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A Conversation with New Executive Director Asaf Bitton

On May 1, Dr. Asaf Bitton becomes the second executive director of Ariadne Labs. Read more about Bitton’s background in the official announcement. A Brigham and Women’s Hospital primary care physician, Bitton has led the Ariadne Labs Primary Health Care Program since 2014. Communications Director Deborah O’Neil sat down with Bitton to talk about health care, the future of Ariadne Labs, and why he will continue to see patients at his practice in Jamaica Plain, MA.

Congratulations! Give me three words to describe how you are feeling as you step into this role.

Excitement. Optimism. Humility.

Let’s start by getting the big question out of the way.  The Atul Gawande question. You are succeeding Atul, the founder, visionary, and public face of Ariadne Labs. Those are big shoes to fill. What do you think about following him as Ariadne’s second executive director?

Yes, Atul and I are quite different. I enjoy reading The New Yorker and reading books on the weekend and he enjoys writing for The New Yorker and writing books on the weekend.

All joking aside, I feel grateful to follow in his footsteps. He has been an incredible friend, partner, and colleague in this journey. What a legacy he is passing on, a lab that was merely an idea seven years ago created to build health care tools that reduce suffering and save lives at critical moments in people’s lives. Having been employee number 12 or 13 at Ariadne Labs, to see that go from notion to reality, from two programs to five, and 100 faculty and 110 staff, has been incredible.

Can you describe that evolution and where you see us now?

Our first five years were about building a core set of clinical programs and platforms that address critical moments in people’s lives. We have made some great bets there and exceeded our expectations. People come here to participate in a community that is dynamic, supportive, and takes on huge problems as a whole. That’s a big shift from the usual mode of business. We have a strong culture that has built a foundation for innovation and impact.

How has working on primary health care systems prepared you to lead Ariadne Labs?

I went into primary care because I was initially trained in public health and I also wanted to take care of people. In medical school, it became abundantly clear early on that primary care was the home for people like me interested in clinical medicine with a population and systems focus.

At Ariadne Labs, we are making a transition. We have learned that we can act successfully at these critical moments in health care, but if the larger systems are fragmented or dysfunctional, we also need to expose that and provide solutions that act in concert. We are building on Atul’s vision. As a primary care physician trained and oriented toward populations and systems, I will assume the mantle and expand it. We can bring this systems lens to the new challenges that have emerged in order to continue to advance our goal of reducing suffering.

What are your priorities in this next chapter of our development?

I have a set of ideas about what those priorities are, but the first preamble, very authentically, is that I need to hear from a lot more people on where we might go. We have been part of a pivot toward a science of systems and a science of scale. Our tools are being used by and for millions of people, and we will continue to do all of the necessary work to make sure what we are building actually translates into improvement. We do that through partnerships and by deeply understanding the experience of people using the health care system. That’s incredibly exciting to me.

An example: In primary health care, what we’re doing now is building data tools that make it easier to expose and measure the state of a primary care system in its totality. On one page, a policy maker can know how her country is performing and what areas to prioritize for investment and improvement. Tools that allow us to distill crisp insights from an almost incomprehensible morass of individual data points are part of our future. We know there is major demand and impact.

As you think about this new pivot toward a broader range of systems solutions, what opportunities do you see for our existing programs in surgery, serious illness, and maternal health?

There are tremendous opportunities within each program to create greater value for populations by working with partners to scale our interventions that work. Take serious illness care, for instance. Our team’s recent trial showed that you can effectively train oncologists to carry out and document an effective conversation about goals at the end of life, and doing so can reduce anxiety and depression by nearly 50 percent. If we had a drug that reduced by half anxiety and depression at the end of life, it would be a blockbuster drug. Our first six years also taught every program that if you are not mindful of the larger systems that are enabling the gaps that we see, we can’t get to where we want to go. We have a conversation and a process that bridges a key gap for seriously ill patients, and we need to work hard to ensure that systems are equipped to deliver this care consistently and reliably everywhere.

What do you see as our most significant challenges?

Our largest challenge is maintaining the ability to keep going for the big targets that are most important and taking on huge challenges and innovative risk in a way that maintains rigor so we learn what doesn’t work. We are best when we combine rigorous methods and a deep purpose with execution at scale.

As a practicing primary care doctor, I understand you will continue to see patients at your practice in Jamaica Plain. What is the connection between your clinical work and your new leadership role at Ariadne Labs?

Yes, I will continue my clinical practice at the Brigham. I have a long-term commitment to my patients–some of whom I’ve known more than 15 years–and South Huntington Advanced Primary Care Associates, which I helped found. It’s a privilege to work there.

So many people love to pontificate about what clinical care looks like. If I am not grounded in that reality, not only do I have a credibility issue, I also have a more profound visibility issue. I cannot fully understand the challenges that I need to speak to if I am not enmeshed in them. We have worked best at Ariadne when we have aligned our work with a deep understanding of the real-world interaction between patients, clinicians, and health care systems. For all of our programs, if you don’t know or aren’t currently struggling through the challenges of the system and imagining the system as it could be in the future, you lose some of the benefit and gain you can bring to this position.

In a very practical sense, I also know that in trying to push forward reforms, you can decrease a lot of resistance with fellow providers and patients when you are speaking peer to peer, colleague to colleague, provider to patient. We hold sacred that space between us and then we can get to a better place in the conversation. Let’s imagine together what the solutions could be.

Why do you see primary care as such an important part of improving health care overall?

Primary care has to be one of three or four major areas any health system across the world has to focus on if it wants to be serious about taking care of populations in an effective and affordable way. Yet, with only a few exceptions, most countries in the world and almost every part of the U.S. considerably under-invests in primary care. It’s under-investment of money, organization, attention, and people’s use of services. We have to start rebalancing how and where and why people use health care toward primary care and away from hospitals if we are to have any chance of controlling health care costs and serving people’s needs.  

Hospitals are fantastic at saving your life and doing complex procedures and being centers of incredible biomedical research, but if we want to take care of people in the communities where they live, we have to also double our investments in primary care and new forms of primary care.  This is not just about offering more office visits and waiting for people to get sick. We have to be proactive about building relationships powered by data that address what matters most. That’s what consumers want, patients want, employers want, health systems want, and insurers want. We need scalable models to do so. This is an area of work we will continue to expand.

Let’s talk big picture. What do you see as the biggest challenges in health care today?

The first problem is we do not have a system that is responsive or attuned to the needs of the people it serves: patients and families. It’s not easy to get health care and too many are left out, completely, for so many reasons. The second problem is having unacceptable failures in maintaining and achieving quality and building safe, reliable, and effective systems.

Third, we have a delivery system that is built to support a financial model, as opposed to a financial model built to serve an optimal delivery system. This is one of the most fundamental problems of American health care and health care throughout the world. We have to change that design parameter. Right now, it’s a historical accident why we pay for health care the way we do. There are a lot of people who need and want it to continue that way. That flaw exacerbates the failures of access, failures of quality, and failures of alignment that don’t give us the system we need.

The team you brought together here is already working globally on primary health care. Do you see Ariadne Labs playing a role in developing those models in the U.S.?

We are going to make a bet on creating solutions to advance domestic U.S. primary care at Ariadne Labs. We’ll be working on defining the strategy in the months to come. You start with finding the right partners ready to look at primary care, both its delivery and payment, in a fundamentally different way. We need to push toward models that reconceptualize how teams take care of people, the use of technology, and our dependence on in-person visits.

You have to break out of the current mental shackles of what primary care can do. If you mistakenly see it as coughs, colds, and blood pressure checks, that’s what you will get. If you see it as teams powered by data and IT to deliver better care to communities, supported by better aligned financial models that encourage the development of long-term relationships, then the possibilities really emerge.

Any busy person would probably agree that sounds amazing, but there’s a lot of obstacles between where we are and what you envision.

Any actor who wants to do something different can get punished for that in health care. It’s a $3 trillion industry and people defend the status quo. Rhode Island wanted to do something different. So they made new regulations in 2010 saying if you are a commercial payer in Rhode Island, you have to increase your rate of spending on primary care in five years by one percent per year in a way that’s budget neutral. The only way to do that is to cap the rate of price growth for hospitals to pay for primary care.

What happened is something you almost never see in health care–a bent cost curve in the commercial population. After seven years it bent the cost curve by nearly $300 per person yearly. That’s serious money. And that is a model to consider for the future.  

Primary care has been a parched territory for so long. You have to create space fiscally to innovate. You can’t just ask primary care practices to work harder. They are already at 99 percent efficiency. There’s a famous quote from the Institute of Medicine Quality report: “Working harder is not a quality improvement strategy; changing systems is.”

Do you ever get overwhelmed by the complexity and difficulty of fixing health care?

I’m at the core a very optimistic person. I’m under no illusions. I’ve spent my career fighting battles at the micro, meso, and macro levels. If you lead with pragmatic optimism, it is amazing how much you can do. Then, if you break down seemingly intractable problems into a target set of more tractable problems that have a smaller set of areas where we can intervene with potential tools, then you get to a cycle of making change. You can’t stay at the macro level where it can all seem so complicated. That’s not what we are doing here. We are going to make a set of bets and risks. In doing so with the right partners, we will be right enough times to be effective.

What kind of executive leader do you aspire to be?

The best leaders enable the people around them to shine and be their best. To do so means you help set a vision and purpose people can get behind. That requires being a listener and hearing what people are trying to say. And it means you are not bound by fear and have a certain amount of appetite for risk and also help people connect to what matters most for us all. We’re trying to reduce suffering for people across the world; that is what matters most and everything should lead up to that.