I really agree with the top commenter and am totally flumoxed as to how Buffet et. al. can back this.
Not only is this going to require 'CEO abilities' - it's also kind of a 'mega corporate startup' - which is another thing very difficult to achieve.
Amazon is ruthlessly operational, by the numbers etc. - this will collide with medical bureaucracy pretty hard ... it's almost as though you want an outsider ...
Or, to buy a small company or two and combine them, a small team with the 'right chops' and then back them with scale, financing etc..
If _all_ this company did was wrangle the complexity of the healthcare system, however, they wouldn't be a step function better than anything else.
For the deeper, more radical changes, you need a visionary at the helm.
Of course, Atul will need to be able to effectively recruit & work with a stellar team to fill the gaps you mention.
Let’s take the checklist manifesto, a fantastic idea that unfortunately isn’t as widely applied as it should be. Why? Because if you ask most surgeons they’ll say, “yeah it’s a great idea, I do it already/I don’t need to do it though because I’m that good”. In practice it doesn’t get applied because humans have ego and incentives get misaligned. It’s not actually that beneficial to reduce complications in surgery for the hospital as long as the patient is insured. And it’s not that beneficial for the insurance company to reduce costs because fundamentally as long as the insurance company can accurately predict how much costs will rise next year, they still make money. They just need to know how much premiums will go up.
Healthcare is full of great ideas and ways to make things better, but they often just don’t get implemented because the whole system is so poorly set up. I don’t see any evidence that Gawande for all his talents has a good approach or the expertise to break through all that.
I'd point to another article, his "cost conundrum" article actually was a pretty insightful piece that I think gets at the core of one of the main drivers of high HC spend: local monopolies [1]
Another article of his, the "hot spotters" [2], was very influential among providers, administrators and even VCs as well. However, I dont think he's right that addressing frequent fliers is the solution -- you see the same cost concentration among a few patients in all countries, and even across time, so it doesnt appear that that phenomenon is the cause of the US' unique expensiveness
i dont know of many other people who have ideas that demonstrate the same combination of independent thinking, reach / visibility and understanding of the system as atul gawande (i actually dont think there are many great ideas to improve healthcare, most dont even diagnose the problems accurately). some of his ideas will be wrong, but he has new and solid hypotheses, and being able to test those and learn is a great way to make progress
[1] https://www.newyorker.com/magazine/2009/06/01/the-cost-conun...
[2] https://www.newyorker.com/magazine/2011/01/24/the-hot-spotte...
I fully agree with you on monopolies and hot spotters. The monopolies are a pernicious issue that's incredibly hard to solve, and targeting hot spotters is not likely to be the silver bullet people hope it will be.
I hope he succeeds given his perspective, I'm just skeptical that he can given the scale and structure of the problem. In particular the monopolies issue seems utterly intractable. Maybe some combination of remote care and creating vertically integrated treatment centers can help? I don't know, healthcare is really hard. I just hope this isn't a flash/vision over nitty gritty execution appointment.
I think these are important because my hypothesis is that the way to tackle the monopoly issue is by reversing the trend of hospital consolidation and purchasing of independent providers, and putting more power in the hands of physicians rather than health systems or payers. But to do that you need to make being an independent physician feasible again, and to learn how to do that you need to connect with a lot of physicians and then be in a position to create services and products to help them become independent (probably by getting payers to pay independent docs more / reducing auth and other burdens; maybe this company has the heft to do so). I don't know that Atul Gawande's the perfect person for that, but I know that anyone who has run a hospital or payer is probably not right
And he’s neither a fraud (e.g. Scott Thompson) nor a finger-on-the-trigger egoist (e.g. Elon Musk)
"According to the U.S. Department of Health and Human Services, it is anywhere between 1 in 100 to 1 in 5000.[1] However a study done in 2008 reported to the Annals of Surgery that mistakes in tool and sponge counts happened in 12.5% of surgeries.[8]"
Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego?
Ref:https://en.wikipedia.org/wiki/Retained_surgical_instruments
Nothing new under the sun. A guy who found that doctors should wash hands between autopsies and deliveries was ostracized by colleagues and died in asylum. [1]
[1] https://www.npr.org/sections/health-shots/2015/01/12/3756639...
He's kind of celebrated for an article he wrote in the New Yorker on healthcare delivery and management. (see 'This magazine article saved $500M in unnecessary Rx spending' https://www.cnbc.com/2015/05/08/this-magazine-article-saved-...)
It impressed Munger, Buffett's partner sufficiently that he sent a cheque for $20,000 to Gawande at the time as a gift without knowing the guy. https://www.cnbc.com/2018/06/20/charlie-munger-once-wrote-at...
In light of this, I'm truly perplexed by this choice.
This is not a 'resarch organization' or something like 'doctors without borders' for whom this guy would be a great choice.
Living outside of 'revenue' and 'products/services' all of one's career makes this a difficult choice.
Basically all successful biotech CEOs are old, former big pharma execs or academics -- two fields not known for their hustle. And they can grow big, fast: look at CEOs of Juno, avexis, kite; those companies were bought for $9-12B cash just 5ish years post series a
The biggest health tech companies are Cerner and Epic. They were founded in the 1970s I think. Have avoided disruption bc they know the system. Many other successful health tech companies are founded by dyed in the wool industry veterans or doctors with a good understanding of the field who work 9-5
Plus Atul probably has some hustle. He became a best selling author while being a surgeon and prof at Harvard. Takes initiative to decide to write books and actually pull off getting them sold. He sure knows how to build an audience -- probably has a bigger audience than any health tech startup CEO
I would say: ex-surgeon Hospital administrator of a progressive hospital. Ex-director of technology and services for a healthcare provider or insurer. Head of a prestigious applied research centre.
'Prof' and 'author' are intellectual, non-leadership, non-outcome, non-operational, non-managerial positions. He's imminently qualified to be the spokesperson and possibly 'Chief Medical Officer', but not CEO.
Does he even have a history of doing in-depth research on the operational and cost challenges of running a healthcare system?
The 'innovation' required here will not be medical - it will be political, operational ... fighting incumbent structures.
Someone with a kind-of relevant background who is also an ex-physician. There are many of those.
I'm still perplexed.
Amazon was hugely successful with AWS because it was an outgrowth of their business. They bought their way into groceries.
They will use their deep distribution and warehousing advantage to move into delivery. All of that makes sense.
But taking on incumbent, politicized structures? With armies of lobbyists to legislate their control of systems?
I think this guy is going to get eaten by the entrenched powers that be.
Though I wish him well and applaud Bezos for going after this.
Wallmart already has some opticians in their stores - I really wish they would move into pharmacies, then maybe 'family doctor locations' and then commoditizing common things and operations.
I actually think Wallmart is in many ways so much better positioned than Amazon to make their way into healthcare by grabbing the low hanging fruit and using their massive pricing power and physical installed base.
I've spoken to / heard talks from several ex-MD hospital admins of large health systems, informatics heads at massive university health systems, and leaders of large providers, and from hearing them I just have no confidence that they have the will to enact change. They are benefiting from the current system and to do something radical to fix the system would go against everything they'd learned in their careers, and probably burn many professional bridges (they'd be fighting their former colleagues)
I'd point to Rushika Fernandopoulle at Iora health as an example of a physician with no ops experience who has excelled in fighting incumbent structures. If Atul has that phenotype, I'd take that over hospital admin experience any day. But of course thats just my perspective and I understand picking Atul is a big risk
I hear you - but I also believe there are a number of them who imminently grasp the dysfunction and would like to do something about it. This is kind of out of my discipline but my Uncle was on the board of governors of a Hospital and he and the board watched as crazy stuff happened and definitely wanted to do something.
I worked in mobile at a once very succesfull handset manufacturer ... I watched the iPhone be borne and eat our lunch. As the execs failed, paradoxically, some of them knew what was happening and just could not get the system they were inside to change ... but a lot of us, were we to be in different systems, I think could be successful at it.
Anyhow. I wish him the best ...
The Internet was wide open 10-15 years ago. Today, not so much.
A CEO of anything in healthcare, especially something like this, had better have a lot of domain expertise.
You have to address questions like "Where are you going to get physicians? Nurses? Ancillary staff of all kinds?"
The real estate and financial models are trivial by comparison.
I have an untested hypothesis that one of the best ways to get physician mindshare is actually through think pieces in publications like the new yorker or new york times -- just the kind of articles Atul Gawande writes. The physicians that I know read these articles much more actively than they use linked in (most dont) or any other online community
Dirty secret of healthcare: “efficiency” translates to “I make less money” for almost everyone in the system, very much including doctors. All will protest and justify their cost, all will make good arguments in the individual case. In the aggregate though, we pay people too much (among many many other issues).
[1] https://jamanetwork.com/journals/jama/article-abstract/26746...
However I think it's odd to point out primary care as a culprit. Prices in the US are higher across the board, so just highlighting primary care salaries doesnt tell the whole story. Better metrics are 1) ratio of average salary of specialists to primary care and 2) total supply of specialists compared to primary care. The US lags on both metrics [2]
Hospital care is the number one driver of spend in the US (over 30% of spend) [1]. A day at a hospital in the US is twice as much as in comparable countries (can dig up source if interested). Pretty sure the U.S. spends more on inpatient care as % of total spend than other countries. US is middle of the pack in terms of drug spend as % of total HC spend. Hospitals have increasingly been buying primary care and specialty practices. When an independent practice gets bought by a large system, they can instantly charge more for the same procedure, bc they're now under the large system's contracts with payers. Literally nothing changes but negotiating leverage. If you want to find a big cause of healthcare spend inefficiency in the US, look there
[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
[2] https://www.milbank.org/2017/07/getting-primary-care-oriente...
The consequences of failure here are not exactly analogous to your example. 330 million people are not going to impacted by whatever is considered a failure here.
The three companies [Amazon, JPMorgan, and Berkshire Hathaway] are self-insured employers, which means that when you're an employee going to a doctor's appointment, your employer, rather than a health insurer, is ultimately footing the bill for the MRI exam you receive... "We're already the insurance company, we're already making these decisions, and we simply want do a better job," - JPMorgan CEO Jamie Dimon http://www.businessinsider.com/amazon-jpmorgan-and-berkshire...
Surely, that should be manageable for an insider like Atul Gawande. And it is nowhere same as wrangling with legacy American healthcare system (where one is dealing with insurance companies among others).
Buffett has repeatedly said this is not an entity that is meant to offer services beyond the scope of the three companies or similar. They plan to share what they learn, and Buffett has said he hopes that can help other companies and the wider healthcare system.
Here's probably the best talk he has given on the subject (13 minutes long, from a few months ago):
I don't think something like Kaiser could be easily rebuilt from scratch, but I don't know too much about the Mayo Clinic except for its reputation for clinical excellence and their active investments in innovation. Have they implemented new models to meaningfully lower cost of care?
I also imagine Atul gawande has enough experience with the existing system to know what ideas have a chance of working vs running into a brick wall of conflicting incentives. He can hire somebody to lead negotiations with insurance companies and providers, etc
Exactly. Reminds me of some parts of the IT department in my company. I don't trust anybody who has worked there for a few years because any reasonable person would have left or lost his mind. They certainly will not be innovators.
No, he’s not.
No offense to him, but he’s a -popularizer-. He takes various bits the HC quality improvement folks have been talking about / doing for years and writes (very articulate, engaging) articles that make it accessible to the wider community, including the wider medical community that normally isn’t in on those discussions. He also has a habit of relating it in a fairly shallow/one dimensional way, compared to the real deb-
Malcolm Gladwell. He’s Malcolm Gladwell, but for healthcare.
Atul Gawande, MD, MPH, is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital. He is Professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. He is also Executive Director of Ariadne Labs, a joint center for health systems innovation, and Chairman of Lifebox, a nonprofit organization making surgery safer globally.
http://atulgawande.com/research/
https://www.ncbi.nlm.nih.gov/pubmed/?term=Gawande%20AA%5BAut...
I point that out so you fully understand that when I say a doctor:healthcare QI as a bees:entomologist, I say that from both sides of the fence. It gives you some more insight in your little slice, but that’s it. And it’s just your little slice: I am not a surgeon, so I know jack shit about their operational processes. I do know from a recent kerfuffle in my hospital that even the surgeons don’t know much about how the OR department books rooms and schedules procedures. They certainly don’t have insight into the parts of the hospital that -aren’t- a core part of their job. Being a physician is an important window into how hc systems and organizations work, but it’s a tiny one. It doesn’t qualify one for hc QI by itself.
As to his cv, by all means, check out where he’s first author, where he’s “contributing guy with a name” (second to last), how many of them are editorials or round tables, how many of them are endocrine surgery, etc. Actual first author, non editorial healthcare ops papers are thin on the ground.
This feels like nitpicking. The guy is intelligent and accomplished, beyond question. But what he -isn’t- is a hc innovator just because he -writes- about the hc system and innovations therein. I’ve never seen him write on a topic that wasn’t already hot shit in the field for two decades; I’ve never seen him present the pile of conflicting data for his preferred solutions (eg, the Checklist Manifesto chose to elide how many hospitals implemented checklists to no improvement, despite plenty of the results being published before his book.)
I agree with parent comment -- there is a difference between being the person/people who came up with brilliant ideas and being the person who brought them to the masses in a pithy, cogent and engaging manner.
One might even make the argument that the latter task is relatively more important than the former for people in high-visibility figurehead type positions such as CEO of a massively ambitious new healthcare venture.
The "Gladwell for healthcare" comparison is a good one, and I say that as someone who has enjoyed reading Gawande's books.
The only people who can differentiate between 1)surgeons who are expert in the O.R. whose patients do well in the long run and 2)those whose reputations exceed their abilities and results are anesthesiologists. Trust me, I was one for 38 years, at UCLA, the University of Virginia, and in private hospitals. I will never forget the time a world-renowned cardiac surgeon at UCLA at the height of his career — holder of an endowed distinguished chair, first author of the then most widely acclaimed textbook in the field, whose surgical skills were so sub-par he was only allowed to operate with a senior cardiac surgeon as his "first assistant" — was repairing a child's AV septal defect by sewing on a patch (on full cardiopulmonary bypass) only to be interrupted by his "first assistant" who quietly told him, "You've got the patch on backwards." I was standing literally two feet from the two of them, behind the drape.
There’s lots of crappy programmers with good reputations too. But it’s a weird reply to “he’s a top tier surgeon” that you say it’s unknowable.
I’m sure you’re right, I’m not a surgeon so I have no idea how to evaluate a good surgeon, but there must be some way to qualify the poor ones from the great ones.
Your anecdote is a great example of high reputation, low skill. But is that the only instance. Is it 10%? Are most board certified, practice for 20 years surgeons good or bad? What’s the actionable intelligence, but it seems like the conversation ends with “it’s unknowable.”
I am sort of aware of quality measurement, but not a healthcare practitioner, but I’ve noticed this comment from lots of docs that the only way to know if medicine is good or bad is to have a doctor review it.
I dont think his ideas are shallow or one dimensional, but I havent read all of his work. I'd certainly push back against the comparison to Malcolm Gladwell -- atul gawande is a practicing surgeon and professor at one of the most well respected hospitals in the world. If Malcolm Gladwell wrote about the 10,000 hour rule from his personal experience becoming, say, a chess grand master through 10,000 hours of practice, then the comparison would be more apt
You wouldn’t. He adds depth through humanity, while eliding the pile of data that contradicts his points - data you have no reason to notice is missing. While the hc QI community was getting over checklists because of the number of studies showing it to be a largely ineffective intervention, he ignored the pile and kicked off a second wave. That’s not really visible to the lay reader.
>I'd certainly push back against the comparison to Malcolm Gladwell -- atul gawande is a practicing surgeon and professor at one of the most well respected hospitals in the world. If Malcolm Gladwell wrote about the 10,000 hour rule from his personal experience becoming, say, a chess grand master through 10,000 hours of practice, then the comparison would be more apt.
AG does not write about healthcare QI from the perspective of someone that works in ops or hc QI. It’s a real profession, and one he hasn’t practiced.
He writes about macroeconomics and corporate management (and if that seems wildly dissimilar to you, you have some appreciation of how far afield he pokes his nose) from the perspective of the factory worker. And when he at least stuck to his area of medical expertise, at least he had some subject matter expertise to inform his perspective. He’s expanded outward from there, with neither academic nor medical expertise on the topic. There’s nothing terrible about that, but he’s -not- 10k hr guy writing about 10k hrs. He’s a guy with a passion, who has read up a bunch on topics he’s passionate about, and written about them well. They have some small overlap with his profession (diagnosing endocrine disorders; cutting out thyroids, Not reorganizing hc delivery processes), which adds some insight. Yeah, he’s slightly better than MG, but not by an awful lot.
I don't mean to offend if you work in HC ops or QI, but I'd rather have someone take a macroeconomic perspective than an ops perspective when looking for solutions to high HC cost. I'm aware of the HC QI field and know a few ppl who work in that space and I know how hard it is to move the needle with that work. You are fighting against a system that in many ways is not incentivized to work with you. I know there's been a lot of great work done in HC QI but frankly it hasn't moved the needle on cost of care. I think it's time to look at changing the broader system to allow all the good HC QI ideas to actually get implemented broadly
I hear your point about intellectual overreach. However many people call it another thing, but with a positive connotation: the "beginners mind". That in fact is one of the 3 criteria bezos had for the CEO. That mindset facilitates learning, growth, risk taking and innovation. Yes you'll make mistakes but that's part of the plan. The experts who never step beyond their area of expertise won't be as successful because healthcare is too interdisciplinary to have leaders who won't reach out intellectually to people from other fields, and too broken for incremental improvements to turn the tide
I just thumbed through meta-analyses on Google scholar and this definitely doesn't look like the results of recent research into checklists (e.g. https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.9381)
It seems like there are problems getting people to agree to do checklists or keep with them, but if you come up with the right checklist and get the right buy-in, you do see fewer complications.
(If anyone wants to look at the recent research for themselves, here's the Google Scholar search I used: https://scholar.google.ca/scholar?as_ylo=2014&q=checklist+su...)
Bingo.
What the state of the research shows is that you have an active QI-focused culture and buy-in, checklists work over the medium long term, but not better than anything else. If you don’t have those things, the checklists do nothing after 3-6 months (a lot of studies hide this by rolling up the study period, but everyone in the field knows how rapidly the effect decays). I haven’t seen any meaningful data on them >2 years out, but let’s let that slide, out of pragmatism.
What that suggests is that checklists are irrelevant to this discussion. It’s just a lot harder to sell something as vague and nebulous as “creating a safety-focused and quality-driven culture” than it is to sell “checklists!”.
Do you have a cite for this?
"Systematic review of safety checklists for use by medical care teams in acute hospital settings - limited evidence of effectiveness" (2011) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3176176/
In the recent years, I find him at an excess amount of healthcare conferences speaking or writing on topics that's not within his realm of expertise such as patient experience, opioid pandemic, technology, artifical intelligence. The audience is often captivated by his stories and writing to not be able to differentiate how he's really repeating others' work and quick to write about what's currently trending in healthcare.
He's a good writer, physician, knowledgeable but not an executor.
As another person said below, they could easily hire a COO to deal with existing aspects of the system and still have the overall direction in the hands of someone like Atul.
Put another way it’s like giving $100M seed round to a visionary but completely unproven founder when the company is not even at garage stage. Might work out, but seems quite a bit more likely to fail than $100M given to someone who had done something like it before.
Jobs/Sculley and later Tim Cook situation comes to mind - Sculley had the whole CEO experience but look how that turned out and look at how Tim Cook took over operations part which Jobs had no interest or knowledge of and made it work so well. If they had Tim Cook as the CEO pre-iphone days - I am not sure if we would have seen the iPhone.
Consider the alternative: the CEO is a professional “manager” who can run the shop, but may (or more likely, may not) understand what the shop is all about. Then who drives vision and strategy? Someone lower in the hierarchy can’t get himself taken seriously enough (sorry, but that’s just the nature of hierarchies). He (Atul) could be made the exec president or something of that sort, but an organization like this one needs a more hands-on visionary, who can corral the staff, while leaving the administrative and political minutiae to a trusted lieutenant.
The ill defined mission of the organization along with perceived potential conflicts in priorities among the 3 companies has made candidates hesistent.
Judging by the companies involved, this is most likely the plan. Whatever they create will like cause the existing system change to it and not the other way around.
This is the equivalent of promoting your best developer into management. Atul is a smart hard working guy. I’m sure he’ll work hard and do ok, but on the face of it he’s a silly choice.
Atul might be the Trump like shock that the establishment of medical sector needs.
Of course at the end of the day CEO appointments are gambles and I see this as one too.
My hope lies with those who question the product, not the delivery methodology. The US needs to rethink health care, not how they provide or pay for it. They needs to rethink how many prescriptions they shovel into the population. They need to rethink how they pigeonhole patients. They need to get people exercising. Those changes aren't going to come from anyone still talking about "how we deliver health care".
If you went to investors and used that as a pitch you'd be laughed out quick. Need to get people exercising? That's exactly the sort of unrealistic target that you don't want to have if you're going to run a company. Instead focusing on what could be realistically improved and doing that - which delivery inefficiencies are certainly a part of - that sounds like the most reasonable way to deal with something as big of a cluster f* the healthcare system in the US is.
Funny. Morning exercises were are part of Japanese corporate culture for a generation. In many European countries employers are expected to support employee fitness goals. My job (military) mandates that we all be given five one-hour periods each week to exercise. Not weekends, during the work day. It is totally normal for someone to go from meeting to the gym and back again during the day. Our civilian employees participate in this too, although they aren't tested.
I think it totally reasonable for any large company to make exercise part of their corporate culture, particularly in the US where employers are so involved in health care. Anyone laughing such ideas out of the room needs to broaden their horizons.
To my knowledge he has never run a large organization or dealt directly with the complex backend of the healthcare system. The was healthcare is delivered and paid for is full of independent, semi monopolistic players that have often conflicting incentives. Oh and lets not forget that we have 50 states and 50 different sets of regulations.
Unless the plan is to create a brand new completely vertically integrated system, you’re gonna have to deal with the existing infrastructure, and I’d be much more confident in success if the person leading that effort had experience there. Having worked with many physicians and insurance companies, I can say from experience those skill sets are not the same.
Even if the idea is to be vertically integrated, someone like the CEO of the Mayo Clinic or Kaiser would have been a better choice.