Medicine and Money, Part I

GUEST: Dr. Herbert Pardes
VTR: 01/24/2006

I’m Richard Heffner, your host on The Open Mind.

And my guest today is one of America’s most eminent medical authorities. Formerly Assistant Surgeon General of the U.S. Public Health Service and Director of the National Institute of Mental Health, later Dean of the College of Physicians and Surgeons at Columbia, Dr. Herbert Pardes is now the accomplished President and CEO of New York-Presbyterian Hospital, itself acclaimed as the extraordinarily successful merger of two giant medical institutions.

The damnable thing about Dr. Pardes being here today, of course, instead of back in perhaps less medically advanced but also less financially pressured days, is that – like it or not — money, rather than medicine, seemingly must be our major topic.

But, so it goes, so it goes. And I’m going to begin today by asking my guest whether – put simply – in our country today money concerns are trumping medical concerns.

PARDES: I think that’s …

HEFFNER: That’s quite a question.

PARDES: I think that’s a wonderful question, Richard. I, I find it distressing that so much of the conversation is around the fiscal aspects. That’s not to say that I am sure you are unconcerned about the impact of the cost of healthcare.

But what dazzles me, having been in medicine for a long time is what we can do today that was not available to us before. I often describe the little black bag that the doctor’s ostensibly handled when they were going to see patients years ago as “little” because there wasn’t much to put in it.

You know there are so many examples of the progress we’ve made. The average individual born in 1900 lived about 47 years. The average individual born in 2000 lives closer to 80 years. That was not due to medicine alone. There were many things. Public health was important. Learning how to live differently.

But medicine played a role and when you add to that … take the nation’s biggest killer, which is heart disease. When I was an Intern if somebody came in with a coronary, a heart attack, all you could do is give them a little pain killer, put them to bed for three weeks, which was a mistake in retrospect and pray.

Today the tools we have available to us are extraordinary. Children born with congenital heart disease who in those days almost invariably died, now almost invariably live. People who have coronary illness can be helped by what’s called “angioplasty”, stents, newer level stents, people with arrhymias, something that we found was much more common than was ever thought of before; we have treatments, we have ways of handling them.

We can do a surgery on a heart valve without putting a cut in your skin. And some of the people who are being the beneficiaries of this treatment are leaving the hospital after a one-day stay. Repair of a valve in your heart … after a one day stay. Well, I can go on.

But the main point is that I lament the fact that we talk too much about the problems, the shortcomings and there are those and they should be addressed. But we fail to give sufficient attention to the extraordinary change in the potential or the possibilities for any of us … you, me, our children, our families, our friends, from health care today as opposed to 30 or 40 years ago.

HEFFNER: But you know, as long ago as … well, the 80s, Dr. Lewis Thomas who was a guest here was saying, and then, of course, things changed in the Clinton Administration …but was saying in the cutbacks that were happening then in medical research, thanks to cutbacks in dollars, that we were beginning to live off the fat of previous years. And I wonder whether that’s happening with a vengeance today. Whether what you are able to do today is a function of the support of research and development in the past.

PARDES: There’s no question but that research builds on itself. But if the point is that … are … were the great discoveries made years ago and are capitalizing on that while not benefiting from more recent discoveries, I would say that’s not the case. That discovery continues. We have a very large research establishment in the United States. People supported by the National Institute of Health who work in academic medical centers, a pharmaceutical industry and device industry which I think contribute all kinds of advances in medical care and so the changes continue.

And let me just return to something I said before as an illustration of that. When a person has a heart attack, it usually means one of their coronary arteries is blocked. At first we had no way of attending to that, then we had ways of going in and try to remove the blockage. And we put in these little internal tunnels or stents which opened it up. That was a major advance.

But, as I mentioned earlier, the tunnel would block. So the person would have to have another procedure. In the last few years we’ve introduced, by “we” I mean the collective medical and academic field, drug coated stents. What happens is these drug coated stents reduce the frequency of blockage. As a result heart procedures, heart surgery has been reduced in the country. That’s an advance that just took place within the last few years.

The other example I mentioned, the notion of non-surgical approaches to heart valve repair is new. It’s still being, in a sense in an evaluative state. But it looks pretty good. And what I enjoyed particularly was an interview with a woman who had her heart valve repaired in this non-surgical approach, you put the instruments through the blood vessels, you cut nothing. And she was being interviewed after the procedure and she said, “I didn’t even know you did anything and incidentally I want to get the hell out of here.”

HEFFNER: (Laughter)

PARDES: So we sent her home after a day. Those are recent. The genome project, having been completed a few years ago is recent. So yes there was great research done before. Great research continues to be done, and I can tell you that, again … you, I, our families, whoever can face a prospect of less time, pain, time away from work or play from illness in our lives going forward, and probably a much longer life.

HEFFNER: Then what am I worrying about? Why did I begin this program by …

PARDES: (Laughter)

HEFFNER: … by … with this grim business about the financial situation of the medical establishment?

PARDES: Well, we, we were talking about … you put very nicely the two issues … juxtaposed against each other.

HEFFNER: Money and medicine.

PARDES: Advances and finances. And you’re right. Money is an issue. I think that it is time that somebody is anointed with the power … I was just talking to Joe Califano(CHECK SPELLING) who I had breakfast with this morning … given the power from the Congress and the Administration to lay out a program of health care going forward in this country. To help us get some of the monies out which are not necessary, in order to preserve as much money for health care, for people as possible.

HEFFNER: Well, wait …

PARDES: So you can say, the, the … the new advances are happening, new clinical treatments, but the system needs attention.

HEFFNER: You’re saying there’s waste. Is that another word …

PARDES: Sure.

HEFFNER: … for what you’re talking about? Of considerable dimension.

PARDES: Absolutely. Let me offer an example. Were we to introduce one process, agreed to by all payers, by which providers would render their bill, this is what I did … this is what I’m owed … and the payor would pay and there would be understandable rules to govern that. You wouldn’t have to have doctors sitting with multiple secretaries in their offices dealing with the multiple forms, arguing with the payers and the payers wouldn’t have to have people arguing with the doctors.

Take that cost out and you’ve already taken a substantial amount of money out of the cost of health care.

HEFFNER: And who, pray tell is the single payor?

PARDES: Who is the single payor? No, I’m not saying we should go to a single payor. No, I’m saying there should be a uniform process by which the payment process is conducted.

HEFFNER: Doesn’t that lead us to a single payor?

PARDES: No. I, I think that this country is built upon people having a certain latitude and choice. And therefore, I think the idea of multiple choices from which people can choose a program is fine. But the mechanical, logistical process of simply rendering a bill and getting paid, and the quarrels and time, money and expense wasted by that kind of dispute, I think should be taken out of the system.

I offer it as an example, but I don’t think it’s the only example. Let me, let me continue. I endorse what President Bush said a year ago, which is that one of the best things we can do is introduce an interconnected information technology system in the United States.

There was a Commission, I sat on it, which rendered that same recommendation. Why is that important? If you had your health care information quickly and easily accessible to you … let me give you the vignette or the anecdote … which illustrates where that becomes beneficial. You walk into my office. And you say to me, “Dr. Pardes, I’ve been having some chest pain, I think maybe I have some heart problems.” I say to you, “Mr. Heffner, have you had this problem before? Yes, a couple of months ago. Did you see somebody? Yes, I saw somebody in Wisconsin for my heart problem.” I said, “Do you have the records of the EKG. No, they’re not immediately available. Fine, let’s do another EKG.”

What if you were able to say to me, “I saw that doctor, I can give you quick access to the EKG I had before, and you, Dr. Pardes, don’t have to do a second EKG on me.” The number of unnecessary tests done redundantly by virtue of the absence or the … or our not yet having put that system in place is enormous. And the IT, the so-called information system has enormous additional virtue.

It allows you to track, through large areas of the country, developing problems. Is there an illness outbreak, does that represent something contagious? Do we see something that might suggest some kind of emerging epidemic infection? What have you. Somebody walks in the Emergency Room … not walks in … is carried into the Emergency Room, you don’t know who they are … but you’ve got, you can access their health information. Anyway, the examples of its benefit are kind of pervasive.

And the Rand Corporation, the Secretary of Health and Human Services, many people have come to be convinced that implementing that kind of system as rapidly as possible would also be a cost saver of consequence for the country. And not only that, it would also improve greatly the quality of care delivered.

HEFFNER: And? What’s happened?

PARDES: What’s happened … it is moving, for my taste, it could move a little more rapidly. And I think one of the things that is important is that sometimes one has to invest in order to see real returns. So that the Secretary, to this credit, it pushing. I think Secretary Levitt is very much interested.

I think it would be healthy if some money were put on to help some of the providers, doctors, various hospitals who may not have the resources to, to put the investment, to get it going, to help them make it happen so that would happen more rapidly.

So I would say, “yes”, there’s movement. I think all of us feel it should be moved more aggressively. But if you partner this notion of a unified system for purchasing and paying and selling bills. And the, the widespread benefits of that information technology system and the use of things like tele-medicine, by which you can work with people at a distance and just monitor their health care at a much lower expense. You can find multiple ways by which expense will be taken out of the health care system and therefore deal with this very considerable problem of health care costs.

HEFFNER: Does that also relate to the activities that go on within an individual hospital?

PARDES: Yes. Well, hospitals … hospitals themselves and many of them are trying to do it. We are have now set up a very aggressive program to get an extensive information technology system within our hospital. But equally important to getting that within the hospital is interconnecting it to other hospitals. Interconnecting it, really, throughout. So a lot of places are doing it. And the Markle Foundation is playing a big role. There’s an organization called “E-Health” which is playing a big role in trying to foster that. I am concerned that one of the things that might hold us back is a reluctance to make investments of the order of magnitude that would make this happen.

Example: in the United Kingdom, the person in charge of implementing this information system was given 19 billion pounds. In Canada, 2 billion Canadian dollars. Right now there have been some monies put in, but they’re modest. Now, Mr. Frist, Senator Frist and Senator Clinton and several others have put a bill forth for information technology. Other leaders have also been aggressively pushing it, like Nancy Johnson.

But to this point they’ve been … I’ll tell you … the leadership to this point has not put the kind of dollars on the table which I think would make it happen.

There are other issues also. There are technical issues like anti-trust issues. You’ve got to let the hospitals help the doctors get their systems. For a doctor to spend thirty, forty thousand dollars to put up the hardware to get that system, is non-trivial, particularly as doctors are pressed harder and harder.

So, simple conclusion. If we make some investments, we will improve the system, reduce medical errors and probably take quite a bit of cost out.

HEFFNER: What indication is there that that investment, as you call it, is going to be made?

PARDES: Oh, I think there’s no question but that there’s a commitment from a lot of leaders as I mentioned. Gingrich … Mr. Gingrich interestingly enough has been advocating the system … it’s on … both, both sides of the aisle see this as valuable.

HEFFNER: But where is it? Where is the money?

PARDES: The problem is the money. I agree with you. Now, there are other things that have to be settled. The Secretary has launched a commission working on standards. Very important for the various vendors to know what the systems will be so that they will all be operating according to one set of principals. That’s been done. And I, I applaud him for that. The anti-trust, again, McCellan …

HEFFNER: I wanted to ask you, what is the anti-trust aspect of this?

PARDES: The anti-trust aspect is that a hospital provider, like a .. a hospital provider has some barriers to giving resources to a physician … and I think this is based on the fact that they … there’s a … concern that hospitals not be giving physicians resources in order to bring them business, in a sense.

That, however, interferes with hospitals who may be able to help providing the doctors with some wherewithal to get the necessary software or the instruments so they can get hooked into the information technology system. And that’s another issue that has to be dealt with. So I don’t want say this is … it’s only how many total dollars go in, but it’s a commitment to do the several things that will launch this.

The good news is we’re starting to see it happen. I think all of us would like to see it happen more rapidly. And the one point I would make is that more money would help it move faster.

HEFFNER: What about the training of doctors? Will the, the use of technology impact upon the way doctors are trained?

PARDES: Absolutely.

HEFFNER: What they know when they leave medical school.

PARDES: Absolutely. Because computers … I think this country … the world in general is adapting to the value of computers and loving the kind of information they can get. Doctors are the same.

We, we have … in New York Presbyterian … and many other hospitals have as well, introduced what we call a “computer order entry system”. A doctor can walk in the hospital, he sees the patient; he puts a bunch of orders on the computer and the next one to pick up those orders is the person who implements them.

Well before, the doctor was writing … it was a handwritten thing, it was often …

HEFFNER: Indescribable.

PARDES: Indescribable, or undecipherable. That would be picked up by some else who didn’t understand it and, you know, in a “telephone message” kind of thing. By the time the thing got down to the end, there were any number of instances of errors. That’s being cleaned up. The doctor studying right now, who’s looking at a given problem can tap into articles, papers, pick any area, so, so studying and training is made much easier.

I think you’re going to see the information technology sweep through the health care industry and it’s overdue. Many other industries have moved much more rapidly than the healthcare. I think it’s one of the unfortunate realities that we’re so far behind. But now I, I think they’re moving. I’d like to see them move aggressively.

HEFFNER: And you’re suggesting it will prevent, or it will cut back on errors …

PARDES: Yes.

HEFFNER: On fatal errors, too.

PARDES: Right. Oh, absolutely.

HEFFNER: Is that a major factor now, the matter of errors?

PARDES: Yes.

HEFFNER: Even fatal errors.

PARDES: Yes.

HEFFNER: In the practice of medicine.

PARDES: It is … it is … listen … one of the things about medicine is that it is not a strict science. We are dealing with billions and billions of encounters over the course of the year and tragically there are errors made.

There’s every attempt now to try to address it. The Institute of Medicine studies loudly proclaim the fact that these errors were there and should be attended to. So whether it was drug errors, whether it was horrendous errors like wrong side surgery or the like, those have to be corrected and information technology will contribute to it.

You … if you decide to go into nursing or medicine, you realize you’re dealing with life and death situations. And people made errors in every field imaginable. But when you’re doing it in health care, it’s … it can be deadly serious.

HEFFNER: You talk about “if you decide to go into nursing or medicine”, what concerns me is the number of friends I have who are in the medical field and who tell their children “go elsewhere”.

PARDES: You’re absolutely right. It is a worry. However, interestingly enough. And I, I was concerned about it, as I saw the declining number of applicants to medical school start about seven, eight years ago. The last year or two, there’s actually been a bit of an up-tick. I’m not comfortable about that. I think your worry is well … needs attention.

Because doctors are feeling the following. They are feeling overwhelmed by the bureaucratic and regulatory nature of it. They are feeling that the ability to extract a reasonable living, given the amount of work they have to do is formidable and there’s also a certain critique in the general community regarding health care that troubles them.

So I, I hear what you say and you’re absolutely right. A lot of doctors have cautioned their children to go towards other careers. I believe that attending to the system, making it a little less bureaucratic, bringing in the value of computers, and doing some other things would make the profession even more attractive and perhaps draw additional people.

But, for what it’s worth, that decline over the last five, six years has seen a leveling, if not a sort of an up-tick recently.

HEFFNER: And women in medicine?

PARDES: Women in medicine are almost there. You know, fifty percent if not threatening to go even higher. And I think that’s spectacular.

HEFFNER: Don’t say “threatening”.

PARDES: I think it’s wonderful that they are. I don’t see it threatening in the … I’m being “cute” …

HEFFNER: Promising.

PARDES: I think … I think the entry of women in large number into medicine is a spectacular development. I’d like to see them also rise more to leadership positions in medicine. But certainly if you look at a medical school now, it’s not unusual for forty-five to fifty percent of the people, even more sometimes … to be women. And in some particular areas, they dominate. OB/GYN, very heavily women. Lot of women in pediatrics. A lot of women in internal medicine, a lot of women in psychiatry and you’re starting to see larger numbers of women go into surgery, an area where there tended to be more men over women over a period of time.

HEFFNER: What about the quality of those entering the medical profession now?

PARDES: I think it’s pretty good. If you, if you want to make money, medicine should not be the thing on your mind. As a result, I think a lot of people have gotten that message and so increasing numbers of people are recently altruistic about it. And there’s nothing more pleasant than spending some time with some medical students today. They’re a delight. I … as the Dean of the medical school used to meet with the students and their idealism is wonderful. And these are people who really want to do something for other people.

You know at the heart of it one of the reasons so many of us chose medicine is there’s no better feeling than to be able to help somebody else who needs the help. I, I often have portrayed it in the following manner because it, it really came together for me.

When I was an intern I worked at Kings County Hospital, a big city hospital in New York. And the hospital extended for blocks and I used to be on call and I’d be sleeping in a little staff house a few blocks away from the Emergency Room.

The call would come at 3 or 4 o’clock in the morning. I’d be in my whites. I picked up my little black bag and I walked through the streets, the inner streets of the hospital complex. And everything was dark, there were smokestacks and big buildings.

And I had this feeling … everybody can just relax and sleep, I’m going to go take care of that patient. And the feeling you had of being the one who was going to bring relief to that patient …going there, often you’d be the only one up besides a nurse or a nurse’s aide on the ward. And you’d work to bring the patient out of the pain or distress they were feeling in those hours, was a spectacular feeling.

And that is replicated any number of times in doctor’s offices and operating rooms and hospitals, all through the country. And to my way of thinking is the primary reason why most people go into nursing and medical, medicine and health care in general.

HEFFNER: And administration of …

PARDES: And administration also. Those of us who … I, I tell people in the hospital … whether you’re cleaning the rooms, whether you’re providing the food, whether you’re the secretary at the desk, you are all contributing to that ultimate result …is to give that person the very best care. Get them out of the hospital. Get them back home. Get them back to their family and get that pain out of their system.

HEFFNER: You think it’s that attitude that has made for the success of the merger that you presided over … or helped develop?

PARDES: Well, first I want to give credit to the people who courageously undertook the merger. And that meant that the Trustees … John Mack, Frank Bennett, Dan Burke, John McGullicutty and the two then hospital presidents … Bill Speck and Dave Skinner took a leap of faith. And it worked. Now why did it work? I think …

HEFFNER: In 30 seconds.

PARDES: I think it worked because we did it with flexibility, realizing that different programs were different and that what would it take to make any good area excellent would depend upon the area and we responded to that.

HEFFNER: And I, I would guess that that all comes from the insights that you gained as a student … as an undergraduate at Rutgers University.

PARDES: Absolutely.

HEFFNER: Okay. I hope that we could do another program and maybe you’ll stay where you are …

PARDES: Happy to stay here.

HEFFNER: … this one is over, but thanks so much for joining me today, Dr. Pardes.

PARDES: 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 $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR 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.