Mixing Health Care And Hip-Hop, This Doctor With Valley Roots Wants To Change Medicine
At the intersection of popular culture and health care innovation is a man the internet knows as ZDoggMD. Thanks to his forward thinking ideas about what he calls Health 3.0, he’s been featured in The Atlantic, Forbes, The Daily Beast, and at the Ted MED conference. Tens of thousands watch his daily online talk show "The Incident Report" that talks about ways to fix the broken health care system, and develop a patient-doctor relationship that's based on more than just technology. His online fans also flock to his viral parody music videos where he takes songs from artists like Eminem and Taylor Swift and transforms them into anthems about things like the opioid epidemic, and critiques of the system that treats medicine like an assembly line.
But while the internet knows him as ZDoggMD, his patients in Las Vegas and his family in Clovis, CA know him as Zubin Damania, MD. A graduate of Fresno's Clovis West High School, he joined us on Valley Edition to talk about his local roots, and how internet celebrity helped take him from a prestigious job at Stanford to founding a clinic in Las Vegas for Zappos founder Tony Hsieh. He also talked about the health care challenges facing the San Joaquin Valley, and how he thinks the industry should evolve from its present form to one with both universal coverage and personal accountability for patients and doctors.
When you talk about Health 3.0 what does that actually mean? Where does this concept come from?
You know what it all started with my father and watching him practice medicine in Clovis back in the 1980’s. He was a private practice primary care doctor, and what I saw was this beautiful relationship between doctor and patient. But what I also saw was not a lot of evidence-based practice and not a lot of science, it was a lot of art and intuition, and also the doctor was always the boss. It was a very paternalistic kind of thing and I'm not just saying that because he was my dad, it was actually, that's how you know, just listen to what the doctor says. And that's what I started thinking of as Health 1.0. Then I went through medical school at UCSF and trained and what I realized was we were entering a new world, something that I like to call Health 2.0.
"At the heart of it medicine is an analog relationship. It's not a digital thing. It's a human relationship that can be powered by technology and powered by process." Zubin Damania, MD
Now 2.0 said “well, you know 1.0 isn’t really working that well, it’s really expensive, patients are now empowered by the tools they can find on the internet, we have technology, electronic records, all this other stuff that could help us, maybe that’s how we ought to be practicing, and we ought to treat medicine more like an assembly line process a series of processes that we could optimize."
What ended up happening there is we saw some good but we saw a lot more harm. Everybody, doctors and patients were both being treated as commodities now, and everybody felt like they were a cog in this big broken machine. And we weren’t really getting better, less expensive, more higher value care. So the idea for Health 3.0 really comes from the ideas that we have to re-personalize medicine. At the heart of it medicine is an analog relationship. It’s not a digital thing. It’s a human relationship that can be powered by technology and powered by process improvement and science. But if we lose sight of the fact that it’s a deep relationship, then we’re going to lose everything that makes medicine what it is. And so re-personalizing medicine, working in teams, empowering patients but also holding them accountable, to release the sort of victimhood of illness and to work in partnership with not just their doctors but health coaches and nurses and social workers and administrators across the system, that's going to generate an engine that actually rewards outcomes that actually matter to our patients and to society as a whole and that's what we're kind of calling Health 3.0.
You were at Stanford and had, at least on the surface a great career, but you were disenchanted with the system. Walk us through what made you leave that behind and go to Las Vegas to start something completely new.
Yes I was a hospital doctor at Stanford for a long time, almost 10 years and what I saw was it was a great tertiary care system they took really good care of the patients, I had fantastic colleagues, unimpeachable. But the problem is what we're doing is patching people up and sending them back out to get sick again. We're not really preventing disease. We’re not really looking holistically at what's going on. You know if you're looking at it if it were like Winnie the Pooh, you're not looking at the whole Hundred Acre Woods. You’re just looking at Winnie the Pooh's diabetic toe problem and your patching it up and he's going to come right back because you're not asking what's going on with Piglet. Like “is there caregiver burnout? What's going on with Tigger? Is there substance abuse problem?” You can't look at all that, and so I started getting deeply disenchanted and finding that you know I felt like I was on a treadmill.
Not only that, but increasingly the sort of burden of Health 2.0 was saying you got to see a lot more patients with a lot less time and you spend most of your time clicking boxes in an electronic health record that isn't designed to take care of people, it's designed as a glorified cash register and a compliance tool. And for all these reasons I got very very depressed.
As a result a sort of a cry for help I kind of reconnected with my roots. You know when I grew up in Clovis I played guitar and I loved to teach. To try to put myself at ease, in a kind of a rural environment where I had a funny last name and I felt a little bit out of place, I learned to develop a sense of humor and kind of put people at ease and read people's minds. Nowadays they call it empathy. So I reconnected with that. I started making these parody rap videos that would educate Winnie-the-Pooh, so that he didn't need to come into the hospital and raise the alarm among other healthcare providers that “you know what, we can do better we can build Health 3.0.” And I put them on YouTube thinking I was going to lose my job, and in a way I did lose my job, because it gave me an opportunity. The videos blew up and they really resonated with people. And by living my own story what happened is I got an opportunity to quit my job at Stanford, move to Las Vegas, start a clinic that operated on the principles of Health 3.0. And the nice thing was moving to Vegas was easy because it was just about as hot as Fresno, so I was used to it!
"In the current system you're paid to do things to people, not for people." - Zubin Damania, MD
You mentioned the clinic in Las Vegas, Turntable Health. Tony Hsehi, founder of Zappos brought you to that city to start this primary care clinic. It had a very interesting model, a lot like a gym membership, where people pay a monthly membership to get access to care. But it shut down earlier this year after 3 years of operations. Looking back at it, was it just that you were too ambitious with it, or was the market not ready for this sort of disruption?
It's a combination of things. The main thing is that we proved that the model works. We showed incredible outcomes. We dropped admissions to the hospital, our patients were incredibly happy, we had deep connections, we improved diabetes and smoking and hypertension and depression screening. But what the fundamental problem was is we were trying to be Health 3.0, in other words deliver real outcomes that matter, in a system that is still Health 1.0 or 2.0, meaning it's paid based volume, on how many patients can you churn through. In the current system you're paid to do things to people, not for people. And as a result we couldn't find the financing to actually pay for the outcomes we were improving. We had an insurance company partner that did that for awhile Nevada Health Co-Op it was one of the experimental companies that started up under the Affordable Care Act, and it went out of business. When it went out of business it took about three thousand patients of ours with it, and that was sort of the final straw, so we were too early. We weren't caught up with the financing model for Health 3.0, but it turns out our partners Iora Health are now growing this model in multiple states working with Medicare patients so we know it works we know it can be paid for we were just a little too early.
So now you're back in a hospital in Las Vegas in addition to doing all the public speaking that you do and the online videos and the music videos. What is that experience like now being back in a hospital after you left Stanford? Is it a different experience for you?
It’s absolutely transformative for me because now I see the system from a really big picture view. So when I go in the hospital and I see our county patients who are struggling with all the social economic determinants of health, I really have a sense of compassion that was beaten out of me when I was struggling through a treadmill. And the beautiful thing is now we started this movement this Health 3.0 movement through the videos through the public speaking stuff like you mentioned, but also through our daily live show on Facebook called Incident Report, and it reaches anywhere from 400,000 to a million people each episode in terms of reach, and in terms of views, 500,000 to a million views per-episode per-night live.
It's a way of giving frontline healthcare providers and patients a voice to say “how are we going to build Health 3.0? Let's talk honestly about the issues that are driving change in healthcare and how we can make it better?” For example if you're talking about is healthcare a right or a privilege we have an episode about how that question doesn't even make sense. We need to think about “what's a pragmatic way to deliver the best care to the most people?” And let's be trans-partisan about it and trans-political about it and let's really address it head-on as caregivers and patients. So for me it's now really transformed into a movement and the work we did at Turntable to build this analog heart of medicine, to re-personalize it, make it team driven, outcomes driven that's what's driving the movement. And there are hundreds of thousands of healthcare providers around the country who are on board and want this change to happen.
So where is that change going to come? Is it going to come from the physician level, the clinic level, the grassroots level, or is it or should we expect it to come from the political centers in Washington or Sacramento?
I'll tell you this, it will never work if it comes from only one source. If it comes from top down, from politicians, it won't work. If it comes just from grassroots, it won't get a hold. So what has to happen is it has to have a grassroots support from clinicians on the front lines and patients who care about getting better and their health. And then we have to work with the politicians. And the great thing about this movement is it is not a Democratic or Republican thing, it is a human thing just like health care itself. And what I see is this groundswell of support for change and whether that means some form of universal coverage that also includes accountability, in other words patients are held accountable and providers are held accountable to provide incredible care, that combination of things where there is some skin in the game for everybody, that's what's going to transform the system. It’s going to take all of us. But the grassroots component is what I'm trying to lead. But we're also connecting with our politicians with our business leaders, with our hospital administrators and with our policy makers because going to take all of us together to do this.
You know something about this area. The San Joaquin Valley faces huge issues in health and health care. Around half of the population is on Medi-Cal, we have a physician shortage. What can local health care leaders do to bring some of these ideas into practice here?
Like you say I'm intimately familiar with the area and and my father still sees patients there, and I did a rotation at UMC sorry UCSF Fresno when I was a student in surgery in emergency medicine, and I've spoken for Sante Medical Group. The environment you guys have in the Central Valley is indicative actually of a lot of California. It's a big struggle and I would say what has to happen is you first have to look at the care model. If they aren't sort of team-based preventive care models that focus on keeping someone from developing diabetes, where everybody has skin in the game, and you're actually paid to prevent disease, that's what's going to actually economically drive improvement. Because right now you know what 3 trillion dollars in our national economy healthcare is a massive ball and chain around our ankles. It's hobbling the economy and I can tell you this is true in the Central Valley, because when when businesses have to pay such a huge amount just for health insurance it means we're doing something wrong.
So let's get the care model right let's focus on preventive measures, a sort of 3.0 collaborative team model and then we can look to government and say “okay how are we going to pay for this.” We've actually made it more efficient, we've made it more cost-effective, so now we can afford to cover our most vulnerable, and that includes Medi-Cal, it includes you know CHIP all of those things can be consolidated. We can have a universal coverage that still has a huge private industry competitive focus where people compete to provide the best outcomes. This is already happening in Medicare Advantage and these sort of plans were companies are actually competing to administer and do the best they can with Medicare dollars. So why can't we do that across the Continuum of Care? That would be a way to help the valley really emerge as a leader actually in health care. Because the doctors there the healthcare institutions that are there are strong, I mean they are great people, great institutions, they're poised to do this, it's just we need that catalyst and that push to make it happen.
The California Senate just passed a bill that would institute a single-payer system in California, and it’s estimated to cost about $400 billion. It’s now before the Assembly and great questions remain about that. But you’re saying we should fix the way healthcare is delivered first before we institute something like this?
"The problem with single-payer is not that it's a horrible idea and that the government's going to destroy everything it touches, which are what you know opponents will say, it's what are you paying for?" - Zubin Damania, MD
You nailed it. The problem with single-payer is not that it's a horrible idea and that the government's going to destroy everything it touches, which are what you know opponents will say, it’s what are you paying for? So if you just reform the payment, for example with Medicaid, Medi-Cal, right now that you know you can walk into emergency department and use it as your primary care, without a lot of penalty. That is the wrong way to incentivize payments because it's the most expensive most dangerous place to be if you have a cough or a cold. If we fix the care model, if we focus on primary care and prevention first as the base of the pyramid instead of what we do now, which is incentivize specialty care, people just jump in line right to the specialist and it's upside down pyramid. If we actually incentivize the care, then we can say “ok, let’s pay for care that we know works, and let's make sure that people have a minimum level of coverage.” And then let's incentivize outcomes, which means private companies competing to actually prove they can do it better than anybody else. And then that way you don't have the government actually running the delivery of healthcare. They may finance part of it but they're not actually on the ground messing with with delivery, because anytime they do that things get really screwed up and we've seen that historically. So I think a universal coverage where the government steps in and says okay we're going to pay for the right stuff and the right models that can help, now of course you've got to build those models in a grassroots way, or else it's never going to work.
What’s next for you, for Zubin Damania 3.0? If 1.0 was your first stint at Stanford, and then Turntable in Las Vegas was 2.0, where do you see yourself going?
"People feel like we don't have a voice in healthcare, and that includes patients and doctors and nurses and respiratory therapists and nutritionists, everybody working the front line. We intend to be that voice."
I think the best approach is staying connected with patients through my clinical work at our county hospitals and the show Incident Report. It's so important because what I find for the thousands of messages I get daily through Facebook, is basically people feel like we don't have a voice in healthcare, and that includes patients and doctors and nurses and respiratory therapists and nutritionists, everybody working the front line. We intend to be that voice and the core message that we are pushing is let's build Health 3.0. And all healthcare, like all politics is local. Which means you can take the principles and apply them locally in a way that actually works for you. So what works in Clovis and Fresno and Madera and Modesto may not work in Las Vegas and that's why we think a Turntable-type model shows some principles, but the way you implement it locally is what's going to make it work. So that's my mission now is to evangelize the cause of Health 3.0 and actually work with government and with administrators to see how can we get a universal coverage system that doesn't destroy American medicine but actually makes it stronger, in a way that people are covered but skin is still in the game. And it's kind of the best of both worlds because we are the only country on Earth that has an opportunity to get healthcare right. Everybody else they either have socialized medicine or single-payer. We have an opportunity to have a hybrid-type system that promotes accountability and covers everyone and my mission now is to is to push that.