these. People can't afford to buy what you and I might want for the sheets in our bed. They want sheets that are gonna be able to last, where they can be washed a hundred times and not fall apart. They want the quality for the dollar, and that is what Walmart provides. They don't do it by being cheap, they do it by doing it well, and so I think all these systems are going to want to preserve their brand. Now can they accomplish it? That's a different question, because that means they gotta be able to change and turn around the 20% of the US GDP. What about these other countries? I think the problem in these other countries is they still have a broken system, even if they have a central form of financing. So you're absolutely right, they have not figured out how to have the flow through be accomplished In the same way, by the way, the US hasn't figured out.
Speaker 3:That's the point that I was making. We didn't have a tool that would allow us to do medicine was advancing too fast to allow us to be able to raise the quality and control the cost with what we had before. My optimism is I think chat, gpt generative AI will have that ability, not because somehow it's just a computer system, but because it will empower patients, and now it will be up to us, as providers of care or someone else as catering to consumers, to help patients to be able to utilize it. I remember early on in computers people would say these machines are great, I could put my yellow sticky notes attached to the screen and be able to find them easily. Well, that's not how you make a computer work. You had to actually understand how to apply it in ways to be able to improve the quality of your life, which I think most people have been able to accomplish. Same with the iPhone. We're gonna have to be able to help patients figure all this out and build systems to support them. Today and I wanna be clear to viewers and to listeners what exists today in generative AI is not ready for prime time. It is a toy compared to what will be here in five years.
Speaker 3:In the book that I wrote, I started six months ago. My goal was to have it complete in six months, not because I wanted to do it fast, because I knew that by two years anything I wrote would be outdated. I had to do it in six months. In the time between when I started to write it and now, open AI has made two massive steps forward. The ability to have plugins means that you, as a clinician, can plug into your patient's system generative AI systems with your expectations and it can measure outcomes against your expectations and, where they deviate, can say care is needed, and where they're the same, it can say you're doing great, you don't need something to accomplish. That didn't exist when I started and just now memory. You, as a patient, can load all of your electronic health record information into the system and it will retain it and remember it so that when you have a problem it will apply your specific information. That's only coming out now Six months, radical change.
Speaker 3:I can't tell you how much rework I had to do to make the technology work because I didn't have these two tools. I kept saying I've only had these tools. But I want to make another point. I wrote an article two years ago predicting that Alexa would be able to do these tasks sometime in the future. I didn't have any insights that generative AI was coming along, but I could see that this would be happening and that's what we now have. Chatgpt is the Alexa that I saw two years ago able to monitor you every day, tell you how you're doing, answer your questions, help you understand your diseases, empower you as a patient.
Speaker 3:I think it's all coming together right now. That doesn't mean it's going to be 2024 or 2025, but by 420, 30, 31 comes. I'm almost certain that it will be able to accomplish these things and have overcome what I found to be a lot of the shortcomings. It hallucinated. It made up an entire story about the exploration of the North Pole that didn't exist, but it got the story about the South Pole perfectly accurate and the story about Shackleton getting trapped in ice. These are the best computer programs in the world, working for Amazon and Google and open AI and Microsoft. I think they're going to be able to solve the challenges over the next five years and a year from now. Two years from now, what's available will be four or five times better than today and, as I said, five years from now, 30 times better at the rate that it's evolving, the algorithmic improvements that are happening.
Speaker 1:Well, I think you set the table for us and now that we've had this conversation, it's clear to me why we need to go to the book.
Speaker 3:So the name of the book again is Chat GPTMD, and it's subtitled how Patients and Doctors Can Reclaim Control Over Medical Practice.
Speaker 1:All right, and it's coming out.
Speaker 3:That's GPTMD.
Speaker 1:It's coming out very quickly when.
Speaker 3:April is either the first or second week in April.
Speaker 1:So very good. So this episode will have already dropped when, about two weeks before the I think about two weeks before the book comes out. Very good.
Speaker 3:And it'll be available through Amazon.
Speaker 1:Very good. Well, phil, I got a kick out of this. I really did. It's nice to have someone thinking about the system and the processes from this direction. I realize we didn't go down a metabolic health trail, but at the end of the day, we still are citizens of a country that has a system that's broken and it's good to hear somebody thinking about ways to actually fix that problem. It might. It makes sense to me now I can see how it works.
Speaker 2:I agree. I'm certainly more optimistic at the end of this conversation and I have seen a lot of the same. I guess I see a lot of the same light at the end of the tunnel, I think that Dr Pearl does. From being in the system, I think metabolic health becomes a. I'm optimistic that the AI is going to do a better job of figuring out that metabolic health is the answer than clinicians in the system have so far. So I do think that there is a natural overlap there. Yeah, this has been a great conversation and certainly look forward to the book and this ongoing dialogue and what the future holds for us, I guess. To wrap up, if people are interested in learning more following you, where is the best places to do that?
Speaker 3:The best place to do that is through my website, wwwrbpurellmdcom. There I can find lots of different articles. They can subscribe. There's no advertising, there's no cost, it's all free. They get monthly musings which attach them to various articles. Invite them to submit their opinion. In fact, rocky, this month's monthly musings asks about the subtitle. The one I gave you is the one that's leading in the voting so far, but we'll see what happens now in the end of the month when it becomes more final.
Speaker 3:The one thing I would like to add, though, for the two of you, since you are such important proponents of metabolic health, which I too am is that everything I'm describing, all the changes I'm talking about moving from fetus surface to capitation that will encourage individuals leading the process to focus on metabolic health and lifestyle medicine. The opportunity to use chat GBT to diminish chronic disease. You don't diminish it just because you say I don't want to have it. You diminish it by changing your diet and your exercise and your other various habits, along with medication if necessary, because sometimes it needs to have an added boost to it. The ways of moving from fragmentation to integration and the ways of moving payment from fetus surface to capitation technology, from the outdated technology in the past to generate AI in the future. Every one of these steps will promote metabolic health.
Speaker 3:I think everyone understands how vital that is to the health of our nation, how crucial that will be in the future to the limitation and moderation in chronic disease. As I said earlier, it's just hard to do Any tool that we can give people that facilitate that, whether it's an educator or a trader, whether it's a technology like chat, GBT, that's only going to add to the positive rate of advancement, to the acceleration. Hopefully that will happen. But I agree with you if we can get metabolic control, eliminate diabetes, reduce heart attacks, minimize strokes, change the blood pressure, heart failure, all the ways that can have a positive influence our nation will be healthier as a result of that. By the way, we'll have the dollars that we need for the other things, like the education, like the safety, like the other parts of the program To me, in all lines in a positive direction. We just have to move forward faster than we have in the past.
Speaker 1:I like it Well. I think that sums it up.
Speaker 3:Thank you for having me today. I appreciate it.
Speaker 1:Dr Robert Perl, thanks for being with us. I look forward to seeing more and hearing more, and I appreciate the optimism. I think that's the key ingredient to get us out of this mess that we're in is the hope and the belief that we can get out of it.
Speaker 3:We're not victims unless we tell ourselves that we are.
Speaker 1:That's right. Last words, Phil.
Speaker 2:Yeah, I'm optimistic and bet long on humanity and I think we're going to get there.
Speaker 1:We're long on humanity. For Dr Philip Ovedia, Dr Robert Perl, this has been the Stay Off my Operating Table podcast. We will talk to you all next time.