Robert M. Wachter, MD Transcript

[00:00:01.240] Announcer:

America’s healthcare system is almost unanimously viewed as being unaffordable, dysfunctional and severely in need of transformation. APG President and CEO Don Crane talks with leading healthcare executives, physicians and other visionaries to explore solutions to lower costs and improving quality of care by accelerating the movement toward value-based care models and away from fee-for-service. Want to be inspired by our nation’s foremost thought leaders in healthcare? Then this show is for you. Here’s your host, Don Crane.

[00:00:35.650] Don Crane:

I sat down last week with Dr. Robert Wachter, one of the nation’s leading authorities and voices on the COVID pandemic, a scourge that might now be better known as the Delta pandemic. The nature of the virus and the war against it—’war’ being the term used by the CDC—has changed so significantly in a matter of weeks that our verbiage, as well as our public health tactics, have changed dramatically. Dr. Wachter is one of those few individuals in our country—Ashish Jha, Andy Slavitt, Gottlieb, to name a few—that have caught the nation’s attention as being reliable sources of information on the pandemic.

Dr. Wachter, for example, has some 200,000 followers on Twitter, but as you will hear in a minute, when I asked him to predict the course of the pandemic, he replied with a catchphrase that we have heard frequently during the pandemic: the need for humility as we predict the course of the virus. The science of scenario modeling has been complicated by the ebbs and flows of the virus and makes the business of prediction very risky, making even the most informed experts cautious about predicting the future.

Take a listen.

[00:01:50.980] Don Crane:

Dr. Wachter, good morning, good to have you with us, Bob, if I may call you that.

[00:01:55.360] Dr. Bob Wachter:

You may. I’m in California, so absolutely.

[00:01:58.390] Don Crane:

It’s allowed in California to use first names. Very good, such a liberal state. You are indeed more than imminently qualified for the conversation we’re about to have, mostly about COVID, et cetera. But you’re the professor and chair of the Department of Medicine at UCSF. And significant to our listenership, I believe, you’re considered by many to be the father of the hospitalist field, having coined the term hospitalist way back in 1996.

[00:02:29.270] Dr. Bob Wachter:

Actually, a twenty-fifth anniversary of that article that did that is next week. So, just to show how old I am.

[00:02:36.880] Don Crane:

Well, to show you how important really because it’s so key, it’s fundamental to what we used to call managed care and we now call pretty much coordinated or integrated care. The whole, you know, the management of inpatient becomes so important when trying to achieve, you know, cost, quality, patient satisfaction, et cetera, et cetera. So, and then more to the point, in a way, to bring us to where we are today in terms of current events over the last couple of years. Your tweets on COVID-19 were viewed by 200 million times by, I think I heard you say, now two-hundred thousand of your followers on Twitter. But whatever the precise numbers by my lights, you are now clearly one of the top, I think, commentators and leading lights basically on COVID and a trusted resource for all of us in the public as we try and stay abreast of this pandemic. And then finally, you have been clearly very conversant with podcasts, having stepped in for our friend Andy Slavitt and been his guest host on ‘In the Bubble’, which is downloaded about a million times. So, you’re pretty famous. And so, we’re really glad to have you with us today, Bob.

[00:03:55.900] Dr. Bob Wachter:

Thank you. It’s an honor to be here. And yeah, it’s interesting because I have done a ton of work in COVID. I’m a little bit of an epidemiologist. I’m not an infectious disease doctor, but I had the sense early on that this was going to be one of those issues that might benefit from folks like me and the way my brain works, which is I’m a true generalist. I really like trying to combine clinical medicine and policy and epidemiology and ethics and finance and sociology. It just felt like one of those problems that was going to be truly multidimensional. And I thought if I could make sense of what was going on, it might be helpful to other people. So, it’s been pretty gratifying.

[00:04:36.010] Don Crane:

Well, good work indeed. You know, I think as I said the other day as we spoke, I think you’ve performed an amazingly important public service, particularly as there’s so much misinformation out there. To have a knowledgeable, trusted resource is critically important. It is interesting for, you know, a CEO of APG, we talk all the time about population health, right? So, now we see really the kind of interface or overlap between population health, our assigned populations and public health. The two fields have had a kind of a merger of sorts or maybe they’re on a continuum. And so, I think we’ve all perhaps, unfortunately, gotten a lot smarter in some areas that we didn’t expect to. But good that we’ve done that. Hey, let me let me basically ask you to start with telling us what the lay of the land is here on the pandemic. So, we saw, you know, a guidance, I think, in the form of a PowerPoint that came out from CDC yesterday. But I think you also alluded to the possible release of a report out of Israel that could be pretty important. And whether that landed yesterday or not, I don’t know. But why don’t you synopsize for us where we are, where we stand with respect to the pandemic? Can I do that?

[00:05:51.380] Dr. Bob Wachter:

Yeah, of course. I think the last week has been jarring and fascinating and a little scary because one of the things that humans do, and that we do in science, is we learn things and then we extrapolate from those things to other things that seem like them. And that’s natural. And you can’t go around having to prove every single fact. So, you know, if the sky, the sun has come up in the sky every single day, you’re going to pretty much assume it’ll come up the next day, too.

[00:06:24.150] Dr. Bob Wachter:

So, I think the stage we’re at in COVID is that we fought so hard over the past year to understand the nature of the virus and how it infects people. And then, you know, how it spreads and what the possibly of getting sick was and dying. And then the vaccines came out and that was a game changer. We began to learn how effective they were and which groups…and then the variants began to hit, and if you remember all of last year, you know, people ask me all the time isn’t the virus mutating? I said, yeah, it is, but, you know, there are little typos in its genetic code, no big deal. What Delta has done is it’s changed the game in a number of ways. And I think the most important thing I’ve learned in the last week is I had gone under the assumption that when we prove that Delta does something different than the old virus, OK, I will accept that. But I’m going to assume that the other things I can just kind of extrapolate from old knowledge and what I think I’ve learned in the last week is that is a little hazardous, that Delta actually almost feels like a new novel virus and a little bit worse in many different dimensions.

So, kind of some of the things that have been surprising in the past week. One, the fact that it’s more infectious as the original, we kind of knew that, but it looks like it’s even a little bit more than I thought. What was a new piece of information is that if you’re vaccinated and you get a breakthrough infection, which we knew could happen, they’re not 100 percent efficacious, that your level of virus in your mouth and nose is as high as if you got a regular infection without a vaccine, which means you are infectious.

We’ve been going under the assumption that you really couldn’t spread the virus if you were vaccinated. People have gone under the assumption that if you’re vaccinated and you get a breakthrough infection, it’s going to be mild. You’re not going to get hospitalized, you’re not going to die. That’s still mostly correct, although we are seeing people get sick and go to the hospital. And part of what we have learned is that a study just came out from Israel a day or two ago in healthcare workers showing that folks that got breakthrough infections, not a ton of them, but enough to be meaningful.

About 20 percent of them continue to have symptoms six weeks later. So, even if you were vaccinated, you still don’t want to get this bug if you can avoid it, because you can spread it to others and you can have a fairly nasty, nasty case. And the final thing I’ll say is, in terms of upending my assumptions, I live in San Francisco. We are the A students when it comes to vaccination, the most vaccinated major city in the country, about 75, 80 percent of people in San Francisco are vaccinated. At least eligible people are vaccinated. Two months ago, I would have said that is high enough to reach regional herd immunity, meaning you’ll hear sporadic cases, but there is not going to be any spread. With that level of vaccination at UCSF Medical Center a month ago or six weeks ago, we had one COVID patient in the hospital. Today we have 40, four zero, 15 patients in the ICU. So, the level of immunity that you need to beat back this beast is significantly higher than we thought under the old bug. And so, a lot of the assumptions that we had, which really led all of us, I think, to say, oh, you know, we’ve been through hell, but the summer is going to be OK and we’re kind of out of the woods. Unless you’re in one of those places that has a 30 percent vaccination rate, those assumptions probably aren’t exactly right, which, of course, is depressing.

[00:09:57.320] Don Crane:

So, I can’t help but look at this through a very kind of practical, pragmatic light, sometimes. We have an annual conference coming up in December and thinking forward to it, and the level of social distancing that might be required, et cetera, et cetera. And I’m reminded of a commentary I heard this very morning from Brett Giroir, and he spoke to something that I was sort of guessing might be the case, which is that given the really, really high level of transmissibility, the RO factor, whatever it’s called, and kind of equating it, I think, to measles and other…

[00:10:33.790] Dr. Bob Wachter:

Chicken pox.

[00:10:35.570] Don Crane:

It’s very, very contagious. I mean, he’s basically saying it’s going to, you know, it’s going to race through the population, and we will have two categories of people…those that have been vaccinated and those that will develop the antibodies by having contracted the disease. And then I think his implication is we will get to herd immunity perhaps far faster than we ever imagined. It will be a painful and difficult course and maybe not be recommended, but that it’s a fact that we might get to herd immunity much quicker than earlier. Now, I would ask your reaction to that and help me with my own thinking. I mean, is this a situation here where almost on the first day of August, given the transmissibility, are we apt to see, you know, us get to a conclusion of this pandemic at an earlier date, one where it might actually make my annual conference in December less constrained by social distancing and the like? Is that a reasonable conjecture under the circumstances?

[00:11:34.370] Dr. Bob Wachter:

You know, Don, there was a famous Hollywood screenwriter who famously said “nobody knows anything” and we are kind of in the “nobody knows anything” category now. You know, because I think that what I thought would happen this summer, two months ago, is wrong. It’s worse than I thought. And it’s spreading faster than I thought and spreading in areas that I thought would have been at that level. Now, is it possible that that way of thinking is right, that it is so infectious that if you’re not vaccinated, you’re highly likely to get it? This has become a little bit of a mantra these days, and sort of a nice, almost cute little tagline. You’re going to get the antibody, you’re going to get immune one way or the other, either through vaccination or through natural infection. But it’s probably not right in ways that we don’t understand. You know, why, if you’re not vaccinated with a virus that’s twice, maybe two and a half times as infectious as the original, why would it not just rampage through the entire population such that either you’re vaccinated or you’re infected? The answer is it just doesn’t seem to be doing that. And that the Exhibit A is the UK, where there was a tremendous spike from Delta that lasted, you know, six weeks or so, and then it started to come down pretty sharply. And when I hear people comment on why, it just looks like a huge amount of handwaving. I mean, the bottom line is, nobody knows. It’s, you know, the soccer matches and that got sunny, and it got la-la. You know, I think there’s just a lot of mystery here about how this thing is working. And it makes…you know, I’ve got a big conference coming up in October…I just have no idea. It’s possible that this thing, this particular spike now will peak and come down in September. That’s what most of the models say. And, you know, and then, but is that going to happen? Because we’re going to be at 90% immunity through a combination of vaccination and natural infection?

I don’t know that we’re going to be that high. And if we’re not, I think there’s every possibility we’ll have another spike in the winter. So, I, you know, that’s been part of what’s been so frustrating about this thing that planning is difficult and the assumptions and the truths that we sort of came to know about the old virus, I think you’d have to say we just have to…humility is the watchword here. We have to be much more circumspect about saying “I’m sure that this is the case” because every new piece of data comes out and often upends what we thought we knew.

[00:14:07.340] Don Crane:

So, in preparing for this podcast this morning and last night, I think I saw the word humility used about 11 times. Speak, tell me about boosters. So, you know, we hear the CEO of Pfizer saying they’re likely. And then earlier we had heard will probably not necessary, et cetera, et cetera. Do you think will be required? Will we be seeing them? How efficacious will they be? How might they affect my annual conference scheduled for December?

[00:14:37.670] Dr. Bob Wachter:

My thinking about boosters has also changed in the last few weeks. And I think boosters are going to pose a very interesting sociological, ethical question, maybe akin to some of the other sociological, ethical questions we have posed, including vaccine mandates and the tension between individual benefit and public benefit. You know, these are sort of macro themes that have reverberated through the pandemic of the last 18 months. Here’s the question about boosters. If…let’s take me, 63-year-old man got my Pfizer shots in December and January. The data are now pretty clear that immunity from your vaccination does begin to wane after about six months or even past six months, it doesn’t go to zero. If I was 95% effective, efficacious of 95% protected after my shots, maybe with Delta, that number seems to be more like 85. And maybe now that I’m more than six months, maybe it’s down to 80 or 75. These are all estimates, but I think they’re probably pretty close. Still about 95% protected against getting very, very sick. I’ve had my two shots already, I tolerated them fine. The booster demonstrably raises your level of immunity significantly and almost certainly gets you back to where you were after shot two, maybe even better. That’s hard to know. At very low risk, very low probability I’m going to have a problem with shot three when I didn’t have problems with shot one or two. If you told me…if I got a call right now saying, Bob, if you go down to the Walgreens about three blocks away, you can get your third shot right now and don’t have to feel guilty about it. You’re not cutting in line. They’ve got extra shots and they’re going to throw them out if you don’t get it. I’m sorry to say, Don, I would stop this interview and I would go get my shot. It feels like low risk. It’s not like I’m sitting here in panic that I’m going to get COVID now because my immunity has waned a little bit or the Delta virus is nastier. But it feels like just weighing the risks and benefits, as we do with every therapeutic decision we make as physicians, I think the benefits probably outweigh the risk.

If I was 75, I would push 63-year-old Bob out of the way to get my shot before. If I was immunosuppressed, I probably would have gotten it yesterday. I would have figured out some way of getting it. If I got my first shot with J&J, I would run. And so, I think the case for boosters is increasingly strong and I’m guessing we will hear that they are now going to be recommended, I’m guessing, within the next month or two, although I have no inside knowledge about that.

Now, why isn’t that being done now? Because at a population level, there’s no question that the benefits of that next shot going into my arm are less than the next shot going into the arm of an unvaccinated person. Want to get really, you know, head-exploding zone in terms of ethics, you would say there’s no question that the benefits at a macro global level is they should go into the shot of the arm of someone in Indonesia rather than someone in the US. But the sort of the real-world question we have is you’re going to have individuals who feel like they’re at higher risk. That booster could help. It’s safe. And we’ve got enough vaccine. Now here’s where we’re going to get, it’s going to get pretty dicey. We have enough vaccine now. What if all these mandates kick in or the hundred bucks kicks in or whatever it is. There’s a run on the bank. Everybody now wants their shots, finally. And there’s not enough shots because folks like me have gotten a booster. That’s going to piss a lot of people off.

So, it’s really a tension between what individuals might want, which I think today many individuals would perfectly rationally want to get a booster. And what’s good for the public health in the population, which is probably not to give boosters to everybody yet maybe with the highest risk groups. And that’s going to be older people than me, who probably folks who got their shots more than six months ago, who are also older, and I think any immunosuppressed patients. So, I think those are going to be the first groups and I think they’ll start rolling out, I’m guessing, in the next month or so.

[00:18:53.990] Don Crane:

Well, I’m looking forward to seeing that happen. I’ll tell you, you know, you’ve touched on a number we said earlier the number of different kinds of disciplines, the areas of study and the like that are now involved as we look at this picture and you included the word sociology, which is in my notes from this morning, and I’m thinking of the Governor of Alabama talking about very explicitly, saying it’s time we start blaming the unvaccinated for the plight we’re now in. She didn’t use those precise words. But I just think at this sort of, you know, apart from the politics of it, the kind of sociology, two camps of citizens sort of on opposite sides, staring each other, glaring at each other. And I’d love your thoughts on the sort of sociology of that, how much civil strife we might see. Is their historical precedent, where you’ve had two or three camps, so confronted against one another, how do you look at that picture?

[00:19:55.370] Dr. Bob Wachter:

Yeah, it all has to be layered on top of the extraordinarily divisive political environment that we have to begin with. And those are just big machines and information/disinformation machines that are designed to keep their camps at loggerheads with each other and keep their bases happy. And on this one, masks fed into that, was shockingly that that became a partisan issue, vaccines and shockingly became a partisan issue. Boosters will be a shocking, you know, will be a partisan issue. You know, it’s sort of everything ultimately gets fed into that machine and gets and is seen through that lens. Is there precedent for it? You know, a little bit with the great influenza, there was an anti-mask camp and it was quite vigorous. But I don’t think…I don’t know of any precedent for the country kind of dividing into and seeing everything, including science, including, you know, you can guess what camp I’m in, including to me, demonstrably truth and facts as being, you know, what one side embraces and another side rejects. It’s profoundly unhealthy. It’s hard to see how you get out of it. And, you know, I think the way we have treated unvaccinated people has been to be quite interesting. In the early days, it really was very sort of understanding of folks with hesitancy. Take into account that a lot of hesitancy relates to historical issues, particularly in the black community in Tuskegee. A lot of, if you see low vaccine rate in certain populations, it’s probably going to be an access sort of an education/access problem.

And so, the job of the system is to make sure people understand the facts and get and make it as easy as possible to get the vaccine to them. I, you know, I think those were all perfectly reasonable strategies. I think to be more kind of aggressive about it would have engendered its own kind of political antibodies and created even more pushback and more partisanship. And so, it’s a perfectly reasonable way to approach things in the beginning. It doesn’t feel right now… I mean, if you are not being…if you’re not vaccinated now, chances are it’s not an access problem. It’s probably not an information problem as in you didn’t have access to good information. It may very well be an information problem, as in the ways you get your information. You’ve made a choice about what TV stations you watch and what radio stations and podcasts you listen to. And so, the sympathy that one has toward that group I think goes down, certainly has on my side.

And because the arguments are libertarian and are so profoundly individualistic, I don’t want to do it for whatever reason. They’re so sort of noncommunal. They don’t take into account the fact that this is not smoking and you’re making a bad choice about what to do with your body. This is secondhand smoke that you’re making a bad choice for the person next to you who may be super vulnerable and has made a different choice. And so, everyone has an interest in your behavior. And so, I think you’re seeing that. I think you’re seeing less tolerance for it. I think you’re seeing less pussyfooting around in terms of getting people vaccinated. We’ve gone from education and cajoling to lottery tickets to you can take a spin around Talladega Racetrack to you’re not getting into the restaurant, you’re not getting to the bar, you’re not going to be allowed back to work to the best…whoever figured out the NFL’s scheme needs to win a Nobel Prize in behavioral economics. You don’t have to get a vaccine, but if you don’t and your team forfeits the game…and your team loses because of an outbreak, because of you, that your team will forfeit the game and none of the players on either side will be paid. So, you’re going to have 100 250-pound-guys really pissed at you. I mean, that is that is so brilliant. And so, I think you’re going to see this get ramped up from, OK, you have to…you can’t go to work if you’re not vaccinated.

I think and I think the dam is broken on that. I think every company is doing that. Every healthcare organization is going to do that or have to answer some hard questions about why they’re not. And, ok, if you don’t do it, you’re going to have to get tested. I think it’s not going to be long before “And you’re going to have to pay for the tests yourself” or your health insurance is going to go up or something that’s more skin in the game. And the fact is we’ve got to do something different because the things we’ve done so far have gotten us to a 50% national vaccination rate. And that’s clearly not enough to get us out of this predicament.

[00:24:39.220] Don Crane:

So, I saw your tweet from maybe yesterday or the day before, about reaching a tipping point in terms of these mandates, but only with respect to, I think, the private sector, right?

[00:24:50.530] Dr. Bob Wachter:

No, the VA announced that they were requiring everybody in the VA…and then yesterday, Biden announced that every federal employee was going to be required. The state of California has done it. The city of San Francisco has done it. So, yeah, the government…I mean, look, nobody wanted to go down this path. It’s politically fraught. There will be battlegrounds and lawsuits and everything. But I think we reached a point where when, you know, as they say, the Churchillian response in a democracy is the worst system except for all the others. We’ve tried all of the other ways to get people vaccinated. They’ve not worked. And so, I think you’re going to see both private and public sectors be much more aggressive than they’ve been before.

[00:25:37.480] Don Crane:

Well, but I think my point would be that the government is a little more constrained than the private sector. So, as CEO of APG, I can say, you know, you’ve got to be vaccinated or you can’t come to work and so forth. The government can do that with respect to its own employees, but it can’t do so generally to the citizenry. We don’t think…we think there’s constitutional limitations on that. I think we’ve seen that historically as well.

[00:25:58.100] Dr. Bob Wachter:

I think that a fair point. And I think, you know, I mean, knowing Andy Slavitt and a fair number of people in the Biden administration…they just thought this was too hot to handle and that they wanted no part of it. And, of course, that was a perfectly reasonable way of thinking. And then when the vaccine rollout started going quite well in February and March, I think they felt like they dodged the bullet. That, OK, thank goodness we don’t…we’re not going to have to get into the vaccine mandate business. And in terms of talking points, you know, until this week, I can tell you every federal employee who had access to a microphone was told “do not say we have no comment on the issue of vaccine mandates.” And, you know, we know people are going to talk about it. We know it might happen. We’re not in that business. That was the talking point. And that was not irrational. But they reached a point in the last two weeks, and it’s because the game changed because of Delta…that they came to recognize that if they shy away from it, and the public and the private sector shies away from it, that the consequence is continued COVID and what that means for health and also for the economy. And so, everybody’s got courage. And then it’s kind of an interesting sort of political sociological phenomenon in, you know, when you look at a tough thing for a leader to do, I think often they’re looking around and seeing do they have cover? I mean, the second Nobel Prize next year has to go to the CEO of Houston Methodist who said, you know, everybody who works in my building has to get vaccinated and ended up firing a hundred people. That a brutally hard thing to do. Ethically, the right thing to do. And, but when he did it, he was out there on a ledge. Since then, AHA, AMA, American Nurses Association, all…every healthcare organization has endorsed the idea that every person who touches a patient should be vaccinated. And of course, I think that’s clearly the Hippocratic Oath ethical thing to do.

[00:27:57.760] Don Crane:

I couldn’t agree more. I can’t help but think about Macron in France. So, some number of months ago he was saying publicly, “Oh, we’ll never mandate vaccines” and the like. And then fast forward in time. You cannot go to your beloved cafe unless you’ve been fully vaccinated. And I think it’s produced a big uptake in the vaccine rate and the percentage that are vaccinated. And France is doing better now than before, I believe. I know England is.

[00:28:24.250] Dr. Bob Wachter:

No, that’s all true. And, you know, I can’t blame any of these people for not wanting to go there. It’s you know, it’s politically brutal. And I think the other thing that has changed is the attitude to the public has changed. So, the recent polls show a very strong majority of Americans, including about half of Republicans, now support mandate. So, I think there’s much more political cover because everybody’s tired of this. I mean, everybody really thought this summer was the end and we’d look back on these 18 months and say that was terrible, but we’ve made it through. And the idea that we haven’t and we’re going to have another uptick. And I went and got vaccinated and you didn’t. And you are threatening me and threatening my children. My tolerance for your private libertarian decision is just going to be lower than it once was. And that’s reflected in the polls. And the politicians and the business leaders here are partly showing courage, but partly responding to public sentiment. And I think, you know, I haven’t seen this yet, but for example, in New York, I think of the big hospital systems, the only one that has mandated is New York Presbyterian. I…it wouldn’t be inconceivable that at some point you’ll see a billboard in Times Square that says, you know, all of our healthcare workers are vaccinated: how about, you know, how about the place where you get your care? You know, which might sway a few people and certainly would motivate the others to move things along.

 [00:30:28.270] Don Crane:

You know, we’ve learned a lot, I think, from the pandemic in terms of systems and delivery models and payment models. And so, let me ask you a perfectly unfair question as we think about, oh, last March and April, when patients stopped seeing their physicians and primary care doctors and others all across the country went bankrupt or very nearly so because their patients wouldn’t show up and they were on a fee-for-service model. We’ve looked at that and see telehealth…so, here’s my unfair question. If you design a healthcare system…

[00:31:03.550] Dr. Bob Wachter:

You’ve prepped me well.

[00:31:06.520] Don Crane:

What would it look like? What is the high point? I mean, what are the leading features of a healthcare system that would be resilient and capable of handling a pandemic in the future, because I think we all know though…we don’t know when, but there’s likely to be another pandemic sometime in the future and one following it, and we’re going to need better systems that are better able to handle it. So, if you had the blackboard here and you were going to identify, I don’t know, three or four or five leading characteristics of a system, of a delivery system and healthcare system, that was well equipped to handle a pandemic, what might it look like?

[00:31:43.690] Dr. Bob Wachter:

Well, I guess I’ll push back slightly on the question. It’s not because it’s unfair, it’s perfectly fair. But I think there are two different questions, Don. One is, what does the system have to look like to deal with pandemics? And it clearly needs a far, far stronger public health infrastructure, better information systems, a button that you can push that automatically just everything rolls out…PPE rolls out, testing rolls out, the system for monitoring vaccinations that’s secure and reliable rolls out, the system to develop vaccines rolls out. That’s the one piece we got pretty right here. The connection between the public health system and the kind of acute care system is stronger than it was. A lot of it is in the information system. Talking to folks at Google who developed this, if you remember, Google and Apple developed this pretty cool tracking system that use your phone and was good for contact tracing. And then they tried to sync it up with the databases in public health systems. And they, you know, I remember talking to Karen DeSalvo who runs healthcare for Google and she said it’s like we went in there and they’re still using soup cans and strings as their information system. So that all has to get far more robust. And I think that, sort of, is going to be critical because there will be something else like this in the future. To me, I don’t think it’s fair to look at the fee-for-service failed in this year of the first of the pandemic because people couldn’t get to see their doctor to get their meds or their screening colonoscopy, or whatever it was. And therefore, fee-for-service is a failure. I don’t think fee-for-service is the right way to organize a healthcare system. I think if you were starting fresh, it would look like a capitated system where the incentives were not to do more stuff, but to keep people healthy. It would have very strong quality and safety measures, in part to be sure that people weren’t skimping on care. And I think that’s what blew managed care out of the water in 1995. There was no credible counterargument to the idea that now you’ve shifted the incentives to skimp on the care that people need.

[00:33:59.440] Dr. Bob Wachter:

So, it’s got to be credibly…it’s got to be a system that’s credibly set up to deliver the best outcomes at the lowest cost. And, you know, living in Northern California I look at Kaiser Permanente and, you know, I like working where I work for a lot of reasons. But I, there’s no question in my mind if I was starting fresh and setting up a system, it would look a hell of a lot more like Kaiser Permanente than it looks like the rest of our systems. You know, the hospitals and the clinics and the nursing homes and the hospices would be part of one system. And there would be a dollar that came into the system on January 1st to provide all the care for people. And so, we’d be agnostic as to where the side of care was and if we could care for people effectively at home and keep the hospitals empty and close them down, that would be what we would do. The system I have I, you know, I work in a hospital where if we could somehow manage to keep everybody out of the hospital and not get any MRIs, we would go out of business by this Friday. That’s not, you know…so, there’s no question in my mind that moving toward a more capitated, a more population health, a more value-based system is a better structure. It emphasizes primary care and prevention. It emphasizes integration. It allows you the opportunity to innovate with digital in ways that the fee-for-service system just tends to thwart. But I guess I don’t see it through the lens of look how screwed up the fee-for-service system was during the first year of the pandemic, because I think that’s, it’s just, it’s not artificial, it happened and it will happen again. But I think…I don’t think that’s the long view. The long view is what is the best system overall? And that if fee-for-service is a great system and it’ll take a six- to 12-month hit every time there’s a pandemic, I don’t think that’s a robust argument to can it.

[00:35:47.070] Don Crane:

It just, I think, triggered a bunch of scrutiny and debate that I think is probably helpful for policymakers. And so, I agree with you. Well, so before I let you go, though, let me go to my next unfair question. You know, we agree heartily in terms of what a future system might look like. Do you think we’re going to get there? So, the question is let’s pick 10 years out. Dare you offer some conjecture as to what our healthcare system will look like then? To what extent will we have learned and implemented fixes based on the lessons we’ve learned? What extent will we not? Have any kind of a prediction as to where we’ll be in ten years from now?

[00:36:34.540] Dr. Bob Wachter:

I think my biggest prediction is less in changes in the payment model, because I think I’m old enough to have remembering the inevitability of the end of fee-for-service because of all of its obvious flaws. I heard that in 1990, I mean, along with…

[00:37:00.270] Don Crane:

…2000, 2010, 2020, yes, I know.

[00:37:06.380] Dr. Bob Wachter:

I mean that’s part of the challenge that anybody, I mean, I’m sure a challenge for you…anybody who sort of says I am going to slant my kind of organization and financial model around the inevitability of value-based payment has gotten burned a fair amount because it turns out that the old system is pretty sticky for a bunch of reasons that I think we all understand. And, you know, along with those calls have been the “well, the healthcare system is unsustainable because we’re spending 11% of our GDP on healthcare.” Well, obviously it was not unsustainable because it was sustained. Sustained, 15 to 18 to 19. So, you know, at some point, clearly, it’s got to hit a tipping point. It can’t go to more than 100% of our GDP spent on healthcare. But these legacy models are pretty sticky.

I think the great disruptor is going to be digital. And I think COVID did accelerate that more than just the growth in telehealth. I think the growth in telehealth was an important tipping point because it made clear that the geographical model for healthcare, that every transaction occurs through a face-to-face interaction between a patient and a doctor is not going to be the way we go forward. But if all that happens is telemedicine and we’re just replacing 15-minute office visits with 15-minute televisits, I don’t think that’s the transformation. Transformation is in a more population health sort of mindset and obviously requires some payment reform that many people were caring for them in their house. We’re getting data from them, from their watch and their digital scale and their digital glucometer and their toilet is wired, and we see their urine electrolytes every day and all of that. That that is the fundamental way we monitor and manage people is sort of through kind of ambient collection of data digitally. And that, I think, is a 10-year…it’s not a three-year thing, but it’s probably a 10-year thing when a lot of care is delivered that way.

And it will mandate a reorganization in care because you then have this great tension between the doctors sitting in offices and hospitals sort of no longer doing much of their care in the form of an office visit. And so, reorganizing around that, when I talk about this, sometimes I’ll tell folks, well you hear about how wonderful it’s going to be for every patient to have all of this digital stuff at home, virtual monitoring, they’re filling out a survey every morning, they’re breathing into their iPhone, and all of that data are going to go to the patient’s primary care doc who’s going to say “thank you, I’m so much better able to manage my 1,800 patients.” You know, that’s not a world I’m familiar with. I’m sure you’re not either. Every primary care doctor I know will quit by five o’clock this afternoon if that’s the world. So, it clearly requires a new population health perspective, a new sort of model of almost air traffic control of sort of seeing all these people and seeing all these digital signals and making sense of them and having AI involved and having triage protocols. That to me is going to be the great disruptor and the legacy healthcare system will do some of it ourselves. But I suspect you’re going to see more and more new companies or old companies, like Google and Apple and others, see opportunities there be convinced that the old healthcare system won’t see these opportunities or won’t pounce on them and build new tools and new ways of caring for patients that begin to disrupt the status quo. Whenever we get into that discussion, I always make clear to people, you know, people say to me, look how healthcare is being disrupted by digital.

I say, are you kidding? You know, the unemployment rate among doctors is zero. The unemployment rate among nurses is zero. There are very few hospitals that have closed. We allow a massive amount of inefficiency in the system. My wife’s a journalist. I know what disruption of an industry looks like. People ask, why is that? And I say, well, first of all, doctors and everybody else in healthcare, we’re better lobbyists than taxicab drivers. And the stakes are higher. And you can’t do fail fast like Silicon Valley likes to do because you can have somebody dead. And so, you know, the regulatory environment is tougher. So, it’ll take…ten years is the right time horizon. Could take a while. I don’t think the payment system is going to change massively. I think it’ll change incrementally. But I do think digital and more virtual care and more care based at home and more entrants of both startups and the digital giants into our space is going to create a lot of substrate for change that I think is going to be very exciting, although a little bit dizzying.

[00:41:52.850] Don Crane:

Well, I look forward to it. You know, the other thing I look forward to is as I let you go here, maybe six or 12 months from now, we’ll redo this podcast and hopefully we’ll be looking backward at a, you know, in the rearview mirror at a pandemic that was sort of fully eradicated. At that point we can do a postmortem. The lessons learned from. Wouldn’t that be great?

[00:42:13.340] Dr. Bob Wachter:

My fear is, you know, if you had said that to me, if you’d interviewed me four months ago, or six months from now, we’ll do that, I would say that’s great, I can’t wait. And so now I’m just a little bit less certain of what that looks like six months from now, but let’s do it anyway.

[00:42:27.050] Don Crane:

At six may be too quick. I mean, we all know the horizon. I think, you know, maybe it’s three years from now, but there will be a day, for sure. And then we can revisit the subject and I really look forward to it.

Bob, this is a lot of fun and really informative. So, stay well my friend, ok?

[00:42:42.680] Dr. Bob Wachter:

Great talking to you. Thanks so much, Don. Be well.

[00:42:43.520] Don Crane:

Thanks. As you may have observed, our annual conference this year will now be held in person December 9th through December 11th at the Marriott Marquis San Diego Marina. Please save the date and be sure to register. It will be, to say the least, and extraordinarily welcome and refreshing chance to see each other in person once again. In the meantime, stay safe and be well.

[00:43:12.200] Announcer:

Thanks for listening to APG on American Healthcare with your host, APG President and CEO Don Crane. For more information about APG and transcripts of this show, visit the APG website at