Transforming Healthcare: A Discussion with Former US Congressman Robert Andrews

Many thanks to former Congressman Robert Andrews, a graduate of Cornell Law School, an original author of The Affordable Care Act, and CEO of the Health Transformation Alliance (HTA). Rob is here today to speak about the fundamental importance of an effective health care system to every individual and some of the ways the US healthcare system can be improved. 

During our 40-minute discussion, we discussed the complex landscape of healthcare in the US that tends to separate physicians and other providers from their patients. Rob estimated that 30% of the money spent in our healthcare system goes to people who are not directly involved in patient care, and “that’s too much.”

During our interview, Rob described how the HTA lowers overhead and improves outcomes by focusing on education, prevention and removing barriers to prescription and provider access.

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Transcript

AW: (0:08) Welcome to the Art of Medicine, the program that explores the arts, business, and clinical (0:13) aspects of the practice of medicine. I'm your host, Dr. Andrew Willner. Today, I'm pleased (0:20) to welcome former Congressman Robert Andrews.Rob spent 24 years as a congressman representing (0:28) New Jersey's 1st Congressional District. He is also an expert on healthcare and helped (0:35) pass the landmark Affordable Care Act. Since leaving Congress, Rob worked as an attorney (0:42) for a couple of years, but then became CEO of the Health Transformational Alliance, an (0:49) organization designed to improve healthcare delivery for millions of people.In a moment, (0:56) he's going to tell us all about it. 

But first, I'd like to thank our sponsor, locumstory.com. (1:03) Maybe you're curious about locums and how it might fit into your career story, but you (1:08) know all the different reasons physicians choose locums and how it works for them? At (1:14) locumstory.com, you can hear firsthand stories as diverse as physicians themselves. There's (1:20) not one solution for everyone.The variety of opportunities might surprise you. LocumStory (1:28) is an unbiased educational resource. It has tools that let you explore trends in your (1:34) specialty and compare different locums agencies.There's even a simple quiz to see if locums (1:40) is right for you. Do your own research at locumstory.com. It's easy. And now to my guest.

(1:49) Welcome, Rob Andrews. 

RA: (1:51) Thank you, Dr. Wilner. I'm really happy to be here today.

AW: (1:55) Well, thanks for coming. I know you have a full schedule from what I saw in your bio. (2:00) I've got it posted over here.And you look just like the picture, even more handsome in, you (2:07) know, moving around. 

RA: (2:08) You may have seen an ophthalmologist. That's a warning sign.

AW: (2:13) So why Congress? You know, I mean, I knew I wanted to go to medical school and be a doctor, (2:18) but you wake up one day and say, I'm going to be a congressman. How does that happen? 

RA: (2:24) When I was about 14, my dream in life was to be a sports writer. I want to cover football, (2:31) basketball and baseball and all that.And I got a job with a local newspaper covering what I (2:38) thought was going to be local sports. And the newspaper instead assigned me to cover city (2:46) council meetings and school board meetings and local government. So I learned a lot about local (2:52) government.I really liked it. I like the ability that local governments could solve a problem. (2:59) They could build a park if the kids had no place to play.They could do trash pickup twice a week (3:04) if the trash was piling up. Long about that time, my father, who had worked for about 40 years in a (3:12) shipyard, lost his job. The shipyard closed and he got laid off.And he hadn't done anything wrong. (3:20) He followed the rules, did a very good job, worked through everything. And our family hit a really (3:27) rough patch.And so on the one hand, I was seeing the fact that government could solve problems. (3:36) On the other hand, I was seeing that my dad and my family had a very serious problem (3:41) because he had no job that was not getting addressed. And it inspired in me the notion (3:48) that maybe someday I could do something that would help people like my family (3:53) through public service.And that's what, from that age, I didn't at 15 say, well, I'm going to (3:58) run for Congress. But it got me interested in serving in public office and eventually led (4:05) to the opportunity to run for Congress in 1990. Which you did over and over again.(4:13) Yeah, I guess I got to get it right. I was fortunate enough to be elected by my constituents (4:19) in southern New Jersey for 12 terms. And it was a great honor to serve them.And I have great (4:28) love for our country and believe that it's a wonderful country that has its flaws, but (4:36) serving it was a great honor. 

AW: Well, that's fantastic. I've been to the (4:40) Hill once or twice and I remember it's like, gee, these people are really working hard.

RA: (4:49) Two things I think will surprise people about Capitol Hill. The first is despite all of what (4:57) you see on social media about conflict, there's a lot of goodwill among elected officials. (5:03) People who disagree on policy can respect each other as men and women.And I think there's still (5:09) a lot of that. The second thing is how hard the staff people work. The unsung heroes of Capitol (5:16) Hill are men and women, very often young men and women, who could be making a lot more money in (5:24) market, but who choose to come and dedicate their work and their lives to serving the country.(5:31) Whenever I hear someone criticize everyone in government, particularly staff people, (5:38) I think that they should stop and think about that. They should understand the sacrifice a (5:44) lot of these people are making and respect them for doing it. I do.

AW: (5:51) Thank you for that. Today, our focus is going to be healthcare. And I'm a practicing neurologist.(5:59) I deal with the healthcare system every day. I know a lot of patients are frustrated. I know a (6:05) lot of physicians are frustrated with the system.I think one thing that everyone can agree on (6:14) is that healthcare is too expensive. (6:18) And the other thing that I know that you're a strong believer in, and I am too, but I think (6:24) maybe it should be articulated, is why everyone needs healthcare, apart from who is going to pay (6:35) for it. Why does everyone need healthcare? 

RA: Health is the foundation of everything else (6:42) you want to do in your life.If you want to teach school or drive a bus or build houses or (6:50) play basketball, whatever it is you want to do with your life, (6:54) if your body isn't working correctly, your mind isn't working correctly, you can't do it. (6:59) And the other thing besides your connection of your vocation in health is the connection to (7:07) people who you love and who love you. You can't be a very good dad or son or husband (7:15) if you are focused mostly on your well-being, if you're sick all the time.You try, but (7:22) health is literally essential to everything else we want to do with our lives. (7:30) So it's really fundamental. It's like food.It's like having a roof over your head. (7:41) Yes, unfortunately, if you have a healthcare crisis, that dominates your day. If, God forbid, (7:50) you're suffering from a malignancy and you need to undergo extensive chemotherapy to address that (7:59) malignancy, you're probably not going to be able to do a whole lot besides deal with your chemo.(8:07) It's something far less dramatic. If you get migraine headaches (8:12) and you can't control them or at least assuage the pain, you probably can't teach school or (8:20) sell real estate or do whatever it is you or play baseball with your daughter. There's probably a (8:25) lot of things you can't do if you've got a splitting migraine headache.So I never want (8:30) to take health for granted. I've been blessed with very good health. My family's been blessed (8:35) with good health.And anything else we've had the chance to do as a family, we've done in part (8:42) because we have that good health. So yeah, it is like breathing. It's like having nourishment or (8:48) a roof over your head.If you don't have it, you probably can't do anything else. 

AW: (8:53) All right. So that's sort of the fundamental.And that leads us to why is healthcare (9:02) first too expensive and second, so complicated. And the examples that you gave, if you have a (9:08) malignancy, it's like, well, where do I go? Who do I see? Which network are they in network, (9:15) out of network? How am I going to pay? It's Byzantine, right? I mean, how did all that happen? 

RA: (9:24) Byzantine is the right word. And of course, the Byzantine Empire eventually got so complicated (9:31) and large, it collapsed under its own weight.Our system is at risk of doing that too. (9:38) But the simple answer to the question you raised about why is healthcare so expensive? (9:44) In my mind is this, too many people who don't treat a patient or discover a cure or somehow (9:53) serve a person's health needs get a big piece of the money in the system. There are too many (9:59) middlemen.So you've got the patient on the left hand side and the employer or the insurer who's (10:07) paying for the patient's care. And you've got the provider, the neurologist or whatever physician, (10:16) therapist or nurse or what have you on the right hand side. But there's so many different people (10:23) between that patient on the left and that provider on the right.Now, many of those middlemen and (10:30) middlewomen perform services that are necessary. Someone has to process the claim and make sure the (10:38) claim gets paid and keep the records and make sure the rules are complied with. But there's pretty (10:45) good evidence in our system that 30% of the money spent in our health system at least goes to those (10:52) middlemen.That's too much. And I think what happens is that to the extent that the value (11:03) provided by the people in the middle is significantly less than the dollars they extract (11:10) from the system, that's why things are so expensive. Look, expensive also is a subjective matter.(11:18) If your child is in the NICU and they're struggling to survive because they were born, (11:26) you know, two and a half months early, the price is not what's important to you. (11:32) Is that the child gets the very best care and has the very best shot to survive. And (11:37) there's been this miracle happened right before our eyes that babies that could never survive (11:44) because of preterm birth make it and they make it to be flourishing, productive, happy, (11:51) productive adults later in life.Not all of them, but many of them do. So I always want to be careful (11:57) that I don't want less expensive health care. I want higher value health care.So to me, (12:06) whatever has to be spent to take that two and a half pound infant and give her a chance to thrive (12:12) and become a young woman is worth it. What isn't worth it is if the prior approvals and the (12:22) documents that have to be filed and the regulatory work that has to be done (12:27) is eating up 30% of the dollar that could go to her care. 

AW: We have a high risk unit here at my (12:35) hospital and we deal with that situation every day.And I agree with you 100%. Well, I know that (12:44) you since leaving Congress got involved with something called the Health Transformation (12:51) Alliance. Would you like to tell us about that? 

RA: I'm so honored to have a chance to be with this (12:57) organization.We're about 70 companies, many of large companies like Intel and Comcast and (13:08) Coca-Cola and Marriott. Five million people in the United States get their health care through (13:15) our employers. What we are essentially is a cooperative of those employers that pools our data (13:24) about what happens to patients and what issues arise and our dollars, our purchasing power (13:32) to try to identify high value care.Again, not low cost care, high value care and try to steer (13:42) consumers, people toward the highest value care to solve a problem that they have. (13:49) We're not 100% successful at it by any stretch of the imagination, (13:54) but that's our objective. And we've been around for nine years now.(14:01) We think that we've produced a lot of better results for people. We don't think that the (14:07) data would show that, for instance, our most active members have hospital readmission rates (14:15) that are about 20% lower than hospital readmission rates for those who are not in our co-op. (14:24) This is on a risk adjusted, I think our audience is a very astute audience.So I'll use the phrase (14:30) risk adjusted basis, knowing people understand that. But yeah, the data show that when employers (14:37) are engaged in using the solutions that we've helped to create, we get better health outcomes (14:42) and not surprisingly, we get lower costs. Typically our members are spending 10 to 15% (14:50) less than the market on healthcare claims.Again, risk adjusted because we've been able to do certain (14:58) things. 

AW: One simple thing that I see that doesn't happen is hospital follow-up. For example, (15:07) patients discharged from the hospital, they get five or 10 prescriptions.Three weeks later, (15:13) they're back. Well, didn't that medicine work for you? I never got it filled. I mean, that happens (15:18) every day.Or I ran out and it's like, how can you run out? Well, I didn't have a ride to the, (15:26) there's just a long, long list of very, not Einstein level equations that need to be solved. (15:35) A lot of it is social determinants of health. 

RA: Well, Dr. Wilner, I think that you've really (15:43) identified the core problem in the US healthcare system, which is that (15:49) in our economy, people do what they get paid to do.In our healthcare system, (15:56) very few actors get paid to follow up on that hospital visit. So they don't. If the physician (16:06) wrote the script for a certain medication follow-up, the way he or she typically is paid, (16:14) if they're on salary at the hospital, the hospital pays their salary.If they're in practice, (16:19) they get fee for service. When they saw the patient, they get a fee for seeing the patient (16:26) for that time. But if they took the time later to call the patient or have their team call the (16:32) patient, they're not getting paid for that.Now, I'm not suggesting that they don't do it. I'll (16:37) bet you do in your practice. A lot of doctors and providers do a lot of things they don't get paid (16:43) for because they care and they truly are driven by the best outcome for the patient.But in any (16:49) business, there's a limit on that. You can't give away your time if you get paid for your time. (16:55) So I don't want to oversimplify this, but I do believe it's the most powerful and consistent (17:00) point.If we reshape our health care system so that doctors, hospitals, drug companies, (17:08) therapists get paid for better outcomes, we'll get better outcomes. And a tiny example of this, (17:17) a limited example of this, is that there have been more effective follow-up regimes after (17:24) hospital discharge because of the Medicare readmission penalty. Now, it's an imperfect (17:31) rule.I think it's very unfair of it. If a hospital discharges a person for a cardiology (17:38) problem and there are car accidents six days later, that counts as a readmission. To me, (17:43) that's not rationed.It should be tied to the underlying condition. It's also not risk adjusted. (17:50) So if you send a patient home to a loving family that'll support her and help her (17:55) not fall and make sure she gets fed and bathed, and you send another patient home by herself (18:02) with no support, yeah, the patient with no support is a lot more likely to wind up back (18:07) in the hospital.And there's tons of that. But putting that aside, because hospital revenue is (18:15) now at risk because you can have a Medicare penalty if you have a high readmission rate, (18:21) or a Medicare bonus if you have a low one, hospitals are now beginning to invest in (18:27) post-surgical care and visits at home and follow-up care, not as much as I'd like to see. (18:34) But there has been something of a change in behavior and something of a change in results (18:39) because of that.That's the systemic change that's happened throughout the system. (18:46) 

AW: The other sort of feature of the system that I see is that it's not a closed loop. In other words, (18:56) one hospital discharges the patient, say they do terrible, but they get admitted somewhere else.(19:01) So it doesn't cost hospital A any money because now they're at hospital B. 

RA: (19:08) It just goes to show you that even a deeply flawed rule, and that's another flaw that you (19:13) just pointed out, has had a positive effect because it, for the first time, tied outcomes (19:20) to payment. This is what it's about. I always want to compare the dramatic drop in COVID fatalities (19:34) to the obesity rate in the country.If you were to draw a graph, it would look like this. (19:40) The number of COVID deaths per month fell precipitously in the spring of 2021, stayed (19:49) there. And it's because the vaccine came along.And the vaccine came along because the federal (19:56) government wisely, at that point, the Trump administration, the first Trump administration, (20:02) said to the pharmaceutical industry, if you can make a safe, effective vaccine for COVID, (20:08) we'll buy every dose. And so they did. And then the Biden administration followed up with that.(20:15) There was a massive vaccination program and the number of deaths fell precipitously and stayed (20:21) low. That's because someone got paid to solve the problem. If you look at obesity rates, (20:29) they have gone up consistently, dramatically, tragically over the last 30 to 40 years in (20:38) the United States because almost no one got paid to try to reverse it.If your hospital said, (20:47) I'll tell you what we're going to do. We are going to do a community education program on nutrition (20:53) and prevention and exercise and diet. And we're going to take everyone who's pre-diabetic and try (20:59) to turn them in a different direction so they'll become type 2 diabetes.You would wind up in (21:05) chapter 11 because you don't get paid for it. As a matter of fact, there's almost a perverse incentive (21:14) that the diabetics who don't wind up in the operating suite for an amputation or don't (21:20) wind up in the ICU because they had a stroke cost you money. Now, I'm not suggesting there's a (21:25) hospital anywhere in America that has consciously said, oh, good, let's hope for a lot of strokes (21:31) this year.But if what they do is invest in a really good prevention program, for the most part, (21:40) they're penalized for it. So now, of course, that's beginning to change a little bit lately because of (21:44) GLP-1s. The last two years, we did see a modest reduction in the percentage of the population (21:52) because for the first time, even though it is a highly flawed industry, the RX industry saw (22:02) massive gains by creating a product that at least apparently can cause and sustain weight loss.(22:14) I preach on this all the time. If we can change our system so that the provider who produces (22:22) great outcomes wins and is rewarded for it, the system will turn around. 

AW: (22:30) Well, I think you're one of the best qualified people to speak to the question (22:38) that's crossed my mind, and that is, can the federal government fix this problem? In other (22:47) words, Medicare for all to close the loop?

RA: It can't fix it by itself. And I wouldn't want to (22:56) see Medicare for all for a lot of reasons. But the federal government can play a huge role in this (23:04) because it's the biggest payer through the Medicare system.And this would have to be (23:11) done carefully. And I want to preface everything I'm about to say by saying that it should be done (23:18) by clinically competent standards. It shouldn't be me deciding this.I'm not clinically competent. (23:25) It should be someone like you who is. But if the Medicare payment system shifted to fee for value (23:32) rather than fee for service, the entire ship of state would turn.I just read this morning (23:40) that what's called the ACO REACH program, which many of our audience would know it. It's accountable (23:47) care organizations that especially emphasize equities and social determinants of medicine. (23:56) The latest data from that, it's not many people, it's like 172,000 Medicare recipients are in this (24:03) system, very small group.But their total cost of care on a risk adjusted basis was about 6% lower (24:11) than the rest of the Medicare population. Now, why is that? Well, and by the way, two thirds of the (24:19) ACOs, that is the organizations within the hospital systems that were running this, (24:26) turned a profit. And one third didn't, which is a problem.But the ones that did basically took (24:33) in a capitated fixed payment from the Medicare system, took overall global responsibility for (24:40) the health of that patient, had an incentive to educate the patient, properly follow up with the (24:47) patient, do all the things that were. And the results, again, are written on a risk adjusted (24:52) basis, were very highly favorable. Now, that's great news for 172,000 people.There are what, (25:01) 45 million people in Medicare, whatever the number is now, it's a lot higher than that. (25:06) So I think that whatever Medicare could do to encourage more people to go into a fee for value (25:14) system, I think that could make an enormous impact. What we're trying to do (25:21) as 5 million people who work for self-insured employers is have that similar kind of impact.(25:28) We're trying to drive more dollars to more providers who are willing to do fee for value (25:33) arrangements than fee for service. 

AW: Well, I think all providers, certainly all, (25:41) and including physicians, want good outcomes. I mean, that's what we wake up for in the morning (25:49) is we pray and use our skills to try and arrange for a good outcome.I think all of us feel we need (25:59) help from the system to make sure the patients have a place to park and can get their medications (26:07) and understand their problem and also have their own personal motivations. (26:17) The individual also has a role in many of these. No question.(26:23) Illness, smoking, for example, alcoholism, there's some self-destructive things that are (26:28) pretty common that add to the bill. If we could help fix those, I think that would take a big (26:36) bite out of the budget. 

RA: I want to reemphasize your point that physicians want good outcomes.(26:41) I think that's almost universally true 100% of the time. The problem is we've saddled (26:48) physicians and other caregivers with a system that militates against good outcomes. (26:54) If we have an economic system that says, well, you're going to have to see (27:00) eight patients an hour if you're a primary care doctor, I don't think in six and a half minutes, (27:09) you're going to be able to do for that patient what you want to do.That's not the PCP's fault. (27:16) It's not the pediatrician's fault. It's the system's fault.Instead, if we said, well, (27:23) you're going to get a certain budget for each patient for a year. (27:27) And if you think you'd want to spend 40 minutes with that patient, go ahead. Go ahead.(27:35) And if that 40 minutes results in the patient takes their meds, or they really understand (27:43) when they should call you if they're starting to see a flare-up of their problem, and it makes (27:49) that person healthier, and that then saves the payer money that your practice is going to share (27:56) in that savings, you're going to benefit from that, and make it worth everybody's while to (28:00) spend that 40 minutes. It isn't the doctor's fault that that happens right now. It is the (28:06) carriers and the Medicare system and the other people, and to some extent employers, (28:12) who are putting their dollars behind it.Again, it comes back to this point. (28:16) In the American economy, people do what they get paid to do, period. And what we are implicitly (28:24) saying to doctors and therapists and others is, see as many people as you can in a shorter period (28:32) of time as you can, and you'll win.Or operate on as many knees as you can, and you'll win. (28:41) Or sell as many doses of the drug as you can, and you will win. Now, very often, (28:50) those incentives overlap with a better outcome.If someone's knee is disintegrating, and an (28:56) artificial knee would make them healthier, that's a good thing. I'm not saying knee surgery is bad. (29:02) I'm saying that knee surgery that might not be clinically called for, that might, maybe could (29:11) be avoided by physical therapy and diet and exercise, that that ought to be valued as well.(29:17) And the physician who recommends that shouldn't be punished because she's taking money out of her (29:24) P&L by not doing the operation. It's not the surgeon's fault. The system's fault.

AW: (29:31) I've been acutely aware of the pressure to see more patients, because the words neurology and (29:41) fast are difficult to put in the same sentence. By its very nature, neurology is a very (29:48) detailed story from the patient, which can take a long time in coming, and a detailed exam, (29:53) the most detailed examination in all of medicine. And doing that in eight minutes is not going to (29:58) get a good outcome.