Spend More, Get Less? The Health Care 'Conundrum'

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Spend More, Get Less? The Health Care 'Conundrum'

TERRY GROSS, host:

This is FRESH AIR. I’m Terry Gross. President Obama recently convened a meeting
of aides in the Oval Office to discuss a piece in the New Yorker magazine about
the high cost of health care in the border town of McAllen, Texas. Obama later
cited the piece in a meeting with senators and referred to its findings when he
spoke to the American Medical Association Monday.

The New Yorker piece was written by our guest, Dr. Atul Gawande, and it offers
both disturbing and encouraging news as the nation begins to grapple with
health-care reform. The troubling news is that in places like McAllen, doctors
are driving costs higher by ordering far more tests and treatments than their
counterparts elsewhere, with no apparent benefit to patients.

The encouraging news is that it might be possible to dramatically cut costs
without reducing the quality of care. Those savings, Gawande writes, will be
needed to achieve universal health coverage.

Atul Gawande is a staff writer for the New Yorker, and he’s a practicing
surgeon at Brigham and Women’s Hospital in Boston and an associate professor at
the Harvard School of Public Health. His most recent book is called “Better: A
Surgeon’s Notes on Performance.” He spoke with FRESH AIR contributor Dave
Davies.

DAVE DAVIES, host:

Well Atul Gawande, welcome back to FRESH AIR. In this piece in the New Yorker,
you focus on McAllen, Texas. It’s a city right down by the Mexico border,
right? What drew your attention to McAllen?

Dr. ATUL GAWANDE (Staff Writer, New Yorker; Surgeon, Brigham and Women’s
Hospital; Associate Professor, Harvard School of Public Health): I was
interested in understanding what to do about our health-care cost problems, and
this happened to be the place that was one of the most expensive places in the
country for health care. Medicare spends about $15,000 per person per year on
Medicare there, and it allowed me to also compare it to another place that’s up
the border, El Paso, which has a very similar set of demographics.

They’re both relatively poor. McAllen’s one of the poorest counties in the
country. They have similar levels of unhealthy behaviors and conditions like
diabetes and obesity, and the other thing they had was a marked difference in
their cost.

While McAllen cost $15,000 per person per year on Medicare, it was $7,500 in El
Paso.

DAVIES: Before we talk about why the costs seem so high in McAllen, let’s get
one other thing on the table, and that is: Do they get better care? Are medical
outcomes better for all this spending?

Dr. GAWANDE: One of the things that I tried to figure out is what is the
quality there? And one thing, you walk around in McAllen to the hospitals, and
you find really fabulous capability and that ranges from high-tech MRI and CT-
scanning and PET-scanning facilities to the full range of surgical capabilities
that anybody would want, whether they’re at Harvard or Mayo Clinic or in
Southern Texas, and so I didn’t think there was a lack of capabilities, or nor
did I find, though, that there was greater capabilities than other places you
find.

They had doctors of great skills, good training. They had the technologies, and
then the striking thing was that when you looked at the quality indicators, for
example Medicare publishes a whole range of quality statistics, the hospitals
in McAllen were actually lower quality than in El Paso. They certainly were not
higher quality than places all around the country that cost less, and so what
they were getting for all of the extra spending didn’t seem to be extremely
high quality. It didn’t seem to be better care.

DAVIES: Now one of the fascinating parts of your article is when you go to
dinner with a group of six McAllen doctors, very experienced people, private
doctors, and talked to them about this. First of all, were these doctors aware
that medical spending overall was much higher in McAllen than in comparable
places like El Paso?

Dr. GAWANDE: It didn’t surprise them to learn, when I started talking through
what the Medicare experience had been on spending. It didn’t surprise them to
learn that they were expensive. They were surprised to hear they were one of
the two most expensive in the country. Miami is the only other city that’s more
expensive, and when you take into account labor and living costs, McAllen could
be regarded as the most expensive city in the country for health care.

DAVIES: And when you get right down to it, what was the reason why costs were
so high there?

Dr. GAWANDE: Well, given that it was no less healthy than El Paso, and they
weren’t getting higher quality for what they were spending, what you saw was a
pattern of simply more services being used there: the volume of specialist
visits, the volume of testing, imaging studies, surgery, home nursing visits.

All of these were markedly higher than El Paso or in the rest of the country,
and by markedly higher, I mean they do two to three times as many pacemaker
insertions, cardiac operations. They have almost double as many ultrasounds
that are done. They have more specialist visits. They have five times as many
home nursing visits as in El Paso. They actually spend $3,500 per person per
year on Medicare just on home nursing visits, which is half of what some cities
spend on their entire health-care budget.

DAVIES: So in other words, a patient who comes to a physician in McAllen, who
presents with a certain history and a certain set of symptoms is much more
likely to get an expensive test or expensive treatment than that same patient
in a whole lot of other places, including El Paso.

Dr. GAWANDE: Yeah, and when I started to the doctors about that and asking, why
does this happen? Is it just that you think this is good medicine, and this is
the way it should be done? The answers were interesting because they came back
saying no, we don’t. We think there is over-testing. There is over-utilization
here, as the technical term is called. There is a drive to have more than may
be necessary, and so the really hard questions that we then started digging
into at that dinner and while I was there in McAllen with other folks was why.

DAVIES: Why do they order more stuff?

Dr. GAWANDE: Right.

DAVIES: And what did they tell you?

Dr. GAWANDE: Well, so the first argument would be maybe this is just better,
and it’s what everybody else should be doing, but as I went through the
numbers, and they saw what was happening, then the second argument was well,
maybe it’s malpractice.

DAVIES: Meaning not that they were committing malpractice but that the threat
of malpractice lawsuits was driving this.

Dr. GAWANDE: That’s right. You know, I give an example. A 40-year-old woman
comes in after a fight with her husband, and she has some chest pain after
this. It goes away. You do an EKG, and it’s normal. Her heart looks normal on
the EKG. So now what do you do?

And the answer 10 or 15 years ago, when McAllen was actually at the norm – they
became more expensive about 10 years ago – so about 15 years ago they said that
you would get a stress test and leave it at that, and even a stress test might
be overkill, but that today, it’s highly likely that she’d get a stress test, a
cardiac ultrasound, a monitor to check the rhythm of her heart and possibly
even a cardiac catheterization. And they sort of laughed ruefully about it, but
there was a sense that there could be fear of malpractice playing into this,
and yet they admitted and pointed out that since the caps came in in Texas –
Texas is a state that passed very strict caps that limit lawsuits.

DAVIES: Caps on jury awards you mean, yeah.

Dr. GAWANDE: Caps on jury awards, exactly. Since that passed six years ago,
they hadn’t seen any reduction. If anything, the pattern of doing more had
accelerated, and second of all, El Paso has the same conditions and doesn’t
have this rate of ordering services, and when one of the other folks there, a
surgeon, finally piped and said this is just overuse, and we just have to admit
it.

And what he was talking about was a tendency to see the revenues behind this,
behind what they did, as one of the factors that could drive a tendency to
order these kinds of tests.

DAVIES: All right, now before we talk about why doctors in McAllen seem to use
their medical practice to maximize revenue in a way that others don’t, I wanted
to probe just a little bit more about this paradox of heavy, heavy spending,
more tests, more procedures, more treatment and the same or even worse medical
outcomes. Why would that be?

I mean, if you were being over-cautious and ordering more tests and more
catheterizations and more stress tests, wouldn’t get at least the same or
better care?

Dr. GAWANDE: Yeah, it seems completely counter-intuitive, doesn’t it? The
general sense is what would be wrong with having – as an example, you have a
heartburn, and you come in. And there have been good studies showing that if
you’re in a low-cost part of the country, they’ll prescribe an antacid for you
and make sure you don’t have this one kind of bacteria that can cause ulcers.
But in the high-cost areas, you are much more likely to also, for just - for
typical heartburn, to be sent to get an endoscopy, a scope that’s put down your
throat, down to your stomach, and other kinds of invasive tests like that.

And yes, that would help make sure that rare chance of there being a cancer
causing the ulcer was addressed, but the one thing we often forget to take into
account is if you do a lot of these things, you have two things happen.

Number one, every procedure, every hospital stay, everything we do in medicine
has risks, and if the value is marginal, the risks can begin to outweigh the
benefits. We do, for example, now more than 60-million operations per year on
Americans, one for every five Americans. And our complication rates are high
enough that we have more than 100,000 die from complications of surgery. At
this point, it’s exceeded the number of deaths in car accidents. And if we
don’t take that into account, we have what you begin to see, which is that over
treatment produces real harm.

The second thing you see is that the less costly and sometimes less profitable
services are the ones that we often are not good at making sure patients get.
They can be as simple as making sure we wash our hands, but they’re also as
simple as making sure patients get good preventive remedies like mammography
consistently for them, or a statin for patients at risk of heart disease, and
also access to primary care.

Those kinds of services actually tend to be worse in high-cost areas and better
in the lower-cost, high-quality parts of the country.

DAVIES: So if you’re really focused on stuff that generates revenue, then
you’re going to pay less attention to the basic preventive stuff.

Dr. GAWANDE: Yeah, the difficulty comes in the conflict between when medicine
is a business versus when it’s a profession. In a grey-zone case, whether a
patient should get that endoscopy for heartburn, whether you send them to have
a particular operation like a carpal-tunnel release for carpal tunnel syndrome,
we make more money, and there is a temptation and a strong incentive to do more
rather than less.

At the same time, if we’ve crossed the border to the point where over treatment
is actually producing harm, we now have to think about how to rein in that part
of what we do, even though it can sometimes mean losing money.

DAVIES: You went and met with some hospital administrators in McAllen. Were
they aware that medical spending was so much higher there than in other
comparable places?

Dr. GAWANDE: They did seem to be. I, for example, spoke to the chief operating
officer of McAllen Heart Hospital, a specialty, for-profit heart hospital there
- and she was surprised to learn that McAllen was such an outlier and
specifically such an outlier in ordering and in doing a lot more cardiac
surgery, pacemakers and so on. And so when we tried to understand what it was,
what it revealed to me - and I thought was really interesting - was that as the
head of a hospital, the executives don’t really know what their impact is on
the overall cost for a whole community.

They know whether their hospital is making revenue, whether they’re meeting
their profit targets. If they’re not, then they try to think of ways to drive
up the use of their hospital and the number of services they’re providing, and
they genuinely believe they’re not in the business of having physicians do
anything except surgery that they’re supposed to be doing.

At the same time, there are not very many incentives to reduce overuse of the
facilities or, in borderline cases, tending to overdo the interventions, and so
although the individual players, whether it’s the hospitals or individual
specialists, just think we’re doing a good job. They’re not aware that the net
effect they’re having is that the whole system is producing extremely high
costs and, in many cases, missing out on preventive opportunities and way
overdoing testing, surgery and many high-risk parts of care.

DAVIES: Our guest is Atul Gawande. He’s a surgeon practicing in Boston, also a
staff writer for the New Yorker. We’ll talk more after a break. This is FRESH
AIR.

(Soundbite of music)

DAVIES: If you’re just joining us, we’re speaking with Atul Gawande. He is
practicing surgeon in Boston. He is also a staff writer for the New Yorker
who’s recently written a widely quoted piece about medical costs.

We were talking about medical utilization in McAllen and how it appears there
that doctors are ordering far more tests and treatment for the same set of
symptoms than their counterparts elsewhere, and as a result, medical spending
is so much higher.

You said that some years back, 10 or 15 years ago, that wasn’t the case and
that costs in McAllen were closer to the national averages. What has changed?

Dr. GAWANDE: This was a question that I sat down and asked the physicians in
the area about over dinner. And the answer was that they thought that the
culture had changed there. It had shifted from a place that had been focused
primarily on what is it that patients need first and foremost to now having
this competing value of also what generates revenues. And that’s where we found
the concerning things that bothered them, the patterns that bothered them and
worried me.

I spoke to a hospital executive for one of the for-profit hospitals there, and
he described to me the concerns that even he as a for-profit executive had,
having worked in different parts of Texas, at other hospitals. And he found
that in McAllen there had been a shift where he was finding physicians who were
owning parts of imaging centers, owning surgical suites, owning parts of a
hospital in town and then having some of those revenue considerations, keeping
up the income for those centers start to drive decision-making.

DAVIES: I have to say that just seems like such an obviously glaring conflict
of interest. Are there any rules which limit a physician’s ability to take a
financial interest in labs or other medical services that they order?

Dr. GAWANDE: Yes, there is a series of laws called the Stark laws to try to
restrain your ability to refer to facilities you’re making a profit from rather
than choosing simply the one that you want to send patients to that gets the
best possible quality and results, but there seem to be loopholes. I don’t
understand all of them, it’s a very convoluted area of the law, but more and
more, you find consulting firms and others that help doctors find their ways
around those laws. And you see, not just in McAllen, but all across the country
a tendency to be able to buy your way into these.

I heard from, recently, a physician in Chicago who bought a part of - a stake
in ownership in an imaging center. They found they were beginning to lose
money, and they had a meeting about what to do about it, and the recognition
was that their only way to close the gap was to order more X-rays and CT scans
and other forms of imaging for their patients, and that was the plan. And when
he came out of that meeting, he felt sick to his stomach because this is what
he’d got himself into.

The only way out of it was to lose a ton of money and to give up his stake in
the operation, and that’s what he did. I think that’s the exact sort of
conflict of interest we don’t want our doctors to find themselves in.

DAVIES: You know, you said that it appeared that the culture among physicians
in McAllen, Texas had changed. And I wonder if we have a situation here where a
certain number of the doctors actually have an arguably corrupt financial
interest in ordering extra tests and procedures, but then that spreads even to
doctors, maybe, who don’t have the same business relationships, it simply
becomes the practice to maximize your revenue, to do an office visit when a
simple follow-up phone call might suffice and to just rack up the dollars as
you engage in medical practice.

Dr. GAWANDE: Well, I think that there are different ways that doctors think
about money in every community. One is simply that many of us are just
oblivious to the financial implications of our decisions, and as long as we see
our patients and make our recommendations and send out our bills, and the
numbers then come out all right at the end of each month, we try to put that
money out of our minds.

There’s a second way that people think about the money, and that’s that they
see it as a resource for actually improving the services they have, and they
will think of how to use that insurance money to install electronic health
records will colleagues or to get easier phone and email access for patients or
to hire a nurse to monitor the diabetic patients more closely.

But then there’s another strain, and we see this in many parts of the country,
which is physicians who begin to see their practice as a business. It’s a
revenue stream. They will instruct their secretary to have patients who call
with follow-up questions schedule an appointment because the insurers don’t pay
for phone calls.

They may decide to open up a service in their office to do Botox injections for
cash, or they may buy an ultrasound machine and take a course and start doing
the scans themselves rather than let the insurance payments go to a hospital,
where they might be doing it at higher quality.

That goal is then to increase your high-margin work, decrease your low-margin
and say well, this is a business after all, and I’m just being realistic. And
what the people who are describing to me there was a sense that, you know,
you’ll have a mix of these views in every community, but in any given
community, one or another of you tends to predominate, and McAllen had seemed
to emerge as one community at that extreme.

One disturbing example, for instance, is that that for-profit executive I had
told you about who helped run a hospital there, when he came and started doing
work in McAllen, he was approached by several other physicians who told him
that we’ll send you patients to your hospital instead of the other hospitals in
town if you pay us for it.

They asked for money that ranged from $100,000 to $500,000 per year. And he
really emphasized to me this was just a handful of physicians in a town with a
couple thousand physicians, but in his career, he’d never been asked for a
kickback before.

He said no, as he said, I have to sleep at night. But it felt to him like it
signified a culture where, if that’s the extreme, you had others who don’t go
quite that far, but it was a world where there were more physicians who were
concerned about the revenue stream than even he as a for-profit executive was
comfortable with.

GROSS: We’ll hear more from Atul Gawande in the second half of the show. He’s a
staff writer for the New Yorker, a surgeon and an associate professor at the
Harvard School of Public Health. He spoke to FRESH AIR contributor, Dave
Davies, who’s a senior writer for the Philadelphia Daily News. I’m Terry Gross,
and this is FRESH AIR.

(Soundbite of music)

GROSS: This is FRESH AIR. I’m Terry Gross. Let's get back to our interview with
Dr. Atul Gawande. His recent story in The New Yorker examined health care in
McAllen, Texas, where doctors are driving cost higher by ordering far more
tests and treatments than their counterparts elsewhere, with no apparent
benefit to patients. President Obama has referred to this piece in his
discussions on health care reform. Atul Gawande is a staff writer for The New
Yorker and a practicing surgeon at Brigham and Women's Hospital in Boston. He
spoke with FRESH AIR contributor, Dave Davies.

DAVIES: You found some models of medical practice that are much more
encouraging, that keep costs down and deliver more effective health care. Give
us some good news. What did you see out there that's working?

Dr. ATUL GAWANDE (Surgeon, staff writer for The New Yorker): I think this is
really important because the striking thing to me about McAllen is that it was
an outlier. In the rest of the country people hadn't all gone this way. And the
interesting thing to me is that if the economic incentives are for us to put
the revenues first, then why hadn't we done it all across the country? Why was
McAllen distinct? And the answer was that you have on the opposite end of the
spectrum places that are extraordinarily low cost. Cost, you know, below half
of what it is in McAllen and have much higher quality. Places like the Mayo
Clinic, which is in the bottom 15th percentile for cost, but has quality scores
that are the envy of most places in the country.

They are not short of technological capabilities. They have cutting-edge care
in Rochester, Minnesota. And yet, they're doing it at costs that if we could
bring the rest of the country to be at that level we would not just have enough
money for health reform, we would save the entire federal government budget and
the economy here. The answer is not that Mayo itself is the only place with the
answer. There are many, many communities. I talked about another one, Grand
Junction, Colorado, which is one of the least expensive places in the country,
where they nonetheless have some of the highest quality results that are
measured. And the answers that they have in places like that is, first of all
they tend to blunt the financial incentives.

Mayo puts their doctors on salary. In Grand Junction, the medical group pools

the income together and then has an adjustment at the end of the year. So
people who see more uninsured or Medicaid patients, which is the Welfare
Program, aren't penalized for seeing the charity. And then the second thing
they do is they create physician-run collaboratives where they actually look
at, are we doing too much over treatment? Are we doing too much under
treatment, and how do we remedy that?

In Grand Junction, Colorado the - which is in a county of only a hundred
thousand, they found a way to install a community-wide electronic health system
for records to travel between doctors so stuff doesn't fall between the cracks.
They actually had the back surgeons get together and review who's doing too
much back surgery. And in one case, the hospital removed the privileges from a
doctor who they thought was doing too much back surgery because they thought it
was to the point of being harmful to patients.

DAVIES: You know I was really struck by what you wrote about Grand Junction,
Colorado, and how, that actually when physicians talk to each other about
patients, not only did they order fewer unnecessary tests and procedures, but
they really did treat people more effectively because of the kind of
collaborative meshing of their various specialties. What brought Grand
Junction, Colorado, to embrace something like that?

Dr. GAWANDE: You know what’s funny is they don't know and I'm not sure. To some
extent it was simply the culture that was present there. I've been really
fascinated by this researcher at Stanford named Woody Powell, who has
researched why cities developed their particular economic cultures. And often
it’s what he calls anchor institutions. Specific institutions, they aren’t
necessarily the dominate one, but they set the norms for a town. They have
leaders who encourage ideals that are not just to meet your revenue goals, and
you have to meet your revenue goals.

You know, a place will collapse if they don’t have money. But they have the
larger mission in mind as well. And in health care what you saw in a place like
Grand Junction was that starting some 30 years ago, a few leaders started
trying to ask, what could we do in this town to make sure that we are as a
group of doctors, and not just as individual people, ensuring that we are
reducing over treatment, reducing under treatment, and are able to make service
here better for patients from one year to the next, even in the areas where it
doesn't necessarily make them as much money, like prevention?

DAVIES: Well we’re now engaged in a national effort to reform health care and
battle lines are forming and ideas are contending. And in your piece you say
that to some extent this whole debate about whether we have a government-run
plan or a combination of government and private-run plans misses an important
point. You say it isn’t so much a matter of who writes the check to the doctor,
but who is accountable for care. How do we build the right incentives and the
right accountability into health reform?

Dr. GAWANDE: The way we do this has a lot to do with who we want to be the
winners in our system. If we want the winners to be the folks who are getting
the cost lower and making the quality higher then we can’t make them lose. And
in the current system they lose. The folks in Grand Junction, Colorado, when
they discovered that they are among the lowest cost people in the country,
immediately had some people challenging in their medical community saying, why
are we leaving money on the table here? And the leaders who want to drive this
to be a process that's about quality and not the quantity of care and to band
physicians together to work as teams for patients, and not just physicians, get
nurses and other critical health care professionals working collaboratively,
those folks are penalized. And our mission, I think is, as we head into reform
is going to be to make it so that organizations of local physicians, their
medical system, is rewarded for improving the quality and controlling the cost.

One way of doing that, for example, is to allow communities to keep half of the
savings they generate by banding together, meeting quality goals, and trying to
collaborate together more effectively. A second approach could be to reserve
some of the benefits that are offered to physicians and other clinicians. Like,
extra money for your health care information technology to be reserved for
those that work together collaboratively between the hospitals and the doctors.

And the second thing that's very important here is to understand this is an
experiment. Now that we've recognized the problem, you know, we look across the
spectrum of health care costs in the country and it varies by almost 300
percent difference between communities. What we want to understand is, what is
going on in those lost cost high quality communities? What are they doing
differently? If it's the way they pay their physicians locally as
organizations, if the way they have peer review to make sure they’re not
overdoing things? Is it there electronic systems? We want to learn those,
research those, and then add them in. And that is going to be a process that
takes 10, 15 years to be effective.

DAVIES: You know, we haven't talked much about a piece that you wrote in
January of this year about health care reform. And one of the points you made
is that as we begin with, you know, a fair amount of consensus on the need for
reform and great resolve among many parties to accomplish it, that the debate
will get complicated and confusing and interested parties will advance cynical
arguments. And given our general distrust of government at many levels, there
will be a tendency to get distracted and confused and maybe even give up. Do
you have any particular advice for those us who are following this debate,
things we should be wary of?

Dr. GAWANDE: I think our core understanding here that we just have to keep
reminding ourselves is the road we’re on is unsustainable. We have the most
expensive health care system in the world. We have a system that is destroying
our competitiveness of businesses. It is devouring our government. And it's
leaving 45 million-plus people without coverage. We’re bankrupting a million
people a year and many of them already have health insurance. The sense that we
have a great deal to fear from any change can completely paralyze us. But if we
let it we will be dooming ourselves as individual people who need to rely on

the health care system and we’ll doom ourselves as a country.

So what I come into this trying to understand is just, where are the
opportunities for a better health system? It is not going to get to perfection
in the next two to three years or even in the next five or 10 years, but it
should be on a path to getting better over time. And I see in many of the
options being considered by the Congress, real hope that we are on our path to
something that would have universal coverage for people and have a better, less
costly system.

DAVIES: In a piece in The New York Times we learned that your article had
become required reading in the White House. I believe the president has quoted
from it. How did that feel?

Dr. GAWANDE: Completely shocking.

(Soundbite of laughter)

Dr. GAWANDE: Look, this is the dream you have, that anything you write is
absorbed by the people who affect your life. And right now, the folks in
Washington are deeply important to us as patients and as clinicians. And so it
felt like a victory. And, at the same time, I also knew that the brickbats
would come and I had better suit up.

DAVIES: Well, Atul Gawande thanks so much for spending some time with us.

Dr. GAWANDE: Thank you.

GROSS: Atul Gawande's article on health care costs was published in the June
1st addition of The New Yorker. He's a staff writer for the magazine. He spoke
with FRESH AIR contributor Dave Davies, a senior writer for the Philadelphia
Daily News.
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Janelle Monae's Funky Unworldly Sounds

TERRY GROSS, host:

I want to introduce you to a young singer and songwriter who I recently heard
for the first time. Her name is Janelle Monae and her music reminds me of the
eclectic hip hop group Outkast. I guess that's no surprise, considering the
group's co-founder, Antwan Big Boi Patten co-executive produced Monae's new CD,
"Metropolis: The Chase Suite." Judi Rosen wrote in "Rolling Stone," Monae has
been called the female Outkast with reason. She has a skill for pulling off
extravagant fashion statements and genre-defying musical tastes.

Janelle Monae's new CD is jointly released by her own record label and Sean
Combs' label, Bad Boy. Her original ambition was to be on Broadway. And as
you'll hear, her music is pretty theatrical. Several of the songs on the CD are
about her fictional creation, android Cindi Mayweather, who lives in the year
2719. This track is called, "Violet Stars Happy Hunting."

Ms. JANELLE MONAE: (as Cindi Mayweather) (Singing) I'm an alien from outer
space (outer space). I'm a cybergirl without a face, a heart or a mind.

(I'm a product of the metal, the product of metal; I'm a product of the man) Ci
ci ci. I'm a savior without a race (without a face). On the run cause they hit
our ways and chase all my kind. They've come to destroy me. They’ve come to
destroy me. And I think to myself (Impossible, it's impossible for me) Wait,
it's impossible. Now they're running from me and they run for you. Or running
too. Oh, and all the sirens go dooodooo. The sirens go dooodoooodooo.
Dooodooooo. Ohhh baby ooh you know the rules. I love you and I won't take no
for an answer. They say that Violet Stars was such a freak (such a freak) When
you're all in lost in love...

GROSS: That's my guest, Janelle Monae from her new album, "Metropolis." Janelle
Monae, welcome to FRESH AIR. I really like your music. Now what we’re hearing
is a very theatrical production and it’s all about a character. You have this
whole like cyborg fantasy. You have this whole futuristic fantasy that's
enacted on your album. And in your videos you're wearing customs and, I mean
it's...

(Soundbite of laughter)

GROSS: …it’s theater. And, in fact, you're ideal was to be in theater. You
wanted to be in Broadway musicals and before ending up in Atlanta, where you
live now, you went to New York after high school to study music there and hoped
to get on to Broadway. Why was Broadway your first ambition?

Ms. MONAE: Well, I've always loved, you know, music and theater. So the first
thing was to combine those two. But in high school I was heavily involved in
musical theater productions and it was a time where I felt most free on stage.
I really did have lots of ideas in my own mind.

(Soundbite of laughter)

Ms. MONAE: I had lots of musical theater ideas myself and I wanted to connect
with other people who I thought were similar to me. There are times when I'll
just be in Walgreen’s or the doctor's office or somewhere, you know, normal, in
a natural environment and I'd just break out into song and come up with
characters and go home and write about it. And so I wanted to meet others like
myself so I didn't feel so odd or weird. I wanted to interpret art and music
the way that I saw it in my own mind.

GROSS: Now I want to play another track from your new CD, “Metropolis.”

Ms. MONAE: Sure.

GROSS: And this is called “Sincerely Jane.” And this isn’t about being in outer
space. This is about being in the inner city, where there's problems with crack
and gangbanging. And is there a story behind writing this song?

Ms. MONAE: Well, it was a letter written to me from my mother. I had left, you
know, Kansas. I grew up in Wyandotte County, one of the poorest county’s in
Kansas. And, you know, at an early age, I was exposed to those, you know,
around me who had gone to really dark places in their lives because of drugs.
One of the lines that I’ve written - are we really living, or just walking
dead? And that's just a question that I’ve asked myself, and I’ve challenged
people in my life to ask themselves, too. Because there's a big difference, of
course.

You know, so a song can change your life. And I was – I’ve always hoped that
whoever listened to that tune, they were able to really self evaluate and
figure out a way to live. And so, yeah, the lyrics are pretty self explanatory,
but they come from a true experience and a place that my mom, you know, told me
to just stay away, you know, because this is what’s going on in your
neighborhood. So…

GROSS: One more thing before we hear “Sincerely Jane” - the arrangement on this
is fantastic. There's, like, French horns and timpani.

Ms. MONAE: Yeah.

GROSS: Can you talk about the arrangement and why you wanted something this big
behind you?

Ms. MONAE: Sure. Well, I’ve always had a deep admiration for the orchestra. And
I visit here in Atlanta, as often as I possibly can, the Atlanta Symphony
Orchestra. You know, we’ve been a huge supporter, too, of James Bond and
Shirley Bassey. She’s one of my favorite vocalists. And what we wanted to do,
we wanted to make the French horn cry because, you know, the letter was so
touching. And I wanted people, when they listen to it, to actually hear those
French horns crying and those strings, you know, pleading, you know. And with
my voice, I wanted it to touch the corners of their heart.

GROSS: Okay. Well, let’s hear it. This is “Sincerely Jane” from Janelle Monae’s
new CD, “Metropolis.”

(Soundbite of song, “Sincerely Jane”)

Ms. MONAE: (Singing) Left the city, mama, she said don't come back home. These
kids round killing each other, they lost their minds, they gone. They quitting
school, making babies and can barely read. Some gone on to their fall. Lord
have mercy on them. One, two, three, four, your cousin's here ‘round here
selling dope, while they daddy, your uncle, is walking round, strung out.
Babies with babies, and they just keep burning, while their dreams go down the
drain now.

Unidentified Group: (Singing) While their dreams go down the drain now.

Ms. MONAE: (Singing) Are we really living or just walking dead now?

Unidentified Group: (Singing) Are we walking dead now?

Ms. MONAE: (Singing) Or dreaming of the hopes riding the wings of angels? The
way we live, the way we die - what a tragedy. I'm so terrified. Daydreamers,
please wake up. We can't sleep no more. Love don't make no sense, ask your
neighbor. The winds have changed, it seems that they've abandoned us. The truth
hurts, and so does yesterday. What good is love if it burns bright, explodes in
flames? I thought every living thing had love, but are we really living or just
walking dead now?

Unidentified Group: (Singing) Are we walking dead now?

Ms. MONAE: (Singing) Or dreaming of the hopes riding the wings of angels?

Unidentified Group: (Singing) The way we live, the way we die.

Ms. MONAE: (Singing) What a tragedy.

Unidentified Group: (Singing) I'm so terrified.

Ms. MONAE: (Singing) Daydreamers, please wake up. We can't sleep no more. I've
seen them shooting up funerals in their Sunday clothes, just been spending
money on spinners, but won't pay college funds. And all you gangers and
bangers, rolling dice and taking lives in a smoky dark,

Unidentified Group: (Singing) Lord have mercy on them.

Ms. MONAE: (Singing) Teacher, teacher, please reach those girls in them videos.

Unidentified Group: (Singing) Live your life.

Ms. MONAE: (Singing) Those little girl are broke, and queen’s confusing bling
for soul. Danger, there's danger when you take off your clothes. All your
dreams go down the drain, girl.

GROSS: That’s Janelle Monae from her new CD "Metropolis." So how did you
actually get out from your neighborhood in Kansas City to study in New York?
Did you get a scholarship?

Ms. MONAE: Yeah, I did. I did. I got a really cool scholarship for the American
Musical and Dramatics Academy. And it was the only school I had applied to. So,
I mean, I was really, like, okay. Hopefully this works, you know, this would be
my golden ticket.

(Soundbite of laughter)

Ms. MONAE: And to make it into that program, you know, was really a defining
moment for my life. And my life really depended on that moment.

GROSS: Did you have an audition? And if so, what did you sing for the audition?

Ms. MONAE: Wow. I did. I had an audition. And I sang - what did I sing? I was,
I wanted to say I was Cinderella in the production in my high school. And so
there was a song called "In My Own Little Corner," which I really connected to
emotionally for some strange reason. But yeah, it was from Rodgers and
Hammerstein's "Cinderella." And I've always loved them to. You know, they gave
me my first real connection with strings…

GROSS: Mm-hmm.

Ms. MONAE: …because of the songs, the tunes they would compose. That's when I
first fell in love with strings, was when I was in that production.

GROSS: Can you sing a few bars of that song?

(Soundbite of laughter)

Ms. MONAE: Ah, I think it was…

(Singing) In my own little corner, in my own little chair, I can be whatever I
want to be. On the wing of my fancy, I can fly anywhere, and the world will
open its arms to me.

So, yeah.

GROSS: Well I can see why you related to that. That sounds exactly like the
story you've been telling us about your life.

(Soundbite of laughter)

Ms. MONAE: Yeah, it's really, really true.

GROSS: My guest is Janelle Monae. Her new CD is called "Metropolis: The Chase
Suite." We'll talk more after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guest is Janelle Monae, a young singer whose original ambition was to
be on Broadway. Now she’s singing eclectic, sci-fi influenced hip-hop. Her new
CD, “Metropolis: The Chase Suite,” is a co-production of Sean Combs’ Bad Boy
record label. Now, I want to play another song, and this is from an album that
you released - I don’t know if it was on your own label or what, but it was
before your new album. And it’s called, “Janelle Monae: The Audition.” And this
track is called “Cindi.” And it sounds a little like the story you’re telling
us, about somebody who wants to sing and who wants to be a star and doesn’t
really find a place for herself.

Ms. MONAE: “Cindi” is a song that’s just about appreciating oneself. There was
a point in time in my life where I searched and – even when I got into the
recording industry, there was a way that people, you know, tried to get me to
go because it was most safe and conventional. And I’ve always had a burning
fire heart like, you know, James Brown, and I would know that. And I knew that,
you know, my gift isn’t and was not going to be easy, you know, to just - for
people to accept, which is fine. And I had to come to grips with that.

So, in writing “Cindi,” I just talked about that journey, that small journey in
which I pondered and I really, you know, toyed with the idea of blending in.
But at the end of the day, you know, that wasn't going to work out.

GROSS: Well, let’s hear it. And this is from Janelle Monae’s first album, a
self‑released CD called, “The Audition.” And this is “Cindi.”

(Soundbite of song, “Cindi”)

Ms. MONAE: (Singing) As I search for a home and a place to belong, I find it
hard to fit in. I meet lots of pretty girls in this fantasy world waiting for
their turn to shine. So I try to be Cindi, in hopes that they’d notice, but I
wasn’t their cup of tea. It’s so lonely when I’m only being me.

GROSS: That’s “Cindi” from Janelle Monae’s first self-released CD called “The
Audition.” And her new CD, which is a collaboration between her label and Sean
Combs record label is called, “Metropolis.”

Now, as we can hear, you have a voice that really could have made it on
Broadway. Like, you have a beautiful, you know, legit-sounding voice. But what
you’re singing now is - in a beautiful voice - is like your own breed of hip-
hop. Did you feel like you had to change your voice in any way to - when you
changed your aspirations from Broadway to hip-hop?

(Soundbite of laughter)

Ms. MONAE: Well, you know, no, I actually didn’t. You know, I don’t really
categorize anything that I do or say all - you know, this is the genre that I’m
trying to go into. And, you know, still to this day, I don’t have a name for
necessarily what I call my sound or what it is that we’re doing. It’s one of
those things where, you know, I don’t have - I don’t force anything. And by
nature, I think that I've always been drawn to women like Judy Garland, who
always kept a very classic and timeless voice - even Anita Baker at times. I
love her voice, as well. So, you know, taking those out would just be taking a
part of me away.

GROSS: Janelle Monae, thank you so much for talking with us.

Ms. MONAE: Oh, thank you again, Terry. It was my pleasure.

GROSS: Janelle Monae’s new CD is called “Metropolis: The Chase Suite.” You can
download Podcasts of our show on our Web site: freshair.npr.org.
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