What Accounts for the High Cost of Care? It’s the People: A Q&A With Eric Topol, MD

Am J Manag Care. 2020;26(1):17-18. https://doi.org/10.37765/ajmc.2020.42139

AJMC^®:

When AJMC^® launched in 1995, it was shortly after the Clinton healthcare plan had failed in Congress and 15 years before the Affordable Care Act was enacted. Right now, more Americans have health insurance, but struggles with price, cost, and access remain. What will it take for the United States to bring down the cost of care and widen access?

Eric Topol: Well, there are many strategies that are required; there’s not a simple solution. The price, the cost of care—it’s preposterous in the United States. That is in part [due to] the lack of negotiation of the government and tolerance for skyrocketing prices, not just of drugs, but [also] of hospitals and every aspect of medical care in this country. It’s whatever the market will bear; there are very significant lobbying forces that need to be reckoned with. So, the cost of care, I do think, is completely out of control, having spent quite a bit of time in the review of the National Health Service in the United Kingdom, where the cost per individual citizen is almost one-third of the US [cost] with outcomes that are superior. We have a ways to go to get this on track.

AJMC^®:

And of course, in the United States, we don’t have a technology assessment the way they do in the United Kingdom.

Topol:

Right, that’s just one of the many facets—that they have the single payer, the government negotiates the prices of things, all citizens are entitled to care. You know, there’s a whole different culture there, and it’s representative of many other countries. We are an outlier, a very negative outlier, with the worst outcomes for life expectancy, 3 years in a row decline, probably will be 4 with 2019, and over $11,000 per person to provide healthcare, and of course, millions of people who are not provided for. We are in a really unique, rarefied, negative outlier group with the worst mortality among mothers, expectant mothers, among children, among infants, of all the OECD’s 36 countries. Everywhere you look, we are too expensive and with poor outcomes.

AJMC^®:

Regarding the Affordable Care Act, 2020 is its 10th anniversary. What do you think has been its biggest achievement? And what do you think has been its biggest flaw?

Topol:

Well, that it’s unaffordable—it’s a major flaw. Basically, the main agenda was to get more people healthcare coverage access, but it didn’t tackle the fundamental issue, which is the out-of-balance cost of care. And that has to be addressed. It’s just been left now a decade with no reckoning, no efforts that are substantive to take it on. All the perverse incentives in this country persist and the Affordable Care Act, unfortunately, didn’t address that and it didn’t really emphasize innovations, the innovations of which could be a way to reduce the cost of care. Now we are seeing that in spades, in terms of ways to shift more responsibility to patients, more autonomy—which they would like—to reduce the cost of care, take advantage of digital technologies, which can do that as well. But we’re not doing it. So, unfortunately, you know, the Affordable Care Act and what we need are, you know, very different, very different orbits.

AJMC^®:

Along those lines, value-based care was heralded as a way to achieve the Triple Aim, but as we’ve been talking about, costs are still rising. On [some] health measures we’re doing worse. Is there a future for value-based care, or, without some other shift that takes place, is this emphasis on value just nibbling around the edges of the problem?

Topol:

It’s a joke, value-based care. Basically, we have one-third of the healthcare, but $3.6 trillion is waste—low-value care. We need to stop that. That’s part of why it’s so costly. And so this whole idea of value-based care doesn’t even get to it. There’s a long list of hundreds of things that each of the professional societies have called out as being shouldn’t be done anymore. And we’re doing it every day, you know, thousands, hundreds of thousands of times, every day and week in this country. We have to get rid of the waste and inappropriate and unnecessary care and we haven’t done anything to do that here of note.

AJMC^®:

JAMA published an update about waste and healthcare spending that estimated a new range of waste in the healthcare system going up to $935 billion.¹ If we took certain actions to cut that waste, we could save as much as $282 billion. This may seem like a chicken-and-egg question, but how can we afford some of those technological innovations and discoveries you discuss in your books while that level of waste still exists? At the same time, there’s an opportunity for those innovations, like AI or machine learning, to get rid of that waste. Can both happen at the same time?

Topol: I know, I’m familiar. There were many different commentaries associated with the JAMA paper, and they claimed a fourth of healthcare dollars [spent] in the United States are waste. Of course, Berwick and my analysis and others would suggest it’s much more than a fourth: It’s more like a third. It’s a multipronged thing. Technology is just 1 part of that. We still reward, basically, a fee-for-service mentality. We reward unnecessary procedures and testing and medications and everything. Until we stop that, we’re not going to get to the root of the problem. But there are technical ways to do that, as well. There are ways to have decision support, to monitor things in real time. There are all sorts of ways that technology can be a supplemental way of getting our arms around that problem, but I do think hundreds of billions of dollars a year in the United States could be saved by eliminating the unnecessary, inappropriate, and wasteful day-to-day practices.

AJMC^®:

Would doing that be a question of will, political will, or some other kind of organizational issue?

Topol: Well, it’s a combination of will, with all the pushback. One of the top lobbying entities in the country is American Hospital Association. Hospitals account for a third of the cost of healthcare in the US. It’s outrageous. We shouldn’t even be using hospitals for the most part, except in intensive care units and emergency rooms and operating rooms. We haven’t done anything to get out of that mode to get people out of hospitals to have them monitored in their own home. That could save not just the waste, but that could cut into the actual, what’s considered nonwaste today. We have, whether it’s pharmaceutical[s], the American Hospital Association,…the American Medical Association…These are all in the top 5 or 6 lobbying groups of the US government, and they’re not going to let up. A lot has been focused on drug pricing, and it’s obviously appropriate to zoom in on that, but it’s much, much bigger than pharma. It’s hospitals and all the associated labor.

The other thing that’s as fundamental is that we keep adding more people—human capital, labor—to the labor force, which is accounting for the absurd cost of care. And there are ways to do that without people. In fact, cutting the job force, and we aren’t doing that…that requires not just will, that requires modernization and not relying on people who [are] very expensive. This country is so into getting the employment rate up or unemployment down and not thinking about ways that we can replace lots of jobs or reduce the human capital requirements.

AJMC^®:

Are you talking about direct care staff or administrative staff or both?

Topol: Well, administrative staff. We have an absurd ratio of administrative staff relative to patient care, frontline people—it’s completely absurd. By the end of this year [2019], it’s projected we will have 100,000 human scribes, which is also absurd. We should be using AI and natural language processing to do that instead of human scribes. There are literally hundreds of thousands of jobs in this country that could be replaced with technology or at least reduced in terms of the number of full-time employees, because much of their effort could be done via machines and algorithms. So we’re not doing that either.

AJMC^®:

Are you talking about remote monitoring technology, or technology at the bedside?

Topol: No, I’m talking about getting rid of keyboards, getting rid of human scribes, getting rid of people who do coding, who do chart reviews, who do all the back-office operations. Basically, a very large proportion of administrators could be reduced without any reduction in outcomes for patients but with reduction in cost. It’s every level, not just the remote monitoring.…Lots of administrative operational functions could be cut drastically, without any reduction in outcomes—in fact, [it would] probably [come] with improvement but certainly with reduction of costs.

AJMC^®:

Would that be an improvement because you wouldn’t have human error when people are cutting and pasting and making assumptions?

Topol: Right, exactly. We are an error-laden healthcare mess, with over 12 million serious diagnostic errors a year—they have to get better. And that’s also driving up the cost of care, [not to mention] poor outcomes. That too has to be addressed.

AJMC^®:

You mentioned drug pricing, and compared with the therapies that existed in 1995, we now have these 1-time curative or potentially curative treatments, but the flip side is that they’re unaffordable for households and public budgets. Can innovation and translational scientific breakthroughs exist in that same space with access and affordability issues? Or do you ultimately think that technology will solve that, if the will were there?

Topol: There’s many different things that are required to keep the costs as low as possible. If you’re talking about pharma biotech, or you’re talking about devices?

AJMC^®:

Biotech.

Topol: One of the problems we have is we have now drugs that are a million dollars a treatment for rare diseases. That’s absurd. And basically, again, the companies can get away with just incredulous pricing, because it’s…whatever the market will bear. There’s no negotiation in this country or pricing, and it’s just accepted, and that’s not acceptable. We have to get serious about that.

AJMC^®:

Speaking of negotiation, can health improvements be brought about by this technology, and by the deep learning that you’ve always talked about, if income inequality still exists or keeps growing? Where does that come into play?

Topol: I think with digital technologies and software algorithms, it would be cheaper to give that to the indigent than to have them come in [for] 1 emergency [department] visit or 1 night in the hospital. Years of smartphone, internet, broadband, apps, sensors—you name it—would be far more parsimonious with expecting better outcomes than the way it costs today in our US healthcare system. We haven’t gotten at all progressive about trying to reduce the digital divide and the inequities by using technology because it’s so much cheaper, and we’re not taking advantage of Moore’s law.²…We don’t even exploit that to reduce the cost of care and also reduce health inequities.

AJMC^®:

Would these advancements also reduce the information-based imbalances that exist between doctors and patients, if this were more widely available?

Topol: Yes, that’s yet another chasm that needs to be addressed as well. That means patients should all have all their data—it’s their data—they should own it. We don’t respect that, we still have basically a paternalistic view, and patients still can’t get all their data, it’s sitting in lots of different health systems. This is just one example of the lack of ways that we’re doing to make healthcare more efficient and also truly patient-centered, instead of that term that’s abused so much.

AJMC^®:

Do you have any hopes for the current initiative by CMS and HHS for the Blue Button initiative?

Topol: No, I don’t. I have no optimism. There’s nothing being done in the United States that’s radical or progressive or what I consider vital to get us out of the woods at this point. I haven’t given up yet. But none of the things that I think are critically needed are being touched at this juncture.

AJMC^®:

Does something have to change at the education level to do that, medical school, and before that?

Topol: We can’t wait for that because that takes years to see any change. Medical school? Sure. But, you know, the vast majority of the workforce of the million physicians in the US is out there practicing and most of them are over 50. So we have a long-in-the-tooth workforce that are not yet part of the solution. It’s not just the people in the medical community, they just have their heads down trying to do the best they can with peak burnout, peak clinical depression, peak suicide levels, a global epidemic of clinician burnout. There’s nothing being done to address that fundamental problem. And we know that the more burnout there is, the more errors occur, the more waste occurs. And so it’s a systemic, kind of vicious cycle. And I see nothing being done to break that up or to get it on track.

AJMC^®:

If you had to look ahead 10 years, or 20 years, where do you think we’ll be in this situation?

Topol: Well, it can’t get much worse. I mean, to go for 4 years with declining life expectancy in this country. That takes a lot of work to do that. And to just keep having soaring costs. Eventually, there’s going to be a realization that you can’t just keep throwing people at it and getting worse outcomes and not ever reducing errors or the waste or the inequities. So I think it will get better because it’s unidirectional at this point—because of the way we have a lack of all citizens getting an entitlement of healthcare, which should be the case, as well as the government taking on an active role in negotiating prices, and then they’re embracing technologies that would liberate not just keyboards but hospital rooms and so many other things.

AJMC^®:

Do you want to say anything else about the future of healthcare?

Topol: [Laughs] No, I think I’ve said enough.REFERENCES

1. Shrank WS, Rogstad TL, Parekh N. Waste in the US health care system: estimated costs and potential for savings. JAMA. 2019;322(15):1501-1509. doi: 10.1001/jama.2019.13978.

2. Alvarnas J. From the editor-in-chief: oncology in the time of “Moore‘s law.” Am J Manag Care. 2019;25(5 Spec No.):SP140.

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