Excerpts from Interview with Atul Gawande
A century ago, we really finally drove childbirth from being one of the biggest killers for women and newborns to becoming a rare cause of death for women and a much, much lower likelihood of death for children. It was a combination of the government and the private sector. The private sector innovated around how you save the mothers’ lives and babies’ lives. But public information—a century now of [recorded] death rates of every hospital, every death of the baby and the mom—total transparency about where things go wrong [also played a role].
The Department of Public Health would potentially shut down a hospital if it was having bad results. It would hold people’s feet to the fire to maintain a minimum standard of care. You could get real competition between places over everything from the experience of care and whether they have a Jacuzzi or whether they have great clinicians. But you weren’t competing over whether your baby would die or the mom would die in one place versus another. The lesson I’ve [learned] from working on the nonprofit side, working on the private sector side, and having worked on the government side is: Given how much the big have gotten bigger, there will need to be much more data transparency about the actual services that are provided and what the outcomes are—whether it’s childbirth, primary care, cancer care, or surgery.
There is going to need to be close involvement from people in the public health system around whether it’s serving its minimum quality and appropriate levels of care. And the pandemic has made that eminently clear. We don’t have the basic information on whether testing is being done and where, who has access, who doesn’t have access, how well it’s being done, where the holes are, how much mental health has been damaged, how much our specialty care has been affected.”
Mémé: I confess I don’t know what WCE intended by the excerpt she provided. I think it has something to with using good data to make policy. So I extracted some sections I thought interesting as well.
Primary care is a service where you should have ready contact for the majority of your medical needs at any time of day. It should be a team that you have contact with, who knows you well enough to know what your goals are and how you’re doing over time against those goals. And it then should be able to deploy the assets of the healthcare system, which are enormous, right? Whether it’s highly complex, specialty care, getting you a COVID test, or recognizing your goal is to get pregnant and getting you on the right path there. It should be a system that could enable all of the assets of the system to serve your needs and then follow along to make sure that when it doesn’t serve your needs, you’re in good hands.
That basic service is a fundamental building block of many systems around the world, but it is not of ours. We don’t have a system for the fact that half of your life or more is going to be spent with at least one or more chronic illnesses, whether it’s high blood pressure or a complex heart disease.
We have a fundamentally broken system by having a healthcare system built around where you work. It means when you stop working, you lose your healthcare, you lose your primary care. You don’t have the connections sustained for big parts of your life like it should be.
I think the way that Medicare Advantage is evolving, Medicare [Accountable Care Organizations], some of the capitated [fee per patient] Medicaid plans is the ideal way to go. And what is that? It means you have a primary care relationship. Dollars flow on a monthly basis to that team to meet a certain level of convenience and efficiency, to get the full range of your needs from medicines to preventive care, to be advocates for you. And if they don’t do a good job, then you take your payment from them and it goes to the next clinician and the insurers reward them for being able to deliver on a certain quality and manage the cost constraints. That has been immensely popular in Medicare with more and more people flowing into that part of the system. I think it would be of great interest if we were to expand in the under-65 population