Tackling Overtreatment and Overspending in U.S. Health Care

JOEL BERVELL: “Do as much as possible for the patient, as little as possible to the patient.”

That’s a credo that makes sense to me, and probably a lot of doctors and other health care workers. So why is it that in the United States, between 2019 and 2021, hospitals performed over 229,000 unnecessary coronary stents, that Medicare wasted as much as $2.44 billion on unnecessary stents, and that at some hospitals, more than 50 percent of all stents met criteria for overuse.

My guest today, Dr. Vikas Saini, a cardiologist and the executive director of the Lown Institute, a think tank dedicated to examining how our health care practices are misaligned when it comes to patient needs, leading to significant overspending and overtreatment.

And that idea — Do as much as possible for the patient, as little as possible to the patient — was the driving philosophy of Boston cardiologist Bernard Lown, who founded the institute. This year the Lown Institute ranked 3,600 hospitals on measures including equity, values, and outcomes. Only 54 got straight A’s. So, how do we rightsize health care in the United States to make more people more healthy? That’s our conversation on this episode.

Dr. Saini, thank you so much for being here today.

VIKAS SAINI: Thank you for having me.

JOEL BERVELL: There’s a lot of report cards on hospitals tracking performance in the areas of patient outcomes, value of care, and equity factors. And you identified 53 criteria with the Lown Institute. Can you break down some of that for us, and what are the meaningful measures that the hospitals index focuses on?

VIKAS SAINI: Sure. Thanks, Joel. I’m happy to do it. The Lown Institute, when we first embarked on this project four or five years ago, we recognized that American health care is in the midst of a shift and needs a really big paradigm shift. A lot of what had been considered the important factors to measure remain important, but we knew that in the era we’re heading into, things like equity, things like the value of care, had to have a lot more prominence. So that’s why we decided to start this.

There are three major areas that our index works on. One is outcomes, which is a very traditional one. That includes things like mortality, readmissions, patient satisfaction, patient safety. It also includes value of care, and we’re the first report card that really attempts to do this. And there, we look at a basket of 12 procedures that are commonly used unnecessarily. Then we report on those for all the hospitals that we rank. We also have a cost-efficiency metric, which uses Medicare data to assess how efficiently outcomes like mortality or readmission are achieved with how little or how many resources.

And then lastly, the one that’s attracted a lot of attention is our equity metrics. And these have three major areas. One is CEO pay, which is really the ratio of the highest-paid person in the hospital, typically the CEO, and an average worker in the hospital. That means nonprofessional workers, clerical, janitorial, other staff, but not the professional workers such as nurses, nurse practitioners. We also looked at community benefits spending, which is what nonprofit hospitals are required to do by the IRS. But many hospitals, indeed all hospitals, do to one extent or another. So we report on that.

And lastly, we have a metric we developed called inclusivity, which has both racial and economic class components. And that looks at the way and the extent to which a hospital’s inpatients, the people the hospital actually admits and takes care of, how they compare to their surrounding region in terms of racial and economic demographics.

JOEL BERVELL: I’m so glad you brought those all up because all of those are really important metrics and feel like it’s different than what’s been out there, especially that equity one that you mentioned. And I’m curious: How does scrutinizing tax records and other public records offer a window into the operational and patient health success of a hospital or a health care system?

VIKAS SAINI: Well, it’s important to understand that we are using data that is publicly available. We want it to be as transparent as possible. Our methods, we also publish, and anybody who decided to do this could replicate this.

JOEL BERVELL: And what’s been the response to these measures and these rankings that you’ve put out there? I’m curious: Have there been stories that have come out or just responses in general to how this data has been received?

VIKAS SAINI: Yeah. When we started, we really weren’t sure whether there would be much interest. We knew — we felt compelled to do it because we thought it was really important. And it’s turned out that there’s been a lot of interest. A lot of the interest is hometown, so in different parts of the country, different local and regional hospitals get attention and get write-ups, but it’s also been true nationally. And I think primarily the reason for that is, one, the pandemic, two, George Floyd’s murder. And between those two things, a generalized sense that how we’re doing things and what we’ve been doing isn’t good enough. And if we’re going to do things differently, we need some tools to do it.

The interest has been there both from national media, the New York Times, USA Today, et cetera, but a lot of regional media. And I think that’s been gratifying, because I think that’s where the action is. In the end, change is going to happen one area, one community at a time.

JOEL BERVELL: Yeah. I’m glad you brought up both the COVID pandemic and the George Floyd protests because I think those were such huge impetuses for the health care field to relook at what we were doing. And your work goes directly with that. I’m curious: Has your work at all been used in policy or by elected officials in order to start making broader strokes of change in terms of policy and using this data?

VIKAS SAINI: Well, in fact, because of the timeliness, and really that was a bit fortuitous, I don’t think we didn’t expect either the movement for Black lives to have the impact it did around the country or for that matter, a pandemic. But the level of interest from regulators, policymakers, and others has also been quite high. We’ve had price transparency law passed by New York City. The Lown Institute participated in developing a report for them on tax exemptions and fair share status of hospitals. We’ve been in conversations with local officials in California, in parts of the Midwest. And we’ve certainly had conversations nationally with the House Ways and Means Committee, people from the various Senate offices, including members of the Senate Finance Committee.

So there’s interest. I won’t be able to tell you that there’s any specific legislation yet, but I would say it’s early innings and almost certainly some kind of regulatory action or legislative action is likely. That’s my guess.

JOEL BERVELL: I want to change topics a little bit and talk broadly for a minute about the cost of both overtreatment and undertreatment in the health care field for both patients and for institutions. So earlier this month, the Lown Institute posted a panel conversation about unnecessary stents. I’m curious: Why focus on this procedure in particular?

VIKAS SAINI: Well, as a cardiologist, I would say that stents and the whole issue of when is a stent appropriate or not has been widely debated for decades. And so it is one of a basket of 12 procedures that we include in our avoiding overuse metric for hospitals. And, in particular, the issue with stents I think illustrates some of the deep problems in American medicine, which has to do with how do you decide when something works and when it doesn’t? How do you decide if it works, how much to pay for it? When something is discovered not to work and you’re already paying for it, how do you turn that down? These are all difficult questions, and they’re not new. They’ve been around for a long time. So we decided to focus on stents because this debate has been going on for 10, 15, 20 years. There have been clinical trials that have shown in large sections of patient populations that were receiving the stents that they really didn’t benefit from them.

So we decided to focus on this because it’s kind of an interesting example for everybody to ponder. How does this happen? We haven’t done the math yet, but just that one issue in that one field last year conservatively was two and one-half billion dollars. In health care maybe that’s not a lot of money anymore because we spent trillions, but two and one-half billion. But those numbers thankfully have been going down really gradually. They were much higher in years past. If you added up everything over 10, 20 years, I’d be afraid to say what that number is, but my guess is it’s 100 billion or more. So when we think about all the ways our health care system needs to be efficient and needs to put its resources in the right place, things like unnecessary tests and procedures have to be on the agenda. How do we reduce them?

JOEL BERVELL: Yeah. And this is going to be a hard question to answer, but how do we get U.S. providers unstuck from that? I’m a medical student right now. I’m in my fourth year, and you know how medicine is. We learn a specific way. It gets hard to change things, especially as we go down in practice. What can U.S. providers do? What can individuals actually start doing to untrain ourselves when we learn things like revascularizing through a stent isn’t as effective in some populations? And the other 12 metrics that you mentioned too.

VIKAS SAINI: Yeah. Well, this has been the challenge. I spent a portion of my career working with a primary care group where we took global contracts, risk contracts, fixed contracts. Nowadays, we call them ACOs. And there’s no question that when there are financial considerations to avoid unnecessary care, providers will focus on it a lot more. Now, there’s a risk that you underprovision care when that happens. So finding the sweet spot is the question that we all have to figure out. And I think it’s going to be a mixture of policy elements, payment elements, educational elements for sure.

As somebody who’s practiced and practiced in private practice for 15, 20 years, I don’t think we want corporate medicine where people on high are issuing rules and orders. So there has to be a peer component to this that’s central, but the peer component has to really be well-informed on the evidence. And I don’t know what they do in med school today, but I remember when I went to med school, which is we’re talking 1975 to ‘79, ‘80, we learned some epi, we learned some statistics, but we didn’t learn rigorous analysis of evidence. We didn’t really learn how the kinds of evidence have grades and need to really be assessed on the basis of their degree of reliability. And the part that’s probably hardest is we didn’t really understand and learn all the ways bias can be hidden in plain sight.

JOEL BERVELL: Absolutely. And I want to ask, what are strategies for rightsizing care? Should the focus be on shrinking executive teams? Why is it so hard to get to the right size? There’s so many things we could talk about, whether it’s culture or technology or the financial incentives, as you’ve mentioned some before. What do you think should be the focus on actually fixing these issues?

VIKAS SAINI: Well, I did a deep dive on this when we wrote a series of papers in The Lancet called the Right Care series. And so rightsizing is precisely what we were aiming for. I think it’s pretty clear that we can’t pay for volume. We can’t pay so that somebody makes more money the more they do. On the other hand, it’s also true that just putting everybody on a salary pure and simple is probably not the answer when you expect people to get up at 2:00 and 3:00 and 4:00 in the morning and be there promptly and do that day after day, year after year. I’ve been there. It’s hard.

But somewhere in there, there’s a mix. And that means, as I said, the compensation structures have to be fine-tuned to avoid overincentivizing volume but also avoiding overincentivizing skimping. And the best way to do that in my view is to make these decisions at a group level. Can’t be at the individual practitioner. Really needs to be at a group where the aggregate numbers are high enough that it’s really, you’re trying to move the needle on averages and you’re not really trying to make decisions on the fly. So I think that’s one important piece of it.

I do think there are opportunities to do things like appropriateness audits. They’re not really done and there’s very few incentives to do it. I don’t think necessarily the authorities should be doing that, but there’s no question that payers have it in their capacity to require it. And maybe the way to require it is to require a peer-reviewed audit process of appropriateness, something like that. And as you point out, in med school you read, but then you go on the wards and then you learn by example, what people used to call, maybe they still do, the hidden curriculum. That’s where a lot of stuff gets transmitted. And sadly, some of what gets transmitted are the attitude and what constitutes whether you’re aggressive or not and all sorts of variables that are in the mix.

This has been a hundred years in the making. We are all the children of Abraham Flexner. He wrote a report in 1910. He said we need more science. He looked to Germany and the United Kingdom, said, “Look, they’re doing things more scientifically. America has too many snake oil salesmen and quacks. We need to fix this.” And by and large we did, but we threw out the baby with the bath water. Historically Black medical schools got closed because of it. Schools that catered to women, medical schools, got closed because of it.

And then with the birth of the postwar economic boom in the medical industrial complex, I like to think that what started in a meaningful and important way, which is a focus on science, has too often now become reductionist and more science-y than science and a lot of focus on gaming, whether it’s just to get the right answer, hacking so you get the right answer, get the right headline, or get the right results in front of the FDA. Whatever it is, all those things have conspired. So, we need a paradigm shift after a hundred years, and that’s not going to be an overnight thing.

JOEL BERVELL: I’m so glad you brought up the Flexner report because I actually think about that a lot, about the intentionality of not having women physicians and also minority, specifically Black physicians from so many HBCUs being closed. And I’m wondering, today we’re talking a lot more about equity as you harkened to before. Do you think that peer-to-peer education is the way to move the needle? Is there more momentum happening because of these conversations about equity?

VIKAS SAINI: Well, we need more Black doctors. No question about it. It’s dropped in my professional lifetime in the last 20, 30 years. It’s ridiculous. And there’s reasons why we need them and it has to do with the kind of effective care you can deliver to the people in your country. So there’s no question in my mind about that, but that wouldn’t be enough. What we really need are the attention to the structural barriers.

So our inclusivity metric I think in many ways is a pretty clear picture of what some people have called hospital redlining. And it’s baked deep into the structure of our society. Our inclusivity metric looks at hospitals and says, “Okay, you admit 20 percent Black patients.” Well, what percentage of people in the community around you are Black? And it depends on which way you look, depending on where you’re situated. If you look out to the suburbs, it’s one percentage. If you look inward, it’s the other. But if you were site-neutral, to use a phrase, if you were actually just imagining a world in which people went to the hospital on the basis of what’s close and drew a circle around it, which is what we do with our inclusivity metric, what you find is it doesn’t work that way. Certain hospitals tend to tilt in one direction, others in the other.

And so what we’re measuring really indicates a legacy that’s 10, 20, 50, 100 years old, legacies from redlining. But it’s also about our labor market is segregated. And we decided as a country to link health insurance to employment. And we did that after the war, World War II. And that’s had consequences for a segregated labor market. Means the kind of insurance coverage people have is different. So these are deep structural problems. And to solve those requires much more significant change and change of an order that actually would be of benefit to the large mass of Americans, white and Black, because most people in America now are really struggling with health care, with the price, the affordability, the access, all of those.

JOEL BERVELL: Absolutely.

VIKAS SAINI: When we set out to do the hospitals index, there had been a lot of talk and a lot of focus on coverage, on insurance coverage. I think part of what we wanted to do with the index was point out that in addition to insurance coverage, there needs to be a serious deep reform of the delivery system itself. It really needs rightsizing, as you put it. And so that’s the other motivation for our work.

JOEL BERVELL: That’s so important. And in this last part of the episode, I want to dive into health care systems and design overall. And I think when I think about the system, I think mainly what’s patient-facing first, which is pricing. I’ll be soon entering the field of medicine as a doctor. But of course, like all of us, we started out first as patients, as a health care consumer at some point. And there are some rules and laws about it, but the one thing I don’t entirely understand is why can’t patients have a clear way to see or figure out, without searching, what their health care is costing? I’ve always wondered why couldn’t it be something more like a McDonald’s where you walk in and the prices are right there, menu prices. So I’m curious: How, if at all, would pricing transparency create greater equity? Is that something that is possible in the U.S. current health care system that has so many other flaws within it already?

VIKAS SAINI: Well, that’s a really important question, and I will admit to a bias upfront, and that is I’ll cite authority. I’ll cite a Nobel Laureate economist. But Ken Arrow in the ‘60s made the point that health care is different economically. It’s hard to treat it as a commodity or as a normal commodity. And I believe that’s true, and I think there are a lot of reasons for it. We can just enumerate them. But the thing people tend to forget about Adam Smith and the free market is he talked about a free market. And what he talked about was where there’s information equality, where there’s information symmetry, where parties enter a transaction freely, et cetera. So you have to believe that that’s possible in health care if you want to believe that price transparency would be the solution.

Now, I don’t think anybody thinks that pure price transparency would be the answer to all our woes. So when I ran the primary care group, getting our docs to know what the price was when they were ordering a test was actually pretty useful because they were in a budgeted arrangement. They needed to know. But the shoppable services, the elective MRI that you have, they’re a fraction of what we do. Maybe a significant fraction, but a fraction of what we do in large sectors of what we do. The information asymmetries are really large, and it’s an emotional business. And lot is driven by trust. And I just don’t think, I personally, it’s my bias, I don’t want to walk into my doctor’s office thinking I’m at a McDonald’s. I want to be listened to. I want to be known. I want my background, my family to be known. I want the clinician to hear me and to give me advice. And I want the dollars and cents in the background.

I get that there’s a business side to this, but I think there are much better models in which those of us responsible for the health care system have to own that problem. And we have to figure out pricing and costs so that it becomes affordable. And transparency for actors within health care is probably a great idea, but whether or not it’s going to make patients switch from one surgeon to another, are you kidding? One hospital to another? Maybe at the margin. And probably the biggest challenge here, and this is what we’d love to see, is not just transparency on price but transparency on utilization and price.

Commercial insurance, the vast majority of Americans who are employed and have commercial insurance, not Medicare, not Medicaid, you can find the price now though you need a computer and AI to get there. But I’m confident we will in the next few years be able to find the price. And it is wild and varying, but you still, a group like ours still can’t look at the price in relationship to the volume and really get a total costs estimate for either particular patients or groups of patients. Insurance companies have it. Hospitals have it for themselves. I think what’s necessary is having third parties like ours have access to that information. So we can actually judge not just the price but the clinical effectiveness of that price. And I think we got to be able to say, “Well, prove it.”

JOEL BERVELL: Yeah. And we’ve talked a lot about what’s wrong with the system, but how aware are health care professionals, doctors, nurses, even executives, about the kind of health care system that they want to see or be a part of? How could we redesign thinking to evolve, to produce change, either incrementally or radically, just starting the conversation with health care professionals?

VIKAS SAINI: That’s a great question. My view is we don’t have the right forum for that. The system is fragmented. We have all these insurance companies. We have all these different setups. We have different guidelines. We have different this, different that, different formularies. I go fill a prescription and from one day to the next, the price is bouncing around because of all sorts of backroom deals. The system is fragmented. But your question points to something else. Discussions about reform of the system are also fragmented. There’s really no good forum for that.

Now physicians are essentially employed by hospitals, and that means that a locus for conversation or discussion about what’s right, what’s wrong, what could we be doing differently, that locus doesn’t exist. The medical societies, I mean the Mass Medical Society, the AMA, they try but in many ways they were organized and they’re structured for a bygone era. And there’s really no place for clinicians to have these kinds of conversations to talk about the business deal that their hospital just cut or this or that. They don’t except in the hallways now. And that’s why I think you see enough disgruntlement that you see unionization efforts. There’s a real lack of a place for clinicians to have conversations about their conditions of work and how the system is designed.

JOEL BERVELL: And do you think doctors and nurses know what a good system would look like? Or are we not able to imagine it because we haven’t seen it before?

VIKAS SAINI: Both things are true. You’re talking to somebody who has spent a lot of time in the last few years imagining that system and describing it. The answer is people in the gut know certain things about what they want that system to look like. But then there are a lot of elements that are more technical that they don’t know, but that’s because they haven’t had a chance to consider it and there’s really no framework to find that. And most of what gets discussed, most of what gets proposed generally is one or another private interest. So it makes it tough.

But I can tell you that if people had an opportunity to work together, crowdsourcing the design of the health care system they want for themselves, their families, and others, I think it’s doable. It’s a big project. But when did we stop trying big projects? Moonshots are what we should try to do, and this is one of the biggest moonshots there is really: fixing American health care.

JOEL BERVELL: Absolutely. Are there concrete technical elements you think people care about changing the most, most urgently right now?

VIKAS SAINI: Well, I think one of the biggest areas that requires focus and attention is primary care and getting primary care for everybody in the country. There’s a moonshot, but it’s just about deciding to do that, figuring out the design, and moving it forward. There’ve been some efforts in Congress, but they’re usually just very minimal or they’re incremental in certain ways.

JOEL BERVELL: And to wrap up our conversation, I’m curious: Are there answers for the United States health care system across the border, whether that’s Canada or somewhere else, that you think places that are doing things right that we should be adopting in order to improve our health care system?

VIKAS SAINI: Well, I went to medical school in Canada, I grew up in Canada. So for me, a single-payer system is almost natural. So I think universal coverage, everybody’s got coverage in a single-payer model makes a ton of sense. I think that Medicare For All is one version of single payer. It may not even be the optimal version. My own view is that we can do a lot better than Medicare or Medicare For All. We can do better in a way that would be different from Canada, different from Europe, different from any other country.

If very American, it would be decentralized. It would have a lot of local and regional autonomy and control. It would have elements that were tuned to the local culture. So I’d say single-payer is certainly nothing to be scared of. It certainly is the largest risk pool. It’s the most efficient in many other ways administratively, many other ways. But what you really need is a highly efficient and transformed delivery system, and that exists nowhere in the world. So I think I can see that America could have the best health care system in the world. It certainly does not now for lots of reasons.

JOEL BERVELL: Yeah. Well, Dr. Saini, thank you so much for your time, for your wisdom, for the work that you’re doing right now that’s so important, and for bringing your experiences to help us make the United States health care system better. I appreciate all your time.

VIKAS SAINI: Joel, thanks for having me. I appreciate it.

JOEL BERVELL: That’s it for The Dose in 2023, but we’ll be back next year, with more conversations about improving health care for everyone. See you then.

This episode of The Dose was produced by Jody Becker, Mickey Capper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There you’ll be able to learn more about today’s episode and explore other resources. That’s it for The Dose. I’m Joel Bervell, and thank you for listening.