Jeff bezos mentioned they were looking for someone with expert knowledge, a beginner's mind, and a long-term perspective. Any leader of a current large healthcare organization would probably fail the 2nd and potentially 3rd criteria. In light of these criteria, the choice of Atul Gawande makes sense

That’s actually my point, I would argue Gawande doesn’t have expert knowledge. Being an expert surgeon is a very different skill set than an expert in healthcare delivery and management.

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.

Your point seems true regarding that particular article, though I dont think that is sufficient to demonstrate that he doesnt understand the system. As a surgeon, I'm sure he knows the barriers to adoption of such a tool, and being the head of a large buying consortium for health insurance (Amazon / berk / jpm) could give him the market power to "wag the dog" and push payers to implement such policies. But i agree that the checklist manifesto is prob not the best / most practical way to reduce spend

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...

Your point is an excellent positive case for his appointment :).

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 agree that lack of ops / execution experience is a potential concern, but for me the characteristics that make me most positive are 1) ability to connect with a wide audience of physicians and 2) courage: a willingness to fight the "powers that be" and try things that probably won't work, as long as you get enough shots on goal to do something that does (not sure how courageous he is but his willingness to put himself out there in ways that most docs dont do is encouraging). Rushika Fernandopoulle at Iora has these qualities and they seem to make up for his lack of healthcare ops experience (though I dont know that his model is sustainable / scalable enough)

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

I think Gawande is a good choice. He’s obviously a smart, visionary-type who lacked the power to implement his vision. Now he will have that power.

And he’s neither a fraud (e.g. Scott Thompson) nor a finger-on-the-trigger egoist (e.g. Elon Musk)

Surgeons don't get to play God as much anymore. Checklists dominate and are the hallmark of a good institution. One of the biggest risks in hospitals are central lines and infection. So cleaning protocols / enforcement and as much automation as possible are ways forward. The ACA imposes financial penalties on hospitals if they don't reduce infection rates and readmission rates. You can only do that if you improve quality. A hotshot with an ego is bad for business.

Also, I think Gawande _wrote_ "The Checklist Manifesto"!

After having worked with some A&Ps (aircraft mechanics) I was shocked that surgeons didn't operate with checklists. Doesn't matter how skilled you are, mistakes happen, especially when you are in a hurry. Aircraft mechanics also typically 'shadow' their toolboxes, which is where every drawer has individual cutouts for each tool to make it easy to verify that all tools are back in their place. And apparently instruments being left in a patient isn't that uncommon:

"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

> Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego?

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...

Yes, that's correct - a very worthwhile read, regardless of your profession.

>doesn’t have expert knowledge ... very different skill set than an expert in healthcare delivery and management.

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...

Yes, but you still need someone with startupy hustle, and with a CEO mindset, as well as a knack for ops.

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.

I think one of the reasons tech startups haven't made a bigger dent in healthcare / biotech is bc they overweight startup hustle and underweight experience and domain expertise. Better to walk towards the right target than run really fast to the wrong one, and in fields like healthcare you can't pivot as quickly once you realize you're going in the wrong direction

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 agree with all of what you are saying but I just don't buy that this is the guy. A prof, surgeon and 'successful author' is just not the right mix for this.

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 completely agree with you philosophically, and your idea that Walmart might be better positioned than amazon makes sense to me. Owning providers (versus paying health systems massive prices for access to providers) seems to be an emerging theme.

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 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"

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 ...

I agree and to refine a bit, I think it depends on the type of business.

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.

I took a short walk down this idea of a vertically integrated system, essentially building the system as a research lab (something like NIH building 10), including approaching some senior people. I sort of wonder if maybe they modified their expectations for the venture after a search revealed that experienced CEOs weren't interested.

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've also done some work trying to get people to implement different models of care outside of the traditional institutions, and getting physicians on board is just a big hurdle. As a group they are pretty conservative and risk averse, hugely busy, and there aren't a lot of places where they congregate, online or otherwise, so outreach is a bit of hand to hand combat.

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

Another (darker) perspective: they don’t want to lose money. Healthcare in the US is expensive in no small part because we pay more for things (duh). One of those things is physician time. Primary care physicians in the US make $60K more a year than comparable nations [1].

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...

I agree that profit motive is underappreciated and often is the real reason for consolidation, formation of ACOs, etc (many ACOs dont form for getting share of cost savings, rather they try to increase volume through partnerships).

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...

Then lets break out the wrecking ball, because most US hospitals are organized around the idea of private rooms that require more equipment, more real estate, and more staff.

Physicians, and others, pay for their medical education in the US. How do physicians pay for their education in other countries or is it paid for them by their governments?

Also, the doctors I know basically give up their 20s and early 30s in the American system. But that might be due to existing doctors making sure supply stays low so their prices stay high, and so they can do that by making credentialing lengthy and difficult.