Proceedings of the 22nd National Conference: Thought Provocateur Session #1 (Geyman Q and A)

We gratefully acknowledge the sponsorship of the Cascades East Family Medicine Rresidency Program/Sky Lakes Medical Center/Oregon Health Sciences University (Doctor Rob Ross, Program Director) for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

Each section’s proceedings will be published as each of the sessions are transcribed, edited and reviewed by the speakers quoted. When this process is completed for a section, that section will carry the date of its posting. After a period of time, that section of the proceedings will revert to the archives (in this case, the archival date will be April 18, 2011).

David Sundwall, MD, University of Utah

David Sundwall, MD, University of Utah (Lead Questioner): John, thank you so much. For all my teasing about being old, I’m going to be 70 next month. Yikes! So, I’m joining the senior ranks, but it’s wonderful for us to have a senior statesman and I say that with great affection and respect for your contributions to family medicine and primary care for many, many years. It sounds like you’ve got more to come.

It’s hard to think of a key question to ask, but I’m going to try and couch one this way. I like what you said at the end in that this really can’t be perceived as a partisan thing, its got to become, its got to come from some kind of a position that I would call fiercely nonpartisan. That’s what we did with MACPAC and I can tell you it wasn’t easy and I won’t dwell on that except to say it’s not a bipartisan effort, it’s nonpartisan. It doesn’t have politics. It has information and recommendations based on data, not philosophy and politics.

So, I’d like to ask, given your years of experience, how do we begin to forge some kind of a nonpartisan, public consensus on the wisdom of health reform to the benefit of everybody? ood water. No I,

Dr Geyman: That’s the big problem – try to get the debate on facts, try to get the debate on experience, try to get the distortion out, try to get the media more accountable. Well just try, because money runs the media, money runs our politics, so it’s really not just an educational challenge, it’s really a political challenge, isn’t it?

That’s where Bill Moyers is coming from right there, so I don’t have a simple answer, except that it will probably take a social movement that will have to come from – I suppose increasing pain. We should have enough pain right now, but we don’t have enough outrage. So, no, I don’t have an easy answer.

Dr Sundwall: Well, hopefully the audience will have some. I would like to see some comments on this presentation from everybody that’s here.

William H. Burnett, MA; Coastal Research Group

William H. Burnett, Coastal Research Group, Granite Bay, California: I’m William Burnett from the Coastal Research Group. I would like to ask Dr Geyman a question and maybe Dr Sundwall would want to comment on it as the lead questioner too. It seems to me that one of the things that might help bring about – maybe not a consensus but at least an intelligent dialogue between the different points of the spectrum that we have now, and that would be to come up with some realistic data on what the healthcare system costs and a discussion of where the cost shifts and the hidden subsidies are.

I was thinking of the discussion that we had two years ago at the 19th National Conference in Monterey in which Dr Margaret McCahill was talking about the Saint Vincent  de Paul Health Center and the fact that the San Diego Police Department was required by law to pick up drunks on the street and call an ambulance and fire trucks every time they did so, sometimes resulting in five ambulance calls a day for the same person, because there was no way that an emergency room could take a drunk into custody. No one could believe this is a good use of public funds, but, because there this regulation existed it took creating a new program to deal with this particular problem.

Obviously, if you begin to add together all of these strange little costs that are in the system and included them into a comprehensive budget, one might be able to get a handle on the system. One of the things about the current debate, as confusing as it is, is that through this legislative process it has been moving more and more dollar costs into a comprehensive budget. And I think one of the reasons why we have suddenly the pushback on funding, because all of these budget bills are now putting everything together in a single figure. Now people are talking about trillions of dollars. To me the costs have always been trillions of dollars, but they were never were counted together. If we can pull together the healthcare related subsidies and the real costs and come up with a comprehensive budget, then we might begin the dialogue and the community meetings that build the political consensus you and Dr Sundwall are talking about..

Dr Geyman: So if I understand what you’re saying, more transparency in the budget will call for more public attention and therefore perhaps facilitate some needed changes. Patients (and often there physicians) don’t really know the costs of their care, and don’t care too much as long as someone else is papying for it. Maybe if they did, having more awareness of the costs, is what you think will drive the policy?

Mr Burnett: I think you are referring to the theory that if people were aware of the costs of their own care, they would make different health care decisions. What I’m talking about is the idea that if the public better understood and could agree on where all of the costs and subsidies are in the healthcare system, after the initial period of shock, there would be an opportunity to discuss how better to use public funds for the purpose in the future.

I would argue that you should identify all the parts. In the past analysts who believe in the concept of “tax expenditures” cite the costs of the healthcare plans being tax exempt and so that’s one big item that could be included. The you bring in Medicare and this and that and pull them all together. Medicaid, as was reported in the Wall Street Journal last month is now the predominant  funder of long-term care.

Dr Geyman: Well, it has been for some time.

Mr Burnett: If one begins to pull the different costa and subsidies together as an intellectual exercise, it begins to suggest that a consensus could develop on what costs everybody should support and where cost savings should be sought.

Dr Geyman: Let me give you my quick take on that. It sounds logical and rational, but I’m not, I don’t think it’ll be effective to help clarify the debate to just add all that complexity and all those figures, what you just said. This is an immensely complicated system we all know that.

Congress has labored for a year and a half and has given us a 2400 page law, weighing 20 pounds. Then the debate ensued, which went all over the place. You can’t boil it down at all so that everyone understands it and can make a rational vote about it.

Compare that with Canada, that had a four page bill, that enumerated the principals of what they were going to do in their healthcare system. Well we could do a very similar thing if we say universal access. If we say we want every citizen to have essential, necessary healthcare, and then a couple other things – equity, equality, etc. That’s not too complicated.

But we make everything so complicated that no one can understand it. Then the enemies of the bill will shoot it up. So, I don’t think more data about all the financial costs is going to change much.

Linda Garcia-Shelton, Ph.D.; California Psychology Internship Council

Linda Garcia-Shelton, California Psychology Internship Council, San Francisco: I work in San Francisco and am the Executive Director of the California Psychology Internship Council. I’ve worked in the field of family medicine for many, many decades. I love this conference.

I think that part of why this is so very difficult is that about the only really almost universally shared religion we have in this country, is the religion of the market. The market can solve all issues and we work in an industry that doesn’t have an optional product. It’s something everybody needs; it’s also an industry where the bulk of the money gets spent on those people who are very, very ill. They are partly in that situation because they because they didn’t get care, but never-the-less, they are the very, very ill. At that point people are scared, they are frightened of death, frightened of disability, frightened of all kinds of things, and that is not a time where people are rational in any kinds of decisions that they make.

The basic assumptions underlying a free market do not exist in this industry and yet, we are apparently bound to work within it. This puts us at great disadvantage, because it is not possible for us to rely on a continual shifting of the balance between supply and demand to create a market that distributes resources wherethey are needed or wanted at a price deemed worth it.

The demand side is gone in terms of influencing the system, because there is little likelihood of balancing the utility of treatment with an experimental drug against an alternate non-health use of the funds. It’s only the supply side that influences the decision and the people that run the supply side want it the way it is. They are  the ones who are so successful at lobbying to assure that the system benefits them.

When I think of it in this way, I think we need to approach this very, very differently. I think our research, our facts, our experiences are irrelevant for influencing this issue, which is a basic issue of religion – of our belief in a market economy that doesn’t work for us with respect to providing the quality health care system that the dollars we spend certainly could provide. We need to lobby for a system that values people and their health care above the abstract belief in an economic theory.

Dr Geyman: Amen. Those are good points.

Dr Sundwall: Right on! Just a fact to support your conclusion, as I understand it. 63% of spending on healthcare is government, either through Medicare or Medicaid or tax incentives or tax forgiveness for business. So if you have a preponderance of the money all in the public sector, what’s the market all about? It’s not a private market, and I couldn’t agree more.

Rick Flinders MD, Santa Rosa Family Medicine Residency

Rick Flinders, MD, Santa Rosa Family Medicine Residency Program: First, I would like to note that I’m from the family medicine residency program in Santa Rosa, California, of which you, Dr Geyman, were the founding director.

John, I have two two quick questions. Number one, is “Medicare for all” too simple for people to understand? And number two, you’ve long been an advocate in the organization of Physicians for a National Health Program (PNHP). At the 17th National Conference in San Diego four years ago; you said “what if we had not 15,000 members but 100,000 members”. Do you think we’re capable of creating that kind of physician organization, and if we were, would it be effective?

Dr Geyman: Well, those are two questions. I’ll take the second one first and I’ll ask Dr Don McCanne (a founding leader of PNHP) the  to respond to that too. in Yes, II think that if we had 100,000 active, activist physicians in PNHP – which for my money is the best organization of US medicine – we would have a lot more clout. It’s already being viewed positively by the media and by health pundits, with a better and more active PNHP website than there has been in the past.

Back to the first question: “Medicare for all” is pretty simple. The only trouble with that is Medicare’s not perfect and I would want to get some of the things improved before extending Medicare to everybody. For instance, “Medicare for all” should be able to deal with cost-effectiveness, right? It should be able to deal with coverage decisions like those $100,000 a year cancer drugs for metastatic breast cancer that only add, maybe, four months of life, without any improvement of quality of life . We’ve got to start dealing with those things. Medicare by law is prohibited from dealing with cost-effectiveness.

Well come on! We better wake up here! I would want to see the overpayments to “Medicare Advantage” gone. I would like to see like to see privatization of Medicare gone. I would like to see a strong “Medicare for all” with some improvements along the lines I mentioned. That, for everyone of all ages from kids to adults that we have in this country is the best outcome, with access to necessary care for everyone – all 310 million of us.

So, yes, that I think would be a simple thing. But the critics would probably shoot it. Yes, there are problems with Medicare. Yes, we’ve got to fix a few things. But it’s still a rock compared to the rest of the system, though it’s being, if you let Congressman Paul Ryan have at it – he’ll just take it apart and decimate it, and privatize it and make it a welfare program. Don I would like your reaction to the Dr Flinders’ questions.

Don McCanne, MD, Physicians for a National Health Program, San Juan Capistrano, California; Thanks John, but I’ll defer until later.

Dr Geyman: That’s fine.

Jay W. Lee, MD; UC Irvine/Long Beach Memorial Hospital, Long Beach, California

Jay Lee, MD, Long Beach Memorial Family Residency, Long Beach, California: I’m the director of health policy at the Long Beach Memorial residency. First, a comment and then a question. First, what do we call a patient who knows that they need to do certain things to improve their health, yet they continue not to do those things? We call that denial, right? I will read this quote that was shared with me by a venture capitalist: “There is no such thing as a free market solution in a market where the majority of beneficiaries are not economically aware of the cost of their individual decisions.” I thought it was a very interesting perspective for someone from Wall Street to take as a view on things. I think at this point in our history is we have this strong denial or we have this strong belief in the market. But we’re in denial of the fact that it’s failed because of the politics.

So the question I have is one that a professor at my school of public health once said to me “Well we have 46 million uninsured patients in this country. If someone was smart enough or savvy enough to have each of those individuals donate a dollar, you would have an incredibly powerful political action committee (PAC) that could go to Washington and make some real nonpartisan changes such as we’re discussing here. How do we organize people? Because to me, that’s a lot of cash. I think that’s a lot of cash to all of us and that would be a lot of cash in Washington. That would have a real political voice because there’s money behind it.

Dr Geyman: That’s an interesting idea. I think those are the kinds of ideas that need to be pursued. I’m not an organizer. I’m not an expert on any of that, but I think we ought to try anything that works in making a major backlash happen. You’re absolutely right that the political action committees are what runs Washington, no question!

Hector Flores, MD; White Memorial Medical Center, Los Angeles

Hector Flores, MD, White Memorial Medical Center, Los Angeles: Thank you again, Dr Geyman, for your presentation and mostly for your passion and leadership in this area. What we’re discussing really reminds me of Winston Churchill’s comment that “Americans will always do the right thing, after they’ve tried everything else.” And we’re still trying everything else, but I am confident that we will get to the right thing.

I’m a “single payer” advocate from the standpoint of efficiency and what would make sense, but I also look at the practicalities. I am really concerned about the tyranny of a single payer such as Medicaid – so until we can find the right checks and balances, I’m guilty of drinking the opposition’s Kool-Aid®.

But part of this is also what Victor Fuchs notes: that in order to get substantial, especially radical, change in any system that we must have the presence of the three C’s. First is a crisis of unprecedented proportions, like the Great Depression, leading to social welfare programs. Second is the need for compulsion – and  there he paranthetically puts courage – from our in our elected officials. And third is the need for cash, that we need to invest if we’re going to radically change in order to get our arms around it. What do you think of his, of Victor Fuchs’ perspective? Are we going to have to wait for a bigger crisis?

Dr Geyman: Well I think we already got a crisis. The question is how much worse is it going to get. It’s getting worse all the time. I think we’ve got enough crisis. I agree that we need a stronger role of government. It’s obvious that the politics of the day right now is about the role of government. That’s a key thing. Until we get a stronger role of government; I don’t think we’re going to pull this off.

The third part of your statement, regarding the amount cash the new legislation will require, may have some results. We will soon need to wake up and realize we would save money through a national health insurance single-payer system. That would actually save money for patients and their families. They would get more for less than what they’re paying now. With a progressive, equitable tax system, we could do the same for the country and the same for business. We can save a lot if we chop the waste out of the system, and chop the private insurance industry out of the system. But we elect not to do it because these entities that should not be part of the system are just  too powerful.

Robert Ross, MD; Cascades East Family Medicine, Klamath Falls, Oregon

Robert Ross, MD, Oregon Health Sciences University/Klamath Falls  Family Medicine Residency: Thanks for your presentation John. I’m a member of PNHP and I believe in the philosophies, but having toiled in both a system of care in Canada and a non-system of care, which is the United States. I think one of the basic ideas that we have to get into our heads here in the United States is that medicine is not a business. I agree wholeheartedly that you cannot apply free market principles, because it is not and never will be a free market.

Every other civilized society on Earth has decided that you need to look after each other as citizens of the country and not to let people go bankrupt over caring for themselves and their family members. But I will caution you that Medicare in this country is horribly complex. How can you possibly have a healthcare system that requires a 17 ½ foot stack of regulations (that are printed on both sides of the paper)?

The one example I use of a health system that’s relatively rational, although imperfect: the teaching rules for physicians for Medicare in Alberta, Canada, comprise one paragraph, three sentences, and they’re called the “whites of the eyes” rules, and they make total sense. If you do not see the the whites of the patient’s eyes, you cannot bill for that patient under your own number for Medicare. If the resident sees them, you can bill for that patient as long as the money goes into a fund for residency teaching and care of the residents, so you bill for everyone.

However, in the United States, the last time I checked, there are 119 pages required in the Federal register to make rules and regulations for teaching physicians. Please, we need a huge reform. I’m totally in favor of blowing the whole damn thing up and starting over again. I’m not sure that Medicare is the best place to start with a total reform.

Dr Geyman: Well I agree with everything you just said.  I was trying to allude to straight Medicare. Right now, it’s administered by a bunch of words. We would need to rationalize the whole program and reframe it. Under current law, the actual national “science based” decisions on what Medicare should pay for are a small minority of the coverage decisions. For instance, currently the coverage decisions are farmed out to all kinds of local places.

If you’re a stent maker or device maker or drug company or whatever, you’ll “game” the system by going to the most lenient, local coverage decision, so you can get into the market that way. Well, that’s really pretty stupid. For those of us believe that Medicare should only pay for interventions that have been proven to be “cost-effective”, it’s obvious that the current system is just not going to deal with that. In fact, by law you’re prohibited from applying “cost-effectiveness” principles to Medicare coverage. So, I yeah, I agree that we need to clean up our act.

Dr Ross: Well, I was going to close by giving one more example. All of us clinicians are waiting for our incentives to use electronic medical records, right? You know what the regulation for attestation that you have to provide to Medicaid/Medicare to get that bonus? 120 pages, and for hospitals it’s 96. It is ludicrous. We’ve got to trim the sails of government in some respects, and maybe have more uniform policies. Thanks John.