HMOs and Responsible Psychiatry, Part II

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Robert Michels
Title: HMOs and Responsible Psychiatry (Part II)
VTR: 10/8/97

I’m Richard Heffner, your host on The Open Mind. And my guest today is once again Dr. Robert Michels, Cornell University’s distinguished Walsh-McDermott University Professor of Medicine and Psychiatry.

Now, last time, Dr. Michels and I began to discuss HMOs and the responsible practice of psychiatry. I think we ought to pick up now and see what other issues Dr. Michels thinks are plaguing (if that’s the word) American medicine today.

Dr. Michels, what’s on the front burner?

MICHELS: I think there’s been a major concern both within the profession and in the larger society around the question of whether we have the right number of doctors and the right kind of doctors.

A few decades ago there was a general agreement: we didn’t have enough doctors. And there were all kinds of government programs to encourage the education of more doctors. Medical schools were paid to increase the size of their classes and to shorten the length of their training programs so they could train more physicians. And we were importing large numbers of physicians from other countries, who would come here to complete their training, and, more often than not, to stay here to practice medicine.

In the last decade, we’ve seen a turnaround in the concept of view of where we’re going. One notion has been that we’ve trained too many doctors, and that we’re going to have a glut of physicians, an excess number, more than we need, and that the excess is one of the causes for the increase in the costs of healthcare in this country.

Another notion has been that we’ve been training the wrong kind of physicians; that we have too many specialists, and not enough generalists, and that somehow or other we’ve failed to train the pattern or mix of physicians that we need for an optimal healthcare system.

Thirdly, since we’re training too many, according to that notion, maybe we should restrict and discourage physicians coming to this country from other countries rather than, as in the past, support and encourage that.

And the field’s been in turmoil with a fairly rapid shift in attitudes and with serious disagreements about how to accomplish the goals, as well as what the goals ought to be.

HEFFNER: Where do you come down on these issues?

MICHELS: Well, I think the first thing to formulate is what our goals are, what our principles are. And I would start with a few. One is clearly, our goal should be the optimal mix of physicians for high-quality medical care in this country. That should be the purpose of our medical education system.

HEFFNER: Are you adding high-quality medical care for everyone?

MICHELS: For everyone. For the people who’ve gotten it in the past, for those who’ve not gotten the high quality in the past, and for the disturbingly large number of people who haven’t gotten any medical care in the past.

I think the second goal has to be fairness. I think we live in a society that places, appropriately, very high value on fairness. And I think that that means that people in the system can’t be categorized into first-class doctors and second-class doctors; and I think that people who are invited into the system have to be guaranteed and assured appropriate treatment by it. If we’ve invited people to come to our country to practice medicine, we should do everything possible to make sure they have every opportunity to practice it appropriately.

A third principle — it really is part of the first: having high-quality care — is that people get healthcare from people they know, close to home. And most of our citizens are more comfortable with people from similar social and cultural and ethnic groups. I think high-quality care means that people who want to get care from someone who looks like themselves and talks like themselves and shares their personal values, has access to health providers who are in that community.

HEFFNER: But doesn’t that automatically lead to the notion that we should no longer be so hospitable, indeed encouraging the immigration of doctors from overseas?

MICHELS: I don’t think so, Dick, because we’ve been very hospitable in encouraging the immigration of citizens from overseas. And if we only train longstanding, third-generation native Americans to become physicians, they’re rapidly going to be startlingly different from the average citizens who come to this country. If we’re going to be having people come to join our country from elsewhere — and we do, and we encourage that — we’re going to want doctors who are friendly to them, and whom they feel comfortable with.

HEFFNER: Now, wait a minute, Dr. Michels. This is a period, certainly, of nativism. It is a period when what we read every day in the press is some other political statement that leads one to think that our traditional, sometimes not so much so, acceptance of immigration has come to an end.

MICHELS: Dick, I have personal political views on what our attitude should be toward immigration and toward nativism, but they’re irrelevant here. I’m not here speaking as a citizen with political views. I’m saying that to deliver quality healthcare to a patient, the caretakers, the doctor they talk to, has to speak their language, know their culture and understand their background. A very good doctor who doesn’t speak the patient’s language and doesn’t know the patient’s culture can’t take good care of that patient. That’s broadly true, but it’s specifically very true in psychiatry and in mental-health care. Can you imagine telling your deepest, most personal secrets or things about your life to somebody who doesn’t understand your language? You might be able to tell them where your arm hurts if you have a fracture, but not what the problem is you’re having with your spouse and your children if you have family difficulties.

HEFFNER: All right. Now, where does lead us in terms of public policy.

MICHELS: In terms of public policy, one is, American medical schools are undoubtedly among the best in the world. They are now turning out about 16,000 or 17,000 physicians a year. That’s probably roughly the number we need to maintain about the size pool of medical practitioners in our country in the near future. We’re also recruiting an additional 20-30-plus percent of physicians who graduated medical schools in other countries, who come to this country for their graduate training, and two-thirds of whom stay in this country to practice after that training. It seems to me that we should examine the policy of the size of our current medical schools. There may be some that are superfluous, inefficient, or too large. But, more importantly, the things that lead to that recruitment of physicians from other countries, and to that retention of those physicians in our culture.

One of the reasons we recruit and retain them is that some of our large, public institutions, such as the New York City hospitals, that serve the indigent and the uninsured are so unattractive as employers that American-trained physicians don’t want to work there, and they don’t pay enough to find enough physicians in this country to provide the services they must provide. So they recruit physicians from other countries, not primarily for their educational experience here, but as cheap manpower. That’s bad public policy. We need the resources to assure that there’s quality care in those institutions, and that their motive in recruiting people from other countries is to educate them and to make them quality physicians.

We also have to make sure that the things that retain them in this country aren’t depriving their countries of origin of the quality of medical care that’s needed back home. It’s in some ways an international tragedy that we bring physicians to this country, which may not need them, from countries which desperately need them, and then get them to stay here afterwards.

HEFFNER: Well, now I’ve got to ask you to restate so that I fully understand your position on the question of quantity. Enough, or not enough here in terms of physicians?

MICHELS: There are two issues in that. One is what kind of healthcare system we’re going to have, and secondly, do we have enough doctors in it. Right now our healthcare system has a majority of specialists. Many of our plans for the future see a reduction in the number of specialists relative to the number of generalists. It’s easy to plan how many generalists you need to provide healthcare, because generalists provide basic healthcare, and that can be calculated in terms of the number of lives that are being covered, and knowing epidemiology of the illnesses that generalists treat. The number of specialists you have in a culture, though, depends in part on what your goal is in terms of quality. Higher-quality healthcare means more specialists. We live in a relatively affluent society. People in our society aren’t satisfied with minimal-quality clothing, entertainment, transportation or housing. I’m not sure it’s ideal public policy to say they ought to be satisfied with minimal-quality healthcare. So the number of specialists we’re going to need is a little bit harder to predict, and depends on how much we’re satisfied with.

Furthermore, you know that there’s something like 40 million people in this country that have no health insurance whatsoever. They get neither low-quality healthcare nor high-quality healthcare. One of the big questions in our projections is: Do you base the projection on demand, or on need? What do I mean? The healthcare system, largely a managed-care system today, knows how many physicians they want per capita to provide the level of care they provide. But the level of care they provide in my discipline, for example, allows people with chronic, untreated, major psychiatric disorders who don’t seek help to continue to be untreated. If you’re happy, as we are today, with fewer than half the patients with depression ever getting treatment from a physician or a psychiatrist, then you have enough. If you want to take care of the sick people who need help, you can’t accept the demand characteristics of the current system which doesn’t take care of them. If you use the need figures, the figures of how many physicians would be required to take care of sick people in a quality way, we’re, for example, woefully short of some specialties, like child psychiatrists, a field where the majority of children who have serious psychiatric disorders that need help never get to see a child psychiatrist.

So my answer is: I want to live in a world where we provide more than the minimal care that our generalist doctors provide, but add to it and enrich it with quality specialty care that takes care of people in real need. We need a few more than we have now to do that. Not a lot more, but a few more. I think we also want the best possible doctors, and that probably is going to mean a heavy reliance on the doctors we train in our own medical schools, which are among the best in the world. But, finally, we want a cultural mix that’s sensitive to the patients. We’ve not done a good job of recruiting minority medical students in this country, because of the huge cost of medical education and the paucity of public resources going to support it. I think we have to do a better job at recruiting minority students in our own country, and we may have to selectively recruit doctors from other countries to make sure that populations in our country from those cultures are cared for by people they know and are comfortable with.

HEFFNER: You raise a great many questions there. Who’s going to answer them?

MICHELS: Well, we don’t have a controlled or regulated system. Every medical school in the United States determines its class size. It has to be reviewed to make sure that its educational criteria are adequate and that it meets curricular standards, but no one polices how large or how small it is in terms of community needs. Furthermore, the healthcare system as a whole has been designed on a regional basis, so communities train doctors not in terms of the nation’s need for doctors but rather in terms of that community’s need for trainees in its hospitals as residents and in its clinics for the same purpose.

There have been attempts to discuss rational national strategies, but there’s no enforcement mechanism in place. The closest we come to that is federal reimbursement, which pays the salaries of a lot of those doctors. And you’ve recently seen, for example, first in New York and then nationally, that the government is making deals with medical educators in the United States to reduce the number of trainees in return for being paid a surplus during the reduction period. Sort of like paying tobacco farmers not to grow tobacco, we’re now paying some of our great teaching hospitals not to train residents.

That makes sense in one way: It will reduce the number of practitioners. It’s a little troublesome that the reduction is coming from the best-quality training programs that have always been able to fill, rather than the lower-quality training programs which had empty slots that they were willing to give up.

So we have to work with the system. I think what we want is a system that stopped rewarding institutions for training doctors for other than educational reasons.

HEFFNER: What do you mean?

MICHELS: What I mean is: a resident who comes to this country or who goes into a residency from this country to learn medicine, or ophthalmology or psychiatry, should be given a position because it’s a quality educational opportunity to train a good doctor, not because the hospital running the program needs someone to take call at night in the emergency room. That’s what I mean in simple terms. That means we have to give that hospital resources to hire doctor employees to work in the emergency room, not force them to rely on cheaper residents to do that kind of work.

HEFFNER: But isn’t the latter pattern something that we’re learning more and more about, about turning over responsibility to people who traditionally are less intensely trained, so that nurses, for instance, can substitute for physicians. Isn’t this a pattern in our country at this time?

MICHELS: It’s a pattern. And I think that it can be done rationally and well. So there are things, it is probably irrational healthcare to have a board-certified pediatrician giving polio vaccine to healthy, young children. You don’t need that training to deliver that treatment.

However, we want to make sure that we’re doing it rationally, and using our resources optimally. It seems to me there is a role for other health professionals to participate in the delivery system, making sure that people are doing what they’re trained to do, and what they’re cost-effective at doing.

However, in the kind of system we have now, it tends to be a marketplace competition for the most remunerative acts, rather than a rational distribution of what people are able to do. So, take here in New York City, for example. You’ve recently seen a group of nurses go into the direct clinical care of medical practice, competing with internists and pediatricians and family practitioners in Midtown Manhattan. Midtown Manhattan is not an underserved area in terms of healthcare. And physicians have much more extensive and complete training for delivering healthcare than nurses do. And our system has great need for physician extenders to enhance the physician’s efficiency in delivering healthcare to underserved populations. So there are several problems that can be solved, but that’s not the one that the independent practice of primary-care health service by a nurse group is going to solve.

HEFFNER: Well, how do you account for it then?

MICHELS: We have a competitive system in which we have rivalry for the market-attractive niches, rather than a rational distribution of scarce resources to deliver the highest quality care to the population. And furthermore, we have managed-care systems that are more interested in reducing their costs than in optimizing their care. So the managed-care companies that are going to reimburse those nurses don’t have data that show the quality of care those nurses are giving equals the quality of care that physicians give.

HEFFNER: What are you suggesting then? You keep using the phrase, “rational basis.”

MICHELS: Right.

HEFFNER: What are you suggesting? Who provides the reasoning?

MICHELS: I’m saying we have to keep in mind in the public dialogue that we can’t make decisions based on lowering cost without any idea of the quality of what we’re buying for that cost.

HEFFNER: Oh, I understand that, Bob, but what I’m really addressing is the question: Who will make the rational decisions?

MICHELS: Well, I think we need better data about what we’re getting for our money. I think we need requirements for reporting on outcome measures that will give us clear, real notions about the quality of care that’s being purchased. And I think we need to inform consumers about what it is they’re going to buy.

When I want to buy a car, I look up in a magazine and find out how many repairs that brand has had in the last few years, how many miles you get for a gallon, and how good the air conditioning is, and the kinds of things people look at when they pick one car rather than another. I also care about the color and the physical comfort of it and the attractiveness of the design, but I’m mostly interested in the efficiency, the safety, and the quality of the infrastructure of the automobile.

HEFFNER: Yes, but I can look up Consumers’ [sic] Reports, and so can you, not so easily when it comes to a general physician, a specialists, a psychiatrist.

MICHELS: Forget “not so easily”; I don’t think it exists at all. I don’t think it’s possible.

HEFFNER: Well…

MICHELS: But we know how to begin to develop those measures. I think we have to build those measures into the system. But between now and then, if there were no Consumers’ [sic] Reports, I wouldn’t ask my banker what car to buy; I’d ask my auto mechanic. I think he would know more about it. I think it’s reasonable to say that until we have objective data — that’s going to be the highest standard — but until we have that data, the people who know most about healthcare and how it’s delivered, the people that most citizens would turn to were the ones that have been delivering it themselves. I think they are the ones to place in central decision making roles.

We have to worry about cost. It’s vital. But it’s not the most vital measure of our healthcare system. I don’t want to live in a country that’s designed a healthcare system that’s the cheapest one in the world.

HEFFNER: But you still, understandably, have not provided me, and therefore have not provided the person who is sitting behind the camera or watching at home, an answer of what the resource is there for John Q. Public, for the citizen, for asking those questions now and getting answers. You say you would ask your mechanic about a car. Who is it you ask?

MICHELS: Well, I would certainly hope that if I were a citizen looking for healthcare I’d want a doctor I knew and trusted. I’d want a doctor who had good credentials, who was, if a specialist, board certified, if not a specialist was a member of the local medical society and on a hospital staff that was able to review his credentials. I would want to be seeing other doctors in referral, specialists, that he or she knew and selected and endorsed. So if I were seeing my general physician and I wanted to see a surgeon or a psychiatrist or an ophthalmologist, I’d want someone referred to by my general physician because he knew him and thought he or she was the right person for me rather than he was on a list of providers covered by the same managed-care contract.

I would rather pick a managed-care company, if I had to use one, that would allow me to see any doctor in my community that was best for me rather than only a doctor on their list. I would never go — never go — to see a doctor who had made any agreement not to tell me everything on his mind. If my doctor has promised the company to keep his thoughts secret from me — and companies have asked doctors to do that — I think he should be kicked out of the medical profession.

HEFFNER: I’ve asked doctors on this program this question. I probably, over the 25 years that you and I have been talking at this table, asked you. What country should I pick when I get sick? Where should I get sick? In the United States? In England? In Germany? In Sweden?

MICHELS: Unfortunately, the answer depends on who you are and what sickness you have. If you are indigent, unemployed, and don’t have Medicaid, don’t get sick in the United States. You’re better off in any one of those other — that’s tragic to say that — but you’re better off in any one of those other countries than being here. If you are not indigent, unemployed, or without insurance, and you have a difficult or complicated disease that requires the finest of modern medicine, you’re better off in the United States than anywhere else in the world. If you have a chronic illness that requires long-term care, but not cutting-edge science, you may also be better off in some communities that are less concerned with conserving financial resources and more concerned with the quality of personal relationships in healthcare. That we’re not first in all three is a national tragedy.

HEFFNER: How did we get this way (in the few minutes we have remaining)?

MICHELS: Well, we’ve always been a very heterogeneous country that refused to have single systems, and insisted on pluralistic systems. And our free enterprise and entrepreneurial and frontier mentality has always paid more attention to the best that we make available rather than to the worst that some of our citizens have to settle for. That’s the answer to why I think we’re almost unique in the world of industrial nations in not taking care of all of our patients. And I think our lack of a strong sense of stable, homogeneous community has left us take some people with chronic disabilities and chronic medical illnesses and leave them by the wayside without the quality of commitment to them that some stable, long-term cultures have.

At the cutting edge of modern, high-technology acute medical care, there is no where better in the world.

HEFFNER: In talking about the end of this century, almost upon us, do you think that we’re going to be dividing up the resources, medically speaking, in such a way that we’ll be limiting what’s available to me if I need dialysis or I need this or that because of my age?

MICHELS: We’re already doing that. We’re doing it subtly and not explicitly. You’re talking about rationing, a word you avoided. But we ration healthcare in this country. We don’t do it so it’s publicly visible. We do it by managed-care insurance programs that define the criteria of medical necessity. We do it by programs that won’t reimburse for experimental treatments which are therapeutically effective but don’t meet certain criteria of the company. We do it by access to insurance. We do it in a variety of ways.

The problem is, we’ve done it in order to maximize the bottom line for the healthcare industry, rather than to maximize the quality of life in our culture and the value of medicine in enhancing the quality of that life.

HEFFNER: Dr. Robert Michels, thank you again for joining me on The Open Mind. It’s always a pleasure to have you here.

MICHELS: Thank you.

HEFFNER: And thanks too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send $4 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150.

Meanwhile, as another 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.