Healthcare Gone Missing: The State of the Union Address

; Henry R. Black, MD; Roxana Mehran, MD


January 26, 2012

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Leslie Kane, MA: Hi, I'm Leslie Kane, Editorial Director for Medscape Business of Medicine. President Obama talked about many important topics in his State of the Union address, but one subject he didn't touch upon at all was healthcare reform. Now, there's so much going on in that area and it's still having a big effect on physicians and consumers, and it is also a topic that evokes strong responses, both pro and con.

Today we have with us 2 physicians who have opposing views on healthcare reform, and they're going to talk about their thoughts on healthcare reform and perhaps about why it was not mentioned more in the State of the Union address.

Joining me today are Dr. Henry Black -- he is Clinical Professor of Internal Medicine and Director of Hypertension Research, NYU Center for the Prevention of Cardiovascular Disease -- and Dr. Roxana Mehran, Director of Interventional Cardiovascular Research and Clinical Trials, Mount Sinai School of Medicine in New York. Thank you both for being with us today.

So let's start right off. Given the magnitude of healthcare reform and all the resulting activity in the medical community, what do you make of the fact that it was not addressed in the State of the Union speech? Was that wise? Let's start with you, Dr. Black.

Henry R. Black, MD: There are probably more important things to worry about right now. Not that I can get into his head or his advisors' heads about what to talk about, but healthcare reform is certainly a critical issue right now, both economically and as far as what happens to our patients and our citizens.

In my view, it's unconscionable, absolutely unconscionable, that we don't cover our citizens compared with what other countries and most of the rest of the world do. Our outcomes data, life expectancy, and infant mortality are so out of line with how much we spend on healthcare. And I think we have to ask why it is that we spend so much and seem to get so little in metrics that you can't argue with.

Ms. Kane: So, you're saying that the fact that he didn't bring it up had no impact and no meaning?

Dr. Black: No, I think it had some meaning, but I think right now we're concerned about jobs, we're concerned about manufacturing, we're concerned about outsourcing things. Those are more important priorities right now. He spent little more than an hour. He didn't do a 5-hour Fidel Castro type of speech, and he has to focus on what seems to be critically important. I think he did a very good job.

Ms. Kane: Okay, thank you. Dr. Mehran, what do you think?

Roxana Mehran, MD: I would really disagree with that. I was sorely disappointed. This is a very important issue that affects us economically, socially, and socioeconomically in every aspect of what we do every day. The healthcare of our citizens is, as you said, very, very important and should be one of the most important topics of discussion. I was sorely disappointed that this was not brought out. The fact that it was absolutely absent from the speech was a major deficiency of our President's address to the nation last night.

Dr. Black: There were some subtle things said that we really ought to talk about. He did mention medical research, something that I'm sure you support as well as one of the things we're not doing well. He did mention excessive regulations, some of which are part of the [Patient Protection and] Affordable Care Act. I think a lot of the regulations have been added and are not going to be helpful.

He did talk about doing the right thing, cost-effectiveness. We have a society and a medical system that have enabled demand-side medicine. The patient comes in and says, "I want this test," and they get it without anybody asking whether that test is really going to help at all. We've seen this recently with what the US Preventive Services Task Force has found out. Maybe we don't need prostate-specific antigen (PSA) testing on everybody.

Dr. Mehran: Can I jump in here for a second? Just to get back to what the President specifically said or didn't say in the State of the Union address, I can speculate on why he did not mention healthcare. He had basically one sentence in the State of the Union address about insurance covering everyone, but beyond that he didn't discuss healthcare reform. I think his current healthcare reform package has a lot of deficiencies.

We all are in agreement that our current healthcare, as it stands today, is perhaps not acceptable and is really costing the nation a lot of dollars. It has a huge impact on the nation's economy. We have to totally agree -- I hope that you agree -- that complete coverage of every single person, while it sounds great, is very difficult to actually implement. Just to go back to what you said about the patient coming in and getting whatever test they want -- I'm a cardiologist dealing with the interventional side. It may be a bit different, but on the subspecialty side of medicine, we as clinicians are spending hours on the phone arguing the fact that a patient needs a nuclear imaging test, a patient needs an MRI. That waste of a clinician's time on telephone conversations with people who are totally not involved is really what--

Dr. Black: I couldn't agree more, but let me ask you who you are talking to. You are not talking to Medicare; you're talking to insurance companies. Insurance companies used to spend 67 cents out of every dollar on healthcare. One of the things in the Affordable Care Act requires that they now have to spend 80 cents on every dollar. That other 13% went to marketing and to CEO salaries, which is unconscionable and adds nothing whatsoever to the health of the patients.

Now having got Medicare and always happily taking Medicare patients, I'm a cognitive doctor, and by the time you get that referral, somebody like me has seen them and said, "I think they need this test." I don't want to argue with an insurance company. I don't think insurance companies add much at all.

Dr. Mehran: But even with Medicare, we're running clinical trials, we're waiting on whether or not a patient is included in a clinical trial, whether or not Medicare will reimburse the hospital for the care that is being given to the patient because the patient happens to be in a clinical trial. There are so many, many issues, I think, on that front.

So what I'm saying -- and I think we're agreeing in many ways rather than opposing -- is that while the healthcare issue is an important issue, I'm sorely disappointed that it was not discussed last night. We do not have a solution. And I think the creative solutions are out there, but President Obama doesn't have them.

Dr. Black: Some of the solutions that you're interested in are part of this Affordable Care Act, such as an electronic medical record. A couple of organizations, one of which is the government and one is the Veterans Administration (VA), have databases for everybody who comes in, regardless of what VA facility you go to. That electronic medical record system has given us the best hypertension control around, except perhaps for Kaiser Permanente in southern California, which does the same thing. Now the question is, how do we translate that? I think it has to come with investment in electronic databases, electronic medical records.

Dr. Mehran: I couldn't agree more with that. I think the ability to not have electronic medical records in silo, but in the very global sense of talking to each other and pooling the data and bringing them together for a patient-based quality outcome, is really the future. We have to focus on that. Unfortunately, I have not seen those types of solutions. There has to be more creative thinking and strategizing on how to implement these really incredible strides we've made toward technology in medicine.

Dr. Black: We need this technology to work. There is a cloud up there, I'm told. I've never seen it, but I've heard it's up there. And there isn't any reason why we can't use the funds that the Affordable Care Act is going to release to get that to work. I think we are focusing on the wrong parts of the Affordable Care Act. There are some very important things: insuring children beyond what they are now, reducing the amount of money that insurance companies can spend on administrative costs rather than on patients. Those are things that are critically important right now. We need a way to deal with paying for drugs and devices, and right now, people talk about rationing healthcare. If you can afford an expensive device, you get it. We're rationing it in a very different way. We're rationing it on the basis of whether you can afford it, not necessarily whether you should get it.

Ms. Kane: You're making some very good points here. Let's move a little bit to another side. Healthcare reform is huge and it's so far-reaching, from providing care to insurance to reimbursements and cost containment. Is there a way that the Affordable Care Act is going to make life and medical practice better for physicians because, as you point out, some are much in favor of it, but many who we hear are complaining and think it's terrible. How will it make life and medical practice better for physicians -- or will it?

Dr. Mehran: Well, I believe that the scrutiny that physicians are under in this era, in these recent years, is so huge that many, many young professionals are steering away from medicine. And the healthcare act is a part of it. Many, many young professionals are very interested in science. Last night, we did see an incredible, young, beautiful scientist, a woman, an Intel Science Talent Search finalist, from this area, come to Washington. But she will not go into medicine (although hopefully she will).

I would love that; it's a wonderful profession. It is one of the world's oldest professions for giving care with no bias to our fellow human beings around us. That's really the role of the physician that has been minimized, has been scrutinized. We are under a microscope. Many physicians are thought of as performing fraud; headlines are all about how terrible physicians are, how inappropriate their use of procedures and medication is, and how drug companies and pharmaceutical companies and device companies have bought them out. This is really a very, very difficult time for physicians.

And this healthcare act is yet another, I would say, nail in the coffin of the field of medicine for many clinicians who felt proud to be doctors, to deliver care. You, Dr. Black, could probably tell us of the wonderful years at Yale and Rush and how you felt that you were the healer. Today, I think that clinicians do not feel proud of what it is that they do, and they feel scrutinized and criticized.

Dr. Black: I'd like to go back a little further, to my medical student days at New York University (NYU). I graduated in 1967; in 1964, Medicare was passed, much to the distress of the American Medical Association (AMA). It was after that event that doctors started to get wealthy, when they didn't do what the lawyers call "pro bono care." We just took care of somebody who was sick, period, and usually didn't get reimbursed for it. I think right now, Medicare pays faster, and the amount of paperwork you have to put in with Medicare once you accept it is much less than you do with the insurance companies you were talking about.

And whereas I am not advocating a single-payer system (I'm getting close, but not right now), I think if we look at senior citizens -- of which I'm a representative right now -- they are very happy to have a Medicare card, and physicians are happy to take care of Medicare patients. When I had an insurance company that used to be in the group that insured me, I couldn't see most of the doctors that I wanted to. Any doctor who takes Medicare, that's fine. I think once [healthcare reform] is [in place], just the way when Medicare started, we'll have a much better system in the end.

The other thing that's part of this Affordable Care Act is something I think you're supportive of, which is the need for cost-effectiveness. What do we do that works? What do we do that doesn't work? That's what I mean by "demand-side medicine." You say you want this particular test, but it hasn't been shown to be helpful. Should anybody pay for that, insurance companies or the government or anybody else? If you want to pay out of pocket, be my guest, but there is no reason why any third party should support something that hasn't been proven to work and is sometimes harmful.

As we begin to look, say, at PSA testing and really look at it in a global fashion, it isn't necessarily useful as a screening tool, and it's even potentially risky once you get a positive study. So, I think there is a lot more in this act that we have to look at.

Dr. Mehran: One piece that nobody talks about that I would like to put out there is that what President Obama and the administration say sounds wonderful: Insure everyone, make sure everyone is getting equal healthcare. There is some rationing of care, as one could imagine -- I think there will be -- but he never talks about the malpractice issues and the fact that clinicians and physicians are under this huge scrutiny with malpractice lawsuits.

A lot of the medicine they're practicing is defensive. It may or may not be cost-effective to practice defensive medicine. But anyone who's ever been through a lawsuit understands how difficult it is and how every line is examined. And if this kind of thing comes through, President Obama, who has a law degree, should probably be thinking about how to handle that part of the equation as well, because you cannot, once again, take away the swords and ammunition that a physician has and give them to the other side for lawyers to come after the physicians.

Dr. Black: I couldn't agree more about liability. I think we all agree with that. But in my view, it is the government's responsibility to build roads and give people bicycles. If you want more, you pay for it, and we do that in everything else. You don't get free care in a grocery store or in a restaurant, and if you want better food, you pay more for it. There's nothing wrong with that, but not to have access to care and to not have the bicycle, I think that's unconscionable.

Ms. Kane: Thank you; excellent comments. We do have to end here. People do not always see eye to eye on healthcare reform, but we've gotten some excellent insights and very key comments from our guests today.

I'd like to thank Dr. Black and Dr. Mehran for being with us today. I'm Leslie Kane from Medscape. Thank you for joining us.


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