The Future of Healthcare: “We must free medicare to negotiate with the pharmaceutical companies” with Etienne Deffarges, serial healthcare entrepreneur

Asa part of my interview series with leaders in healthcare, I had the pleasure to interview Etienne Deffarges, serial healthcare entrepreneur. Etienne Deffarges is a Co-Founder and Operating Partner at Chicago Pacific Founders, a private equity firm focusing on healthcare delivery providers. Etienne is an entrepreneur who participated in several IPOs and exits — most recently Accumen, a healthcare laboratory excellence company, in January 2019. He is the author of “Untangling the USA: The Cost of Complexity and What Can Be Done About It,” published in July 2018 by Routledge, Taylor & Francis. He serves on the boards of Alain Ducasse Entreprises, ConXtech and Sight MD, and is a board advisor at AEye and NG1 Technologies. He is also a member of the Executive Council at the Harvard School of Public Health. Between 2004 and 2014, Etienne was part of the founding management team, EVP and Vice-Chairman of R1 RCM, which was launched with $17M of committed capital and became cash-flow positive after $4M deployed. He took the company public in May 2010, at a $1.2B valuation. He also established the company as a healthcare partner with the World Economic Forum in Davos, Switzerland. Before, Etienne was Global Managing Partner of the Utilities Practice, and member of the Executive Committee and Global Management Council at Accenture. He participated in the company’s IPO on the NYSE in 2001, at a $14B valuation. He was the first Market Maker at Accenture, negotiating several billion $ deals successfully. He also founded Accenture’s Energy Advisory Board, chaired by Secretary George Shultz, and was a member of the Aspen Institute. Prior, Etienne was Senior Partner and Global Practice Leader, Energy, Chemicals and Pharmaceuticals at Booz Allen Hamilton, and member of the firm’s Executive Committee. Etienne holds a MBA from the Harvard Business School, where he graduated as a Baker Scholar; a MS in civil engineering from UC Berkeley, where he was a French Government Fellow; and BS/MS degrees from ISAE/Sup‘Aero in aeronautical engineering. He is Chairman of the Harvard Business School Alumni Angels NC, a private pilot, and fluent in five languages.

Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

After twenty years as a management consultant and business executive, I had the opportunity to become an entrepreneur and launch a new company in that most traditional of industries, health care. It was very exciting to bring the latest technology know-how to not-for-profit hospitals that often lacked the relevant administrative resources to navigate the complex world of claim reimbursement dominated by powerful for-profit insurance groups. “To do well while doing good” was a powerful motivator.

The company I co-started in 2003, R1 RCM, helps hospitals get full reimbursement for the amounts they are contractually owed by health insurance companies, avoiding costly denials of payments for legitimate insurance claims. The company also helps hospitals find funding for those uninsured and low-insured patients who are treated through emergency departments. As a result of this work, hospital clients see a strong reduction in financial “leakage” and significant improvement to their operating margins, which are very low (0–1% on average) in the U.S. We launched the company in late 2003 with $17M of committed capital and became cash-flow positive after only $4M deployed. I was the lead executive officer (#2 of the company) present at the NYSE when we had our successful IPO in May of 2010, valuing the company at $1.2B (A “Unicorn” before the term became popular).

When we started the company, my partner / CEO and I did not know the way to the nearest hospital. My background had been in aeronautical engineering and energy, not healthcare. Fortunately, our chairman of the board was a healthcare specialist, with a wealth of industry contacts to offer us. I am a quick study, and not being fully versed in the traditional ways of doing business in healthcare allowed me to ask the critical “why?” questions. We changed the status quo and created an innovative and disruptive business that ended-up helping not-for-profit hospitals (90% of U.S. hospitals) a great deal. Helping these hospitals, many of them struggling to stay afloat while performing indispensable health services to their communities, was a very motivating factor for me, and a great source of entrepreneurial “fire.”

Can you share the most interesting story that happened to you since you began leading your company?

Prior to launching my company, I had been a senior partner with Booz Allen Hamilton and a global managing partner at Accenture. I advised CEOs and governments globally, and in the U.S. essentially flew coast to coast, from San Francisco, Los Angeles and Seattle to Boston, New York and Washington DC. Yes, I also stopped occasionally in Atlanta, Chicago, Dallas, Denver and Houston, but these are huge cities as well. Even though I had been to all fifty states, mostly because my curiosity in discovering our vast country as a student and young immigrant, I really did not know how most people live in the “flyover country.” Then I became an entrepreneur, and my first clients (the best!) happened to be in Michigan, Eastern Pennsylvania, Tennessee and Wisconsin. For a year and a half, I went every week to Kalamazoo, Flint and Saginaw in Michigan — where our first hospital clients were. Typically we worked with about a hundred administrative people in each hospital we served. Quite a few such hospital employees were wives of laid off auto industry workers. Cream of the people, saying what they thought and doing what they said, many of them invited me to their homes and I got to appreciate them a lot. But they all suffered from forty years of regional industrial decline, infrastructure dereliction and even creeping poverty. And when I was back in California, and dared suggest that we need a Marshall Plan for the Great Lakes region, people laughed at me…This certainly gave me some insight on why people in the region gave their votes in 2016 to the presidential candidates who claimed to have heard them and understood their plight — Bernie Sanders in the democratic primaries and Donald Trump in the main election.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

When we were negotiating our first client contract with a very large not-for-profit hospital network, my lead investor asked to join me at a key meeting with the potential client CFO. I said yes, and as soon as the meeting started it was clear there was no chemistry whatsoever between my investor and my would be client. At some point, the investor tried to earn brownie points by telling the CFO, “I can help you with your taxes, I have great tax people in my employ.” To which the not-for-profit CFO replied, deadpan, “I don’t pay any taxes.” Lessons learned: Investors in the company are not part of the sales force.

What do you think makes your company stand out? Can you share a story?

Help turning around the financial viability of struggling community hospitals.

One of the initial insights our company was built upon was to understand early on the challenges faced by hospital administrative staff when dealing with disputed and delayed claims sent to health insurance companies. Prior to our company being launched, hospital management teams would try to address these either through detailed management consulting reports — which were never thoroughly implemented — or purchases of dedicated software that were either user unfriendly or not what the staff felt was needed. We decided to pioneer an entirely different approach, which rested on three pillars: First, new technology dedicated to these specific claim reimbursement problems, which leveraged early-stage AI and machine learning to make it as user friendly as possible, with lots of simple touch screen functions taking the hospital staff through all the relevant decision-making steps. This proprietary technology was only available to our clients, and also designed to be compatible with every existing hospital patient accounting system, so as not to be a burden on already overworked hospital IT teams; Second, a philosophy of “no stone left unturned” applied to the complex process of preparing insurance claims and following-through until they are paid in full; And third, supplementing the hospital staff with half a dozen resident managers from my company, who guided the relevant operations and helped the local teams make the absolute best of our new technology. This allowed us to help successfully many hospitals with low or negative operating margins: In more than one instance, our new approach saved community and safety net hospitals that had been in danger of being closed.

What advice would you give to other healthcare leaders to help their team to thrive?

Think first about the patients, the people who need medical care, or even better, preventive medicine. That is what great hospitals, physicians and healthcare delivery organizations do. We all have our problems, but when one’s health becomes a challenge, not much else counts.

Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the U.S. healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

1) The U.S. has by far the most expensive healthcare system of any high-income nation. We spent $3.5 trillion in this area, or 17.9% of GDP. Americans spent $10,740 on health care in 2017, more than twice as much as of our direct economic competitors. This per capita healthcare spending was $5,700 in Germany; $5,000 in Australia; $4,900 in France; $4,800 in Canada; $4,700 in Japan; $4,200 in the U.K.; and an average of $5,300 for a dozen such wealthy countries, according to the Kaiser Family Foundation and OECD data. Spending almost a fifth of our GDP on healthcare, compared to 9–11% for other large developed economies (and much less in China), is like having a chain tied to our ankles when it comes to our economic competitiveness.

2) Health outcomes in our country are below par relative to other developed economies. In many annual health studies, ranging from the World Health Organization (WHO) indicators to the Bloomberg health efficiency index, the U.S. lags most other developed countries in life expectancy; infant mortality; women’s deaths in childbirth; heart disease, and several other health outcomes. For example, according to WHO rankings for OECD countries, U.S. life expectancy at birth was 79 years in 2017, versus 84 years in Japan; 83 in Australia and France; 82 in Canada; 81 in Germany and the U.K.; and an average of 82 years in Europe and Japan.

3) We still have 30 million uninsured people in the U.S., whereas every other developed country enjoys universal healthcare: This is a very undesirable type of “exceptionalism.”

4) Our health care system is a massively complex construction, involving a lot of entities: Government onese.g. Medicare; 50 Medicaid programs; the VA — 62 cents out of every healthcare dollar in our country is spent by government entities: in that respect Uncle Sam is much more involved in our health care system than, say, the governments of Germany, the Netherlands or Switzerland; private sector ones, some not-for-profit (e.g. most U.S. hospitals; the Blue Cross Blue Shield insurers; the Kaiser Health Plansand others for-profit (e.g. giant insurers like United Health and Aetna). This creates myriad interfaces that make the system both unproductive and ineffective.

5) In the land of free markets, competition and open markets are systematically thwarted in healthcare. For example in most states there is at best a duopoly of health insurers, with little or no competitionBut the best illustration of this is pharmaceuticals. Why is the price of drugs galloping in the U.S.? For two simple, anti-competitive reasons: First, the absurd clause in Medicare Part D that prohibits Medicare / CMS to negotiate drug prices directly with pharmaceutical companies. Have you ever heard of any other large industry where the principal purchaser of products is not allowed to exercise its negotiating power? I think not. Second, the fact that we prohibit drug imports from reputable developed countries (think European Union countries; Japan; and Canada) to enter our country to increase competition in this very large market. This corporate welfare for drug companies needs to end, yesterday.

You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall U.S. healthcare system? Please share a story or example for each.

1) Cut the cost of drugs. We need to stop protecting our pharmaceutical companies by freeing their largest purchaser, Medicare, to negotiate with them, and allowing lower-cost imports from reputable countries. U.S. Drug costs have grown in double digits annually in the 90s and 2000s, reaching $333 billion in 2017, or almost 10% of our total healthcare spending. As a result, Americans spend about twice as much in this area than residents of other rich developed countries. For example, the cost of a vial of Humalog insulin made by the U.S. company Eli Lilly is $55 in Germany, versus $137 for a generic brand and $275 for the Humalog branded one in the U.S. As is often the case in industries with “cosy” government relationships, we also have seen far too many scandals in the U.S. pharmaceuticals industry: Remember Martin Shkreli? The Valeant Saga, which made many people comment that drug companies should not be run like hedge funds, or Enron? And so many prices abuses, even by reputable companies like Gilead?

2) Move to value-based pricing: Most services provided by U.S. physicians are under a fee-for-service regime that encourages overtreatment. In contrast, there are emerging “capitated” (i.e.with a not to exceed ceiling) reimbursement models revolving around the primary care physician, who acts as the “gate keeper” to other care givers such as specialist physicians. In these models, for example applied to senior populations, Medicare pays a fixed amount per “life insured” to Medicare Advantage plans who then work with independent physician organizations managing patient populations. These coordinated care models, where doctors are empowered with data, technology and nursing teams, produce the best patient satisfaction and cost efficiency, managing global risk for commercial, Medicare Advantage and dual eligible populations.

3) Lower out of control healthcare administrative costs: They have risen a whopping 65% over the last decade, and totaled $260 billion in 2017. What good can come out of excess administrative costs? Employment! Yes, but this is not the type of employment that adds to our economic competitiveness… We spend more on administrative costs than the United Kingdom spends on total healthcare. Let’s do some quick math here: The half dozen large developed economies mentioned above spend an average of 2% of total healthcare costs on administration, versus 7.4% in the U.S. All other things being equal, if we too spent 2% on administrative costs, we would save $190 billion per year, enough to insure pretty much all our uninsured at today’s costs. Unfortunately, this sad state of affairs is the reflection of the enormous complexity of our healthcare system, and as long as we cannot surmise the political will to do a complete overhaul of how we provide healthcare to our citizens, this will continue. A potential sign of improvement in this area will be when technology innovations lead for the first time to a demonstrated ability to cut healthcare costs. Thus far, and unlike in any other industry, the opposite has proven true, and administrative costs have grown hand in hand with ever more complex electronic health records, patient accounting systems, the use of big data and other IT innovations. Complexity reigns supreme in U.S. healthcare, and even Silicon Valley is unable to do anything about it.

4) Insure everyone: 30 million Americans do not have healthcare insurance. This lack of access to basic care leads to expensive emergency rooms visits, and much increased costs. Today, Medicare and Medicare Advantage plans are extremely popular, with the government providing the safety net and the private sector being very involved in more comprehensive plans. Why not extend this to all our population, with more economical plans for the young? This is the simplest way to achieve universal coverage, with both a public option that would offer Medicare to anyone wanting it and private plans — people who are happy with their work related private insurance could keep it. It is important to keep the ability of the private sector to innovate in the area of leading edge medical treatments, and provide enough capacity so that no queuing exist, even for medical operations that merely improve our physical comfort. We need to do this with particular attention on the overall costs of the system, to prevent our healthcare costs to crash the barrier of 20% of our GDP, something that could well happen within a decade if current trends continue. How would such a solution work?

· Medicare would be extended as government guaranteed health insurance to everyone above 26 years of age who would want it, younger individuals keeping the option to stay on their parents’ insurance plans, as they have today.

· As a cost containment measure, today’s Medicare, which is a very generous and comprehensive plan, would remain available only to those sixty-five years of age and older. It would be called “Comprehensive,” or “Platinum.”

· There would be three, lower cost but higher co-pay and deductible plans. A “Basic” Medicare, akin to a “Bronze” plan, available to those between twenty-six and forty, with the lowest fees but highest co-pays and deductibles; a “Silver” plan, available to those between forty and fifty-five. And a “Gold” plan, available to those between fifty-five and sixty-five. The health exchanges set up as part of the ACA would be closed.

· Anyone wishing to get better quality coverage than provided in the Basic, Silver, Gold or Comprehensive Medicare plans, would have to go to the private sector for supplementary coverage providing lower co-pays and deductibles. All such private sector supplementary insurance plans, as well as remaining employer-based coverage, would be allowed to operate across state lines. Private health insurers would be encouraged to compete nationally, just like any other form of insurance such as for homes or cars.

5) Reduce system complexityand the overlapping role of the private and public sectors. A government more focused on our health, and a private sector free of playing a role in our welfare, will both become more effective as a result. The system described above in 4) would be a lot simpler than today’s healthcare in our country. The administrative costs of the existing multi-state private insurance plans within each state (remember, our current private system of private insurance does not cross state lines) would be greatly simplified with one national, Universal Medicare Option plan. Private Medicare supplemental plans would operate across state lines, transforming a multi-state system into a national one, also simplifying administrative processes significantly. The fifty state Medicaid programs, with their enormous differences, would essentially disappear. States that would elect to administrate Medicare in their state would do so under a unified set of national guidelines. The mosaic of interactions between the governments — federal and fifty states — and the private health sector today would be replaced by a much smaller number of interactions between Medicare and private plans operating at a national level. The ACA’s health exchanges at the federal and state level, a source of much complexity and poor results, would cease to exist. With them a whole lot of very complicated and confusing set of eligibility rules, subsidies and tax credits would disappear. The roles of the federal government and the private sector in healthcare would no longer overlap significantly like today. The government would focus on universal healthcare with basic coverage, the operations of VA hospitals (which could be reversed to the private sector without changing the proposed system fundamentally), some medical research and the regulatory role played by the FDA. The private sector would do all the rest, including operating most of our hospitals. With this simplification of state-private interactions in healthcare, information systems could also become much simpler over time.

Ok, it is very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

The above changes do indeed require the emergence of a political consensus that we do not enjoy today. However, even in the short term, there are quite a lot of things individuals, corporations, communities and leaders can do to improve health in our country and reduce the enormous costs of U.S. healthcare.

a) Individuals can play a key role in improving their own health, focusing on preventive care, improved nutrition and wellness efforts. This has been very effective in other countries. For example, who has not heard of the fabled “Mediterranean diet?” Rich in seafood, organic fruits and vegetables, olive oil and nuts, with little or no room for packaged and processed foods, it leads to lower rates of cardiovascular diseases and diabetes. Healthy dietary habits have helped propel Spain and Italy to the top of the 2019 Bloomberg Health Index rankings. Japan, with the longest life expectancy among developed countries, can boast of legendary and centuries-old food traditions emphasizing balance, variety and freshness of ingredients. One very tangible result of all these culinary traditions is a much lower rate of obesity than in America. Obesity leads to a number of potential causes of premature death such as heart diseases (the leading cause of death in the U.S.), diabetes and kidney ailments. It is unfortunately a well-known fact that adult obesity in the U.S. exceeds that of most countries in the world. About 40% of adults in the USA are obese, with a body mass index (BMI, a measure of a person’s weight relative to her or his height) above 30. In Spain, only 25% of adults have a BMI above 30; that percentage is 20% in Italy; and a remarkable 5% in Japan. The causes for obesity in America are well known: A poor diet, with too much consumption of packaged and processed food, which is not as well regulated as it ought to be; too many fast food meals; and low levels of exercise due to excess driving caused by an urban sprawl absent in Europe and Japan. Many individuals in America have started to make critical changes to their lifestyle, with more exercise, a better balanced diet, and increased levels of wellness. Consumption of snacks and packaged food is declining, and this positive trend needs to accelerate. Individuals can also take local healthcare policy initiatives, in particular by voting to put Medicaid expansion on statewide ballots, like the habitants of Idaho, Nebraska and Utah successfully did in the November 2018 elections. Most Medicaids have a rather low profile compared to Medicare. Yet they work very well in most states, providing access to decent quality care to millions of low-income Americans of all ages. Medicaid programs are also lower cost than Medicare or private insurance programs — the typical cost of a Medicaid insured patient is around $7,500 per year, much lower than our national average.

b) There is a lot that corporations can do as well. After all, 180 million Americans get health insurance through employer sponsored plans. Corporations can join networks that use the purchasing power of their aggregate insured employee populations to demand lower drug prices from pharmaceutical companies. This is already happening, with a growing number of large corporations launching initiatives to help cut the price of prescription drugs for their workers. For example, over 40 Fortune 500 companies have started programs in 2018 to offer drug discounts to their employees. Some of these programs cut middlemen and get drug-manufacturer rebates from direct purchasing efforts, with the savings passed on to employees. A noted initiative has seen three preeminent hospital groups, HCA Healthcare, Intermountain Healthcare and the Mayo Clinic launching a new venture called Civica Rx: This joint company will manufacture and market 14 common generic drugs that have been in short supply and seen their prices increase significantly in recent years. Other heath care delivery networks have joined this initiative, which now includes over 300 hospitals. And of course there is Amazon, which sent shockwaves to the healthcare world when it announced early in 2018 an ambitious partnership with Berkshire Hathaway and JP Morgan to reduce healthcare costs for their employees. Since then, Amazon has announced initiatives in numerous areas such as the supply of medical devices and prescription drugs; on-line pharmacy; healthcare technologies for the elderly; disease management; wellness; data science applied to health analytics; artificial intelligence (AI) applied to drug development; blockchain technology applied to claim reimbursements; and AI applied to medical diagnostics.

c) Communities can take a leading role in educating individuals: As seen above, much progress need to take place in the U.S. in the areas of preventive care, improved nutrition and wellness efforts. Communities can launch efforts to communicate the benefits of preventive care, and facilitate meetings with health counsellors for their population, in coordination with local health delivery outlets. Education is key here, since even today many Americans do not understand the negative impact of a poor diet, for example. It is at the community level that this education process is the most effective. Much of our health system has also become so complex that individuals can no longer cope. Communities can help uninsured individuals enroll in Affordable Health Care (ACA) exchange plans, a process that is challenging for many. Communities can also help promote the advent of new urgent care centers that offer an easier point of access compared to hospital emergency departments for routine, non life threatening health incidents such as superficial cuts and burns; simple infections requiring antibiotics; and many other minor ailments.

d) Healthcare leaders can accelerate their current efforts in a number of areas: Hospital executives should continue their emerging efforts to ween their operations away from fee for service, embracing Accounting Care Organizations or ACOs; embracing capitated insurance plans; and bundling health services to focus on patient health outcomes as opposed to individual treatments. Insurance executives are often heard complaining about the ever increasing cost of drugs, which they have to cover in their plans. They too can use their aggregate purchasing power to lower the cost of drugs, like the corporations who employ the individuals they insure. Both hospital and insurance leaders should promote the use of telehealth and urgent care centers to increase access to healthcare and reduce costs. And state wide leaders such as governors and members of state legislatures may eventually take matters in their own hands if nothing changes at the federal level. We could see a number of statewide universal healthcare initiatives, such as the ones that were launched and voted upon in local legislatures during the last few years in California, Nevada and New York. Nevada came the closest to enact such a momentous change, with the local legislature approving on June 7, 2017 a “Medicaid for all” plan for the state, which was vetoed at the 11th hour, after much reflection, by then Republican Governor Brian Sandoval. There are also single-payer initiatives in fourteen other states: Colorado; Illinois; Maine; Maryland; Massachusetts; Minnesota; New Mexico; Ohio; Oregon; Pennsylvania; Rhode Island; South Carolina; Vermont; and Washington. In the short-term, some states are also tackling the issue of high prescription drug prices. During his January 2019 inauguration, California Governor Gavin Newsom stated he intended to use the aggregate purchasing power of California’s Medical enrollees and state government employees to demand lower prices directly from drug companies.

When one compares the above list of concrete steps with my earlier list of five changes that need to be made to improve the overall U.S. healthcare system, one can find a fair amount of overlap, which is a good thing. Even in the current political gridlock, there is much individuals, corporations, communities and leaders can do in reducing the cost of drugs; moving health care services to value-based pricing or capitated prices, away from fee for service; and help as many Americans as possible gain access to health insurance.The only critical healthcare issues that remain difficult to solve through grass-roots initiatives are system complexity and the resulting excess administrative costs.

As a healthcare professional myself, i am particularly interested in the interplay between the general healthcare system and the mental health system. Right now we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

I believe in integrated medicine. My preferred model is one where a generalist / primary care physician coordinates all aspects of care for her or his patients, including all general health specialties but also mental / behavioral health and every aspect of wellness, including nutrition. Beyond my personal opinion, the best case for integrating mental and general health is made by the role mental illnesses play in the tragic increase in suicides in our country, and in so many gun related homicides. We have experienced recently an alarming rise in suicides in the U.S. The number of suicides in our country rose 30% since 2000, reaching 43,000 deaths in 2017, or 13 per 100,000 people. This tragedy is afflicting disproportionately those in mid-life, between 45 to 54 years of age. It did not use to be this way; remember the stories about high rates of suicide in Nordic countries relative to ours? Yet, during the last 15–20 years, suicide rates fell in other developed countries, particularly in Europe. According to the WHO, suicide rates are now at 5 per 100,000 in Spain, or less than half the U.S. rate. In Denmark and Norway this rate is 9, and 11 in Sweden, all below ours. Are there explanations for this tragedy? This is obviously a very sad and sensitive topic, much beyond the scope of this article, but a number of studies have looked at economic and social causes for this affliction, as well as untreated mental health issues. Mental health is also at the heart of many gun related homicides and massacres — facilitated by the widespread availability of firearms in the U.S. We suffered 40,000 gun deaths in 2017. About 60% of these were suicides; and 40% homicides, or 4.4 deaths per 100,000 habitants. This is a real health emergency, in which our statistics are an order of magnitude worse — 10 times or more — than in other developed nations. According to the WHO, gun related homicides per 100,000 habitants total 0.47 in Canada; 0.06 in the United Kingdom; 0.04 in Japan; and 0.02 in Singapore. Many people clamor for tough gun control laws, while others claim that untreated mental health diseases are the main culprit. Both, together, are true. We need to integrate mental health into the general care of our population, and also make sure we have much tougher gun control laws and that in no case sick people get access to fire arms.

How would you define an “excellent healthcare provider”?

A provider of integrated medicine, with a strong focus on preventing care: Easy access to generalists who bring to their patients the best in general health, mental health, nutrition and wellness; and specialist physicians who can also provide the best acute care when necessary, including in complex cancer cases. In my San Francisco hometown, UCSF would qualify, as would the Cleveland Clinic; Intermountain Healthcare; John Hopkins; Mass General; the Mayo Clinic; MD Anderson; NY Presbyterian; UCLA; and UPMC in other parts of the U.S.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

Being an entrepreneur is never easy, and above all requires infinite patience to follow a sound game plan that might unfold over many years. One can never claim victory too soon! Even when one has done an IPO, and the share price is growing nicely, one should remember what my entrepreneurship professor at Harvard told us: “Real money is green.” Many paper billionaires during the turn of the century boom will remember this one…But my favorite life lesson quote, one that epitomized that there is always much to fight for even after a great achievement, comes from the great Winston Churchill. Just after the young Royal Air Force pilots had won the decisive “Battle of England” that prevented nazi Germany from invading the U.K., Churchill was asked about the significance of this decisive victory, and said: “This is not the end. This is not even the beginning of the end. But it is, perhaps, the end of the beginning.

Are you working on any exciting new projects now? How do you think that will help people?

I have recently joined the Executive Council of the Harvard School of Public Health, which is a great forum to debate and advance healthcare solutions for the American people. I also continue to be an active “angel” investor and coach to young companies, focusing on healthcare start-ups. Many new medical devices and innovative health technologies can be brought to patients more quickly if entrepreneurs get the support they need. I am active with a team of fellow volunteers in helping local not-for-profit entities in the Bay Area, such as local education centers. I am also working on the French, Japanese and Spanish translations of my book, “Untangling the USA: The Cost of Complexity and What Can Be Done About It.” This book has a significant healthcare content, since healthcare is unfortunately our most complex socio-economic sector.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

I am a voracious reader, and like books that deal with significant events, as well as biographies of people who have made a difference for good in our world. Recent books I have read include, in chronological order:

Steve Jobs, by Walter Isaacson, 2011.

Affluence & Influence: Economic Inequality and the Political Power in America, by Martin Gilens, 2011.

The Big Short: Inside the Doomsday Machine, by Michael Lewis, 2010.

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, by Shannon Brownlee, 2007.

The Greatest Generation, by Tom Brokaw, 1998.

Commander in Chief: Franklin Delano Roosevelt, His Lieutenants, and Their War, by Eric Larrabee, 1987.

The Sleepwalkers: How Europe Went to War in 1914, by Christopher Clark, 2012.

In particular, Overtreated is a must read for anyone interested in healthcare in America, because it explains how pernicious incentives in our health system lead to abuses by a few, high costs everywhere and poor health for many.

I prefer spending my free time reading rather than to listening to podcasts. However, one Podcast I listen to is Nate Silver’s FiveThirtyEight: It helps me understand the intricacies of polling and actual voting results state by state, district by district. It also provides a good understanding of what most Americans think are the most pressing issues facing our country — and guess what: Healthcare is mentioned as the #1 issue by 78% of Americans, a clear bi-partisan consensus among voters.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger.

Bring universal healthcare to all Americans! Being the only country in the developed world that does not have universal healthcare represents one of the worst injustices of the modern world, and is a national embarrassment. I would be delighted to inspire and support any movement that would aim to end this injustice and bring affordable healthcare to the 30 million Americans who do not enjoy it today.

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