Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
The Great Healthcare Disruption: Marschall Runge
4 Plays17 minutes ago
Season 4, Episode 1: Dr. Marschall Runge is the former dean of University of Michigan Medical School and CEO of Michigan Medicine. He is also the author of the The Great Healthcare Disruption: Big Tech, Bold Policy, and the Future of American Medicine. Listen to Marschall discuss realistic expectations for our healthcare system, the potential uses of artificial intelligence in medicine and the importance of primary care providers.
Check out Dr. Runge's work here.
Recommended
Transcript
Introduction to The Wound Dresser
00:00:09
Speaker
You're listening to The Wound
Guest Introduction: Dr. Marshall Runge
00:00:10
Speaker
Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neary.
00:00:21
Speaker
My guest today is Dr. Marshall Runge. Trained as a cardiologist, Dr. Runge has held faculty appointments at Massachusetts General Hospital, Emory University, University of Texas Medical Branch at Galveston, and UNC Chapel Hill.
00:00:33
Speaker
More recently, Dr. Runge served as CEO of Michigan Medicine and Dean of the University of Michigan Medical School for 10 years. Dr.
The Great Healthcare Disruption
00:00:41
Speaker
Runge is also the author of The Great Healthcare Disruption, which explores technology and policies that will shape the future of American medicine.
00:00:49
Speaker
Dr. Marshall
Definition of Health and Healthcare Focus
00:00:50
Speaker
Runge, welcome to The Wound Dresser. It's great to be on your show, John. Thank you. So in your recent book, The the Great Healthcare Disruption, which I really enjoyed reading, ah you outlined some expectations that are are kind of prevalent our society about our healthcare system.
00:01:07
Speaker
And we'll we'll jump into those a second. I want to hear your your thoughts on how they affect the delivery of healthcare. But
U.S. Healthcare System and Improvement Needs
00:01:13
Speaker
um at a more basic level, I'd just like to hear, um you know, how do you define health?
00:01:19
Speaker
And from there, um based on that definition, how do you define health care? Well, ah that's really a great question. Actually, one that hadn't been offered and asked to me before. So I think health has many different definitions and to to different people. But my view of health is that a person is able from a both a physical and a cognitive standpoint to live the life they want to live. And they're not limited
00:01:50
Speaker
Now, you can be limited and still in various ways, physically or cognitively, and still be able to accomplish what you want to do or live the life you choose.
00:02:02
Speaker
But really, it's about that. And I think a key component to health, which we can't always control, is how much of our time and effort we spend on health versus our interactions with the health system and health care.
00:02:18
Speaker
so
Healthcare as a Right vs. Cost Challenges
00:02:20
Speaker
I think healthcare, so I think it is undeniable that in the United States, I don't think we focus as much on health, at least not from the standpoint of healthcare care providers.
00:02:33
Speaker
We don't focus as much on health because we're thinking more about these acute episodes when people have to come to a urgent care site or an emergency room or to the hospital. And that's very important. and And actually, I think we do as well as anyone in the world and better than almost anyone in the world in terms of complicated healthcare.
00:02:54
Speaker
But we don't do so well in access to healthcare. care And I think where we really have the opportunity to have an impact on people's lives is as we help them become healthy.
00:03:06
Speaker
There is a measure that i really like a lot called healthy average life expectancy, H-A-L-E. I'll say that doesn't have anything to do with the Michigan fight song, Hail to the Victors. um But it's a, and I'm in Michigan, but a um it's an it's a well-recognized measure. And the healthy average life expectancy in the United States is really disappointingly low compared to peer countries. We rank about 60th in the world in different countries. And so we we have lots of opportunity for improvement. And
Addressing High Healthcare Costs
00:03:44
Speaker
I think that should be a big focus of how we move forward.
00:03:48
Speaker
so so So with those definitions now, um you outlined six expectations in your book that kind of affect how we frame our healthcare system. The first is healthcare care is a fundamental right. Can you talk about how um that sort of affects the delivery of healthcare care in our country?
00:04:08
Speaker
Well, I think I believe that healthcare care is a fundamental right, but we aren't always delivering it to people. And Sometimes that's because of social or socioeconomic status or circumstances, but sometimes it's a responsibility of people to seek health care, and sometimes it's a responsibility of the health system.
00:04:30
Speaker
So that, is as you know from looking
AI in Healthcare: Scheduling and Administration
00:04:34
Speaker
at the book, that does intersect with the cost of health care, which is quite high in the United States, higher than in any other similar, well, higher than any other country in the world.
00:04:45
Speaker
So That tells me that it's it's a great goal that to have health care as a fundamental right, but we have to figure out how do we pay for that. And so, yeah, I'm going to go right down the line here. your Your second expectation is patients deserve the right care at the right time in the right place. Can you talk more about that?
00:05:06
Speaker
Yes. That's also, i think that is a goal of many health care providers, but it's one that we don't always achieve. So I i think in this case, giving some examples is helpful.
00:05:20
Speaker
So let's say i have a significant respiratory illness. I don't know if it's, there was an article recently, how do you tell if it's the flu or COVID or just a viral infection?
00:05:34
Speaker
ah But I have a fever and I i do need to be seen. Well, one possibility is by telehealth, but in telehealth, you can't, necessarily, you can't do a physical examination and
AI in Drug Development
00:05:48
Speaker
you can't understand how debilitating the current symptoms are. You can't get vital signs. You can't get the temperature or blood pressure or heart rate. So while it's an entree and a convenient entree, ah I would say in that circumstance, maybe it's a good screen, but it's not really the right care in the right place at the right time.
00:06:10
Speaker
So what do I do? Well, I call my doctor's office and Turns out they don't have any openings and they don't, um, it's, they, they can't see me.
00:06:21
Speaker
So then I'm left with an urgent care center or an emergency room where there's, um, lots of wait time in our emergency room, for example, at the university of Michigan, we have long wait times because many people don't have a choice. They, they can't get in to see their primary care physician and they can't, uh,
00:06:43
Speaker
They don't have any other choice. And so they come to the emergency room and they wait sometimes for many hours, which is inconvenient,
Healthcare Business Dynamics
00:06:50
Speaker
inefficient. And sometimes those those who come in need to be admitted, but that's the minority of patients who are seen in our emergency room. Most times they're patients who have a problem, ah but they don't need to be admitted to the hospital. And for that reason, they don't really need to be in the emergency room. So taking that example to an extreme, I called telehealth.
00:07:11
Speaker
They said, well, you need to be seen. I called up my primary care provider and they don't they don't have the capacity to see me. Everyone's busy these days. So I go to the emergency room.
00:07:22
Speaker
I sit there for half the day and feeling miserable. And at the end of it, I'm finally seen. And it turns out I just have a virus. But they they did test me for COVID. They test me for the flu.
00:07:35
Speaker
had chest x-ray. I had blood work done. And I might not have had to have all that done I'd been seen by a physician initially, somebody who knew me. So I i didn't get, i ah but ultimately got the right care, but not at the right timing and not in the right place. And it turned out to be expensive. An average emergency room bill is $1,000 to $1,500 that somebody has to pay.
00:08:02
Speaker
And so could that have been accomplished if we had the capacity in the system? I'm not talking about any primary care provider, but if we had the capacity for people to see their primary care provider right away. And there are countries that
Interoperability and Patient Experience
00:08:18
Speaker
really focus on that. That's just not been a focus in the United States.
00:08:23
Speaker
And then at the end of the book, you qualified that expectation by saying like patients deserve the right care at the right time and the right place, but that they also have responsibility for their own health. How do you feel like that healthcare care systems should,
00:08:36
Speaker
um you know, kind of divvy up the the responsibility ah of everyone's health between the patients and that of the healthcare system.
00:08:47
Speaker
I think the healthcare care system is the right place to turn for those answers. I don't think it's insurance companies. I don't think it's people who ah are necessarily providers because they don't have the reach.
00:09:02
Speaker
We have at Michigan Medicine, we have 4 million patients.
Restoring Trust in Healthcare
00:09:06
Speaker
And if we could do something to improve this dynamic, that would be very helpful. So part of that is education.
00:09:15
Speaker
Part of that is oh spending a significant effort with every person who gets their health care here to understand how they can improve their health. So that's putting some, and then those people have to take that on.
00:09:32
Speaker
And it's, although it sounds easy, it's much harder than education. and said, ah if it was easy, why would anybody have trouble with their addictive habits like smoking or alcohol or food addictions, which has led to so much obesity? So it's it's not an easy thing. So that I think the health system not only has to provide that education, but to provide tools.
00:09:57
Speaker
um And
Role of Primary Care and AI
00:10:00
Speaker
I think that ought to be part of our health system responsibilities. Unfortunately, the way that Healthcare care is paid for in the United States.
00:10:09
Speaker
There's not any capacity to pay people who do that kind of work. Now, you and I were talking before the before we started the podcast about AI, and I do think there are may be real opportunities in AI to provide some of this level of care. Not not directly, but as what I'll call an AI assistant.
00:10:30
Speaker
And already AI assistants are being developed for ah healthcare care providers but a really interesting concept that I have heard people talk about and I've engaged in discussions is how about if a healthcare system could provide every single person in the healthcare system with an AI um assistant?
00:10:50
Speaker
So what would what might an AI assistant do? Well, an AI assistant might both help with arranging appointments, help with access, help with all kinds of things, but a an AI assistant can also b a partner with patients to help them remember and do what they need to do. And I don't i don't have a great example in healthcare. I do have a great example in education as being at the University of Michigan.
00:11:16
Speaker
ah A year ago, but and now maybe two two years ago, the university decided to provide every incoming freshman, undergraduate freshman, with an AI tutor.
00:11:27
Speaker
And the initial thought was, or an AI assistant, the initial thought was that that AI assistant, if They missed class, could get the notes, or they could get the slide sets. But it quickly evolved to an understanding that the AI assistant can actually help the undergraduates learn.
00:11:44
Speaker
And how, you might ask, well, how does that happen? Well, the AI assistant can help evaluate when I'm studying, do I do the best if I read?
00:11:55
Speaker
do I do the best if I listen to a lecture? Do I do the best if i ah and try to answer practice questions? For me, it's actually the latter. ah But it would figure that out for everyone. And the the experiment's not concluded, but the the early findings are that that AI assistant helps students learn and retain faster than they do without it.
00:12:21
Speaker
So if we can provide something like that, different different setting altogether for people in their health care, ah we're a long way from that, but that's replicable, ah as AI is rep replicable. So we may not have enough doctors or nurses or therapists or um nutritionists, but we do have the capacity to fill some of those voids, not not the not the prescription and practice of medicine part, but the part that is someone like a coach that I think could be valuable. So I waxed and
Transitioning Healthcare Focus
00:12:56
Speaker
waned far and wide there, John, on that question, but I think there's the potential
00:13:01
Speaker
i think we have we as healthcare care providers have responsibility. I think individuals and all of us as is people have the responsibility responsibility to try to do everything we can do for our health. Last thing I'll say is it's very different for different people.
00:13:19
Speaker
Some people ah only feel healthy if they're working out 30 minutes, 75 minutes a a day. Other people feel quite healthy if they ah do If they get up and get out of the chair and walk around and ah focus more on their nutrition and more on their mental health.
00:13:40
Speaker
So that's another advantage of these approaches with AI is that they're very, very able to accommodate to the person that they're working with.
00:13:51
Speaker
Yeah, you're making me think I went to University of Michigan a little too early. i was there until 2018. could have really used that AI tutor. Oh, you just missed it. I mean, and we're doing this with medical students here also. oh really? Okay.
00:14:04
Speaker
And just starting it. But they the feedback is so positive about AI assistance in general. we don We don't call it that program, but we have a lot of AI inserted both into technology.
00:14:18
Speaker
education,
Personal Insights and Community Experiences
00:14:19
Speaker
but also in how one obtains education. You can always come back, John. ah I'll definitely considerate. It sounds like I'll have a little helper there. ah So last ah part of the expectations, though, that that I wanted to touch on. um Expectations three in your book is we cannot accept rationing care or a two-tiered system. And expectation four is insurance should cover all necessary treatments. So that's Those are kind of some expectations that folks have about our healthcare system. Like later in the book, you kind of, um you know, qualify those statements again. Can you kind of talk about, you know, realistic expectations for, you know, the tiering of our healthcare system and what insurance should cover? Yeah, I'm going to start with insurance, whether it's commercial insurance or federal or statewide insurance.
00:15:12
Speaker
I think a great... and a great deficiency in you U.S. health care is we don't provide some level of health care for everyone.
00:15:25
Speaker
Now, I'm not talking about universal care, which has been proposed for decades now, a or some sort of extremely high level of care. I'm talking about the basics.
00:15:36
Speaker
And we just don't do that. And we are, in fact, the only advanced country in the world that does not do that. that That doesn't provide all of health care.
00:15:46
Speaker
And even if you think about countries like Denmark, which gets high marks for access to their health care and how great it is, one thing I learned when I was writing the book was that although they do have a very good government-sponsored health care plan, ah as many as 50% of the population, maybe more, also purchase supplemental health care insurance. So it's sort of like if you have Medicare and you purchase from one of the commercial providers, supplemental insurance.
00:16:18
Speaker
And they
Dr. Runge's Personal Interests
00:16:19
Speaker
do that because they the government provided health care is good, it's solid, it's not everything, and and and they can involve weights if you have something that you need, like a surgical procedure, like a knee replacement, or something that's elective.
00:16:34
Speaker
So I think somewhere on that spectrum is where we ought to try to get on that spectrum. And the question is, so so when I say this, it's one of the few areas where I can irritate the entire polls of the political spectrum.
00:16:48
Speaker
So, I'm, I'm middle of the road. So I'm neither, neither poll. Um, and I try to reflect that in my comments, but, uh, the Republicans, for example, say we can't do that. That just costs too much. And we have to reduce the cost of healthcare. care Now, my critique of that is the best way to recruit, recruit, reduce the cost of healthcare is to improve health and having these kinds of systems will improve health.
00:17:14
Speaker
Um, But you know that that falls on deaf ears. The Democrats, and ah I have many in my family, the most passionate will say, it's unethical to have two levels of health care.
00:17:28
Speaker
And so
Future Plans in Healthcare
00:17:29
Speaker
we we cannot support something that is a lower level of health care than is for anyone. Everyone ought to have the same high level of health care. And absolutely, we can't afford that.
00:17:43
Speaker
But what I tell them is, look, You're kidding yourself. We have at least three levels of healthcare right now. We have commercial insurance. That's not even counting. count concierge care where people pay thousands and thousands of dollars to get instant access to their providers.
00:17:59
Speaker
that We have four levels. There's concierge care. There's commercial insurance. There's federal insurance like Medicare and Medicaid. Medicare and Medicaid are not the same as high-touch commercial insurance plan. Now, commercial insurance also offers various tiers.
00:18:18
Speaker
You pay less money and you get less high-touch care. And then we have another problem in the United States, which is only found worldwide in really third-world countries. And that is we have, and it varies from year to year, but we have 15% or more, depending on your location, totally totally under uninsured people.
00:18:43
Speaker
So I tell my friends, Look, we already have it. don't Don't close your eyes and say that we did we won't accept it because that's that's reality. Let's figure out how we provide And I'll give you a couple of examples about, as it turns out, I'm a big fan of the government providing some level of this insurance.
00:19:02
Speaker
And the reason is that I've worked in several different government settings. um I've worked in federal federally qualified health care centers, which are which are supported by the federal government.
00:19:15
Speaker
They're clinics, and they're all over. Michigan has maybe 35 to 40 of those, and ah they provide tremendous health care. I used to work on one, working on one at in North Carolina when I was there ah that I went to about half a day every other week, and I provided some continuity care and cardiology. I'm a cardiologist.
00:19:36
Speaker
But what I observed is the level of health care there is, it's great. and it's great because they have really mastered what's called a medical home. you can You can walk into the clinic I worked in, just walk in, and they'll figure out, well, do you need to see a medical assistant? you need to see a a nurse, a a physician's assistant, or a nurse practitioner, or a doctor?
00:20:01
Speaker
And they'll get it taken care of. And and they work together as a team. And it is so impressive. And they have their own pharmacy with low-cost drugs. So you know why don't we expand that model? That could be great. I hadn't had the privilege really of working in the Indian Health Service.
00:20:19
Speaker
like It's still called the Indian Health Service at a
00:20:25
Speaker
a care facility in New Mexico, in Shiprock, New Mexico. And they provide the same level of care as these federally qualified health centers.
00:20:37
Speaker
They do a fabulous job. It's only available for tribal members. It's on the nava in the Navajo Nation. ah But they also have a 60-bed general hospital.
00:20:48
Speaker
If you need a cardiac catheterization or you need an MRI, they make accommodations for you to go to a facility that has that. But the doctors and nurses and staff that work there are so dedicated to their mission.
00:21:04
Speaker
And the quality of health care is fantastic. I finally decided this year I'd never, I've been in veterans VA hospitals many times for short times, but I've decided I'm going to start seeing cardiology patients and general medicine patients in the VA, which is here and in in Ann Arbor.
00:21:23
Speaker
and But my experience is the same. it's It's that we can provide that level of care. We can provide it. Finally, I'll say that when you think about money that comes out of your health care dollar, um about 16 percent of your healthcare dollar in the United States goes to administrative costs for commercial insurance insurance companies. So you pay $100, 16 of that's gonna go for things like advertising, for prior approval, all the processes and that insurance companies do. You look at that number in Europe and Germany's a pretty comparable health system to ours in in commercial insurance.
00:22:03
Speaker
They charge about, so their administrative costs are about 6%. The shocker to me was, Medicare, which gets griped at all the time about how expensive it is, the the administrative costs of Medicare are 2%.
00:22:19
Speaker
So to me, that just shouts that we we can afford to do this. We can afford to do it in in a different way. And those those costs that i mentioned also, I'll mention one other topic that is very much in the news about pharmacy benefit managers.
00:22:39
Speaker
They take also up to 50% of the profit from drug sales. And where does it go? It goes to their shareholders. And so and they don't provide any meaningful meaningful use to either care providers or patients.
00:22:59
Speaker
So we're kind of riffed with all these inflated and bloated costs in our healthcare care system, which makes me believe that we can we can provide this level of care That's a political nightmare. and But we can provide it, and we can provide it at a reasonable cost.
00:23:14
Speaker
And it cannot and should not attempt to be gold-plate health care insurance. It's not. But it's great day-to-day access available health care.
00:23:30
Speaker
Yeah, I definitely like reading your book was the first time I i heard about the the federally ah the federal health centers that you mentioned. I really feel like I need to to look into those. It sounds like they have this sort of like a great triaging model that can like help people get the care they need.
00:23:46
Speaker
um Also funny, i just ah just a side note, I did my um senior design project for Michigan Engineering at the Ann Arbor VA. Oh, is that right? Yeah, we did a... Tell me about your experience. I'd love to hear it.
00:23:59
Speaker
Yeah, we did um like a um basically a sling for folks who were either had an amputation or limited mobility to get in and out of their car. We were we were doing the second or third iteration of a project for sling like that. And it was ah it it was kind of ah a ragtag operation, but it it was fun to meet with the folks there at at the VA. Well, I'll tell you what, John, if you find yourself coming back to Ann Arbor for any reason, we have a great relationship with an FQHC system here called Packard Health.
00:24:33
Speaker
They have locations in Ypsilanti. and They have three locations. I think they're all in Ypsilanti. And I'm very connected to them. I'll take you over there. And you you will be amazed at what they do.
00:24:46
Speaker
Fantastic. I'll hold you to um But, yeah, so in terms of... um your book, it's appropriately titled The the Great Healthcare Disruption.
00:24:59
Speaker
my I was telling my roommate about the book and he says, based on the sound of the book, that its it should be the the great healthcare disruptions because there's a lot of different things going on. ah He'll appreciate that shout out.
00:25:11
Speaker
um But you know the first ah obvious one that you already touched on, ai um you you were saying you know coaches for for patients, administrative assistance, for you know healthcare care workers. Can you just elaborate on more on the way you see AI changing healthcare? care And I think even maybe even more interestingly for a lot of people, it's we're we're curious about the timeline that that's gonna happen on.
00:25:38
Speaker
Well, first I do wanna make a comment. When I used that term disruption in the title of the book, I'm looking at that in a positive way. Cause healthcare care here is good. It's not great, but it's good. But I think some of these disruptive forces, and what I mean by disruptive is they're going change the way we do things, ah can actually be tremendously positive for everyone.
00:26:00
Speaker
So ah AI in general. So I have to tell you, a man alive, the tsunami of AI coming in has been something I've never seen in my entire life.
00:26:15
Speaker
And I think that's true for all of us. And it's affecting our life in many different ways. And many different positive ways. The only caution I have about AI in healthcare care is that there is such a focus on entrepreneurism among those who are developing these tools that we have to be careful about it. When I wrote the book at that time, there were over a hundred new AI startups in for healthcare.
00:26:43
Speaker
And at the end of the day, how many of those will make it? Well, ah maybe five. So everyone, whether it's a healthcare big healthcare system or healthcare providers or individuals, we we have to be a little cautious about what we put our money into in terms of bringing on AI because it's not everything's gonna be great.
00:27:04
Speaker
However, and when when you think about what an AI, some examples of what AI could do administratively to start with,
00:27:17
Speaker
So some of this is that it's very mundane things. So if if you call our system or virtually any big system for an appointment, and let's say you have a particular cardiac problem, and you've heard that Dr. Jones is a great cardiologist you'd like to see him.
00:27:36
Speaker
Well, you talk to a person on the phone, they say, well, Dr. Jones is booked up for the next eight months. And then they say, well, any any other chance? And they say, well, we'll we'll put you on a list of people in case he has cancellation. well that's okay, but that usually doesn't work out all that great.
00:27:53
Speaker
And so then they might go to another you know series of other doctors that you might see. um And for whatever particular reason, it may turn out that you're not as well, they're not as well suited to see you. So let's turn out, let's say Dr. Jones was a real expert in atrial fibrillation, but instead they connect me with cardiologist whose real expertise is in heart failure.
00:28:21
Speaker
You know, so so those, you need that tailored. And so you can spend a lot of time on the phone and end up with an unsatisfactory result. We have done a pilot. We're not totally on it yet.
00:28:34
Speaker
Some places are totally on it where this is all directed by AI and not in the clunky kind of AI that's like when you call to make a reservation at a restaurant or for a hotel or whatever.
00:28:49
Speaker
um But it's, it puts you into a system and AI, just as it can do everything else and in moments, in moments can say, find, you you set the criteria. Well, I want to be seen in a week.
00:29:04
Speaker
I want to see somebody with this expertise. I want to be seen at this time of day. i i work and I can't be seen until after four. um And really mean in just seconds, you'll have appointment opportunities.
00:29:21
Speaker
And it can do that because it can look at millions and millions of potential appointments out there, just like it looks at millions and millions of of of ah data of any sort and can come up with the answer. So that's one. i mentioned that first because access to health care is maybe one of the most difficult things for people as they try to get in to see the right doctor at the right time the right place.
00:29:49
Speaker
I want to give you one other example that we don't think so much directly about health care, but it's absolutely related. AI turns out to be incredible tool in drug development.
00:30:01
Speaker
It can look into these big databases and can figure out before the development of a chemical drug, for example, a pill, starts, well, these are properties that are likely to make it have side effects based on analysis of a million other drugs that a drug company might have available. They've they've characterized, never never made it to the market, but they know the side effects.
00:30:21
Speaker
um Secondly, we do these clinical trials, which are very important, but they take a long, long time because you have to enroll 5,000 people or more.
00:30:32
Speaker
AI has already enabled enrollment of a much smaller group based on not just who might have heart failure, but speak too much in cardiology terms, who might who might have an inflammatory disease, ah but a subset of it.
00:30:52
Speaker
And that's it's that subset that the drug is designed to treat, and then now they can do the clinical trials. And so those clinical trials being done that way even now have accelerated the process of figuring out do drugs work and do they have side effects by, I don't know, 50% right now, but I think that'll get faster and faster. So apply that to any area of healthcare. care And as I said, it's moving at rocket speed. So I think that AI is gonna really be transformative.
00:31:22
Speaker
Yeah. it I think the the drug stuff that you talked about, the drug development stuff with AI you talked about your book is really fascinating. I think also the what you touched on earlier with the the ability to have like see streamlined appointment scheduling and stuff like that. When I talked to Dr. John Reisman about artificial intelligence a little while back, he was describing that our healthcare system is kind of in the horse and carriage era of just like scheduling and stuff like that. and I can totally relate. you know I need to schedule a doctor appointment right now. and I've been putting it off, doing it for months, just because I think it's just going to be like a a very difficult task. But if there was AI to just make that a more efficient process, I think it would get me the care I needed, you know, far, far sooner and far better care.
00:32:05
Speaker
um So that's, that's really exciting. And I think that like this, this discussion ties nicely into another ah point you bring up a lot in your book, which is that, you know, healthcare is a business customer experience matters um because of that, you know, you have folks like Amazon, Walmart, um a lot of different, you know, redefined pharmacies are emerging.
00:32:26
Speaker
um Can you talk about like, how, how can we, how can the healthcare care system deliver the best customer experience? Are we going to lean a lot on these other, you know, private sector folks or,
00:32:38
Speaker
how How do we optimize customer experience? Several things. First is I think we have to work with partners. So, a and what you said initially is healthcare care is a business and there's no denying that. So trying to say, well, we're too pure to be a business, that's not today.
00:33:00
Speaker
um So, well, how do we partner with Amazon? Amazon, one thing that they offer that we can't offer is 24-7 availability. yeah have You have a problem at 3 in the morning, there's somebody there for you.
00:33:16
Speaker
Now, is it optimal health care? No, not really, ah because they don't know you. They don't really have access to your electronic medical record. They know what you tell them, which you may have forgotten. You may be sick and you forgot to tell them something that is really important. So I think that partnership goes both ways.
00:33:34
Speaker
And that gets to a big, big problem in the United States, which is referred to as interoperability of medical records. So they just don't talk to each other at all.
00:33:46
Speaker
And so I think a critical step to being able to use partners like that is for our electronic medical records to talk to each other. And we have to be able to do that in a way that's safe and doesn't risk private and protected health information from getting it out there.
00:34:02
Speaker
but But I think we can get there. So, so I think ideally a health system or a small practice of two or three physicians can and should partner with people who groups that can provide the services that they cannot.
00:34:18
Speaker
Secondly, i think that we have to get over this competition that goes on between health systems and and startups and others vying for providing these services. Now, Amazon clinics,
00:34:35
Speaker
and many others, what they have done is they've stepped into a void. They identify what's the problem. The problem is like people can't see their doctor the way they'd like. Okay, well, how how do we fix that?
00:34:47
Speaker
And I think there are many, many other problems that many startups are looking at as to how can we fix this. And, you know, just as I don't, you probably don't have to take any medicines, but if if you get a medication, if you want to, you can look online and see, well, where can I get that least expensively?
00:35:07
Speaker
then you have to put in information about your health care insurance and your pharmacy plan. um That can always be made possible through um use of AI, for example. and So I could need a prescription for penicillin and it would say the closest pharmacy to you is ah CVS on State Street, which ah but the cost there is going to be twice what it is if you use an online provider.
00:35:42
Speaker
or horse I'm making up examples, but things like that. So you decide, well, do I just want don't want to run over CVS, or can I wait the day or two that it might take for me to get medicine from an online provider?
00:35:54
Speaker
men So figuring out that dynamic is an important one. um I think the last comment I'll make about the patient experience, which I've read many other people say recently is that it's a real problem that we have that healthcare decisions have for my entire life in healthcare, 40 years in healthcare, care have been made it made by a ah collaboration of healthcare providers and patients.
00:36:29
Speaker
And we've gotten a lot better at than that. when When I started medical school, we just kind of told people, okay, here's what you do. Now it's a conversation which I think is much, much better. But now, I said now, it has always been that for the last 20 years at least.
00:36:45
Speaker
Now, though, healthcare care decisions are being made by insurance companies. And they're being made by insurance companies whos who aren't uninterested in the best healthcare, but what they are interested in is the margin that healthcare care generates.
00:37:00
Speaker
And so that some of that decision-making has been taken entirely away from this kind this these very important conversations between healthcare providers and patients.
00:37:13
Speaker
And I think that is absolutely the wrong direction. And the more we see of that, the more dissatisfaction we're going to see from all of us about our our healthcare. and you know that's That's in the news all the time.
00:37:26
Speaker
a Sometimes it's anedote anecdotes, ah but often it's reality. So that is also a critical component of people being satisfied with their health care.
00:37:38
Speaker
Final thing I'll say is, is anyone ever satisfied that their favorite sports team has done well enough? Not very often. i mean, there are few champions and then everybody else wishes their team was a champion.
00:37:51
Speaker
The same is true for health care. i do I do not think it's realistic that everybody in the United States is going to always be said have high satisfaction with health care. just Just not going to happen.
00:38:03
Speaker
But I think we can move the needle substantially. Yeah, you said in the book, perfect let ah let not perfect be the enemy of of better, right? and Yeah. I think, yeah. haven't read the book, John. um Yeah, yeah. Word for word, no. I think another thing I've been, you know, you you even said too was that –
00:38:28
Speaker
this, you know, focus on customer experience that can probably lead to like the fragmentation of care that, um that you're, you know, people, different parties where people are receiving healthcare, aren't really talking to each other. And, and so I continue to wonder whether if we're just because of market force is going to be focused on, um you know, convenience and, and the the customer experience, and then we're going to lose some of that, continue to lose what's already been lost in terms of,
00:38:57
Speaker
continuity of care. John, I think you hit the nail on the head. And what that without focused attention to this, I see it getting worse. And, you know, one thing I, what the primary reason I wrote that book was because of the opportunity to get some of these messages out in a nonpartisan wade you know, trying to be as fair to every leanings as I could, but to try to get these messages out.
00:39:29
Speaker
um I want to say two things about the book. The first is ah when you work with some publishers like Forbes, which is a prestigious publisher, there is a cost to it, not not gigantic, but um the University of Michigan actually paid those costs, which I thought was extraordinarily generous, in arrangement which I also was fine with, and that is all royalties or any kind of income related to the book goes to the university because I love the university and I wasn't doing this to make money, but it enables me to tell people this book. I'm trying, I am trying to get it out there much more in the public and it's not because I'm going to make any money off of it.
00:40:11
Speaker
I mean, I'll get some, ah perhaps a, my 10 seconds of fame and glory, but really it's about trying to get these messages out and start conversations. And for that, I'm um'm doing, I'm doing a little self-promoting here.
00:40:25
Speaker
ah For that reason, I have a website that's called drmarshallrongyal, one word, and marshall spelled like my name is, dot com, that is a ah way to connect with people who are interested in health care.
00:40:41
Speaker
The second is, I'm doing as much as I can in terms of trying to promote the book. I really appreciate being on your show. But for those who are listening, I do also do either Zoom or ah personal appearances and have these conversations and with, with an audience.
00:41:01
Speaker
And generally between the university of Michigan and Forbes, I can provide ah copies of the book to to anybody who comes either for free or at very low cost.
00:41:14
Speaker
So I'm, I'm doing this. I do, i do this. I've done this several times with the university of Michigan alumni association. So if, if any of your listeners are interested in that, I'm, I'm happy to to hear from them. And if i can if they'd like me to discuss these topics, I'm happy to do that.
00:41:35
Speaker
And free books. All right. Well, we'll have you come over to Philly. It's going to the 250th anniversary of the country and and the the sign of the Declaration Independence. So we could get you here in 2026. I'd love to do that.
00:41:49
Speaker
Yeah. i want to I want to wrap up here by... um talking about two of the prescriptions that you offered at the end of your book. um The first one is that you you you really leaned into this idea of that we, you know, need more primary care providers. we um We, you know, everybody should have a primary care provider and they should be like the the the center point for coordinating, ah you know, health and healthcare. care um Can you talk about why that would be helpful to building a better healthcare system?
00:42:22
Speaker
Yes, it's it's it's been shown worldwide to be helpful, first of all. um and ah But we have a particular problem in the United States. Other countries have it, but not nearly to the dec degree we do, which is um primary care as a practice is is really take somebody with passion to go into it because it pays poorly.
00:42:45
Speaker
Their colleagues who just finished and going into a highly specialized field can make three, five, 10 times as much as they do. Now, should everybody be rich? Well, everybody doesn't to be rich, but when you think about it, the cost of medical education, many people leave medical school with debts of $200,000. That's the cost of a house.
00:43:09
Speaker
and And then with a a salary and compensation, it's hard to pay it back. So step number one is we need to figure out how we can get people more interested in primary care, I'll tell you, the incoming class every year for since I've been here at the University of Michigan, you know, 25 or 30% of the people want to go into primary care. By the end, you know, we're lucky if it's up to 10%. It's because of these both financial and logistic log logistic problems where they know they're going to get crushed because we just don't have enough of primary care providers. So we are, in other places, are now testing models, and we're approaching this
00:43:51
Speaker
both practically within ourselves, but also with philanthropy to try to create new ways to train primary care providers. It's faster, prevents them from having debt and enables them to practice in the right kind of environment so that they really find it, the reward vastly outweighs the headaches.
00:44:13
Speaker
So I don't i don't see, it honestly, i don't see a way out of this until We have primary care providers for everybody because it's that one, not necessarily person, but group of people who know everything about your health and can help you make health decisions in a way you can't make if you go from specialist to specialist to specialist.
00:44:35
Speaker
I heard an interesting discussion of a model for Medicare, which was set up some criteria. I mean, this would take decades. Set up criteria that are what we want. We want you at the age of 22 or whatever, to have a primary care provider, to have a healthcare care insurance of some sort, and you know variety of other boxes that can be ticked, which might include and guidelines around diet and exercise, et cetera.
00:45:09
Speaker
And if you do all those, you you build up points. And so if you do all those, when you get to be 65, Medicare is free. And if you don't do all those, By the time you get to be 65, Medicare is expensive, which it is now.
00:45:25
Speaker
I'm not saying that's the perfect plan, but I think doing some social engineering into how we help people take take charge of their own health can really change health health in the United States and really reduce our health care spend.
00:45:42
Speaker
And I think that all revolves around having really strong primary care. As I've said, quip about with people. know, if I get any more primary care focused, they're going to take back my membership card as a cardiologist, but but I'm willing to let that happen.
00:46:00
Speaker
Yeah, I can definitely relate to all the things you're saying about, you know, the the challenges going to primary care. I am interested in primary care. i would I would say people don't, you know, consider it to have a lot of curb appeal. I think it, you know,
00:46:15
Speaker
but But like you're saying, it's it's really important to improving the health of you know our community. So I'm almost kind of optimistic about the the possibilities of AI really helping primary care providers in the sense that it can expand their, you know,
00:46:31
Speaker
technical capabilities, um you know, who knows, like, do do do you see that as as AI really, you know, perhaps leading to a new era of primary care where primary care providers can provide a wider range of care, maybe even in both inpatient and outpatient settings?
00:46:47
Speaker
I do. And I share your enthusiasm, John. And I think a the more of us, so one of the reasons I'm so delighted to be on your show is the more of us that get out and spread that message, you know,
00:47:02
Speaker
Things aren't going to hell in a handbasket here in the United States. And we have ways to improve health. And I think just coming back over and over again, it's it's about health because we have great health care. mean, if I i needed a brain transplant, which my wife says I do, um no place I'd rather have it. in And there is no such thing as a brain transplant, but no place no such place I'd rather have it in the United States. Or if I need complicated surgery, or if we had a child who had really as desperate,
00:47:33
Speaker
healthcare needs. This is where I want to be. So we we got that part licked. Now we've got to figure out how we deal with the rest of it. But we need strong, strong spokespeople. So keep getting the message out there.
00:47:47
Speaker
Yeah, you can throw me on the list for the brain transplant too. Yeah. I'm sure my my my folks would will put me on that list. ah Last thing, um prescription number six that you offer is all about reestablishing trust in the medical community. and I think this is just huge because there's clearly a lack of ah you know trust and with with with medical professionals. And you know you you see that with the obvious emergence of like figures like RFK who you know, you set aside the like vaccine stuff. We know how the medical community feels about his views on vaccines, but like he's connecting with people in a way that the medical community isn't that people feel that America is really unhealthy. People feel like that there's a lot of crap in their food. People feel that, um, you know,
00:48:37
Speaker
these medical professionals are putting me on 10 or 12 drugs and I'm still like incredibly unhealthy. Like, why should I be listening to them? So how do you reestablish that trust and connection that is coming from maybe not the best voices at this time?
00:48:51
Speaker
Yeah, I think it's multifactorial. i agree with you though. Any efforts, including RFK juniors um to reestablish that trust is really needed at this point in time. And the reason I say it's multifactorial is It's not all just the interaction of people with their healthcare care providers.
00:49:14
Speaker
It's the the things like challenges with getting medications or procedures or even visits approved that stresses that.
00:49:27
Speaker
So who ends up having to deliver the bad news? Well, it's a healthcare care provider or their office. So that that's a reality. ah When I'm in a public place, and whether it's in an airport or I'm riding a bus somewhere or whatever it is, you just hear people talking about, and I not hear it all the time, you know, I just wonder, is my doctor doing that because it's going to make him more money?
00:49:58
Speaker
Is the reason I'm having all these tests because they're going to make more money off of that? um And, ah you know, that it is the truth. that in healthcare, care the more procedures and things you have, testing, all that in one way or another generates income for either physicians or for the healthcare system.
00:50:22
Speaker
Now, i I do believe, and I want to believe, but I think it's right, that most healthcare care providers do what's right. they don't they don't They're not doing it because it's going to make them more money, but there sure surely are those who do.
00:50:36
Speaker
And you only have to hear a few stories about that. My doctor had me have three CTs and over the last month and everyone else, which I can't believe they got it approved. But the next time I saw a doctor, they said, wow, why did you have all three those? It's very unusual.
00:50:55
Speaker
And there are some Dr. Mills and things that exist out there. So the medical profession, we're we're culpable. Payers, they're culpable.
00:51:10
Speaker
It's going in the wrong direction right now. And I do think that that trust has to be turned around and redeveloped. I tend to think that that's more possible when you have a single health care provider, like a primary care provider, than doing sort of episodic visits to different specialists or different facilities or kind of doctor shopping or facility shopping. If have So again, i don't want to lean too heavily on primary care providers, but I think they can provide a building of that trust.
00:51:44
Speaker
And that's part of what they why they go into primary care. And we talked about earlier, I talked about my experiences at the FQHCs and also at Shiprock.
00:51:56
Speaker
Those are primary care physicians. And that first, I told somebody when I got back, it actually... from Shiprock, it restored my faith in healthcare. care I mean, I was kind of feeling like, man, we're go going the wrong direction. But they're there. They get paid a decent, they didn get paid decently. you know They're not going to get rich off of it. Their loans get repaid.
00:52:18
Speaker
And, but they're able to live the life they wanted to live. They they want to, i mean, they're driven by their their passion, not by dollars.
00:52:29
Speaker
And I think a whole lot of people in medicine are like that. And we have to create the environment's It will enable them to do that. And and that in itself will help rebuild trust. You if I didn't have to, there's term in that you probably noticed in the book called RVUs, relative value units.
00:52:45
Speaker
If doctors didn't have to worry about how many RVUs they're generating and whether they're going to get a bonus for generating more RVUs, but rather they just spend time with patients and they get paid a salary or or salary plus benefits, it'd be a totally different dynamic.
00:53:03
Speaker
talk I talked to a person who recently who has a model that is agnostic for how many RVUs you generate.
00:53:15
Speaker
And the satisfaction of patients and their physicians is so much higher. And RVUs was a concept developed by Medicare back in the 1960s. And it's just irrelevant today.
00:53:26
Speaker
But it's ah it's something that can be tracked, and that's why it's still in use. With that, it's time for a lightning round, a series of rapid fire questions to tell us more about you.
00:53:38
Speaker
I'm ready. All right. So I know you're cardiologist, as you've you've alluded to. What's your favorite chamber of the heart? ah That's a great question. Oh, no, never been asked that before. But my favorite chamber of the heart is the left atrium.
00:53:54
Speaker
So the ventricles are the pumping chambers. The left ventricle pumps blood to the body. The right ventricle pumps blood to the lungs, but the left atrium is the cause of more grief because there different arrhythmias, but one is called atrial fibrillation.
00:54:10
Speaker
And it leads to all kinds of problems. It can lead to heart failure. It can lead to stroke. And it just gets more and more common, both the older you get, by the time you get to be 75, as many as 25% of the population have atrial fibrillation.
00:54:26
Speaker
But also if you have high blood pressure or any of a number of risk factors, you're more likely to develop atrial fibrillation. So never been asked that question, but the way I see it, if we can control the left atrium and get it whipped into shape, we're in good shape.
00:54:40
Speaker
if um Just reading your bio, it it sounds like you've lived in ah a lot of different cities, Atlanta, Boston, Ann Arbor. ah I'm sure I'm missing a bunch. Oh, what's what's the best city to live in, in your opinion?
00:54:56
Speaker
Ha, ha, ha. Another great question, which I do get asked. So the first thing I'd say is that I've loved them all. we We've never moved because we didn't like a city.
00:55:07
Speaker
and we moved for We moved for job opportunities. But I'm going to pick one that probably would not be the choice. I mean, Ann Arbor is fantastic. I mean, how can you complain? Chapel Hill is fantastic. Boston, I love. They have so many activities. We love Baltimore and the different places we live.
00:55:23
Speaker
But the one I'm picking is Galveston, Texas. Wow. why Why do I pick Galveston? Well, Galveston... is a quirky little town. Its population is about 80,000. eighty thousand It's on an island, has a rich history.
00:55:36
Speaker
And, you know, it has some cool things to do, but related to being a and yeah ocean front town.
00:55:47
Speaker
But what I loved was the population. And so the population of Galveston um was about really almost equally split, third to third and third of and Caucasian, Latino, and African-American.
00:56:02
Speaker
And it's something about the place. Just people get along. You know, you don't you don't have these giant um misunderstandings because ah they can come up. ah You know, it's not perfect. Nowhere's perfect. But people, you know, but when you're in that when you in that environment, it just it just has a warm feel to it.
00:56:23
Speaker
And I like Texas anyway. was born in Texas. My grandparents actually lived in Galveston. so and But I just, I still love the place. My wife and family, sometimestime are sometimes our kids go back there just to visit.
00:56:37
Speaker
All right, Galveston, Texas. What's a ah book you're looking forward to reading? Well, um it's a simple answer, but there's not a said book.
00:56:48
Speaker
um um I look forward to whatever the next John Grisham book is. I love John Grisham. I already read My wife, and this kills my wife. I buy it when it's only available on hardback or the Kindle is really expensive. But I just read his latest, which is called The Widow.
00:57:05
Speaker
Another great book. So I'm waiting for the next one. What's your ideal Saturday afternoon? My ideal Saturday. Well, when I can, and it's gotten much more possible recently because I don't have administrative responsibilities like I did, is to either...
00:57:26
Speaker
to get some exercise, watch some kind of sports and go have dinner with my wife and and when possible, as many of our kids and grandkids as we can.
00:57:37
Speaker
All right. And last question, I think you've already kind of talked about this a little bit, but what you just moved on from, i believe your your role as CEO of Michigan Medicine and Dean of the Medical School. So what's the next chapter of your your career, Holden?
00:57:51
Speaker
Well, um it's great. It sounds bad, but you know the the those jobs are twenty four seven stressful jobs. and and you know most I've had jobs like that at that level for 40 years.
00:58:08
Speaker
Not having that is fantastic. I'm doing more writing. I'm doing more speaking, and I'm going to do more clinical care. I could do some clinical care, but I i got into medicine because I loved clinical care.
00:58:20
Speaker
I ventured into the VA while still seeing patients at main hospital, and I think I'll get back to the FQHCs. I find that really interesting, rewarding, and fun. So I'm going write, I'm going to speak, I'm going to do a MOOC. I'm doing a MOOC that I'm working on getting put into place. So that kind stuff.
00:58:39
Speaker
And more podcasting too, right? More podcasting for sure. Dr. Marshall Rungi, thanks for joining the Wound Dresser. Thank you, John.
00:58:58
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host, John Neary. Be well.