My wife called while I was out walking to let me know that she had just heard that Atul Gawande had been named as CEO for the new healthcare organization that is proposed as a joint venture between Amazon, Berkshire Hathaway, and JP Morgan Chase. I was surprised at first and thought, “Atul is amazing, but he is not a medical manager. Why would he want this job?” Answering that question and exploring the hope of how someone of Atul Gawande’s knowledge, experience, and temperament might just be the answer to our prayers for a breakthrough that puts us back on course toward universal coverage and the Triple Aim was suddenly a very interesting subject to consider.
I’ve read some of Atul’s books and almost all of his New Yorker articles. I referred patients to his care for things as simple as a hernia repair and as delicate as a parathyroidectomy when we were both physicians in the same multispecialty practice. I am delighted to point to him along with Don Berwick, and Glenn Steele as former colleagues who, like me, were exposed to important concepts and breathed the same air of quality, safety, and innovation in the learning environment that Robert Ebert created when he launched the Harvard Community Health Plan.
One of the best speeches I ever heard was the one Atul graciously gave at one of our annual awards banquets where he focused on “the difference between ignorance and ineptitude.” I am just an acquaintance from his past, but I fondly remember the big smile on his face when he walked across the baggage claim area in the New Orleans Airport several years ago just to say hello and introduce me to his son when he saw me traveling with one of my sons. His success in many different spheres greatly exceed the achievements of most of us in one sphere. One of my fantasies is that, like Superman, he really comes from a more advanced planet in another galaxy.
He leads gently through his example as a practitioner, his willingness as a teacher to share what he has extracted from his reading and experience, and his insightful and inspiring prose. He is a connector of people and thoughts. When he speaks, people listen. In retrospect his choice to lead this new private effort of industry to improve health was a “no brainer.” If Elon Musk can get us all into space travel through the exercise of private enterprise, then perhaps Atul Gawande can lead us to universal care and the Triple Aim on a path through these three companies.
You may not know that there is a catalog of all of his writings from the New Yorker, Slate, and other publications that is available online. Any article that I mentioned below can be accessed through this resource. Through his writing the New Yorker has become a powerful voice in the debate about the future of healthcare. Perhaps it is a stretch, but at times I have thought that because of his writing the New Yorker may have eclipsed the New England Journal of Medicine as a source for insightful articles about current issues and the future of healthcare. His writing always builds on the lessons from the past, or what can be learned from data that we are collecting now. He has shown us that there is much to learn from how other industries manage complexity and safety. He is a believer in the benefits of both “low tech” and “high tech” innovations. He understands the necessity of disruption, but he also respects tradition.
I have many “favorite” Atul Gawande articles but when I heard of his new opportunity I immediately thought of the article that is probably my favorite, “Getting There From Here” written in 2009. I know that you may have a different favorite like “Cowboys and Pit Crews”, The “Cost Conundrum,” or the very powerfully written “The Hot Spotters”. Let me make the case for why “Getting There From Here” is an important article to remember as we think about what the choice of Atul Gawande might mean for all of us even though he will be working for Jeff Bezos, Warren Buffett, and Jamie Dimon.
Gawande begins the story with a profound observation:
In every industrialized nation, the movement to reform health care has begun with stories about cruelty…The stories become unconscionable in any society that purports to serve the needs of ordinary people, and, at some alchemical point, they combine with opportunity and leadership to produce change.
He was writing in 2009 as Congress was working on the ACA. He goes on to show how universal healthcare arose from patient concerns in Britain, France, Switzerland, and Canada and evolved out of the different systems that previously existed. In each case what happened was built on what previously existed when it became obvious to the public and to leadership that the status quo and the healthcare injustices that became motivating stories were no longer acceptable.
He adds more about the counter movements that have resisted change. Remember he wrote this article in 2009. It was prescient if you look back over the last eight years of Republican attack on the ACA that continues now in the form of President Trump’s “Association” plans, the undermining of Medicaid and Medicare, the reversal of the mandate, and the new legal uncertainty around coverage for preexisting conditions.
Yet wherever the prospect of universal health insurance has been considered, it has been widely attacked as a Bolshevik fantasy—a coercive system to be imposed upon people by benighted socialist master planners. People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse—especially for those who already have dependable coverage and access to good doctors and hospitals.
He covers a lot of history getting to his key point that the future will evolve from what exists now. This may not be good news for those whose opinions lie further left than his and look forward to abandoning what we have now for something new.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
He presents the concept of “path dependency” that drives a lot of outcomes like whether VHS or Beta would be the dominant format for video tape, or whether IBM’s PCs would be the initial computer choice of most businesses over Apple’s products. Over many decades, indeed over almost two centuries, our path in healthcare has been a path of private ownership. Over the last seventy years it also been employer funded for most preretirement consumers and families. That is a hard path to exit. That is the same path that Atul will have an opportunity to widen and pave with the resources of Amazon, Berkshire Hathaway, and JP Morgan Chase. He supports the validity of “path dependency” as an important economic concept by pointing out that Paul Krugman won the Nobel Prize, as did John Nash (remember a “Beautiful Mind”), articulating examples and demonstrating the theory behind “path dependency.” Gawande uses history and economic principles to argue that because of “path dependency” we are unlikely to get on a different path than private care in our quest for universal access and the Triple Aim.
With path-dependent processes, the outcome is unpredictable at the start. Small, often random events early in the process are “remembered,” continuing to have influence later. And, as you go along, the range of future possibilities gets narrower. It becomes more and more unlikely that you can simply shift from one path to another, even if you are locked in on a path that has a lower payoff than an alternate one.
In retrospect the hope of the ACA was founded in line with the principle of path dependency. It sought to continue the private delivery of care while expanding access through the public funding of those who were excluded from care by circumstances of poverty, previous illness, or the realities of difficult finance in the self insured market. He wrote when the last eight years were the future and not the past. I am sure that the ideas and the optimism that he expressed in 2009 are now buttressed by a clear analysis of what will work and what must be avoided as we continue our “path dependent” journey.
In designing this program, we’ll inevitably want to build on the institutions we already have. That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s).
When we live in confusing times our fears and worries are heightened when we look around and do not see credible leadership. Democrats don’t see credible leadership for the future of healthcare in the White House now, and Republicans did not see it when Barack Obama was the occupant. Perhaps we are looking for leadership in the wrong places when we look at the White House or at Capital Hill. Maybe a better place to look over the next few years will be Boston where Bezos, Buffett, and Dimon will be setting up Dr. Gawande with the resources necessary to shine some guiding light on the rest of the path that we all can follow. It will be an interesting process to observe. Gawande will not forget Don Berwick’s work and all the learning of the quality and safety efforts of the last quarter century. He has the advantage of age and experience. He is only 53 and has been thinking and working on the issues for over twenty years. He is a leader who has already made a big difference.
I think that he got off to a good start on the long journey ahead with his brief statement made at the time of the announcement of his new opportunity and challenge:
“I’m thrilled to be named CEO of this healthcare initiative. I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the U.S. and across the world. This work will take time but must be done. The system is broken, and better is possible.”
Providing better care for everyone that lives here and expanding that expertise for the benefit of the world is a huge objective. Success would definitely make America great. Leadership with the ability to coordinate people, ideas, and resources is always core to success when the task is solving difficult problems involving complex systems. There is reason to smile with renewed hope and expectations, and perhaps say a prayer of thanks on hearing of Atul’s opportunity to help all of us. It would be nice to think that Atul Gawande might enable all of us to enjoy better health at a sustainable expense before Elon Musk enables us to take long weekends in outer space.
