IW: Is this an optimistic book? You talk a lot about barriers to change.
Bush: The early drafts of the book were more negative. I was appalled when I was working with Stephen Baker, who's the real author -- who took my outlines and my stories and did the interviews with me, really did the work of putting sentence structure around it -- that in my early sessions with him, what he came back with sounded really negative.
There is a lot of energy in me that wants to see forward motion. One of the great ironies in healthcare is the amount of incredibly well-meaning resources that go into freezing forward motion. The government is the most obvious and hilarious example, but there are a lot of other examples. Employers really don't stand up for what they believe to be right for employees. It's not just government that is doing this well-meaning neutering of the demand curve and of progress. It's all of us. And there are good reasons for it. It's not that government is doing this, or government is evil, or there are people with ulterior motives. This is scary, complicated stuff, and we're afraid of the harm. It's very much related to the Hippocratic Oath, which is a good oath.
The goal was a positive book, because the only way government will let go is if we ask them to, and if we start to make genuine forward progress in the health status and the cost of health status of people.
IW: This isn't really a book about technology, is it? You have one chapter, "Software Wars," that talks about what it's like to compete and coexist with Epic.
Bush: Even that one isn't really about Epic; it's what the customers of Epic are asking Epic to do. I don't fault Judy [Faulkner, Epic's CEO] for doing what her customers want, which is to create big iron systems that are impossible to refer outside of.
The question is, why are hospitals doing that? We're spending so many millions of dollars tracking primary care into more expensive venues. That's not a noble enough use of their time and capital. I'm making a case for everybody to allow or incent or to foment, to cause, disruption.
One of the reasons now is the time for this book -- and last year or 10 years ago or 20 years ago wasn't -- is that before, there was no Athena network, no Epocrates, Doximity -- no national networks positioned to enable instant, secure flow of health information.
IW: Even though you have a family partisan connection, I noticed the first story in the book is about legislation initiated under your cousin's administration that posed an existential threat to your company.
Bush: The issue is the scale of the government, regardless of which party you're in. The point of that chapter was to illustrate the scale of the impact of unintended consequences. We live in an ocean of unintended consequences. We create unintended consequences by the best intentioned of policies. Think of the hundreds of thousands of Mexicans killed as a result of the war on drugs. It's not a Republican or a Democrat thing.
IW: Your biggest foil in the book is really the big university research hospital.
Bush: Toward the end of the writing process, I started to get ideas that the foil should have been the third-party payment system. I now see an avenue for university hospitals, as well, which is the notion of super-regionalization. I started doing calculations on the cost of a small community hospital versus the cost of a helicopter, instead of doing secondary care at a tertiary medical center, stealing tertiary care from other tertiary care hospitals, and adding the cost of an airplane.
The opportunity for academic medical centers to be good guys in this book is greater than I thought. In fact, [Dean] Jeffrey Flier recently invited me on to the board of Harvard Medical School, and I accepted. I feel weird, like I'm sleeping with the enemy. I'm going to be the one in those meetings arguing that the story of Harvard Medical School is not the same as the story of [Harvard-affiliated] Partners Healthcare, and the story of Partners Healthcare is not the story of 18 community hospitals feeding three overpriced hospitals.
IW: Beyond helicopters, you also outline a role for jets with the Lowe's-Cleveland Clinic example.
Bush: Yeah. This is where, while Mass General and Brigham and Women's are too big for eastern Massachusetts, they're not too big for the United States. Even if you cut out 80% of what those two institutions do and refilled it with the 20% of the things they do in a truly unique, sensationally better way, they still would not be that big.
If you look at septal defect repairs on newborn children, there's only 4,000 babies born [with this defect] who live through birth, who live long enough to have heart defects repaired. You know, you can't have that many hospitals doing that. We probably have 40 in the United States, and we probably need three. You could do four, so that they're hungry.
Every tertiary medical center has the potential to be 10 times as big and profitable as it is today, 10 times as good at this rare work, 10 times as attractive for fellows and research, and yet one-half the impact on the cost [per patient]. This is the brave thing that hospital executives need to do, and 99% of them won't. But 1% of them -- maybe a little bit because of this book, and more because the healthcare Internet made it possible to market in the medical records supply chain where it wasn't before -- there will be a couple of kooks, a couple of crazy ones, where, when we look back in 25 years, ended up the geniuses -- ended up the Steve Jobs of healthcare.
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