What do you think?
Rate this book
The Long Fix: Solving America's Health Care Crisis with Strategies that Work for Everyone
It may not be a quick fix, but this concrete action plan for reform can create a less costly and healthier system for all.
Beyond the outrageous expense, the quality of care varies wildly, and millions of Americans can’t get care when they need it. This is bad for patients, bad for doctors, and bad for business.
In The Long Fix, physician and health care CEO Vivian S. Lee, MD, cuts to the heart of the health care crisis. The problem with the way medicine is practiced, she explains, is not so much who’s paying, it’s what we are paying for. Insurers, employers, the government, and individuals pay for every procedure, prescription, and lab test, whether or not it makes us better—and that is both backward and dangerous.
Dr. Lee proposes turning the way we receive care completely inside out. When doctors, hospitals, and pharmaceutical companies are paid to keep people healthy, care improves and costs decrease. Lee shares inspiring examples of how this has been done, from physicians’ practices that prioritize preventative care, to hospitals that adapt lessons from manufacturing plants to make them safer, to health care organizations that share online how much care costs and how well each physician is caring for patients.
Using clear and compelling language, Dr. Lee paints a picture that is both realistic and optimistic. It may not be a quick fix, but her concrete action plan for reform—for employers and other payers, patients, clinicians, and policy makers—can reinvent health care, and create a less costly, more efficient, and healthier system for all.
Beyond the outrageous expense, the quality of care varies wildly, and millions of Americans can’t get care when they need it. This is bad for patients, bad for doctors, and bad for business.
In The Long Fix, physician and health care CEO Vivian S. Lee, MD, cuts to the heart of the health care crisis. The problem with the way medicine is practiced, she explains, is not so much who’s paying, it’s what we are paying for. Insurers, employers, the government, and individuals pay for every procedure, prescription, and lab test, whether or not it makes us better—and that is both backward and dangerous.
Dr. Lee proposes turning the way we receive care completely inside out. When doctors, hospitals, and pharmaceutical companies are paid to keep people healthy, care improves and costs decrease. Lee shares inspiring examples of how this has been done, from physicians’ practices that prioritize preventative care, to hospitals that adapt lessons from manufacturing plants to make them safer, to health care organizations that share online how much care costs and how well each physician is caring for patients.
Using clear and compelling language, Dr. Lee paints a picture that is both realistic and optimistic. It may not be a quick fix, but her concrete action plan for reform—for employers and other payers, patients, clinicians, and policy makers—can reinvent health care, and create a less costly, more efficient, and healthier system for all.
302 pages, Kindle Edition
First published May 26, 2020
210 people are currently reading
1407 people want to read
Ratings & Reviews
Friends & Following
Create a free account to discover what your friends think of this book!
Community Reviews
Displaying 1 - 30 of 76 reviews
November 15, 2020
Always happy to hear physicians in positions of power who recognize we need deep change in our healthcare system and bring the absurdities of the U.S. healthcare system into the light for the public. However, I don't think she goes far enough. I disagree with her fundamental premise that "It doesn't matter who is paying, but what they are paying for." As a self-righteous med student, this is a position that I cynically expect coming from a sub-specialist and CEO as opposed to a physician working directly with un- and underinsured patients.
August 24, 2020
While it's easy to complain about how broken the American health care system is, it feels almost impossible to fully grasp the scale of the problem. This book did an excellent job bringing insight to every single problem the system face, and more importantly how to fix it. The author's hopeful outlook on the future was refreshing to read compared to the media's narrative around this issue.
July 2, 2020
If you are looking for an optimistic view on the push for value based healthcare this is a good read. Book is filled with great anecdotes, insightful stats, and actionable steps to improve US healthcare.
August 29, 2021
Quick read about the US health care system and recommendations to change it for the better.
Read
December 11, 2020Vivian Lee has an interesting perspective to share—she's worked as a radiologist, CEO of University of Utah Health, and now President of Alphabet's Verily Health Platforms.
This book covers some of the problems Lee identifies in the US healthcare system as well as some of the places where changes are working (or might work?). She's cautiously optimistic in spite of what reads to me as a bad situation with no sign of the market facilitating changes on their own and no few intimations of support from the institutional power forces as they are. It seems this is a problem that people will have to try to affect with their votes. She largely circumvents the discussion of single-payer healthcare until the final chapter which I found somewhat neglectful. I think the benefits of single-payer healthcare have been widely demonstrated outside of the US and would alleviate many (though certainly not all) of the problems Lee talks through in this book. (Here is a nicely presented case for single-payer model made by the Physicians for a National Health Program https://bit.ly/37TAAwS .)
This book was useful in understanding some of the underlying reasons for the "zero-gravity economics" in our healthcare system today (costs for treatment that float without any grounding principles). Much of the problem, she argues, boils down to how prices are set without regulation and how we have built a market that pays for services, not results.
The book basically hits the following beats
-Paying for health services instead of paying for health results is irrational
-We aren't treating patients in the best ways because it's not as profitable in the current system—she argues it's best to help people stay healthy at home (as opposed to visits in the hospital)
-Currently physicians/hospitals are at odds with insurance companies because hospitals have a business incentive to over-treat (patients have also grown to expect a full battery of treatments)
-Argues that we should use Six-Sigma-style process enhancements like in factories to improve quality of care in hospitals, but again, this isn't really incentivized by the way hospitals make money now
-Another way to improve quality of care is by publicly sharing the performance of individual physicians and by continuing to receive critical feedback throughout a career
-One of the first steps to fixing the 'zero-gravity' healthcare costs is to start making clear the actual costs of treatment (not the inflated price the market now pays for an MRI, but the actual cost)
-Pharmaceuticals is a web of vested interests that needs untangling and regulation
-Lee is optimistic about the potential of electronic medical records (and the potential of big data in healthcare)
-Encourages learning from employer health programs and also encourages employers to look out for employees' health through special programs
-Covers some things we can learn from government-run health systems like the VA
-Throws in a few comparisons with mostly European countries
Very readable. In my opinion she didn't dive enough into concrete policy suggestions, but I don't think that was her intent with this book. It should be read—like all things—with skepticism. Several other reviewers reminded me that Lee's perspective may be too affected her experience running for-profit healthcare businesses.
----Notes---
"By a few measures the US healthcare system is one of the best in the world, and by some measures it is one of the worst. The United States leads the world in medical innovation and its scientists are discovering new cures at an exhilarating pace... At the same time, some of the most ordinary but vital care isn't being received. For example, 46% of US adults have high blood pressure... but half of those affected aren't taking the life-saving pills that can cost just 10 cents per day. Hands down, the United States spends more per capita than any other nation... 2 to 3 times more than other high-income OECD nations. Despite this, about 1 in 11 Americans don't have health insurance and can't afford care."
"While most of the rest of the world is getting healthier and living longer, life expectancy in the US is declining."
"Americans spend more to get less health because we spend far too little on social services like housing, nutrition, education, environment and unemployment support."
-I thought this line was especially insightful and would've appreciated more discussion
Mental health
"In the 1980s, when rising costs led to complaints that people were overusing mental health care, health insurers began to carve out the care... They created separate policies and separate networks. Through clever pricing and network schemes like those that discourage patients with substance abuse or those who are more likely to use services from signing up, they drove the cost of care down. But these lower costs mostly came from reducing care."
-2008 congress passed Mental Health and Addiction Equity act, but it hasn't worked that well. Because so many providers are considered 'out of network' only about 2 of 5 adults with mental health condition received some care for it in a given year.
One thing I didn't understand about health insurance payouts from insurance companies to hospitals is that it is based on the price each hospital negotiates with the insurance company at the beginning of the year. For the same procedure, one insurer might pay three totally different payouts.
"Mark it up to mark it down" system
-Hospitals will make an initial estimate of what something costs and then they will make it up, sometimes 500%. Insurance brokers measure their success in the size of the discount they get. That's how you end up with $17 pieces of gauze! It loses all connection to reality.
-The biggest markups are in anesthesiology, CT scans, and MRIs—13 TIMES THE MEDICARE PRICES! This hurts patients. Uninsured and those out of network are charged at these exorbitant rates.
Complicated codes to report treatment to patients that apply to problems and comorbidities
-Over 70,000 ICD10 codes for diagnosis
-Figuring out which codes yield the highest payments is a high-stakes game for hospitals tallying up your bill
-Within Medicare, there is a base rate paid out for hospitalizations and then there is a multiplier for the types of treatments or major complications (a hip/knee replacement is 2x an appendectomy)
-Comorbidities and complications substantially boost the reimbursement so hospitals are always trawling for records of complications that they can bill insurers for
-Clinician's paychecks in a round-about way depend on how many diagnoses they type into the computer
-Example of Utah's medicaid program switching to a fixed-per-year payment for each medicaid beneficiary. When this switched the hospital drastically shifted to focus on results and preventative care.
-Argues to make costs available publicly
-"Patients should demand to know how much you will have to spend for every hospitalization and every test or drug. Ask your employer to obtain this information as part of their insurance negotiations."
-You should also provide customer feedback on websites that evaluate hospitals, doctors, healthplans and any other services.
Burnout and depression of physicians partially due to the healthcare system
-Death by suicide is the most common cause of death among males in their training as residents and the second leading cause of death among all residents.
Why do doctors err on the side of extra tests?
-Because of malpractice suits
-Lifetime of having to report that lawsuit for the rest of his life
--"These days there is little evidence that the threat of being sued improves the quality of care."
"Every hospital should follow every patient it treats long enough to determine if the treatment has been successful and then inquire if not, why not, with a view to preventing similar failures in the future."
-Ernest Codman
2016, Avg. generalist physician in the US made $218,173. Double the average of generalists in 10 other high-income countries (Netherlands, UK, Australia, Germany, etc.). Specialists average more too. Nurse make more in US. That said, she says the impact of the high salaries isn't the main problem in the cost of healthcare.
-Debt incentivizes students to pursue lucrative specialties instead of important roles as pediatricians, geriatricians, family med and internal med doctors.
Pharmaceuticals and "zero-gravity economics"
There is little regulation on drug prices. They exist at whatever the market will bear. In 2015 one pharma company raised the price of an anti-parasite med from $13 to $750 per dose.
-Like handing near-monopolies that can last decades
-Medicare, the nation's largest purchaser, is required to cover medication for six major conditions, including cancer, regardless of price and it isn't even allowed to negotiate
-Valeant CEO reportedly often said, "All I care about is our shareholders."
-Between 1996 and 2016, academic institutions spun out over 12,000 companies in pharma and health and biotech companies
-Should establish ways to measure the effectiveness of drugs and set price accordingly. "Cost for quality adjusted life year" is one of the metrics other countries use.
Employer-sponsored
How did we end up in the peculiar position of a country with mostly employer provided health insurance? In WW2, the government put measures in place to control wages. Crafty employers started offering fringe benefits to attract and retain employees. In 1943, the government stated that employers health insurance was not subject to wage controls rules and from then on employer-sponsored health insurance became a fixture of full-time US employment.
-Rising costs of healthcare supposedly is increasing the costs of US-produced goods (GM was spending $71 per worker per hour on healthcare, Toyota was spending $47).
-"GM is a health and benefits company with an auto company attached." - Warren Buffet
One of the things Lee advocates for in this chapter is that businesses should look at the anonymized health claims of its employees to try to figure out which health programs to offer. Also proposes health assessment questionnaires. It was interesting to be reading this book at the same time as Weapons of Math Destruction in which proxies for mental health in hiring questionnaires were weaponized against people. If the employer starts to use medical data from wellness programs to reward or punish it becomes very bleak very fast.
"Healthcare is a problem with bipartisan solutions"
"Is healthcare a universal right?"
-in 2018 surveys: 6/10 Americans believe it is the responsibility of the fed gov to make sure that all Americans have healthcare, that's up from 2014 when 4/10 thought so.
-Access to care or access to free care? is the most contentious point.
-What's the right public/private balance? We can learn from our three models 1. VA 2. Medicare and medicaid that operates through private-sector healthcare and 3. Private insurers and private-sector care
British, Swedish, Danish hospitals use a national health service. These countries negotiate pharmaceutical prices and allocate a fixed amount per year per person.
In Canada and Australia, the government manages health benefits while healthcare is provided by a mix of public and private hospitals. Basic coverage is mandatory, and then supplemental for-profit health insurance is also available for added benefits. Unlike the US system, the government budgets and pays hospitals a fixed amount each year. Prices of fees for service are limited.
Still other countries have models that are all private-sector, but regulated by the government. Switzerland has great health outcomes and costs a 1/3 less than the US spending. All citizens must buy insurance from private insurers that compete for their business. They must get at least the basic health plan. Policies and prices are standardized by the government and most pick the basic option. Insurance companies can't make money on basic policies, but they can on supplemental policies. Payments from insurers are not negotiated, but standardized by gov regulation.
She didn't spend a lot of time on this, but mentioned that Singapore has mandatory health saving accounts.
Decent Radiowest interview with Lee here:
https://radiowest.kuer.org/post/vivia...
This book covers some of the problems Lee identifies in the US healthcare system as well as some of the places where changes are working (or might work?). She's cautiously optimistic in spite of what reads to me as a bad situation with no sign of the market facilitating changes on their own and no few intimations of support from the institutional power forces as they are. It seems this is a problem that people will have to try to affect with their votes. She largely circumvents the discussion of single-payer healthcare until the final chapter which I found somewhat neglectful. I think the benefits of single-payer healthcare have been widely demonstrated outside of the US and would alleviate many (though certainly not all) of the problems Lee talks through in this book. (Here is a nicely presented case for single-payer model made by the Physicians for a National Health Program https://bit.ly/37TAAwS .)
This book was useful in understanding some of the underlying reasons for the "zero-gravity economics" in our healthcare system today (costs for treatment that float without any grounding principles). Much of the problem, she argues, boils down to how prices are set without regulation and how we have built a market that pays for services, not results.
The book basically hits the following beats
-Paying for health services instead of paying for health results is irrational
-We aren't treating patients in the best ways because it's not as profitable in the current system—she argues it's best to help people stay healthy at home (as opposed to visits in the hospital)
-Currently physicians/hospitals are at odds with insurance companies because hospitals have a business incentive to over-treat (patients have also grown to expect a full battery of treatments)
-Argues that we should use Six-Sigma-style process enhancements like in factories to improve quality of care in hospitals, but again, this isn't really incentivized by the way hospitals make money now
-Another way to improve quality of care is by publicly sharing the performance of individual physicians and by continuing to receive critical feedback throughout a career
-One of the first steps to fixing the 'zero-gravity' healthcare costs is to start making clear the actual costs of treatment (not the inflated price the market now pays for an MRI, but the actual cost)
-Pharmaceuticals is a web of vested interests that needs untangling and regulation
-Lee is optimistic about the potential of electronic medical records (and the potential of big data in healthcare)
-Encourages learning from employer health programs and also encourages employers to look out for employees' health through special programs
-Covers some things we can learn from government-run health systems like the VA
-Throws in a few comparisons with mostly European countries
Very readable. In my opinion she didn't dive enough into concrete policy suggestions, but I don't think that was her intent with this book. It should be read—like all things—with skepticism. Several other reviewers reminded me that Lee's perspective may be too affected her experience running for-profit healthcare businesses.
----Notes---
"By a few measures the US healthcare system is one of the best in the world, and by some measures it is one of the worst. The United States leads the world in medical innovation and its scientists are discovering new cures at an exhilarating pace... At the same time, some of the most ordinary but vital care isn't being received. For example, 46% of US adults have high blood pressure... but half of those affected aren't taking the life-saving pills that can cost just 10 cents per day. Hands down, the United States spends more per capita than any other nation... 2 to 3 times more than other high-income OECD nations. Despite this, about 1 in 11 Americans don't have health insurance and can't afford care."
"While most of the rest of the world is getting healthier and living longer, life expectancy in the US is declining."
"Americans spend more to get less health because we spend far too little on social services like housing, nutrition, education, environment and unemployment support."
-I thought this line was especially insightful and would've appreciated more discussion
Mental health
"In the 1980s, when rising costs led to complaints that people were overusing mental health care, health insurers began to carve out the care... They created separate policies and separate networks. Through clever pricing and network schemes like those that discourage patients with substance abuse or those who are more likely to use services from signing up, they drove the cost of care down. But these lower costs mostly came from reducing care."
-2008 congress passed Mental Health and Addiction Equity act, but it hasn't worked that well. Because so many providers are considered 'out of network' only about 2 of 5 adults with mental health condition received some care for it in a given year.
One thing I didn't understand about health insurance payouts from insurance companies to hospitals is that it is based on the price each hospital negotiates with the insurance company at the beginning of the year. For the same procedure, one insurer might pay three totally different payouts.
"Mark it up to mark it down" system
-Hospitals will make an initial estimate of what something costs and then they will make it up, sometimes 500%. Insurance brokers measure their success in the size of the discount they get. That's how you end up with $17 pieces of gauze! It loses all connection to reality.
-The biggest markups are in anesthesiology, CT scans, and MRIs—13 TIMES THE MEDICARE PRICES! This hurts patients. Uninsured and those out of network are charged at these exorbitant rates.
Complicated codes to report treatment to patients that apply to problems and comorbidities
-Over 70,000 ICD10 codes for diagnosis
-Figuring out which codes yield the highest payments is a high-stakes game for hospitals tallying up your bill
-Within Medicare, there is a base rate paid out for hospitalizations and then there is a multiplier for the types of treatments or major complications (a hip/knee replacement is 2x an appendectomy)
-Comorbidities and complications substantially boost the reimbursement so hospitals are always trawling for records of complications that they can bill insurers for
-Clinician's paychecks in a round-about way depend on how many diagnoses they type into the computer
-Example of Utah's medicaid program switching to a fixed-per-year payment for each medicaid beneficiary. When this switched the hospital drastically shifted to focus on results and preventative care.
-Argues to make costs available publicly
-"Patients should demand to know how much you will have to spend for every hospitalization and every test or drug. Ask your employer to obtain this information as part of their insurance negotiations."
-You should also provide customer feedback on websites that evaluate hospitals, doctors, healthplans and any other services.
Burnout and depression of physicians partially due to the healthcare system
-Death by suicide is the most common cause of death among males in their training as residents and the second leading cause of death among all residents.
Why do doctors err on the side of extra tests?
-Because of malpractice suits
-Lifetime of having to report that lawsuit for the rest of his life
--"These days there is little evidence that the threat of being sued improves the quality of care."
"Every hospital should follow every patient it treats long enough to determine if the treatment has been successful and then inquire if not, why not, with a view to preventing similar failures in the future."
-Ernest Codman
2016, Avg. generalist physician in the US made $218,173. Double the average of generalists in 10 other high-income countries (Netherlands, UK, Australia, Germany, etc.). Specialists average more too. Nurse make more in US. That said, she says the impact of the high salaries isn't the main problem in the cost of healthcare.
-Debt incentivizes students to pursue lucrative specialties instead of important roles as pediatricians, geriatricians, family med and internal med doctors.
Pharmaceuticals and "zero-gravity economics"
There is little regulation on drug prices. They exist at whatever the market will bear. In 2015 one pharma company raised the price of an anti-parasite med from $13 to $750 per dose.
-Like handing near-monopolies that can last decades
-Medicare, the nation's largest purchaser, is required to cover medication for six major conditions, including cancer, regardless of price and it isn't even allowed to negotiate
-Valeant CEO reportedly often said, "All I care about is our shareholders."
-Between 1996 and 2016, academic institutions spun out over 12,000 companies in pharma and health and biotech companies
-Should establish ways to measure the effectiveness of drugs and set price accordingly. "Cost for quality adjusted life year" is one of the metrics other countries use.
Employer-sponsored
How did we end up in the peculiar position of a country with mostly employer provided health insurance? In WW2, the government put measures in place to control wages. Crafty employers started offering fringe benefits to attract and retain employees. In 1943, the government stated that employers health insurance was not subject to wage controls rules and from then on employer-sponsored health insurance became a fixture of full-time US employment.
-Rising costs of healthcare supposedly is increasing the costs of US-produced goods (GM was spending $71 per worker per hour on healthcare, Toyota was spending $47).
-"GM is a health and benefits company with an auto company attached." - Warren Buffet
One of the things Lee advocates for in this chapter is that businesses should look at the anonymized health claims of its employees to try to figure out which health programs to offer. Also proposes health assessment questionnaires. It was interesting to be reading this book at the same time as Weapons of Math Destruction in which proxies for mental health in hiring questionnaires were weaponized against people. If the employer starts to use medical data from wellness programs to reward or punish it becomes very bleak very fast.
"Healthcare is a problem with bipartisan solutions"
"Is healthcare a universal right?"
-in 2018 surveys: 6/10 Americans believe it is the responsibility of the fed gov to make sure that all Americans have healthcare, that's up from 2014 when 4/10 thought so.
-Access to care or access to free care? is the most contentious point.
-What's the right public/private balance? We can learn from our three models 1. VA 2. Medicare and medicaid that operates through private-sector healthcare and 3. Private insurers and private-sector care
British, Swedish, Danish hospitals use a national health service. These countries negotiate pharmaceutical prices and allocate a fixed amount per year per person.
In Canada and Australia, the government manages health benefits while healthcare is provided by a mix of public and private hospitals. Basic coverage is mandatory, and then supplemental for-profit health insurance is also available for added benefits. Unlike the US system, the government budgets and pays hospitals a fixed amount each year. Prices of fees for service are limited.
Still other countries have models that are all private-sector, but regulated by the government. Switzerland has great health outcomes and costs a 1/3 less than the US spending. All citizens must buy insurance from private insurers that compete for their business. They must get at least the basic health plan. Policies and prices are standardized by the government and most pick the basic option. Insurance companies can't make money on basic policies, but they can on supplemental policies. Payments from insurers are not negotiated, but standardized by gov regulation.
She didn't spend a lot of time on this, but mentioned that Singapore has mandatory health saving accounts.
Decent Radiowest interview with Lee here:
https://radiowest.kuer.org/post/vivia...
October 27, 2022
A fascinating lesson with lots of practical ideas and research base strategies for improving health care. And now if we only had the wheel to implement them.
July 12, 2022
Insightful, compelling overview of the headaches and opportunities that characterize modern American healthcare.
A bit heavy on the “my company is awesome,” and almost exclusively a modern viewpoint, but touches on all key topics (pharma, insurance, digital health, etc.) in a succinct yet helpful way.
A bit heavy on the “my company is awesome,” and almost exclusively a modern viewpoint, but touches on all key topics (pharma, insurance, digital health, etc.) in a succinct yet helpful way.
July 31, 2021
Nobody likes our current health care system. There are countless people who complain online, or point to panaceas that should happen and fix everything instantly. I found this book to be a refreshing practical look at a variety of issues in the healthcare system, with pragmatic, pointed solutions. None of these solutions would necessarily create a utopia, but each of them would make incremental improvements that add up over time.
Our health care system is plagued by problems of convoluted billing and not enough time to focus on outcomes. Even this summarization doesn't do the book justice, as the author uses their experience to dive deep into each topic with plenty of data and results from actual efforts to make these improvements. Now that we know they work, it seems much easier to justify broadening these ideas.
Of the many people out there seeking health care system reform, this book is one of the few who knows exactly what to do.
Our health care system is plagued by problems of convoluted billing and not enough time to focus on outcomes. Even this summarization doesn't do the book justice, as the author uses their experience to dive deep into each topic with plenty of data and results from actual efforts to make these improvements. Now that we know they work, it seems much easier to justify broadening these ideas.
Of the many people out there seeking health care system reform, this book is one of the few who knows exactly what to do.
October 21, 2020
Sold. I want these changes and I want them now! Not just for me and my loved ones, but for all of America. No more pay-for-action, please give us pay-for-results. If I go to the doctor with a complaint, I prefer a good diagnosis instead of all the unnecessary testing. I’ve been on that treadmill before, and it wasted my time and money and was very anxiety-causing. I appreciated Lee’s breakdown analysis of all the different parts of our healthcare system, and giving us actionable steps to implement each one. Please, lawmakers and employers and insurance companies, please read and implement!! It’s a win for all of us.
November 27, 2020
I'm reading this book as I prepare for an interview at my top choice medical school. As prep material for such a high-stakes interview, I recommend this book. It will get you thinking on topics that are hugely important in the medical industry, from medical error to treatment costs. It does have its blind spots; as another reviewer said, the strength of "The Long Fix" is not tackling healthcare inequity. Lee's battle hymn is inefficiency and unnecessary expense, but the dots could easily be connected between those issues and the dearth of healthcare resources in underserved communities. Perhaps if health centers in wealthier areas were run more efficiently and and were incentivized to keep their patients healthier, those healthcare systems could better afford to maintain clinics in disadvantaged areas...in an ideal world where profit wasn't the bottom line, that is.
I would also recommend it to people not in healthcare. Before I gave birth, I interviewed my hospital about the possibility of hidden costs, and what I could expect my plan to cover. Dr. Lee recommends that all patients take this interest when they are going to have a procedure done, doing at least as much due diligence as they would if they were going to choose a restaurant for a nice date. I appreciated that take on the responsibility of the consumer, even while it saddens me that capitalism dictates our current healthcare system here in the US more than any other force right now.
I would also recommend it to people not in healthcare. Before I gave birth, I interviewed my hospital about the possibility of hidden costs, and what I could expect my plan to cover. Dr. Lee recommends that all patients take this interest when they are going to have a procedure done, doing at least as much due diligence as they would if they were going to choose a restaurant for a nice date. I appreciated that take on the responsibility of the consumer, even while it saddens me that capitalism dictates our current healthcare system here in the US more than any other force right now.
June 19, 2023
[19 Jun 2023]
I'm diabetic and in my 70s, so I'm a frequent user of healthcare. I'm also educated and reasonably comfortable financially, though not wealthy by any means. So I'm very interested in the state of the American health care system and how to fix it. Because it's definitely broken.
This book is interesting, but mostly disappointing. A lot of what she recommends has been said before many times, but not much changes. Her primary recommendation is that the basis for providing care should be results, as opposed to the current "fee for service" system. There are a few efforts along the lines she recommends, but none of the big power centers are behind them. To my mind things will not significantly improve as long as the American medical system is profit driven, and to change that, the government must be involved. I recently read an interesting article in the NY Times that compares our system to several others in similar countries and makes that very point.
Lee's book is still worth reading, since it goes into some detail about a number of different aspects of our health systems, though it can be somewhat repetitive. But it's a short book -- slightly more than 200 pages of actual text -- and it's an easy read.
I'm diabetic and in my 70s, so I'm a frequent user of healthcare. I'm also educated and reasonably comfortable financially, though not wealthy by any means. So I'm very interested in the state of the American health care system and how to fix it. Because it's definitely broken.
This book is interesting, but mostly disappointing. A lot of what she recommends has been said before many times, but not much changes. Her primary recommendation is that the basis for providing care should be results, as opposed to the current "fee for service" system. There are a few efforts along the lines she recommends, but none of the big power centers are behind them. To my mind things will not significantly improve as long as the American medical system is profit driven, and to change that, the government must be involved. I recently read an interesting article in the NY Times that compares our system to several others in similar countries and makes that very point.
Lee's book is still worth reading, since it goes into some detail about a number of different aspects of our health systems, though it can be somewhat repetitive. But it's a short book -- slightly more than 200 pages of actual text -- and it's an easy read.
July 18, 2021
"Hands down, the United States spends more on health care per capita than any other nation - nearly one-fifth of the US economy goes to pay for health. That's two to three times more than other high-income Organization for Economic Co-operation and Development (OECD) nations like the UK, Canada, Germany, Japan, and Australia, where health coverage is universal. Despite this, about 1 in 11 Americans don't have health insurance and can't afford care." - Vivian Lee.
Vivian Lee is able to clearly write about the challenges that the US healthcare system has been facing, and different approaches of reform to solve for the long term (like a fee-for-results system instead of the current fee-for-service system). However, I felt like it could have gone more in depth, given how complex of an issue this is involving many, many stakeholders. Overall, definitely recommend this read for everyone, but especially those interested in healthcare and health policy.
Vivian Lee is able to clearly write about the challenges that the US healthcare system has been facing, and different approaches of reform to solve for the long term (like a fee-for-results system instead of the current fee-for-service system). However, I felt like it could have gone more in depth, given how complex of an issue this is involving many, many stakeholders. Overall, definitely recommend this read for everyone, but especially those interested in healthcare and health policy.
March 25, 2022
As a healthcare worker, I wasn’t startled by any of the information in this book, but it was a nice refresher on the structural deficiencies in our system that lead to expensive care with suboptimal outcomes. The author did a great job of giving specific, actionable suggestions for how each person can push for change at whatever level of the system they participate in. Finally, it was a very balanced book that didn’t push for one solution, but instead opted for generalized goals that anybody of any political background would have a hard time opposing.
April 30, 2025
Insightful, mindful thoughts from a global healthcare leader. As a faculty member at Utah, I saw first hand how her creative energies crafted a best-in-class value-driven enterprise, topping the Vizient rankings repeatedly. Presently, as our department partners with UC Davis healthsystem leadership, i continually reference what I have learned from her. Highly recommend this read for those dedicated to improving U.S. healthcare.
October 15, 2020
Must read for every US citizen to understand our health system and the role each of us can play (there are concrete recommendations) in improving it.
September 13, 2020
Awesome Read
This book is a positive, understandable overview of our healthcare system. The fix to a better care/ better outcome system that also saves money and lives laid out in simple precise detail . Excellent read!!
This book is a positive, understandable overview of our healthcare system. The fix to a better care/ better outcome system that also saves money and lives laid out in simple precise detail . Excellent read!!
January 8, 2024
The Long Fix: Solving America’s Health Care Crisis with Strategies That Work for Everyone by Vivian Lee.
5/5 rating. 208 pages.
Book #37 of 2021. Read April 26, 2021.
I have read 442 books since the beginning of 2017 and this is one of the 3 best out of all of those. EVERYONE should read this book about how we can change our health system.
Each and every person is impacted by the choices that not only you, but your insurer, the government, and the hospitals make about your health. It's time to stop being passive consumers of the single most important service in our lives: healthcare. Vivian has held many important positions within the healthcare field, and she has used her experience and research to come up with the ways that our system is most broken. I think even more importantly, at the end of most of the chapters, there are steps that we all can take to improve these systems: whether you are an insurer, a medical professional, or just a consumer of healthcare.
Unlike "The Healing of America" this book is much more based on the healthcare itself as opposed to the insurance system. Vivian makes the absolutely obvious statement that we need to shift from pay-for-service to pay-for-results. In what other realm would we pay just because something was done? Who cares if 100 different tests were completed but you are no closer to being properly treated? Along with this, there needs to be vastly more transparency in the medical system: did you know that it's not just you who doesn't know how much care costs? Almost no one in the system knows the costs, what kind of "business" is this!?!
It may be counter-intuitive, but as Vivian says: "If our nation stopped expecting quick fixes—a prescription, a referral to a specialist, an MRI, an operation—and instead put a premium on measurably improving lives for good, then prevention would become paramount. The medical world would focus on diet, sleep, and fitness."
Fixing our healthcare will certainly not be easy, but if everyone reads this book and starts to push for the ideas that Vivian recommends, maybe we can start to turn it around and make a healthier America.
Quotes:
"Hands down, the United States spends more on health care per capita than any other nation—nearly one-fifth of the US economy goes to pay for health. That’s two to three times more than other high-income Organization for Economic Co-operation and Development (OECD) nations like the UK, Canada, Germany, Japan, and Australia, where health coverage is universal. Despite this, about 1 in 11 Americans don’t have health insurance and can’t afford care."
"Babies born in the United States in 2017 are expected to live 78.6 years, 5.6 years less than those born in Japan, which places us 26th out of 35 OECD nations in life expectancy."
"The Institute of Medicine (now National Academy of Medicine) estimated in 2012 that we waste 30 cents of every dollar we spend on health care. That’s over $1 trillion per year. Some of the waste is fraud and abuse, but most of it comes from failures to care for patients properly."
"In the United States, about 8% of spending on health care is spent on administration."
"We put people in hospitals who would be better off at home. In the hospital, we attach them to costly life support systems, even when they have asked to be left alone. While four out of five people would prefer to die at home, only one out of five does. Most people still die in a hospital or nursing home."
"Our system rewards action, not better health outcomes. It encourages overtreatment and specialty care at the expense of prevention and primary care."
"If our nation stopped expecting quick fixes—a prescription, a referral to a specialist, an MRI, an operation—and instead put a premium on measurably improving lives for good, then prevention would become paramount. The medical world would focus on diet, sleep, and fitness."
"Because we have an insurance model of paying for health care, the normal economic rules of the market don’t readily apply."
"Health systems like ChenMed that are paid to keep patients healthy recognize that what happens to patients in their clinics is often less important to their health than their circumstances at home: whether they are financially secure, have access to fresh food, live and work in a safe environment, and have adequate access to transportation and housing."
"One study estimated that about 25 cents of every dollar collected by a hospital is spent on administration, which means American hospitals spend more on paperwork than they do on nurses."
"Because Medicare’s internal costs for administration are a fraction of those commercial payers, Medicare-for-all could reduce administrative costs from around 14% to 6% or less."
"If doctors and hospitals only got paid if patients did at least as well as expected, it could obviate most of the billing and coding requirements, with considerable potential savings. By simplifying and clarifying services that health insurers, hospitals, and medical groups offer, and by making information about their costs available publicly, people could make choices based on quality, accessibility, service, and other amenities, in addition to price."
"Every time a patient receives a medication in the hospital, there’s a 20%–25% probability that it involves at least one clinical error—the drug may be given at the wrong time or at the wrong injection rate, or maybe it’s the wrong formulation."
"This happens so often that as many as 30% of laboratory tests and 20%–50% of advanced radiologic imaging may be unnecessary, and as much as 2%–3% of health spending in the United States (over $50 billion) is considered defensive spending."
"The number of deaths due to medical mistakes in the United States equates to somewhere between two and six 737s crashing every day, depending on which estimate you believe."
"To transform health care, we need to align purpose, autonomy, and mastery with the delivery of better, safer, and more affordable care."
"I’ve asked thousands of physicians and other professionals, 'Do you know what it costs to provide health care for each of your patients?' It’s rare that a single hand goes up. They don’t know how much it costs to run the MRI scanner or the echocardiography machine. They don’t know how much every minute a patient stays in the emergency department or intensive care unit costs."
"A study published 12 years later found that the three expansion states had significantly lower death rates (19.6 fewer deaths per 100,000 adults per year) than their neighboring states, and people reported their own health to be significantly better. Since the Affordable Care Act, several hundred published research studies have shown that Medicaid expansion has consistently improved access to basic health care, and that people have gotten healthier because of that access—their blood pressure and diabetes are better, mental health has improved, and more have been screened for diseases like cervical and prostate cancer."
"High-deductible health plans could benefit from redesign, too. Up to the point of the deductible, people are incentivized to avoid using any care—even when it’s sensible and necessary. If they do end up reaching the deductible, they are then incentivized to use as much care as possible because it’s 'free.'"
"In 2018, nursing schools turned away more than 75,000 qualified applicants because of insufficient faculty and clinical preceptors."
5/5 rating. 208 pages.
Book #37 of 2021. Read April 26, 2021.
I have read 442 books since the beginning of 2017 and this is one of the 3 best out of all of those. EVERYONE should read this book about how we can change our health system.
Each and every person is impacted by the choices that not only you, but your insurer, the government, and the hospitals make about your health. It's time to stop being passive consumers of the single most important service in our lives: healthcare. Vivian has held many important positions within the healthcare field, and she has used her experience and research to come up with the ways that our system is most broken. I think even more importantly, at the end of most of the chapters, there are steps that we all can take to improve these systems: whether you are an insurer, a medical professional, or just a consumer of healthcare.
Unlike "The Healing of America" this book is much more based on the healthcare itself as opposed to the insurance system. Vivian makes the absolutely obvious statement that we need to shift from pay-for-service to pay-for-results. In what other realm would we pay just because something was done? Who cares if 100 different tests were completed but you are no closer to being properly treated? Along with this, there needs to be vastly more transparency in the medical system: did you know that it's not just you who doesn't know how much care costs? Almost no one in the system knows the costs, what kind of "business" is this!?!
It may be counter-intuitive, but as Vivian says: "If our nation stopped expecting quick fixes—a prescription, a referral to a specialist, an MRI, an operation—and instead put a premium on measurably improving lives for good, then prevention would become paramount. The medical world would focus on diet, sleep, and fitness."
Fixing our healthcare will certainly not be easy, but if everyone reads this book and starts to push for the ideas that Vivian recommends, maybe we can start to turn it around and make a healthier America.
Quotes:
"Hands down, the United States spends more on health care per capita than any other nation—nearly one-fifth of the US economy goes to pay for health. That’s two to three times more than other high-income Organization for Economic Co-operation and Development (OECD) nations like the UK, Canada, Germany, Japan, and Australia, where health coverage is universal. Despite this, about 1 in 11 Americans don’t have health insurance and can’t afford care."
"Babies born in the United States in 2017 are expected to live 78.6 years, 5.6 years less than those born in Japan, which places us 26th out of 35 OECD nations in life expectancy."
"The Institute of Medicine (now National Academy of Medicine) estimated in 2012 that we waste 30 cents of every dollar we spend on health care. That’s over $1 trillion per year. Some of the waste is fraud and abuse, but most of it comes from failures to care for patients properly."
"In the United States, about 8% of spending on health care is spent on administration."
"We put people in hospitals who would be better off at home. In the hospital, we attach them to costly life support systems, even when they have asked to be left alone. While four out of five people would prefer to die at home, only one out of five does. Most people still die in a hospital or nursing home."
"Our system rewards action, not better health outcomes. It encourages overtreatment and specialty care at the expense of prevention and primary care."
"If our nation stopped expecting quick fixes—a prescription, a referral to a specialist, an MRI, an operation—and instead put a premium on measurably improving lives for good, then prevention would become paramount. The medical world would focus on diet, sleep, and fitness."
"Because we have an insurance model of paying for health care, the normal economic rules of the market don’t readily apply."
"Health systems like ChenMed that are paid to keep patients healthy recognize that what happens to patients in their clinics is often less important to their health than their circumstances at home: whether they are financially secure, have access to fresh food, live and work in a safe environment, and have adequate access to transportation and housing."
"One study estimated that about 25 cents of every dollar collected by a hospital is spent on administration, which means American hospitals spend more on paperwork than they do on nurses."
"Because Medicare’s internal costs for administration are a fraction of those commercial payers, Medicare-for-all could reduce administrative costs from around 14% to 6% or less."
"If doctors and hospitals only got paid if patients did at least as well as expected, it could obviate most of the billing and coding requirements, with considerable potential savings. By simplifying and clarifying services that health insurers, hospitals, and medical groups offer, and by making information about their costs available publicly, people could make choices based on quality, accessibility, service, and other amenities, in addition to price."
"Every time a patient receives a medication in the hospital, there’s a 20%–25% probability that it involves at least one clinical error—the drug may be given at the wrong time or at the wrong injection rate, or maybe it’s the wrong formulation."
"This happens so often that as many as 30% of laboratory tests and 20%–50% of advanced radiologic imaging may be unnecessary, and as much as 2%–3% of health spending in the United States (over $50 billion) is considered defensive spending."
"The number of deaths due to medical mistakes in the United States equates to somewhere between two and six 737s crashing every day, depending on which estimate you believe."
"To transform health care, we need to align purpose, autonomy, and mastery with the delivery of better, safer, and more affordable care."
"I’ve asked thousands of physicians and other professionals, 'Do you know what it costs to provide health care for each of your patients?' It’s rare that a single hand goes up. They don’t know how much it costs to run the MRI scanner or the echocardiography machine. They don’t know how much every minute a patient stays in the emergency department or intensive care unit costs."
"A study published 12 years later found that the three expansion states had significantly lower death rates (19.6 fewer deaths per 100,000 adults per year) than their neighboring states, and people reported their own health to be significantly better. Since the Affordable Care Act, several hundred published research studies have shown that Medicaid expansion has consistently improved access to basic health care, and that people have gotten healthier because of that access—their blood pressure and diabetes are better, mental health has improved, and more have been screened for diseases like cervical and prostate cancer."
"High-deductible health plans could benefit from redesign, too. Up to the point of the deductible, people are incentivized to avoid using any care—even when it’s sensible and necessary. If they do end up reaching the deductible, they are then incentivized to use as much care as possible because it’s 'free.'"
"In 2018, nursing schools turned away more than 75,000 qualified applicants because of insufficient faculty and clinical preceptors."
November 30, 2021
Read for PBPL 41: "Economics of Public Policymaking" at Dartmouth.
In The Long Fix (2020), Dr. Vivian Lee puts her stethoscope to America’s heart and sets out to outline how America might escape our current healthcare situation, one which she describes as an “ailing, failing, system” in the first chapter.
Lee’s anecdote-laden, and at times, overly-optimistic prognosis of issues plaguing American healthcare guides readers through different problems she has diagnosed in the American medical-industrial complex — such as preventative care, cost, data, the pharmaceutical industry, community engagement, manufacture, and an overall focus on results.
The Long Fix’s central thesis asserts that American healthcare requires just that: a long fix. Just like Roosevelt’s 20th century New Deal, or today’s Green New Deal, Lee’s “long fix” does not seek to treat the chronic issues in American healthcare with a ‘bandaid’ or one-off policy, but rather with a comprehensive course of action.
The most salient aspects of this book are Lee’s interviews with experts and trailblazers in healthcare. These anecdotes lend credibility to Lee’s arguments and help me envision the possibilities that she discusses. For example, in “Big Data Dreams,” Lee turns to Mandy Cohen, North Carolina’s health and human services secretary, who uses patient data to connect them with community programs like food banks. This example brought to life Lee’s suggestion that big data could improve healthcare.
As a reporter and profilist myself, I appreciate her stylistic approach to weaving these stories into her arguments; it felt natural. I also enjoy the stories of individual experiences with healthcare that bring a human element to each of Lee’s points. However, at times, I wish Lee had included more stories of individuals’ experiences with healthcare. The strongest chapters balanced expert opinions with relatable, grounding stories. Lee accomplishes this best in “An Apple a Day Keeps the Patient Away,” wherein many of the professionals also tell stories about their patients, but certain chapters — like “Pharmaceuticals: A Web of Vested Interests,” and “Manufacturing Out The Mishaps” — lacked that human element.
Another strength of this book is Lee’s choice to end each chapter with a concise, bullet-pointed “action plan” detailing how actors — such as patients, physicians, payers, and policy-makers — can work towards the long fix. Oftentimes with political books written by outsiders, there’s a fair but perhaps low-hanging critique that the authors don't engage enough with how to accomplish the reforms they suggest, but Lee skirts around that critique by walking her readers through high-level implementation.
As much as I enjoy reading the book, I do have gripes with it—most of which I could summarize by stating that this book replaces a comprehensive analysis with a never-ending string of liberal reforms.
Namely, in the final chapter, Lee mentions that one of healthcare's defining challenges is the need to square two opposing “human drives:” a drive to be compassionate and a drive to succeed financially. The very fact that our healthcare system must square these two desires does not bode well (and I, for one, am skeptical of how innately “human” the latter drive is anyway). What’s more, Lee doesn’t prove that these two desires can ever be compatible. She suggests at one point that we look elsewhere in the world at other high-income nations which spend comparatively less than the U.S and keep their citizens healthier, but she doesn’t explain the differences between America and these countries. Thus, it’s difficult to believe why these two opposing human drives can yield desirable results.
Furthermore, nearly every action plan (8 out of 11) ends with “and most importantly, all of us need to elect leaders who…” and then something related to that chapter's themes. I see why Lee included this call to voters, but it felt lazy and tacked on — and seemed to overstate the power of electoralism and personal responsibility in the face of a medical-industrial complex. While I agree that everyone has a role in fixing healthcare, her recommendations often fell short of addressing the root causes of health inequity and asked individuals to make personal decisions to make up for those inequities. For example, in “An Apple a Day Keeps the Patient Away,” Lee posits that medical centers can improve the care they provide by being engaged with the communities their patients come from. And although I accept this premise, racial health disparities don’t exist because pastors aren’t doing a good enough job encouraging prostate exams; they exist because the U.S has (by design) systematically marginalized, brutalized, and stolen from Black communities. If the United States is a settler-colonial state built on the violent dispossession of indigenous people and the violent extraction of labor from Black people, why would we expect that American healthcare can work for everyone?
Despite the sometimes hands-off approach to addressing the underlying structures that compromise the medical system, The Long Fix is worth a read. It’s more than Healthcare 101, giving a strong picture of both the failings and possibilities, but it’s written for people of a certain political persuasion. If you identify as a hopeful liberal, you might see this book as a great outline for what could save America in the coming decades. However, if you want solutions that get rid of problems, or are skeptical of government-led social programs, or feel at all disillusioned, Lee’s hopeful book might read more like an indictment not only of the American healthcare “system,” but of the United States and the American experiment itself.
In The Long Fix (2020), Dr. Vivian Lee puts her stethoscope to America’s heart and sets out to outline how America might escape our current healthcare situation, one which she describes as an “ailing, failing, system” in the first chapter.
Lee’s anecdote-laden, and at times, overly-optimistic prognosis of issues plaguing American healthcare guides readers through different problems she has diagnosed in the American medical-industrial complex — such as preventative care, cost, data, the pharmaceutical industry, community engagement, manufacture, and an overall focus on results.
The Long Fix’s central thesis asserts that American healthcare requires just that: a long fix. Just like Roosevelt’s 20th century New Deal, or today’s Green New Deal, Lee’s “long fix” does not seek to treat the chronic issues in American healthcare with a ‘bandaid’ or one-off policy, but rather with a comprehensive course of action.
The most salient aspects of this book are Lee’s interviews with experts and trailblazers in healthcare. These anecdotes lend credibility to Lee’s arguments and help me envision the possibilities that she discusses. For example, in “Big Data Dreams,” Lee turns to Mandy Cohen, North Carolina’s health and human services secretary, who uses patient data to connect them with community programs like food banks. This example brought to life Lee’s suggestion that big data could improve healthcare.
As a reporter and profilist myself, I appreciate her stylistic approach to weaving these stories into her arguments; it felt natural. I also enjoy the stories of individual experiences with healthcare that bring a human element to each of Lee’s points. However, at times, I wish Lee had included more stories of individuals’ experiences with healthcare. The strongest chapters balanced expert opinions with relatable, grounding stories. Lee accomplishes this best in “An Apple a Day Keeps the Patient Away,” wherein many of the professionals also tell stories about their patients, but certain chapters — like “Pharmaceuticals: A Web of Vested Interests,” and “Manufacturing Out The Mishaps” — lacked that human element.
Another strength of this book is Lee’s choice to end each chapter with a concise, bullet-pointed “action plan” detailing how actors — such as patients, physicians, payers, and policy-makers — can work towards the long fix. Oftentimes with political books written by outsiders, there’s a fair but perhaps low-hanging critique that the authors don't engage enough with how to accomplish the reforms they suggest, but Lee skirts around that critique by walking her readers through high-level implementation.
As much as I enjoy reading the book, I do have gripes with it—most of which I could summarize by stating that this book replaces a comprehensive analysis with a never-ending string of liberal reforms.
Namely, in the final chapter, Lee mentions that one of healthcare's defining challenges is the need to square two opposing “human drives:” a drive to be compassionate and a drive to succeed financially. The very fact that our healthcare system must square these two desires does not bode well (and I, for one, am skeptical of how innately “human” the latter drive is anyway). What’s more, Lee doesn’t prove that these two desires can ever be compatible. She suggests at one point that we look elsewhere in the world at other high-income nations which spend comparatively less than the U.S and keep their citizens healthier, but she doesn’t explain the differences between America and these countries. Thus, it’s difficult to believe why these two opposing human drives can yield desirable results.
Furthermore, nearly every action plan (8 out of 11) ends with “and most importantly, all of us need to elect leaders who…” and then something related to that chapter's themes. I see why Lee included this call to voters, but it felt lazy and tacked on — and seemed to overstate the power of electoralism and personal responsibility in the face of a medical-industrial complex. While I agree that everyone has a role in fixing healthcare, her recommendations often fell short of addressing the root causes of health inequity and asked individuals to make personal decisions to make up for those inequities. For example, in “An Apple a Day Keeps the Patient Away,” Lee posits that medical centers can improve the care they provide by being engaged with the communities their patients come from. And although I accept this premise, racial health disparities don’t exist because pastors aren’t doing a good enough job encouraging prostate exams; they exist because the U.S has (by design) systematically marginalized, brutalized, and stolen from Black communities. If the United States is a settler-colonial state built on the violent dispossession of indigenous people and the violent extraction of labor from Black people, why would we expect that American healthcare can work for everyone?
Despite the sometimes hands-off approach to addressing the underlying structures that compromise the medical system, The Long Fix is worth a read. It’s more than Healthcare 101, giving a strong picture of both the failings and possibilities, but it’s written for people of a certain political persuasion. If you identify as a hopeful liberal, you might see this book as a great outline for what could save America in the coming decades. However, if you want solutions that get rid of problems, or are skeptical of government-led social programs, or feel at all disillusioned, Lee’s hopeful book might read more like an indictment not only of the American healthcare “system,” but of the United States and the American experiment itself.
July 31, 2020
I highly recommend this book as a concise and informative book on fixing the healthcare system in America. Lee takes a nonpartisan approach and offers recommendations for cost cutting and improving care. She provides historical perspective to explain how we got in the mess we are in. She advocates for a use of data to improve care, reduce errors, and standardize treatment methods for various medical conditions. She also calls on all of us to “coproduce” our health with physicians and focus on strategies to prevent illness and avoid debilitating chronic illness. I would choose her to be HHS secretary.
January 26, 2025
Going into this book, I never considered myself well-informed enough to have a position on Medicare-for-all in America. I understood that there were plenty of valid concerns about the cost of such a program; it’s not something that could be paid for just by taxing the wealthy and corporations, and even if it was financed properly through general tax hikes across the board (a VAT perhaps?), the chance of funding for it becoming insolvent is high.
Yet despite Vivian Lee not taking a position on who pays for health care in this book—not going into whether it should be the government, employers or individuals—after reading The Long Fix, I’m now leaning toward the position that if we’re serious about making health care affordable, it needs to be funded through a single payer: the government.
The U.S. government, through Medicaid, Medicare and the VA, spends more GDP per capita on health care than any other OECD nation, and yet many of them offer universal coverage and we do not. Vivian Lee is persuasive in arguing that the main reason for the expensiveness of our healthcare comes from the “pay-for-action” model that incentivizes hospitals and doctors to overprescribe, overtreat, order unnecessary X-rays/MRIs and so on, and that we’d be better off switching to a “pay-for-results” model: as a payer, I don’t care what procedures the hospital does to treat a patient; I just care if they are healthy in the end.
Yet I think a single government payer would better be able to shift to that model while lowering costs for several reasons:
- The cheapest, most effective care is preventative. Yet the initial up front costs of preventative care for things like disease management programs and Pap smears take years to pay dividends—why would BlueCross Blue Shield, for example, invest in it when 5 years from now, much of their current clientele is likely to have switched to Aetna because of a job change? Investments in preventative care for Insurance Company or Employer A is basically offering savings to Insurance Company or Employer B. Under a single payer, the government would be incentivized to make the necessary investments in preventative care since the same patient would be staying with the same payer for the duration of their life.
- 8% of US health care spending is administrative costs, compared to an average of 3% for other OECD nations. A large reason for that is how decentralized health care is and the amount of players involved—insurance companies, pharmacy benefit managers, employers, hospitals, primary care clinics and so on, with each having their own offerings. A single payer could standardize offerings, reducing bureaucracy.
- Similarly, pricing in health care is extremely opaque also because of this decentralization. There are too many payers offering too many plans with too many variables: deductibles, copays, coinsurance, in-network/out-of-network and covered benefits. It’s impossible to tell ahead of time what cost your specific permutation of these variables results in, which is what leads to those awful medical “surprise bills.” I can imagine with a government single payer, there could be a government website where you say which of the several government-offered plans you have, which hospital you want to go to, and then it spits out the price for an operation.
- The price negotiation ability of a massive payer like a government allows to shoot down bad behavior from some of the players in the system. The government could be its own Pharmacy Benefit Manager, reducing the profit incentives they normally have. The book does well to describe the crookedness of the relationship between Pharmacy Benefit Managers and Pharmaceutical Companies that ends up lining both their pockets at the expense of patients. While currently Pharmacy Benefit Managers essentially determine their formularies based on the size of rebates pharmaceuticals give them (a “you scratch my back, I scratch yours" model), the government could only include generics and cost-effective, proven medication in its formularies.
- Another example of bad behavior a government payer could shoot down is hospital chargemasters, a list prepared by hospitals of charges for every supply item and every procedure they offer. Hospitals purposefully mark these up because they know insurance companies will try to bring it down, and that insurance companies measure their success based on how much they can bring it down and not the actual value. That’s how you end up with a hospital charging insurance companies something like $17 for a piece of gauze, or one hospital charging three different insurance companies wildly different amounts for the same procedure. Private insurers pay, on average, 2.5 times the rate that Medicare pays for items/procedures on chargemasters.
Overall, I came into this book only knowing that health care in the US is a mess, but not much information on why it’s a mess. While I’m sure there’s still a lot of stuff I’m missing, I came out of it feeling much better informed about the problems plaguing our health care system. The sense I get is that the decentralization of health care is really a key problem, and that having the government set clearer direction is needed. We are a sick society plagued by chronic conditions and wildly unacceptable rates of obesity, hypertension, diabetes, sleep deprivation, unhealthy nutrition. The longer these go untreated, the more expensive health care ends up being, and I don’t think a primarily private-based system is set up to tackle that.
Yet despite Vivian Lee not taking a position on who pays for health care in this book—not going into whether it should be the government, employers or individuals—after reading The Long Fix, I’m now leaning toward the position that if we’re serious about making health care affordable, it needs to be funded through a single payer: the government.
The U.S. government, through Medicaid, Medicare and the VA, spends more GDP per capita on health care than any other OECD nation, and yet many of them offer universal coverage and we do not. Vivian Lee is persuasive in arguing that the main reason for the expensiveness of our healthcare comes from the “pay-for-action” model that incentivizes hospitals and doctors to overprescribe, overtreat, order unnecessary X-rays/MRIs and so on, and that we’d be better off switching to a “pay-for-results” model: as a payer, I don’t care what procedures the hospital does to treat a patient; I just care if they are healthy in the end.
Yet I think a single government payer would better be able to shift to that model while lowering costs for several reasons:
- The cheapest, most effective care is preventative. Yet the initial up front costs of preventative care for things like disease management programs and Pap smears take years to pay dividends—why would BlueCross Blue Shield, for example, invest in it when 5 years from now, much of their current clientele is likely to have switched to Aetna because of a job change? Investments in preventative care for Insurance Company or Employer A is basically offering savings to Insurance Company or Employer B. Under a single payer, the government would be incentivized to make the necessary investments in preventative care since the same patient would be staying with the same payer for the duration of their life.
- 8% of US health care spending is administrative costs, compared to an average of 3% for other OECD nations. A large reason for that is how decentralized health care is and the amount of players involved—insurance companies, pharmacy benefit managers, employers, hospitals, primary care clinics and so on, with each having their own offerings. A single payer could standardize offerings, reducing bureaucracy.
- Similarly, pricing in health care is extremely opaque also because of this decentralization. There are too many payers offering too many plans with too many variables: deductibles, copays, coinsurance, in-network/out-of-network and covered benefits. It’s impossible to tell ahead of time what cost your specific permutation of these variables results in, which is what leads to those awful medical “surprise bills.” I can imagine with a government single payer, there could be a government website where you say which of the several government-offered plans you have, which hospital you want to go to, and then it spits out the price for an operation.
- The price negotiation ability of a massive payer like a government allows to shoot down bad behavior from some of the players in the system. The government could be its own Pharmacy Benefit Manager, reducing the profit incentives they normally have. The book does well to describe the crookedness of the relationship between Pharmacy Benefit Managers and Pharmaceutical Companies that ends up lining both their pockets at the expense of patients. While currently Pharmacy Benefit Managers essentially determine their formularies based on the size of rebates pharmaceuticals give them (a “you scratch my back, I scratch yours" model), the government could only include generics and cost-effective, proven medication in its formularies.
- Another example of bad behavior a government payer could shoot down is hospital chargemasters, a list prepared by hospitals of charges for every supply item and every procedure they offer. Hospitals purposefully mark these up because they know insurance companies will try to bring it down, and that insurance companies measure their success based on how much they can bring it down and not the actual value. That’s how you end up with a hospital charging insurance companies something like $17 for a piece of gauze, or one hospital charging three different insurance companies wildly different amounts for the same procedure. Private insurers pay, on average, 2.5 times the rate that Medicare pays for items/procedures on chargemasters.
Overall, I came into this book only knowing that health care in the US is a mess, but not much information on why it’s a mess. While I’m sure there’s still a lot of stuff I’m missing, I came out of it feeling much better informed about the problems plaguing our health care system. The sense I get is that the decentralization of health care is really a key problem, and that having the government set clearer direction is needed. We are a sick society plagued by chronic conditions and wildly unacceptable rates of obesity, hypertension, diabetes, sleep deprivation, unhealthy nutrition. The longer these go untreated, the more expensive health care ends up being, and I don’t think a primarily private-based system is set up to tackle that.
April 12, 2021
Optimism despite: Medical mistakes are the 3rd largest cause of death in the USA! Radiologists miss 30% of irregularities in a scan! Medication error (wrong dose, wrong time, wrong...patient) occurs at a rate of 1 per patient per day! Our 'zero gravity' healthcare costs are undermining the vitality of Our American Economy, for instance GM spends $71/worker/hour on health insurance!
August 17, 2022
Great overview of the state of American Healthcare with proposed solutions.
# Intro
We Pay More for Less With health care spending rapidly approaching $4 trillion per year, the obvious but misguided solution would be to reduce expenses by cutting care, but that’s dangerous for patients and for our future. It’s not care that needs to be cut, it’s the wasteful spending that doesn’t contribute to better health. We have to stop paying more to get less. Here are a few of the opportunities most of us in health care agree on:
- We waste. The Institute of Medicine (now National Academy of Medicine) estimated in 2012 that we waste 30 cents of every dollar we spend on health care. That’s over $1 trillion per year. Some of the waste is fraud and abuse, but most of it comes from failures to care for patients properly.
- We overtreat. A substantial part of the waste is driven by overdiagnosis and overtreatment. In a 2016 survey, US physicians thought that about 20% of all medical care was unnecessary.
- We make deadly mistakes. Medical errors are the third-leading cause of death in the United States—over 250,000 deaths each year. That’s about 9.5% of all deaths, behind only heart disease and cancer. - We practice medicine inconsistently. Clinicians make decisions without being fully informed about the latest science and without information about costs (to the patient, and overall). Physicians follow recommended guidelines only one-half to two-thirds of the time.
- We are choking on bureaucracy. In the United States, about 8% of spending on health care is spent on administration. Among ten high-income OECD nations, the figure averaged only 3%.
- Health care professionals are paid generously but waste a lot of time. The average US generalist physician makes about $218,000; specialists average $316,000. These expensive professionals waste a large percentage of their time on frustrating administrative tasks like computer data entry and disputing with insurance companies instead of caring for patients.
- We push expensive new technologies and treatments even if they aren’t any better than cheaper (or generic) alternatives. We spend double to triple what Canada and some European countries do on pharmaceuticals, mostly due to high-cost, branded drugs and the overprescription of antibiotics and other medications.
- We wait until it’s too late. About 8.5% of the US population is uninsured, and more are forgoing preventive and primary care because they are underinsured. By the time the health system sees them, we’ve missed our chance at prevention.
- We wish patients would enjoy healthier diets and more exercise, but we can’t seem to influence them to change their behaviors. As a nation, we seem to favor sugar- and high-fructose corn syrup–laden sweets and drinks (spending $4 billion on them annually), deep-fried food ($200 billion for fast food), tobacco ($130 billion), and sedentary lifestyles with plenty of screen time and video gaming ($43 billion) over healthier alternatives. Eight-minute clinic visits aren’t long enough for primary care providers to have meaningful conversations to influence these habits.
- We deny the wishes of the dying. We put people in hospitals who would be better off at home. In the hospital, we attach them to costly life support systems, even when they have asked to be left alone. While four out of five people would prefer to die at home, only one out of five does. Most people still die in a hospital or nursing home.
# The Long-Fix principles
Principle #1: Health Care Is a Problem with Bipartisan Solutions
Principle #2: Pay for Results, Not Action
Principle #3: Make Health a Strategic Imperative for the Nation
The Most Powerful Drug: Coproducing Your Health Every one of us has a role in the Long Fix—we are all soldiers in the war against disease. Sometimes we’re the supporter, the caregiver, the cheerleader. We may take on the role of the community member—like the grandma who picks up donated books and hands them out to kids in her beauty salon, or the volunteer shuttle driver for seniors who need to pick up their medications. We may be the parent, the brother, the daughter-in-law, the next-door neighbor. Or we just may be the patient.
“there’s no drug as powerful as people engaged in their own health.”
Call to actions:
- shift from a reactive to proactive health care system
- move to new pay-for-results models of care
- improve safety and reduce medical mistakes
- develop a learning health system
- The Action Plan for Collaring Costs
- coproduce health and codesign health care
- The Action Plan for Sensible Drug Prices
- An Action Plan for Realizing Big Data’s Potential
- A Ten-Point Action Plan for Employers
- Learning from Our Military and Veterans Health Administration Systems
Full summary: https://docs.google.com/document/d/1v...
# Intro
We Pay More for Less With health care spending rapidly approaching $4 trillion per year, the obvious but misguided solution would be to reduce expenses by cutting care, but that’s dangerous for patients and for our future. It’s not care that needs to be cut, it’s the wasteful spending that doesn’t contribute to better health. We have to stop paying more to get less. Here are a few of the opportunities most of us in health care agree on:
- We waste. The Institute of Medicine (now National Academy of Medicine) estimated in 2012 that we waste 30 cents of every dollar we spend on health care. That’s over $1 trillion per year. Some of the waste is fraud and abuse, but most of it comes from failures to care for patients properly.
- We overtreat. A substantial part of the waste is driven by overdiagnosis and overtreatment. In a 2016 survey, US physicians thought that about 20% of all medical care was unnecessary.
- We make deadly mistakes. Medical errors are the third-leading cause of death in the United States—over 250,000 deaths each year. That’s about 9.5% of all deaths, behind only heart disease and cancer. - We practice medicine inconsistently. Clinicians make decisions without being fully informed about the latest science and without information about costs (to the patient, and overall). Physicians follow recommended guidelines only one-half to two-thirds of the time.
- We are choking on bureaucracy. In the United States, about 8% of spending on health care is spent on administration. Among ten high-income OECD nations, the figure averaged only 3%.
- Health care professionals are paid generously but waste a lot of time. The average US generalist physician makes about $218,000; specialists average $316,000. These expensive professionals waste a large percentage of their time on frustrating administrative tasks like computer data entry and disputing with insurance companies instead of caring for patients.
- We push expensive new technologies and treatments even if they aren’t any better than cheaper (or generic) alternatives. We spend double to triple what Canada and some European countries do on pharmaceuticals, mostly due to high-cost, branded drugs and the overprescription of antibiotics and other medications.
- We wait until it’s too late. About 8.5% of the US population is uninsured, and more are forgoing preventive and primary care because they are underinsured. By the time the health system sees them, we’ve missed our chance at prevention.
- We wish patients would enjoy healthier diets and more exercise, but we can’t seem to influence them to change their behaviors. As a nation, we seem to favor sugar- and high-fructose corn syrup–laden sweets and drinks (spending $4 billion on them annually), deep-fried food ($200 billion for fast food), tobacco ($130 billion), and sedentary lifestyles with plenty of screen time and video gaming ($43 billion) over healthier alternatives. Eight-minute clinic visits aren’t long enough for primary care providers to have meaningful conversations to influence these habits.
- We deny the wishes of the dying. We put people in hospitals who would be better off at home. In the hospital, we attach them to costly life support systems, even when they have asked to be left alone. While four out of five people would prefer to die at home, only one out of five does. Most people still die in a hospital or nursing home.
# The Long-Fix principles
Principle #1: Health Care Is a Problem with Bipartisan Solutions
Principle #2: Pay for Results, Not Action
Principle #3: Make Health a Strategic Imperative for the Nation
The Most Powerful Drug: Coproducing Your Health Every one of us has a role in the Long Fix—we are all soldiers in the war against disease. Sometimes we’re the supporter, the caregiver, the cheerleader. We may take on the role of the community member—like the grandma who picks up donated books and hands them out to kids in her beauty salon, or the volunteer shuttle driver for seniors who need to pick up their medications. We may be the parent, the brother, the daughter-in-law, the next-door neighbor. Or we just may be the patient.
“there’s no drug as powerful as people engaged in their own health.”
Call to actions:
- shift from a reactive to proactive health care system
- move to new pay-for-results models of care
- improve safety and reduce medical mistakes
- develop a learning health system
- The Action Plan for Collaring Costs
- coproduce health and codesign health care
- The Action Plan for Sensible Drug Prices
- An Action Plan for Realizing Big Data’s Potential
- A Ten-Point Action Plan for Employers
- Learning from Our Military and Veterans Health Administration Systems
Full summary: https://docs.google.com/document/d/1v...
May 16, 2021
[Imported automatically from my blog. Some formatting there may not have translated here.]
Every so often, I get it in my head to read a book about the American health care sector. (Also to beat my head against a concrete wall for a few hours, but that's not important right now.)
By the way: calling it a health care "system" is something I will try to avoid. The very language seems to presume something that's the result of design, instead of (more accurately) a sector that's been kludged over decades by powerful forces operating under the wrong incentives.
Also a "system" implies something that actually works well.
And the author, Doctor Vivian Lee, contends otherwise. She has some facts on her side. For example, US Covid-19 deaths just passed 200K. In comparison, Johns Hopkins researchers estimate the body count for medical errors at around 250K. That's per year, every year. Eek.
I wish I liked the book better. It's written in what I've come to think of as USAToday-ese: short paragraphs, heavy on anecdotes, short on statistics, punchy-cute section headings (E.g., "Rebate and Switch" on pharmaceutical manufacturers offering rebates to pharmaceutical benefit managers.) This comes off as condescending.
Worse, Dr. Lee seems to rely on slogans instead of concrete policy proposals. She advocates moving away from a "fee-for-service" pricing model, toward a "pay-for-results" model. I'm still not sure what that means. No charge if the patient ends up dead? There might be a good idea there, but I think it's buried in all the salesmanship. The numerous anecdotes point to successful programs spearheaded by talented and devoted reformers, but Dr. Lee seems to not be skeptical of whether these reforms can scale when the keys are tossed to the less talented and devoted.
Each chapter tackles a different topic (drug costs, mistakes, health records,…) and closes with a set of action-recommendations for patients, doctors, and payers. And ends with "And most importantly, all of us need to elect leaders who will…". And what follows is some vague prescription that assumes government can top-down regulate/mandate/subsidize our way to medical nirvana.
A specific gripe: It's a clichéd observation that the US devotes a huge amount of its economy to the health-care sector, with mediocre results. Geez, why can't we be like those other countries, at least as far as spending goes?
I've noted in the past that one way other countries save money is pretty simple: paying lower salaries to the folks in the medical field. Doctor Lee seems to reinforce that:
Many health care professionals are highly paid (especially doctors, dentists, and administrators). Analysis of 2016 data showed the average generalist physician in the United States made $218,173 a year, double the average of generalists in ten other high-income countries (including the Netherlands, UK, Canada, Australia, and Germany). Specialists averaged $316,000, also higher than in any of those nations. US nurses also make more than their international peers, averaging more than $74,000 per year comparied to $42,000-$65.000.
(Reference to a JAMA article described here.)
But then Dr Lee sticks a pin in this balloon:
While high salaries undoubtedly worsen the US health care crisis, the impact on the economics is not that big. Health care economist Uwe Reinhardt showed in 2007 that higher salaries added about 2% to total national health care spending.
I've even heard of Uwe, so case closed, right? Well… the reference here is not to a peer-reviewed medical economics journal, but to a 250-word LTE Reinhardt wrote to the NYT back then, in response to an earlier column by Alex Berenson.
In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.
Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.
Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.
This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.
Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.
In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid. A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.
Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.
Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.
This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.
Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.
Notice one thing right off the bat: Uwe is only talking about physician salaries; if you've (God help you) been in a medical building recently, you'll have noticed there are a lot more people running around than the doctors. So Dr. Lee's wrong in claiming that Uwe "showed" that "higher salaries" were a 2% effect on the total health care bill; Uwe's not counting all those other folks, not to mention the paper-pushers behind the closed doors, in insurance company offices, in regulatory agencies….
I'm also unconvinced by Uwe's argument on its face, which seems to be a lot of handwaving. And, at least in part, it really seems to amount to: "We gotta pay doctors high salaries, or they'll kill even more of us." (See above.)
November 13, 2020
Dr. Lee's book, "The Long Fix" provides a good insiders view of the health care. Insider because she ran health organizations. It of course was disturbing to see how often revenue is prioritized over health and care in the system. As has been noted often, a bad system beats good people every time. She clearly explains how this bad system beats good health care providers because it leads to less care than should be provided and or outrageous charges. As she notes, the problem is the Fee-For-Service model. This means they get paid for action instead of results. She suggests pay should be based on results not just action. She even explains they get paid to do things wrong and get paid again to fix mistakes made. This of course provides a stunning example of the wrong types of motivation. This means the system is designed to diagnose and fix problems not prevent or cure. In addition prevention is not attractive to people who feel fine which makes it a difficult sell. In addition, the separation of who pays, insurance, and who gets service causes more problems.
She does mention Deming's Quality methods and how it can and should be used with healthcare. She also highlights how 25¢ of every health care dollar is wasted. In addition she points out often that despite the cost, results are bad. In fact, health care is the 3rd leading cause of death in America, documenting the poor quality health care offered in the US, even though it is the most expensive of any of the rich nations in the OECD (Organization for Co-operation and Economic Development). With how to improve she recommends EndResults initiative as stated by Ernest Codman and better methods. For better methods she cites the need for intrinsically motivated changes, rather than paying for better results because it does not work.
She also suggests using Big Data to improve care. Some better methods associated with this include using Open Notes and OurNotes where doctors and patients share notes taken so they are more complete. She also offers shared online practices such as Geisinger's ProvenCare and Utah's PerfectCare. In addition she highlights how the FDA will use big data to study and determine the best drugs based on their impact with FDA's Sentinel Initiative. In addition she explains that Virginia Mason Medical Center set up specific specs to be met such as only using what works, satisfaction, same-day care, rapid return to function and consistent prices. She even suggested using Leapfrog because they provide quality metrics.
While I found all of this interesting and informative, I thought she confused process and results. It seemed especially confused since she cited Dr. Deming's quality methods. Deming often demonstrated that changing methods based on results, rather than continually improving the process, is tampering and this will lead to worse outcomes. Her idea of using Codman's End Results may result in tampering and if so will cause more problems. Instead it seems changes should be designed to improved processes. I addition medicine should only be used for treatment and society must develop an environment that nurtures, supports, educates and reinforces health promoting processes - thus making treatment less needed and when needed, more effective because people are healthier.
She does mention Deming's Quality methods and how it can and should be used with healthcare. She also highlights how 25¢ of every health care dollar is wasted. In addition she points out often that despite the cost, results are bad. In fact, health care is the 3rd leading cause of death in America, documenting the poor quality health care offered in the US, even though it is the most expensive of any of the rich nations in the OECD (Organization for Co-operation and Economic Development). With how to improve she recommends EndResults initiative as stated by Ernest Codman and better methods. For better methods she cites the need for intrinsically motivated changes, rather than paying for better results because it does not work.
She also suggests using Big Data to improve care. Some better methods associated with this include using Open Notes and OurNotes where doctors and patients share notes taken so they are more complete. She also offers shared online practices such as Geisinger's ProvenCare and Utah's PerfectCare. In addition she highlights how the FDA will use big data to study and determine the best drugs based on their impact with FDA's Sentinel Initiative. In addition she explains that Virginia Mason Medical Center set up specific specs to be met such as only using what works, satisfaction, same-day care, rapid return to function and consistent prices. She even suggested using Leapfrog because they provide quality metrics.
While I found all of this interesting and informative, I thought she confused process and results. It seemed especially confused since she cited Dr. Deming's quality methods. Deming often demonstrated that changing methods based on results, rather than continually improving the process, is tampering and this will lead to worse outcomes. Her idea of using Codman's End Results may result in tampering and if so will cause more problems. Instead it seems changes should be designed to improved processes. I addition medicine should only be used for treatment and society must develop an environment that nurtures, supports, educates and reinforces health promoting processes - thus making treatment less needed and when needed, more effective because people are healthier.
February 5, 2024
I had an ER physician recommend this book to me. Dr. Vivian Lee, apart from having an unbelievable resume and experience to give that extra layer of perspective in understanding the behemoth of our healthcare system, has done something impressive in diagnosing the messy, multi-layered issues facing the madness of healthcare in the United States (which is impossible enough), but also proposes specific solutions to each underlying symptom.
I'm also reading Daniel Kahneman's "Thinking Fast and Slow" at the same time as reading this, and I can't help but connect the various biases, instances of overconfidence, poor reasoning, and the trusting of intuition where intuition ought not be trusted to my interactions with other physicians in my years throughout medical school. I see some of this in myself too, which is why Kahneman's book is equally as illuminating as it is disturbing, but he gives multiple examples on how these principles of error in psychology become present and ubiquitous in the medical world, and I noticed some overlap that was being discussed by Dr. Lee here.
As a medical student you're not once taught how the medical system actually works, or even an estimation of it. Given that, part of the major advantage of books like this is that the expansion of perspective it gives you imbues at least the possibility for desiring change, insofar as you can do your part to help that so, and although learning medicine is obviously important, learning how the system is rusted and where components are broken, and how that influences the psychology of our performance for those who will become providers, is equally as important to learn, especially in an environment where the shortage of primary care providers is worsening and the demand for care by an aging patient population will only continue to increase.
I'm also reading Daniel Kahneman's "Thinking Fast and Slow" at the same time as reading this, and I can't help but connect the various biases, instances of overconfidence, poor reasoning, and the trusting of intuition where intuition ought not be trusted to my interactions with other physicians in my years throughout medical school. I see some of this in myself too, which is why Kahneman's book is equally as illuminating as it is disturbing, but he gives multiple examples on how these principles of error in psychology become present and ubiquitous in the medical world, and I noticed some overlap that was being discussed by Dr. Lee here.
As a medical student you're not once taught how the medical system actually works, or even an estimation of it. Given that, part of the major advantage of books like this is that the expansion of perspective it gives you imbues at least the possibility for desiring change, insofar as you can do your part to help that so, and although learning medicine is obviously important, learning how the system is rusted and where components are broken, and how that influences the psychology of our performance for those who will become providers, is equally as important to learn, especially in an environment where the shortage of primary care providers is worsening and the demand for care by an aging patient population will only continue to increase.
June 21, 2021
Great overview of the issues confronting the US healthcare system, as well as the solutions that various players in the industry are trying to implement.
It begins by diagnosing the shortcomings of American healthcare from a macro perspective – the egregious prices, high amounts of waste, medical errors, high admin spend, overtreatment, etc., which the author attributes to the fee-for-service system. (I think this is not super controversial of an opinion nowadays.) She dives into this and explains how payments work under FFS (ICD10 codes, DRGs, billing processes,…). She then explains a variety of solutions that do a better job of aligning incentives, including bundled payments and Medicare Advantage value based care. It cites examples of innovators such as ChenMed and Geisinger.
The book then goes into discussing the resistance to identifying and adopting best practices in medicine, as well as challenges surrounding quantifying cost of care. Lee cites a bunch of examples of how the University of Utah Health System, which she led as CEO, addressed those challenges. Most of these solutions are conceptually quite simple: scorecards, comprehensive cost databases, patient surveys and publicly accessible ratings. One thing I’m still trying to understand better is why the solutions that she mentioned aren’t common practice across hospitals now (or maybe they are?)
There are a number of other topics the book addresses as well, including the debate around rebates in pharma and the implications of malpractice lawsuits on treatment. The ones mentioned above stood out to me as the ones that the author focused the most on (and implicitly which seemed like the highest-impact issues, from the way that she told it). Overall great book – not scared of digging into details or complexities. Would recommend to anyone interested in diving deeper into American healthcare,but be warned that it takes some time to digest!
It begins by diagnosing the shortcomings of American healthcare from a macro perspective – the egregious prices, high amounts of waste, medical errors, high admin spend, overtreatment, etc., which the author attributes to the fee-for-service system. (I think this is not super controversial of an opinion nowadays.) She dives into this and explains how payments work under FFS (ICD10 codes, DRGs, billing processes,…). She then explains a variety of solutions that do a better job of aligning incentives, including bundled payments and Medicare Advantage value based care. It cites examples of innovators such as ChenMed and Geisinger.
The book then goes into discussing the resistance to identifying and adopting best practices in medicine, as well as challenges surrounding quantifying cost of care. Lee cites a bunch of examples of how the University of Utah Health System, which she led as CEO, addressed those challenges. Most of these solutions are conceptually quite simple: scorecards, comprehensive cost databases, patient surveys and publicly accessible ratings. One thing I’m still trying to understand better is why the solutions that she mentioned aren’t common practice across hospitals now (or maybe they are?)
There are a number of other topics the book addresses as well, including the debate around rebates in pharma and the implications of malpractice lawsuits on treatment. The ones mentioned above stood out to me as the ones that the author focused the most on (and implicitly which seemed like the highest-impact issues, from the way that she told it). Overall great book – not scared of digging into details or complexities. Would recommend to anyone interested in diving deeper into American healthcare,but be warned that it takes some time to digest!
November 18, 2020
Vivian Lee wants to transform the US health care system into one the rest of the world would envy. She's been the CEO of hospital systems and has been on the front lines of trying to improve efficiencies, incentivize the right behaviors, put technologies in the right places, and tweak the regulations to better tune the whole system. All that and more in this well-organized, informative, easy to read, hopeful, and helpful book.
I ran some of the ideas in this book by my family members who are clinicians. Some were enthusiastically greeted, some evoked more caution. It's understandable. People and health care is complicated. Reducing what doctors do to codes and pay schedules is fraught. Which means the right solution needs to have proper feedback loops. I don't think she used that term but that's what she described. Get the observations and data into the right hands. Give the front line folks the ability to drive improvements (a la six sigma). And do the common sense stuff. It might take 25 more years but I think we in the US are closer to the right track than I did before.
I ran some of the ideas in this book by my family members who are clinicians. Some were enthusiastically greeted, some evoked more caution. It's understandable. People and health care is complicated. Reducing what doctors do to codes and pay schedules is fraught. Which means the right solution needs to have proper feedback loops. I don't think she used that term but that's what she described. Get the observations and data into the right hands. Give the front line folks the ability to drive improvements (a la six sigma). And do the common sense stuff. It might take 25 more years but I think we in the US are closer to the right track than I did before.
October 9, 2023
Having had the opportunity to collaborate with Vivian at Verily, I was very excited to listen to this book. Overall, I was not disappointed with the breadth of topics tackled.
I was most impressed with the way Vivian dove into complex web of incentives within the healthcare industry, and explaining how we reached today’s status quo. She masterfully unravels the tangled threads of profit-driven medicine, showcasing how it often leads to suboptimal patient care and skyrocketing costs. Her bold call to action for realigning these incentives is spot on.
Moreover, “The Long Fix” offers a comprehensive exploration of innovative solutions that promise a brighter future for healthcare. Vivian’s vision for a patient-centric, value-based system is not just a theory; it’s a roadmap for transformation. Her real-world examples and case studies demonstrate that change is possible. I thoroughly enjoyed the call out of leveraging new operating models in the delivery of care which are inspired from other industries.
In my opinion, if you care about or are interesting in modern healthcare and want to understand the root causes of its issues, “The Long Fix” is essential reading/listening.
I was most impressed with the way Vivian dove into complex web of incentives within the healthcare industry, and explaining how we reached today’s status quo. She masterfully unravels the tangled threads of profit-driven medicine, showcasing how it often leads to suboptimal patient care and skyrocketing costs. Her bold call to action for realigning these incentives is spot on.
Moreover, “The Long Fix” offers a comprehensive exploration of innovative solutions that promise a brighter future for healthcare. Vivian’s vision for a patient-centric, value-based system is not just a theory; it’s a roadmap for transformation. Her real-world examples and case studies demonstrate that change is possible. I thoroughly enjoyed the call out of leveraging new operating models in the delivery of care which are inspired from other industries.
In my opinion, if you care about or are interesting in modern healthcare and want to understand the root causes of its issues, “The Long Fix” is essential reading/listening.
July 13, 2021
Not the best healthcare reform book I've read. I thought Dr. Vivian Lee had some strong chapters with great theoretical points. However, for a book titled "The Long Fix", the concrete solutions for patients, physicians, payers and policy makers were lacking. Much of the book consisted of fragmented anecdotes and vague takeaways. I also thought the last chapter was a mess and did not tie together the points made throughout the book.
In my opinion, the strongest elements of the book were:
-The theme that compassionate care can drive financial savings. Often doing what's right for patients generates massive cost savings (i.e. shuttling elderly patients to doctor appointments, buying fridges for low income diabetic patients, providing insurance to low income populations to limit ER visits, paying for mental health benefits, etc.)
-The examples of business concepts that can be applied to the healthcare sector (i.e. operation checklists, hospital cost accounting, predictive analytics in electronic health records, employers managing employee health, etc.)
In my opinion, the strongest elements of the book were:
-The theme that compassionate care can drive financial savings. Often doing what's right for patients generates massive cost savings (i.e. shuttling elderly patients to doctor appointments, buying fridges for low income diabetic patients, providing insurance to low income populations to limit ER visits, paying for mental health benefits, etc.)
-The examples of business concepts that can be applied to the healthcare sector (i.e. operation checklists, hospital cost accounting, predictive analytics in electronic health records, employers managing employee health, etc.)
January 2, 2025
This is a perfect introduction for anyone interested in the current status of the American healthcare system; this was like 90% of my college curriculum condensed into a surprisingly digestible book.
It's been close to five years since this book was originally released and unfortunately a lot of information that this book covers is still relevant today. It would've been nice to see an addendum of sorts that covered how hospitals and other medical institutions were responding to the aftermath of the pandemic, but that's a minor nitpick and more of a testament to the author's remarkable ability to deliver this information so easily.
I think this is essential reading for anyone interested in American healthcare. You'll get much more mileage if you're already familiar with the concepts this book covers through a career in health, but there's still a lot of valuable chapters dedicated to the behind-the-scenes decisions that explain some of the baffling decisions that uninformed patients are forced to endure.
It's been close to five years since this book was originally released and unfortunately a lot of information that this book covers is still relevant today. It would've been nice to see an addendum of sorts that covered how hospitals and other medical institutions were responding to the aftermath of the pandemic, but that's a minor nitpick and more of a testament to the author's remarkable ability to deliver this information so easily.
I think this is essential reading for anyone interested in American healthcare. You'll get much more mileage if you're already familiar with the concepts this book covers through a career in health, but there's still a lot of valuable chapters dedicated to the behind-the-scenes decisions that explain some of the baffling decisions that uninformed patients are forced to endure.
Displaying 1 - 30 of 76 reviews