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Join us for an insightful conversation with nephrologist and physician executive, David W. Moskowitz, as he shares his transformative views on the U.S. health care system. Drawing from his time as a Marshall Scholar and extensive experience in patient care, David discusses the challenges of national health services, the shortcomings of Medicare as the single payer for dialysis, and the importance of prioritizing quality to lower costs and alleviate suffering. He proposes a reimagined Public Health Service (PHS) to address the needs of 50 million un- and underinsured Americans while maintaining a balanced public-private sector system.
David W. Moskowitz is a nephrologist and physician executive.
He discusses the KevinMD article, “Health care reform requires better access and quality: dialysis as an example.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome David Moskowitz. He’s a nephrologist and physician executive. Today’s KevinMD article is “Health Care Reform Requires Better Access and Quality: Dialysis as an Example.” David, welcome to the show.
David Moskowitz: Thanks so much for having me.
Kevin Pho: Let’s start by briefly sharing your story and journey.
David Moskowitz: So I, you know, I trained to be an academic physician. I went to good schools. I did biochemistry twice, once at Harvard and once at Oxford on a Marshall Scholarship. I went back to Harvard-MIT and went to Barnes for residency in medicine.
I was going to be a membrane biochemist, and nutrition seemed the closest thing. But when I came to apply for a GI fellowship at WashU, I was tired of moving around. Only renal was available, so that became my organ because you have to subspecialize to be an academic. Renal patients are interesting because my other interest has always been primary care and outpatient internal medicine, not so much hospital-based.
The thing about dialysis patients is that they’re too sick for anybody to touch them. So you wind up being the primary care provider for your dialysis patients, and that was fine with me. The two things I was interested in as a nephrologist were acute renal failure and chronic renal failure.
About 30 years ago, I found a way to avoid both and was promptly fired. My life, instead of becoming a division director of nephrology somewhere or department of medicine chairman, has been living in the desert for the last 30 years.
Kevin Pho: All right. So, you wrote your KevinMD article, Health care Reform Requires Better Access and Quality: Dialysis as an Example. For those who haven’t had a chance to read your article, tell us what it’s about.
David Moskowitz: Well, in brief, you know, there should be no more dialysis. It should be obsolete by now, based on the protocols that I published in one form or another in 2002. And yet, dialysis continues as a $200 billion-a-year industry.
Acute renal failure still hasn’t been solved according to the NIDDK. There are still workshops and grants being issued. And this is in the information age, the age of instant news. All you can conclude is either I’m a doofus and a liar—which I don’t think I am, because I graduated summa cum laude at both Harvard and with first-class honors at Oxford—or that health care is anti-innovative. I think the latter.
In the case of dialysis, and perhaps the rest of human disease, health care has become too satisfied with the lucrative $4.7 trillion-a-year status quo in the U.S. alone. The point of my article was that you can’t count on health care to innovate anymore, even at a time when science is revolutionizing medicine. Genomics now lets you know exactly what’s wrong with every patient you see.
Science is hamstringing you in terms of what you can do for your patients. This is like perfect managed care and fits in with all the frustrations physicians have been feeling for the last 30 years.
If you want health care reform, not only do you need greater access—which was the goal of Obamacare—but you also need to emphasize quality and quality improvement. You can’t have one without the other. It’s not fair. It’s not just. The current system is basically manure. Increasing access is just spreading manure.
We need a QI system. My proposal was to involve the public sector, specifically the VA, since they have the highest responsibility to their patients—the veterans who sacrificed their lives for this country. Unfortunately, the VA refused to adopt my anti-dialysis protocols.
I propose giving the VA back to the Public Health Service, which was created by Congress in 1789. Keep the VA doctors, who are the foundation of academic medicine and great investigators, but restructure the system. I want the surgeon general to be responsible for improving clinical outcomes, which currently nobody in health care is tasked to do.
Kevin Pho: Tell me, when you said innovation is being held back today by most medical entities, what are the forces you see holding innovation back?
David Moskowitz: Let’s take dialysis. Every nephrologist makes their money from dialysis in one way or another. Academics need a robust dialysis program to bring money into their division. Private practitioners don’t get to go on vacation or buy fancy cars unless they have a stable of 50 dialysis patients. Chronic kidney disease patients are loss leaders in the clinic; you don’t make money from them until they’re on dialysis. Then they bring in $100,000 a year for the two or three years they stay alive.
Dialysis is a stopgap with horrible quality of life, but it’s the most lucrative pillar of hospital-based medicine. Half a million dialysis patients bring in as much revenue as all the cardiac patients in the country. Nonprofits don’t want to publicize that dialysis is preventable because it threatens their six-figure salaries.
Medicare, which is single-payer for dialysis, hasn’t cut its dialysis budget because no bureaucrat wants to jeopardize their salary. As Upton Sinclair said, “Don’t expect a man to understand what you’re saying when his salary depends on his not understanding it.” That’s been my experience for 30 years—no one wants to kill the golden goose.
Kevin Pho: So, you’re saying that because of how lucrative dialysis is, there’s no financial incentive to innovate and get people off dialysis purely because of the financial benefit it brings to medical institutions?
David Moskowitz: Exactly. There is no financial incentive to prevent any disease in medicine. In addition to the scientific revolution, which has been ready to happen thanks to genomics for 30 years, there has to be a moral revolution. Public education is needed to expose the system for what it is—a racket.
Health care today is a racket, much like what was said about the military-industrial complex back in the 1930s. In the 1950s, health care was different. Polio was defeated joyously based on minimal data from Jonas Salk. Today, you need 40 million patient-years of experience before anyone will listen to your new protocol. It’s absurd. No one has the money for that, so we’re stuck with the status quo year after year.
Kevin Pho: You talk about reconstituting the Public Health Service, which you mentioned was formed in the 1700s. For those unfamiliar, tell us about its history and role.
David Moskowitz: The Public Health Service (PHS) is one of the few untarnished government institutions left. In the 20th century, they ran tuberculosis hospitals until streptomycin was invented in the 1950s. After World War I, in 1921, the PHS loaned 57 hospitals to the VA to care for veterans, many of whom were lying on the roadside. It wasn’t a gift; it was a loan, and it’s time for repayment.
In Taiwan, their veterans’ health service was turned into a public health service for the entire country. That’s what needs to happen in the U.S. Veterans I spoke to in St. Louis, where I lived for 11 years, said they’d much rather give the VA back to the PHS than see it dismantled piece by piece, which was happening before the first Gulf War.
Kevin Pho: How would a reimagined Public Health Service encourage innovation and break away from the financial incentives holding the status quo in place?
David Moskowitz: The beauty of the public sector is that you’re on a salary. Unlike the private sector, where you “eat what you kill,” the public sector allows you to focus on patient outcomes without worrying about financial pressures. The incentive in the public sector has traditionally been to do as little as possible while still getting paid, which is why the VA has a reputation for laziness.
The private sector, on the other hand, hustles to perform unnecessary procedures and tests to increase revenue. To reform the public sector, we must demand that physicians focus on improving patient outcomes. The VA is already good at clinically focused research compared to the NIH, whose research often emphasizes mechanisms over clinical outcomes.
By reconstituting the PHS, we can make grants clinically focused and outcomes-based. Genomics allows us to achieve this more efficiently than ever before.
Kevin Pho: In transitioning the VA back to the Public Health Service, how would veterans’ care be impacted under your proposal?
David Moskowitz: Veterans would become the most valued patients—the MVPs—of this new system. They would benefit most from innovation. For example, I discovered how to prevent dialysis 30 years ago, yet veterans are still dying on dialysis—a modality that should have become obsolete if the VA had done its job and innovated.
What we need is leadership willing to crack the whip and hold everyone accountable. Every grant must benefit patients and improve outcomes. For instance, if one physician has significantly better outcomes than others, they should teach the rest of us what they’re doing. This would turn the PHS into a learning machine, something physicians currently don’t do well for one another.
Kevin Pho: With the rise of value-based care concepts in the private sector, do you see any progress toward tying physician compensation to quality measures?
David Moskowitz: No, I don’t think so. Medicare drives these initiatives, and they’ve never measured outcomes, let alone improved them. What passes for quality in the managed care and Medicare environment are HEDIS measures, which have never been shown to correlate with outcomes.
For example, HEDIS measures might require that all diabetics get an eye exam or that diabetics with normal lipids take a minimal dose of a statin. If managed care plans don’t meet these measures, they don’t get five stars, which limits their ability to recruit patients. These measures are superficial and do nothing to actually improve patient outcomes.
ACOs (Accountable Care Organizations) have also failed to save Medicare money or improve outcomes. None of them were interested in prevention measures like avoiding dialysis. The incentives aren’t aligned for long-term savings because Medicare assumes savings will continue indefinitely and stops rewarding ACOs after a few years.
That’s why I believe Medicare is doomed to fail at improving outcomes. My focus would be on reconstituting the PHS. By publishing outcomes improvements, the rest of the U.S. health care system would have to match or risk losing patients to a PHS system that actually prioritizes quality improvement.
Kevin Pho: We’re talking to David Moskowitz, a nephrologist and physician executive. Today’s KevinMD article is “Health Care Reform Requires Better Access and Quality: Dialysis as an Example.” David, let’s end with some take-home messages for the KevinMD audience.
David Moskowitz: Sure. I’ll share a personal example of how genomics has impacted me. I developed calcification of my aortic valve, which was surprising. My alkaline phosphatase (ALKFOS) had always been high—around 300—but my gamma-GT was normal, so I knew the ALKFOS was coming from bone.
I got my whole genome sequenced by Nebula, a very good firm, and found that I have mutations in the two genes associated with Paget’s disease. A CAT scan done for my new aortic valve, a TAVR, showed Paget’s disease in my right hemipelvis. Suddenly, I understood why my valve calcified, even though there’s no medical literature connecting Paget’s disease and valve calcification.
Whole genome sequencing will become standard for primary care. Internists will need to interpret it for their patients, revolutionizing prevention, health care, and longevity. I’m very excited about the future.
Kevin Pho: David, thank you so much for sharing your perspective and insight.
David Moskowitz: My greatest pleasure.
