sick around america

Thomas Delbanco, M.D.

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A physician at Beth Israel Deaconess Medical Center in Boston and professor of primary care and medicine at Harvard Medical School, his work has focused on improving patient health services. This is the edited transcript of an interview conducted on Feb. 18, 2009.

“We've been waiting for big changes in American medicine for a long time, about 40 years. And the way I've understood [it], you need a real crisis. You need everyone to hurt.”

Would you say the American health care payment system helps you treat your patients, or does it get in the way?

I think the way health care pays for patients in this country is so complicated that one can't generalize about it. For some people it's a total blessing; for other people it's a curse. And for me, in a given part in the day, I'm thrilled with it, and another part of the day I wish it would go away. ...

Is cost a factor for your patients?

Cost is, of course, a factor for our patients. Some of them don't come back to see us; some of them don't get the medicines that they ought to get or we think they ought to get. Others argue with us about what we're going to do, often very constructively. And for some it's absolutely no issue at all. ...

Do you think patients would make harder choices, or do you think patients [would] be more involved in these decisions if they had to pay the bill out of pocket?

Yeah. I think money has an impact on how you think about yourself. ... The best example of that is that when an animal gets sick, you think very hard about taking it to the vet because you don't have insurance. And people who have insurance very often don't think about the cost implications or the financial implications. Or at least that used to be the case -- not so much anymore. ...

Would you say most of your patients are indifferent to the costs because of insurance, or is everybody concerned?

... What has happened in the last few years is an extraordinary change. People are far more worried about money. They're far more worried about the cost of drugs. They're far more worried about the cost of seeing me or seeing a specialist. They're far more worried about operations or tests and also, of course, days away from work, days away from doing other things. Money is on everybody's mind today -- you'd have to be crazy if it isn't -- and patients are certainly no exceptions to that. ...

... In America, we have one health care system for people over 65; we have a different one for veterans; we have a different one for active military personnel; and we have one for members of Congress, one for Native Americans, one for people under 16 with 120 percent of poverty income, one for people with 200 percent. Is that a good idea to have all those different systems, or would one system for everybody be better?

My own bias is that we should have one system for everyone. ... I think a lot of doctors feel that way. I actually think it would save money. My personal view is that a lot of the insurance industry is just adding costs and we're not getting much value for it. I think it would be easier for everyone to understand. It would be more clear; it would be more transparent, an important issue in today's world. ... Whether America could ever stand for that is a different question. ...

One proposal many people suggest is that we just extend Medicare to cover everybody. Then there's one system covering everybody, one system paying all the docs. What do you think?

... Medicare is a very good insurance system. I have it. I've been sick under it, and it was painless to deal with them. They treated me fairly. I have supplemental insurance also which covers some of the things Medicare didn't, and I'm privileged in that respect. I think it works very well, and I think it works much better than a lot of the other systems, and I would be very happy to see it extend further.

Do you think America is not ready to do that?

You know, we've been waiting for big changes in American medicine for a long time. It's been just around the corner for about 40 years. And the way I've understood [it] is that you need a real crisis. You need everyone to hurt: You need the patient to hurt; you need the doctor to hurt; you need industry to hurt; you need the government to hurt. And if everyone hurts, you might think in a rational world something more appropriate will be put together.

Now, we're in a pretty big crisis right now. This should be a terrific opportunity. Whether our new administration can pull that off or not I don't know, but I sure hope they can, and I will tell you that all parties, I think, are interested in helping that.

So you're kind of making an economic argument there: Industry hurts, doctors hurt, it hurts the national economy. I'm going to argue to you that maybe the stronger argument to motivate change in America is the moral argument. ... Is that a winning argument in America, or do people not care?

I think people care. Moral arguments carry enormous weight. I think our last election reflected that. Whether moral arguments are the same, are powerful enough to overcome economic self-interest, entrenched interests, different value systems, is a different argument. I mean, a lot of Republicans are good people, as are Democrats, but boy, they have different views on these things, and they would all call themselves moral people. ...

... We spend twice as much as any other country. We still leave tens of millions with no coverage at all, and we have less good medical outcomes than the other rich countries. What's going on there? Why is that true?

... It is so hard to gauge [what] you're talking about. I mean, if you eat at McDonald's all the time and get very obese, ... [is] that a problem with our medical care system, or [is] that a problem with our society, or was that the problem [with] the way we urge people to live in this country? ...

So it's very hard to sort out medicine from kind of the social circumstance, but I'm not defending what we do. We don't have good systems; we're not well organized. An awful lot of people fall through the cracks, and because of the money and because of a lack of insurance, far more fall through the cracks than ought to, and that's unconscionable. That's immoral.

How would you measure medical outcomes? I look[ed] at things like the recovery rates for major diseases, healthy life expectancy at age 60, infant mortality. On those measures, the U.S. comes in 20th out of 25.

Yeah, on those measures we come in very well for the people who have resources and very badly for the people who don't have resources, and that's where the moral failing is in this country. That's where the inequity is. ...

... My father just died at 98. His motor just stopped. I just said goodbye to one of my favorite patients at 86 who died of terrible heart failure. He would have lived 20 years less when I was training in medicine. We can do things for him that are extraordinary -- and we did things for him -- and he had a good quality of life, and he enjoyed life. It was very expensive, that quality of life. It added to our costs, but he had resources. And for the inner-city person who can't reach us as easily or doesn't have insurance or doesn't come in time, that person doesn't live as long, doesn't live as well, and there's inequity there, there's no question about it.

So some people are always going to get great medicine, particularly in the U.S., with our world-class doctors, hospitals, etc. But you're saying we ought to find some way to smooth things out for the people who are not getting this?

I think everyone should get the same great medicine. There's no doubt in my mind about that. ... It will mean giving something less to something else, and we always dance around that. We don't want to give less money to education. We don't want to give less money to the police force. … And we're not used to rationing in this country. …

I was born in England just at the beginning of World War II, and I didn't see my first banana until I came to this country, and when we got our first banana it sat on the mantelpiece -- it turned from green to yellow -- and then the family divided it up and ate it. I knew what rationing was about.

I came to this country, and there is no rationing. Everyone has a right to everything, and we're a very generous, very kind people. If you have kidney diseases and you're 90 years old and you can't think straight and you can't see anymore and you don't hear well and you talk to yourself rather than to other people and one of your legs is missing, you have a right to have kidney dialysis, and you'll get it if you ask for it or if your family asks for it. Our law says that. Other nations would not think that very rational, would not do that. They're more used to constrained resources. They're more used to explicit rationing. ...

In our film, we meet people who can't go to the doctor, who can't afford the medicine they're supposed to take. To me, that's rationing of care.

It's inappropriate distribution of resources. It's a moral catastrophe. It's sad. But you can't go and give a big speech and say, "We're rationing care," because no one will listen to you in this country. ...

So what would you say are the reasons that we spend twice as much as other countries and have fewer people getting the care they need? ...

… Our institutions are paid pretty well. … Some of the doctors I think make too much money; some of the institutions make too much money. Some of the pharmaceutical companies bring in too many dollars. Some of the insurance industry, for sure, makes too much money. I think a lot of doctors are angry about them. And in the end it adds up to an awful lot of money. …

If we had a better system, if we had better organization, that could probably save a lot of money. These are experiments that are under way. ... Using electronic technologies such as computers, there will be much more self-care in the future, I predict. I think there will be many patients who are less interested in actually seeing a doctor but will be treating themselves with the aid of the Internet or with a faceless doctor, the other end, or a nurse or just an interactive protocol. There will be much more electronic commerce. We're seeing that already.

I'll be sitting in front of my computer looking at your rash on the computer -- looking at the rash of the young woman I saw today -- passing judgment just as easily as if she came in to pay $130. I'm not sure how I'll be paid for that, and people are nervous about that, but you're going to see enormous changes in the way we deliver care, and some of that will probably save money; some of it will not save money but make care better; and some of it will be foolish.

But then the next step is a woman with the rash picks up the phone to call a doctor and gets a guy in India.

Oh, there's absolutely no question that will happen. I dictate my notes after I saw the patient today and an automatic machine translate[s] my word into imperfect English. A man in India sits down, or a woman, and corrects it. I get it the next day on my computer. I edit one more time and sign it electronically, and that's the way I do my business nowadays. There's no question that everything we're going [toward] is global, and I'll also probably be treating people in India that way. It's a very exciting, very interesting and very scary time in medicine in that sense.

Let's talk about health insurance. I would think that for-profit free enterprise is the most efficient way to do anything. But the American insurance companies have administrative costs six, eight, 10 times as much as nonprofit insurance firms overseas. What's going on there?

The insurance industry in this country is really a puzzle to me and many of my colleagues. Quite honestly, I don't really see the value added. What I do see is an awful lot of paperwork, an awful lot of incursion into my time and my patients' time and an awful lot of fuss at times about very little.

They're not regulated. You know, we're watched over increasingly; patients are watched over increasingly; federal agencies are watched over. But the insurance industry, as far as I can see, in large part is out there to make some money, to do well, to reward its shareholders if it's for profit, and I wish they were treated a little bit more like a public utility. I wish they had rules. I wish they had things that they should follow. I wish they had more constraints in what they do.

I wish they weren't such big bullies. It often feels to us as doctors that we're being bullied by the insurance industry; that our patients, who are supposed to have them as their advocates, are also being bullied by them. And I don't really see, when I sit back and think about it, if they're worth the 10 or 15 percent incremental costs that come from them being in the middle of the picture.

They would say the value added is they're helping keep costs down. Do you see that? Is that happening?

I don't think they're really keeping costs down. Let me give you a very simple example. You're on Lipitor for your high cholesterol, and I get a message, and my patient gets a message: "We don't cover Lipitor. We carry another drug that's the same family, the same class; works just as well. Please prescribe that different drug, Dr. Delbanco." I do it. Then I say to myself, but it's not identical. I have to monitor the cholesterol now on Tom and see what's happening. And, in fact, I'd better be sure that it's not harming his liver. So, Tom, would you make an extra visit and see me next week? Come in fasting. I'll get some blood from you, and I hope you're going to be feeling OK, because if this doesn't work, I'll have to call the insurance company and say, "Tom really needs to take that first drug." So it's not so clear that they're saving a penny. ...

You've been critical of the health insurance companies, their high costs, their bullying doctors, but your state, Massachusetts, just passed this plan where they mandate [that] everybody buy insurance from the private health insurance companies. Is that working?

We don't know if it's working yet. It seems to be working. There haven't been any enormous catastrophes.

I think the state would be afraid to go against the private companies and say, "Let's do it a different way." They have enormous power. So it's a practical, pragmatic way of going about it and starting, and so far people feel pretty good about it. We're being held up as a model, and more people have insurance than used to. We've been seeing people coming to us who say, "I came to you because I got insurance." That's pretty exciting. "I didn't go to the doctor for many years because I wasn't insured. I now have insurance because of the new system in Massachusetts." To me, that's terrific. ...

We hear that Massachusetts has a real problem with runaway costs. Does that sound right to you?

You know, I don't think the changes have been so enormous. People forget one thing: All these uninsured people, when they were sick, they got care. It was chaotic care. They'd come to the emergency room, they'd get free care, and then places would be reimbursed in part by pools of money in states [where there] were free-care pools of money.

What Massachusetts is trying to do -- and what I think the nation should try and do -- is make care more rational, more organized, more systematic. And whether that will cost more, less or the same in the long run, I don't think, honestly and truly, we have a clue. I do think it will be better for people, and if you come back to the moral discussion, that has to be good.

One advantage from Massachusetts is they had a pretty low rate of people uninsured relative to other states.

Massachusetts has been generous. Poor people knew that if they needed health care, it might be sensible to move to Massachusetts. Medicaid is terribly different in different parts of our country, has terribly different coverage rates. It offers very different access, and we've been a generous state for a long time. I know that, and it's hard to generalize from us to this big nation as a result of that. But I think the early sense of this experiment in this state is positive, and I don't think people are moaning, even at a time of economic catastrophe, that it's health care in Massachusetts that's going to break our backs.

I gather Massachusetts drew an income line at $62,000 a year and above that you don't get in the system. Is that right?

You know, the day we can develop a system in which people don't fall between the cracks, we're going to be pretty good. We're trying the best we can. The actuaries sit there, and they work and they work and they work, and they say, "On average this should work well for most of the citizenry." And we'll make mistakes until we as a nation say: "We're going to cover everyone. The hell with this. Everyone in this country gets health care, and we'll figure out how to pay for it after we do it," in a sense.

When we went around the world, other countries [have designed] systems where people don't fall through the cracks because everybody's covered. How come they can do it and the United States can't?

Other nations have said, "We are going to our citizenry, and we're going to work backward from that." So you hear stories about [how] you have to wait a long time to get your hip replaced electively in some of those countries. They're rationing care in a different way. They're distributing care in a different way. ...

[You have to wait a long time in Canada. Canadians don't mind] waiting that much, as long as the rich Canadian and the poor Canadian have to wait about the same amount of time. Now, that's a social mind-set.

Yes. Social mind-sets are important. People line up in England. They queue in England, right? They wait for things. When does an American not try and get to the front of the line? We're a different nation, and it cannot be understated how important that is when we develop systems or when we compare ourselves to others.

These nations in Europe that we always talk about, they're tiny. They're as big as one of our states. We're 50 states. You travel around this country, you're [more] in a ... foreign country when you go 1,000 miles away from where you live than if you go to Europe in some respects. It's very hard to get one size that fits all in that circumstance.

You said the other countries have made a decision that everybody should be covered, and then they found ways to do it. Are you saying that moral decision to cover everybody has to come first in doing health care reform?

I actually think there are so many forces against change in this nation -- I don't care what the change is -- that sometimes you have to begin with a statement that says, "We're going to do this, and now we're going to figure out how to do it," not, "Should we do this, and let's try and figure out if we can do it." That has always paralyzed us, because there are so many forces on so many sides of the coin that say: "We don't want that change. We're not going to permit that change. We're going to lobby this person and not have that happen."

But if we as a nation woke up one morning and said, "What is incontrovertible is that we're going to take everyone by giving them access to care, at least financial access to care," I think we would then muddle through and make systems that work for those people. It would be very hard; it would be painful. We'd make a lot of mistakes; we'd get a lot of things wrong. But it's a much better chance of having it happen than going the other way and going from the bottom up.

Americans are decent people. We're generous people. Why haven't we made the commitment to give health care to everybody who needs it?

Because I don't think there's been a leader who's stood up in front of the citizenry, made the moral argument, and said: "Folks, I hope you agree with me. In fact, you elected me. You said health care was a very high priority for everybody -- 80 to 90 percent or whatever the last poll would be. I am going to do it." I think the citizenry would then fall into place. But what happens when you do it in little bits of pieces, little piecemeal thing, there's an equal and opposite argument for everything, and that leads to paralysis.

There's another view [of] paying for health care that we ought to make people pay out of their pocket for anything up to $3,000 to $4,000 and just have insurance for the really big stuff. That work?

There have been debates for years about how much -- no gain, no pain, right? -- how much should you pay before you get something. The argument has always been, if you have to pay for something, you don't come for a frivolous reason. You think twice about bothering that busy doctor who should be with someone else. The argument against that is that when you get the first symptom of something that can be treated then, but not treated well later, that that will keep you away.

It's very hard to get that right number. There have been fascinating experiments about that over the years where we've literally taken cohorts of patients and charged them $100 a visit and another cohort and charged them $500 a visit and another cohort that says, "This is the deductible," and see what happens to those populations. And you can see little differences. But it's a very complicated question. The bottom line that we often forget is that most people feel fine most of the time, and when they feel sick, everything changes.

How would it work for your patients if, say, they had to pay out of their pocket up to $1,000, and then, if you had to do something serious, the insurance kicked in?

That happens with many patients right now.

Really?

Yeah. We have deductibles. You may have a very fancy insurance that doesn't give you a big deductible, but most of the citizenry has an insurance plan that says after the first $250 or $500 or $750 or $2,000, and then you get coverage. When it's $5,000, we call it catastrophic insurance. ...

There are many plans you can buy. If you go [to] an insurer, they will offer you all kinds of little plans with different deductibles, and the cost will be the same. It's not very different from a mortgage. It's not very different from buying a car. It's not different from buying a house.

If you had to buy an insurance plan, would you buy one of those very high catastrophic [plans], or would you buy something that pays for regular care?

You're asking a silly question. Some people are risk-averse; some people take risks. Some people insure everything in their houses; some people say, if the house burns down -- of which there's a low probability -- I'll lose everything, but I've saved all the money for the last 30 years that I didn't pay for insurance.

People, when they feel well, don't want to spend money on stuff they don't have. One of the problems with health care is, again, if you feel well, why should [you put] all this money out? Are you insurance-minded or not?

That's the question to really ask, and people vary all over the lot in that respect.

Other countries have decided, therefore, they have to make everybody buy insurance to get over that resistance.

I'm going to be the last person that says that the nation should tell everyone what to do. I think the citizenry should have abundant choice. I think they should have a right to do what they want. On the other hand, there are interesting public health implications if you don't have insurance. Let me give you an example. Let's say you don't want to buy insurance.

I'm healthy.

You're healthy. You get a little something here, and then it turns out three years later, you have an awful disease that you might have gotten past or prevented if you'd had insurance and gone in in the first place. Look what you're doing to your family. Look what you're doing to the rest of the world. Look at the expenses you've incurred -- both emotional, social and dollarwise -- for the rest of the world by saying, "Well, I'm risk-averse." ... Look at the expense you've [incurred] for our society by making that, in a way, selfish decision, or you could call it just an individual decision.

So what are you telling me? We should do the nanny-state thing and say, ... "It's costly to a lot of people, and therefore you have to do it"?

I would take the public health point of view. I think it's fair to say, what is the greatest good for the greatest number of people? And to that degree you lose some choice. You know, you would like to be able to drive your car very quickly. You have a fancy car, and you'd like to hit 100 on it someday. But society has said you shouldn't do that because you may hurt someone else. So I think overall it's fair to say that our nation should make it such that everyone has access to care, everyone has to try and use that access in as rational a way as the body politic, as the collective, thinks. ...

[There is the argument that buying insurance is a matter of personal responsibility.] What do you think of that formulation?

I would extend it more widely. I think it's personal responsibility, and what you [make] as a personal decision has enormous impact on other people. My wife used to say to our kids: "You should wear a helmet. It's your business if you want to crack your head, fine. But if you crack your head, look what it's going to do to me. Look what it's going to do to everyone else to take care of you for the next 20 years. That's a selfish decision. Therefore, put on that helmet." ...

We heard a lot of families here just can't afford the cost of insurance under the Massachusetts plan.

I think that may be true. You know, everything is relative. And health care is very expensive; it's gotten more expensive. And the problem is that it's gotten more expensive because a lot of the things that we do are expensive work. We've got these new gadgets. We've got these new X-rays. We've got these new medicines. We've got things that really work, and they cost a lot. ...

All I know is that, as a doctor who's been practicing for a long time and teaching and studying for a long time, I can keep people alive now with a good quality of life whom I would have just said goodbye to earlier on. That's very expensive. So that trickles down to everybody. ...

We saw overseas that there's often very strong price control from the top. They tell the doctors what [they] can charge for an MRI or for fixing a broken leg or something. Could that fly in America?

... I like the violin, and I remember there was a surgeon in Cleveland who had a Stradivarius. I would have loved to have a Stradivarius. ... Someone asked him, "How much did it cost?" He said it cost him 22 gallstones.

That's piecework, right? That's being paid by the stone.

Yeah.

People used to be paid by the number of stitches they put in a wound. If you could sew really well, you could get more money for a given wound. I don't think it's so bad to put caps on that. I think this kind of piecework way of giving health care is ridiculous. ... I shouldn't be paid by everything I order for you or every operation I do or every test I do. You pay a surgeon a lot of money to take out your gallbladder; you pay him or her virtually nothing to tell you to leave it in. That doesn't make sense.

He's going to want to tell me to take it out --

You bet.

-- and get paid for it. Are you spending money on defensive medicine so you don't get sued?

My own bias is that we overstate this defensive medicine quite a lot. I'm a primary care doctor. Primary care doctors don't get sued all that much if they have good relationships with their patients, which is what we're about. ...

So I worry about it less. There's lots of hoopla about defensive medicine, and I spend a lot of time telling my students what test not to order rather than tests to order. It's very easy to order a test. One of the problems with the electronic gadgets [is] that ... you push a button and you order something. It's very easy. Everything is too easy to do these days, and they run up an enormous cost. We used to have to call someone to get a test or write it down or do something. But I actually think defensive medicine is a little overstated.

[What about doctors being too busy with procedures to give patients proper attention?]

The problem with our new technologies, the problem with new medicines, the problem with our electronics is, to some degree, they distance us from our patients. We're playing with our computer or ordering the 15 new things that we can do now, and the human interaction fades into the background.

On the other hand, [computers] can also facilitate that interaction. If I know what you need when you come into my office before you come because you send me an e-mail listing what's on your mind that day, if I can send you via the Internet some educational material that you'll really use and remember -- you won't remember a thing when you're with me, I know that, but you may remember something I send you afterward -- then I can spend some real human time with you looking at you as a unique individual, and that interaction will mean a lot to you and to me. And by the way, that's the pleasure of being a doctor and hopefully the pleasure of a patient having a good doctor. ...

[We spoke with] Dr. Jeff Kang at Cigna, and he said he'd like to see a price schedule, probably set by the government, that covers the procedures so everybody pays the same thing for the same procedures.

... You know, that's reinventing the wheel, as we did very often. There was discussion about that when Jeff really was a student here probably 30 years ago or so. There's a lot of merit to that, but we get around all these systems. That's what's so bad. If you have a one-inch-long wound and you get paid X dollars for suturing up that wound, then you find some of the doctors saying, "There was also a bruise, and the person was also slipping, so there were really three things I treated."

It's very hard to pay in little bits and pieces for everything. There are all kinds of interesting experiments. You know, it used to be if you needed coronary artery bypass surgery, you paid to visit the doctor, then you paid for another visit, then you paid for another visit, then you paid for the surgery, and then you paid for the postoperative care. Now they bundle these things. You know, if you need a coronary artery [surgery], it's a full-service thing.

It's very hard to do that for a lot of medicine. You know, you may have pneumonia and kidney failure and a little bit of chest pain and you're depressed. So how do I bill for that under the Jeff Kang principle? Do I spend the rest of my life filling out little spots, or ... you should pay me to be a doctor and leave it at that?

A salary.

Yes. ...

You keep telling us [that] people are different. Some people want this; some people want that. We should allow patients and people to be different. And at the same time, you've endorsed this notion of Medicare for everybody or everybody under the same system. Isn't that a contradiction?

I don't think so at all. Things are not black and white. This world is gray. We make terrible mistakes when we think "on the one hand" or "on the other hand." We have to figure out systems that modulate. If we begin with the principle that you will have health insurance, it will be different in different parts of the country. It will be different for different patients, and it will be different for different doctors. But we should be able to muddle along and get it straight.

Would covering everybody save money for America?

I have no idea what the net impact on our costs would be if we covered everybody. I really don't. You can say at one level, well, we'll have a rational, seamless, beautiful system that has to bring down costs. At another level you can say, we're having trouble taking care of most of our people now. You add another 40 million, heaven knows what's going happen. And no one in the world can know. That's the problem the economists face right now in Washington, isn't it? They don't know what to do about the crashing everything. There's no empirical evidence. We don't have evidence for that in medicine either.

So I think you're saying to me, instead of worrying about these economic imponderables, we should focus on the moral question.

I think we should begin with the moral question. We should make a moral decision that all our citizenry has health care, and then after that, we'll have to get downright dirty, roll up our sleeves, figure out how to do it. But say that it's a given that we will do it. Then we may be able to come up with a system that's better than what we have now, and is certainly much more equitable. …

posted march 31, 2009

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