The Future of Health Care In America, Part II

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Robert Michels
Title: “The Future of HealthCare in America, Part II
VTR: 10/30/96

I’m Richard Heffner, your host on The Open Mind. And this is the second of two programs on the future of HealthCare in America with Dr. Robert Michels, the Walsh McDermott University Professor of Medicine at Cornell Medical College.

Now, when Dr. Michels first joined me here on The Open Mind more than 21 years ago, he was chairman of the Department of Psychiatry at the Cornell University Medical College, and Psychiatrist-in-Chief at New York Hospital. Later, he served as dean of Cornell’s Medical College. And he’s so doggone smart that I count very much on him for his answer to questions about the future of American medicine.

Dr. Michels, when we concluded the last program, we were on the verge of the 21st Century. But before we get there, in terms of your picture of the HealthCare we will deserve and will receive, I want to ask you what the transition is going to he in the area of academic medicine. What’s going to be happening to the major research and educational institutions in this field?

MICHELS: That’s a major issue of concern to academic medicine, but also to HealthCare and to the nation. In many ways, the things that academic medicine does have been the pride of our society. Most people in the health field provide HealthCare to citizens; they care for the sick. But, in addition to that, the academic institutions do two other things. One is they train; they educate professionals who will be future HealthCare people. They run medical schools. There are 125 in the United States. They train nurses and social workers and psychologists and pharmacists and other health professionals. And they other thing they do is they develop new methods of treatment, new drugs, new diagnostic procedures, new strategies of HealthCare that will be more effective and more efficient. And if there’s any area that our nation has excelled in. in the last few decades, it’s in the study and development of new methods of HealthCare. Pharmacologically: in terms of systems of imaging the body, in terms of methods of delivering treatment. The economic point of view would show that academic medicine’s a very small part of the total Health bill. The HealthCare industry spends a much smaller percentage of money on research and development than the automobile industry does. But it’s a vital part of what we do because it’s that, that makes our children’s HealthCare better than ours, just as ours is better than our parents’ was.

Historically, over the last few decades, academic medicine has largely been funded by subtle, often invisible, cross-subsidization from the resources that were developed in the health-delivery system. To put it briefly, HealthCare in the private sphere, outside of academia, made a profit. In the academic sphere, that same HealthCare made a surplus that was used to support the expensive cost of research and education. But the HealthCare changes we’ve been talking about, the shift to managed care, the rationalization of the system, the concern with cost control, have reduced the profit in the private sector, but they reduced the surplus that was used to subsidize research and education in our academic institutions. And those institutions don’t have a substitute source of resources. So as we’re rationalizing our HealthCare system, an unintended but extremely important consequence is we are starving to death the academic institutions that have provided the research and education.

HEFFNER: What’s the answer to that problem?

MICHELS: The answer is that we have to fund them appropriately, knowing what their value is, and devoting social resources to that value. But when you’ve previously not known you were paying for something, it feels like it’s free. And then, when that source of resources, that cross-subsidization, disappears, and you’re told, “If you want to have medical research, we’re going to have to raise your taxes to get money for it,” or, “If you want to educate medical students, they’re either going to have to pay tuition, they’re going to have to raise money to give them scholarships,” people start looking much more carefully about how much it costs and whether it’s reasonable. And, in some places, they may be right; we may have been educating too many medical students. And some of them may have been educated in the wrong way, and rationalizing the system may correct that.

In other areas, we find the public is extremely desirous of one thing academic medicine does: research for better treatments, and cures for diseases. And they, when you ask them, think we’re not spending enough money on that. But to get that message effectively into the political dialogue so that money is generated through our national appropriations and our taxes is a bit of a political and educational effort.

HEFFNER: What’s the situation right now, even as we sit here?

MICHELS: Well, the expenditures for healthcare through the federal government have been relatively protected from budget cuts, although the rate of increase has slowed somewhat. The public thinks this is a good thing to spend money for, but there are major pressures on reducing federal budgets. Private expenditures have also been reduced in terms of their rate of growth. And the opportunities are expanding extraordinarily. Our research for healthcare, of course, is an international resource. We don’t discover treatments or cures for diseases in New York and California but not in Germany or Japan. But most of the resources are developed from national sources. Developing a rational system for this is an urgent concern again of the end of this century and the beginning of the next, and one that we haven’t fully solved.

HEFFNER: Lou Thomas, the late Louis Thomas, was here, I guess, maybe six or seven years ago, and said very much what you’re saying, hut said in the whole scientific endeavor we were still living off the fat of a decade, two decades, three decades ago, when more resources were devoted to basic research.

MICHELS: I think that there was a period in which we weren’t even aware of resource constraints as the country enthusiastically supported such research, and good science didn’t have to worry about adequate support. We have a problem today in that the amount of good scientists seeking support, and the ratio of their numbers to the support available, make being a scientist a dangerous game of chance in which only a small percentage of all the applications for funded research get approved and funded, and that the average scientists sees excellent applications for research funding get turned down. Some of them get discouraged and leave the field. Even more tragically, others are discouraged from entering the field in the first place. And we’re worried that we’re, in effect, destroying our seed for the future in this area.

HEFFNER: Well, I listened to a recording of the grand rounds you conducted at Cornell. I gather you said it was your last grand rounds. And I was impressed, or depressed — I don’t know which — by the statistic you offered of the probability of a third of the present-day medical colleges disappearing.

MICHELS: Well, that’s probably a…

HEFFNER: Or should I cheer?

MICHELS: Well, that’s a dramatic prediction, but right now the United States has 125 medical schools. In the evolving HealthCare system, there has been a great deal of concern that we’re training the wrong kind of doctors, that we’re training too many specialists, and not enough generalists or primary care doctors. There’s been somewhat less concern, but considerable concern, that we may also be moving into a world where we have too many doctors. Now, that second question is particularly complicated because all the doctors aren’t trained in those 125 medical schools. A significant percentage of doctors in post-medical-school training in the United States, perhaps 30 percent, graduate foreign medical schools, and then enter this country And 70 percent of them stay here to practice medicine. They often make very fine doctors. They contribute by their participation in our system. But if we have too many doctors, cuffing one group, say, the American medical schools, without dealing with the graduates of foreign medical schools, doesn’t solve the problem any more than the reverse does. And we don’t have a national plan that’s enforced for how many doctors will be trained in this country; we have a free system in which medical schools generate doctors, doctors from abroad immigrate into the country, and the total is too many for our system.

HEFFNER: Would you recommend an end to that free system?

MICHELS: I would recommend, again, a dialogue about what to do about it, and I think, short of enforcing an end to the system, we might remove some incentives that are built into the system for things we don’t want to happen. So, for example, one of the reasons that we have people coming in this country for residency training is that our current reimbursement system rewards hospitals for training residents that we don’t need. If we were to make the system more rational so that there was no reward for training excess physicians, that would lead to a solution to the problem that might he much less painful than mandating or enforcing number of trainees.

HEFFNER: Well, now, that, the irrationality that you describe, must come from a failure at coordination.

MICHELS: Or from an absence of coordination. There are a great many systems involved. There’s the medical schools generating physicians, there are individual hospitals seeking trainees, often finding that under the current reimbursement system trainees are cheap labor. They’re physicians who perform physicians’ tasks for lower salaries than they’d have to pay if they were hiring physicians who were graduates to do those tasks. They’re people who are highly motivated to enter into this country to practice medicine. And there are accreditation groups that are required to have the residencies approved that may have lower standards than they would like to have because they are fearful of the review process that goes on when they discredit someone. Ideally, we’d want the right number of doctors, we’d want the highest quality doctors with the best possible training, and we’d want them trained primarily in those institutions with the best faculty able to teach them.

HEFFNER: That means consolidation, doesn’t it?

MICHELS: In many areas it means consolidation. It means recognizing that hospitals with small or borderline programs should close those programs, that the great teaching institutions with the finest faculties should concentrate more effort on teaching, and that we need a reimbursement system that recognizes the cost of that and provides them resources to do it.

HEFFNER: Okay. Now, you were talking at the end of our last program about the opening decade of the 21st Century. How do you see all of this as developing? How do you see all these chairs being placed around the large table of medical care?

MICHELS: Well, the American way is not to find a solution to a problem, mandate it from above, and enforce it in all 50 states at the same time and solve it.

HEFFNER: Maybe it needs to be.

MICHELS: Well, if we were absolutely confident in the total wisdom of our national leaders, perhaps. But I don’t think most of us are. And I think what you’re going to see is some experiments. I think you’re going to see experiments in various components of the system. Perhaps in the state or region. Perhaps in the network of medical institutions. I think you’re going to see some of the for-profit HealthCare systems that are developing, decide that they want to have their own medical schools training physicians for what they want physicians to do. I think you’ll see some of our great research universities recognizing that the training of investigative or academic physicians is sufficiently different from the training of primary-care clinicians, that it wouldn’t be a good idea for every medical school to devote its mission to training primary-care physicians, and nobody training scientists and researchers for the future. I think you’ll see communities trying different experiments. I think you’ll see a study of the way in which we may have inadvertently supported the wrong goals by, for example, providing resources for hospitals to develop training programs to train graduates that we don’t need in the system because while they’re in the program they take care of patients.

New York is a particular example of a problem here. It has the largest number of foreign medical graduates in residency training programs, and that’s largely driven by the needs of our great public hospitals to have manpower to care for indigent patients. If we figure out a way to get the indigent patients taken care of in the private system, we may be able to shrink the size of those great public hospitals and make the training programs geared not to the work of the trainee, but rather to the need for the graduate in our HealthCare system.

HEFFNER: Going on to the question of HMOs, do you feel there’s a larger question, do you feel comfortable with the notion of making this a profit center, making medicine a profit center? I know your answer is going to be, ‘It always has been.’ But institutionalizing it this way, is this a source of comfort for you?

MICHELS: Medicine’s a profession. And that’s good. It means that a physician isn’t only trying to maximize his personal gain, but he or she has a very important mission of doing what’s best for the patient. That’s not the classic market situation. And if you’re buying an automobile or getting an accountant or buying a new suit, it makes perfect sense to go into a market situation where the seller is trying to maximize their gain, the purchaser is trying to maximize their benefit. But if you’re in pain, or scared that you might die, or need to tell somebody all of your secrets to make sure they can give you the best possible help, you don’t want to he in a quasi-adversarial relationship with them where you’re negotiating for who ends up ahead in the deal. How we can maintain the profession of medicine and the nature of the relationship between the physician and patient and all that that implies of the physicians’ in some ways in loco parentis role with the economics of a for-profit system around it is a major problem. I guess I’m old fashioned in the sense that I think it’s an unfortunate way to organize HealthCare, that it has the advantage of forcing efficiencies on the system. But I wouldn’t be surprised if, once those are forced on the system, if its disadvantages loomed so large, that it withered away and was replaced by something more supportive of the professional ideology of HealthCare in medicine.

HEFFNER: How would you describe the possibility of that something?

MICHELS: Well, I think that if we’d get an organized, efficient, less cottage- industry HealthCare system going, we may find that the competition squeezes the profits out of it. So a kind of either regulated-industry approach or a public-industry approach becomes more politically palatable, and, at the same time, more ethically acceptable both to the public and to the HealthCare professionals in it.

HEFFNER: Someone showed me a newspaper clipping the other day, I think it was Daphne Dodger, that indicated that a great many private physicians who had just almost automatically opposed the notion of the Canadian system, of a single payer, were now having been caught up in HMOs looking in that direction again, saying that the single payer was desirable. What do you think?

MICHELS: Well, I think the surveys that have been done suggest that Canadian physicians are happier with the setting and ambiance and the structure of their HealthCare system that…

HEFFNER: And their patients?

MICHELS: And their patients seem happy too compared to American patients and American professionals in some of our HMO structures and our managed- care structures. I think that the system problems, when the first HealthCare changes were proposed, physicians reacted very negatively to the notion that the government would be telling them what to do. What they discovered is the government may be a more benevolent manager than a for-profit HealthCare organization which is trying to squeeze the last dollar out of the bottom line, and some of them now long for the government looking over their shoulder rather than an accountant looking over their shoulder. I think you’re going to again see a lot of experimentation in that area. I wouldn’t be surprised if some states go all the way toward a publicly organized system while others encourage competition in managed care, and we have a kind of period of competition among models of care. I think that would be interesting, and we might even be able to do some good studies on the way in which different models influence the quality of care.

HEFFNER: Any such studies thus far?

MICHELS: They’re just beginning. There have been some studies on the way that reimbursement systems influence the quality of care. That whole area is an important area of research and has been hung up around the, until very recently, our not having measures or even definitions of the quality of care. So doctors think they know good care when they see it. But, in fact, to get measures that are objective and reliable so we can say, “This HealthCare system excelled in this area but failed in this area, and that one had this other profile, and their total scores were such and such,” is something we’re just beginning to approach. When we can evaluate what the quality of HealthCare is, we can make rational decisions about whether System A or System B delivers better quality.

HEFFNER: Meanwhile, you said you were old fashioned, and the concept of the marketplace, the concept of medicine as a profit center, disturbs you. It doesn’t fit with or set into your traditional approach. What about the younger doctors? You’ve just retired as dean of the Cornell Medical College. What about the young men and women?

MICHELS: I would say the people entering the field are better than ever before. They’re brighter, they’re more well-trained, and their personal goals and desires couldn’t be more desirable. I think that, in the old system, there was a profit element in the individual practitioner’s practice. And I think, as that’s getting shaken out, it’s probably good for medicine and for HealthCare. What I’m concerned about is, if medicine becomes a job rather than a profession, another way to make a living, and if the work is defined as an occupation without a special moral, almost a religious quality to the vocation of medicine, it’s going to attract a different kind of person. I don’t want to be cared for by a doctor, if I’m sick, who became a physician because he or she learned that was the way to make a lot of money.

HEFFNER: Now, just take that point. That has been the criticism, as you suggest, of a fairly recent generation of doctors, leaving out the question of HMOs and huge companies in this business. Did they bring this about on themselves?

MICHELS: I think in part. I think that, if you look at the history of medicine or you do a cross-cultural look at medicine, physicians in the United States in the last 50 years have been more affluent than at any other point in time or in any other culture or nation. And I think that’s probably an accidental blip because of changes in federal reimbursement systems of Medicare, and because of the economy after World War IL I think that that’s going to get corrected. I think, what I’m hoping for is that, in correcting it, we don’t throw out the baby with the bath water; we don’t end the profession of medicine and replace it with the occupation of applying biologic knowledge to disease care by somebody who sees himself or herself as working from nine to five, Monday through Friday.

HEFFNER: The young people that you’ve been dealing with view medicine as a calling?

MICHELS: Absolutely.

HEFFNER: Why do you say they’re trained better than ever before? That I didn’t understand. Trained better at the university level? At the college level?

MICHELS: We’re going through a revolution in medical education, and it’s a wonderful revolution. And there’s several components to it. One is that our basic science training, which had often been boring, rote memory of many, many facts, has been so enriched by new knowledge that its content has become intellectually more exciting, and, at the same time, it’s expanded so much that there’s no possibility of learning all the facts. And the leading medical schools have shifted their curricula so that learning the basic sciences of medicine is now an intellectually challenging, learning how to use methods of problem-solving rather than memorizing lists of facts, it’s a great advance. Secondly, our clinical training, which had, over the decades in most medical schools, become more and more a series of sequential rotations in the various medical specialties – four weeks of this specialty, four weeks of that specialty – has become a more integrated and organized HealthCare system with an emphasis on primary care and ambulatory care, and a much more cohesive sense of knowing what it’s like to be a doctor with patients rather than learning a series of technical sub- specialties of medicine. Finally, a third theme of medicine, ignored in the past to a great extent: the sociology of medicine, the economics of medicine, the politics of medicine, ethical aspects of medicine. The significance of medicine and its role is the physician and the patient are together in a social structure has become an educational theme and attention is being paid to it in our teaching and our curricula. Medical school curricula are much better than they were a few decades ago, and the students like them more.

HEFFNER: You think, if you talk about Aerosmith to them, they’ll know who you’re talking about these days? A dozen years ago, it seemed to me, there were very few medical school students whom I knew who had ever heard of Aerosmith.

HEFFNER: Well, I don’t know whether I should give away my age by telling you that I read Aerosmith before I went to medical school. I’m not sure that Aerosmith himself would be known to them, but I would suspect you’re going to find replacing him a few very, very popular contemporary television programs. I noticed recently that one of the greatest increases in sub-specialty interests of graduating medical students was their interest in emergency medicine. And I have a theory about where that comes from, which I’m sure you can guess.

HEFFNER: Yes, I can guess. Of course, the trouble is we don’t have Marcus Welby with us anymore. You’re very optimistic then, about the nature of the future of medical students.

MICHELS; I think the medical students we’re getting are great. We’re getting a different, a wider variety…

HEFFNER: In 30 seconds.

MICHELS: …we’re getting many more women, we’re getting many more minorities, and we’re getting the brightest and best. I’m very optimistic about the students. I hope we live up to what they deserve.

HEFFNER: In the few seconds left: Is this a change in the last half-decade?

MICHELS I would say it’s accelerated in the last decade, though it’s been going on before that.

HEFFNER: And I have a sign that says, ‘Say Goodbye.” Goodbye, Dr. Michels. Thank you so much for joining me again today.

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 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150

Meanwhile, as another 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.