5 ms·

I know appeal to authority is obviously a bad way to support an argument, but I would imagine one thing the most senior people at Amazon, Berkshire Hathaway and

by qaq 8y ago

I know appeal to authority is obviously a bad way to support an argument, but I would imagine one thing the most senior people at Amazon, Berkshire Hathaway and JPM are fairly decent @ is picking management talent. So if all 3 sides agreed on a pick I would imaging there was pretty compelling case.

killjoywashere 8y ago
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.
- aaavl2821 8y ago
  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
  - entee 8y ago
    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/2674671 https://jamanetwork.com/journals/jama/article-abstract/26746...
    - aaavl2821 8y ago
      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/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta... [2] https://www.milbank.org/2017/07/getting-primary-care-oriented-measuring-primary-care-spending/ https://www.milbank.org/2017/07/getting-primary-care-oriente...
      - coredog64 8y ago
        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.
    - siculars 8y ago
      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?
      - 8y ago
aaavl2821 8y ago
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
- entee 8y ago
  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.
  - deleted 8y ago
    [deleted]
  - sjg007 8y ago
    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.

by qaq 8y ago

killjoywashere 8y ago

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.

aaavl2821 8y ago
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
- entee 8y ago
  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/2674671 https://jamanetwork.com/journals/jama/article-abstract/26746...
  - aaavl2821 8y ago
    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/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta... [2] https://www.milbank.org/2017/07/getting-primary-care-oriented-measuring-primary-care-spending/ https://www.milbank.org/2017/07/getting-primary-care-oriente...
    - coredog64 8y ago
      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.
  - siculars 8y ago
    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?
    - 8y ago

aaavl2821 8y ago

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

entee 8y ago
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.
- deleted 8y ago
  [deleted]
- sjg007 8y ago
  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.