The Future of American Medicine

GUEST: Dr. Herbert Pardes
AIR DATE: 02/02/2013
VTR: 01/10/2013

I’m Richard Heffner, your host on The Open Mind. And when my guest first joined me at this table just seven years ago to record programs I then simply titled “Money and Medicine”, Dr. Herbert Pardes did so as the particularly accomplished President and CEO of New York-Presbyterian Hospital, itself acclaimed as the extraordinarily successful merger of New York City’s two major medical institutions.

Today, after serving in that capacity for most of a dozen years, Dr. Pardes has become Executive Vice Chairman of the Hospital’s Board of Trustees.

A noted psychiatrist, my guest has chaired three different departments of psychiatry, served as Director of the National Institute of Mental Health and, during the Carter and Reagan Administrations, as the United States Assistant Surgeon General.

Dr. Pardes has also been President of the American Psychiatric Association.

And now I would like him to look at his profession, at American medicine generally — its promises and its challenges — and tell us what we have to cheer … and what we have to fear. Is that a fair question, Herb?

PARDES: It’s a marvelous question, Richard. So let me comment that the innovation and research in health goes on. We are finding new things on a daily basis, which should give great comfort to the general population of the country.

And let me illustrate, just in one area … I’ll take heart disease as one area. The … there’s an illness of older people which involves their major blood vessel, the aortic blood vessel. And the valve which allows the blood to go all over the body and feeds the body can become dysfunctional as people get older.

The treatment of that condition, until recently, was massive surgery on the heart … going into the chest … not a pleasant phenomenon for anybody, and put people out of commission for months.

In the last few years, people at our place who, we’re very proud took the lead, but many people around the country, many hospitals, have developed a new technique in which instead of going in surgically to get at that valve, they go through a little catheter that’s threaded from the leg to the heart … it contains a collapsed new valve … they put it exactly at the position of the old valve … dismantle the old valve … put in the new valve and the person who may have been having all kinds of trouble … has blood now flowing freely.

So let me give you my favorite example. Our seventh patient … when we were trying this out first … was a 95 year old woman who had had about a dozen hospitalizations in the previous year and a half to two … because of recurrent problems as a result of this valve dysfunction.

We did the procedure. She was out of the hospital within three days and back to normal life. Five years later we interviewed her …

HEFFNER: (Laughter)

PARDES: … at the age of 100 … and the question was put to her … “How do you feel?” and she said, “I have a little problem with my hearing.”

HEFFNER: (Laughter.) You’re just trying to make old people like me, feel good.

PARDES: Oh, you’re a young guy. Right after that, other of our doctors worked on another heart problem which is called mitral regurgitation. It’s something that’s relatively widespread … again … and again causes congestive heart failure. And it’s again involving a different valve … but instead of the valve become constricted so it blocks the flow … it leaks.

When the heart tries to squeeze and send blood out … blood goes the other way because the valve has deteriorated and that it doesn’t close good … it doesn’t stop the back flow of blood.

He has a technique now which does stop the back flow of blood … it’s in the experimental phase … but he believes that he can develop that to a point where we will offer people … again … a simple way of creating a valve defect … incidentally, these procedures involve not a single outside cut to the body, except to put the catheter in … you have to go through a blood vessel, which is like having … your blood drawn.

The combination of those two will have, I believe, a tremendous effect on heart failure, a very common condition, a common cause of fatalities … and it’s being produced now in many different ways.

That’s an example … I would say the fact that 20, 30 years ago, 5% of children with cancer survived … and today over 65% of, of children do … is remarkable.

And the new, the new experimental approaches of genomics, of stem cells, of molecular biology, of using various ways of imaging different parts of the body, promise extraordinary advances.

That’s … there’s a lot of good news with regard to what medicine can accomplish. And while I would hardly claim that medicine alone was responsible for the fact that you and I and other people are living longer … it does play a role.

Public health is very critical. There are all kinds of other things that are important … but there are things like transplants which were unknown, and now we do about 30,000 a year. Hip repair, knee repair, treatments now for various kinds of eye conditions for which we could do nothing some time ago. I think that’s a cause, at least I think, a cause for celebration by all of us. And those of us in health care simply love those developments.

HEFFNER: Then … what’s the down side? Because that has to be there.

PARDES: Sure. The downside is that the United States health care system, which, when it’s functioning at its best is terrific … has a number of problems in it.

Number one is the fact … not, not everybody is covered in this country. And that is horrendous for the given individual or family. And actually is an economic loser. Because if you got people covered then they’re not reluctant to go for help … people who are not covered with insurance, tend to wait, the illness gets worse. It hurts them more, it puts them at greater risk for damaging results and it also can cost more.

They wind up in the Emergency Room rather than having been in a doctor’s office six months before and gotten appropriate prophylactic approaches which would saved the more distressing situation.

HEFFNER: Do you think we’re coming into a period now with what has been called “Obama care”?

PARDES: I think the Obama care which has many pluses and minuses to it … I think by and large is a very good thing because it expands coverage to people. And so hopefully we will get and be … and start to rival other countries in that we will have fuller coverage for people across the country.

But Obama care and the health care developments in the last few years have a large number of aspects to them intended to make it better.

So its not only make sure the people have access and coverage, but when you get there … that you have a good result. So there’s a big focus on reducing infections in hospitals. There’s a big focus on reducing falls in hospitals. There’s a big focus on reducing length of stay.

We want you to go in and go out. As fast as possible. For your health, it’s better. There is a real focus on reducing the number of re-admissions.

Let me put something in … rather … I think very clear terms. Patient comes into the hospital, has their health care. Goes home. We’ve instituted a process by which we do an after hospitalization call. I call up the patient … “Mr. Smith, how was your hospitalization? Fine. How are you doing? Fine. Did you make that appointment with the clinic or the doctor that we suggested? What appointment? Are you taking that medication? Yeah, what was that medication again? What dosage are you taking. I forgot what the dosage should be.”

Okay, so what do we find … that better preparation of people going out … checking with them, educating them as to the criticality of, of taking care of themselves.

People’s own engagement is critical. And I think we’re going to see that expanded more and more. It’s not only the post hospital episode. It’s … what is a sensible approach to a … of a given individual to their own care.

If people don’t go to a physician or a nurse practitioner sometimes … with reasonable frequency … a high blood pressure goes undetected. The high blood pressure can result in terrible danger … terribly dangerous circumstances in their cardiovascular system. And you can be dealing with somebody who is near dead rather than somebody who, with appropriate treatment would never have that kind of problem.

A person who’s diabetic and decides to do well by themselves in terms of exercise, diet, no smoking and the like … and also checking themselves regularly … will not have to come up to amputations, blindness, kidney failure, heart failure, etc.

The point being that we in … as, as the health profession … have to do as much as we can, but there’s a very important role here for patient engagement and responsibility on their own or because their family prods them.

HEFFNER: How is that achieved, Herb?

PARDES: Well, I think that you need as much education as possible. I favor something which I’ve been talking about and whether we can get it as an, as an actual fact … I don’t know. I told to … I talked to Joel Klein, a good friend of mine, who ran the school system here … let me tell you what it was.

I thought in order to create health advocates … what better way than to start making health care and all the related subjects a mandatory part of the education curriculum from day one in kindergarten and go all the way through.

I’m, I’m sure many of us have seen the picture of a young child coming into the parents who are smoking and saying, “Dad, Mom stop that smoking, I don’t want you to die”, because the advertising has made the case.

You know, it’s not easy to get broad behavioral change amongst, God knows, large numbers of people. But the country has made progress in an area called smoking.

And also, there’s more people out there exercising than I remember when I was … you know 30, 40 years ago. So we can make changes, but you’ve got to have a lot of focus on, on doing it.

The practitioners in their own offices, sure they have to treat whatever the condition. But they also have to be talking to the person about the prevention, the prophylactic, the pro-health aspects of their life, in order to protect them. And, and they can do it. It would reduce re-admissions, reduce Emergency Room visits.

We, we’re doing this … I can describe in a very expanded way … right next to Presbyterian Hospital, in upper Manhattan, with a population that is indigent … that, that doesn’t have the money and I think it’s working rather well.

And if you want … I, I could tell you a little bit about that … just as another example. The population adjacent to Presbyterian Hospital is one of the poorest in the country. It’s a marvelous Hispanic population with many different ethnic groups there.

We have taken responsibility for something approximating close to 300,000 such people and we are working on their health care. We have organized a set of primary care physicians in the community who are helping provide health care for them.

We have created what is called “a medical home” which is a place where such patients can be sent for help with all the related issues to health care.

Because health care is affected by social issues, by financial issues, by work issues, by housing issues, so we’re not only doing the medicine itself, we’re also doing the ancillary issues which are not so ancillary. They can be very central.

We have hooked the doctors up electronically to the hospital. So if you’re a primary care doctor, you’re not surprised by your patient leaving the hospital, we call you and tell you that your patient is leaving the hospital, so you can pick up on it.

And we employ new people, called “Navigators” who speak the language, know the culture and can go to the people’s houses and say, “Let me help you navigate the system. Let me help you in terms of what you should do for your own health.”

We’re been tracking it in terms of the results of this effort. In the first year we reduced Emergency Room visits, we reduced hospitalizations and we believe we’ve also reduced money or cost and now we’re into the second year, we’ll have the figures come out for that.

But this is not peculiar only to New York Presbyterian, it’s being done by other hospitals around the country and I think that kind of effort along with the educational efforts I, I mentioned … the Ad Council with its public health … it’s got to be a broad based assault on people’s … not an assault, but an education, I should say, to have people recognize their role that they can be critical in how their life will go, how they will be healthy or not healthy, what their financial condition as a result will be … and I, I think that’s an important kind of approach which will be wider and wider initiated.

HEFFNER: Are the “Navigators” working?

PARDES: Yeah. I, I think they’re working very well. And, and their … the doctors, nurses, social workers love them being there because they, they pick up … I mean a big issue is language.

We are a changing nation in terms of the culture of the country. When I talk to my friends who have hospitals out in Nebraska and Wyoming and Idaho … my question to them, just so they’ll understand that it isn’t the same situation all over the country … is to say, “Can you tell me how, how many languages you think New York Presbyterian can translate?”

When I tell them we translate 100 languages and that last year there were 250,000 health care exchanges or episodes of care, in which language was necessary, their mouths open … they, they never heard anything like that.

Now there are other places in the country which have a similar phenomenon. But we’ve got to recognize that culture, language are very important and you want people … on your side in terms of helping them, you want them to understand and feel good and that … so that’s critical.

HEFFNER: But you know, we keep coming back … or at least I think we have to keep coming back to how do we pay for this? Because you must be paying for this.

PARDES: You, you’re right on target. The cost of health care is a big issue today. Anybody reading the newspaper or even living in the country for a minute … knows that.

HEFFNER: Or paying a medical bill.

PARDES: Right. So one has to look at what are the ways by which we’re going to reduce costs. And there is a move toward having health care people take responsibility for populations of people, just like I said we were doing …

HEFFNER: Right.

PARDES: … by engaging people, encouraging them to take more responsibility for their own health care. Coordinating better the health care, making sure that the communications are better.

You’d be amazed at how much that can save. Second, the electronic conversion of health care is going to be extraordinary. So if you walk into my office and say, “I’m having some chest pain … and I say, “Has this been recent? Well, I’ve had it for a while. Have you had a recent EKG? And you say, Yes, my doctor back in another place, took it.”

With the electronic record I can get it in a second (snaps fingers) and look at it. I don’t have to do another EKG necessarily on you. I may or I may not. There are many duplicate tests which won’t be done.

The, the hospitals themselves when the Obama care was being considered, volunteered a reduction of $155 billion dollars over the next 10 years in health care costs.

That was the cost to New York Presbyterian of one billion dollars over the next 10 years. We instituted an effort, divided it into six different teams … gave them targets for money we wanted them to take out through efficiencies.

Well, what are the efficiencies? Well, the efficiencies are we have 10, 15, 20 … whatever the number of doctors doing a given procedure. We bring their records, how they handle a situation in front of all of them.

Well, Dr. Jones why is it that you … taking care of a gallbladder, a heart condition … whatever … are using twice the number of tests that your colleagues are? Or keeping the patient three more days … that kind of focus on provider behavior has remarkable effect, because the so-called “outliers”, the people doing those excessive stuff, tend to, to pull it down.

There are a whole host of things whether it’s reducing unnecessary re-admissions. Whether … reducing the likelihood of infections, which simply cost more money. Errors within the hospital itself that help in this regard.

We’re also talking about partnerships between doctors and hospitals working together, being reimbursed together and as a result they’re able to do it at a lower … at a lower cost and we incentivize them by giving them some benefit if they cut costs … they get some benefit from it, so put some pressure on the provider community.

So I see a variety of people around the country coming up with all kinds of innovative ideas to reduce costs and I think we’re starting to see some value of it. It’s interesting that in the last few years there’s been a lowering of the level of cost increase in, in the country.

Some of that may have been due to some of the economic conditions. I wouldn’t necessarily claim that all for the results of these efforts.

I think these efforts are starting to have some, some help … have some effect. Now there are some other things I think I should be done that are a little more contentious.

Because I believe that the long-standing problem of malpractice in this country has to be dealt with. And the way it should be dealt with is that instead of bringing these cases into a courtroom where people who do not understand health care or medicine as much as perhaps we would like … are replaced by experts in a health care court which looks at … fairly satisfied complaint of the person who’s been hurt … makes appropriate judgments and I believe that could have a substantial effect on the cost of malpractice which contributes to the overall cost of health care.

To his credit, Governor Cuomo last year, after working with a number of different Administrations … I can tell you … pressed hard enough so we got one measure of relief in malpractice and it is having some benefit.

If you talk to states like Texas or California, where they’ve also done some corrective corrections on malpractice, they show reductions in cost.

So it’s just another area where it could be done. So you take, you put all these things together and, and you push it and my feeling is you start to see that cost flatten out. It shouldn’t flatten out to the point where it interferes with quality efforts. But it should take out some of the extravagance, the extras, etc.

HEFFNER: Do you think that if you took the profit making element out of medicine … I’m thinking of insurance companies, I’m thinking of many, many other drug companies, etc. that we’d be better off as a people?

PARDES: Oh, I think there are a number … I don’t know if I’d go the route … I, I tend to like the capitalist system. But there are things that those entities could do.

When Max Baucus, the Head of the Senate Finance Committee brought the six constituencies of insurances companies, pharmaceutical, device companies, doctors, hospitals, unions together … the question was, “How could everybody help in terms of cutting costs.

I mentioned that the hospitals volunteered a cut of $150 billion dollars. At that meeting, the plans indicated that if you streamlined the billing and collecting function in health care, which is a, a nightmare, that you could save a tremendous amount of money and their rough estimate, Karen Ignagni, was a Representative as I recall, she’s a very, very fine representative of that group … thought that they, they may be able to save as much as a half trillion dollars in 10 years.

So if you could get everybody to working together … if we could say, “Look, we want to maintain the highest quality, but we’ve got a lot to do, everybody has a role here”. I think you can get there. And I think … not perfectly, but I think we’re seeing some success in that regard.

HEFFNER: You know what puzzles me … we only have a few minutes left … I’m aware that you’ve written about Sandy …

PARDES: Right.

HEFFNER: You’ve written about the impact of Sandy and the wonderful way in which New York hospitals were able, to a considerable extent … to take up the slack …

PARDES: Right.

HEFFNER: That was needed. But you seemed to be concerned that we’re not going to stay at that level of preparation.

PARDES: Well, you know, we’re, we’re right now in a period in the country where we’re talking about needing to bring the deficit under control … with which I agree. But then when we talked about cutting Medicare or cutting Medicaid … we’ve got to be very careful as to how we do that.

Because the resources that come from those two entitlements are the ones that fuel our ability to do these very things.

With regard to Sandy I think most people did not realize at the beginning how dramatic and how challenging this disaster was.

It didn’t only involve the first few days, (cough) certainly there were eight hospitals closed, there were 2,000 acute care beds lost in, in New York. There were 3,500 nursing home beds. That was a big deal and we had to accommodate, we had to accommodate it. But it’s continuing. Those hospitals are still … most of those hospitals are still closed.

So the, the resources with which we have the capacity to handle that kind of situation come from largely from the government paid Medicare and Medicaid.

And you can’t … you can only cut so far without starting to cut into the ability of the health care system to respond. And many people are saying now, I’m fresh from a panel that’s working on this in Washington, that one has to consider this kind of planning for disaster with climate change and the various other things that cause disasters in a way which is integrated into the budget situation of the entire health care system.

So, if you want capacity, if you want to be able to effectively respond to a disaster, you also have to make sure you’re keeping your institutions reasonably well supported so they have the resources to do it.

HEFFNER: Is there a good indication that that’s the case and will continue to be the case?

PARDES: I think it’s a bit of a struggle. There are some people … quite appropriately … we understand the need to, to reduce the deficit. Our point is … my point that “let’s reduce the deficit, but make sure we sustain the quality and reduce the deficit in a way which doesn’t hurt.”

Let me give you one example. There are a number of hospitals which do the training of physicians in this country. There are five to six thousand hospitals in the country. If you want to cut, if you have to cut some, don’t cut the group that are training the doctors that are so necessarily needed …give a smaller cut to 5,000 of the hospitals, rather than a larger cut to 400 hospitals. Don’t do targeted cuts against critical aspects of our health care system.

HEFFNER: Dr. Pardes, it sounds as though, just as we come to the end of the program, we’re at the beginning of a lot of other issues to discuss. So you’ve got to come back and discuss them.

PARDES: Coming back and being with you is a pleasure any time.

HEFFNER: Herb Pardes, thank you so much …

PARDES: Thank you.

HEFFNER: … for joining me today. And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as another 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.