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Arun K. Gosain, M.D.
Dr. Robert Pearl has served as chief executive officer and executive director of the Permanente Medical Group. The Kaiser system (which dates from the 1940s) is responsible for the health of over 11 million subscribers and has over 200,000 employees; over 25,000 of them are physicians. As of the end of 2017, their operating revenue was $72.7 billion. Dr. Pearl is also known to us as a plastic surgeon and member of our specialty societies, including the American Association of Plastic Surgeons. He created the popular preparatory course for the oral board examination (full disclosure: I took the course in 1996.) He is a member of the Stanford faculty, where he continues to teach at both the medical and the business schools. Dr. Pearl’s expertise as a health care leader was tapped in the early formulations of the Affordable Care Act, and he gives an illuminating and honest appraisal of the process and the product. However, as this book went to print, Donald Trump had won the presidency and so there was uncertainty as to the direction of the threatened “repeal and replace” versus perhaps a “reexamine and reconfigure” of “Obamacare” to “Trumpcare.”
However, the motivating spirit (and dedicatee) of this book is the author’s late father, Jack Pearl, and the sequence of medical miscommunication and inefficiency that led to his untimely death. Indeed, starting with the very personal story of his dad’s health care experience and the effect on his siblings, the author effortlessly focuses both microscopic and macroscopic lenses on our health care system by engaging the reader with other individual patient anecdotes mixed with an analysis of the history, trajectory, and even psychology of this nation’s struggle to provide health care to all its citizens. For Dr. Pearl, context is everything in understanding how we as a nation stand at the precipice of unsustainable health care cost and yet lag behind so many other developed countries in outcomes such as infant mortality. He critically describes the powerful “legacy players”—stakeholders such as major insurers, hospitals, physician specialty societies, and drug/device companies—and how they shape not only policy but also the perception of quality and value in American health care, which is often incorrect and ever more expensive.
Dr. Pearl defines a patient-centric set of outcome metrics based on “the four Cs”: (1) cost, (2) clinical excellence, (3) coordination, and (4) compassion. How American health care can be repaired and transformed to yield this rests on four pillars (1) physician integration, vertically and horizontally; (2) preventive care; (3) full technologic enablement of health care; and (4) greater leadership training and development for physicians. Although zealous for the use of technology (e.g., fully intraoperable and accessible electronic medical record, video or telemedicine), Dr. Pearl is also fully sympathetic with the drudgery of electronic medical record data entry foisted on already overburdened physicians, and the looming loss of “high touch” for “high tech.” He is also wary of technology in search of problems to solve, rather than the other way around.
By definition, transformation will require disruption of our current broken system and how it is financed. Bundled prepayments, capitation, and other risk arrangements would reward better primary care and population health, as opposed to traditional fee-for-service that is canted toward specialist volume. Smaller practices, community hospitals/health systems, and even some insurers may not survive this drive for focus and the efficiency of scale, which, as sheer process, would be costly at first (few organizations have the organizational or financial heft of a Kaiser). However, Dr. Pearl, in business school parlance, displays the talents of both the “poet” and the “quant” in making convincing arguments for inevitable change. Few could integrate a better discussion of the social determinants of health or a meditation on baseball with such engaging prose. The bibliography alone is an excellent curriculum for those who want to read further. Treat yourself to Mistreated, and then be inspired to lead and help effect change.