INTERVIEW SERIES

Meet Community Member
David Blumenthal
Former President, The Commonwealth Fund;
Professor, Practice
Public Health Harvard Chan School of Public Health

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Transcript

Dough Riddle: (0:01)

Dr. David Blumenthal has spent his career at the intersection of medicine, policy, and innovation, bringing a rare combination of clinical insight, academic rigor, and public leadership to some of the most pressing challenges in healthcare.

He has served as an award-winning researcher, acclaimed teacher, and leader in healthcare, government policy, and international health, and has returned to Harvard's Kennedy School as a member of the faculty. We have been blessed to benefit from his leadership of The Carol Emmott Foundation's governing council and as a mentor for the Carol Emmott Fellows.

I am pleased to welcome you to The Treasure Hunt, David.

David Blumenthal (00:42)

Pleasure to be with you, Doug.

Doug Riddle (00:44)

Thanks, David. I understand you didn't set out to be a physician. What led you into medicine?

David Blumenthal (00:53)

Well, I was of a generation where the Vietnam War was a very important part of our lives. And I graduated from college in 1970 at the height of the war. At that point, the draft had turned into a lottery. And if your birthdate was below a certain level, you were virtually certain to be drafted.

That ended up being true for me. I think I was number 13 out of 365 or whatever it was, and there were two sources of deferment. One was to go to divinity school, and the other was to go to medical school.

So I had the basic requirements with some advanced placement from high school for medical school. I chose that as an option, thinking that I could pursue my other interests in government, history, and policy from the platform of medicine.

So it was history. Every generation carries a burden, and our burden was the Vietnam War, which profoundly changed my direction, but I've been very happy with my career.

Doug Riddle (02:18)

At what point in that process did you say you've been very happy with it? I'm curious about your own kind of mental change. Was there something that grabbed your attention or that convinced you that, in fact, this was a nexus that would allow you to do all of the things you wanted to do?

David Blumenthal (02:38)

Well, it was a while coming. Medical school was not a delight for me. I took journeys off into other things that interested me more.

I got a master's degree from the John F. Kennedy School of Government at Harvard while a medical student in a five-year program that gave me a master's and an MD. I left my residency to go to work for Ted Kennedy, which was not a common event in a highly competitive Harvard residency program.

And I did these kinds of back-and-forth jogs into public policy out of medicine and then created a career where the actual practice of medicine was a part-time event and research and public service were more central.

So I think what I found was that I could combine my medical training and skills with the things I enjoy doing the most, such as writing, serving, and teaching. And I never gave up practice because I discovered that it really fed my other interests, and it gave me credibility with my colleagues.

And it taught me a lot about the healthcare system and about what was possible to do in the way of change within that system: what the problems were that clinicians and patients faced on the ground in the real world.

Doug Riddle (04:23)

I know that both you and your brother have been involved in public service. Is this something that was a part of your upbringing? Was your family at large involved in this before?

David Blumenthal (04:39)

My father was a refugee from Nazi Germany. He arrived in the United States in 1935. He was a German Jew. He was thrown out of high school; he actually never completed high school or college. But he was, as a result of that experience, always very, very committed to human rights.

And I think he conveyed to both my brother and me a sense that we were fortunate to be where we were at the time we were, and that things could have been very different. So I think that was something that made an impression on both of us.

I also think that we were a product of the John F. Kennedy presidency and the inspiration that John F. Kennedy brought to a generation of possible public servants. I think and have hoped that Barack Obama had the same effect on young people in a more recent period.

But that combination of influences, I think, was important for us, at least for me. I can't always speak for my brother, obviously.

Doug Riddle (06:19)

Let me turn our attention to your leadership in healthcare. You were chief medical officer and chief health information and innovation officer at Partners Health. For physicians in particular who are considering greater administrative leadership roles, what would you warn them about with regard to the sources of pressure in that job?

David Blumenthal (06:20)

So just to correct the record, I was not chief medical officer. I was chief health information and innovation officer. And I took that job when I came back from working in government, running the office of national coordinator and trying to get physicians in hospitals to adopt electronic health records.

When I returned, I was aware that I was possibly in a transitional role, and I sought out something that would be challenging and stimulating to me.

So I went to the leaders at Partners and said, I'm ready to take some of my own medicine. If you want me to help you with a project that you've undertaken, which is to switch out a bunch of homegrown electronic health records and put in place a uniform system-wide commercial record, I'm willing to give that a try.

And they said, sounds good to us. So my job was to choose a new electronic health record and then to lead its implementation. Now, there is an important overlap between that and chief medical officer because, in fact, the information systems in a health system are one of the very few things that touch virtually every clinical person and every non-clinical person in that entire system.

So the tens of thousands of people working for Partners Health System at the time, now it's called Mass General Brigham, with multiple hospitals and internationally prominent teaching hospitals.

It's a network of community physicians, a network of community health centers, long-term care facilities, and a mental hospital. All of them were affected by this system, and all had to come together to think about how to get it implemented, and it changed the processes of care. So it required, really, to be done effectively, a deep knowledge of clinical care and a deep knowledge of hospital management.

I had previously been a senior vice president at Brigham Women's Hospital, so I had that management experience as well. And once again, it wasn't my technical information or knowledge that was valuable; it was my understanding of the needs, wishes, and constraints of doctors, administrators, and patients that I think made it possible for me to lead that project successfully.

Douglas Riddle (09:47)

I think there's a dilemma with electronic health records in terms of public policy and so on. I noticed just in the last couple of years the ascendance of one of the companies that provides this service all across the board.

But I wonder, I've never had a chance to ask anybody in terms of the policy considerations, we like to say that we're fond of competition in these areas. But of course, there's a kind of dilemma when you have the issue you were focused on, interoperability, I think is what it's called. If you have multiple vendors, then you have to balance some of that somehow.

Is that what you see with that, and do you have concerns about how we're solving it as a nation now?

David Blumenthal (10:38)

I am delighted to answer that question. First, you had asked another about what people might learn from my experience about leadership. And I got kind of sidetracked onto another story. But I think that the most important quality for leaders is their ability to communicate and their ability to discipline themselves to set a number of priorities, a limited number of priorities, and to reinforce the importance of those priorities repeatedly with the organizations that they're leading and the people they're trying to inspire.

And I had this experience with my boss. When I worked for President Obama, my boss was Kathleen Sebelius, who was the Secretary of Health and Human Services at the time. And I was out talking about electronic health records. There we are, talking about electronic health records again. But I was doing that. That was my job. And at one point in a joint appearance, I said, You know, I'm really tired of saying the same thing over and over again. And she said, and she had been governor of Kansas, a Democrat who was governor in a red state. And she said, You know, I had the same problem when I was running for governor. And my campaign manager said, when you start to get nauseated about saying the same thing over and over again, that's when it's probably just getting through. Communication and the inspiration that you can provide from that communication is a skill that I think health professionals are not always taught or are not emphasized to them. So that's one message I would send.

Communication and humanizing that communication, narrative, storytelling. Even for us, pointy-headed professionals, we're still people, and we still respond to stories. So let's get back now to competition among electronic health records.

You know, there's one system, it's the Epic system, that has become dominant. And one way to get interoperability is to have everyone use the same record. And that would have been a quick and easy way to interoperability. The problem was that it would have been impossible politically for the federal government to tell 500,000 physicians and 7,000 hospitals exactly which record was right for them.

And it wouldn't have been wise because of competition, especially in a highly innovative field like technology, to make sure that you get the best technological solutions and the best human solutions. The reason why Epic has become dominant is in part that they were better at implementing electronic health records, especially in large systems, than any of its competitors.

And I saw this because I negotiated the contract for Partners Health System with Epic. And I spent a lot of time going to other places that had implemented Epic and other systems and learning what the strengths and weaknesses were. And the one thing that came across clearly was that Epic knew how to implement large-scale projects in this field. And as I worked with them, I saw why.

There comes a time when the most successful product can lose its edge because it is no longer competing successfully with other organizations. And Epic will have to deal with that just the way IBM had to deal with it and Microsoft had to deal with it. You know, when you get dominant out of success, it doesn't mean that you're going to be allowed to continue with that dominance.

I think I wouldn't be surprised if we saw, at some point, antitrust activity addressing Epic's market share, but we're not there yet.

Doug Riddle (15:24)

Those are the challenges, though. Go ahead.

David Blumenthal (15:27)

Now, the other point you were asking about was interoperability.

Well, if we believe in markets and competition, then we should understand that interoperability is not going to be part of the bargain, because it's anti-competitive and contrary to the financial interests of the competing institutions. That is the problem with interoperability. It is the conflict between a market dynamic and what we would want to be a public good, a shared good, which is health information.

The analogy I'd like to use is that we don't expect BMW and Toyota to exchange information on their clients. We would consider that bizarre and probably anti-competitive, but we expect neighboring hospitals and systems in the same community to exchange information about their clients. That is the patients who use them.

The problem with interoperability is not technology; it's people. So many of the problems we have with technology result from the humans who try to use it. There is no business case for interoperability, nor has there been in a fee-for-service environment. As a matter of fact, there's a disincentive to exchange information.

Doug Riddle (16:50)

There's been much bewailing- just referring to the market conditions and this sort of thing- there's been much bewailing about the introduction, I'd say introduction, but I don't have enough historical perspective on market language in healthcare.

You know, we still, I think to a huge extent, our mythology is of the country doc and the personal relationships, and that that's somehow different in some way from what we see with modern medicine. Can you say a little bit about your perspective on that?

David Blumenthal (17:27)

Well, I actually just wrote a piece in the Journal of the American Medical Association on the role of markets, though I didn't talk about markets explicitly; I talked about something called the vocabulary of our discontent. And people in the medical profession and people who observe it have brought a new vocabulary to bear that expresses their concern and sometimes astonishment at trends in the healthcare system. And there are terms like financialization, corporatization, commercialization, and marketization.

But there are some problems with the pursuit of self-interest on the part of physicians and hospitals. And that is that the people who use them do not play on a level playing field with those self-interested professionals and hospital managers, and now, in the for-profit sense, owners.

In my view, they all represent aspects of a common problem or common issue in the United States, which is the strong ideological commitment we have in this country to markets as a way of organizing the allocation of resources in every field. We have decided that markets are the way to make healthcare less expensive, maybe higher in quality, but certainly less expensive.
Now, if we drill down on what markets are about and the premises underlying them, what Adam Smith said, in effect, is that the pursuit of self-interest would result in greater public good than other ways of organizing the systems, the economies in which we work.

Well, I'm a physician who has practiced primary care for 35 years. Both my children are physicians. My wife is a physician. And I still feel vulnerable as a patient. I still am dependent on my primary care physician and my specialty advisors to help me make choices. And if that's true of me, how can it not be true for the average user of healthcare services? We are so dependent and so much at the mercy of the people we want to trust in healthcare that to call this a typical market, I think, misses a huge fact of life.

And there's a fundamental disconnect that other economists, as some economists have noted, between the conditions for effective markets and the conditions of healthcare. One of the things that makes markets work is that consumers can understand the products they're purchasing. There's a level playing field. There's no dramatic asymmetry of information between the sellers of goods and the purchasers of goods.

Private equity functions in many sectors of our economy, whether it's the restaurant sector or the many retail sectors, and so on. The stakes there, though, are different. They're not life and death. Retail outlets are not a central community function, nor are muffler shops, nor is a restaurant chain. But in healthcare, the local hospital often is.

And there are out-of-pocket limits to expenses. So competition takes place, but within a narrow range of accepted behavior. We don't have those limits in the United States, and that's a big problem for markets. The latest example of this is private equity, which is a natural result of treating healthcare as a market.

There are places in the world where competition works without having the side effects that it has had in the United States. And they are generally fairly highly regulated markets where prices are regulated, and insurance packages are regulated. Low-income individuals are protected against the cost of care. People with chronic illnesses are protected against the cost of care.

And to put that at the mercy of an approach to organizing resources, which private equity represents, can often prove very damaging. So I'm not sure where we started with your question, but I think you got a sense of my response. I believe in competition. I supported it with respect to the electronic health record movement. I believe it's a good way to organize economies, but I don't think everything belongs in a market. We don't sell votes. We don't sell children. We don't sell organs. We don't enslave people and sell them. There are limits to markets, and I think that one limit probably should be around the functioning of markets in the healthcare sector.

Doug Riddle (23:50)

Well put, thank you. I'd like to ask you a little bit about your involvement. You've been such a key piece of my own relationship with the Carol Emmott community. What is meaningful? What drew you to the Carol Emmott community and keeps you involved with us?

David Blumenthal (24:08)

I'll say there are a bunch of things. First, Carol Emmott was a dear friend. I knew her when we worked together in Washington. I worked for Ted Kennedy. She worked for Joe Califano. For younger listeners to this podcast, some of those names may be a little out of their vocabulary, but this was during the Carter administration, and Carol and I worked together on healthcare issues, she representing Joe Califano, me representing Ted Kennedy.

My wife and I, Cameron, her husband, and Carol became good friends. We visited over the years in California, in Washington, and elsewhere. Our children, my son and her son, were born about the same time.

After she became ill, we stayed in touch. And I actually hired her to do a search for my foundation when I was running The Commonwealth Fund. And I was deeply touched and distressed as her illness progressed and then as she passed away. So the opportunity to be involved in something that was dedicated to her and her memory was something that I wanted to be involved in.

And then I've just found it incredibly rewarding to mentor the young women whom I've had a chance to interact with as part of this Fellowship. And I have a daughter and a wife who are both physicians. I'm very supportive of their careers, and I feel that women deserve more from the health system as professionals than they've gotten.

So it's a combination of personal feelings, philosophy, and commitment to a cause that has kept me involved.

Doug Riddle (26:34)

Thank you, David. I appreciate this time with you so much, and we look forward to what comes next as you continue working with our board and also mentoring. And thank you for this time this morning. That's it for The Treasure Hunt.

David Blumenthal (26:47)

Thank you, Doug.