Opening Session Offers a Whole-Person Approach to Disease Management, Treatment

During the opening session at AMCP Nexus 2020 Virtual, Marty Makary, MD, a “health care futurist,” a Johns Hopkins Medicine surgeon, and professor of health policy, champions lifestyle medicine and the redesign of how people interface with the health care system. He advocates for the new movement of relationship-based clinics that spend time with patients to address the social, economic, and lifestyle determinants of health.

In his New York Times best-selling book, “The Price We Pay,” he talks about rebuilding the public trust in the medical profession and exposes the practice of hospitals suing patients—a practice he has led to fight against, which has resulted in many hospitals stopping all lawsuits against patients.

“We’ve learned that we should be doing less,” he said, citing the move toward precision medicine and care. “We’re now starting to ask ourselves, ‘What’s the most appropriate care?’” He said that annual health care visits may not be testing for the right things, citing a New York Times article that noted that lipoprotein(a) is a good screening tool for those at high risk of early heart attack.

“The intervention that gets the least attention … that we are not talking about, that we need to be talking about more is lifestyle change,” he said. Underlying drivers of illness include nutrition, exercise, tobacco/alcohol, stress management, sleep, and healthy relationships. “There isn’t a lot of research on lifestyle changes.”

He uncovered wasteful prescribing practices. Ten years ago, there were 2.4 billion prescriptions, while last year, there were around five billion. “Did disease really double in the last 10 years?” he asked. “No, we have a crisis of appropriateness.” He said the younger generation of patients is exploring things like stress management and physical therapy for disease and condition management, instead of just prescription drugs. Lifestyle choices have not been a part of the conversation at the doctor’s office, but trends are moving more in this direction. “This is the exciting revolution right now in medicine.”

We measure the outcome, but not the appropriateness of the operation, medication, and test for each person, he said, noting that the industry is focused on consequences and not appropriateness of care. His team developed a new generation of quality measures to assess appropriateness of care by talking to practicing physicians about overuse that can be measured. “Sometimes the solutions are simple, and we just need to listen to people on the front lines of American medicine like … pharmacists,” said Dr. Makary.

As we think about how to redesign health care, we need to think about how we are treating our most vulnerable members, he said, including older patients, children, and low-income individuals. He noted that pharmacists should not be a separate part of health care but should be partners who are embedded within the clinical team.

Dr. Makary then compared the airline industry to health care, “Airlines provide a price before a flight was purchased. Imagine if airlines did not give you a price. Imagine the airline said we can’t give you a price, we don’t know how much something is going cost. We don’t know if there is going to be a delay, or if there are different staffing costs, or the pilot could experience turbulence and then bill for more relative value units.”

“We would say that is a ridiculous system. We would say that is a system that can be disrupted with predictable risk built into transparent prices that are honest, fair, and disclosed upfront. Yet, this broken system of not having prices is exactly what American health care is today and people are getting frustrated,” said Dr. Makary. The average American spends 48% of federal tax dollars on health care, and, on average, American families spend $20,000 on health insurance. Dr. Makary goes on to say, “I believe we don’t have an insurance crisis, we have a pricing crisis.”

Dr. Makary then shared patient stories related to unaffordable medical bills stating that about 20% to 30% of hospitals engage in predatory billing, even suing patients. “We decided to tell their stories,” he said, which can be found at www.restoringmedicine.org. For many individuals who cannot pay their medical bills, they are taken to court to have their wages garnished. A study published in JAMA found that about 30% of hospitals in the state of Virginia were aggressively suing patients to garnish their paychecks, “representing the most predatory form of medical billing violating everything sacred about the doctor-patient relationship and our great heritage as a health care community.”

“None of us took an oath to heal a patient … and then ruin their life financially,” he said. Dr. Makary noted five billing quality measures that should be publicly available for patients to “shop” itemized bills, price transparency, service quality, suing patients, and surprise bills. “We can create honesty in health care around billing practices.”

Presentation: Opening General Session. AMCP Nexus 2020 Virtual.