More about the Future of American Medicine

I’m Richard Heffner, your host on The Open Mind. And it was seven months ago that today’s distinguished medical guest last joined me here to discuss the future of American medicine.

I was then just a few days away from rather heavy duty surgery that for good or for bad … both probably … I had put off for 40 years. And there were two programs I very much wanted to get done just in case things turned particularly sour for me.

One was my first program ever with my wife, Elaine … about her weekly blog and new book identically titled Good Enough Mothering.com.

But the other was with the psychiatrist who had first joined me a number of years ago as the accomplished President and CEO of New York-Presbyterian Hospital, itself acclaimed as the extraordinarily successful merger of two of this nation’s major medical institutions.

Today — after most of a dozen years as its President — Dr. Herbert Pardes is the peripatetic Executive Vice Chairman of New York-Presbyterian Hospital’s Board of Trustees … having earlier headed three different departments of psychiatry, served as Director of the National Institute of Mental Health, and been President of the American Psychiatric Association.

Well, last time, I asked Dr. Pardes to take a good look at his profession, at contemporary American medicine, and to share with us its promises and challenges. I’d like him to continue doing so today, perhaps beginning with the crucial matter of healthcare costs. I know that’s a tough one, Herb.

PARDES: No, it’s a very appropriate one because it’s one of the compelling issues that we have to deal with in the country. And I think there’s some good news here, which has emerged from some of the government offices in Washington.

And by that I mean that they are … showing the data which indicates that there’s a flattening of healthcare curve … occurring in the last several years.

HEFFNER: How do you account for that?

PARDES: Why …that’s a good question and people try to struggle with one of the answers and I think as most issues, it’s probably multi-determined.

So, one thing that’s true is that there was a recession and at first people felt, “Well, maybe people were being more conservative about spending money on, on health care.”

A second, I would say, there are a lot of people in the country, a lot of constituents who are working hard to bring down some of those costs.

Some people say that a certain amount of shifting that’s going on from employers to workers in terms of how much of the cost they pick up may have something to do with it.

But it’s multi-determined. The first response of the financial people which was, “This is the recession”, I think is being modified even in their minds … as they speak about it … that there’s something else going on.

Well, I can illustrate that in major places like ours and others there are big things happening to take out cost. And I think the accumulative effect of that is contributory.

HEFFNER: What … what are those big things happening?

PARDES: Well …

HEFFNER: … because one hears publicly … John Doe or John Q. Citizen …

PARDES: Right.

HEFFNER: … hears about rising costs.

PARDES: Well, you’ve got a kind of very mixed picture. As I said there’s a flattening of the curve. Let me give you an example of the type of thing … I’ll mention it in regard to New York Presbyterian, but other places are doing it as well.

We took responsibility to cover the health care of several hundred thousand of some of the poorest people in the country … right adjacent to Presbyterian Hospital, about 300,000.

We provided primary care physicians, we created electronic hook-ups so a physician would know their … their patient’s coming out of the hospital. We brought on board a number of navigators … since our population is heavily Hispanic … we wanted people who could talk the language, help people navigate the often confusing kind of highway when, when you go to take that healthcare and even educate them somewhat about health.

We did that for the next couple of years and, and one thing … there’s something called a “medical home” that’s being created which is designed to address the social, economic and other related issues to healthcare.

So if a person having a healthcare problem and they’re also having a problem whether its with a job, with family … with, with anything … they can go and have additional help from that.

Monitoring the data over the course of a year, we reduced the Emergency Room visits by 5% … 9% … excuse me. We reduced the hospitalizations by 5% … those are healthcare services which didn’t need to be done because the other care was taking care of it.

I will tell you that we have data on … in the second year and I can’t comment on it because it’s part of a publication that’s going on, but things continue to improve.

We’re not the only ones who’ve done this … Massachusetts General has done this, University of Pennsylvania, Johns Hopkins … there are many, many around the country. And those things add up.

In addition … whether it’s the pharmaceutical companies, whether it’s the payers, everybody is feeling they have to squeeze some … some of that’s government … I think to his credit, the Governor in New York did a good job in terms of putting a cap on the Medicaid budget. And he worked collaboratively with the providers and brought the cost down substantially.

So, the whole story isn’t beautiful, but there are parts which are.

HEFFNER: But you’re saying, I gather … and that’s a beautiful point, if, if I understand correctly … that service is not going down, costs are not leveling because people are being less well served.

PARDES: Well, that’s exactly the kind of combined focus that people should undertake. Which is to say, bring costs down, but not at the expense of a clinical care of the patients. And we feel very strongly about that. So wherever we’ve taken out costs and there’s another part to this story, which is New York Presbyterian simply taking out costs … we’ve done it, but protected the clinical care aspect of our hospital. So …

HEFFNER: Are there figures on that?

PARDES: Hmm, yeah, we, we can show you where we have taken out costs … I’ll be very specific. At the time that Baucus … who is the head of the Senate Finance … Senator Baucus was negotiating the ACA … the Affordable Care Act … Obamacare, he approached many of the constituents and came to the hospitals.

And we were asked to reduce our costs. And what we did, is we agreed as a, as a group to save $155 billion dollars over the next ten years.

To New York Presbyterian that represented a one billion dollar reduction in costs, and we’re doing it.

Now, you could say, “Well, were are you doing it?”. Well, we’re asking all kinds of questions. “Do we need that many different kinds of sutures … the less you order, the less expensive it is.” Bring a bunch of doctors together who all may be doing the same procedure and say, “How is it that nine people here have a patient for, let’s say, a gallbladder disorder … in the hospital for just a couple of days and Dr. Jones over here has it for four days. How come he’s using double the number of tests or double the number of x-rays?”

And you’d be amazed … or perhaps not amazed at the impact that being compared and shown to be an outlier in terms of expenditures, days in the hospital, costs, etc. … how rapidly that can be modified.

Those are a couple of examples, but we have a whole bunch of others. Standardizing protocols for care … there are ways to do this, we learn from each other … a little less isolation on the part of the individual doctor.

Doctors, for years have been trained to be strong individuals who run their program. We’re all in the field arguing for more in the way of teamwork, collaboration, interchange … you learn from others, you work as teams and those are cost saving.

HEFFNER: If I were sitting here … across the table from an individual practitioner … would I see tears as those words …

PARDES: Yeah, you would see for some. You would see some practitioners who feel there’s too much bureaucracy, there’s too much administration, there’s too much paperwork, the electronic record is extremely formidable and challenging and there’s a reasonable amount of truth to that.

However, at the end of the day … the information technology or electronic records are going to be enormously helpful. I believe they’ll save money, they’ll make quality better. If you’re in … a New Yorker … who happens to be in San Francisco and you all of a sudden have a health event which makes you unconscious or puts you in great trouble … we can access your health information and rather than do a bunch of redundant tests … (snaps fingers) know immediately what the problem is and therefore act better in your behalf.

Incidentally, all under your control … assuming your conscious to make it or your … whoever is your next of kin can speak for you.

HEFFNER: Dr. Pardes what, what does that really mean? “Under my control” … I don’t know anything … I’m a civilian.

PARDES: What, what it means is that you are the person who endorses the right of a second doctor or other people to look at your records. It’s under your control.

So you may know that there was something called a HIPPA Rule that was created a few years ago … which was designed … to protect …

HEFFNER: Privacy.

PARDES: … privacy. And what that says is that if you’re in the hospital and if I get a call from somebody “Can you tell me how Richard is doing?”, I can’t respond. I can ask you if you’d like me to respond, but I can’t respond as a doctor. It’s under your control. Same thing with any and all of your information. And what you’re seeing … we’re in the middle of a process by which that ability to communicate and, and … to communicate between institutions and providers is growing stronger and stronger.

New York happens to be particularly successful in this regard. There’s a very good information technology commission … I commend the leadership in New York State … who put money in it and also the Federal government who put money in … and you see that happening more and more rapidly. We will have, ultimately, an interconnected information technology system … it means data is available more rapidly, it means you can search large amounts of data to figure out relationships between a disease and certain causes and it serves for the benefit of the patient because he or she can have the information available immediately.

If you ask me, what was I vaccinated for some years ago. I would say, “First let me figure out if I can tell where I had lunch yesterday”. Most people are like that. There’s, there’s a repository available under your control.

HEFFNER: You know, that’s what disturbs me about the whole thing. If you were to ask me what happened 10 minutes ago, I wouldn’t know. And if you were to ask me, what happened medically, I’d say, “Ask my doctor”. Do you think that we patients are really very much involved in the maintenance of privacy.

I’m not saying it’s not important. I’m not saying it’s not important for jobs, for insurance, for many, many things. But it seems to be it’s a little bit of a red herring.

PARDES: Well, it, it’s variable. First of all people are different than … you’d be impressed by the degree of specifics that some patients want. Other do not want, they are very happy to put their, their welfare in the hands of their physicians and assume they’ll take care of it.

But I’m not saying that what we’re looking for is for you to know all the exhaustive details of your medical story. I’m just saying the information is there. If a doctor wanted to know what happened … why did you … why did you have all this? You can say … you may not know … but you say, “Here’s my record, you look at it”. But it’s you saying he can do it. And I … that’s an advantage.

HEFFNER: What about the downside on the privacy issue. Do you think that is very meaningful or do you think … we are, of necessity, given modern medicine … and it’s needs, losing our control. Losing our privacy? In terms of the big issues.

PARDES: Well, first of all, I think a certain degree of privacy is quite appropriate. And that the given patient should decide whether they want information revealed or not revealed. Some of the information, they may feel, puts them in a problematic light for a variety of reasons.

You have a major business figure who runs a major corporation, comes into the hospital because they’ve got some transient memory loss … they may not want that kind of … spoken about loosely because it may threaten their credibility in terms of running their company.

You may have another one who had a sexually generated disease or may, may, maybe the person had AIDS or maybe … there maybe any number of things. So a certain amount of privacy is, is right and it should be under the control of the, of the patient.

Now when you say … well … is … are we losing our privacy, I think there’s an attempt to prevent that … to provide this control and on the other hand the more rapid communication is, I think, helpful to the patient. But I couldn’t guarantee that there aren’t instances in which the privacy is less than perfect.

HEFFNER: Tell me what you think is going to happen with the … what we’ve been calling Obamacare?

PARDES: Well, obviously, you’ve got one of the most controversial issues in the country here. And I think there are some good things and there’s some worrisome things.

So let me just walk through a few of them. I think the idea that one will enable people who have pre-existing conditions to get health coverage is, to me, a very valuable step forward.

The second thing is that … to cover more people is also very valuable. To be in this country, much less any other country … and not be covered for healthcare I think is a travesty. That we should be trying to find ways to cover as many people as possible, preferably the entire country.

The initial advantage incidentally is that the covered person often does better and costs less because they, they are willing to go when they have to go for care and not come with … too late or so late that it becomes more expensive.

The extension for young people of coverage under their family to age 26 I also think was a benefit.

So there are a lot of good things and this … the attempt really is to try to get the whole country under an insurance scheme.

Now, concerns … the exchanges … there obviously is some unevenness and division across the country. There are a number of people doing it. But while, I, I abhor the opportunity to deny people insurance coverage at a reasonable cost, I also would want to make sure that insurance coverage is good coverage, that it covers the benefits reasonably well.

I, I don’t think we should do it on the “cheap”. It may be a little costly, but that’s my own personal feeling.

One of the other areas I’m concerned about is some of the best of American medicine is practiced in major centers like New York Presbyterian and Hopkins and Mass General in Pennsylvania, University of California in San Francisco and we’ve got to be careful that those are appreciated for the enormous assets they are and they’re not reduced too far down in terms of assets. Otherwise they can’t do the, the many things they do that are valuable.

HEFFNER: What do you mean?

PARDES: Well …

HEFFNER: Reduced too far down …

PARDES: Well … if … if … we said we’re taking out a …

HEFFNER: A billion.

PARDES: … a billion out of the New York Presbyterian. Now there have been further suggestions for additional cuts coming from Washington.

Let me give you an example which I find particularly provocative. The shortage of doctors in this country is projected to be about 125,000 by 2025 … that’s a lot of doctors.

Why is that true? Because every day 10,000 new people go on to Medicare … as an example. So there’s much more care going to be needed and you want to have a doctor to do it.

There is a two step in becoming a doctor … you go to medical school and the medical school in response to this concern have stepped up the number of people they’re bringing in to medical school.

But you have the second part. You are a resident … you are a house staff person … who gets the special training, whether it’s in pediatrics or internal medicine or surgery.

And in that area the, the … there’s been some policymakers down in Washington who actually considered cutting the money with which the hospitals support the training of doctors.

Well, if you’ve got this massive shortage, why in the world would you want to cut the dollars with which we train those doctors? So that’s a current issue.

We’ve made some progress in this. I have been spending a lot of time in Washington with my colleagues from other major hospitals around the country … and we’re hoping that people will see … sense and sensible not only to not cut any more, but even to consider adding positions so we can have enough doctors to take care of people. That’s an example.

There’s another example. And that is that in constructing the overall healthcare program that Obamacare represented, the anticipation was that a lot of people would be covered by Medicaid who weren’t covered before.

And as a result, that would bring additional revenue into hospitals. Well, hospitals paid by Medicaid don’t get their costs covered. But at least some revenue is better than none.

At the same time, there had been an existing program to give us money for caring for indigent patients … called “dish” money and they felt “Well, if you’re going to get extra revenue here … we can take down the “dish” money”. In some places that worked fine … you have some places in the South or other parts of the country who have so many people not on Medicaid, not covered … that that revenue stream would be substantial against the money they would lose.

In New York, it’s just the reverse. We have … we have a generous system for getting on to Medicaid … people get covered and as a result we will not have as many people coming on, but we will have substantial “dish” cuts and that’s an issue right now.

And so there’s a, a discussion going on, a Bill put up by one of the distinguished Georgia legislators to say “We’d better delay these cuts a bit until we see what kind of revenue is going to come in.”

But, those are examples. My point is that we, we … there was a big cut, we took, we’re taking it … what I’m concerned about is you don’t keep cutting and cutting to the point where you do cut into quality.

HEFFNER: What’s the mood in Washington now, in relation to these cuts and other possible dangerous actions …

PARDES: I would …

HEFFNER: … in relation to medicine.

PARDES: … I would say the mood in Washington generally, as I think is apparent to everybody … is frustration at the inability of the two parties to work together. And second, I think that there’s quite a, a difference in terms of attitudes of Congressional people toward spending money of any sort.

I was an Institute leader in Washington for six years. When I was down there, I had Republicans and Democrats both interested in finding new answers to disease, really working together.

Today, it is a very unfortunate situation and therefore some are preoccupied only with how, how can we cut anything and everything. That goes back to their doctor training … and they would consider maybe we should cut doctor training.

There are others who still, unfortunately, less than there were before, feel that healthcare is critical … we want to support it and, and there are times when we have to spend money and they don’t have as restricted a view.

So you’ve got this clash going on and for those of us in healthcare, we’re concerned that “Yes, we, we want to help bring down costs, but if you cut excessively that’s a problem.”

In an area other than critical care, which is research there’s been substantial cuts … at the National Institute of Health … they’re talking about more cuts and that’s our medical research pipeline. While we’re cutting money, other countries like China, like Singapore, are putting more money into medical research.

And I’ve always been … still am … a … very excited about what’s happening in research and how we can make people’s lives better.

HEFFNER: Are there any signs that others are beginning to outpace us. I don’t mean just in the expenditures, I … in, in not experiencing cuts … but in terms of the intellectual quality of medical research life.

PARDES: We had some presentations from people from Asia and they’re, they’re very excited about the power of genetics and genomics. And they’ve created centers there which can do tremendous things. They’ve put enormous investment in. Now just recently in New York I’m happy to say, a dozen institutions, 12 of the very best in medical research got together and created a new … a genome center in New York. We’re behind China, but at least we’re doing it now.

And the ability to examine a person and figure out all the genes in his or her body is a wonderful development at a decreasing cost. And so invaluable in terms of research and also developing better clinical answers.

So, are we behind? Well, they had this going before we did … we’re now doing it here … it’s not as if New York is the only place that’s doing … other places have done it as well.

But I would say the simple answer is … there is concern that a field in which we had been so dominant is one where we’re seeing some challenge by virtue of the squeeze in dollars.

HEFFNER: And it is a matter of dollars.

PARDES: Absolutely.

HEFFNER: Not of intellect …

PARDES: No.

HEFFNER: … not of desire …

PARDES: You’ve got plenty of excellent people who are wanting to do research, going into research … one other thing that’s kind of interesting … which is a kind of an indication … we have always drawn tremendous numbers from other countries in terms of people who came in to study, research, become fellows and also often became faculty.

More frequently now people who’ve come here for training, which is very strong … are ready to go back to their home country because the opportunities there are getting better and better. And here we’re squeezed.

HEFFNER: In a sense it’s a good thing.

PARDES: Well, yeah, there’s positive aspects to that. We don’t want to be stripping the rest of the world of talent. On the other hand we want to make sure that the vigor with which the research here is on-going is sustained.

Now there’s a, there’s a company fact which is also worrisome. And that is that many of the drug companies are finding it more and more difficult to afford the expenditure to bring drugs to use to make them valuable.

And, for example, one area we’re worried about is the brain research area, which they seem to be actively pulling back. And so the worry is will we still see a flow of new treatments from that research … and if the NIH cuts back and if the drug companies cut back, it paints a somewhat bleak picture here. And to the young person going into research or excited about it … I say, well, how am I going to be supported? And that’s a concern.

HEFFNER: Dr. Pardes I hate to end on that negative note, but you’re such a positive person, I’m sure you have it all planned that we’re going to work out way out of this.

PARDES: I … I agree … we, we will not let these factors take us down. We will do everything we can to sustain the record of research and clinical care in this country.

HEFFNER: Dr. Herbert Pardes I thank you for joining me today and making me feel better on that positive note.

PARDES: (Laughter)

HEFFNER: You’re going to come back, I’m sure.

PARDES: Absolutely.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”

And do visit the Open Mind Website at thirteen.org/openmind to reprise this program online right now or to draw upon our Archive of 1,500 or so other Open Mind and related programs. That’s thirteen.org/openmind.