Medicine and Money, Part II

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

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

And my guest again today is one of the most eminent persons in American medicine … Dr. Herbert Pardes, the particularly accomplished President and CEO of New York-Presbyterian Hospital, itself acclaimed as the extraordinarily successful merger of two giant medical institutions.

Well, last time – just because of the harsh realities of our times – my guest and I, under my leadership, were going to speak more about the nexus of money and medicine than about the more significant and ultimately more compelling miracles of modern medicine and the promise of so many more to come.

Yet I know from so much that psychiatrist Herbert Pardes has done and written over the years, from his papers on “Psychiatry and World Peace”, on “Neuroscience and Psychiatry”, on “Defending Humanistic Values”, which was his Presidential Address as head of the American Psychiatric Association, that for him dollars are only a means to more important medical ends. And I want to go on today, Dr. Pardes with some questions and conversation relating to those wonderful pieces that you wrote.

But I want to go back to money, if I can for a moment and ask about managed care and what your “fix” is about those two words?

PARDES: Well I think the country had to do something to make sure that we didn’t bankrupt ourselves by virtue of health care costs. So the managed care companies have served a purpose in that regard. The United States and people in the United States are rather free spirits to some extent and they don’t like to be roped in too much.

So the idea that the primary care doctor would control the entry point to specialists did not play well. Americans like their choices. So today I’d say that the managed care companies are playing their own role in terms of trying to control costs, push for quality and the like.

I would like to see even more in the way of collaboration between providers and managed care payers in terms their own interactions. But I think the situation has improved quite a bit and I don’t think you hear the same kind of screams we heard a few years ago regarding the managed care companies.

I think the direction for health policy is going to have to focus on how Federal leadership will describe the path or the vision for the next number of years. And that’s not because I argue for a government system. It’s rather that I believe that one needs convening power from the top of our government in order to address some of the critical things necessary to improve the health care system and make sure whatever dollars were spent are spent productively.

HEFFNER: Well, you talk about “we’re individualistic” in this country. What about the doctors? What about the doctor who feels that this is the path of care that must be taken for, for me, or for some other patient, but finds that the, the paying people, those who are going to pay for the care, say “No, not this path, but that path.”

PARDES: I think that medicine is still … does … still has a good bit of “art”, if you will, in it. And that we should listen carefully to the patient’s own physician. On the other hand, I think physicians should be aware as possible of current information and be sensitive to the fact that we have a big problem in terms of the overall cost of health care.

I am very proud of my identity as a physician. I think the physicians in this country are an extraordinary group. There are always bad eggs in every barrel, if you will. Or basket. But by and large most of the doctors in this country are motivated by doing something worthwhile for other people.

You need enough latitude to respect their assessment of what are the individual characteristics of the patient’s problem. But hospitals, for example, encourage … I’ll give you an example … our hospital, and many others, encourage doctors to try to look more carefully about how many different kinds of sutures, how many different kinds of instruments do we need?

If we are a little bit more careful in that decision, that takes out costs. I’m not sure that it is so much the doctors who are generating the financial problems, however. I think other issues are pertinent.

Let me kind of bring up one that is a concern for myself as a doctor, as a hospital leader, etc. And that is the simple problem of malpractice and tort reform. The amount of dollars being spent on defense of medicine I think are extraordinary. We have a system today in which people who have a legitimate claim, and should get some kind of compensation wait years and years and years for settlement. Some of the cases received settlements when there was no actual malpractice performed.

We need tort reform in this country. We need a system which settles people’s claims more rapidly so that that can be taken care. But doctors as a result are saddled with malpractice premiums of a level that is threatening their ability to function. One of the most glaring examples of that is the fact that there are less applicants today for training in obstetrics and gynecology than there are open positions.

Now medicine has always had the benefit of having far more people applying than positions available. Which means you got to choose and therefore the quality was very high. I think there’s a danger when you take an area, such as OB/GYN, obstetrics and gynecology, and find that you, you literally have open spots and you’ve got to take whatever numbers of people. They’re excellent people there, but we’d like even larger numbers. And that threat is going to extend itself to other areas as well.

What’s the problem? The problem is the cost of malpractice insurance is at a level threatening the ability of many doctors to be able to continue their practice.

HEFFNER: And tort reform of what kind?

PARDES: What should happen would be … The Common Good which is an organization that’s led by Phil Howard has put forth some interesting ideas. And one of the suggestions is that we do some trial runs on these to see if they work. There’s a Bill to that effect in the Congress that I’d like to see go through.

What he focuses on is having “expert courts”. People who would know more about medical issues, that decisions would not be made sheerly on the basis of one attorney or another attorney being able to be particularly charismatic in the courtroom. But that it be based on facts. That people be paid at a reasonable level for compensation and that the, the overall result of that would probably be patients who have legitimate complaints being responded to; many of the complaints which don’t have legitimacy going by the wayside and a more evidence, or data, based conclusion regarding a claim … what it should be paid, etc.

That kind of approach would do a tremendous amount for a variety of reasons. One, it would reduce the cost of the malpractice and, as I say, handle claims more expeditiously. But also, it would make doctors fee a little less inclined to have to order extra tests to make sure they’ve covered every single base.

HEFFNER: You think that’s a common practice?

PARDES: That defensive medicine … yes, I think there’s a lot of defensive medicine done and I think along with the other things that we’ve talked about, if you wanted to put a program together and said, “We’re going to have a unified process for claims and collections of dollars for healthcare. We’re going to have an information technology system which will help benefit us in reducing unnecessary tests. We’re going to have a tort reform, which would reduce malpractice costs and defensive medicine.”

You can build a case for a number of things which would not reduce the amount of health care that was provided, but on the other hand, would take some costs out. If you then added to that a greater focus on reimbursement of preventive techniques, rather than just treatment techniques, so that we take care of the diabetic patient and get them on a good course and keep them in charge of their blood sugar and keep it controlled, then you’d be paying for prevention which would be far less expensive than paying for amputations, kidney disease, blindness, heart disease and all the other terrible complications of diabetes.

HEFFNER: What likelihood, in your estimation, is there that these kinds of changes are going to be put into effect?

PARDES: I wish I could be more optimistic. I am concerned that what’s needed to bring this about is cooperation among political leadership. And if it were up to me I would suggest what’s needed is a single appointed leader, probably in the Administration in health care, dealing with health care policy, with clear notion that the Congress would try to be supportive and that that office, that leader, whoever be charged with coming up with a healthcare program that would accomplish some of the things I’ve mentioned.

Incidentally, I, I am hardly the author of these. We have some distinguished leaders, already, who are out there trying to see … to, to improve things in health care. I think the Secretary Levitt is trying to do that with the IT system. I think Mrs. Clinton tried earlier and I think the one thing to be careful about is, it’s easy to be critical that it didn’t go well, but it’s also admirable that somebody wants to try.

This is not an easy proposition. It is a big, complicated problem. But I think it’s something that is, that it’s going to have to be dealt with because we are really reaching an enormous crisis in this country regarding the system of care. Not, not what doctors can do. Not what nurses can do. But the system of care and the financing of it.

HEFFNER: Do you, and then I want to move away from it … are you a single payer person?

PARDES: No. I think there should be total coverage. I think everybody should have some kind of coverage …

HEFFNER: How do we achieve it?

PARDES: Pardon me?

HEFFNER: How do we achieve this?

PARDES: You can do that by increments. One of the people whom I admire very much, is Karen Davis, the head of the Commonwealth Foundation who’s written extensively on this. She was at one point the primary policy expert in the United States government for health care. And what she does is she takes various populations and says, “Can, can we, for example, allow Medicare coverage for people a little earlier in their life? Can we spread Medicaid? Can we find ways of working with small businesses to encourage them to cover more people?”

So it doesn’t have to be one, and shouldn’t be one approach, but rather a approach which involves multiple aspects. I, I think its … something like this is going to have to be done.

Let me just comment for a moment on the tragedy of the 46 million people who are uncovered in this country.

HEFFNER: And increasing.

PARDES: Right. And what happens is … first of all, I think it’s a matter of extraordinary indignity, if you will, for a person to have to walk into a hospital or health care system without coverage. Why shouldn’t everybody be able to walk in, feeling the same, that they’re entitled to good health care and that they will get it.

The fact that they don’t have that healthcare means they often do not have a primary care provider; they wait too long for their healthcare; they come to the emergency room when they really don’t belong in the Emergency Room, they belong in a doctor or a nurse practitioner’s office. And when they get there, they come late so that often the treatment is treating a more serious illness in a more costly way. The whole thing is really ravaged with problems.

Far better, it would be for us, to have coverage, as I say, which is comprehensive. That doesn’t mean you can get their overnight, but you can, can start a plan which would get you there over a period of time and then people would more likely have regular health care checks, prevention would be more of a focus and we would be seeing less of the horrible end stage complications for a lot of illnesses.

HEFFNER: End stage. What’s your own estimate, as a scientist, as a doctor, as a psychiatrist of what the end stage … at what point the end stage could come … for you and for me … for … and our children, grandchildren, etc. … mankind.

PARDES: I think that we’re going to see life expectancy continue to increase and that … let me just give you an example in terms of my own experience. When I was an Intern, which is about 30, 40 years ago, the average age of individuals coming into the hospital, were people in their forties and fifties. We saw a number of people in their sixties. We would see occasional people in their seventies, very few people in their eighties and it was unheard of to see somebody who was ninety or over a hundred years of age.

Today we are seeing increasing numbers of people seventy, eighty, ninety and one hundred. At New York Presbyterian, Karl Krieger and Wayne Isom showed a report of 72 heart surgeries they did on people aged 91 to 97, the overwhelming bulk of whom did extremely well. Heart surgery on people in their nineties. I think that’s spectacular.

I think we could move toward a dream, which is not, not unrealistic of people living ninety, perhaps even a hundred years in which the amount of time over their lifetime that would be devoted to illness care would be reduced dramatically; they would have a reasonably decent quality of life for most of that.

And our hope would be that people lived, that we were able to treat most illnesses and that when the end finally comes, it kind of comes quickly, it is done … it is a little painful as possible. I think that’s something not, not necessarily there today, but something we’ve been moving toward and I think it’s achievable.

HEFFNER: And how do you relate to that prophecy as a professional? As a psychiatrist.

PARDES: I think that’s marvelous. People love life. People want to live. For us to be able to say to anybody, “You have many years in front of you, we will be there for you if there’s any kind of illness or problem that develops. We want you to spend as much time in whatever your productive working or non-working career is. We want you to spend your time with your family. Not in a hospital with us. We want to send you back home.” I think that’s a spectacular dream. And when people talk about how important it is … well, what … let’s face it … how important does the average human being think that is against the other important areas of their life? My feeling is people want food, people want clothing, they want work, they want a reasonable income and they want healthcare. And I think healthcare is going to become so important that it has to be seen as one basic right to which all people should be entitled.

HEFFNER: What is, in your profession the most exciting thing going on? In your estimation.

PARDES: I think one of the most exciting things going on is that we are introducing increasing numbers of treatments which are reducing the burden, the pain and the extent of healthcare for a given problem.

When Eisenhower had is heart attack, he was out of commission for seven weeks. When Vice President Cheney had his heart episode, he was back to work within a couple of days. There are multiple examples. There are people who are back to some kind of reasonable existence because of knee repairs, hip repairs. We can control an enormous amount of infectious diseases. We have new problems in that area which is another topic. But a lot of infections that used to kill, we have some control over. We have … I think we’ve radically transformed the whole attitude toward heart disease.

I think we see much greater improvement in cancer. Years ago, twenty, thirty years ago, about five percent of children survived children’s cancer. Today over sixty percent do. Children with congenital heart disease survive whereas they, they were dying before. I see treatments that are becoming increasingly specific and with the promise of the genome and our understanding of a person’s genetic composition, we will be able to give them better and better advice as to what things they particularly should be cautious about.

So, for example, one individual may have genes and those genes pre-dispose to the person having lung cancers, so that the person has to be particularly careful in that area. Somebody else may have a pre-disposition to heart disease. The knowledge of a person’s genetic make-up will help us advise them better. It will also help us tailor the right medicine, which again is contingent to some degree on their genetic composition.

HEFFNER: Dr. Pardes you use the word “advice”. And “advise”. Won’t an increase in knowledge in this area lead to compulsion rather than just “advice”?

PARDES: You mean compulsion on the part … oh I think that’s something that we have to be concerned about. I think we have to be very careful about people’s privacy and confidentiality. We live in a … and I, I celebrate … a culture of a free and independent society in which people should make their own choices about things. However, providing the individual with the information. If I say to you, “Richard, I want you to be particularly careful about your diet because you have a greater disposition than somebody else.” We all know people who seem to be eating excessively and they don’t become sickly from heart disease. There’s something different about the genes. There’s a combination, I think, for many illnesses which involve genetic, or constitutional factors, and environmental factors and I think we’re going to learn more and more about them as we understand the role of genetics more and more.

HEFFNER: But won’t we, of necessity, because we are under financial pressure, won’t we of necessity, out of necessity, make more compulsory the … turn into compulsions the knowledge we will develop about my genetic make up?
PARDES: Well, I think that … I’m not terribly intrigued by the idea of compulsion. I like the idea of giving people information. Also, the country as a whole has an obligation to people to appoint, but people also have to take some responsibility themselves. So I’m not sure if I know exactly which aspect of compulsion you’re talking about?

HEFFNER: Well, I’m thinking of insurance, for instance. I’m thinking of being able to be insured if, within the framework of what is known about our genetic make up, we do this rather than refrain from it. We do that, rather than refrain from it. Smoking, for instance.

PARDES: Well, what you’re saying is … might a company penalize somebody who continues to do something adverse like smoking? That’s … that’s worth thinking about. I’m not sure that’s so much compulsion, as saying, “Look if you want to put yourself at greater risk, and therefore be a greater cost to the general community, then it’s going to cost you a little more yourself. Maybe I’ll increase your premium if you continue to do something which is so adverse to your own health.” That doesn’t mean I’m compelling you.

HEFFNER: Would you favor that?

PARDES: I think that’s worth thinking about.

HEFFNER: What do you mean it’s not compelling? What else is it?

PARDES: Oh, listen, you, you make choices. If I decide that it’s more important for me to smoke than to safeguard my health and therefore I’m cavalier about the cost that it is to the general community, maybe I should pay something for that.

HEFFNER: Do you think that the degree to which we now know that the hip bone is connected to the thigh bone is going to make us live in a less free society … I mean we do know what causes things. We’re talking now about smoking and cancer. Referred smoke. But there’s so many things we’re learning now it would seem.

PARDES: Well you want to be very careful because there are very few absolute facts. So a lot of things make you … might make you more prone to certain illness. But there maybe some people for whom that will, will not be a problem. You want my basic … basic philosophy?

HEFFNER: Yup.

PARDES: I am very slow to compulsion. I am very fast to education and to try to work with people behaviorally in order to induce them to understand and do what, what I think might be in their best interests. So I do know if that … where that characterizes me, but that’s where I am.

HEFFNER: Okay, we have just a couple of minutes left. What the biggest, most important research area in psychiatry now?

PARDES: In psychiatry I think that the ability to understand the basic causes of these psychiatric illnesses is most critical. It’s been a very formidable problem because psychiatric illnesses are multi-determined. I think many of these illnesses are not single illnesses. I think we’re going to find there are multiple schizophrenias. I think we’re going to find there are multiple manic depressive disorders. And teasing out which ones are caused by what is important.

Let me give you a prototype. Mental retardation at one point was just thought about as mental retardation, with maybe a few causes. Today, after much work, it’s known that mental retardation can be brought about by something in the neighborhood of 200 to 250 different circumstances. I think that’s what’s going to happen with a lot of medical care, or medical illnesses. And the important thing for psychiatry is both to understand that and then to try to develop treatments specific to that specific sub-type. I think one of the reasons that the results in terms of outcomes from psychiatric diseases are not as good as we’d like them to be is because we haven’t been able to get ourselves to that differentiation yet. And for psychiatry what’s going to be very important is to find specific tests that correlate directly with specific illnesses. We don’t have much of that yet.

HEFFNER: And the “talking cure”?

PARDES: Oh, I think the talking cure is very important. Not only in psychiatry, but also in non-psychiatric areas. Let me just say … I’m very excited about technology in medicine and health care generally.

HEFFNER: Imaging?

PARDES: Yes. I think … I think what’s happening in imaging is spectacular. But it may …it must never negate the appropriate attention to the humanistic interaction between a provider and a patient or the family. Because that also has a tremendous impact on how well that person will do.

HEFFNER: That’s your personal act of faith. What’s happening in the profession, in the practice of psychiatry?

PARDES: I would say from the profession there was a swing a few years back to a heavy focus on biology, which is appropriate and if I were to characterize the situation today, I think people are trying to find more about the interaction between the biological and the behavioral. And that has it’s counterpart in terms of the clinical, clinical treatment so that very often … an optimal clinical treatment consists of both medicines and talking.

HEFFNER: You’re pretty optimistic, aren’t you?

PARDES: I think that’s a, a good way to live. And certainly I would recommend it as a kind of a characteristic for leaders.

HEFFNER: Thank you, Dr. Pardes, so much for joining me again today.

PARDES: My pleasure.

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.