Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (2)

Dr. Jon LaPook Interviews President Obama About Healthcare Reform

Watch CBS Videos Online

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.

Watch a four-minute clip from Dr. LaPook’s interview with President Obama

Watch the full twelve minute clip of Dr. LaPook’s interview with President Obama


You may also like these posts

    None Found

Read comments »

2 Responses to “Dr. Jon LaPook Interviews President Obama About Healthcare Reform”

  1. previouslyagovtemployee says:

    Dear Dr. LaPook,

    The ONLY members of this present health care system who have made any concessions or charged less now that I don't have health care insurance ARE THE PHYSICIANS. Just about every physician (except one) that I have seen in the last year has asked what my current coverage is as they were aware that I had had COBRA . Without COBRA or other coverage they (the physicians) have not charged me anywhere near what their regular rate would have been (and the visits were not brief, either). ONLY the PHYSICIANS have done this, no one else! They also checked for samples of medicines, even those prescribed by other specialists that (the prescription) had not expired. I sincerely hope that they will not give up their seat at the table and repeat what I thought I saw in the nineties, where the head of their organization seemed to sell them down the river and then took a job for a great deal of money with one of the organizations that should have been a conflict of interest. And, no, I am not a physician or in the health care field by any measure. Just an observation.

  2. drlapook says:

    Thanks for your comment. I can guarantee you that doctors are not giving up their seat at the table. They are weighing in heavily. For me, a key feature of any new system has to be the ability to adapt as we start to figure out what works and what doesn't.

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles