Judson Howe It fascinates me in the medical hierarchy that there are these elite physicians that go into IM and FM, not because they don't have other options, but because that's where they want to serve. And I don't want this — Katherine and I turned into an infomercial last night about FM, and it was totally fine.
Asaf Bitton This is a really important conversation. And when we think about workforce both pipeline and burnout, inflow, outflow, deconstructing and understanding, why do people make an economically irrational choice? Why do they make a socially irrational choice?
Judson Howe It's like what you said, it's not really a sacrifice.
Asaf Bitton It's something that's right. And I agree and disagree. It is like putting it on the table, lifetime earnings, we both left millions of dollars on the table. We left going on certain subspecialty hierarchy, prestige stuff, if that's important to you. So the question is, maybe I think for many of us less, what did we give up? But why was it such a natural choice to sort of give that up? And why is there this kind of strange hierarchy that there is something to give up in the first place to do the right thing to serve the patient?
Judson Howe Yeah, why does that decision even exist? And why does Yale nor Harvard even have family medicine as a rotation?
Bruce Finke A lot of work done over the last 20 years around waste in the system, right? And a lot of efficiency work. And in general, the redesign of care, the redesign of primary care has been efficiency focused. One could argue that the greatest waste in the system is in the relationship between the clinician and the patient. And that's where we leave stuff on the table. That's where when we don't allow people who go into primary care to engage with patients in the way that they wanted to, in the way that drew them into primary care, then we're actually wasting a huge amount of resource. But you can't quantify it in dollars and cents in quite the same way.
Asaf Bitton The value of primary care is mediated by relationships that are meaningful, that are substantial, that have offshoots of things that we want to foment, like trust, like engagement, like health behavior change. But the unit of intermediation, the unit of transfer of that value is the relationship. So the very thing that's going, that at population level studies, having more primary care in a given county is associated with less mortality, controlling for everything. That is a true statement.
Judson Howe Is it also associated with lower costs as well?
Asaf Bitton We should talk about that. It's not clear because there are a lot of – probably over decades, but not over years. And that's worth a whole conversation. But if you put the same study number of specialists, pick any specialty, number of ERs, number of hospitals in a county density per 100,000, good things to have, but not associated with mortality benefits. Primary care is driving that mortality benefit because of this relationship mediation. And yet the thing that is so valuable is the thing under pressure: the time, the space, the mental awareness, the ability to gather a team of clinicians and a principal clinician to be in relationship with that person and walk with them, accompany them over a lifetime. And that is worth way more than the 3.5% that we spend of the total healthcare dollar on primary care. So when Bruce talks about waste, we're wasting the very thing because we thought we could in the last 15 years dress it up as, well, the problem with primary care is it's not efficient enough. They need to do team-based care and they use the EHR and do just run cycle times and processes faster and better. But primary care is not a hospital. Primary care is a series of relationships that over time create health inside the walls of the clinic and outside the walls of the clinic. And that's the kind of opportunities case, you know, we can talk we can talk more about it, but that's the opportunity case we're dealing with.
Judson Howe How do you scale that? Right, because I think there's been, and in you two here, CMMI and Ariadne, right, I imagine it goes in there a little bit, and yet we've seen these different initiatives, these care-based models, these patients that are in medical homes, and I'm really probably very limited on what all these initiatives have been, and yet it feels like we're going the wrong direction. Why do you think these things have not taken off at scale?
Bruce Finke There's not a single thing that's going to make it happen. There's a payment context, sort of changing from the dysfunctional visit-based payment that I'm sure you've talked about in a number of your conversations.
Judson Howe A little bit, yeah.
Bruce Finke To a population-based payment, that's like a contextual factor. The efficiencies we've talked about that we've worked on for 20 years, that's all important work. And that's all to enable the relationship. But at some point, we have to look at making space for that relationship. We have to prioritize space and time for that relationship. Thinking about the system at CMMI, and Asaf and I worked for —
Judson Howe What does CMMI stand for?
Bruce Finke The Innovation Center at CMS. That was started as part of the Affordable Care Act. We've done a number of very large, the kind of scale you can only get in federal government, primary care tests of payment change leading to care delivery change. All of that is working from the outside in to create the context for stronger relationships, the kind of relationships that Asaf talks about. The relationships that lead to better outcomes. At some point, we have to start to look from the inside of that relationship and say, how do we create space? Whether that's time, that's more about what we expect to come out of that. It's both about the time to have the conversation and what we expect to come out of the conversation. What are patients looking for?
Judson Howe Give me an example of where this is actually working well or where you've actually received some hope that something could actually work.
Bruce Finke I'll give you an example that is not one that I think is scalable, or that we want to scale in part because of the equity considerations, but concierge medicine.
Judson Howe I've been hearing about direct primary care.
Bruce Finke Direct primary care? What do they do? They create a context in which there's time for the relationship and people who have the money can pay for that time and that relationship and value it enough to pay for it.
Judson Howe Why couldn't that be equitable? Is there a mechanism we could make that equitable?
Bruce Finke Well, right now it's based on individuals' ability to pay and these are individuals — a monthly fee — and people can barely pay their premiums.
Judson Howe So why couldn't a community organization —
Asaf Bitton Or a government, or a payer? This is the logic of … If we step back for one second, what I think the thesis is, is that we've been asking the wrong questions about what's the matter in large parts of our healthcare system. So we've been asking, as Bruce said, a series of questions about efficiency. Good questions. We need to think about how to make our systems more efficient.
Judson Howe I hear us think waste to efficiency.
Asaf Bitton Yeah, waste, efficiency. We want production cycles that actually produce access and produce safe care. This is all important. But the challenge and where we need a frame shift in the right questions around missing the value of primary care is that primary care doesn't fit into an easy management induced kind of, you know, Taylorism, the sort of management theories from the 40s and 50s. We're not making widgets here. And in fact, even worse, the payment model, which is an idiosyncratic just accident of how things came to be, has essentially said primary care in the US is about churning the number of visits. That's pretty much the lever that you have to induce access and revenue. So you live within those really narrow quadrants, even though the right question to ask is, what does every successful health system in the world have at its core? And that is a strong primary care base, primary healthcare base. And we can talk about the differences between primary care and primary healthcare. But if that's the case, and I still haven't found a counter example — show me a high-performing, efficient, effective, respectful, high-outcome system that serves a community, it always has a primary care, strong primary care base. So in the US, the issue has been we have a production model that's based on visits and money that isn't attuned to the ways in which primary care in all of these communities, including in the US, produce good care. So part of the issue is how do you create the space and the time for clinicians to have meaningful relationships, as more can and should be done in primary care. We've expanded from a few quality measures to hundreds of quality measures. We have chronic disease treatments that expand widely. You need a team, a team that's connected by IT, a team that isn't just playing on a visit calendar of 20 or 15-minute visits to be able to proactively, preemptively, reach out to a population. It's able to deal with their acute needs, and it's able to not just do acute and chronic, but also the other parts of good care, which are palliative, which are rehabilitative, which are promotive. Those start to then get into kind of a function of a primary health care system where it's not just about visits for outpatients, you know, chronic diseases, but it's really about the core functions of primary care, first contact access, comprehensiveness, coordination, continuity, but also the ability of the medical system at its edge, which is primary care, to reach out to communities and to reach out to other segments of society to create health in the community. So that interplay between public health and medicine is often interlayed through primary care.
Judson Howe I think my concern, and again, I was an executive on what I joke is the fraying edges of the American system. So in my market, we were short by 45 primary care physicians for a couple hundred thousand people. And there was no recruiting strategy that we discovered that was really going to address that. And by 2022, we were spending $330,000 for a new grad coming out of residency and that still wasn't enough to close that gap. And it almost feels like we're going the wrong direction from a workforce development perspective. Assuming what you're saying is true, which is if we want to make a dent in the American healthcare system, we're going to have to figure out how to incentivize primary care in a very different way.
Bruce Finke I think incentivize, but when we talk about incentivization —
Judson Howe I heard you talking about incentive models.
Bruce Finke Well, there's payment models. Not the same as incentive models.
Judson Howe Tell me, okay, I got to stop. What is the difference?
Bruce Finke So incentive models assume — I mean, I'm assuming you're using incentive in terms of dollars.
Judson Howe I was.
Bruce Finke But we know from Deming's work that actually those kinds of incentives actually often undermine performance. They undermine the intrinsic motivation that leads folks into the work and leads folks to want to excel at the work. It's not to say that folks don't want to be compensated well, but if we rely entirely on compensation, we'll drive salaries up and that'll be good. No complaints.
Judson Howe And that is happening?
Bruce Finke And that's happening. But if those clinicians — and here I'd say physicians, nurse practitioners, PAs, because increasingly we're not talking about a primary care workforce that's physicians, we're really talking about a primary care workforce with physicians, nurse practitioners, and PAs — and that if they're still caught in a delivery system model that constrains their ability to talk to the person in front of them and understand them and know who they are and provide care out of that knowing with a sense of sort of mutuality, a sense of shared purpose, they'll take the money. But when they're done, they'll take the money and work less, which we see. Because no one can actually manage to work a full time, it's very difficult to work a full-time job as a primary care physician.
Judson Howe I had a doc calculate it recently and they said to do all the things that you asked me to do, it's 27 hours a day.
Asaf Bitton There's a famous series of studies.
Judson Howe Does that sound about right?
Asaf Bitton Well, it sounds right and I think it is right. In fact, it's only grown. There are BU studies about a decade ago and they've just been redone. If a primary care your physician, PA, NP did everything that was on the recommended list for acute and chronic conditions, for chronic conditions and preventive conditions, they would have to work 365 days a year at 27 hours a day. And that doesn't even count the acute care, like just people showing up with like a knee contusion or pneumonia or stuff.
Bruce Finke I'll tell you what folks are doing, primary care folks are doing with the increased money. They're buying down their time. They're working 70%, 60%, 40%, and they're spending extra time at home charting, documenting, looking things up so that when they go see the patient, they know what they're doing and can give the patient 100% of the care that they want to give. So they're using the extra dollars, but not the way we think that they are.
Judson Howe But aren't we also seeing, and we don't have to put data to this one, but are we emotionally also seeing physicians become almost more like ‘scrip writers referring to specialists more quickly without the extended practice of medicine.
Asaf Bitton I think that's one of the ways in which this kind of dystopia of when you have the sort of the tyranny of the hamster wheel and you're on this hamster wheel trying to do an impossible number of things in a short visit. Some people go the, you know, I'll take down my time so that I can prepare and spend more time with patients or etcetera. Some people go the script and refer. And remember, as the pipeline reduces or the outflow increases in terms of workforce, it only then costs the people staying. Panels are growing because the people need the care.
Judson Howe How big are they getting right now?
Asaf Bitton I can say in our system where we practice in teams, the FTE panel size is about 2,600 people.
Judson Howe Okay, that's up from what?
Asaf Bitton A few years ago, before team-based care, we had people with panels per FTE, 1,500, 1,800. Now, you should be able to take care of more people with a team. But we did a study with just Medicare beneficiaries. The average PCP, just for their 15 or 20% Medicare beneficiaries in their panel, interacts with over 150 specialists. That's just for Medicare.
Judson Howe 150 specialists? Different specialties, or different people and specialties?
Asaf Bitton Different people and specialties. So you think about the sort of cognitive load you're asking people, when every chart for your patients is cc’ed to you, for every specialty visit, when every hospitalization, when you have to track their chronic disease and their preventive kind of, it becomes a massive information chaos that is alone not tenable. And so what you see people doing, which is a rational decision to say, pay me more, but they want to use the money to build teams to help share the care. What you're seeing is people taking down their time so that they don't practice as much so they can do more or taking down their practice panels, which is direct primary care, which is that membership model or a version of it, which is concierge, where people — and we know folks here — used to have a panel of 2, 000 patients. They say I'm tired, I want to take care of 300 people because I know how to be their doctor. To make the economics work, I want off the treadmill, so I'm going to charge whoever can pay $5,000, $10,000, it goes up to I've seen $50,000 a year. Now, people do that because they want to practice in a way that they went into primary care. Again, this relationship focus, time, the ability to sit and be with a person, not to waste time, but to figure out, yes they might have come in for belly pain, but what's behind that? Is it an abdominal organ dysfunction or are they depressed or are they abused or what's the story? It all takes time, and I think this is sort of looking from the hourglass of primary care outwards to all healthcare. Healthcare workers want time. They want time with their patients, and the system has become so chaotic and complex that it depersonalizes the relationship because there's such a constraint on time. And so much of the work that we've done in trying to build payment models for primary care, it's to build the space for relationship to happen or the work at Ariadne, you build communication models or you build sort of palliative care models that allow people to recenter and get back into why did I go into sort of this healing professional together? I didn't come in to sort of just do paperwork and to be a typist like while we're sitting in the chart doing that or to move messages around late at night or to see 40 people in an ER or to do 10 surgeries in a day. I, as a healthcare worker, nurse, doctor, whatever, came in to — if you're a spiritual person — to enter a sacred space between people, where people come to you at their most vulnerable or at their most needy, and you say, I'm not here to fix you. I'm not even here to help you. I'm here to serve you. I'm here to walk with you. This is a frame from a mentor of mine, Rachel Naomi Remen. She said, a true healer isn't here to sort of — if I say I'm here to fix you, then I assume you're broken. If I say I'm here to help you, then I assume that I'm better than you. But if I'm here to serve you, we're going to walk together and figure this out. That's what people want in healthcare.
Judson Howe So that resonates with me, Asaf. But I've also heard, the classic specialist, let's take an EP, say enough of the kumbaya medicine. What would you say to a colleague, specialist that said enough?
Asaf Bitton No, listen, I would say that when I send somebody with a dangerous arrhythmia to an electrophysiologist, I want them to be locked in, technically astute, respectful of the patient and how scared they probably are, and do a dang good procedure to hopefully fix that issue. And same with many of our procedural colleagues. And that's what patients say. send me to a colonoscopist and she'll do the best job for that issue. But so much of medicine and so much of if you look at the patient experience surveys and why people are so pissed off, they know that in the technical procedural brokering or when they're in the ICU, they want safety, respect, technical proficiency, and get out of there as fast as possible. But in the rest of medicine and healthcare, they want to be seen, they want to be known, they want someone to walk with them, to give them choices, to help them make a choice that's aligned with who they are. And I push back ferociously to any of our colleagues who say, well, that's soft stuff. I say, your hard stuff and soft stuff. You're asking the wrong questions, my friends. Your reason why — we know this from surgery literature, work that some of our surgical teams did. You can predict the risk of surgical errors by putting a camera on a preoperative patient visit and measuring the communication quality of that conversation. You could even predict the risk of a surgical error or malpractice if you turn the volume off on the camera and just by the quality of observable non-visit-based communication — eye contact, listening, who, how much, who talked, length of conversation — you can predict that on the basis of communication. So when people say — not that you were saying — but when people say that's soft stuff, but I'm interested in the real stuff, they actually need to look at the reality of the literature a bit more.
Bruce Finke And you were talking about incentives and we started this stream of conversation with incentives. And we were talking about incentives as money. And what Assaf's talking about is a different kind of incentive. So if we want to increase access to primary care, we want to increase the pipeline into primary care and decrease the outflow from it from people who retire early, give up, cut back because they can't manage a full-time schedule. What primary care folks want is that time and space for that relationship. And that's what patients tell us also. So in that way, we're aligned.
Judson Howe You mentioned Deming earlier, which I think his classic line was every system is designed to get exactly what it gets. Is that the general gist? And so I guess we're getting it. We're getting what we designed. And I think in healthcare, I've heard this throughout my entire time in healthcare, which is we can't fix it. We've tried that before. And so I think of something, somebody like Donella Meadows, and she talks about these leverage points in systems. So I can't imagine two better people to ask who helped lead CMMI or Ariadne, what are those leverage points in this big system as the problem broadly defined we just went through? What should we be doing to actually make a difference in this space?
Bruce Finke So I'll start. We've talked about the fact that there's been a lot of work around both efficiency, development of care teams, and a lot of that piece of work is captured beautifully in the National Academy of Science and Medicine report on primary care that Asaf was involved in a few years ago. It really captures that work. That work is really important. That efficiency at a system level. That's like critical. Again, that enables the relationship. We probably need to look at the problem additionally from a different direction. Because whenever you run out of solutions, it's time to turn the problem around a little bit.
Judson Howe Reframe it.
Bruce Finke. Reframe it. Exactly. One of the ways to reframe it is to look from the relationship out.
Judson Howe You’re saying from inside?
Bruce Finke From inside the relationship.
Judson Howe And potentially also from the outside in, but we've started to —
Bruce Finke We’ve gotten a lot of outside-in in the work a lot of folks have done around thinking about whole health, whole person care, in the work that patients have done, that the patient advocacy community has done to say, what is it that patients want, what people want and care, to look at redesign from that perspective out? And that's a critical leverage point. And it's about creating time and sort of mental space for relationship.
Judson Howe What is mental space?
Bruce Finke Mental space means that you're not as much worried about are you applying the right diagnosis for a code as are you naming the condition in a way that helps the patient move forward? Are you able to sit down — so there's two ways to walk into an exam room. You can open the door and say, so I heard you're having some problems with your knee.
Judson Howe Kind of like you were saying, there's a problem with you, and I've heard about it.
Bruce Finke Right away, you signal to the patient, we're narrowing the conversation down to a problem, and then you're going to head out the door and I'm going to go on to the next one.
Judson Howe And this is biomedical science.
Bruce Finke Or you can walk into the room and say, I'm Dr. Fink, Bruce Fink. It's really good to meet you. You know, what brought you in today? And that's just one way of doing it. I've been working a lot with folks with dementia, with Alzheimer's. And it's striking the degree to which walking in, talking to the person who's living with dementia, introducing myself —
Judson Howe The person experiencing it?
Bruce Finke The person who's living with it, who's experiencing it. They're both living with it. But often talking to the person who's living with dementia, introducing myself, looking at them, having them look at me, and then having them introduce the person with them and start the conversation that way opens up. That right away makes it a different conversation. So that's about opening up space. And communicating that this conversation is something more than about addressing a set of problems. It's about addressing you and what you need. And I, you know, that's another leverage point.
Judson Howe. Yeah. What are your thoughts on it?
Asaf Bitton You know, I can almost sense a little bit that like from an executive or financial perspective, it can be hard or maybe hard for some of the listeners to sort of be like, you know, these primary care folks, they're talking about nice things, but I'm bottom line. I'm trying to make a next two —
Judson Howe I’ve got 340B cuts coming in January. I've got work requirements. I've got a budget to close this.
Asaf Bitton Totally. Yeah. And I have patients to see next week. And I have messages that are building in my inbox right now. And public health and healthcare improvement organization that is waiting for us to come back. And we can play the game. We can play the game of I can make your inbox more efficient. I can get your 340B waiver done a little faster. I can get your length of stay 0.2 days down. I can even maybe dip your toes in the water of value-based care.
Judson Howe Hire me. Come do it.
Asaf Bitton Right. So we're nibbling on the edges. If we're having a conversation, as I think we are, and I think we need to, about reframing healthcare, rethinking it, I'm not interested in nibbling. I'm not interested in what high-paid consultants can tell you. That's the easy stuff. I'm interested in asking the biggest questions. So it's trite to say we basically built a sick care system, not a healthcare system. That’s true.
Judson Howe Why is that trite?
Asaf Bitton Because that we need to pull that string and what do we actually mean? Well, what we mean is that every time we try to have a conversation on the fundamentals, on what we're willing to spend $5.2 trillion as a society on, you get so far into this conversation and say, but, yeah, but then you guys are talking about things that are just squishy or too impossible or and we can just label it as we're good at sick care and we're not good at healthcare. And I would say, okay, but like that's just the start of the conversation. The conversation goes like this. We're actually not that different from every other OECD country. We're all willing to spend the same combined amount on health and social care. The difference between us and France, and us and the UK, or whatever OECD you want, is that they spend two-thirds of that health and social budget on social care, social welfare, the dementia supports, better food in the community, environmental stuff, and then one-third on healthcare. We've deluded ourselves that we can produce health by building beautiful glassy hospitals, by optimizing 340B and length of stay. You've already lost the game. When we get to you in the hospital, we've already lost the health promotion and population game because you can only nibble at the edges. It's really important to have acute care hospitals and specialists who technically do really good technical things. But I hear you asking, how is it that we're spending five and a half trillion and have a life expectancy that's falling and we're 38 out of 38 on OECD and we can go on and on. And then, and then anytime someone says, well, we need to just change the frame of the conversation, we're told, yeah, but we have to deal with —. Either we reframe the conversation around, there's an imbalance between what we're willing to build and do. And right now we're willing to build and do acute care systems that work on acute care payment, and outpatient systems that work on historically accidental payment frames that induce absurd behavior, bad outcomes for patients and populations, and a burned out workforce, such that the part of your healthcare system that could most be leveraged to fix the super expensive broken acute care system is being burned out and dissipated and seen as basically a charity case worthy of 4% of the healthcare dollar. Instead, we're trying to fix healthcare from the rubric of the expensive, monolith of acute care health care systems that know one thing: how to fill beds, fill ORs, fill EP suites, fill colonoscopy suites. And I think what we're saying is the real reframe is to invert the pyramid. You want a good health care system, you spend more on primary health care, you spend more outside of the clinic and the walls of the hospital, but that requires, yes, you to solve what you do next Tuesday with your acute care system, but it requires the decentralization, the decentralization of the primacy of acute care and specialty care in the US. And nobody wants to talk about that because, oh, don't get into the specialty-primary care wars. But we have to actually have that discussion because the US becomes the US healthcare system when we can spend the type of money that allows the kind of money flow into specialty care and then sees primary care as a charity.
Judson Howe So I mentioned Donella Meadows and she wrote a lot about systems thinking and the thing that impacted me the most was her leverage points. But I think you just called it out, which is we can spend all of our time on the lower leverage points, the parameters of healthcare, which is where people like myself, CFOs, recovering CFOs, we're tinkering with the parameters. We're changing the valve flows. And I hear what you're saying is change the goals of the system.
Bruce Finke Correct.
Judson Howe Or challenge the paradigm.
Asaf Bitton We're playing the wrong game.
Bruce Finke And we've seen that tested actually from the CMS Innovation Center, right? Their models, the Maryland model, put a cap on Medicare spend and then with it and then increased spend in primary care through the Maryland primary care model. And then there's an entity within Maryland that sets rates and sort of within the cap on Medicare spend, figures out how to distribute that cap.
Asaf Bitton And redistribute. That's the word. Redistribute our focus, money, time, and what we privilege and what we hold high. And unless you get into this redistribution game and, you know, you go to a doctors meeting and the big thing to not say is redistribution.
Judson Howe Well, I was going to say, Biden intentionally used the term pre-investment, right? Because that word is so heavy.
Asaf Bitton You see this in the Medicare fee schedule, which is like the fee schedule that most other payers then use on paying codes. And this year, you know, there's what's called an efficiency adjustment. For the first time ever, Medicare is proposing to take these mainly technical procedural codes and put a 2.5% reduction on their value year by year but not put that reduction on primary care codes. And you would think from some of the discussion and the specialties that this essential redistribution is like the end of the world as we know it. And I understand people will fight for their cheese and they'll fight for their own interests, but we as a healthcare community, and there are so many thought leaders who, they sit around and they tell you it's just all about rebalancing the deck chairs on a sinking ship. No, we need a new ship. And unless you figure out how to jump to that new ship, we're just all kind of quietly going down.
Judson Howe So that's a really good point, because are we trying to steer this ship, or do we truly build a new canoe? Maybe start with a canoe?
Bruce Finke We're building it while we're steering it. I don't know what is the right analogy, but Asaf and I have been in a number of discussions and almost always someone says, we just need to start over.
Judson Howe Yeah. What would that look like?
Bruce Finke You don't.
Judson Howe That’s the DOGE method.
Asaf Bitton You don't start over. That's the VC mentality of great startup companies that, you know, in primary care, we don’t need to name them, but there have been a bunch of great startups. Their famous founders have said, it's time to just blow up the system. We'll get a new fund flow. We'll get the money and we'll do it a different way. And you can create great innovation insights from that. But not at scale. So you actually have to fix the ship.
Bruce Finke You have to fix it while you're in it. You just, I mean, that's what we're doing. So it's not a small change. It's a big change, but it happens a piece at a time.
Judson Howe But I feel, no, I don't feel. Well, maybe I do feel. We've been talking about this for 40 years, right? We talk about, you know, the Dartmouth Atlas came out, what, 40 years ago? 35 years ago?
Asaf Bitton 35 years ago.
Judson Howe Talking about care variation, price variation. We're worse now than we were in the 90s. I'm forgetting the professor's name right now. Wes Jeff. It doesn't matter. We'll skip that. And I did ask him, I did interview Elliott. You spent your entire career on this and yet we've moved backwards. So how do we, in our moral responsibility as leaders in healthcare today, make sure that in five years we can look back and say something's better?
Bruce Finke We do that by learning from what we're doing. From what we've done. So one thing we've talked about is the drive for efficiency, the drive to actually pull cost out, if you will, of primary care or make primary care do more for the same dollar.
Judson Howe Why don't we put more cost into primary care?
Bruce Finke Right, well, the drive over the last 25 years has not been to put more money in, right? It's been to make care more efficient and ask primary care to do more.
Asaf Bitton For every dollar input, primary care is the only part of an improvement system that's been asked to show a nearly immediate ROI on the new dollars in. So that's what never does that happen for the new PET scanner or the new oncology suite. You know that from Europe.
Bruce Finke That's what we've been doing, right? And what's it led to, it's led to a degradation of the workforce, not the quality of the workforce, but the numbers. Fewer folks coming in, more people leaving or cutting back time. That's a 25-year experience. So we can say, well, we failed. Or we can say, we learned.
Judson Howe What did we learn?
Bruce Finke And what we should have learned, what we need to learn —
Asaf Bitton And what we did learn.
Bruce Finke Is that that kind of efficiency, while important, isn't enough. That one has to value what happens in primary care. That that has to have a value in the system. If you start with the place that says primary care is the essential part of our system, and this gets into geriatrics again, right? Where do most older folks get their care? They get their care in primary care. We're not going to improve geriatric care in America through more geriatricians. Geriatricians have an incredible and important role to play. We're going to improve geriatric care in the United States when primary care has the ability to provide better geriatric care. We have to start with the assumption that the solution is through primary care and then we start to think about the design from that perspective.
Judson Howe Your field is geriatrics, right? But you could say that for almost the entire continuum. But yet HMOs made primary care the gatekeepers and that’s almost part of why we got here.
Asaf Bitton They made some central errors, a) that primary care would become gatekeeper, barrier, border guard, cost control center. By the way, the UK made the same mistake when they said, well — they saw the logic, they said, we'll give primary care trust, these primary care little ACOs, essentially all the money, and they can dole it out. So then they neither had the financial wherewithal nor the sort of hustle and bustle to sort of throw elbows and be in charge of their other specialty colleagues. The point is, as Bruce said —. So I want to challenge one thing. A learning frame asks us to ask questions about what we know and how we know it. And if we do that around primary care, which I think we're making the argument as one of the central leverage points to change all of healthcare, primary care as a way of doing healthcare, as a focus and site of healthcare, as a sort of rejection of sick care, transactional, factory-based, in and out, expensive, error-filled care. What we have learned in the last 10 years has not been abject failure. While the workforce issues in primary care are getting worse, what we are learning is that when you start by reframing the business model, the business model is not about a unit of service that's paid for by visit, but rather needs to move to a risk-adjusted amount per person to be paid to primary care prospectively to take care of that person and their needs over a year. And that shift toward this kind of hybrid and prospective payment is actually happening. When we started some of the work as senior advisors at the CMS Innovation Center, we asked a fundamental question, which is, well, can Medicare capitate or partially capitate primary care?
Judson Howe Did they do it?
Asaf Bitton And the answer was, well, it can't be done.
Judson Howe That was the rote answer, you mean?
Asaf Bitton It was the rote answer. So we said, well, is it in statute, like in the original statute? Long story short, a year or two into this conversation, it turns out it's not that it's in law or needs an act of Congress or anything, it's just it hadn't been done. And there's some important and kind of time-consuming reprogramming of the claims-based system, which is retrospective, that needs to be done. But by the model that we both worked on called the Comprehensive Primary Care Plus model. And so for the first time, capitating part, for practices that were ready to receive, they were receiving Medicare partially capitated payments to care for those patients over a year. And then the next model, Primary Care First, it's a fully capitated model. So what was just undreamable and can't happen and there's probably a statute is now possible. Now, did those models, were they the home run and allowed CMMI to scale through the legislature? No, they didn't meet their —
Judson Howe Why?
Asaf Bitton Well, part of it is that the frame of the task at hand is written in the ACA. It was understood that a scalable model is one that both improves outcomes and at the same time decreases costs.
Judson Howe You have to do both. You have to do both to qualify for this classification.
Asaf Bitton And the designation is that if they do that, then the actuary certifies them, they take it to the head of CMS, the Secretary of HHS, and he or she without consulting Congress, can just say this is a model that all beneficiaries in Medicare should have, and then by virtue other payers will follow. So let's get back to our earlier question, which is, is meaningful third-party evaluation, statistically significant outcome improvement, plus cost reduction within a couple of years, both a realistic target, and the right target for a field that's essentially been parched as a desert in terms of resources. You put in a little bit of drip irrigation and you want in a year a bumper crop? I mean, I'm asking it reflexively, but I think you know —
Judson Howe I will say yes. I mean, why not right away?
Asaf Bitton Why not? Because these are teams, as Bruce was saying, that were operating — I mean, the first model that we built together with colleagues less than half of the clinics had a working budget annually that they could show us so that we could understand how will you use these new payments? Do you have a budget? And only half of them said that they did.
Bruce Finke Also some of the changes that happen that this kind of care allows to happen, it takes time. If someone stops smoking now, you don't necessarily save money in the next year, right? You save money over the next decade, two decades, three decades. So part of it is timeframe. You know, primary care is a long game. It's about investing in the individual. It's about valuing the individual in front of you, investing in them, and investing in the relationship that you have with them so that they can live the best life possible. The life that they want to live. And that pays off, that can pay off for a health system over time. And when we see mortality rates in the US increase and we see life expectancy decreasing, that's a failure of our system over time. That's not a single, there's not a single point of failure.
Judson Howe I'm almost hearing us say we're putting too much on primary care. Primary care is a powerful leverage point to reduce. But we're asking you to fix the churches and the community structures and the social groups and the neighborhoods.
Asaf Bitton And the broken workforce and the, you know —
Judson Howe We’re going to use primary care to fix society.
Asaf Bitton So, and that's a hard problem.
Judson Howe When health is a society issue.
Asaf Bitton And that's what Tressie McMillan Cottom calls a thick problem. So there's layers to that. It's complex. It's not an overnight solution. We're trying to have a conversation about thick problems with thin solutions. I'll pay you differently. I'll give you $100 per month to do differently, but I want better outcomes and I want lower costs. The whole idea was over the last decade, the reason to invest in primary care is because we'll do site of care switching. We're going to drain your ERs and some of your hospital admissions because they're preventable and that preventable admission will pay for the investment in primary care. Well, the truth of the matter is that to do that takes at least five years, except in high-risk, kind of hot spotting groups. And even then, you have to invest a lot in primary care to get a lot. So there's probably a cost neutral investment. The real gains that we see in systems like Nuka, Kaiser Permanente, parts of IHS, where you invest in primary care over a decade, you get the kind of population level and fiscal impacts. If you look at the countries in Europe, if you look at middle income countries like Costa Rica — we've done a lot of work in Costa Rica at Ariadne really working with them to understand how does this little country of barely 5 million people that spends about $950 per person per year on healthcare — we spend about $13,500 — and they have a higher life expectancy, better chronic disease outcomes, better preventive care. And so how are they doing it? And the answer is that they're doing it because they went through this decision process 30 years ago — 30 years ago! — where they said, we can invest our budgets in either building hospitals in big cities and acute care and better specialty care, or we can essentially build out teams where each team, doctor, nurse, pharmacists, and a couple of community health workers is responsible for about 5,000 people. They're going to see every family, either at their home or in the clinic every year. They're going to collect information on their healthcare needs and their social care needs. They're going to integrate it into a central record. They're going to do proactive outreach. They're going to do acute care follow-up. And they're going to take care of all of that in an information system that works and they're going to integrate public health and medical care functions into these teams. And what happens? Those kind of outcomes for 10% of our costs per year. Is Costa Rica replicable tomorrow? No. But there are aspects of Costa Rica that you see in the highest performing systems in the US that we would do well to ask questions on how we flip the questions.
Judson Howe It reminds me, I had a conversation with a CMO of a large system. And I was an employee or a leader in the system at the time. And I had a very similar conversation. I was talking about Haiti and Paul Farmer. And I think I used the country of Chad as an example of some of these care team models. And I think I actually said Uganda. And he's like, are you kidding me that we're using Uganda to compare it to our healthcare system? And I said, absolutely.
Asaf Bitton We should absolutely do that. And Rwanda.
Judson Howe We have to flatten that hubris right now if we're going to actually really make inroads in this space.
Bruce Finke The current system hasn't always existed. It's really about a 30 year development to get us where we are in the US. I mean, 30 years ago, dermatologists and internists made roughly the same amount of money. Cardiologists and internists. It's been the evolution over time, over the last 30 to 40 years of this system. So we can't expect it to turn around instantly. But we also can't expect it to change unless we start changing things now.
Judson Howe Is healthcare a — I don't know the right language to use — is it a self-created problem or are we in healthcare a symptom of the broader society, like maybe our whole society is being financialized and we are just a byproduct.
Asaf Bitton We all are products of the complex social and ecological systems that we're in. But, when I talk to healthcare executives, when I talk to healthcare teams, government folks, et cetera, the failures in healthcare, the failures in leadership in healthcare, to be frank and direct, are the failures to imagine that it could be different. They are the reflex towards cynicism. They are yes, the financialization of healthcare, but the financialization of healthcare onto short term, low horizon, near term horizon, where again, the cynical take is that nothing can change because it never changed, even though, as Bruce said, actually all this stuff, if you look under the hood is idiosyncratic, fairly recent, totally changeable with a combination of political will, redistribution, and some sacrifice. And I'm not saying political will like on the political spectrum. I'm saying actually here's where there can actually be bipartisan consensus. Like no side of the political aisle wants to keep paying a lot more for crap. The patients who make up the voting electorate are being asked to pay more and more out of pocket for impersonal, unsafe, overly expensive systems that aren't meeting their needs. That's a political liability wherever you sit on the aisle. But the more important thing is I am very impatient and I strongly push back with facts, not emotion, to healthcare leaders who presume to believe the conventional wisdom that they're actually asking the right questions. Or even worse, to sort of say that they come to these conferences and everybody drinks from the cup that runneth over of value-based care, and they say nice things about the slow transition from volume to value, and then do nothing about it because they are afraid to provide the fiscal, moral, and healthcare leadership that might cost them their jobs, yes, but that would actually transform the system because we know what we need to do. It just takes a lot of courage to do it. It's about creating a system that's not just about running up the technical, the procedural, and the capture of all these expensive procedures and hospitalizations. We have, and we are willing as a country, to spend more money than any other country. It isn't a resource question. It's a question of are we willing to tell huge parts of the system, the 35% that Berwick and others have said don't really contribute to the bottom line, are we willing to sort of say you are going to get less. We don't care if you squeak and squawk, you are going to get less because you're not adding to the bottom line. We are going to invest enough but not more than we need in our acute procedural and technical parts of our healthcare system. And we are not going to look at the geriatrics, primary care, pediatrics part of our system as an also ran kind of charity case, basket case. We're going to say it needs to be doubled in five years from five percent spend to 10% spend. If we double that five to 10% and we can get the investments in the best part of our primary health care system, which are community health centers —right now they care for 10%, they could care for 20% of the population and get great outcomes amongst the poorest parts of our communities. And we could create a primary care system that Instead of only retaining 20% of its postgraduates, it can retain 40% because they see a job that they want to do, that's attuned with their values, that they go into medical and nursing school to do, and they see that it's doable.
Judson Howe Make this very tactical for me. So put yourself in the shoes of a green visor-wearing Kansas hospital CFO. No, let's not do Kansas because they're not Medicaid expansion, so they're getting a bonus out of this administration. Bad example. Let's take a Medicaid expansion. Let's take Missouri. You're in a rural hospital in Missouri, and you've got 340B cuts in the millions. You've got work eligibility requirements. Your uninsured is going to go way up. So let's say you're facing a $5 to $10 million gap. You have to close in your budget for December 31. What is the Asaf the CFO doing right now to ready the hospital and the care delivery system for that?
Asaf Bitton The CFO is the wrong person to ask to solve the problem.
Judson Howe Okay, I like that.
Asaf Bitton The question is with Medicaid, the question is with the commercial payers and with Medicare and the state.
Judson Howe But they're the ones going to walk into the primary care office at four in the afternoon saying, you're seven days behind in your charting.
Bruce Finke The question they may want to ask themselves is what's it going to take to keep the primary care workforce we've got? And where can I get a recruiting advantage to bring more primary care in, whether it's docs, NPs, PAs into our system? And is it going to be by increasing the salary by 10 or 20%?
Judson Howe Probably not an option.
Bruce Finke Probably not an option and probably not going to make the difference, right? You've been there.
Judson Howe Or if it was the option, you're going to ask them to see more patients, which I’m hearing you say will exacerbate the issue.
Bruce Finke Exacerbate. So are they willing to take a gamble on saying, we're going to shift from a 15-minute visit to a 30 or a 20, 40, 60 from a 15, 45, take it a little bit at a time.
Asaf Bitton Hire some NPs and PAs to see if we can make this tenable.
Bruce Finke We're going to look at our compensation strategies and start to say — one of the realities, even as we've moved bits of the system into population-based, value-based care, is that that final mile, how are we compensating clinicians? We're doing it based on RVUs. We're going to change the way we compensate. We're going to increase the percentage of compensation that is based on the panel size and decrease the importance of throughput. So changes like that and asking yourself will that bring more folks in? Because if you can build more capacity in primary care, you can do more in primary care.
Asaf Bitton You're asking the right question, perhaps. Yes, the right question of the wrong people. Because you're right. If you said that she's sitting there as the CFO with this reality, that so many of your listeners or so many of these things, so the question first is why do we hold up hospital C-suite leaders as being responsible and being the solution avatars for the entire country. The problem with healthcare starts but doesn't end with payment. You have to change the way that money flows, that money is structured, before you can ask the person in the middle level — which I know we're supposed to think of hospital execs as the highest level — but you're already nearly checkmated in that scenario. I'm not going to give you a trite answer.
Judson Howe That's exactly right.
Asaf Bitton So I'm saying we need to not play the end game on that move. We need to reorient and give you some degrees of freedom where you're not down both rooks and a bishop. I need to give you some bishops back. And that requires that we rewind the game and you didn't make some moves that you did. And that rewinding starts then with Medicare, Medicaid, and the payers, including the employers that are in conduit with the commercial payers, to sort of say, what are you buying? What do you think you're buying? You have a chronic disease crisis, you're sick of buying crap healthcare that's expensive, so why are you paying 95% into the part that's most expensive and then thinking that you're going to get anything different? Why are you mostly still paying a fee for service? Why are you paying for stuff that doesn't work? Salvage chemo and new PET scanners and then sort of saying that things like good geriatrics care, good palliative care, good primary care, good pediatrics — which makes no money, it's a loss leader. Why aren't you investing in that? So Medicaid, you take care in a kid's lifespan, you take care of about 50% of the kids at some point in their childhood in this country. You need to tell me that you really think that you can pay for that, those crumbs to take care of our kids. Medicare is willing to just hemorrhage money in certain acute care cases but then give laughable small amounts of money to rural hospitals or to primary care. Invest in different ways of paying. And I'm not saying just value-based care. Invest in hospital at home. Invest in ways of reframing. We just finished an RCT, a randomized controlled trial, on applying the urban home hospital models to super rural areas. Well, it's going to come out, but I'm telling you, let's just say I'm telling you about it now because it probably has some very interesting findings that are coming out soon. And so rural community hospitals can do this without totally depressing their census counts. They need, point being, my long-winded way of explaining is I need to give you some rooks and some couple pawns and maybe your knight back to have a fair fight here. You need to give those pawns and knights back to primary care to have a fair fight. And so the person who you're giving back from, well, they might be a procedural subspecialist or a very wealthy hospital in a big city that might not be super happy with that, but that's what it's going to take.
Judson Howe I mean, I 100% agree that hospital leaders are middlemen. But I can tell you that it doesn't feel that way when the community is hammering you, when to every primary care doc in the nation, the hospital president is the root of all evil, right? In my experience, and partly well-deserved, right? But partly it's because the relationship hasn't been built, the vernacular is not the same. I actually really agree with what you're saying, and without going into my story, like what if we changed that leverage point to what would it take to retain you? And use retention as the recruiting tool, because if I can keep Dr. Bruce, then Dr. Bruce probably has a few friends that would want to come hang out. And you're right, I will say that's one of the most powerful tools that I have found in middle America.
Asaf Bitton And part of it is like from the quality, and you said this earlier Bruce, from the perspective of what do we know from good learning health systems, what does a really good leader do? She, when faced with a crisis, goes out and talks to a bunch of people. She goes and talks to her primary care workforce and says like, what's the matter here? What's the problem? What game are you playing? What problem are you trying to solve for? Not what can I sit here in my office in three months?
Judson Howe You’re right. There is a common assumption that these overpaid primary care doctors are lazy. There's an assumption that it's pervasive.
Asaf Bitton And if you give them more money they're going to play golf on Wednesdays.
Judson Howe And there's also this very challenging stigma among especially family medicine, but a little bit with internal medicine, that it's not the cream of the crop. And yet you've got the Bruces, you've got the Paul Farmers, you've got the humanitarian and that world and beyond that has choosing that specialty.
Bruce Finke Do you know who doesn't believe that fallacy?
Judson Howe Who doesn't?
Bruce Finke Patients.
Judson Howe That's a really good point.
Bruce Finke They come in and they're —
Judson Howe Well, many of them don't know their specialties. There's a doctor and that's what they're looking for.
Bruce Finke They're looking for someone to be on their side. And who's going to be there with them? Asaf, you used the term accompaniment. They're looking for that.
Judson Howe Wait, wasn't that Paul Farmer's term.
Asaf Bitton Totally Paul Farmer. Paul used to say when I would round with him in the hospital that I may be an infectious disease doc, but actually I’m a primary care doc.
Bruce Finke They know what they're looking for.
Judson Howe And you say they're looking for a relationship.
Bruce Finke They're looking for a relationship in which, and it's a relationship of mutuality. It's a relationship in which each person brings something. And what we can bring on a clinical side, we have power, right? We have the power of the knowledge we have. That's not a power to use, that's a power to put at the service of the patient in front of us. And that's what they're looking for. They're looking for somebody who has some power, and in our case, the power is knowledge. The power is access to the tools of the system. And they're looking for someone who's going to bring that to them. That requires that we know who they are, that we know what's important to them. And then that builds a sense of trust. Guess what? When you have trust, by the way, you have better utilization, right?
Judson Howe I just learned the other day that mistrust is one of the unwritten social determinants of health.
Asaf Bitton Totally.
Bruce Finke And it drives waste, it drives excess utilization. It's what drives people to say, maybe I need one more test because I don't know if somebody really knows what's going on with me. When you operate in a primary care relationship out of trust, and it takes some time, but you can build, it's remarkable how generous folks are in giving you trust.
Asaf Bitton And think about the societal goals that healthcare system planners, that business executives, community leaders, patients themselves want. They want help addressing the chronic disease crisis. They want help with substance abuse treatment. They want help with vaccine information. In any study on trust, the top two, one, two kind of positions are primary care physicians and other clinicians. They are the people who patients are going to. I see this in my practice all the time. I have many people who are vaccine hesitant, many people from all over the political spectrum. Should I do this? You know, and do they always listen? No. But can they have a conversation to be brokered in a way that they feel seen? And does that often help them make a decision that's more attuned with what they want to do, that's good for their health? Yes. And that's this, you know, we started the conversation about hard and soft skills. And the funny thing about all those hard skills, again, zap my heart really well when it needs to be zapped. I want you to be the best at it. But most of the time, it's not about heart zapping. It's about helping a person make an incremental change a little bit better today, tomorrow, the next day, that'll keep them out of the EP suite. And who does that? A person in primary care who can broker a longitudinal, trusted relationship. They're like right down the street, there's a famous bar called Cheers, right? And what's the old tagline where everyone knows your name? People want to go where they’re known.
Judson Howe Why don’t we make that Mass General's motto?
Asaf Bitton That would be a great question for the Mass General leaders. Mass General Brigham leaders. And in fact, one might say after their recent vote of the primary care docs to unionize, I don't think it was an accident that in the midst of that discussion came an announcement of a five-year, $400 million investment in primary care.
Judson Howe I'm going to pivot to establishing your credibility, because I should have done that at the beginning, I'm going to pivot to that now as we wrap up. So Dr. Asaf Bitton, Executive Director of Ariadne Labs. Tell me what were the emotional and economic scenarios of your childhood, of your dinner table? Tell me about who you are. Let me make that one again. What were the emotional and economic conditions of the home that you grew up in and how did that shape who you are today?
Asaf Bitton I grew up across cultures and across countries and states. I was born in a small farming community. It's called a kibbutz in southern Israel, of pretty modest means, and kibbutz where everything was sort of shared communally in a very desert community. My mother's American, my dad is originally Moroccan, Moroccan Israeli. And so, my life was a series of conversations across cultures and languages. I came to the US as a kid, moved to Texas and then to Minnesota. I think I would call the conversations at the dinner table sort of bi- or trilingual conversations across cultures, across communities, across continents. And I guess the extent to which that impacts and informs my work today, I have a particular interest and affinity to try to hear people's stories and try to understand their journeys, especially people who've moved a lot and come from a lot of different cultures. Because I know the feeling of being a kid in a classroom where English was my second language, being totally unaware of what these people were babbling. I know the feeling of being an immigrant to the country and my experience as an immigrant, and the feeling of really understanding that there are multiple ways of looking at the world. There are multiple truths that can be true at the same time.
Judson Howe Two things that we can hold in tension as opposing ideas. You're a public figure. You've been with CMMI. Yeah. You're friends with some of the more prominent voices in American Healthcare. I imagine you've developed a mask over time and a script. If you were to pull that down, who are you really? What are you most concerned about?
Asaf Bitton I have to say, and I say this honestly, I really don't feel that I have a mask or I'm putting on a performance. I see any credibility, any useful leadership that I have is deriving from a layer and a level of authenticity and directness and being able to be in conversation with people in power, with people who have no power. Many of my patients have very little agency and power in their lives with people who I work with across the spectrum of education and seniority. Look, I get it from my days as a camp counselor, which I would submit to you as one of the greats, as a teenager to be a counselor for a bunch of rascally boys and you're kind of entrusted with their lives and got to figure out this issue that I would call or that was called to us as being on stage, that people are always watching what you do when you're in a position of leadership. And I've also learned from a lot of good leaders, and perhaps leaders that I haven't found to be super skilled, that authenticity and approachability and the remembrance that maybe my primary care training teaches me is that we're all humans that kind of look the same and act the same when we're in an exam room, have the same bodily functions. I'm not particularly swayed or cowed by famous people or not famous people. I see a certain leveling here so that then translates into an intention, probably imperfect, of the way that I would hope I come across as a leader is quite similar to the way that I would hope I come across in my house, to my kids, to my friends. You'd have to ask them as to the veracity of that inference, but that I didn't feel, especially when I did more public work at Ariadne, that it was like time to sort of put on the cape or the mask and then take it off. I think actually showing vulnerability is really important.
Judson Howe What was your darkest moment in the last three or four years as a leader?
Asaf Bitton I think it's a shared moment with a lot of clinicians around. I felt, and just by virtue of having, you know, being in public health and epidemiological circles, it was pretty clear that this COVID thing was coming. And I felt, and many of us did, so I'm not taking any particular credit, I remember days in early February of 2020 counting in our clinic — it takes care about 10,000 people in Boston — counting the number of N95 masks we had. We have about 45 staff members, clinicians, et cetera. We had, I think I remember, 42 N95s. That was an oblique moment. I mean, it was clear to me that this was going to happen and we weren't ready. And we, luckily, we had a wonderful clinic director who managed to find us some N95s because our clinic, of the 17 in the Brigham network, our clinic was one of the two that stayed open the whole time, with our sister clinic down the street. One was the respiratory clinic. It was essentially an ambulatory ER for obvious COVID cases. And we were the non-respiratory acute ambulatory ER with lots of people with COVID and acute appendicitis and all sorts of crazy things. And that process of realizing that the storm is gathering and coming, and 42 N95s, and we have no other real PPE. I mean, that was a shared experience across primary care in the US. In fact, the statistics that I'm familiar with of all healthcare workers, only people in the ER and ICUs had comparable mortality rates to primary care clinicians and staff, almost certainly because of the PPE shortages. And the first contact that primary care offers for so many things.
Judson Howe Same thing for you, Dr. Bruce Fink, also from Ariadne and a family medicine physician in Western Massachusetts. But take me to your dinner table as a child and paint that picture for me.
Bruce Finke My mother was a teacher and taught primary grades. And that commitment to that group of kids every year, and I watched her in that classroom and I knew she was caring for them the way she cared for me, I think that was a huge influence. And then I had the gift of having grandparents live with us for parts of their lives. And I think it's a real richness to live — it can be challenging — but it's a real beauty and a real richness to live with older folks and grandparents as they age. Those were both sort of elements that formed me.
Judson Howe When was the moment that you're like, I want to go into being a physician, and also why family medicine?
Bruce Finke So relatively late for me in terms of medicine. I decided to go into medicine in a tentative way. I said, if I don't like what I'm doing, I'll go do something else afterwards. And I just actually liked it. So I stayed in it. And I think I always knew for me, medicine was about people. And it felt like primary care was about people. I remember, this is a little later, but working in an ER and had a person come in quite ill with a very high sodium and called the nephrologist who came in. And I was young in my training and oh, that the highest sodium I've ever seen in someone who was alive. I was just amazed. And the nephrologist came in and he was kind of bored. He'd seen it before. He did a great job, took care of that guy. And I thought, you know, I can see that. At some point, as a specialist, you're going to see what you're going to see. And if it's about the numbers or about the technical aspects of care, you're hopefully going to master, you're going to get some level of mastery. If it's about the people, everybody's going to be different. It's going to be different every time. And that's what drew me into primary care. The idea that every time someone's in front of me, there's someone else. There's someone new. There's a new person to meet and a new story to hear.
Judson Howe What is your proudest moment in your tenured career of serving family medicine?
Bruce Finke You know, it's not a single moment. I've done a lot of administrative work and it has a lot of program level work. We talked about the Innovation Center, work at IHS, leadership work. All of that's really important and you can kind of, you hope to be able to make change at scale. But it takes time. There's very few true victories, even if you're moving the ball down the field. Every time a patient walks out of a room feeling better than they walked in, even if they don't physically feel better, but they feel more at peace, more confident, they feel like they're on the right direction. That's like an immediate jolt of reward. And that's, I think, why the focus on relationship feels so important. Because some of what makes that patient feel better is that they have confidence in me from a technical standpoint, that I'm going to make good decisions, and that I'm going to explain those decisions in a way they understand, and that collectively we'll make good decisions together and that we'll choose a path that is good for them. But a lot of that makes what makes them feel better walking out of the room is all the stuff that goes around the technical piece, the ability to communicate intent, that I'm there for them and we're going to do what we need to do.
Judson Howe So if Robert F. Kennedy Jr. called you tomorrow and said, Bruce, the things we're trying isn't working. I'm under a lot of pressure with the biomedical community. What should I do to improve healthcare in America? What would your advice be?
Bruce Finke So I'm just going to say it's not what a single person does. And there isn't a single thing to do. So we've had a really rich discussion about things that can be done, leverage points. And I think that your use of the term leverage points, I think that's right. That's a really good way to think about a system is, where can we make a difference so that we're making maybe a small difference on that leverage point, but it's a huge difference in the system of care. And it's not amenable to a single decision or a single individual. It's something we all have to own and be part of. So that's not a good answer. That's not the answer to your question. That's the best answer I can come up with.
Asaf Bitton But I wonder, so much of what we've tried to do at Ariadne has been to sort of say, okay, there are a set of definable, important, population relevant problems in healthcare where there's a clear know-do gap and that's no with a K. We know what should happen, evidence is there, consensus is there. What does happen is because of the many opportunities for failure in the healthcare system. So instead of dwell on the failures or dwell on the evidence is here, just do it. That's an old model of quality improvement or just pay somebody a little a little more to do it. That's the pay for performance model. The system change model says, why don't we create a system in which it becomes easier for most people, not for the heroes in healthcare, but for most people in healthcare who are just trying to do the right thing, take care of their patients, let's make it easier for them to do the right thing more of the time. What would it look like to do that? So, you know, you start with a surgical checklist that's really, yes, these are 17 things that should happen before every surgery, but it's actually masked and it's an opportunity for teams that come together and reform and unform and reform again around really dangerous things in healthcare to have a platform for communication. And then you have something like the work that we've done in serious illness care, which is you say, gosh, there are these incredible specialists in the healthcare system called palliative care docs and they do something magical. They walk into somebody's room and they don't even know them. They're often called at these crisis moments in time, and they help families, patients, the healthcare system make better decisions. What would it take? We can't produce enough of them, just like we can't produce enough geriatricians. But what would it take to boil down the essence of palliative care? Make it a trainable entrustable a possible structure of communication, not a checklist, but a way of being and knowing and working. And could that actually happen? Fast forward seven years, you cycle that, you do a lot of human-centered design, you work with patients, clinicians, oncologists, et cetera, and you build an approach to approaching these serious illness crisis moments that elevates not just what matters a lot to the patient, but in a way that you can train a fellow clinician in two hours elevates critical questions about, so tell me what matters most to you as you're sick right now, but also what are your hopes and fears? What are the trade-offs that you're willing to make to achieve what matters most? And how does that then inform what we do together as a respectful dyad? And fast forward that later, or after randomized controlled trials that show that this approach, this training, reduces anxiety and depression by 52% at the end of people's lives with late-stage cancer, an impact that you can't get with any meds. And you sort of say, huh, well, if we can do it for serious illness care and now there are 300,000 clinicians trained all over the country in this model, can we then do it for something like dementia and geriatrics where you say — so this is an answer to like, what would I tell healthcare leaders? What could you do differently? Could we reframe the conversation about this coming silver tsunami of people with dementia around who's going to take care of them? It's primary care. We don't have enough geriatricians. What can we boil down the essence of geriatrics, palliative care, and the tacit knowledge of primary care who sees most of these folks and ask a very simple question, which is how can we make it easier in the chaos and maelstrom of primary care to approach the difficulty of the conversations around asking about cognitive status, diagnosing dementia, disclosing that diagnosis, making it clear you're on the journey with those patients, that you'll be able to offer them your accompaniment and a variety of community supports, maybe med treatments, maybe not. What would it take to reframe the conversation of dementia away from what neurologists say and what neurology guidelines tell, you know, screen, screen, screen and refer, and more to how do we make it easier for primary care to be primary care, to be the primary care they need to be for their patients with dementia? And how will that help us approach this coming wave of patients with it? That's the kind of work, that's the kind of reframing, often through communication and reframing the questions as opposed to efficiency throughputs or management methods. We're giving clinicians at the frontline tools to better be in relationship with their patients as they go through hard things.
Judson Howe I've been really moved by this conversation and I want to thank you, Dr. Bruce Fink. And you, Dr. Asaf Bitton, and what Ariadne Group is doing. Thank you so much for your time today. I really appreciate it.