Serving America's Medical Needs

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Samuel O. Their
Title: Serving America’s Medical Needs
VTR: 9/07/01

I’m Richard Heffner, your host on The Open Mind. And my guest today is a nationally respected authority on internal medicine, who is equally well known for his expertise in the areas of national health policy, medical education and bio-medical research. All of which certainly looms so large in our concerns today.

A professor now at Harvard Medical School, Dr. Samuel O. Their has been President of the famed Massachusetts General Hospital and of the Institute of Medicine of the National Academy of Sciences. He earlier served 11 years as Chair of the Department of Internal Medicine at Yale Medical School.

Of course when he joined me on The Open Mind a decade ago, Dr. Their had just become President of Brandeis University, and as much as I wanted to engage with him about the health of America’s universities, we talked instead at great length and to real purpose about our nation’s health care policies and problems, as we will to a considerable extent again today.

Indeed, I would begin our program by asking Dr. Their in what ways the changes in medicine in the decade since we last spoke make him any more or less hopeful about its ability and readiness to serve Americans’ real needs. Dr. Their?

THEIR: That’s quite an opening. [Laughter]

HEFFNER: It’s a tough question.

THEIR: I’d say that ten years ago we were at the … coming toward the end of a period in which, I think, the…rise in health care costs was enormous. And we were, I would say, a little bit profligate in medicine in terms of not controlling costs. Managed care came in, in a major way … it had begun to come in before, but in the 90s it really came in aggressively … flattened out the, the inflation in health care and basically put the health care system into a requirement to become a lot more efficient and to manage itself more responsibly.

That would have been a pretty good start. But what also happened in the same period of time, without people realizing it was going to be a big a blow, is the Balanced Budget Act came in in 97. So added to the managed care pressures, you suddenly had a mis-calculation on the part of the Federal government in terms of how extensive the reductions in Medicare payments were going to be. They missed by a factor of 100% in terms of how much they were going to reduce the payments. And they then injured the institutions that were delivering services rather dramatically, so that by the end of the 90′s, I’d say … oh, a third at least, and in some places like the Northeast, two-thirds of the hospitals were operating in the red from operations.

HEFFNER: Not as a function of profligacy?

THEIR: No, by that point, they had cut down rather dramatically, many had been cut to the bone. The result was that many of the institutions failed. And in fact, in Massachusetts 25% of the hospitals have closed in the last decade. The number of… beds in the Boston area has gone down by 30%. So capacity was wrung out. That efficiency occurred. Shortening the length of stay occurred. Dropping back on work forces and having them work harder. All of that occurred. But it went beyond what was reasonable.

At the same time, there were a bunch of other things happening that were very exciting. The growth of biological research. The introduction of new technologies, particularly with the end of the Cold War, the introduction of new technologies that were coming out of the Defense Department … from miniaturization and easy sensing, made it possible for the first time to consider that we were really going to be able to deliver care that was less invasive, more accurate, and in fact, could be less expensive. The problem at the moment is that the places where those translations of the opportunities of… the genetic revolution and of new technology, the places where that goes on … which is the academic health centers … have been hardest hit by the changes in managed care and the Balanced Budget Act.

HEFFNER: Why and how have they been hardest hit?

THEIR: Well, for openers, they’re the most expensive. They’re the most expensive because first of all they deliver the most complex services and draw the sickest patients. Second, they have the cost of education. Third, they are at a place that most translational research, that is, basic research being taken to use for patients … that research occurs most commonly at those institutions. In order to do that you have to have grants and support. The Federal government has been the best payer for those research grants, but even the Federal government requires those institutions to generate enough surplus from their other operations to pay a portion of the research costs. When you begin to cut back all the other cost sources of income to those institutions, they can’t keep up with their commitments to subsidize the research that they need to be doing. So a… an equilibrium that we had before was thrown off rather dramatically.

5:00

HEFFNER: With what result?

THEIR: The result is that if you look at what’s going on, the academic health centers which used to be doing the majority of translational research and the majority of clinical trials, now see clinical trials being done by for-profit organizations off-line, whose main responsibility is only to collect a certain amount of data but not to get new insights. Not to advance knowledge. Not to come up with experimental new approaches. So the result is that you’re losing that additive function of doing the clinical research. The other thing is that the people who were doing the clinical research are now so engaged and working so much harder, as I mentioned before, just to keep in place, like the Alice in Wonderland … running faster and faster just to stay where you are. They are not doing the clinical research to the extent that they were before. So you have the places that are … you’re counting on to do this … not having the people have the time to do it. Not having their own resources any longer to put to it the way they did before. And the result is that you have a potential bottle neck. You have the genetic revolution about to deliver some phenomenal opportunities and the result is that they’re going to come up against a rate limiting step at the translational step.

HEFFNER: What indication is there that there’s a recognition of the situation as you describe it and then one could hope that there will be some kind of resolution.

THEIR: Well I think that there was some recognition. Harold Varmus when he was head of the National Institutes of Health, who I would say is one of the brightest and most entertaining fellows I know, is a… phenomenal basic scientist … Nobel laureate. Came in, I think, with the sense that maybe this was being over-played. I would say by the time he finished his term at the NIH, he had agreed that the support of clinical research was really a critical, important responsibility of the NIH and put in place a number of programs and support mechanism to carry that forward. So there was some recognition there. When the Balanced Budget Act began to hit, it took a bunch of us a fair number of trips to Washington to convince people in the Legislature and in the Administration that they had in fact mis-calculated. They had said they were going to put a hundred billion dollars back into the Trust fund over the next several years and by the second or third year they were going to… put over two hundred billion dollars back into the Trust fund …

HEFFNER: And?

THEIR: And we got some relief. We had … there have been two Legislative eases of the Balanced Budget Act. But if you take the cuts that we received and the argument they made was that you were not really … cutting research and were not really cutting the payment to hospitals and doctors, we’re just slowing the rate of increase. Well, that wasn’t what happened. They projected a six and a half percent increase … first year it was one and a half percent; next year it was minus one percent. So, we got them to agree that they had made a mistake. Of the 100% cut over the two different pieces of Legislative relief, they’ve put back 25% of that. If they were off by 100% in the first place, you can see that we’re still not back to where we need to be.

HEFFNER: What’s been the impact of that upon my health? And your health? And our viewers’ health?

THEIR: It’s a little hard to say. I think that… at the moment I would say that it’s been fairly modest except in the … potentially in the clinical research area. What has happened is that …

HEFFNER: That’s quite an exception.

THEIR: That’s an…that is quite an exception, but in terms of the … what the public will see, it isn’t, it isn’t very much. Because when you cut Medicare payments we don’t stop taking care of the patients, we just get paid less for taking care of them. And over a period of time your infrastructure and your capacity to function gets undercut. But the patients don’t see it. They won’t see it until very late on. In our situation, for example, when we make cuts, we cut everything except that which is directly impacting on patient care. We try to the very end to protect patient care. There are places around the country now where they are having to restrict access to some extent by either cutting down services or frequency of services. Or in our case, for example, closing 30% of the beds in Boston, not having enough Emergency Room services and the public then begins to see that it’s tough to get into a hospital, and that it’s tough to get emergency services.

10:00

HEFFNER: But in the meantime basic research is impacted. Correct?

THEIR: Basic research itself is impacted minimally. The reason is that basic research is supported by the NIH. It’s conducted in the medical school and in the academic teaching hospitals and is reasonably well supported by the NIH. The ability to take that basic research and translate it, which is where you have the academic health centers coming into play. That’s where the problem in. And so if you really have benefits from the genetic revolution, from genomics and proteomics coming forward. And I can’t imagine that there will not be things beyond what we can imagine … we’re going to have trouble getting those translated and making them available. That will be an impact … but it’s down the road.

HEFFNER: Are we different in that respect than other countries?

THEIR: I think that… other countries are… have stable health care systems which ensure everybody. We’re pretty much the only industrialized nation that doesn’t cover all of its citizens. And so we’re different to that extent. On the other hand, we’re probably the country that invests most effectively in basic biomedical research. We have a relationship between the biotechnology industry and the academic health centers and the pharmaceutical industry which is a … has been a very, very productive one in terms of innovation in the production of new drugs and new treatments. And if you look at the new things that have come forward … a vast majority of them have come out of our system. My worry is that there’s a basic shift right now with the genetics and genomics … with the new technologies and that the advantage that we have could easily be lost if the institutions which have to carry out that…next set of advances are too severely constrained.

HEFFNER: What will be the indication that they aren’t too severely constrained?

THEIR: You’ll see more and more of the more exciting innovations and new treatments and new technologies coming out of other countries.

HEFFNER: Is that happening at all now?

THEIR: I think some. I think some of the European countries are … I think Japan was, was beginning to move also, but its had its own economic difficulties. But I think you’re beginning to see a bit more of that. You’re also seeing a bit more globalization. If you can’t get the research done in this country, then you simply … if you’re a global bio-technology or pharmaceutical company, you simply move it to England. Or … with stem cell research and so on, well, you know, if we don’t get it done here, it’s not going to not get done. I mean its … the idea is that somehow that will not advance. It will advance. It just won’t advance here. And to the extent that the economy and the health of the population is related to the time of translation, then our population is disadvantaged, even though we’ve made some very major investments in the past.

HEFFNER: But globalization in other areas, implies what some of us thought many, many generations ago would be a good thing. That this country would specialize in one area … let’s say one area of medical research and that country in another. What about that picture?

THEIR: I think in terms of basic research that’s probably true. But I think in terms of proprietary aspects of research and the translation of research into products for the use of people. I think that that’s not true. I think that the countries that … each of the countries has a different approval system, regulatory system, financing mechanism. And you can either get things to you personnel quickly, or you can get them to them slowly. And one of the reasons that this country worked in the 80′s to upgrade the FDA’s ability to approve drugs was that there were drugs that were being used that were very effective being used in other countries … early beta-blockers and so on that weren’t available to the patients in this country.

HEFFNER: Just before he died, Lew Thomas on this program, said he was afraid we were beginning to live off of the fat of our earlier research and that we would come to rue that. Is that what’s happening because not enough funds are going into the academic research centers?

THEIR: No, I … let me give you a little story. When I was in Washington, the World Health Organization asked me to participate in a review of a subject. The subject was the… tropical research program that they had. The idea was to develop new diagnostic and therapeutic programs for use in tropical medicine, largely in Africa. Turns out that their research, the development of new drugs and new diagnostics was phenomenally successful. Turns out the ability to get it out into the use by the populations was’n…was not successful. The World Health Organization was discussing, “well since we can’t get that, why stockpile all this stuff? Why not stop supporting that basic research?” We finally convinced them that that was not the right solution. The right solution was to figure out how to get it to move out. We are still producing research, some of the fundamental research, I think, at a phenomenal rate and the government in the United States, through the NIH, which has nearly doubled its budget in the last four or five years, is invested very heavily in exactly … the … not the halfway technology that Dr. Thomas liked to talk about, but in the very basic research. And in this country, I think the research aspects are going phenomenally well. Whether we will run into a bottle neck in making those, the fruits of that available to our population, that’s where my concern is. Not in that first part.

15:00

HEFFNER: Stem cell research.

THEIR: Yes.

HEFFNER: What’s your fix on that?

THEIR: I think it’s, it’s a little hard to say. I think the, the promise is phenomenal. I understand that there are a series of ethical and other dilemmas. I think that… staying out of it will not in any way do anything except shift the focus of stem cell research to other places. What the exact output of it is, I don’t know. In almost all things that we do in medicine, we get very excited and enthusiastic. It was the same with genetics. It was the same with technology. It’s the same with stem cells. The possibilities are enormous. Until you do the research, you simply don’t know what the outcome will be.

HEFFNER: And your bet?

THEIR: My bet is that they’ll have a tremendous benefit. And I think I would, if I were in charge, I would invest very heavily in, in stem cell research.

HEFFNER: What do you think is going to be the impact of the Bush Administrations policy upon stem cell research here … because as you say, it’s going on elsewhere.

THEIR: Well, it depends on whether that policy holds. I think Congress has not had its whack at this at the moment. I think there are going to be hearings right now, going on about stem cell research and whether the President’s policy was too restrictive. And I think we’ll have to see what the final outcome is. My view is that it is too restrictive. And that what we’ll see is a … basically a movement of a, a very important technology and the advances of the technology moving out of this country.

HEFFNER: Is that happening? I mean …

THEIR: Oh, yeah. The U.K. is …

HEFFNER: Talk about it.

THEIR: They’ve, they’ve got some pretty good folks in the United Kingdom and Sweden and so on.

HEFFNER: And we’re going to provide them more.

THEIR: [Laughter] Yes.

HEFFNER: What would your … as you say if, if you could … or as I asked you now … if you were King … President, perhaps, and Congress all rolled together … what should our stem cell research policy be?

THEIR: I think you need to have some very clear boundaries as to what it is that you include in making stem cell lines available. My own personal bias, and I understand that there are strong moral views on the other side, is that if you have a stored embryo, which is about to be discarded, that to not allow that embryo to be used, is just kind of foolish. To say that discarding the embryo is okay, but that using it for stem cell research is… the moral equivalent of murder is, is to me inconsistent to the nth degree. The thing you want to be careful of is that ;you don’t, if you, if you are … because that, that stem cell possibility is already there and already about to be discarded. If you’re talking about those circumstances in which you’re going to generate an industry that will just simply fertilize things, I think that … I could see that there … until we know what the possibilities are from that first one … I would think that you could have some clear guidelines and some clear boundaries on that.

HEFFNER: What do you think’s going to happen there … since you’re optimistic about the development of stem cell research … do you think we will move ahead and … or to some people … backwards … morally speaking … move ahead and … we’re pretty good at commercializing everything … in this country …

THEIR: MmmHmmm.

HEFFNER: … and do that here, too?

THEIR: I think that that … I don’t know that. I think that that’s going to be tough. It depends on whether you allow people who are doing research to be using stem cells that are commercially generated and still be doing research which is supported by NIH funding. I think that that nexus is, is a tricky one and I think it’s going to be a problem. What I think in the long run is going to happen is that somewhere, whether it’s here or elsewhere, the benefits of stem cell research are going to be developed. And if they are even remotely as promising as they appear to be, the public is going to demand access to that kind of treatment. It’s not going to be something that you’ll be able to restrict from public use.

20:00

HEFFNER: Academic research centers. How did they originate?

THEIR: They originated basically as medical schools, which needed clinical bases to teach. And began to develop associations with … or even develop their own teaching hospitals. So a medical school with a teaching hospital and frequently with other schools, Public Health, nursing, and so on, became the focus for several things. That’s where the future doctors were educated. That’s where the translational and other biological research went on. That’s where the new treatments got developed. And in most places that’s also where the uninsured and other people went for their care. And they developed that as a base of a set of responsibilities that they had to the community. And I would say that this country, in the health field, that the academic health centers are the gem of what this country has. If you go to our places, you will find hundreds, or… literally hundreds of people from all over the world coming to study at our academic health centers. And, for example, at Mass General and the Brigham, the largest percentage of people are from China now. But they’re from Japan and they’re from Europe. These are places that the rest of the world thinks know how to do biomedical research and know how to train the people who are going to think about what happens in the future.

HEFFNER: And know how to treat patients.

THEIR: And, and have always innovated in how to treat patients. And taken responsibilities when nobody else would do it. They represent six or seven percent of hospitals and they …

HEFFNER: Only?

THEIR: Yeah. There are about 125 of these major academic health centers.

HEFFNER: What about patients?

THEIR: They represent a very significantly higher percentage of patients … I don’t know, it might be 15%. But they represent 30% to 40% of indigent care. Of care of the uninsured. And they’re the safety net for this country. We have over 40 million people who are sometime during the year are uninsured. Those people need care, the one place they can pretty much count on going without being turned away are the academic health centers.

HEFFNER: There must be another way of solving their problem. I don’t mean to eliminate the academic health centers …

THEIR: Solving the problem of the uninsured?

HEFFNER: Yes.

THEIR: Oh, absolutely. I mean from my vantage point the…one of the best likelihoods you would have of getting some control over health care costs would be to know where 15% to 20% of the population are at any given time, what their needs are and develop the needs services for them. I just think it’s an enormous embarrassment, and I thought it was ten years ago … that…then it was only us and South Africa that were the industrialized nations without universal coverage.

HEFFNER: Now we stand alone.

THEIR: Not it’s only us.

HEFFNER: How do you account for that … seriously?

THEIR: I think it’s a cultural, historical, Darwinian approach to life. From the very beginning in this country we divided health care into those people who were “worthy” of health care (in quotes) … that is the people who formed the health care institutions and the people who worked for them. So that when you formed the Massachusetts General Hospital, it was formed to take care of those people. You also formed at the same time, an alms house for the “unworthy”. The alms houses grew into city hospitals. The city hospitals took care of the “unworthy”. Over the time we have always kept that separation. Even if we only keep it as an undercurrent in what’s going on. If you want to see that institutionalized, look at health care reform in 1965-6 … Medicare was put in as a … an entitlement program for the worthy … Medicaid, a means tested, welfare program for the unworthy. My concern in all the debates that occurred when Clinton came into power was that… we were talking about getting … broadening of coverage. But we never talked about that sense that there were people who wanted coverage, who other people thought didn’t deserve it. The AIDS epidemic magnified that.

HEFFNER: You know, I was so fascinated going back, looking at the transcript of our earlier programs, we talked about a Christmas card that you had received from a Princeton economist, a friend of yours and the card was a set of surveys, and it said, “Do you think that everybody should have universal health care?” 85 percent of Americans said, “yes”. “Who do you think should be responsible?” 75 percent said the government. “How should we pay for it?” 65 percent said increase taxes. “Would you be willing to spend more than $50 a year to provide that?” Only 20 percent said “yes”. Is that what you mean?

25:00

THEIR: That’s exactly what I mean. That’s Uve Reinhardt’s Christmas card. Who is still complaining that that’s the problem. But it is the problem. And if it’s never debated, if it’s never discussed, you can’t solve the problem by, by trying to bury that. And particularly at a time … we had a chance in the last several years to, to ramp this up when the economy was really good. Now, as the economy is starting to get into difficulty again, the middle class, which are clearly the people who drive the Legislative process, their Congressmen are going to hear from them yell, “I want everybody to be covered as long as I don’t give up anything. As long as my coverage isn’t reduced. As long as I don’t have to pay more for my own care.” And that’s not what they’re going to hear.

HEFFNER: You think the medical profession … we have one minute left … the medical profession has to take some responsibility for the continuance of this Darwinian attitude?

THEIR: Yes. I think so. I think the medical profession has allowed itself to operate, from time to time as a business. I can get, get in as a final my Brandeis quote … Brandeis said that a profession is a group that has a body of knowledge that involves… information that was passed on from the past generation. it advances and passes it on again. Second, it has a code of ethics which has a component of service to others. Third, it sets and enforces its own rules and regulations. And most important, it values performance above reward. We lost that last one and that, I think, put the social contract at issue. It’s not too late, nobody else is stepping into this void now. The profession could get itself a bit more organized and focussed. And I think it should be taking that responsibility. We’re trying to do that.

HEFFNER: I think that’s a good way to say thank you so much for joining me again today, Dr. Samuel Their.

THEIR: Thank you.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. And if you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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