In October 2008 the three Major League Baseball teams with the highest budgets—the New York Yankees, the Detroit Tigers, and the New York Mets—were sullenly watching from the sidelines while the Tampa Bay Rays, the franchise with the second-lowest payroll in the league, were playing in the World Series and glorified on televisions across America. The difference between the teams, besides payroll, was that Tampa was the only one using a data-driven approach. The Oakland A’s had a mediocre 2008 season, finishing third in their division, but the data-driven approach that Billy Beane had pioneered was once again proving its merit.
On October 24, a day off between games two and three, a curious op-ed appeared in the New York Times. You would have been forgiven if, after reading the authors’ names, you thought it was a prank. The co-authors were Newt Gingrich, a far-right Republican; John Kerry, a far-left Democrat; and Billy Beane, the general manager of the Oakland Athletics. The subject that was able to unite this strange trio was health care. The title of the op-ed was “How to Take American Health Care from Worst to First.” In summary, it was a recognition of the enormity of the problem and a plea to do better. “In the past decade, baseball has experienced a data-driven information revolution. Number-crunchers now routinely use statistics to put better teams on the field for less money. Our overpriced, underperforming health care system needs a similar revolution,” they wrote.1
The problems with health care are easy to spot, they wrote, consisting of everything we’ve examined so far—overtreatment, inconsistent treatment, procedures backed by slim evidence, bad incentives—and a failure to broadly adopt basic things such as handwashing, checklists, and repurposed drugs. And these problems, noted the authors, always circle back to a single issue: a lack of guiding data. “Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not—be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition,” they wrote. They went on: “America’s health care system behaves like a hidebound, tradition-based ball club that chases after aging sluggers and plays by the old rules: We pay too much and get too little in return. To deliver better health care, we should learn from the successful teams that have adopted baseball’s new evidence-based methods. The best way to start improving quality and lowering costs is to study the stats.”
But the op-ed didn’t just point out the problems with America’s health care system. The trio offered a solution. They proposed the formation of a data-driven institute with the sole purpose of providing this critical guiding data. “Working closely with doctors, the federal government and the private sector should create a new institute for evidence-based medicine. This institute would conduct new studies and systematically review the existing medical literature to help inform our nation’s over-stretched medical providers.” And the institute, they were careful to point out, would not overly encroach on the autonomy of physicians. “Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.” They also offered up success stories. Health care systems that were incorporating evidence-based measures to provide care that was not only better but at a fraction of the traditional cost.
One such system mentioned in the op-ed was an organization called Intermountain Healthcare. What makes Intermountain Healthcare so special? One name comes up: Brent James.
The Billy Beane of Health Care
Make no mistake: medicine must now begin a revolutionary transformation to transition from a central ethos based on physician self-sufficiency to one that cleverly constructs a data-derived boundary around cognitive bias–induced mistakes while still allowing the best parts of a physician’s intuition to flourish. Human intuition is an extraordinary, almost indescribable force. In medicine, intuition can be magical—an unconscious tapestry of connections percolating through to a conscious epiphany. The examples are everywhere: Eiseman’s “gut feeling” that antibiotics were causing dysentery and that feces might be the cure. The intuition that whispered to Crile that the radical mastectomy might be unnecessary. My favorite example is from the movie Lorenzo’s Oil. It’s the true story of a child with a rare inherited metabolic disorder that typically follows a tragic course, attacking the brain and central nervous system and causing blindness, deafness, paralysis, and then death at an early age. There was no treatment. In fact, the experts had yet to elucidate the precise metabolic pathway underpinning the disease. The parents, with no medical background, refused to give up. They immersed themselves in the endeavor to understand the core pathway behind the disease, reading countless textbooks, journals, and papers, day and night, until the exact metabolic pathology—and the cure—came to the father in a dream. The story is a profound metaphor for the mystical dimensions of human intuition.
Without question, this transformation in medicine is sure to be bumpy as we grapple for the right balance between a physician’s autonomy and data-based guidelines—an equilibrium that strives to mitigate flawed decision-making while still retaining, even enhancing, the profound power of human intuition. As this delicate balance is sought, the transformation is sure to be rocky. During the tumultuous transition the Oakland A’s went through after Billy Beane fired his talent scouts and committed to analytics the initial backlash was fierce. This transformation will have shades of the battle that Fisher fought to dethrone the radical mastectomy. He, too, faced fierce backlash, some colleagues even calling him a “murderer.” Indeed, this fundamental restructuring of the way medicine is practiced recalls an antiquated debate, a debate that has smoldered since the Greeks: intuition versus imperialism—the value of human judgment versus pure data. The clinical trial was the first incursion into a purely intuition-driven system. But it won’t be the last.
Since the arrival of the first clinical trial in 1947, the explosion of clinical trials sponsored by the pharmaceutical industry has saturated medicine with a mindboggling amount of data on individual medications, procedures, and surgeries. But, ironically, this data tsunami has also created new gaps in knowledge. The spectrum of five treatments available for someone with newly diagnosed early prostate cancer, referenced in an example given earlier, exemplifies this problem. No one knows which treatment is better because no trial has been done to directly compare one to another. Doctors face decisions like this daily—decisions they must make in a haze of uncertainty. And it’s right there—at the fuzzy interface where doctors must make decisions with limited data—where, behavior science shows, humans don’t perform well.
The consequences are easy to measure: massive variations in health care from one hospital to the next, from one clinic to the next, and from one physician to the next. Clearly all of the extremes in treatment can’t be right at the same time. There have to be “best practices” that lead to the best outcomes somewhere in the spectrum. But to search for the “best practice” is to encroach on the cowboy culture of medicine. Inevitably, some will view adherence to best practices as imposing limits on physicians—restricting their autonomy, devaluing their intuition, and valuing apathetic numbers over empathetic people. This is the frontline in the transition of the practice of medicine into a more evidence-based system.
Now, if there is one hero navigating this transition with the logic of Aristotle and the diplomacy of Kofi Annan, it is Brent James. But some heroes are more conspicuous than others. The archetypal hero is the fireman rushing into a burning building, the quarterback throwing the game-winning pass, the soldier that dies selflessly for his comrades. Brent James is not a household name. He is a different kind of hero, one who is not immediately obvious—except to the few who are paying attention. But if heroism were scaled in terms of human lives and money saved, Brent James would rise to the very top. James’s heroism has saved thousands upon thousands of lives, prevented an untold amount of suffering, and conserved billions and billions of dollars.
For over thirty years, sixty-seven-year-old Brent James served as the executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education for Intermountain Healthcare, a not-for-profit health system based in Salt Lake City, Utah. With 22 hospitals, more than 185 clinics, and 37,000 employees, it is the largest health system in the region. James entered medical school more out of practicality than passion. His first love was math. As the eldest of six kids growing up on a cattle ranch in Blackfoot Idaho, James often read a calculus book for fun. “I’m one of the relatively rare subset of people that finds math fun. Just thinking about it is fun. It’s how my brain is wired.” It became apparent to James, however, that it might be difficult to make a living with a math degree, and so he turned to medicine. But James never lost his love of numbers. After completing a residence in surgery, he again felt the seduction of numbers. Heeding his impulse, James took a job at the American College of Surgeons, where he employed statistics to study the variation that occurs among oncologists when they attempt to determine cancer stages. Soon after, James took a faculty position at Harvard’s T.H. Chan School of Public Health.
While in Boston a rattling divorce left him with a desire to be closer to his family out west. He seized the opportunity to take a position at Intermountain Healthcare in Salt Lake City. James arrived at Intermountain in 1986, on the heels of finishing his training in advanced statistics. His timing was perfect. Intermountain was one of the first adopters of an electronic medical records (EMR) system. For a statistician interested in improving health care, an EMR system represented unlimited possibility—it was the equivalent of a scalpel for a surgeon. James immediately recognized the opportunity. He would be able to use his knowledge of statistics to address one of the most vexing problems in health care: treatment variation.
When James took a look at the records he was astonished. The EMR revealed massive variation in treatment within even the single hospital system. “We started to follow up on the variations. We couldn’t determine who was right and who was wrong, but we could sure show that they were different,” said James. As disturbing as it was, it was also an opportunity to do better. James called a meeting with the physicians at Intermountain. He showed them the massive differences in treatment for patients with the same diagnosis. “We provoked a firestorm, frankly, a discussion about the best clinical practice within our medical staff.” James forced the doctors at Intermountain to confront a question: What treatment is best? This led first to constructive discussions and eventually to a consensus agreement on the best treatment for many conditions. James again turned to the medical record system. “We demonstrated a fairly massive narrowing in the variation that seemed to arise from those professional discussions, and it was associated with big improvements in clinical outcomes and at the same time significant drops in cost of care delivery.”2 By themselves, the doctors could not see beyond their own exam room walls. They couldn’t track the patient outcomes; they had no way of knowing what the best care was in every scenario. But armed with the EMR, James could.
The die was cast. In James’s view there was now unlimited opportunity to improve health care at Intermountain. His unique approach divided health care into two parts: the doctor and the system. Typically the system is intended to be passive, considered as little more than a shell within which the doctors operate, an infrastructure designed to be invisible. But James saw it differently. He boldly imagined how the system could help, becoming a dynamic partner with the doctors. James viewed his job as providing the data for doctors to do better, as working with them. “Ninety-five percent of our opportunity to improve outcomes is at the level of making it easier to do it right.… The trouble is when you mix complex systems with earnest hardworking, smart people, they will fail.… As a leader most of the time it’s you, not them, it’s the system and the context and environment that you create for them. My job is to make it easy to do it right.”3
James created teams that scoured through the medical records looking for opportunities to improve. When studies clearly provided optimal treatment guidelines, the Intermountain EMR allowed James to see whether or not the doctors were following the guidelines. Electively (meaning optionally) induced labor was one such example. Both doctors and patients often decide to induce labor for various nonmedical reasons, discomfort and convenience being the most cited reasons. In 1999 a recommendation was made by the American College of Obstetricians and Gynecologists, that, for the baby’s health, labor should not be electively induced before the 39th week of pregnancy. But doctors across the country didn’t seem to heed the advice. Either they missed the recommendation, or they simply had no incentive to follow it. This failure came with consequences. To induce a labor early increased the risk that the baby would be born with respiratory problems. When James and his team looked through Intermountain’s records they noticed that the doctors there were doing elective inductions before the 39th week at the same rate as the national average: roughly 30 percent of the time. James immediately sent out a protocol to the hospital’s gynecologists urging them to adhere to the recommended guidelines: no elective inductions before the 39th week. The gynecologists took notice, and the rate of elective inductions at Intermountain is now less than 2 percent. Coincident with this reduction, the number of C-sections and babies born with respiratory problems has also fallen. The total savings: $50 million per year.
James and his team went further. When data didn’t exist to establish optimal treatment guidelines for a given procedure, James and his doctors designed and executed the necessary studies there at Intermountain. For example, they thoughtfully considered the antibiotics given to patients to prevent surgical infection. A previous RCT had established that antibiotics were effective in preventing surgical-wound infections. The study, however, didn’t establish the optimal time to take the antibiotics. When James and his team examined Intermountain’s surgical records they noticed enormous variation in when the patients received the antibiotics. Some were getting the antibiotics 24 hours before surgery; others, an hour before surgery; and still others, 24 hours after surgery. The timing was all over the map. James reasoned that there had to be an optimal time to deliver the antibiotics that would result in the least surgical infections. To determine the best timing, James and his team convened four groups of surgeons. They asked one group to give the antibiotics within a 2-to-24-hour window prior to surgery, one group to give them within 2 hours prior to the surgery, one group to give them within 3 hours after the surgery, and the last group to give them in a 3-to-24-hour window after surgery.
After analyzing the data obtained from 2,847 patients, the result was clear: There was a massive reduction in infections in the group given the antibiotics 2 hours before the first incision. “Today of course it’s a no-brainer,” said James. “At the time it was amazingly counterintuitive.” James initiated the procedural change among his surgical staff at Intermountain. From now on, across the board, antibiotics were to be given 2 hours before surgery. That year, 1987, the cost savings from reduced surgical infections was a million dollars. Since then, that seemingly simple change has saved thousands of lives and hundreds of millions of dollars.
James and his team then tackled a condition called acute respiratory distress syndrome, usually a complication of the flu, in the same methodical way. In the late 1980s a ventilator was introduced at Intermountain as a possible treatment for respiratory distress syndrome. But the new machine came with a caveat: No one knew the optimal ventilator settings. James and his team soon noticed that the ventilator settings varied wildly from one physician to the next, each one convinced that their settings made the most sense. “I thought there wasn’t anybody better in the world at twiddling the knobs than I was,” confessed one doctor. But James had a plan: have the doctors decide on consistent settings as a starting point. “Guys, it’s more important that you do it the same way than what you think is the right way,” James pleaded. When the doctors began twisting the knobs to the agreed-upon settings, James’s EMR could then isolate and capture the data. Next, they adjusted the settings and again measured the outcome. In this methodical way, they eventually arrived at the optimal settings. Once these were established, the survival rate quadrupled, from approximately 10 percent before the optimization, to 40 percent.
The list of James’s victories at Intermountain goes on and on. Through a series of system tweaks, adverse drug events were reduced by half. Death rates from bypass surgery were also halved—from the national average of 3 percent to 1.5 percent. They standardized lung care for premature babies and cut the number that required ventilator support by 75 percent. They tackled cholecystectomies (removal of the gallbladder), hip replacements, and pacemaker implants. To date, James and his team have optimized hundreds of medical procedures, and the results are measured in human lives. “I can document more than 1,000 [patients] per year in Utah that a few years ago would have died, but today they don’t because of that approach,” James said.4
None of this was easy for Brent James. Once he had established a best-practice protocol at Intermountain he then faced the daunting task of getting the doctors across Intermountain’s 22 hospitals and 185 clinics to adopt it. There was the inevitable clash with the cowboy culture of health care. But James was prepared. He knew that once he established irrefutable data showing the best way to treat a patient with a certain condition, getting the doctors at Intermountain to implement it would take finesse and statesmanship.
Robert Watcher, chief of hospital medicine at the University of California, San Francisco, appreciated the delicate situation James was in. He told a New York Times reporter, “He knows that the minute he says, ‘I’m right, and you must do this,’ he loses everybody but the true believers.”5 But this isn’t what James did. And here lies his next display of artistry: inspired diplomacy. James did not see what he was doing as a direct challenge to the most important and coveted qualities of the physician: autonomy, intuition, and self-governance. In fact, he made it clear he had no intention of encroaching in a way that limited a doctor’s intuition. James acknowledged that every patient is different. Even with an established, evidence-based protocol, there will be patients that won’t benefit—and these patients need the skill and intuition of the individual doctor. “And this idea of a cookbook, a straitjacket, it just doesn’t fit reality. So we established an evidence-based best practice protocol fully realizing that you could not write a protocol that perfectly fit any patient in the vast majority of circumstances. There are a few narrow circumstances where you can,” says James.
Appreciating the touchy nature of the problem, Brent James’s deep understanding of psychology helped. Again, he turned to Intermountain’s medical records system. Once the data had established the optimal practice for a given treatment, James used the system to find the doctors who had consistently adopted the protocol. He would then track their outcomes. Once it was apparent that they were getting better outcomes than their colleagues, he would become their champion. “Then my main role, believe it or not, was to trumpet their success. So everyplace I went, if you saw me coming down the hall, you could count on me buttonholing you and telling you about the last couple of projects and who did them.”
What happened then was a sort of bandwagon effect—one doctor tells another, who tells another … Essentially, James, through positive reinforcement, co-opted the power of peer pressure. He created a self-perpetuating mechanism of peer-to-peer engagement to push uniform adoption. “Next thing you know, you’ve got somebody else on board and then you’ve got a few more on board, and the next thing you know, you’re well past the tipping-point.” James admits, “They were never going to respond to Intermountain. It’s when their colleagues within the profession started to lean on them.”
Ultimately, what James was trying to do, he says, was make it easier for doctors to practice medicine. To use data to look out beyond the walls of the hospital or clinic, to sidestep cognitive bias by giving them guidance in moments of uncertainty so that they could focus on what matters the most: the patient. To him, it’s not a battle at all, but an opportunity for the system to be better. “The key question for a leader is: How do we make it easy for them [the doctors] to do it right?” asks James. He masterfully frames the evidence-based system not as a fight, but as a collaboration that allows the intuition of the doctor to be less distracted and more focused. A system that is akin to a guardrail—a background safety buffer that allows doctors to direct their focus and intuition wherever it is most needed.
Another contributor to Intermountain’s massive savings—since implemented by other high-quality providers, including the Mayo and Cleveland clinics—is doing away with the main incentive to overtreatment: the fee-for-service payment system, a construct that behavior scientists have been pounding the table about for some time, calling it out as the most obvious and corrosive conflict of interest in all of medicine. It’s no coincidence that the best health care providers in the country pay their doctors a salary. “Fee-for-service payments have adverse consequences that dwarf those of the payments from pharmaceutical companies and device manufacturers that have received the lion’s share of attention in the conflict of interest literature,” said Professor George Loewenstein, a leading expert on conflicts of interest at Carnegie Mellon University.6 Recognizing the power of incentives, Intermountain takes it a step further. In addition to taking away the incentive to overtreat, Intermountain gives bonuses to the doctors with the best outcomes.
Because the system changes at Intermountain are preventative by nature and also realign incentives, the results may be tallied in both lives and dollars saved. By preventing surgical infections, adverse drug interactions, newborn respiratory problems, and on down the list, thousands and thousands of lives are saved every year. As are hundreds of millions of dollars. As Utah’s largest health care provider, Intermountain’s efficiency is immediately obvious. When the Kaiser Family Foundation, a nonprofit agency for health policy analysis, tallied Utah’s per capita spending on health care, they found it to be an astonishing 44 percent below the national average. And according to a 2008 report written by researchers at Dartmouth, if all providers across the country were to achieve Intermountain’s level of efficiency, the nation could reduce health care spending on acute and chronic illnesses by as much as 40 percent.7 In 2009, as the health care debate raged in Washington, DC, President Obama singled out Intermountain as a model of how to do better. “We have long known that some places, like Intermountain Healthcare in Utah, offer high-quality care at cost below average.”8
Of course, those who are ultimately paying the bill for health care can’t help but notice the successes of well-managed health care systems such as Intermountain’s. Insurance companies have begun to adopt some of the same evidence-based, best-practice protocols to rein in the massive variations in treatment and spiraling costs. They, too, are using payment incentives, awarding bonuses to physicians who follow these protocols. And given Charlie Munger’s emphasis on proper incentives, the Berkshire-Amazon-JPMorgan health care venture is almost certain to engineer a similarly creative incentive structure.
Variation in treatment has caused health care costs to soar along a dizzying trajectory. In reaction, many insurance companies have adopted “clinical pathways” as a tool to rein in costs. A clinical pathway is a suggested flowchart of treatment for a given condition. There now exist clinical pathways for most broad categories of medicine: cardiovascular disease, cancer, mental illness, and acute care, to name a few. The idea is to standardize treatment using the same formula as Intermountain—pinning down treatment protocols that offer the best outcome for the least cost. For example, when comparing chemotherapies, if two drugs show similar efficacy and have similar toxicity profiles, the insurance company will suggest the lower-cost drug in the clinical pathway. Incorporating the lower-cost drug results in an immediate cost benefit without diminishing a patient’s chances for survival. One study that looked at non-small cell lung cancer showed that treating patients “on-pathway” versus “off-pathway” resulted in a 35 percent decrease in cost—$18,042 versus $27,737—with no difference in overall survival.
Owing to the obvious benefits provided by clinical pathways, their use is growing. Today, roughly sixty individual insurance plans across the county, covering more than 170 million Americans, have implemented treatment pathways in oncology. Still, however, physician compliance is not guaranteed. Just as Brent James did, insurance companies have found they must incentivize physicians to follow the pathways. To do this, they typically dangle a carrot in the form of bonuses for those who follow the pathways.
With other hospitals beginning to adopt James’s managed-care strategy, and insurance companies steering more and more doctors toward clinical pathways, the noose is slowly tightening around the doctor’s long-standing autonomy. For better or worse, top-down oversight of their day-to-day practice has begun. As has the inevitable backlash. Some doctors are pushing back against what they call “cookbook medicine”—medicine that they say comes at the cost of treating each patient as an individual, the cost of restricting a doctor’s vaunted intuition. “It’s terrifying,” said a physician friend of mine who interviewed for a position at the Kaiser Permanente health system—an evidence-based managed-care system very similar to Intermountain—before starting his own private practice. “You feel like someone is always looking over your shoulder and watching your every move.”
“When we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients,” said Jerome Groopman, Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and best-selling author. “But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients.” Groopman is fueling the inevitable debate between a physician’s independence and groups like Intermountain and the insurance companies, who, in his view, have gone too far in directing doctors how to treat their patients. “Contracts for medical care that incorporate ‘pay for performance’ direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice,” says Groopman.9
The problem, claims Groopman, comes down to the occasional patient who might benefit from going “off pathway.” The patient’s doctor is then forced to face a moral dilemma: Do what he or she thinks is best for that patient and suffer financially or conform to the suggested pathway and get the bonus. “Margaret Tempero of the National Comprehensive Cancer Network observed that every day oncologists saw patients for whom deviation from treatment guidelines made sense: ‘Will oncologists be reluctant to make these decisions because of adverse effects on payment?’” asks Groopman. Groopman sees the incursion of best practices and clinical pathways as a blanket that smothers the ability of doctors to remain autonomous, to rely on intuition, and ultimately, to make the best decisions for their patients. “In truth, the power belongs to the insurers and regulators that control payment. There is now a new paternalism, largely invisible to the public, diminishing the autonomy of both doctor and patient,” Groopman wrote in 2014.10
Does Groopman’s argument hold water? Fundamentally, the question is whether or not the “new paternalism” is better for patients than holding on to the old culture that allows physicians to have all of the control when treating patients. When confronted with this age-old question, James falls back on the data. In fact, it’s hard to argue with the results: pneumonia mortality rates cut by 40 percent, surgical infection rates cut by over half, quadrupling the survival rate of acute respiratory distress syndrome. And a 40 percent reduction in overall cost. It’s impossible to ignore these results. On one side of the argument, it really is about numbers. “Don’t argue philosophy, show me your mortality rates, and then I’ll believe you,” says James. The numbers don’t lie. Reducing the amount of variation in treatment toward an evidence-based protocol saves lives. Period.
But Groopman argues that this comes at an invisible cost. The statistical approach used by James and, increasingly, by insurance companies turns doctors into a type of automaton, putting them on autopilot. He believes that this will inevitably engender a new physician-patient relationship in which doctors will rely too heavily on management. They won’t fully consider the person in front of them, digging deep into their personal history and making the intuitive connections that only the wisdom of years of experience will provide. Their intuition will inevitably diminish, and once-sharp instincts will dull. “Medical care is not just another marketplace commodity,” says Groopman. “Physicians should never have an incentive to override the best interests of their patients.” It’s easy to see his point. Anyone who has ever been sick knows the deep desire for intimate, one-on-one interaction with a provider. Patients want empathy, intuition, and to be treated as an individual. As a species, we desperately crave the human side of medicine—to be heard.
But Brent James doesn’t see it as a zero-sum game where one or the other must prevail. When data can narrow treatment and guide doctors, it should; but, James admits, it will never be able to solve all the problems in health care. There will always be situations in which we must rely on a doctor’s intuition. The way James sees it, best-practice guidelines do not diminish the role of the doctor. They serve merely as a signpost—a data-powered spotlight to help illuminate a small area of the darkness in which medicine is often practiced. Providing best-practice protocols narrows the vast uncertainty and allows doctors to better focus on the patient, says James. However, in the situations where data are not yet conclusive—the many cases where a best-practice protocol does not yet exist—patients need a doctor and his or her intuition. “To our physicians I say, ‘ladies and gentlemen, it’s not just that we allow or even encourage that you adjust this to the needs of your individual patients, we demand it,’” says James.
In the end, this debate circles back to Daniel Kahneman and Amos Tversky’s groundbreaking work. Brent James’s success at Intermountain is empirical proof that in many circumstances doctors don’t make optimal decisions. Intuition is often deceptive. This is not an admonishment, but rather simple recognition of what it is to be a human being. Individually, doctors can’t look out and track outcomes to guide treatment. But clinical trials and James’s EMR can. The history of medicine—examples like the radical mastectomy—offer a poignant narrative of the mistakes of the past. We have a health care system that is still thrashing and heaving, still grappling with the age-old debate between intuition and culture and empirical data and statistics.
But reforms like Brent James’s at Intermountain are offering a solution, an awakening, a truce between the two opposing sides and a path to work together moving forward. “Brent is the future. But how long are you willing to wait? It may take a hundred years,” said Lucian Leap, a former surgeon and professor of public health at Harvard.11 What is James’s response? “We have not yet begun to understand how good we can be.”
Brent James isn’t the only “moneyball” type of health care reformer. There are others, too, who have embraced creative, evidence-based solutions to improving health care. While stumping for health care reform in 2009, Barack Obama mentioned a few other such innovators. “We have to ask why places like the Geisinger Health system in rural Pennsylvania, Intermountain Health in Salt Lake City or communities like Green Bay can offer high-quality care at costs well below average, but other places in America can’t,” Obama said to an overflowing gymnasium at Green Bay Southwest High School. “We need to identify the best practices across the country, learn from the success and replicate that success elsewhere,” he continued. “And we should change the warped incentives that reward doctors and hospitals based on how many tests or procedures they prescribe, even if those tests or procedures aren’t necessary or result from medical mistakes. Doctors across this country did not get into the medical profession to be bean counters or paper pushers, to be lawyers or business executives. They became doctors to heal people. And that’s what we must free them to do.”12
One of the health systems Obama mentioned, Geisinger Health—a group of a dozen hospitals and clinics in rural Northeastern and central Pennsylvania—looked for a creative solution to tackle the already massive and growing problem of type 2 diabetes. Like checklists, handwashing, and the repurposing of five-cent, generic drugs, Geisinger’s idea seemed, on the surface, like an extraordinarily simple solution centered on treating the cause, rather than the symptoms, of type 2 diabetes. Their solution consisted of a single prescription: eat fresh, healthy food.
Globally, type 2 diabetes is a slow-moving health crisis. The majority of adults in the United States (52.3 percent), have either type 2 diabetes (14.3 percent) or prediabetes (38 percent), a category that is just a hop and a skip away from a diagnosis of full-blown type 2 diabetes. And the cost of treating type 2 diabetes in the United States is staggering—it currently exceeds $240 billion per year—and rising at a dizzying pace.
At its core, diabetes is the inability to process blood sugar due to a condition called “insulin resistance.” When we eat a carbohydrate-rich meal, the carbs are broken down through digestion into glucose (sugar). The pancreas, sensing the rise in blood glucose, then releases the hormone insulin. Insulin then facilitates the transport of glucose into cells, where it can be burned as fuel or processed into fat. As we age, however, this finely tuned process can become dysregulated. Our cells begin to lose the ability to respond to insulin; they become resistant to the hormone. The result of this phenomenon is excessive glucose lingering in our blood, elevating our blood sugar to dangerous levels. Glucose, a very rigid molecule, can easily cause physical damage to tissues it comes in contact with. This is why diabetics can experience such a wide range of problems, from nerve damage and cardiovascular disease to kidney disease, blindness, impotence, weight gain, brain fog, and a poorly functioning immune system.
The underlying cause behind the meteoric rise of type 2 diabetes in the world is a function of two lifestyle factors: diet and exercise. Exercise bypasses the need for the pancreas to secret insulin. Even mild movement like walking or doing household chores, for example, will cause muscles to act like sponges, soaking up glucose from the blood—sparing the need for the pancreas to secrete insulin. Additionally, avoiding eating too many carbohydrates also reduces the reliance on the pancreas to secret insulin. However, the combination of a sedentary lifestyle and the overconsumption of carbohydrates is increasing across the globe. Over time, this pernicious combination leads to insulin resistance. Insulin’s ability to funnel blood glucose into cells becomes worn out, leading first to prediabetes and then to type 2 diabetes.
The traditional way a doctor will treat diabetes is to do two things: First, prescribe one of the many drugs for type 2 diabetes; and, second, coach the patient on changing lifestyle factors. The problem is that most patients will try changing their lifestyle for a while, but then inevitably slip back into their old routine and become reliant on the drug alone. “I always try to motivate overweight, prediabetic, or type 2 patients on lifestyle changes. I’m not sure it makes any difference,” said my family practitioner. “It’s like the surge in gym memberships after people make all their New Year’s resolutions. The initial enthusiasm eventually fades.”
Aware of the futility of the standard approach, Geisinger set out to do better. Their idea: “The Fresh Food Farmacy”—a prescription for free, healthy food and continuous support. The pilot program, which kicked off in 2016, first screened for individuals who would benefit the most: low-income individuals with type 2 diabetes. (Being in a low-income bracket translates into a two- to three-times higher risk for developing type 2 diabetes.) The screening identified 95 individuals who matched the criteria. The doctors at Geisinger then wrote a prescription for free food from the Farmacy, a Geisinger-owned grocery store stocked with healthy, fresh food. The patients were provided with enough free food for two meals a day, along with a suggested weekly menu and recipes. Here, however, the team at Geisinger encountered a pitfall: It would be difficult for an individual to maintain the diet unless the whole family was on board. “The way we behave is really influenced by others around us.” Engaging the whole family could “make the program a lot more sticky and more likely to succeed,” said Mitesh Patel, a physician and assistant professor of health care management at the Wharton School at the University of Pennsylvania.13
Along with the prescription came support. Each patient was required to attend 15 hours of group counseling where they were taught the basics of diabetes—the role of insulin, what blood sugar is, and why too much sugar in the blood is bad, for example. The counselors also dove into topics thoughtfully designed to achieve sustainable lifestyle improvements: healthy eating habits, goal setting, exercise, and mindfulness. The patients were given access to a vast support network along the way, including a nurse, a primary care physician, a registered dietitian, a pharmacist, a health coach, a community health assistant, and administrative support personnel—all there to make sure the patient didn’t “fall off the wagon.” The team offered a range of help, including direct medication-management assistance; nutrition counseling; health coaching; and ongoing case management to address transportation, family care, and any other challenge that might derail a patient. The upshot of this immersive support was striking: patients became engaged. They began to ask about exercise, how to stop smoking, and other health-related concerns.
They also stayed compliant. The lifestyle changes stuck. And the results were dramatic. The blood marker hemoglobin A1C (or simply A1C) is a measurement that reflects the average level of glucose in a person’s blood over the previous three months. An A1C level below 5.7 percent is considered normal. An A1C between 5.7 and 6.4 percent signals prediabetes. And type 2 diabetes is usually diagnosed when the A1C is over 6.5 percent. The goal for any diabetes treatment is to lower A1C to a more normal level. After 18 months, the Fresh Food Farmacy program lowered the participants’ A1C an average of 2.1 percentage points. This result is remarkable when compared to medication, which lowers A1C by only 0.5 to 1.2 percentage points on average. Each percentage point decrease in A1C is estimated to save $8,000 per year in overall health care costs for the patient, insurance company, or government depending on the situation. But the calculated savings from the pilot program, so far, have proven even more incredible: “Because many of the participants are insured by Geisinger Health Plan, health care spending data are available for 37 of our patients. Thus far, claims data shows costs for our pilot patients dropped by 80 percent, from an average of $240,000 per member per year, to $48,000 per member per year,” according to David Feinberg, president and chief executive officer of Geisinger Health System.14
With these kinds of savings, it’s easy to see how the program will pay for itself rapidly. “It’s life-changing,” says Feinberg about the results so far. “It’s mind-blowing.” Because Geisinger has been able to supply the majority of the food from local food banks, with the remaining 40 percent of fresh vegetables, fruits, and fish coming from retail grocery stores, the operational cost per patient is only $2,400 per year—about $6 per week per patient. “If a new diabetes drug became available that could double the effectiveness of glucose control, it would likely be priced considerably higher than $6 per week (and if it wasn’t, the pharmaceutical firm’s stockholders would be in revolt),” wrote Feinberg.
Moreover, the effects on the patients are immediate. As Feinberg says, “[They] won’t go blind; [they] won’t have kidney disease, amputations. The list goes on and on.” But the ancillary effects are where a program like this gets really interesting. Because of the dramatic lifestyle changes, extending to the entire family in some cases, the Fresh Food Farmacy is shifting how the kids growing up in low-income households perceive the relationship between food and health. “It’s always a challenge to get people to maintain lifestyle changes over the long term. If you get the entire family to change the way they eat, you’re much more likely to improve health,” says Patel. “In health care we spend an awful lot on drugs and devices because it’s business,” notes Feinberg. “But we spend a very small amount on preventive medicine.… It’s sort of like we’re upside down and backward.” Geisinger’s Fresh Food Farmacy is a striking example of health care at its best.