Health Care Stakeholder Discussion: Physicians

(Conversation before meeting)
Dr. Emanuel: So, just to get your attention for a second,
Nancy-Ann DeParle is busy on a call from someone in the West Wing.
So we are going to be delayed about ten minutes.
So if you want to get up and stretch,
if you want to talk to other colleagues --
A Speaker: (inaudible) five minutes from the professor's --
A Speaker: It will probably be 10 more minutes.
I think we are probably going to start at 1 15, I apologize.
(More conversation before meeting)
Ms. DeParle: Everybody is sitting pretty close together here?
Dr. Emanuel: We're all friends.
Ms. DeParle: Thanks, everybody for coming. I'm Nancy-Ann DeParle, the
director of the White House Office of Health Reform.
Hey, Shelly (phonetic). It's good to see a good group of
physicians here with us today. I think this is our second
physician meeting on health reform and we are really eager
to hear from you how you're surviving these days in the real
world practice of medicine and what we could do to make it
better. We are hopeful that through the President's
commitment to address health reform this year that some of
the things we'll be able to do will improve the experience of
practicing medicine and certainly improve the care that
patients receive which is one of our top goals. As you know,
quality is very uneven across our system right now.
We have both many of the world's best hospitals as well as too
many that struggle to achieve basic core measure results.
So the best and the worst at the same time. And choice is also
threatened as physician practices are unable to accept
new patients, and as options for patients are narrowed by benefit
design. So, our goal is to try to address all of these
challenges, and we are doing it by working with Congress and
stakeholders across the system, including you, including
physicians. As I said, we believe that reform offers a big
opportunity to improve the experience of practicing
medicine. We want to talk to you about your thoughts about
staying in medicine versus doing something else,
which is something that as we look at physician -- I see some
smiles here -- I know a few people in here who have thought
about that, but we are, you know, want to make sure that
there are adequate clinicians around the country in all of the
places where they are needed. And one of the ways, as one of
my colleagues here suggested to me, one of the ways to do that
is to make sure that all of you stay engaged in treating
patients as long as possible. So that's something that I'm
interested in hearing from you about. So we are really
fortunate to have more than 30 physician leaders from around
the country who have agreed to spend some time with us,
including deans of medical schools,CEO's of teaching
hospitals, leaders of specialty societies, chairs of academic
departments, and several private practicing physicians. And we
really appreciate your willingness to come and share
your perspective and expertise with us. I'm very fortunate,
because I get to work with a number of clinicians here at the
White House on our health reform efforts. And I want to introduce
them and have them tell you a little bit about themselves.
I'll start on my far left with Bob Kocher (phonetic).
Dr. Kocher: Hi, my name is Bob Kocher. I work on the national economic
council where I focus on health care economics, in both the
national health expenditure as well as the federal and state
health expenditures. I'm an internal medicine doctor,
by background. I did my training (inaudible) in Boston. Many of
your hospitals (inaudible) company where health economics
was researched there -- prior to joining the white house.
Dr. Hughes: I'm Doris Hughes. I'm an internist by background. I also
have a master's in public health. I trained in Brigham and
Women's Hospital in Boston. Following that, I worked at
common law fund foundation, (inaudible) policy issues.
I've worked (inaudible) Kennedy -- Obama and now I'm happy to
working in the Obama administration.
Dr. Emanuel: I'm Zeke Emanuel, an oncologist and bioethicist, and I'm working
here on detail from the NIH at OMB. And I guess I started out
in Boston as the Beth Israel Deaconess, and then did oncology
and stayed in Boston for number of years before moving to the
NIH where I ran the Department of Bioethics.
Dr. Patel: Kavita Patel. I'm an internist and a hospitalist by training
and a health services researcher. I was in practice
for a while before I did the Robert Wood Johnson clinical
scholars program, and then worked a RAND in UCLA in
clinical work and health services on the quality of care
at RAND with Beth McGland (phonetic) and Bob Brook
(phonetic), and then came to D.C. by help from people like
Dr. Hughes and worked for Ted Kennedy in his senate health
education labor intentions office. And now I'm here working
for Valerie Jarrett as the policy director for public
engagement and intergovernmental affairs.
Ms. DeParle: Zeke just suggested, and I would love to have everyone introduce
themselves, so if we can go around quickly starting with you, Jim.
Dr. O'Connell: Sure, I'm Jim O'Connell. I'm a practicing internist.
I run the health care for the homeless program in Boston and work closely with
Mass General and Brigham and and Women's Hospital as well as
health centers (inaudible).
Ms. DeParle: He does look kind of beaten down.
(laughter)
Speaker: I'm Christine (inaudible), I'm a general internist based in
Philadelphia. I'm on the faculty at Jefferson Medical College
where I teach and still see patients occasionally.
But I spend most of my time at (inaudible) internal medicine in
The American College of Physicians.
Dr. Bestermann: I'm Dr. William Bestermann. I direct integrated health
services and host medical group and we perform
coordinated integrated management of vascular
risk factors in that organization.
Dr. Chen: My name is Christopher Chen, I'm another Beth Israel training
resident. I did my residency there, and then did my
fellowship at Cornell where I'm a cardiologist now.
Currently down in South Florida I helped to run a
multi-specialty group and (inaudible).
Dr. Kennedy: David Kennedy. I'm a practicing otolarnygologist at University
of Pennsylvania and currently the president of the American
Academy of Otolaryngology.
Dr. Richardson: I'm Mark Richardson, one of three otolaryngologists in this
room (inaudible) University.
Dr. Boinis: My name is George Boinis. I'm a practicing cardiologist at
Washington Hospital Center, a teaching affiliate at Georgetown
and a former White House fellow working with the secretary of
Veterans and Affairs.
Dr. Lee: My name is Steven Lee. I'm a pulmonary critical care
physician. I also did my residency at Beth Israel
Deaconess with Bob actually. I'm in San Diego and part of a
large multi-specialty group of about 300 doctors, four
pulmonologists, and I feel like a group that's really made a big
effort to become a very organized integrated group.
Dr. Schriger: I'm David Schriger. I'm a professor of emergency
medicine at UCLA.
Dr. Callender: Clive Callender, director at Howard University
Hospital, Washington, DC.
Dr. Bosserman: I'm Linda Bosserman. I'm the managing partner of (inaudible)
College, six office sites in California where we also take
care of the two largest and poorest counties, (inaudible)
Riverside. And I practice oncology living. I'm also the
chief medical officer of a national group of private
practices called Cancer Clinics of Excellence in 16 states with
about 200 oncologists who have come together to practice on
evidence based guidelines and improved health care.
Dr. Pariser: I'm David Pariser, a practicing dermatologist from southeastern
Virginia, in a ten dermatologist's single-specialty
group. I'm also a very active voluntary professor at the
Department of Dermatology Eastern Virginia Medical School.
And in another life I was president of a 2200 doctor IPA
that provided coordinated care down in southeastern Virginia.
Dr. King: I'm Jim King. I'm the board chair for the American Academy
of Family physicians. I practice in a little town called Selmer,
Tennessee, Over in West Tennessee in a group practice of
about eight family physicians (inaudible) -- (laughter) and
nurse practitioners, patients trying to do their patients in a
medical home in this present environment.
Dr. Johns: I'm Mike Johns (inaudible). I'm really happy to sit next to
James King who actually talks right (inaudible). I'm a
chancellor now at Emory University. Prior to that I was
the (inaudible) of the health sciences there. Prior to that I
was the Dean of the medical school at Johns Hopkins.
Dr. (inaudible): I'm Laura (inaudible) at the Mayo Clinic and Johns Hopkins
(inaudible) health care strategy finance work. I'm now in a
somewhat unusual job. I'm in an experimental free-standing
nonprofit (inaudible) wide range with grants and donations to be
able to provide care for (inaudible).
Ms. DeParle: Where are you?
A Speaker: Charleston, South Carolina.
Dr. Crandall: Brian Crandall (inaudible) from the University of Utah in Salt
Lake City representing American Society of Cataract and
Refractive Surgery (inaudible) cataract and glaucoma service at
the University of Utah. Member of the international team
(inaudible) just returned from a visit to Ethiopia where we
have an International Cataract Society there.
Dr. Brawley: I'm Otis Brawley. I'm a medical oncologist and epidemiologist.
I do a lot of outcomes work. I'm the chief medical officer of the
American Cancer Society at Emory University where I work.
Dr. Gage: I'm John Gage. I'm a practicing general surgeon at Pensacola,
Florida in a multi-specialty group. I guess I'm old school in
trying (inaudible) stay in practice with the old school
where we did trauma, general surgery vascular surgery.
Dr. DeAngelis: I'm Cathy DeAngelis, the Editor in Chief of JAMA, the Journal of
the American Medical Association. I'm trained in
pediatrics/young adult medicine. I started life a nurse.
I also have an MPH. So maybe I'm the ultimate consumer.
(laughter)
Dr. Brown: Kenneth Brown. I'm in the clinical practice of internal
medicine and gastroenterology providing care to the basic residents of the
city of Washington, DC. I did not train at Beth Israel, I'm
sorry, I trained at Tufts New England Medical Center.
We used to also provide education experience for fellows
at local Howard University School of Medicine and training
in gastroenterology, biliary tract disease.
Dr. Wilson: I'm Cecil Wilson, a member of the AMA Board. And in response
to the introduction, my day-time job is I solo practice as an
internist in Winter Park, Florida.
Dr. Berkowitz: Hi, my name is Scott Berkowitz.
I did my internal medicine training at Hopkins and am
currently a cardiology fellow at Hopkins.
And thank you very much for having me.
A Speaker: My name is (inaudible). I'm a practicing oncologist here in
Bethesda, Maryland. I trained at the NIH and was on the faculty
there before going into practice. We are a single specialty
groups, six physicians, trying to incorporate (inaudible)
medical records and dealing with some of the challenges
on a daily basis.
Dr. Moore: I'm Roger Moore. I'm a pediatrician and an
anesthesiologist. I work at the Deborah Heart Lung Center which
is a cherry hospital that does not charge patients anything.
We are all salaried physicians. And I'm also president of the
American Society of Anesthesiologists.
Dr. Levine: Sharon Levine, also a pediatrician and I also did my
training at the Tufts New England Medical Center. I'm a
pediatrician as I stated and I work for the Permanente Medical Group which is the Permanente
part of Kaiser Permanente in California. I'm working the
leadership of the multi-specialty group practice, 6600
physicians. All of them are salaried, integrated delivery system.
Dr. Zinberg: I'm Shelly Zinberg (phonetic) formerly an
internist/gastroenterologist chairman emeritus at (inaudible)
-- integrated -- now president of Nifty After Fifty. (laughter)
Dedicated to decreasing hospital -- (inaudible) utilization from
all causes (inaudible) save you billions of dollars
(laughter)
Dr. (inaudible): I'm Herb (inaudible). I'm trained in psychiatry.
I trained downstate. Been down here for about six years,
National Center (inaudible) Columbian Presbyterian and New
York Hospital (inaudible) 5500 physicians (inaudible).
Dr. Jenkins: I'm Renee Jenkins. I'm the immediate past-president of the
American Academy of Pediatrics (inaudible). And I am the former
(inaudible). And now I'm (inaudible).
(laughter)
Dr. Gottlieb: Hi, My name is Gary Gottlieb. I'm a
geriatric psychiatrist, and the president of Brigham and Women's
Hospital in Boston which is part of the partners health care
system (inaudible) Massachusetts General Hospital,
which is also (inaudible) the largest (inaudible).
Dr. Bjorkman: It's apleasure to be here. Thank you for inviting me.
I'm David Bjorkman. I'm Dean of the University of Utah School of
Medicine. I'm trained in internal medicine and
gastroenterology at the Brigham. And I also have degrees in
public health and epidemiology. As dean, I'm also the medical
director of our medical group of of 1000 academic physicians
working for university health care. I also direct the Utah
Medical Education Council which has a CMS waiver to try to
rationalize work force needs with GME payments.
Dr. Landsberg: I'm Lewis Landsberg. I'm an internist/endocrinologist.
I trained at Yale. I was formerly the chair of medicine
and the dean at Northwest University Feinberg School of
Medicine. And I'm currently running a comprehensive center
of obesity there also.
Dr. Robertson: My name is Russ Robertson. I'm a former elementary and junior
high school teacher and I went back to school and got a medical
degree. I became a family physician and I've been in
academics my entire life. Dr. Landsberg hired me as the chair
of the now Department of Family Community Medicine at Feinberg,
and I'm also the chair of the Council of (inaudible) Medical Education.
Dr. (inaudible): My name is Dr. Alexander (inaudible). I'm from California
(inaudible) practicing physician everyday since 1981.
I was trained at USC (inaudible) medical center.
I signed my first managed care contract (inaudible) for
patients in 1984, and to this day,
and signed my first Medicare HMO (inaudible) for seniors in
September of 1986 and obtained it to this day.
Dr. Califf: Good afternoon. I'm Rob Califf. I'm Vice Chancellor for Clinical
Research at Duke University. Practicing cardiologist by
training. I guess (inaudible) generation ranges from
developing (inaudible) to implementation of health care
systems in (inaudible) North Carolina.
Ms. DeParle: Well, I can tell this is going to be a fascinating discussion.
We want to just table set and talk a little bit about how
President Obama, how our administration views the task we
have ahead of us with health reform. Bob, can you drive this
-- I'll start and you can finish up. So just to set our table.
You've heard this, because The President, of course,
campaigned around the country for two years talking about the
need to lower costs for all families and businesses and the
need to make sure that people have a choice of doctors,
plans and hospitals, and to assure affordable quality health
care for all Americans. And those are the three things that
the people sitting up here in front of you get up every
morning thinking about how can we work with Congress to get
this done and work with all of you to get this done.
We very much are starting from building on the strengths of our
health system. We are not starting the position of wanting
to, you know, get out a white board and start from scratch.
We think there are a lot of strengths about our current
health care system, including the fact.
And some of you here are testimony to this,
that we have unparalleled medical research and innovation
which we all want and desire as citizens and as consumers.
We have access to leading technology.
And we have the availability of specialized resources without
prolonged waiting times. And those are all things that we
think are strengths of our system, we want to preserve
them and build upon them. And that's part of the way we
are approaching the idea of health care reform. At the same
time, our level of health spending is extraordinary, and a
number of you are here, not just as practicing physicians or
researchers, but also as employers. Herb, you are, Gary,
a number of you are. And so you see this, Michael -- you see
this both as people who are practicing the system, but also
as those who have to purchase on behalf of your employees and
figure out how to make this all work. And we know that these
costs are unsustainable for our businesses and for families.
This is an illustration that is kind of shocking when you think
about it, that when we spend more on health care than we do
on food now, more of course than China does on personal
consumption at 2. 2 trillion a year. So it's an extraordinary
rate of spending. And the rate of cost growth is consuming our
budget. If we can continue at this rate it will be crowding
out the spending that we agree that we need to do on education,
national security, and everything. So, that is part of
why you've heard the President talking about bending the cost
curve and doing some things differently that over time will
lower the rate of growth so that it's more sustainable by our
country. Bob -- oh, actually I have the last line which is the
three challenges we need to address together.
One, costs; two choice; and three quality care.
So those are the three things that we would like you to keep
top of mind as we begin our discussion.
Dr. Kocher: And I'll take a moment and give you some context with each of
these questions as we enter each discussion (inaudible). So we
think the time is actually no better time than now actually to
get serious about costs (inaudible). Let me talk a
little bit about costs. If we take the $2. 4 trillion dollar
that we spend today and (inaudible). The single largest
category is outpatient care. So what happens in our office,
doctors' offices, in the outpatient imagery and
diagnostics (inaudible) practicing ER (inaudible)
hospital outpatient departments. Single digits category of care
(inaudible) that one that actually -- something about
helping (inaudible) value of growth in that category
different will make almost everything else not as
effective as it should be. These are the growth rates.
So if you look on the right-hand side, these are categories same-
day hospital care; (inaudible) which are our largest portions
growing at 89 percent a year. Far faster than the rest of the
health care system, much more faster than the economy as a
whole. Even this year in a period where (inaudible) these
categories are still growing at the (inaudible) rate.
I also point out when we look at what is happening happened here,
this is so (inaudible) who are receiving care (inaudible)
action going up on a regular basis.
The other category (inaudible) our hospital care which is about
the size of the (inaudible). The next big categories are
pharmaceutical care (inaudible) $45 million dollars,
and the administration intermediation of health care
(inaudible). This is much, much bigger. Looking at the hospitals
in the U.S., our hospitals (inaudible) stay is shorter --
productivity is higher, but we have a tendency to be much more
irrational and invasive types of treatments (inaudible) . These
are important conditions that stand out (inaudible) other
countries. Back surgery, knee replacement, DCI's, and
diagnostic cardiac catheterization. These are four
procedures where actually we do 49 percent more than other
countries on a risk conducted basis. So we have an approach
that's different from the rest of the world. If we were to
simply be similar to other countries, that would be a $20
billion savings in our system (inaudible). We have a tendency
as well as (inaudible). For prostate cancer, widespread that
everybody (inaudible). Androgen deprivation therapy is you know
(inaudible). Interestingly many times it's even prescribed by
a urologist on the date it was actually already (inaudible)
treatments. When we think about creating therapy there's four
voices. And to be able to say that these are very similar
(inaudible). There's a $70,000 difference between the choices
of the doctor (inaudible) -- most expensive ones,
which are faster than on the other. If you can figure that
out (inaudible) what are the incentives of these behaviors.
With that kind of table setting, I want to point out that the
President has been very sincere about the principles
that (inaudible). I think one that was striking and very
inspiring differences in how performance (inaudible) on the
fact that there's an ideology where you need to have a system
that's better valued (inaudible) where we reduce the variation in
quality and hope that will step change in the quality of
patients experiencing care. We preserve (inaudible) the fact
all of you (inaudible) and all of you practicing (inaudible).
That being said, while preserving those we need to
satisfy the principle which are really about
making sure that the families and businesses and government
(inaudible) affordable and sustainable over time.
(inaudible) If you lose your job (inaudible) there's a way to
maintain the continuity of care. If your income grows for that
matter, then you also (inaudible). Quality I say there
are two prongs to this. One is there are a lot we can do better
about making us live better (inaudible). Take advantage of
the (inaudible) make sure that we disseminate better
(inaudible). Then on the clinical side, you all know the
variations in here is dramatic. Make sure that it's easier for
patients to have a (inaudible) is a major goal we would
have in this reform. I want to point out that the President has
demonstrated a seriousness in the stimulus bill that was
significant and consider long needed (inaudible). In the
budget we mentioned (inaudible) left to the right of figuring
out (inaudible) million dollars for the down payment.
But funded through both entitlement savings and
(inaudible). With that simply say that we really want to hear
from you on what would make reform successful and really
(inaudible). So how do we make quality if we are not worried
about (inaudible) and making sure that every American has
access to the type of care we all want and have (inaudible).
He can kick us off.
Dr. Emanuel: Well, thank you. This is as Nancy mentioned the second time
we have met with physicians as a group. And the reason we are
interested is, you guys are in the trenches and we are in
desperate need of ideas about how things work and what we can
do to actually address these big issues. So I would say that our
challenge and the questions we need answered are, what specific
changes can we make that are going to help control costs and
improve quality with the goal of using that as the basis for
covering all Americans in a sustainable way that we can go
forward with, without robbing our children and our
grandchildren, and making sure that everyone really can live as
healthy a life as possible. And with that, we are really going
to open it up and hope to have a freewheeling discussion. Please
no set speeches and position papers. We really want ideas.
Dr. Bestermann: (inaudible) cardiovascular conditions and the risk factors
that cause cardiovascular conditions. And if you just
apply the principles laid out in (inaudible) and then with primary
care doctors if you form cardio metabolic medical polls where
you (inaudible) blood pressure, lipids, and blood sugar and
insert (inaudible), we have actually shown in our practice
that you can produce risk factors at a level we
(inaudible). So that can be done in the community.
And then if you look at costs and outcomes the cost of
interventional strategy in that segue intervention is triple
what an intended medical specialty is.
And then in those intensively managed patients,
the outcomes are dramatic.
You have one-fifth strokes; one-fourth heart attacks;
(inaudible) ; one-third amputations and one-sixth of the
people go on dialysis. (inaudible) .
Dr. Emanuel: So how do we be incentivize docs to do that?
Dr. Bestermann: Well, I thank the four (inaudible) who can cross
(inaudible). So if you need to identify big primary care
practices with electronic medical records, join in
together a greater global vascular risk registry, and give
those doctors in practices feedback on how to reform it.
And it's not about punishment, it's about framing the best care
to patients, and you know, and paying the doctor
for his valuable service.
A Speaker: Yeah, I certainly agree with everything you've said,
and we have demonstrated a 40 percent reduction in cardiac
mortality over the last seven years. We have got a smoking
rate of less 9 percent now within our population.
And an intervention rate that's less than half of the median for
the country by doing all of the things that you are talking
about. I was struck, Nancy-Ann, by your putting up there
building on the strengths of our current health system the fact
that we do many more MRI's than any other country, except Japan,
and at the same time, the cost discussion, that our love of
interventions and on the incentive system that drives
intervention. So we have got -- I think that is reflective of
the national ambivalence about the tension between innovation
for innovation's sake and the inability to distinguish new
from improved and value from just doing more and doing less
and so on. From my perspective how do we get docs to do what
you described, and what we have been able to do is to change the
incentives. And I think it's more than about paper performance.
I think when you look at a 9 percent annual increase in
doctors' office visits because that's the way doctors get paid.
You know that a third of that care can be delivered in other
ways, other than driving to a doctor's office, parking,
generating carbon, impacting the environment.
And yet there's no way for physicians to be paid to do the
right thing in a more efficient way. I think unless we address
payment reform we are not going to see the level of improvement
that you're hoping to get out of this.
Dr. Brawley: Yes. I would agree with Dr. Bestermann but I would expand it
to preventive services for all diseases.
In that tone I would resource a body like (inaudible) Services
Task Force so they can quickly assess,
propagate what is good for prevention.
It sometimes takes the (inaudible) Services Task Force
five years to come up with a recommendation on something like
prostate cancers. Also, I'd expand cognitive reimbursements,
reimbursement for cognitive services. Doctors do not get
paid to talk to patients or counsel patients. Part of the
reason you have the knee replacement and all of these
other things that you listed is that doctors get paid to
do things to patients.
Dr. Schriger: I totally agree with what has been said in regards to getting
this kind of care and putting groups together. In order to do
all of this, docs can't practice in solo silos anymore.
And my specialty in dermatology is one where almost 50 percent
of the dermatologists in that solo practice,
it would be nice to find some way where docs could be
aggregated through specialty societies, through state,
medical (inaudible) societies, something where they could in
fact be able to take advantage of some of these economies and
some of this data gathering (inaudible) these large groups
have. And for us it's a work force issue, and I'm sure it is
for many of you. So what we are trying to say in the room to be
expected to comply with this as a solo doc, it's going to be
very, very difficult. So if there could be some way or some
incentive for to aggregate in some fashion I
think that would help.
Dr. Emanuel: Dr. Wilson, you're a solo practitioner still?
Dr. Wilson: Thank you. I still am and actually that was a great segue
to a different perspective, and I do not want to give a set
speech. But I think that it would not be appropriate not to
recognize what this administration has already done
in the stimulus package putting a big down payment investment
and compare it to the (inaudible) research and health
information technology, and in the budget looking for a pathway
to resolve the Medicare of payment issue.
Dr. Emanuel: Those are good things, you say?
Dr. Wilson: They are good things, absolutely. (laughter) This was
in the list of compliments.
Dr. Emanuel: We are ready for the second half.
Dr. Wilson: Actually there's not a second half. And then the third is the
recognition by the President that defensive medicine is a
cost for this country which is not sustainable.
So let me just get to -- and I'm going to quote one of your
papers, as a matter of fact, from JAMA where you can --
Dr. Emanuel: Nancy had a nightmare is what I wrote in the past.
Dr. Wilson: You can observe it if I get it right. But you pointed out --
and this sort of the face of medicine in this country, not
the face of all medicine, but the face of medicine which
really is me. You pointed out one billion office visits in
this country per year, 40 percent of them are deliberate
and solo practice offices, and another 37 in offices of two to
five physicians. So 77 percent of the outpatients which you
described in your slides are in practices. So I think unless you
-- all of the things that we are talking about which are good --
and that's performance measures and compare it to the technical
research and evidence based medicine are things I think all
of us feel in the long run are going to make a difference
in quality of care, and if the cost doesn't come down,
at least we'll be spending it more appropriately.
So what do we need to do? $120 billion in defensive medicine
each year, so tort reform so that when I look at a measure
which says that not every 8 year old who has a bump on the head
and goes to the emergency room needs a CAT scan,
I don't have to worry about being sued because I followed
that guideline. Absent that defense, that's the challenge.
The other is the whole business of electronic health records,
and that is to get information to me and my practice at the
point of care when I'm seeing the patient.
And a lot of that involves what was just alluded to and that is
how can physicians join together this group of physicians who are
way out there and that gets to initiatives related to
anti-trust. In other words, a method by which physicians in
small practices can clinically integrate to take advantage of
quality improvement measures of electronic health records,
and that will require the ability to negotiate with the
health plans to do that.
And finally, and I think this really unfortunately does
override all of this, and that is that physicians over the last
8 years have been living with an annual threat of significant pay
cuts. No physician, and we are small businesses, no physician
can make plans for the future, can make plans to expand what
we are doing when we worry each year whether we are going to get
a pay cut. Now I think we are a little numb there and we don't
think that's going to happen. But even that is not a coherent
system. So I think those are measures that will make a
difference in the world that I represent.
Dr. Califf: (inaudible) I guess it's obvious for this to work (inaudible).
The only self-serving -- you really have to rev up the
evidence generating -- we just published an article in JAMA
showing where we have more random (inaudible) than in any
other field, most of what we are recommending we don't know if
it's right or not. On the surface you would say just
figure out what is right and pay for what is right and then
you've got it made because it's not doing all of the things that
don't work. But the fact is we don't have enough research which
is giving us an answer. So I hope you'll beat down the
critics (inaudible). If you learned what was right and then
pay for it, the bugaboo to me that I can't figure out that I
hope you'll figure out completely is accountability.
That is for paying customers who are intelligent,
well-educated and can use the system well,
it's pretty easy to gravitate towards a reduction and
unnecessary things and adequate reimbursement.
But measuring effective health care,
when we can't cherry pick your customers,
which is what I think we need is a very difficult and complicated
thing to do. And if you don't figure it out, just because of
the way Americans are, we'll figure out how to cherry pick.
And I wish I had an answer.
Dr. Gage: I agree with all of the things that have been said.
One of the things that concerns me, and I think we have to
rethink our whole thought process, and therefore
reimbursement. The reimbursement system as it exists today is
obviously busted and it is not going to work, SGR doesn't work.
We keep hearing we are going to get a ten percent (inaudible) we
get more than one percent increase,
but the debt is still back there to be paid at some point.
When? We don't know. So it prevents us -- I think we got to
get away totally from a system of being reimbursed for widgets.
That's not going to work anymore.
Dr. Emanuel: So how would you recommend, what do you think about the
bundle payment idea?
Dr. Gage: Well, it bothers me in some respects,
because who's going to control the bundle?
Dr. Emanuel: We ask that question a lot too.
Dr. Gage: (inaudible) And the last thing they want to hear is
the insurance industry has control over the bundle.
The hospital has control over the bundle.
And hear we are sitting out here as some of us have done in the
past, please help me. That I don't think is going to work.
But we've got to get away from this,
if I do more widgets then I get paid more money.
Because you perpetuate the improprieties of what you don't
even realize you're doing maybe. I see friends of mine that
operate on 85 year olds that have inguinal hernias and the
only reason they knew it is because they went to their
primary care physician and found out they have one.
It doesn't change their life style,
may alter their life style permanently if they get it
fixed, because they may die. Wrong process.
If it doesn't bother you, don't worry about it (inaudible) Don't
fix it. Save money. But, unless we get away from I did more
today or I saw more today, we are not going to get a different
thought process of how we get reimbursed.
There is value and quality and maybe more value and quality
then there is in the number of widgets we produced last year.
Dr. King: Definitely more (inaudible) won't have to really focus on
services primary care. The concept we have (inaudible) what
are we going to do and (inaudible) you're going to have
to pay us different in primary care. It's the same thing.
You have to count how many patients I see everyday --
(inaudible) if I can't get them sitting on the table I don't get
any money out of it. Forty percent of what we do in our
offices each day we are not paid for. As I try to help my
patients navigate through this complicated health care system,
most the work we do in our offices are not covered.
I have a lady that's just in charge of making sure my
referrals are done properly so the hospital gets paid when I
order an MRI. My subspecialties colleagues are paid for if I get
them to the right person. While we do this we don't mind taking
that responsibility but you have to fix the way you pay us.
I don't see the service going completely away.
But the management fee is coming forth with paying us to manage
our patients, take care of our patients,
have them go through the system is important.
Then what else can I pay for performance or what I really
call it pay for quality, because (inaudible) perform.
What I mean, providing quality, but it's going to take all of
that kind of to get (inaudible) you just pay me a fee for
service, you pay me do as much to as many as I can.
Ms. DeParle: Do you have information, technology,
clinical information systems in your office?
Dr. King: Yes, I have electronic health records. We have three
systems all tied together. So we are seeing our patients.
Ms. DeParle: Three, in Selma?
Dr. King: Well, we have one in Selma, one in Henderson (inaudible),
and one in Adamsville. (laughter)
We are about 15 miles (inaudible) one of the small
communities, each one is about 5000 (inaudible) . Working out
of one hospital that we use right here.
We get tired of our hospitals because of all of the things.
Our system is different and all of (inaudible) subspecialties in
Jackson, 45 miles down the road, causes the same problem.
Dr. Emanuel: Is that interoperability --
Dr. King: Interoperability.
Dr. Emanuel: Or is that antitrust or --
Dr. King: It's whatever the vendors use as an excuse not to do it or --
(laughter)
A Speaker: They have a different vendor than you do --
Dr. King: They have different vendors and connectivity.
There's too many of us -- too few primary care physicians,
(inaudible) people are choosing and it doesn't matter what you
do with everybody else. You don't have that face to take
care of those patients. And it's affordable to get them into the
system to get all of these things mentioned (inaudible).
Dr. Chen: You know, I have the least experience of anybody in the
room, but what I do have is micro example down in South Florida. When you talk about
incentives for the physician, we actually have an
at-risk (inaudible) primary care physicians.
And essentially, what we are doing is trying to reduce
catastrophic events, because it's how we are being paid as a
group, everybody in a group actually participates.
We have actually pushed forward through EMR system,
but we do all of our on own. We come up with the first ever,
manless digital pharmacy. And because we are also being
paid for outcomes for reducing catastrophic events, we actually
go pick our patients up and bring them to us if they don't
show up, because we are accountable for their outcomes.
We are accountable for them doing well. And that's
actually how we are reimbursed. So every small physician that
practices, their polls are saying how can I reduce the
catastrophic events? And what we found is it took us a while to
convince the insurance companies to allow us to do this --
because we spent 20 percent more on medications than everybody
else. (inaudible) we spent referrals. Physician/patient
ratios are smaller than everybody else's, I know beyond
California, ours are probably they are a lot smaller.
But they are a lot smaller. We ask you, Dr. (inaudible) thank
you so much because all of the data that you're generating,
we actually use that, that in our practice and we look at
them. We say, look, what are the things we are going to fail to
do that are going to reduce bad outcomes, really bad things.
Now we can't reduce them all, but we can reduce some of them.
And we can adhere to those principles and those guidelines
as a group. Everybody agrees. So physicians aren't upset that
they're you know, they are cutting down my procedures -- or
everybody is working on the same rules. It's a team effort.
And at the end of the day, you know,
the overall costs of the care that we were able to prove,
is significantly less because it's those big catastrophic
events (inaudible) it's that two week stay in the ICU, intubated,
on (inaudible), or it's the most horrible complication --
your 92 year-old patient who goes in for a hernia surgery,
gets a little bit of sedation and next thing you know,
she (inaudible) in the ICU for two weeks and (inaudible).
Those are the cases that you really have to (inaudible)
that's how you're going to incentives, that you actually
make physicians accountable to outcomes.
A Speaker: What is the digital pharmacy?
Dr. Chen: This is just an example of what we have -- because we are all
working as a team and we thought it was (inaudible) we said,
you know what, we spend a lot of time dealing with pharmacists
going back and forth. We try to give the patients three-month
supply, but the pharmacies don't want to give it,
because they get more revenue from monthly supply.
Plus, our patients where compliance is a big issue,
all those things were major, major issues.
We want our patients to take medications.
Unlike some other -- we actually -- we (inaudible) the way we do
that is we work with a company, to help develop the first game
office in practice full functioning pharmacy. You're
basically cutting up pharmacists. But here's the
benefit. I know (inaudible). (laughter)
(Conversation among themselves)
Dr. Chen: Here's the benefit.
Before we implement the system we stuck this less than 50
percent of the time (inaudible) electronic medical record and
what the patients are actually take are two completely
different things. That's a scary thing, because I'm a medical
doctor, okay. So, my tools and my (inaudible) -- less than 50
percent of the time they are not going to use the same medication
(inaudible). But I tell you when patients go home after an MI,
the number of medications they go home on is anywhere from 8 to
11 medications. These are 70 year-old patients with possibly
lower profusion of the brain. They are not going to be able
to, you know, no more medications stop and start --
(inaudible) if they do decide to go to the pharmacy -- so we came
up with a system, when you put the medication into the
electronic medical records, it goes through some fancy
machine that we help to develop 18 months. The reason why we
developed is this is because the doctors asked for it --
outcomes. This huge rumor (inaudible) pharmaceutical
companies, does robotic and other things, grabs the
medications, sealed from the manufacturer, never touched by
human hands, labels it, boom, goes right to the patient.
That way when the doctor walks out of the room and cracks his
door, he says, instead of saying oh,
here's some samples that the local drug reps gave me which
(inaudible) we say here, here's the 90 day supply of,
or 30 day supply of whatever medication, especially for my
sick heart patients. They are so tender. And those cost a lot of
money for a lot of them. I can sit there and say I want you to
take this, put this in your mouth. And when you come back
next time you bring those same drugs to me.
This is an effort to improve compliance.
What we have noticed, concordance and (inaudible)
between what the patient are thinking and what the patients
are actually thinking -- (inaudible) greater than 90
percent now. The patient is overwhelmingly happy. Okay.
Eventually start tracking outcomes and reduction of
(inaudible) . Now actually my patients are taking their
medications. And I see significant reduction in costs.
We are talking about 10 to 20 percent of reduction of all
medication costs. That's huge. This is a system that was born
in an environment where I have 20 some doctors sitting together
saying how can we improve our outcomes and reduce costs.
This is an example.
Dr. Landsberg: Let me emphasize something that's been alluded to.
And that is the need to save primary care.
I mean, medical students now are not opting into primary care.
They are going into specialties, and it's easily understandable.
Like graduate medical school with a debt of over $150,000.
They have -- their training after college is anywhere from 7
to 14 years at which point they make maybe 50,000
a year on the average. So they are opting for lucrative
procedure based widget making, specialties. So, we have to do
something because, increasing the access, and with the baby
boomers coming along, there's going to be a (inaudible) need
for primary care physicians. And there are several different ways
I think that that could be approached. I've been very
impressed by the speed with which the economic realities are
translated into career choices that physicians make.
So, a program of loan forgiveness I think would be an
important first step in encouraging people to go into
primary care. And I think the other is the maldistribution of
physicians, getting them in the right place.
I think financial incentives to get physicians to practice in
underserved areas, is critically important.
And I think the evidence suggests that many people who go
to underserved areas because of a financial stimulus, if you
will, tend to stay there. They become an important part of the
community. So I think that's -- this I think is critically
important. I want to ask one other point about generating
evidence. I think that the practice based research network
is something that is -- it's a step beyond clinical trials.
Clinical trials have done a tremendous amount.
They are very useful. It's an artificial situation.
I think with the electronic health record in which the kind
of databases that we heard about,
it's possible to actually develop practice based research
networks that will answer some of these important questions in
a real, rather than in the artificial situation.
Dr.Jenkins : You know, I want to (inaudible) people in getting all of the
constituents. Because I think with this big problem being
attacked, the way to do it is to have a multiple solutions that
can allocate to each area. Some way by which we get better.
That's terrific. So I think the administration what it's pushing
right now is already in that direction. If you cover the
uninsured my impression is that's going to cut our
emergency room activity and also cut down on some of the
unnecessary hospitalizations. This cost (inaudible). The
second thing is you heard it before, I think you've got to
make it easier for us to work with each other.
And that means a re-look at the stock provisions.
And third, the defensive medicine malpractice is
something that affects us all, and it may be a tough one to
take on, but I think what has been impressive is the
administration's willing to take on all kinds of things.
So that belongs in that pot along with also trying to do
something about streamlining, billing, and collections,
because you've got doctors and hospitals who have compliance --
we hire more compliance officers than clinicians.
And they are hiring (inaudible) --
A Speaker: I have a question, if we streamlined it what
would you save?
Dr. Jenkins: What would I save?
A Speaker: Yes.
Dr. Jenkins: I would -- Rough?
A Speaker: Rough. We are not asking for the cents.
Dr. Jenkings; Three, four, five percent which is non-trivial for us.
A Speaker: I don't think so --
A Speaker: But in that range?
Dr. Jenkins: Yeah, might be a little higher. All I know is is we have spent a
tremendous -- you take that and malpractice insurance out,
or you give us some kind of national figures on that --
A Speaker: And we can cut the rest of your budget?
Dr. Jenkins: Pardon me?
A Speaker: We can cut the rest of your budget?
(laughter)
A Speaker: He didn't say anything.
(inaudible)
A Speaker: 1400 at Duke?
A Speaker: Do nothing but process bills -- (inaudible).
A Speaker: How many at Brigham?
A Speaker: Probably close to a couple of thousand, 1500 (inaudible).
(Conversation among themselves)
A Speaker: How many do you have?
Mr. Johns: (inaudible) published in health care. $60,000 was just in
billing. Three hours of -- (inaudible) conversation.
Total waste of a great resource. Actually (inaudible).
A Speaker: We are on to this. Emergency room? I just want to ask
Dr. Schriger, you're an emergency room doc, if we cover every one,
are we going to make your life easier or harder?
Dr. Schriger: Neither. I really don't think that's what the issue is.
I'm a little bit surprised that no one is -- I'm not surprised
in a sense that the group of physicians assembled here have
all talked about tweaks and involved physicians.
As I sit here, I think of the following things -- if the first
principle is we have to live within our means,
taking into account the fact that some have more means than
others and we need to account for -- I've set a baseline for
the typical person in America. That's step 1. Does that has to
come before all of these excellent ideas on how to tweak.
If we are going to live within our means,
you have to set a level of health care which we can afford.
No one is really talking about that. I think -- unless you talk
about that, the (inaudible) health care, health is the
easiest thing to sell. Everyone wants to live well and live
long. Even if you do it risk reduction and keep people alive
until 90, they are still going to have other crises at 90 and
you're going to keep paying as long as you say the pot of gold
is there and we are going to keep dipping into it for more
health care. It just perpetuates itself. So unless you accept the
fact we have to set a budget and live with it and a notion we
have to decide is it better to put more dollars, to benefit
social welfare. Should we put the money into education or to
health care? If we put it into public health mode measures,
advertising, walk to work, bicycle to work, or are we going
to get more dollars for our bucks, putting up billboards and
having companies have incentives for people who ride to work or
walk to work than we are about having 1,000 extra offices among
people. That's the level that this has to be solved.
After you get through what can we afford,
and what is the best amount of resources to put into health
care, then you can do all of these things to optimize it.
I don't disagree with anything that's been said.
I think we are really missing the boat if we don't -- if we
don't live with reality that health care will consume every
single dollar we have unless we say no, that's not acceptable.
A Speaker: One thing that concerns me is that throughout the entire
discussion we haven't talked very much about education.
Dr. Landsberg brought it up. Student debt is a huge issue.
But a bigger issue is that our method of funding medical
education, both undergraduate and graduate medical education
is fatally flawed. With the Balance Budget Act of 1996, '97,
it capped the number of residency positions.
In a state like Utah where we already have dramatic physician
shortage, it has really impacted our ability to serve our
populous. I think that needs to be addressed. I believe there's
a bill in Congress right now to address that. I'm even more
concerned. And I think that the IME, GME issues with Medicare
are -- they don't make any sense to me. But, you need to replace
it with something. You have to have some way of funding
graduate medical education. I would go further and say that
you actually have to address academic medical centers and how
they will fund undergraduate medical education.
The issue that Dr. Landsberg brings out, the issue of primary
care, issue of debt, has a lot of to do with how
undergraduate medical education is funded. And right now, our
students fund their own education. And our students
have about $135, 000 in debt when they graduate, which
affects their career choices. We have to figure out some way that
we are going to support undergraduate medical education
other than expecting the students to pay for it or
expecting the specialists who are having are ordering for
widgets or doing more widgets to then cross-subsidize
the educational mission.
Dr. Emanuel: How would you change GME?
Dr. Landsberg: I would get an entirely that system. I think -- I think it
needs to be based on what workforce needs are. I think you
need to look at regions of the country. I don't think you
should have a national workforce office, because I think then you
miss what regional needs are. Because medical schools are
distributed mainly in the east. And that's just for historic
purposes. And therefore GME programs are distributed mainly
in the east. The best predictor of where a physician will
practice is where they finish their residency training.
So I think what you need to do is you need to look at workforce
needs and develop a system to fund graduate medical education
and undergraduate medical education in a way that makes
sense. If we are going to realign incentives and we are
going to decrease payment for specialists to perform more
procedures, to order more tests, that's money that right now we
use to cross-subsidize our education mission.
As Dr. Crandall will tell you he takes on less money because we
take his money to perform our education.
And this year we had to cut our medical school class by 20
percent because of loss of funding. And that's perverse.
A Speaker: One issue that doesn't come up is end of life sort of issues.
And being an oncologist I see a lot of waste at the end of life.
You know, this morning since I'm in Bethesda, I saw
patients before I came in. I saw a 51 year-old gentleman; he's
got refractory colon cancer. His daughter is graduating on
Tuesday, but he's sort of at the end of life. It's a 15 minute
visit. That's not a rush conversation to sit down for 45
minutes and to say I've got a meeting at the White House, I'm
going to be late. But to talk about hospice, to talk about --
you know, so then I have to go back and dictate, think about
doing that, 10 review systems or 12. Then the billing person that
works to support me is also --has to figure out what I'm
going to get paid for that. And the system is not at all
structured to encourage that kind of conversation.
And there's such waste of resources at the end of life
that do not improve quality of life or increase length of life.
Other than we all see in the hospital and outside of it.
Primarily, I think it's time and relationship driven.
I mean, I've seen this patient for two years. I could tell them
and say look we fought hard for this long, it's time to stop.
Then there's an easy transition into hospice.
But if you don't have those relationships and the system
right now is not set up to cultivate those relationships,
you don't -- it would be much easier,
and I get better reimbursed if I gave him treatment.
But to do what I did was actually financially -- I think
that system has to change.
Dr. Zinberg: (inaudible) if you could reduce one hospital,
one (inaudible) day a year, you would save with today's Medicare
population 40 million -- you would save $100 billion.
And as the Medicare population grows from are 100 -- from 40
million to 80 million, you're talking about $200 billion a
day. And in response to your comment and you're absolutely right, people are
going to keep getting older if you make them healthier,
and eventually going to face catastrophe.
Christiaan Barnard said the goal should be to die as young as you
can but as late as you can.
In other words, let's stay healthy and drop dead.
That's exactly what prescription fitness can do.
I'm talking about (inaudible) customize programs that
identifies general levels of fitness and specific areas
(inaudible) because as we age, and I know I'm 76 years old,
as we age, our specific areas of (inaudible) are worse.
One from the other -- they are different one from the other
(inaudible) and we can address them and we can with
prescription fitness. We can save 1.04 hospital days per
year in the Medicare population at $2,200 a day minimum.
That's a huge decrease in Medicare. We can save 1.04,
almost one and-a-half sniff days per year in the Medicare
population. We are talking about saving more than $100 million
today with today's program and also inform thousands of people
in a new variety of fitness that was prescribed in
the senior population.
Dr. Hughes: I think as a segue (inaudible) we had a list of topics that we
wanted to cover and we surmised at the beginning all of them had
come up (inaudible) been very helpful conversation.
In our remaining few minutes we would like to really challenge
all of you to drill down and say we have covered all of these
issues and challenges, how exactly, what is the role of the
Federal Government in this? In a healthy reform package, what
explicitly would you be looking for in terms of what will help
to reduce costs, improve quality, address population
health? I mean thinking of all of these areas, what exactly do
we need to be doing considering the mixture we have
on the table? And so --
Dr. Zinberg: (inaudible) I would suggest that the program provide prescription
fitness as a Medicare benefit if they should qualify.
(inaudible), physical therapists, people who have
degrees in physical education, and certify them to be
provided around the country. This is the low approach; this
is the DNA of health care management (inaudible).
A Speaker: I think there are multiple things. You've heard some of
them already. Streamline billing collections. Get a malpractice
fix. Modify (inaudible). There's a whole flock of things that we
put on the table.
Dr. Brawley: There's another element though that I'm thinking, thinking,
that's public education. One of the things that perhaps the
government (inaudible)surgeon general, help with --
(inaudible) truly understand the health care problem.
Last time I looked I think per capita health expenditures were
the greatest thing in the world. 1.7 times the number 2 country
which is Switzerland. And it's because there is medical
gluttony in the United States. It's quite interesting.
We have all of these health experiences, but we have a part
of the population that consumes too much health care.
And a part of the population that doesn't consume enough
health care. I'm hoping that public education about public,
personal responsibility, we might actually get people to use
-- you guys can use this phrase -- we are not for health care
rationing, we are for the rational use of health care.
And I'm (inaudible) health care public education beyond just
physician education (inaudible) or trying to satisfy physician
(inaudible)
Dr. Johns: This comment on the (inaudible) prevention where I think it's
really important driving us -- all kinds of health care.
So you mentioned earlier looking at it from two sides (inaudible)
there are incentives for federal, all employers,
all employees actually -- as well as prevention programs.
There are some marvelous examples out there; I know
you've heard about them. And large something who can show
statistics and data.(inaudible) actually lowered these costs.
That's one of my concerns, (inaudible) employer/health.
What happens -- always interested in the health of
their employees.They don't only retrieve the health of savings
-- activities savings -- (inaudible) you need to keep
your eye on that ball -- we have to look at how can we invest in
that? Does it really put some incentives into employers to
actually put in place these programs?
(inaudible) try to push it out of university.
It's still amazing how much resistance we have.
Plus, there are certain laws that prevent us from getting
access to the kind of things to even want to help people.
So we need to think that through.
(inaudible) consider going back to something that was on the
table (inaudible). If you want to fix the workforce you're
going to have to produce more doctors --
Ms. DeParle: Others would contribute to --
Dr. Johns: Go back to (inaudible).
Ms. DeParle: Just to be clear, you said something about if we don't have
an employer; the president's plan builds on the
employer based system.
Dr. Johns: But there are people we have talked about (inaudible).
Ms. DeParle: That's not us. Thanks.
Dr. Crandell: -- one of the specialists here, I just want to remember,
(inaudible) if everyone in this room does what they claim,
which I hope they do, 100 percent of them are going to get
cataracts, four percent are going to get glaucoma.
So we still need to consider maintaining a very good
high quality subspecialty.
A Speaker: I just want to say a couple of tactical things that could
essentially be done (inaudible) One addresses the issue of
different health systems not speaking to one another.
There are these standards, but they are not mandatory and they
are not implemented while something called IHE,
which is the committee, that implements these (inaudible) HL7
standards, I'm coming at this from an imaging perspective.
One thing that is very important for us -- (inaudible) all of the
integrated (inaudible) for private practice physicians.
(inaudible) no idea whether the tests they are ordering are
actually going to be helpful or not. We can't provide them that.
These things should be able to plug in play (inaudible)
computer. But the way that these companies get paid,
they make actually the most money on the integration.
So one thing that can be done would be to federally regulate
people on quality standards, make this data transferable
between the systems in a way that is plug and play that would
allow different physicians' offices with different products
to be able to transfer data (inaudible). Another thing that
I would just say very briefly would be to make sure that any
changes that are made are tied to quality.
You know, it doesn't make any sense at all that an MRI that's
done very well that's read by a fellowship training radiologist
and read in a timely matter is reimbursed the same,
or perhaps poorly, more poorly than one that's done for
purposes of informing an interpreted (inaudible). So
that doesn't make any sense. Deficit reduction cut across the
board didn't reward (inaudible) quality imaging. There are
standards out there. the American college of radiology
has started with the appropriateness criteria in
terms of what should be used when, and also accreditation
imaging, it's a good base that needs to be built.
Dr. Gottlieb: Just a few things as a trainee. First of all, with respect to
picking up on the integration piece, even within our hospital
we have at least three different information systems.
We have paper charts in other parts.
If you compare that with neighboring institutions we
don't have access to any of their data.
We don't have access to their same studies.
We are not able to get them in a timely matter.
So a lot of this information is then repeated. And without
having the means to actually access that even within our own
institution. Secondarily, with respect to with the primary care
issue, I think one of the other things that discussed and has
been studied at Kaiser as well has ben the issue of the amount
of alternative ways to have visits, and looking at ways of
phone calls and other methods. And what I appreciated is that
some of the physicians that were the most beloved by their
patients are the people that actually spend for every hour
you see patients in clinic,they are spending almost an
equivalent amount of time following up on studies getting
back to them about results. That type of human interaction, when
you have a 20 minute return visit, you need that extra time
to be able to speak to people, and the system isn't necessarily
in place to be able to allow them to get that type of
interaction. Even afterwards those people are not compensated
for all that additional work that is essential to their care.
So that there have been a number of very successful and
interesting demonstrations projects that have come from
CMS, high user Medicare populations, dual eligible
populations in which there's been flexibility of payment.
I think that that addresses issues of end of life care of
using preventive medicine and of starting to reduce some perverse
incentives. The brilliance though of the $630 billion is
that it theoretically buys you an opportunity with some
patients, because as you unravel pieces of the system there will
be unintended consequences. And to have the knee jerk purely
focused on costs without understanding the beauty of
pieces like that exist in those demonstrations could be costly
as it was to health care where essentially we subcapitated,
moved from 8 percent premium on the commercial side to less
than 2 percent of premium. We have lost generations of people
providing care to people with depression, schizophrenia and
other disorders which haven't gone away. And so, the
thoughtfulness and patience that's going to be necessary to
be able to use the data that you have because there's a latency
to compare it to the (inaudible) research -- A latency to the
workforce plan that's necessary to build portals on both ends to
be able to manage chronic disease and to create prevention.
Dr. Emanuel: Let me push you for a second. We are very interested in the dual
eligibles. You have a specific demonstration you
thought was successful --
Dr. Gottlieb: Well, there are senior care options,
dual eligible populations that have been very,
very interesting, essentially allowed groups of providers to
work together and essentially to enable access to a variety of
non-health care components.
One of the issues of payment reform is that it can't rip away
the notion that there's a lot of the social fabric of health care
that exists within academic medical centers and elsewhere
that are paid for through cross subsidization.
A Speaker: Yeah, just real quickly; 2008 double AMC questionnaires,
14.2 percent of (inaudible) medical students said they want to go
into primary care. If you subtract out the 5 percent who
want to be pediatricians, That's 9 percent, so if you want an
idea of what the pipeline for primary care physicians looks
like -- (laughter) respect the pediatricians in the room.
Dr. Landsbuerg: Dr. Hughes, you asked for specific points.
A specific point is you have to address the pipeline,
because if you're going to increase the number of people on
the system, you need to increase the number of providers.
We know that future providers are working fewer hours than
the providers now.
A Speaker: Part of what I'm concerned about is care for adults with chronic
disease. I think that's an area where we have got significance
issues. And the reality is a lot of physicians do not want to
care for these people because they are complex,
they take a long time, the return on the feeling of fearing
for them is sometimes compromised. So I just wanted to get that out
there so that you are aware of that. The other problem with
regard to GME is that hospitals drive GME. If hospitals want
more GME positions they generally can find a way to fund
them, but they are generally not in primary care areas.
There have been 37 family medicine residency programs that
have been closed over the last four or five years.
They are very expensive programs to run the way GME is
structured. It is not focused on -- it doesn't provide
reimbursement for people who are learning in those settings.
A couple of quick thoughts. (inaudible) is recommended an
all payor approach and a number of publications.
So I'm happy to hear that. But another thought that's out there
is a base closing commission to deal with GME.
Something along those lines to bring in people together to make
a corporate solution, that really has the tendency to I
think to mitigate some of the capacities of other
organizations to influence the process.
Dr. Boinis: (inaudible) I spent 45 minutes on the phone yesterday to try to
get a stress test (inaudible) I said, well, you know,
there's risks (inaudible) right now (inaudible) doesn't board
certification decrease that risk?
Board certification certifies my training,
but it says nothing about my practice, doesn't say anything,
if I'm reading (inaudible) articles.
There are creative ways of making risk for other people.
And is there some way that I would like (inaudible) because I
have proven that I am that caliber of provider.
And I think that (inaudible) that level of transparency,
that they could be talking about competitive issues,
marketing forces because (inaudible) (laughter)
(inaudible) sitting on a very big problem (inaudible). So the
reason that I like my job now is because I worked less than I did
when I was a cardiology fellow. But I can tell you that these
new (inaudible) probably be working more as an attending
staff physician than they did as a trainee. That's going to
create a lot of tension. People are more and more thinking about
their own personal lives. (inaudible) it has to
be addressed wholeheartedly.
Dr. Kennedy: (inaudible) from the UK system and just look at what that
involves the government can do here. I see a few differences
(inaudible). One is obviously the amount of money that goes
into end of life care(inaudible) about what is (inaudible) health
care -- I think that's important. What really is health
care like? The UK has done that better. They have a better
understanding of what really is health care like.
We can provide so much in medicine now,
that the costs are potentially almost unlimited.
And we do have to have some idea of what is health care like.
A couple of other issues.
One is, of course, the debt when they leave medical school,
which essentially is (inaudible) system,
and that's not a big issue here.
(inaudible) the other issue is that when it comes to end of
life care over there, if you say I am not going to do another
bone marrow transplant (inaudible) you are indemnified
because there's crowned indemnity for all physicians
acting within the state.
So that's a huge issue.
So you are supported in your decisions.
So the defensive aspects of health care are just not there.
So those are some of the things that could be done.
Dr. Emanuel: We are going to have a few more comments and then we are going
to a couple of polling questions.
Dr. Callender: I want to expand upon a comment made about chronic health,
because I think that the place where chronic health can be
managed is best perhaps in the community.
In looking in that model and trying to identify,
expand if I may to be more cost-effective than we talked
about so far.
Dr. Bosserman: (inaudible) eighty-five percent oncology in the community have
an aging population. If we could come up with a federal pilot so
that networks who have come together, who are getting
electronic medical records on network who have been prompted
at the time of decision making and giving data on evidence-
based guidelines, if our patients can get data back,
or get a benefit on their co-pays,
right now they are forcing California to join HMO's,
and we are forced to prescribe expensive chemotherapy drugs
that have drug co-pays where the generics don't have any
reimbursement. We can come with the pilot model in the
community, I think can save significant revenue for
Medicare in (inaudible).
Dr. Brown: One comment. And all of these ideas are great and all of these
academic physicians. And I'm in the community and I agree with a
point that was first raised by your emergency room physician,
correct? These are all great ideas, the ITs needed,
all of these things are needed. You're working the margins.
And you're dealing with all supply sides from the GME's
exception. This country has to cross a philosophical divide.
You have to look at the demands on it.
That's what you were talking about.
That's what I was trying to raise my point of.
We can do a lot of things as physicians.
We are very successful. And the consumer wants that thing that
we do, that is successful, at some point we are going to have
to figure where the dividing line is end of life for
instance. We see it daily in private practice. ICU care.
You talk about $2,300 a day for just a hospital day.
Imagine what ICU cost is. And the doctor is put in a bad
position if the family demands that everything be done.
Where does the doctor say now? Where does the doctor say
there's a limit on what we can do as physicians? Okay.
We have to -- the country and the politicians in the country
have to look at the information that we give our consumers.
And that's what people are, health care consumers.
Where is it rational to stop care?
Where is it rational to -- when does it become an ineffective
care? And at what point in life? I mean we all know the
statistics that have been out there for years about the 80
percent or 90 percent of the Medicare buck is spent in the
last two years of life. What I tell some of my families is,
do you understand what that means?
We have all gone to school or we have had cars that we have been
trying to nurse, we can't afford a new car.
The water pump goes. And then you fix the water pump.
And then the transmission goes. We keep throwing dollars at a
failing enterprise here and at some point we are going to have
to make a philosophical choice like they have in other
countries to set up a rational system of non-rationing but of
telling us what our limits are. I mean, the demand is unlimited.
The money is not.
Dr. Boinis: (inaudible) All primary care doctors cardiologists to have
that discussion and mediate financially viable --
(inaudible) specialists can be incredibly (inaudible).
Dr. Emanuel: Jim, you've been waiting patiently --
Dr. O'Connell I wanted to sneak in just a gentle couple of words
about vulnerable populations who are very expensive,
a lot like the medicaid dual eligibles.
And if we have learned anything in homeless care which I realize
is a small part of the big picture, they often show us
kind of weaknesses in the system as a whole.
So I think what we have learned is that for a certain population
-- like in Massachusetts, we basically have insurance for all
of our homeless people now. But as those of you working in
Massachusetts know that doesn't guarantee access.
So we have learned we have to get out to where they are.
So I suspect that's a lesson that most of the -- if you're
going to look at high-risk populations you've got get
doctors out to them. The second thing is that, and I leave it at
this, is that we have also learned in these populations,
unless we have some way to integrate the primary and
medical care with the mental health and psychiatric care and
the substance abuse care it doesn't seem to work.
So I would throw those gently under the table.
Dr. Emanuel: Okay. One of the things we did in our last physician group that
was successful to end is to ask a few questions prompted by your
comments to see how much agreement and unanimity,
especially among people who either didn't say anything or
said a comment on the other side.
So one of the things I at least heard was the interest in being
paid differently and in particular, being either paid
for performance or given a capitated rate.
So I want to ask first, how many docs in the room think it would
be a good idea if we shifted over to being paid for
performance, raise your hands.
A Speaker: When you talk about team-based care is that a way
to address that?
Dr. Emanuel: Look, of course there are going to be details.
But presumably, we are going to have some quality metrics and we
are going to pay you for hitting quality metrics.
Leave it at that. Big assumptions. That's right.
Okay. All right. We are just surveying.
You can't write in the margin in this survey.
Ms. DeParle: You've got to watch these New Yorkers.
Dr. Emanuel: Can we lift up our hand -- pay for performance, yes or no?
A Speaker: Pay for quality.
Dr. Emanuel: Pay for quality. How many people would be interested in shifting
to more capitated payments which we have heard about? Much less.
(inaudible)
I didn't say they were, I just want to find out -- people seem
less inclined to that. Something about GME, shifting off the
current GME schedule to either all payor GME or GME for
something different than the current formula.
Just the hospital thing. Yeah, off a hospital based GME.
Less hospital very interested in that. Interesting.
(inaudible)
What?
(inaudible)
And the last one I want to ask is something that got hinted at,
but shifting co-pays or some other arrangement for -- goes
along with public education -- for what people actually,
the consumers actually pay for their care related to something
like how important it is or how neat,
how much it's needed or coheres with guidelines.
A Speaker: Could you say that again?
A Speaker: Yeah, I'm confused.
Dr. Emanuel: Adjusting the co-pay as to whether it adheres with
guidelines the patient needs it more rather than just --
discretion. If it adheres to guidelines. More value based.
(inaudible)
Ms. DeParle: Really helpful.
Thank you for me as the non-clinician here, especially,
this has been very invigorating and helpful to hear your ideas.
A Speaker: Thank you.
Dr. Emanuel: We'll stay in touch with you through a variety of ways.
And I think that all of us are interested,
if you have any more materials to send our direction.
Thank you.
(conversation after meeting)