One of the best documentaries I saw at the Sundance Film Festival in January was Escape Fire, a look at doctors, patients, and hospital administrators who are trying to bend the curve on health care, both by looking at costs and insurance, but even more importantly, at what we get for our money and our insurance. From Sgt. Robert Yates, who makes the decision to kick his addiction to pain medication after suffering serious combat injuries in Afghanistan and recovers with the help of alternative therapies as part of the military’s grappling with overprescription, to Dr. Erin Martin, who moves from clinic to clinic looking for a way to practice patient-centric medicine and to focus on outcomes rather than services, the movie raises questions far beyond the problems addressed by the Affordable Care Act. I spoke with the movie’s co-director Matthew Heineman about how to tackle some of the biggest, hardest changes in health care. This interview has been edited for clarity and length.
There are a lot of different stories in this movie—in a way, it reminded me of reading through Atul Gwande’s archives at The New Yorker. How did you find your subjects for the movie? And here there any who didn’t make the cut?
I think from day one, Susan [Frömke, Heinman's co-director] and I started making the film about three years ago as the health care debate was heating up. Like so many Americans, we were so confused about all the rhetoric, all the hyperbole. Health care was dividing our country. We wanted to cut through that and find out why our system was so broken, and who was out there trying to change it? We ddn’t want to make a film that was just about the problem, we wanted to be about solutions. We found characters and storylines who looked at the story through different angles…Like many films that we’ve done, we spent six to eight months doing research before we even turned on the camera…It was a pretty organic process. We met a few of our experts early on in that process, Dr. Andy Weil and Dr. Dean Ornish, and through them met some of our subjects…It’s a really complicated, wonky subject. So we know we also had to make it interesting, make it entertaining. We didn’t just want to make a film with a bunch of talking heads. We knew we wanted powerful, human stories that would carry the narrative, so at all times, that was in the back of our heads, how can we find characters that tell larger truths about our health care system, but that also have some sort of narrative arc. We found that in Dr. Martin, the primary care physician that’s struggling in a system that’s preventing her from practicing the way she wants to practice, and to find a place where she can practice the kind of medicine she wants to, [in] Sgt. Yates.
So much of the focus of our debate over health care reform is about getting people the insurance that will let them pay for care. But Escape Fire seems to be oriented towards the next debate: what it is that we’re paying for in the first place. I loved Sgt. Yates story because it got at the heart of what our expectations are for our care, and what we’re open to.
Completely. I think health care is incredibly, incredibly important. But i think the key question that our film presents is access to what? Access to a disease care or a health care system? Access to expensive care, to high-tech care, or oriented towards health care and patient-centered care? So many of these films are preach to the choir and are so partisan. We really didn’t want to make a partisan film. We wanted to make a film that would bring all stake-holders to the table…We screened the film at 62 medical schools. Last week we screened it at the Pentagon. And I think what we’ve found is that change doesn’t really have to come from Washington, change can really come at the local level, community by community, and hospital by hospital.
What was the reaction of students at those medical schools?
I was at Johns Hopkins, and just to see the reaction of these young, idealistic doctors. There’s a number that surprised us, 52 percent of doctors would get out of medicine if they could. So many young doctors are recognizing how broken the system is…In our screenings, it really inspired them that they can be part of the change, that they are part of the change, they are part of the future, and they can control the future of how they provide care.
Dr. Martin’s story seems to suggest that it’s not just individual will, though. There are big issues like Medicaid reimbursement rates that impact doctor’s abilities to practice the way they want to.
The barriers, the status quo is enormous. There’s this huge resistance to change. The system is extremely broken. And as Andy Weil says in our film, there are rivers of money flowing to very few pockets, and most of those pockets don’t want to see anything change. But in terms of how individual doctors practice, they’re really hamstrung by how they’re paid. They’re paid for quantity, they’re not paid for quality. It’s changing, hopefully it’s changing, but the fee-for-service system pays for pieces, and therefor we get pieces. The Affordable Care Act is trying to move away from that to some degree. We’ll see if that’s successful. Doctors are as frustrated as patients are. That’s what we see in the film. And I think there’s no question that most people agree that the way we reimburse medicine needs to change.
If doctors are contemplating leading the profession en masse, they could be a powerful lobby.
Everyone can’t do what Dr. Martin does, which is go from clinic to clinic, trying to find the way that works for her. That’s not a viable solution for everybody. What we hope the film does is sort of inspire a grassroots movement to really push for viable change and much-needed change, to really create a more sustainable system for the future.
Dr. Nissen said at your Sundance panel that movies can be a movement-building tool. But one thing that struck me about the movie is that there are so many elements of care that we need to change, from the time doctors spend with patients, to the sorts of treatments that are even considered viable. Where do we start? Do you think there’s a through line to all of these stories that a movement can coalesce around?
I think awareness is one thing that can happen. We have a disease care system, not a health care system. And I think so far, as I’ve said, so far the debate and the fight and the thing that’s really polarized our country is that access to care. And I really think we’re somewhat having the worng debate. We really need tot talk about these more systemic issues that are facing our country. Where I see hope and I see change happening is community by community. We see major institutions changing. They’re changing beuase they’re forced to change. They’re forced to change because of skyrocketing health care costs. We see that in them military. They’re one of the only single-payer systems in the country and they’re forced to innovate, because of thse crises of cost, of over-medication, of suicide, they’re forced to look to these escape fires. Safeway, they saw that health care costs were exceeding profits. Change will come from institutions…
I think one of the biggest things that we learned in making the film is that we do have a lot of power as individuals and we need to take greater control of our health. Seventy-five percent of health care costs go to preventable diseasese. We as a society need to become healthier. We need to create better incentives for that and more supportive enviromnents, but some of it does lie in our heands. We also need to become greater consumers of health. There’s this fascination in America that more is better, we want that procedure. And more is not necessarily better when it comes to health care. We as consumers really need to undestand that. As a society, one third of health care costs don’t actually improve health in any shape or form. We as consumers need to recognize that, that more isn’t necessarily better, that more can be a bad thing. This is the greatest place in the world to be in a car crash or have a heart attack, but that doesn’t mean we should alway resort to high-tech procedures or pills.