A 20/20 Vision for Health Care, Part II

GUEST: Karen Davis
AIR DATE: 02/03/2001
VTR: 12/20/2000

I’m Richard Heffner, your host on The Open Mind. And today’s guest is Karen Davis, President of The Commonwealth Fund, a major national philanthropy heavily engaged in independent research on health and social issues. When I first spoke with her here about “A 20/20 Vision for American Health Care” by the year 2020, Dr. Davis counted off it’s five basic features as 1) automatic and affordable health insurance coverage for all; 2) access to health care for all; 3) patient responsive health care; 4) information-driven health care; and 5) commitment to quality improvement.

So let’s now go back to her impressive check list and let me ask where we left off last time, Dr. Davis, I know left so many, many things hanging that people must have questions about that I have questions about. I’d like to go on to this question of access to health care for all. Are you particularly concerned about what that access is now?

DAVIS: I think that is the most serious problem in American health care, that we, we don’t assure that everybody can take advantage of the modern medicine that is available to some and certainly the studies show that if you’re uninsured, you’re much less likely to get preventive care and to not get serious medical conditions ranging from diabetes to arthritis to hypertension well-controlled. So certainly dealing with the insurance problem is the number one problem. But, we are often complacent about the quality of care in American medicine. We think America has the best health care in the world. And we don’t actually have a good way of knowing if that’s true. And we know that there are major problems with American health care. We’ve learned that medical errors occur at an alarming rate. At a rate of error that we would never tolerate in the rest of American industry. And most of us think that that happens because there’s some bad doctors in the system cutting off the wrong leg, or operating …

HEFFNER: That is dramatic, you’ll agree.

DAVIS: … that’s dramatic. And it catches our attention and makes us think we’d better mark on our leg when we go in for surgery as a little help to, to the doctor. But that’s not the real problem, the real problem is that we have a health system that relies on human memory, that doesn’t have systems to prevent errors from happening. I think if our airline pilot were just trying to remember, “now what are all the things I was supposed to do this time?”, and to do it 100 percent of the time … we’d be, we’d be pretty worried about that. So, we’ve done surveys at The Commonwealth Fund of Physicians in different countries and the message we’re getting back is … they’re pretty overwhelmed. There are ten thousand new studies that come out every year, that tell doctors there’s a new way of treating a given condition, a new way of preventing a given condition, and even the best physician can’t keep up with all of that new information. Now we could make that available to a physician on a computer or even a hand-held computer …

HEFFNER: Don’t we?

DAVIS: And we don’t routinely do that. There are a few institutions in the U.S. that have pretty sophisticated marvelous systems. But it’s not standard practice in the American system to have a doctor have a computer aid that helps them with diagnosis, helps them with know which drug to prescribe, knows the dosage that’s appropriate for that patient, checks for interactions with other drugs that patient may be taking, sending a warning to the physician, “you may want to re-consider that dosage for a patient that age”, or “you might want to remember this patient is also on this other medication”. So we haven’t built in safeguards that work to prevent medical errors from happening.

HEFFNER: Are we doing it now? Are we beginning at least?

DAVIS: It’s very slow. Hospitals are strapped for money, they say, “New sophisticated information systems are expensive, where will we get the, the money? The managed care plans aren’t paying us well. Medicare and Medicaid are cutting back on what they’re paying us”. And I think we need to recognize that’s a legitimate concern and add to the bill for a given service, a payment to the doctor, or a payment to the hospital that, that says, “you’ve got a good system in place, we appreciate that, we think it’s better care and we’re going to reward the places that do, do this”. So I think that’s part of the solution to preventing errors. The other are clinical guidelines. You should never forget to, say, use a beta-blocker medication for a patient with a heart attack where it’s indicated. But we know that even in managed care plans that monitor this type of performance, only 85% of the patients get that medication after a heart attack even though the studies show that it’s indicated. We know that only half of hyper intensive patients are getting blood pressure medication. Only a fifth of depressed patients are getting anti-depressive medications. So we need clinical guidelines that physicians and their specialty societies develop; that physicians are comfortable with, but then we need to make … assure that we’re doing that and following the check list 100% of the time.

HEFFNER: Well, you know, Dr. Davis, I was shocked, to say the least in reading your Commonwealth Fund President’s Message on the quality of American care, “Can We Do Better?” you begin by saying, “Not long ago we asked our Harkness Fellows, health care experts visiting the United States from the United Kingdom, Australia, and New Zealand, how the American health care system compares with their own”. And this is what shocked me. “Uniformly, they replied that although our specialty care has much to commend it, they would strongly prefer to be cared for at home if they became ill. In their view, health care in the United States is hard to navigate, poorly coordinated, expensive and lacking in attention to basic primary care services”. That’s quite an indictment.

DAVIS: It was pretty surprising to me. I must say I’ve shared that complacency of saying, “American health care is the best in the world”. At least in the those people who are insured and able to get access to it. But in fact the World Health Organization this year, for the first time, tried to rate countries, 191 countries around the world on how good their health care systems are. The U.S. was number 1 in one category, and that was called “Responsiveness To Care” which is largely measured by waiting lists … how long do you have to wait to get a surgery? How long do you have to wait to get a test? And Americans don’t wait. And we’ve confirmed that in Commonwealth Fund surveys of patients in countries like Canada, the UK, Australia, New Zealand.

HEFFNER: How significant is that? What does it do to the morbidity rate?

DAVIS: Well, I think it is important. If you’ve got cancer, there’s a lump that needs to be checked out very quickly, it makes a difference how long you have to wait to, to get that procedure. And the U.S. does well according to the World Health Organization Report on things like breast cancer survival, we have one of the highest survival rates for prostate cancer. We do pretty well on heart attack patients, cardiac disease mortality … better than, than a lot of other countries. Where we don’t do very well is on the simple stuff. We have an abysmal rate on infant mortality. So there are lost years of life that come from not doing something as simple as basic prenatal care for all women early on in pregnancy.

HEFFNER: And you seem to feel that that’s connected with the matter of information more than anything else.

DAVIS: Well, I think information is important. I’ve talked about information for physicians so they don’t make mistakes; but I would stress equally information for patients. They need to know how to be partners in their own care. They need information on appropriate preventive services; they should be talking with their doctors. For example, mid-life women about what their options are post menopause to reduce their risk of osteoporosis in old, their risk of cardiac disease. So women need information to take care of their own health, and often to take care of the health of their other family members, not just themselves. But everyone needs this kind of information. But the other kind of information that patients want is information on the quality of care. You really can’t find out who’s the best doctor. You might get opinions from your family members or friends. You might ask your doctor what he thinks is the best surgeon, or where’s the best place to go for a complicated medical problem. But there’s no systematic information. One of the simple things we know is that when a hospital, when a surgeon does a minimum volume of procedures, you’re chance of surviving to a healthy old age are much better. Suppose you went on the Internet and you wanted to look up how many times that doctor had done a coronary by-pass operation. Or how many times it had been done in that hospital. There are a couple of states where you could find that out. But it’s certainly far from common.

HEFFNER: Just a couple of states?

DAVIS: Ah, New York and Pennsylvania have good information …

HEFFNER: Right.

DAVIS: … on things, for example, like cardiac surgery survival rates, which all of us are interested in. There’s a group in California, call the Pacific Business Group on Health that has information on volume of procedures and surgeries in a number of hospitals in California and some other West Coast states, but it’s, it’s not universal. So we don’t even know basic things like, how many operations a doctor has done and where’s the place that has the team both with the most experience and the best record on survival, or fewest complications. But you want to know a lot more than that when you’ve got a specific kind of medical problem, not just whether they do lots of those kinds of cases. But does your physician do better than other physicians in controlling diabetes, and there are wide variations from person to person on those kinds of things. And right now you can’t, you can’t find that out. We’re beginning to be able to find it out on a managed care plan basis, which managed care plans do patients rate the highest? And that’s very important to have patient responsive care … do doctors listen to you? Do they answer your questions? Do they spend enough time with you? How well do they treat you? Do they help your family understand your medical problems? And again a few places, particularly managed care plans are starting to have patients fill out questionnaires on “how was your doctor visit?”, beginning to learn from other industries about customer satisfaction and getting feedback form patients, which physicians value. We found in our surveys that physicians want to know what their patients think they’re doing well and what they’re not doing so well. But that’s not standard across the U.S. So, if you want to pick a doctor you can’t find out what do his other patients think about him, you can’t find the information about clinical outcomes, like control of diabetes, or survival from heart surgery. Those are things that could be done. Very simple to do … that we’re not doing.

HEFFNER: Dr. Davis what will the vehicle be for getting these, what you call “very simple things” done.

DAVIS: Well, I think there’s a role for everyone in the health care system. I think patients have to demand this.

HEFFNER: Well, you said the patient has to think in terms of partnership …

DAVIS: Right. And I think we need to financially reward physicians that take the time to do these things … so that’s part of it. Reward hospitals that really do diabetes education. Right now if a hospital does a good job of sending a nurse to work with you and how you manage your diabetes, and it works to keep you out of the hospital, the hospital will lose money and they won’t be paid for this nurse who’s educating you about self-management. Or if they’ve got an information system with a print-out for the patient who comes in for a visit about what you could do for self-care … so we’ve got the incentives all wrong. So that’s part of what we need to change.

HEFFNER: Yes, but my question really is “what’s the vehicle?”, where do people begin? Who begins it? Is it the Commonwealth Fund that will?

DAVIS: Well …

HEFFNER: Is it a United States Department?

DAVIS: I don’t think a single organization can do it. I think it really needs to get … particularly in the health care sector themselves, that we’re not doing as good a job as we could be doing. And we need to change. So there needs to be an openness to using information technology and making things publicly available. I certainly think the government can play a role here; it can help change some of the financial incentives. It can help set standards. Now one of the things that slows down a hospital or a physician office group practice from adopting an expensive information system they say, you know, “is it going to be compatible with what others are using”. If the patient is to have an electronic medical record that goes with them from their primary care physician to their cardiologist office, to their hospital, to their physical therapist … everybody’s got to have a compatible system, whether it’s Internet based or some other based. So I think setting some standards nationally would be helpful to move this forward as well.

HEFFNER: You know I have a sense in talking with you now that there is an enormous amount of enthusiasm here at this table … over there … and I guess as an economist, as a person who has dealt with systems, you do believe this all can be accomplished. And you talk about a 20/20 vision for the year … by the year 2020 … you really do believe because you’ve, you’ve listed so many, many, many changes that must be made.

DAVIS: Well, I’m an optimist by nature.

HEFFNER: Clearly. Clearly.

DAVIS: But I do think this will take time and some of it has to start with education of our medical students. It is hard to change established ways of providing care, so I think even from the time someone is a medical student, they need to be trained in information systems. They need to be trained in quality improvement methods, to really understand that they’re part of a team, that they’re not just a “Lone Ranger” out there on their own providing medical care. They need to really be interested in comparing what they do with their peers, with other physicians. They need to form … when they’re in practice a virtual network so that they can say, “This is the result I’m getting on my patients with this condition. What are the results you’re getting on your patients? What are you doing differently than what I’m doing?”. And I think some of this can reduce costs. For example, we know in the hospital setting that how long a patient is in the hospital, how well … how quickly they’re able to get back on their feet and function varies from one place to another. And doctors can learn from each other, those who are doing similar things with different kinds of patients. But you need to start in medical school and we need to train medical student differently from the way we’re training them today.

HEFFNER: Are we doing it? Are we at least beginning?

DAVIS: In some places. I would again say it’s pretty limited. I think doctors also need to know how to work with a changing American population. Right now, for example, 28% of all Americans are members of minority groups … African-American, Hispanic-American, Asian-Americans and others. By 2030, 40% of all Americans will be members of minority groups. And the way you practice medicine with a Hispanic-American family, with an Asian-American family has to be different than the way you practice medicine with other patients. First of all language may be an issue. So having translation. But also understanding cultural barriers that when the patient agrees with you, says “Yes”, when you say “Do you understand”, they say, “Yes”, they may just be being polite. Not really understanding. So cultural competency, again getting that kind of exposure early on in medical education I think is part of, again, having a different system. So it’s going to take time to really transform the American system. But we need to start now and we need to have a vision of where we’re going.

HEFFNER: I’m sure you could identify the dozen top medical schools in this country. If you were to do that and to visit them now, what would you find in terms of these changes that you feel so important to take place now.

DAVIS: I think you’d find good examples, what you might call “best practices at least somewhere around the country. So part of what this is about is to encourage learning across institutions, so that we know what the models of excellence, whether it’s training in information technology. And we do know that there are some hospital systems that have very sophisticated information systems. Certainly the Brighman and Woman’s Hospital in Boston, along with the Massachusetts General Hospital has a very sophisticated system. The Latter Day Saints hospital in Salt Lake City also is held up as an example of, of top care. It’s not that it doesn’t exist. The real problem is that it’s not the standard of care … it’s not everywhere. It’s not everywhere in medical schools, it’s not everywhere in hospital and even our best academic health centers sometimes have invested in that highly specialized, top-quality care without really having the information systems that are up to the task of assuring good quality uniformly.
HEFFNER: That harks back to something you said before about specialists. That here’s where we spend a very great deal of money. Here is where we have higher incomes. How do you, how do you work at that? How do you surround that problem?

DAVIS: Well, I think we need to focus a lot on primary care. I think that needs to be … that’s the entry point. That’s where people get started on the health care system, and that’s their guide through a complicated health care system. And I think that first thing really is changing the way we pay. Right now we pay on a procedure basis … the number of visits, the number of tests … there’s a whole list of 5,000 codes …

HEFFNER: Right.

DAVIS: … that physicians use to bill the insurance companies and there are systems, like in Denmark, where the physician is paid one-third on a monthly capitation basis, so he gets a certain amount for every patient whose care he’s responsible for. And two-thirds on the basis of how hard he works or the different services that he provides. They also have a very interesting system of off-hours coverage. And again, I think in even some of our most sophisticated cities, getting care at night or on the weekend is very hard, you wind up going to an Emergency Room because you can’t get through to your doctor or, you know, he says, “you know, it’s not convenient to come to the office, go to the Emergency Room”, so … we found, for example, in New York City that three-fourths of all Emergency Room use is not really true emergency that requires an Emergency Room. It either needs just a regular primary care doctor or clinic, or it’s something that could have been prevented if people had gone to primary care early on. So, having good coverage on nights and weekends is important. And in Denmark, again, they use the financial incentives to reward that … they have in every county and every area at night total coverage. There will be four physicians in a room with headphones on, right in front of a computer, and you call in, you’ve immediately got a doctor on the line, they pull up your Health Registry information. They listen to what your problem is and they say, “you need this prescription and I’ll order it right here, you can go over to your local pharmacy”. And then they send an e-mail to your primary care physician so the next morning when he comes in, he knows you’ve called the off-hours services and been given a prescription and he can then take over your care again. Or they have a clinic where people can come in who need to see the doctor directly.

HEFFNER: Would it be mean of me to ask what the total population is?

DAVIS: Well four million people is an easier population to deal with than 270 million people, so certainly … that’s a difference. But it is a system that values primary care, everybody having a regular doctor … easy to get an appointment. Many of us will wait two or three weeks and by then many people forget that they’ve had an appointment and they’ve miss it. And there’s starting to be, again, some places that are developing what are called “open access systems” of scheduling. And that basically means letting you have an appointment the day you want to get in. So if it’s today, they have a flexible scheduling that will get you in today. If tomorrow will do, then they’ll schedule you tomorrow. Other places let patients schedule themselves over the Internet. So you could look up and see what time slots are available and pick the one that works best for you. But this is revolutionary in the U.S. We’ve got a health system that’s set up more for doctors than it is for patients. And what we really need to do is to listen to patients, find out what they want from the health care system and then re-design the system so that it’s responsive to providing the kind of care and the kind of information that patients want when they want it. And that could be in the middle of the night for a mother with a sick baby and maybe she wants to look up what she should do on the Internet with a child who’s crying and pulling its ear at 2 in the morning. And if we had the Danish system and could call up the off-hours service and get a doctor who would prescribe an ear infection medicine for her, you know, that might be a better system. So, these are some things that are do-able.

HEFFNER: It’s interesting when you ask in your President’s message the quality of American health care, can we do better? I gather that part of the answer is “we can do better when American medicine is geared to the patient, not primarily to the physician.”

DAVIS: I think that is key … listening to the patient, having a much more sophisticated feed-back system about what patients want. And designing a system with that in mind. But we can also learn from looking at the experiences of other countries … the fact that we think we’ve got the best health system in the world means we don’t even find out what other countries are doing. I was shocked, for example, in our survey of physicians to find out that physicians in New Zealand, again a country with 4 million people, that the primary care physicians already have electronic prescription ordering systems. They already have electronic medical record systems, and they certainly spend for less on health care than, than we do. So we can find good practices in other places and figure out an American way of doing that.

HEFFNER: You are an optimist. One question left in 30 seconds. Do you think that we’re going to get to the rationing of the specialty medicine?

DAVIS: Well, I think that we probably do spend too much in some areas. I know you’ve been very sensitive to care of the dying. And I think one of the issues there is again, listening to patient preferences. We often do things that are futile or painful even for patients because we don’t have a good way of talking about death and dying and find out what patients really want. And the kind of comfort and time with families that may be a higher priority than some of our complicated care.

HEFFNER: Dr; Karen Davis that’s why I’m so glad you put your emphasis upon information and communication. And thank you for joining me again on The Open Mind.
DAVIS: 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 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.