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Dr. Irwin Redlener on health care reform.

Monday, July 6, 2009
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HH: This hour, someone from the left side of the political spectrum. Dr. Irwin Redlener is the president and co-founder of the Children’s Health Fund. He’s also the director of the National Center for Disaster Preparedness. He’s a clinical professor of population and family health at the Mailman School of Public Health at Columbia University. He’s also a clinical professor of pediatrics at the College of Physicians and Surgeons at Columbia University. He knows of which he speaks, but I think it’s fair, Irwin, isn’t it, to refer to you as a man of the center-left or left?

IR: Oh, I like that center part of it, but yeah, I would call myself a more progressive, I guess, thinker about when it comes to health care.

HH: Now I know you’ve been paired with Dr. Moffit before on PBS in debating the future of health care in America.

IR: Right.

HH: How about Professor Christensen? What do you think of his work?

IR: I actually don’t know.

HH: Okay, he wrote The Innovator’s Prescription, so, HBS. We’ll put that aside.

IR: Yeah.

HH: Irwin, let’s start from 30,000 feet.

IR: Yeah.

HH: What do you think is wrong with the American health system?

IR: I think the American health system spends way too much for what we get in return, that it’s, we have some extraordinary, innovative, brilliant, world-leading health care opportunities for people, but it is very scattershot. It is disorganized, it is incredibly expensive, and it leaves a whole lot of people out of the system. So…and I don’t even like using the word system, frankly, when we talk about it, because it’s so random and disorganized, that it needs to be more organized than it is. And I think we can sustain the innovation and the excellence, and at the same time make the system a heck of a lot more cost effective when we get finished with whatever we’re going to call health reform.

HH: Now what is, let’s also set the stage for what the Children’s Health Fund is, and what it does.

IR: Yeah. So the Children’s Health Fund is a 22 year old organization now that does health care for what we refer to as medically underserved children. These are kids living in rural and urban communities around the country who for a variety of reasons do not have regular access to health care. And they tend to be everything from homeless kids in urban areas like New York City and South Central Los Angeles, to children living in very difficult economic environment in rural areas throughout the country. So it is a wide range of children, all of whom have other, different kinds of barriers in terms of getting the health care they need.

HH: Now in terms of the large problem that you described, and the specific problem that the Children’s Health Fund addresses, and by the way, the website for it is www.childrenshealthfund.org. And a specific problem, does the legislation being debated in the House and the Senate address those concerns of yours?

IR: Well, in a general way, yes. But…and I wish it was a lot more specific. You know, the reason, one of the reasons that we are so involved in health reform is not that I like hanging around Washington, D.C. But since we have on the ground actual health care programs for human beings and children in particular, we have some very specific perspectives that I would like to see addressed that are more peripherally discussed now because it’s getting lost in some of the macro issues of tweaking this massive health care industry. But you know, just to answer your question, which I think is one of the most important questions we have to deal with, what’s the reality for people like us who are doctors and nurses in the field there, and what are we seeing? So, and interestingly to your point, we see a lot of children who have health insurance. They have Medicaid or they have sometimes even, if dad’s working, they have some employer-based insurance. But they may live in an area that doesn’t have a doctor. There may be no doctor for two counties. So it is not just a matter of fixing the insurance system. It’s also a matter of understanding what the needs are in terms of where are the doctors, where are the providers. When Massachusetts went to universal care, the waiting time to get an appointment with a doctor, you know, an internist or a family doctor, went through the roof, because no one had really fully addressed, or even understood, the issue of are there doctors to provide the care once we fix the insurance part.

HH: Now you know, Dr. Redlener is my guest, he is the president and co-founder of the Children’s Health Fund. Irwin, that’s my biggest problem with this. As you know, as we’ve discussed in the past, I’ve served for more than ten years on a foundation board that gives away millions of dollars to serve underserved children in Southern California.

IR: Right.

HH: And lots of them have insurance. Very few of them have doctors or actually cultural backups to go get medical care.

IR: Exactly.

HH: So this debate about health insurance to me often misses the boat, for example, an epidemic in childhood obesity. It just doesn’t have anything to do with curbing that epidemic.

IR: And not only that, even if you have insurance, we deal with a lot of children with obesity and nutritional problems, all of whom are extremely, as you well know, Hugh, at risk for diabetes and other diseases. So I would like to have a system where my doctors would actually get reimbursed if they spend time with a child who is getting obese, did not yet have a diagnosis of diabetes, because without the diagnoses, you can’t get payment for it. So it disincentivizes some of the most important work that we do, which is around prevention and discussing lifestyle and diet and all that kind of thing with children, and adults for that matter. So there’s something just, there’s so many issues that need to be addressed at once, which is by the way why, you know, I did some stuff in ’93 with the Health Care Reform Task Force at that point. And it became 1,300 pages, because it was so complicated at the end of the day, which worries me about anything that looks like a quick and simple fix to what we have in America.

HH: Let’s get to the center point of this debate, left, right and center, which is the so-called government option, the so-called public plan.

IR: Yeah.

HH: Do you support that, Dr. Redlener?

IR: I support the public plan, because again, I’m coming, really, from my on the ground experience, Hugh. So I’m looking for a place where the maximum number of people can get into the system. So it seems to me that the public plan is one way of doing it. People have talked about co-ops and other arrangements. And you know, I believe that…well, let me put it this way. I’m not sure what else is going to reach people who are in a borderline financial situation in terms of their family finances are concerned. How do they deal with this very costly health care system, and health care insurance that we have now, just to take that as a barrier? And if you don’t get into some significant options for people to buy into it, if we’re going to maintain the fee for service system that we have, which I think we probably should, then what is the other options other than a public plan? So the answer is long-windedly, yes I do support…

HH: Well, that disconnects for me, because we just agreed and stipulated that the health insurance…a lot of people have health insurance that can’t get them doctors.

IR: Yes.

HH: Then we stipulate they need to get to doctors. And so I think of this massive amount of money we’re going to spend to get people insurance when what we need are community clinics that are paid for?

IR: Listen, I don’t disagree with that. So in other words, if somebody said instead of a public option, we’re going to triple the, you know, whatever the support is that we need for community health centers, and make sure they’re available to people, let’s say on a sliding scale, which is the way they function now, as you know, but really make them available. To me, that works. But right now, although the community health centers are getting funding, it’s not necessarily that fast or efficient, and we have a lot of people that are still out of the system. If you live in a community where you have a good federally qualified community health center, FQHC it’s called…

HH: Yup.

IR: You’re in good shape. Yes, you can get access to care. So I’m for whatever works to get people into the system. Now there’s one caveat here that’s very important to me, is that I am very troubled, now I’m talking as a physician again, by the amount of things that are done to people, or for people, that are unnecessary, and are over the top unnecessary. I have countless examples of what…one of the things that drives up the costs a lot. I don’t really believe in rationing, for instance, because of your age, let’s say. That’s an individual decision between the doctor and the patient. I do believe in rationing to the sense, rationing to the sense that if you go to a surgeon, and the surgeon says you need to have this procedure, I just want to make sure that the surgeon and the patient are operating from valid information. And I think we do far too much interventions and testing and MRIs and procedures that we don’t need to be paying for.

HH: Well, we had that whole debate earlier this year on whether or not every prostate cancer needs to be surgically removed. That’s sort of an example of that. But I want to stay, and after the break we’ll come back to it, with Dr. Irwin Redlener, on the disconnect, because I think this whole debate has got a huge disconnect, which is are we talking about the uninsured, or are we talking about the failure to get medical services to people who need them?

IR: Sure, yeah.

– – – –

HH: By the way, I have to ask you while I’ve got you, Irwin, how’d you make of the United States response to the Swine Flu when it arrived on our shores?

IR: Well, this is a very interesting point, and it’s actually related to what we were talking about before, Hugh, so I think we’ve made a lot of progress in our ability to do the public health things we need to do with an epidemic or pandemic. So for instance, we got pretty good at surveillance and tracking the disease, although we still have real problems with our laboratory capacity to make a diagnosis. It’s kind of ridiculous that there were these long, long waiting lines for lab samples to be analyzed in Atlanta, and we’re just now beginning to spread that capacity around the country. But the big problem to me, and I got a chilling reminder of this, is that the health care system is absolutely not ready to deal with a major pandemic, if it were to occur. And don’t forget, the Swine flu episode, this outbreak that we had, called a pandemic, was really very mild. But we had absolutely overrun our many emergency rooms in many parts of the country. And it is a little bit of a hint as to what we might get in a really serious pandemic, where I’m telling you the health system is way, way ill-prepared to deal with any sort of major pandemic.

HH: Well, I’m wondering if you agree with me we should still be on alert, because if I recall, the 1918 epidemic arrived in the spring, went into hiding in the summer, and came back with a killing vengeance in the fall.

IR: Yes, absolutely. They typically occur in what’s called waves, literally. So there’s a quiescent period, which we’re in now. This could come back far more resistant to Tamiflu, much more severe, and much more lethal. Now nobody knows this for a fact, and it could be mild when it comes back. But the fact of the matter is that we really do need to be on the alert, and I think our public health community is in fact monitoring it very, very closely. But we’re not going to be in a position in October, November, God forbid we get a really severe pandemic. I dread what’s going to happen to the hospitals and the health care system.

HH: All right, let’s go back to the debate underway on Capitol Hill right now, and A) are you participating at all? You’re one of the…I asked Clayton Christensen and I asked Bob Moffit this. Bob Moffit testified on the Hill, Clayton Christensen’s phone hasn’t rung. How about yours, because I always view Congress as sort of the blind leading the blind when it comes to health care reform?

IR: Well, you know, first of all, I have been doing a little bit, I’ve been asked a couple of things, not much, not significantly, let me put it that way. I’m not a consultant for, or on any kind of regular basis, and I don’t know who’s rolodex I’m in. But I am available, and would be happy to help if they asked me to do so more. But as far as what’s informing the Congress right now, you know, it doesn’t take long for health care to become highly politicized and ideological as it’s trying to wind its way through that big sausage factory down in D.C. And I don’t know what we’re going to get at the end of the day. But I do know that the President is very committed to doing whatever is possible to fix the system. And of that concept, I am extremely supportive of course. But I do think we’re going to have to watch carefully and see what that end product is, because there’s a lot of room for getting this done very superficially, and not really getting the progress that we want to get at the end of the day.

HH: Well, you’re a doctor. It strikes me if my critique is right, that it’s like a patient arriving in an ER who’s got appendicitis being treated for a broken arm. It just does not seem to make sense to me that we look and we see a huge…we have a number of issues – cost and underservice.

IR: Yes.

HH: …and that we choose to treat this by the creation of a massive public bureaucracy, the public choice, the public plan, the government option, whatever you want to call it, that will employ, you know, thousands and thousands of federal bureaucrats making thousands and thousands of decisions about what procedures should be given to what people, when in fact we’re not empowering doctors, and we’re not increasing the supply of medicine.

IR: Well, here’s the problem, Hugh, and I understand where you’re coming from in this, and listen, I think the fact of the matter is that we say we have choice now, and I mean, I’m making a fine living, thank you. I’m working in the university. I have a choice of two different programs at my university. I choose one program. I look at the list of who’s available for primary care doctors. I’m making calls left and right. My choice is actually far more limited than a lot of people think it might be. Secondly, who’s making decisions about the health care I get? Well, the doctor says I think you need this. Do you know how many times the insurance company tells me, and even in the medical profession, we’re not covering that, or you can’t have that? Or they do everything in their power to make it more difficult for people to get their claims paid. That’s not exactly choice and freedom and independence. Yes, it may not be a government bureaucrat telling me what to do, but it certainly is, often for many of us, maybe even yourself, an insurance company clerk that you’re fighting with about something that you or your loved one needs, and that’s just horrendous. And I don’t think, I don’t see anywhere near that being an advantage over a government system.

HH: Well, I’ve actually lived that with in-laws who have been denied critical care.

IR: It’s horrible.

HH: It’s horrible. I’m a lawyer. I know how to scream at health care bureaucrats in the private sector. But again, I go back to, I can agree with everything you said. Tell me how this massive bureaucracy changes any of that, though.

IR: Well, here’s what…think about Medicare. So there are problems with Medicare, there are Medicare issues with their payment for doctors, and there’s the hospitals are frightened it’s going to be cut back, and sort of their reimbursements. But the fact is, the system works. My mother’s on Medicare, you probably have relatives on Medicare. They are generally happy about it. And why don’t we just expand Medicare to make it available to more people? That, in essence, is what we’re talking about in a public plan. Their overhead is…

HH: Stop. I agree. We’re talking about extending Medicare to the population, right?

IR: Yes.

HH: The cost of that is staggering.

IR: I know, Hugh, but it’s not exactly cheap to have 47 million people not in the system, who when they get really sick and show up in an ER, they’re getting charged, it’s costing unbelievable amounts of money for things that maybe could have been prevented in the first place.

HH: But you know it’ll happen. If we go Medicare for everyone, the government’s going to put the squeeze on reimbursements, doctors are going to begin to dump patients, and they’re going to begin to do, they’re going to have boutique and concierge practices, and the elite will be taken care of, the elite, and the rest will get in line.

IR: Yeah. Well, let me ask, this is what I would say to the people, let’s say, on the other side of the debate. What is the alternative to this horrible mess we have now where the insurance company clerks are prohibiting me and people I know from getting the health care they need?

HH: $100 billion dollars a year for community clinics, so that poor people get served. $100 billion bucks a year. It’s one-tenth the cost of what the Obama administration is pushing, and it will deliver hundreds of times the actual care.

IR: And you know, I don’t disagree with that. So the question is, it is a politically feasible reality? And this is the point I was making to you before. I don’t care how we get there. But we have to figure out how we’re going to control the costs, prevent these unbelievable numbers of unnecessary procedures and interventions and surgeries, and make that people are getting good, quality, comprehensive care that they need, that’s preventive in its orientation. If we could figure that out, I don’t think I have a problem with that. But how are you going to get $100 billion dollar a year program passed?

HH: Because the Republicans will spend that rather than the trillion that the government plan will spend.

– – – –

HH: Irwin, for your patients, I want to make sure we at least tell people what the Children’s Health Fund does, and how they can help you in doing what you do.

IR: Yeah, so you’re asking how to get in touch with us?

HH: Yeah, yeah. Give a commercial.

IR: So what we do, we’ve been doing this for 22 years, Hugh, and thanks for this opportunity. And basically, we, this is with no barriers, we say if you have children, and you can’t get health care for them, and you live in a community, or people are homeless and now the economic impact of the recession has been horrible, and a million more children are not getting the health care they need than was the case in November of ’07, we have programs that really allow people to get good, quality health care, no strings attached, and help them through some very difficult times. And if people want to know more about the organization, by the way, we’re very happy, I’ve got to tell you this, third year in a row we were given four stars, the highest rating by Charity Navigator. Only 11% of the not for profits in the country get that kind of rating. So people can learn more about it by going to www.childrenshealthfund.org. Just look around the site, and you’ll see what we do.

HH: Yeah, it is a regulator of this. I can say when you get up to 87% effective delivery of services per dollar, you’re in the highest tier of medical services, because the overhead is so extraordinary for these things.

IR: Yeah.

HH: Now Irwin, dream big here. If the government said Irwin, here’s a billion dollars, or here’s ten billion dollars…

IR: Yeah.

HH: Couldn’t you deliver the kind of care we’re talking about without a bunch of bureaucrats? If we gave it to doctors to do doctoring, or nurses to do nursing, doesn’t that make a lot more sense than giving it to feds?

IR: Well, it makes a lot of sense, and the question is, does it make more sense than giving it to insurance companies. And I still, I guess I’m even getting more confused, Hugh, about what is it that these big insurance companies are actually doing for us right now? And I don’t know the answer to that, so I’m asking it rhetorically. But I do think there are people who need health care, and there’s doctors and nurses who are willing and able to give it. And somehow, there’s too much in between those two worlds there. And I do think that we could spend money wisely. And so the idea is to get at close as possible to that direct model. There’s a patient, there’s a doctor, there’s a way of paying for it, and let’s get on with it. But it’s gotten very, very complicated. And I’ll tell you, as far as medicine is concerned, twenty five years ago, American medicine knew what was coming. We had a major crisis brewing as you well know, Hugh, in the health care system. Costs were going up, people were uninsured and so forth. American medicine stepped away from the plate. They did not pick up the chance to fix our health care system. They reneged, and left it to government and insurance companies to take control of the country’s health care system. And I always think back to an opportunity that we would have had as a profession to really be front and center, and we flubbed it, unfortunately.

HH: Doc, last year at this time, I was in the Dominican Republic with Children’s International, and I visited a lot of the community clinics run by CI.

IR: Yeah.

HH: And they have a lot of doctors in the Dominican Republic.

IR: Yeah.

HH: Now they may not be trained the way you train them at Columbia, but they’re trained to do a lot of stuff.

IR: Yes.

HH: Isn’t part of our problem that we have an undersupply that’s getting worse of physicians and nurse practitioners?

IR: Oh, we have a terrible undersupply and maldistribution especially of doctors who do the so-called primary care – family medicine, internal medicine, and pediatrics. And the ones we do have are bunched up in the cities and suburbs leaving, literally, there’s about 45 million Americans, not the uninsured, but people who live in federally designated health shortage areas, where there’s simply not enough doctors. You know, my son just graduated from medical school two years ago, $185,000 dollars in debt. And here’s a kid that we’re helping him, he’s a wonderful guy, and he probably would have gone into pediatrics like his old man, but he didn’t. There was no way to pay back these medical school loans if he went into one of the primary care programs. And we have to be able to understand the entire system. The point you made at the beginning remains apt throughout, Hugh, which is that we have to think of several things at once, and one of them is how do we get doctors and clinics, community health centers, whatever it is, to where the patients are. And then how do we pay for it.

– – – –

HH: I’ve got to cover three subjects with you, Irwin, again asking, does the law that we see unfolding on the Hill treat these. One, tort law – you and I both know that the tort bar is making the cost of medicine prohibitive. It drives a lot of those tests and defensive medicine that you bemoaned.

IR: Yes.

HH: Do you see this law doing anything about that?

IR: I don’t actually see that definitive tort reform is going to happen in this round. I think it needs to happen, and it needs to happen, maybe we probably disagree on how it should happen. But the fact of the matter is that I am concerned about the fact that it’s not so much the, I don’t care about how big the level of the lawsuit award payments so much as the defensive medicine that’s practiced, where people have to order everything for everyone. I spoke to a doctor literally yesterday about treating patients, he was talking to some residents, with something called a ganglion, a little swelling that you get on your wrist, that’s treated usually with smacking it with a book, and it just dissipates.

HH: I like that kind of medicine.

IR: Yes, I like that. It’s my favorite kind. So the resident said to him, well, I guess we should order an MRI, and this guy who lives next to me, he’s an orthopedist, said no, no, we don’t get an MRI. We don’t need an MRI for this. We need to do X,Y,Z. It’ll take five minutes, and that’s all we need. So the young resident was taught by somebody else that this needs a very, very expensive thousand dollar test, when it clearly does not. So this is rampant in medicine, unfortunately. And we do need to do something about it.

HH: Well then, don’t damage limits add…that’s what works in California. You only get a quarter million bucks max for pain and suffering on unrelated…so…

IR: Well, listen, but also what works in Michigan and a couple of other pilot projects is negotiations, pre-trial, that keep patients out of the courtroom, where you develop a settlement with the hospital, where doctors who are following the standards of their profession and their specialty are very much not liable for being sued in the way that doctors are being sued all over the country.

HH: That’s a long conversation, and I have to say I don’t think that works effectively. If you get sued, you’re screwed. Even if you win in the end, or you get a decent settlement, and there’s so many strike plaintiffs out there, and so many rotten tort lawyers who will just bring any lawsuit. But let me get to the second one.

IR: Yes.

HH: Nurse practitioners and the de-licensing of non-elite medicine.

IR: Yes.

HH: What do you think?

IR: Well, I’m a big believer in the use of mid-level practitioners and nurse practitioners, but particularly so when they’re in teams. I believe, this is why I like the community health centers so much that you mentioned. You go to a community health center, there’s the doctors, there’s the nurse practitioners, there’s the nurses, there’s the nutritionist, the pharmacist. The whole team is there, and their whole purpose is to look holistically at patients to make sure that they’re getting the best possible care. Nurse practitioners can be extraordinarily effective, and they are effective in many, many parts of the country. And I think with the proviso that they, along with the doctors, are part of these health care teams, I’m all for it.

HH: Okay, last one. Clayton Christensen urges, and this is the Harvard Business School model obviously…

IR: Yeah.

HH: …that we have to push the drugs, we have to push development of new standards. We have to push new technology. Do you think the FDA is helping or hindering us? And do you see any kind of comprehensive solution to drug approvals in this legislation? I don’t.

IR: Well you know, it’s interesting, because since I deal with a lot of disaster preparedness issues, we are very, very concerned from that community about the speed at which new drugs are approved for various kinds of very specific purposes around disaster response. But I do think, I’ll tell you what the good news is. I think Peggy Hamburg, Margaret Hamburg, the new FDA director, is fantastic, and I think we’ll see some very explicit focus on fixing some of the slowdowns in bureaucracies in the FDA, and I’m very hopeful about that agency.

HH: Okay let’s conclude our conversation with Dr. Irwin Redlener by asking you to prognosticate a bit. You’re a doctor, you have to guess all the time, or at least you have to make informed predictions all the time. What do you think’s going to happen this summer?

IR: I think we are going to end up with a health reform, something called a health reform bill. What I’m concerned is that it has the potential of getting watered down enough because of political, ideological, other issues, maybe economic issues, that we’ll end up getting far less than we may have hoped for. So I think we’ll get something, but not enough. And the problem with that is that people will now wash their hands of it and go on to the next topic, and we won’t return to revisit this for a very long time, and that’ll be unfortunate.

HH: Would you be willing to take a bunch of things on your list, Irwin Redlener, that did not include the public plan? Because I know my side will fight forever. We may not win, but we’ll fight forever before empowering the expansion of Medicare into everyone’s lives.

IR: Yeah, well what I would like to see are people focused on the goals. You show me that you can deal with the uninsured and underserved, which I think is a blight on our society, really, to have so many people outside the system, you can serve them, and you can control the costs of health care, and as much as possible, provide the quality and innovation, and I don’t care what you call it, or whether it’s got a public plan or it doesn’t have a public plan. At the end of the day is what are we getting for our money? And we’re spending a lot of it. And we need to have the ability to ask that question, and get it responsibly answered. So I’m not avoiding your question at all. I just think the public plan, I can see it making sense for accomplishing some of the goals I just mentioned to you. But if there’s an alternative that does the same thing and it may be cheaper, bring it on.

HH: Yeah, that’s…because obviously, people are going to call you in Manhattan, you’re well wired in this discussion. There’s going to be something on the table at some point that doesn’t have a public plan in there, and they’re going to ask activists from the center-left and to the left, does this make sense? And are you willing to at least look at that and say yes, go for that rather than stand all day on the public plan? In other words, a public plan for you is not for you a necessary, if not sufficient part of any solution or any part of legislation this summer?

IR: No. Hugh, to me, it’s all about outcome. We could do it another way. Let’s hear about it. But please don’t leave me with an insurance clerk at the end of a disembodied telephone line limiting the health care that my mother or any member of my family, or your family, is getting. This is, we’re not in a good place right now, and it needs fixing, and I think everybody hopefully is recognizing that.

HH: I think they do, and I think it’s all going to be about whether or not that clerk on the end of the line is a federal employee who cannot ever be cajoled because they’re unaccountable, or at least as in the private sector where they stand to lose some business. Irwin Redlener, always a pleasure, Dr. Dr. Irwin Redlener is the co-founder and president of the Children’s Health Fund, www.childrenshealthfund.org.

End of interview.

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