My Interview With President Obama On Health Care Reform
I met President Obama yesterday. I interviewed him at the White House about his proposals for health care reform. But naturally, as we greeted each other, I asked about his throwing out the first ball at the All Star Game the night before.
“Were you nervous about bouncing the ball?” I asked. He grinned. “I will say it’s actually nerve-wracking,” he said. “When they hand you the ball, there are just a lot of things that can go wrong.” I found that to be a perfect metaphor for his assuming the Presidency of the United States and attempting to overhaul the health care system.
The biggest news from yesterday’s interview: President Obama has changed his position from the campaign trail and now believes that health care insurance should be mandated for all Americans, with a hardship exemption.
Dr. LaPook: Ultimately, philosophically, do you believe that each individual American should be required to have health insurance?
President Obama: I have come to that conclusion. During the campaign, I was opposed to this idea because my general attitude was the reason people don’t have health insurance is not because they don’t want it, but because they can’t afford it. And if you make it affordable, then they will come. I’ve been persuaded that there are enough young uninsured people who are cheap to cover, but are opting out. To make sure that those folks are part of the overall pool is the best way to make sure that all of our premiums go down. I am now in favor of some sort of individual mandate as long as there’s a hardship exemption. If somebody truly just can’t afford health insurance even with the subsidies that the government is now providing, we don’t want to double penalize them. We want to phase this in, in a way that we have time to make sure that coverage is actually affordable before we’re saying to people “go out and get it.”
The interview went very smoothly and fairly predictably until we reached the following exchange:
Dr. LaPook: You’ve said that if doctors have the information, they’ll do the right thing. And generally, I like to — I’m a physician and practicing — I think that’s true. But actually, there are a lot of times when that’s not the case. For example, angioplasties — elective angioplasties, where you open up a clogged artery in the heart. It turns out that about 30 percent of them are unnecessary, that they’re done and you try to open up an artery of the heart, but really it’s no better than medication, and doctors know this, but they still order them.
President Obama: Why are they still ordering them, do you think?
I will admit that he took me by surprise by turning the question on me. Suddenly I was not in a one-way interview, I was in a conversation. Politics aside, it was clear to me that he was listening and he was curious.
Dr. LaPook: I think that because they believe — there’s this thing about — if an artery’s closed. It’s got to be better if it’s open, and it turns out that’s not true. So they have on the one side their intuition as a physician, in their bellies, and then there’s the evidence-based medicine that we talk about, and they clash a lot at times, so how do you make that doctor do the right thing or give him the right incentives?
President Obama: I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices. And at the very least, you’re not taking money out of physicians’ pockets for making the better choice. So it’s a combination of better information and then, I think, a different system of reimbursement that says, “let’s look at the overall quality of the care of the patient.”
My conversation with President Obama illustrates a crucial focus of the current healthcare debate: figuring out if the American people are getting their bang for the buck when doctors order tests, perform procedures, and prescribe medications. The current buzzwords among doctors and politicians are “evidence-based medicine” (is there proof that something works?) and “comparative effectiveness” (if there’s more than one way to do something, what works best?). An Institute of Medicine workshop about evidence-based medicine began today in Washington, with the following listed as “issues prompting the discussion”:
. “Health costs in the United States this year will be about $2.5 trillion—nearly 17% of the economy.
. The United States spends far more on health care than any other nation, 50% more than the 2nd highest spender and about twice as high as the average for other developed countries.
. Overall health outcomes in the United States lag behind those achieved in other countries.
. Consistent with the per capita figures, many researchers studying the nature of U.S. health expenditures feel that 20% of our expenditures do not contribute to better health.”
Expert groups are currently trying to establish guidelines for reimbursing health expenses based on clear results from well-designed clinical studies. The problem is that for many medical issues, there is no definitive, evidence-based approach. Clinical medicine is often based on inexact, immeasurable tools such as intuition and experience. As doctors, we don’t have the luxury of waiting for the twenty-year study to be completed. We have to treat the patient now, as best we can, without perfect information.
In the absence of definitive data, we will need to account for clinical judgment in an overhauled health care system. What will happen when the doctor suggests something the insurance company says is not indicated? Opponents of a public option for insurance warn about the danger of having a bureaucrat in between the patient and the physician. But that threat already exists in the current system every time an insurance company decides whether to approve a claim. Wendell Potter, former head of Public Relations for Cigna, recently told
Bill Moyers about Cigna’s decision to deny a liver transplant to a 17-year-old girl, Nataline Sarkisyan, even though her doctors at UCLA had recommended the procedure.
A public-relations uproar forced Cigna to reverse its decision; the company subsequently explained its reversal as an exception, saying the surgery was approved “despite the lack of medical evidence regarding the effectiveness of such treatment.”
Ms. Sarkisyan died hours after Cigna’s decision, without having received the transplant.
A critical flaw in the current system – and one that must be addressed in any overhaul – is that the same people who refuse to pay for a recommended course of action are the ones who consider the appeal of that decision. And, lo and behold, they usually end up agreeing with themselves! In more than two decades of medical practice, I have spent countless hours trying to get various services covered by payors. One encounter – when I tried unsuccessfully to get a stomach-acid lowering pill approved for a patient who needed it -ended up as an example of twentieth-century frustration in
Letters of the Century.
Yes, our current health care system is not sustainable and we do need an overhaul. But there is no “exactly how” and we cannot afford to wait for one. There are so many nuances to the moving target of health care and so many unknowns that it is impossible to create a perfect solution on paper. I’ll settle for an imperfect solution that addresses the most important problems first and represents the best efforts of our most thoughtful experts. But it should not be set in stone. It must include provisions to mature gracefully into versions 2.0 and beyond.
A team at Johns Hopkins has coordinated the world’s largest kidney swap, involving sixteen patients in multiple medical centers across the US. One of the donors was the vice president of human resources at Johns Hopkins Health System, a woman who has promoted organ donation and finally got a chance to do the ultimate charity work herself.
Johns Hopkins reports:
An altruistic donor started the domino effect. Altruistic donors are those willing to donate a kidney to any needy recipient. Just like falling dominoes, the altruistic donor kidney went to a recipient from one of the incompatible pairs, that recipient’s donor’s kidney went to a recipient from a second pair and so on. The last remaining kidney from the final incompatible pair went to a recipient who had been on the United Network for Organ Sharing (UNOS) waiting list.
As part of this complex procedure, Johns Hopkins flew one kidney to Henry Ford, one kidney to INTEGRIS Baptist and one kidney to Barnes-Jewish, In exchange, Henry Ford, INTEGRIS Baptists and Barnes Jewish each flew a kidney to Johns Hopkins.
The 16 surgeries were performed on four different dates, June 15, June 16, June 22 and July 6. The 10 surgeons in charge included four at Johns Hopkins, two at INTEGRIS Baptist, two at Barnes-Jewish and two at Henry Ford.
Johns Hopkins surgeons performed one of the first KPD transplants in the United States in 2001, the first triple-swap in 2003, the first double and triple domino transplant in 2005, the first five-way domino transplant in 2006 and the first six-way domino transplant in 2007. Johns Hopkins also performed the first multihospital, transcontinental three-way swap transplant in 2007 and the first multihospital, transcontinental six-way swap transplant in 2009.
Nearly 100 medical professionals took part in the transplants, including immunogeneticists, anesthesiologists, operating room nurses, nephrologists, transfusion medicine physicians, critical care doctors, nurse coordinators, technicians, social workers, psychologists, pharmacists, financial coordinators and administrative support people.
*This blog post was originally published at Medgadget*
I discussed my thoughts on risk and how all physicians theoretically carry the same risk, not because one field has more bad outcomes than another (which they obviously do) but because all physicians are trained to be experts in their field of training. This expert training should theoretically create no difference in risk between different subspecialties, as long as all physicians practice within their scope of practice.
In a follow up post, I discussed my experience with discharging patients from the emergency department and how this increased my risk exposure not because the science of the discharge is wrong, but rather because the perception of negligence is greater. I discussed the irrational standards of care that have been created out of a legal necessity to avoid litigation at all costs. An irrational standard that creates exponentially infinite costs that are bankrupting this country with little to no benefit to society as a whole. By expecting perfection on an individual basis, an expectation that will never be achieved, we are risking the implosion of affordable care for all. This is physician driven. Driven out of a fear of bad outcomes, which sets irrational standards, which creates negligence when those impossible standards cannot be achieved.
And a reader hit the nail on the head with this comment. I couldn’t have said it any better.
as a hospitalist, you are at the bottom of the funnel in the risk cascade.
If you continue to send pts home from the ER, by numbers alone, somebody is going to have a bad outcome and it’s all going to fall on you.
If you are willing to accept this, more power to you.
Problem X- undifferentiated, high risk, broad ddx type problem.
ie chest pain, dyspnea,abdominal pain,fever,headache, etc.
PMD busy in office, doesn’t want to deal with it.
sends pt to ER for “work-up”
-if something goes awry, “I knew he was sick, so I sent him to the ER”.
Then:
ER gets pt, checks a “pan-panel” and multiple imaging studies.
If anything turns up–admit to hospitalist.
If negative-“I don’t know what’s wrong, better admit.”
Hospitalist is now last one standing; if send pt home and adverse outcome= “Doc HH, you mean two physicians thought this pt was too sick to be at home, yet you sent them home?”
Safe move is to always admit–as you say, if adverse outcome in house, doesn’t seem as bad. Now, you have a three way risk pie–and any specialists that were called to consult.
Not great medicine, but the risks are too high to hold it all by yourself
I can’t tell you how true this is. This is the basis of establishing irrational standards of care. The last bolded section says it all. You the patient, have become the legal hot potato in your journey through your illness. The rational being, if you put the responsibility of certain aspects of care on someone else, it is that someone else who will ultimately be responsible should a bad outcome occur.
The lawyers want you to believe this doesn’t exist. I can tell you categorically, 100%, without a doubt that patients are treated like hot potatoes, in one way or another, with just about every encounter they experience in American medicine.
I have a really hard time playing that game when I have experience and science on my side. At some point, physicians need to be held accountable for the irrational standards they have implemented out of fear and establish standards based on most likely plausible explanations, not the least likely explanation. Until we can do that for our profession, we are a big part of the problem for the financing of this country’s health care needs.
When it comes to facilitating transportation for wounded military personnel and their families, US Airways tops the generosity list, providing about $1 million in complimentary plane tickets/year. Steve Craven, a volunteer pilot with Mercy Medical Airlift, sat next to me en route to a recent Red Cross volunteer recognition ceremony at Walter Reed Army Medical Center. He told me about the great lengths that some airlines will go to to help military families in need. For example, United Airlines and Delta Airlines have both recently offered assistance with the transportation of military personnel to cancer centers of excellence. Sadly, American Airlines, Continental Airlines, and Southwest Airlines have repeatedly turned down requests for assistance.
According to Mr. Craven, his organization coordinates about 25,000 Angel Flights, 10,000 cancer-related flights, and 6,000 Iraq war veteran flights (via Air Compassion for Veterans) per year, with over 7,000 volunteer angel pilots nationwide. Mercy Medical Airlift also runs a National Patient Travel Center which acts as a clearing house/military travel agency for charitable ticket programs, air ambulance discounts, and special lift programs – including transportation to the NIH for clinical trials.
I asked Mr. Craven what sort of patients need the air ambulance service. He responded that often times elderly veterans or military personnel with terminal illnesses wish to die at home (rather than in a specialty hospital or facility) but are too sick to travel in a regular airplane. The air ambulance service allows them to fulfill their last wish and die with dignity.
Sometimes, military families have a very sick child and have exhausted their resources but need specialty treatment at an academic center. Mercy Medical Airlift makes sure they get where they need to go. Once there, the families often stay at Ronald McDonald House or Fisher House. We’re so grateful to our partner airlines who make it possible for military families to stay together in times of medical hardship.
I offer my thanks to US Airways for their generosity to military personnel and their families – as a rehab physician, I know how much it means to them to have their family with them in sickness and in health.
Secretary Robert Gates Addresses The Red Cross At Walter Reed
Evan Falchuk is the President and COO of Best Doctors – a company designed to solve the “failure of information synthesis” that occurs in a convoluted healthcare system that rewards speed over accuracy. I met Evan for a breakfast in Boston last month – and found him to be a highly perceptive, passionate, and affable individual. He’s the kind of guy who asks the right questions, and has a firm grasp of what ails us – both at a personal and systemic level. I like what he’s up to – and invited him to be a regular contributor to Better Health. So for your reading enjoyment, I’ve prepared a transcript of our recent interview:
Dr. Val: What is Best Doctors?
Falchuk: Best Doctors exists for a simple reason: as many as one in five patients get the wrong diagnosis. It usually happens because of a failure to put together the information in a patient’s case in a way that leads to the right answer. Best Doctors offers an in-depth analysis of a patient’s medical information to make sure they have the right diagnosis – and that they are on the right treatment path given their condition and preferences.
Doctors receive the information from Best Doctors well, because it’s pertinent, useful, and from recognized experts in the important questions in the case. We have a very high regard for doctors, and so we do our best to make sure the information we deliver helps the doctor and their patient make good decisions together.
Best Doctors makes money by selling its service to companies, who give Best Doctors as a free benefit to their employees and their families. We do a lot of work with these companies to encourage their employees to call us when they’re facing a medical situation. All our cases are voluntary, confidential and independent of health coverage.
Our customers say they buy Best Doctors for a couple of reasons. First, they want to help their employees deal with the uncertainty they face when they or a family member are sick. And second, they find that if they can help their employees avoid incorrect diagnosis and treatment, they can save a lot of money on health expenses. Since we find that about 20% of cases have something wrong with the diagnosis, and about half have something wrong with the treatment, you can see where the improvement in quality and cost happens.
Dr. Val: Is Best Doctors a family business?
Falchuk: It started out that way.
My father, who is an internist and Professor at Harvard Medical School, started the company about 20 years ago, along with another doctor. They are both from overseas, and regularly saw patients who traveled to Boston for answers to their medical problems. Usually, they were able to tell their patients that their doctors had done the right things, but often they found serious problems. In those cases they worked closely with the patients and their doctors to fix them.
My father taught me that if you spend time thinking about the right questions, often the answers become obvious. This has always been the philosophy he teaches his medical students, and it is the vision we try to implement every day at Best Doctors.
So much of how our health care system is organized today seriously undervalues thinking. We can’t really change the health care system but we can change what happens to each person we help. It’s an important and inspiring mission.
As far as the business is concerned, what started out as an idea 20 years ago is now in 20 countries around the world and covers millions of people. It’s come a very long way, but there is still so much more to do.
Dr. Val: Why did you leave your law practice in DC to work with your dad in the medical world (or – why didn’t YOU become a doctor?)
Falchuk: After studying history in college, I became an attorney. For the next five years, I worked in a big law firm in Washington, DC– although if you count up the hours I worked, it was probably more like 50 years. I learned a lot and had the privilege of working with some extraordinarily gifted people. I liked being a lawyer. The trouble was, I didn’t love it. So I am very fortunate to have a father who not only created such a great business, but who also was thrilled to have the chance to have his son work in it with him.
Some people tell me I was destined to do something in health care. My mother is a nurse, and is now the President of Hadassah, perhaps most well-known for its terrific global health programs and its world-renowned hospital in Israel. My sister works for a big pharmaceutical company. Among my uncles and cousins on both sides of my family I count no fewer than a dozen doctors. Even my brother is in on it – he is an executive producer and director of the TV show Nip/Tuck.
Dr. Val: Tell me about your brother’s brush with a misdiagnosis.
Falchuk: His story is really a classic example of what Best Doctors is all about. He was working on his new TV show, Glee, and woke up one day with numbness on one side of his body.
His doctor first told him to wait it out, then sent him to a chiropractor, then some physical therapy. Nothing worked. He was thinking about getting a steroid injection, but his doctor first ordered an MRI. It found bad news: a malignant tumor in his spinal cord, high up in his neck. He was referred to a neurosurgeon.
The neurosurgeon told my brother he would first have radiation on the tumor. Then he would have surgery in which his spinal cord would be carefully cut open to remove the tumor. He was told he could end up paralyzed, or dead. That was when he called me, and we started a case at Best Doctors.
One of our nurses took a history, and we collected his records. Two internists spent hours reviewing them. The records noted our family history of a kind of malformed blood vessel called a cavernous hemangioma. Our grandfather had hundreds of them in his brain when he died at 101, and our father has dozens of them in his. I’ve got one in my brain, too. This was in my brother’s charts, but none of his doctors had mentioned it.
We asked an expert in these malformations if this was something that ought to be ruled out. The expert said an MRA should be done to see if that was what was going on. We gave that information to my brother and his doctors, and they agreed. The test showed that this was exactly what my brother had in his spinal cord.
Quickly, the plan changed. Although he still needed surgery, there would be no radiation. That might have caused the malformation to bleed, which would have caused the terrible complications we were worried about. Even if that didn’t happen, the surgeons were prepared to operate on a malignant tumor. They would have been surprised to find a delicate malformation there instead.
He had his surgery at the end of November and it went well. He is having a good recovery and is very busy with his new TV show. But his case is a sobering example of the kinds of things we see all the time.
Dr. Val: Who should use Best Doctors services?
Falchuk: If your company has Best Doctors, I always say that if you feel unsure about your medical care you ought to call us. From what I have seen, patients are the first ones to know that something isn’t right and have the most at stake in the outcome. The worst that happens is that we will confirm you are on the right path. But everyone is entitled to feel confident that they are making the right decisions for themselves and we want to do whatever we can to help provide that.
Dr. Val: How can people gain access to Best Doctors services?
Falchuk: Your employer signs up for Best Doctors and then makes it available to you and your family for free. We don’t have an individual consumer program – we prefer to provide this for free to members and their families.
Dr. Val: What do you make of the “Health 2.0” movement – and how is it impacting your business?
Falchuk: I see Health 2.0 as being about consumers being active participants in their care. There are a couple of trends intersecting. Yes, there is a ton of information available on the internet, some good, some not so good. But there is also this growing sense that you have to advocate for yourself so you don’t fall through the many cracks in our health care system. This idea of an “activist” patient is going to be an increasingly important part of the landscape. As a business, we play an important role helping people be good, smart, helpful advocates for their own cause.
Dr. Val: Do you have any words of wisdom for patients out there who are trying to get good care?
Falchuk: My best advice is: don’t get sick. If you must get sick, make sure that you ask as many questions as you can, and learn as much as you can about what is going on. If you’re not satisfied with the answers you are getting, don’t be afraid to ask for a second opinion. Remember, you are entitled to feel confident that you are making the right decision for yourself.
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