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The American Journal of Managed Care January 2020
Using Applied Machine Learning to Predict Healthcare Utilization Based on Socioeconomic Determinants of Care
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What Accounts for the High Cost of Care? It’s the People: A Q&A With Eric Topol, MD
Interview by Allison Inserro
Health Information Technology for Ambulatory Care in Health Systems
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What Accounts for the High Cost of Care? It’s the People: A Q&A With Eric Topol, MD

Interview by Allison Inserro
To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a healthcare thought leader. Because January is our annual health information technology issue, we turned to Eric Topol, MD, of Scripps Research.
Am J Manag Care. 2020;26(1):17-18.
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.

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