Disclosure
Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Yancy is the 2009 to 2010 president of the American Heart Association, Dallas, Texas. Dr. W. Roberts has received honoraria for speaking from Merck, Whitehouse Station, New Jersey; Schering-Plough, Kenilworth, New Jersey; and Novartis. Drs. Cohn, Kelly, R. Roberts, Wesson, and Willerson have no relevant financial relationships to disclose.
Disclosure
Dr. Friedewald has received honoraria for speaking from Novartis, East Hanover, New Jersey. Dr. Yancy is the 2009 to 2010 president of the American Heart Association, Dallas, Texas. Dr. W. Roberts has received honoraria for speaking from Merck, Whitehouse Station, New Jersey; Schering-Plough, Kenilworth, New Jersey; and Novartis. Drs. Cohn, Kelly, R. Roberts, Wesson, and Willerson have no relevant financial relationships to disclose.
Introduction
Six and a half million Americans aged 18 to 64 years who have some type of heart disease, stroke, or hypertension do not have medical insurance. Even among insured patients, cardiovascular disease is commonly excluded from coverage as a preexisting condition, such as when children with congenital heart defects—even defects that have been surgically corrected—reach adulthood. Failure to have adequate medical coverage results in worse morbidity and mortality for patients with stroke and myocardial infarctions. Thus, there is general agreement among physicians that changes in the American health care system are needed to improve accessibility to medical care. The following discussion is that of a panel of experts in cardiovascular medicine convened to express their views on how this should be accomplished.
Dr. Friedewald: Dr. Bob Roberts can give a unique perspective on health care reform because he has practiced in both the USA as chief of cardiology at Baylor College of Medicine in Houston and now in Canada as chief executive officer and president of the Ottawa Heart Institute. Since so much of our discussion in the USA involves looking at Canada for some answers, I would like to start with his thoughts.
Dr. Bob Roberts: The Canadian health care system provides universal health care for all ages and populations. There is only 1 payer: the government. Physicians are paid fee for service. Emergency services are treated as true emergencies, with no “wait time” for those patients. For treatment of chronic cardiovascular conditions, there also is no delay in treatment. Treatment of other chronic conditions that are not life threatening, such as joint replacement, however, may require a long wait time. The average Canadian citizen believes our system is fantastic . The Canada Health Care Act, however, is a strong impediment to the practice of private medicine, so the government program has no competition. Comparing the single-payer Canadian system to the system I knew in Houston is informative. The cardiology department at Baylor College of Medicine dealt with 64 different payers, and that required 14 staff members to provide diagnostic codes and other information before we got paid. About 8% to 9% of our overhead went to the administrative costs of collecting the bills. With a single payer in Canada, we do not have this expense. Another difference between the 2 systems is that every patient visit with every physician in Canada is automatically paid for. It is a very easy system from that point of view, as opposed to my experience in Houston, where, no matter what we did, we always had—even in the best of years—10% to 15% of bills we did not collect.
A negative side of the Canadian system is the lack of any competition because of the lack of private insurance—Canada is a single-tier system. The consequence is that it is much more difficult to keep the technology up to date in the hospitals and in the doctors’ offices in Canada compared with the capitalist approach in the USA.
Dr. Friedewald: How do Canadian physicians view your system?
Dr. Bob Roberts: Canadian physicians are reasonably happy. They certainly want to keep the fee-for-service system. The fee-for-service system, however, does suffer to some extent in that it does not pay as much per patient visit as in the USA. For procedures like cardiac catheterization, payments in Canada are comparable to Medicare in the USA.
Dr. Wesson: What can you say about the quality of health care in Canada compared with the USA?
Dr. Bob Roberts: The quality of care is the same as in the USA. For example, our complication and mortality rates following cardiac surgery and coronary angioplasty are comparable. At the Ottawa Heart Institute, our patients stay in the hospital after these procedures about a half day longer than in the USA.
Dr. Friedewald: There is no private care in Canada?
Dr. Bob Roberts: The Canada Health Care Act prevents private medical practice, including private catheterization laboratories and private hospitals. Catheterization laboratories can exist only in hospitals. All hospitals are owned by the government, and they all must be approved by the Ministry of Health. This system appears to decrease some of the procedural redundancies that are common in the USA.
Dr. Friedewald: Would you like to see the introduction of a private care alternative in Canada?
Dr. Bob Roberts: Yes, because a government and single-payer system has inefficiencies that would be reduced by a competitive 2-tier system. All the universal health care countries in other developed countries, such as France and UK, have evolved into 2-tier systems. In UK, this was brought about by Prime Minister Margaret Thatcher. The 2-tier system made those systems far more efficient and improved the quality of care. According to the World Health Organization, France leads the world in quality of care, and the USA ranks 43rd.
Dr. Friedewald: Tort reform is a topic of great discussion in the current debate in the USA. How is medical liability handled in Canada?
Dr. Bob Roberts: This is not a large issue in Canada for 2 reasons. First, we have arbitration, which settles more than 90% of malpractice claims. Second, attorneys do not receive contingencies. They are paid by the hour.
Dr. Yancy: My understanding is that when one looks at quantifiable volume metrics—for example, adherence to guideline performance measures—that the Canadian system is quite good.
Dr. Bob Roberts: Yes, benchmarks of prevention and treatment guidelines such as the percentage of patients taking aspirin and cholesterol-lowering drugs are quite good: 92% of cardiovascular patients take aspirin, and 82% of patients know their cholesterol levels.
Dr. Yancy: Is medical care truly accessible to everyone in Canada?
Dr. Bob Roberts: Yes, but as I mentioned, the wait time can be long for noncardiovascular procedures, especially in the territories. One hundred percent of candidates for hip replacement, however, can receive that procedure.
Dr. Yancy: One reason I raise the question about access is that disparate care as a function of race, ethnicity, age, and gender appear to exist in many health care systems. Are those gaps present in Canada?
Dr. Bob Roberts: We do not have those gaps, but we do not have the same large numbers of minorities as live in the USA. The only exception is Native Canadians, who have higher rates of disease and higher mortality rates.
Dr. Friedewald: Are illegal Canadian residents covered in Canada?
Dr. Bob Roberts: Yes, at this time. Persons who move to Canada legally, however, are not covered until they have lived in Canada for 3 months.
Dr. Bill Roberts: The population of the USA is about 306 million and that of Canada about 33 million, or a 10-fold difference. Do you think the Canadian system could effectively work in the USA, in which the population is so much larger?
Dr. Bob Roberts: I do not believe it could. I do not believe the USA could afford the Canadian system, and I am concerned whether Canada also can sustain our current system.
Dr. Friedewald: With your experience in both countries, what do you believe should be our first priority in health reform?
Dr. Bob Roberts: I would place catastrophic coverage as the number 1 priority.
Dr. Kelly: How does your single-payer system exert cost control? Is it dependent on the economy or on the growth of certain age groups?
Dr. Bob Roberts: I believe this is handled similar to the current Medicare system in the USA. Each year, the government determines the budget and what it can afford to pay—with a lot of lobbying. My institution deals directly with the provincial government, as each Canadian province has its own system into which the federal government places money. Everything is managed at the provincial level, as it would be at a state level in the USA. Each year, we stratify for technology, for building construction, for extensions, and other cost items, on the basis of need.
Dr. Kelly: What percentage of the Canadian gross domestic product is accounted for by health care?
Dr. Bob Roberts: About 14%, which is about 30% less than in the USA.
Dr. Willerson: Are there age and co-morbidity restrictions for cardiovascular and other procedures, such as hemodialysis?
Dr. Bob Roberts: We have no rationing in Canada, although it is a recurring question. As you know, the British system does have such age- and co-morbidity-based rationing. We perform cardiac transplantations on patients in their 80s, and there is no rationing for dialysis.
Dr. Willerson: Is the system of governmental payment an estimate, by you for instance, at your heart institute of what you will need in the coming year? If you run out of money before the year has ended, is it hard to get more money?
Dr. Bob Roberts: If the budget runs out, there is emergency funding, and they add to it. Any time we have, for example, more patients or more procedures than projected, they will pay for them.
Dr. Willerson: Does that added payment occur quickly?
Dr. Bob Roberts: We have never had a problem with such shortfalls in cardiovascular medicine in my 5 years in Canada. The same, however, cannot be said for elective procedures such as hip replacement, as that can wait until the next year.
Dr. Bill Roberts: Do patients have a choice of physicians?
Dr. Bob Roberts: Yes, which is a big “plus” for the Canadian system. No matter where you are, whether you are in Baffin Island, or St. John’s, Newfoundland, or Vancouver, the system is universal, and you can go anywhere and it is paid for. Patients must, however, be referred by their general practitioners (GPs) for specialty care.
Dr. Bill Roberts: Even though each province has a different budget?
Dr. Bob Roberts: That is correct. For example, in Ottawa, we are on the border between the Ontario province and the Quebec province. We take care of 500,000 people from Quebec. They pay what Ontario would pay, not what Quebec would pay. That is a universal agreement that was not established until the 1990s. All provinces pay the fees charged by the province in which the patient is seen except Quebec, which pays slightly less.
Dr. Bill Roberts: Are there problems with referrals being controlled by GPs?
Dr. Bob Roberts: Yes, definitely, for 2 reasons. First, GPs are very busy. We have a severe and increasing shortage of GPs. It is difficult for patients to see a GP in the cities. If they could come directly to a specialist, it would save some of those long waits. Forcing everyone to get to a specialist through a GP with this significant shortage is definitely a problem of the Canadian system, perhaps deliberately in attempt to control costs, but it is a real problem.
Dr. Friedewald: Do you believe that universal deployment of health information technology (HIT), which is being advocated by the federal government in the USA, will help reduce cost and improve quality, as contended?
Dr. Bob Roberts: All the pharmacies in Canada have electronic records. Thus, patients’ medication records are available everywhere in Canada. That was put into place a few years ago. Complete electronic medical records (EMRs) across the entire health care system, however, is developing slowly, and most electronic medical records use today is confined to the hospitals. Does HIT save money? Yes. For example, in the Ottawa region, physicians have immediate access to all previous procedures, tests, and so on, which reduce redundancies and saves money, while also improving care.
Dr. Wesson: The same is true in our system at Scott and White in Texas. The connection of the EMR between our hospitals and our outpatient clinics also helps to smooth the transfer of care from one physician to another and between our hospitals and clinics. The EMR eliminates a lot of wasted time in trying to track down information. While it does not eliminate the desirability of physicians to communicate directly by telephone, a common EMR helps back up these communications. Thus, HIT definitely helps with cost savings and quality of care.
Dr. Bill Roberts: Bob Roberts, you mentioned patients are happy with the Canadian system. Are practicing physicians in Canada also happy with your system?
Dr. Bob Roberts: I do not know if the GPs are happy. The specialists in Canada are pretty happy because it is fee for service. One of the unhappy areas is making all patients go through a GP to get a referral to a specialist. Often the GP becomes just a trafficker and simply says “yes” and sends the patient on to the specialist. Also, patients often do not get to the specialist as quickly as they should, or to the appropriate specialist. The incomes of cardiologists practicing in Canada—excluding those in the USA who own their own catheterization laboratories—are comparable to cardiologists practicing in the USA. The salaries in academic institutions in Canada are much higher than they are in the USA.
Dr. Kelly: Are the number and type of medical specialists and subspecialists in Canada regulated by the government? Regulation of the number of specialists, and access to such specialists, is a mechanism for government to control costs.
Dr. Bob Roberts: That is a complex question. In the USA, Medicare pays the hospital based on numbers of residents being trained in that hospital. This is not true in Canada. The health care system is completely separate from the training. The Royal College has established the number of resident positions for each subspecialty. Thus, a hospital can have more residents if it desires, but it must pay for them. The Royal College of Canada will not pay for those slots but there is a system within the ministry whereby about a third of them are paid for.
Dr. Kelly: We are having a problem filling residency spots in cardiovascular surgery. These residency slots were down by 1/3 in 2007. Extrapolating that to 2025, we project being down by 25% of our workforce that will be needed by that date.
Dr. Bill Roberts: In the USA, physicians get a fee for interpreting a test such as an echocardiogram or a nuclear study, and since the nuclear study pays a little bit better, that might be favored in some physician groups.
Dr. Bob Roberts: Canada is very similar to the USA in that regard. There is a physician’s fee for reading results of procedures, and there is a technical fee. In most cases, the technical fees are paid to the hospitals by the government, not to physician owners of the equipment.
Dr. Bill Roberts: Can private clinics offer technology testing and be paid for it?
Dr. Bob Roberts: They can offer tests like echocardiograms, resting electrocardiograms, and exercise testing and be paid both the technical and interpretation fees. They cannot, however, be paid for more extensive tests like rapid computerized tomography or cardiac catheterization outside of hospitals.
Dr. Friedewald: Don Wesson, do large clinics in the USA, such as Scott and White, have lessons for us as we consider health care reform?
Dr. Wesson: Yes. One lesson we have learned at Scott and White is the benefit of functioning as a system rather than as individual departments, divisions, or physicians. We have learned that we can achieve good quality—and do so at lower cost—when we standardize many things we do across the system, including both hospital care and outpatient care. We have hundreds of general or standardized protocols for practice. That does not mean that individual physicians cannot vary from those protocols if they have reasons to do so or that they can demonstrate to the institution by doing so provides cost or quality benefits. In general, however, we do things as a system, and that standardizes care across the system. Our guidelines are based on quality first and cost savings second. For example, we constantly have discussions about new equipment that comes on-line, and we also have discussions when new physicians join our system and have previously used technology that differs from our current equipment. We always ask, Can you show us that your way provides better quality care or that it provides the same quality of care at lower cost? If those 2 questions cannot be answered with respect to the current way by which we do things, then we do not change. This approach helps us in standardizing care across the system, which now involves about 850 physicians in clinics and hospital settings.
Dr. Friedewald: The USA is facing huge physician shortages, which some believe, with good reason, may become worse with health care reform. Don Wesson, as vice chancellor of Texas A&M College of Medicine, how do you view our physician supply?
Dr. Wesson: With respect to the Texas A&M College of Medicine and Texas in particular, we, like everybody else, are short of physicians, particularly short of primary care physicians. Thus, Texas A&M focuses on encouraging its graduates to go into primary care specialties. We are proud of the fact that over the past few years, we have the highest percentage of graduates in the USA who are going into primary care medicine. In 2008, 29% of our graduates did so. A lot has to do with the settings in which we practice. Our students spend more of their time in outpatient clinics compared with most other academic health centers, which place more emphasis on inpatient care.
Dr. Friedewald: What role do guidelines play—such as the American College of Cardiology/American Heart Association consensus guidelines—in decisions you make about your standards, and what role do you believe that guidelines should play in health care reform?
Dr. Wesson: We emphasize such guidelines to our physicians when they become available and we build them into our EMRs. For example, the computer may identify a patient as a candidate for a renin-angiotensin inhibitor therapy for renal or vascular protection, so when the patient is either discharged from the hospital or discharged from the clinic a note will inform the physician, “This patient appears to be a candidate for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB). Is there a reason that you have not prescribed one of these drugs for this patient?” That question allows the physician to respond, “I do not want to put this patient on an ACE inhibitor or an ARB for a given reason.” Thus, the EMR does not force the physician to act, but it is a reminder that helps in the system. When there is a new nationally recognized guideline, and we as a physician group decide to adopt that guideline, we try to implement it into our practice such that it does not depend on a physician’s memory. Instead, it is hardwired into the EMR as a reminder.
Dr. Bill Roberts: All the hospitals in Canada are owned by the provincial governments?
Dr. Bob Roberts: Yes.
Dr. Bill Roberts: There are no private hospitals?
Dr. Bob Roberts: Correct.
Dr. Bill Roberts: But the physicians own their own offices.
Dr. Bob Roberts: Yes.
Dr. Bill Roberts: What changes do you believe the USA should make in health care reform about cardiac procedures?
Dr. Bob Roberts: There should be more control over certain procedures, because some of the high costs of medical care in the USA are due to procedural excesses. I can recall conducting a clinical-pathological conference in San Francisco in which a patient had undergone 16 cardiac catheterizations. Echocardiograms are commonplace, often without adequate technical quality, requiring them to be repeated when patients reach medical centers where there are adequate volumes to maintain sufficient technical expertise. Such test redundancies need to be eliminated.
A few additional points. All outpatient drugs in Canada are paid for by patients themselves, until they reach age 65. The Canadian system works reasonably well. I think it would be good for the Americans to look at it because Canadians think the American health care system is awful, and Americans think the Canadian system is awful because we have these waits. Neither has the proper perspective. The universal health care system in Canada or in UK or in France cannot be transplanted to the USA, given the size of the USA and all the problems of immigration. I doubt if the USA could afford it, and medical care could deteriorate if the systems employed in other developed countries were suddenly transplanted in the USA.
Dr. Wesson: Scott and White focuses on the system and coming up with system solutions. We have learned that wherever variations from “the standard” are limited, better quality and lower costs ensue. In general, our physicians like the system very well, although there is the occasional unhappy physician who believes there is something special about their practice that is not reflected in the guidelines. Typically, however, we prefer not to let an individual rule the day. Overall, the more we can systematize things, the better.
Dr. Friedewald: In the USA, we do not have a true “system,” which you are suggesting we should strive for.
Dr. Wesson: That is exactly what I am saying. We do not have 800 physicians practicing independently; rather, we have 800 physicians practicing in a system.
Dr. Bill Roberts: All Scott and White physicians are on salary?
Dr. Wesson: That is correct.
Dr. Bill Roberts: Are they good salaries?
Dr. Wesson: Our salaries are about 80% to 85% of the incomes of physicians in comparable private practices in our area, but there are academic opportunities and other benefits of practice in an academic health center that we offer.
Dr. Friedewald: Another unique feature of the Scott and White system is that it has clinics in many rural areas, which of course improves accessibility. What have you learned at Scott and White about serving rural communities?
Dr. Wesson: We do it with our outpatient clinic system. We have more than 50 clinics in the central Texas area, and we place them geographically according to what patients and doctors in the area tell us they need. We will put a clinic there and then staff it with our own salaried physicians. Many of our physicians at these smaller clinics do not earn their salaries, but we are nonetheless able to pay them respectable salaries because we can use our system as a whole to pay them based on referrals to our specialists.
Dr. Friedewald: Dr. Willerson, your priorities about health care reform?
Dr. Willerson: First, insure the children . There are approximately 11 million uninsured children in the USA. As part of better care for children, I would like to see the creation of more neighborhood clinics , which would help the care of pregnant women as well, children in the CHIP (Children’s Health Insurance Program), and the indigent, including their education about health-related issues. Neighborhood clinics also would help us deal with obesity, diabetes mellitus, and disease prevention, including vaccinations and promotion of healthy lifestyles, such as smoking cessation and drug avoidance. Neighborhood clinics could be staffed by a cadre of physicians who would be available 24/7. I would require the physicians trained with federal and state hospital funds to spend some time in these clinics—maybe for 2 years following their training period—before they went into private practice. Bill Roberts and others of you will remember that when we were going through training, we had a payback of some kind, generally in the military service. Something like that could be created. Additionally, retired physicians could help in these clinics.
I would create centers of excellence to deal with problems such as heart and vascular disease, kidney disease, cancer, trauma, mental illness, and diabetes mellitus, for patients referred from rural areas lacking such facilities and/or adequately trained physicians. I think that would reduce medical care costs because these centers and the hospitals would be accountable to use best practice guidelines, to show improvements in survival, rehospitalization rates, and other measurable outcomes.
I would like to see the states that receive support for health care be held accountable for improvements in outcome and in the environment . For example, Texas should become accountable for showing a lower incidence of uninsured children and improvement in air and water quality.
Dr. Friedewald: Dr. Willerson, you have pointed out areas where improvements could be made with health care reform. Do you have any concern for areas in which health care reform could set the USA back , in terms of the quality of care offered?
Dr. Willerson: Our goal should be to improve and make less costly the best medical care system in the world. I do not believe there is any system in any other country to emulate. I appreciate Bob Roberts’s comments and learned much about the system in Canada, which appears to work well for our neighbors to the north, but I do not believe that anyone else in the world has a better health care system. I would hate to see competition eliminated from health care in the USA, which would lead to stagnation in developing and implementing new technologies that save and prolong life. We must have competition that will drive down, not increase, costs. We should be focused on improving the world’s best health care system and reducing its cost, which can be driven down by simple common sense .
I think that the government, President Obama included, should be talking to a wider number of physicians as part of the dialogue about health reform. I am not aware of anyone leading this debate who has come to the Texas Medical Center, the largest medical center in the world, with leading institutions in both cancer and cardiovascular care and research, to solicit our opinion. Physician opinion leaders from all over the nation should be engaged. Almost everyone agrees health care needs to be reformed in the USA, and most physicians want to see that occur, but we should not destroy the best of what we have in the process, the best that exists anywhere in the world.
Dr. Friedewald: We have focused on government as the center of health care reform. What about the responsibility of individuals?
Dr. Willerson: Individuals need to take more responsibility for their own health. I would create insurance programs and federal and state programs that reward them for doing that: losing weight, exercising, not smoking, and so on. This might be in the form of tax rebates or reductions in health care costs. However it is accomplished, we need to make everyone responsible for his or her own health.
Dr. Friedewald: The Texas Heart Institute has been a world leader in the correction of congenital heart defects. Many of these children, as they grow up and are no longer covered by their parents’ health plans, have preconditions that preclude obtaining their own insurance.
Dr. Willerson: Individuals should not be denied insurance based on preexisting conditions.
Dr. Bill Roberts: I understand that 90% of the health insurance in the state of Alabama goes to 1 company, which seems inappropriate. And every state has its own insurance commissioner.
Dr. Willerson: Insurance should also be portable across state lines. There is no reason to allow insurance companies to confine care to a certain region.
Dr. Friedewald: Let’s discuss tort reform . Dr. Cohn, what is your view on tort reform?
Dr. Cohn: A lot of people think it is an important issue for good or bad medicine, which misses the point. Rather, tort reform directly impacts accessibility, which uncontrolled malpractice laws severely limit. Until tort reform was enacted in Pennsylvania, neurosurgery became almost nonexistent in that state, due to high insurance premiums. Accessibility is the issue, as much as quality of the medical care in tort reform.
Dr. Friedewald: Do you believe that tort reform in Texas has had a favorable effect on costs?
Dr. Willerson: It has limited the amount that a claimant can acquire so that doctors are more able to help on the road and maybe not be required to do as many tests. That has helped, and it discourages some lawsuits. I believe we are not effective enough in controlling physicians who do egregious things to their patients.
Dr. Friedewald: Dr. Kelly, what is your perspective as a private practicing cardiothoracic surgeon?
Dr. Kelly: I am currently in Indiana. Governor Otis Bowen, who is a physician, years ago put a reasonable reform on the tort system in this state. The legal environment for medical practice in Indiana has definitely improved, when comparing Indiana with some of the neighboring states, especially Illinois. In certain areas like obstetrics and neurosurgery, tort reform is dramatically needed to improve the quality of all of medicine.
As for health care reform in general, insurance companies need better regulation . We have a reasonably educated workforce that knows about insurance, but they do not understand how insurance companies function. One thing that the government could do would be to better regulate how insurance companies face issues such as preexisting conditions and what their pricing structure is for individuals in terms of families and how families are charged for their medical insurance.
Dr. Friedewald: How do you view the shortage of health care workers?
Dr. Kelly: There is a dramatic shortage of health care workers. If you consider all health care workers—nurses, physician assistants, laboratory technicians, et cetera—any reform should dramatically increase training programs so that we have enough workers within the system. We need more primary care physicians as well as specialists. I am especially concerned for thoracic surgery, but even general surgery also faces shortages, with estimates of 1,300 positions short in general surgery by next year. We can graduate more physicians from medical school, but more resident and fellowship positions need to be funded.
This is all in a backdrop of improving quality in medicine. It is important to look at various outcome-related and outcome-focused databases, such as the Society of Thoracic Surgery database, the American College of Cardiology interventional catheterization database, and the American College of Surgeons SQUID registry. All of these are going to improve the day-to-day care of surgical and interventional medicine. We need more of this overall quality monitoring to judge how we are doing.
Dr. Friedewald: Are you hearing among your colleagues any talk that, depending on the nature of the health reform, we could see doctors retiring early, causing an even more serious shortage of physicians?
Dr. Kelly: The last comparative figures I saw were that 50% of the cardiac surgeons in the USA are >55 years of age, as opposed to the general physician population, whereas about 30% of the nonsurgical practicing physicians are >55 years of age. There could be an increase in the percentage of physicians who might retire. I like Jim Willerson’s idea of using retired physicians to staff more of the neighborhood clinics and to create a national health service to help care for the underserved population .
Dr. Yancy: My viewpoint represents my own, but it is heavily influenced by the American Heart Association and the tenets that are espoused by that organization. I think that what we have heard so far is exactly the kind of dialogue that needs to occur. I too am struck by a relative silence from our physician leaders in the current national debate. What we have heard today are concepts and ideas that merit further review and further discussion. We have heard opinions from a National Health Service (Canada), a major academic institution (Texas Heart Institute and the Texas Medical Center), very prominent and efficiently run health care entities (Scott and White), and then from the private sector. Each voice has contributed what I think is a very reasonable set of comments and ideas that merit further review.
Health reform is coming, as we all know. It is much better to be participatory rather than pedestrian. The concept of putting together best practices—and I love Dr. Willerson’s advocacy of using common sense , which should prevail. We can overengineer this thing and end up with a system that destroys what, I agree, is among the best if not the very best health care system in the world. The idea of identifying best practices makes sense.
Another important issue involves large numbers of individuals, especially minorities, in this country who, when presenting with the same set of clinical circumstances, do not receive the same quality of care (i.e., disparate health care). That needs to be addressed. I agree fully that we have many families, especially young people, at great risk because they do not have access. In my discussions with many physicians across the country, I find very few people who disagree with the idea of improving access and preserving quality. Dr. Willerson has put forward some interesting thoughts about something akin to a national health service.
Dr. Robert Roberts brought forth the best practice of using arbitration instead of going into the court system when there are questions of performance and malpractice. There has not been adequate attention paid to tort reform, and those who are in that mix need to be more cognizant of those concerns. We have heard some very real concerns that are prominent throughout all the systems; these concerns have to do with the availability and accessibility to primary care physicians. I agree. That is the backbone of any of these health care reform systems.
We also need to understand that the American system has some unique challenges. Ours is a tremendously large space, 10 times the size of the Canadian system. Most of the capital fueling the pharmacological and technological innovations that have so favorably impacted health care is derived from the American market. What will happen if that working capital resource disappears? The USA drives the regulatory environment of the world. The work that is done at the United States Food and Drug Administration is incredibly important for codifying and establishing the benefits and the risks of a number of drug and device strategies. Many countries are aligned with that effort, but we in the USA bear the responsibility and the cost. Thus, we have to recognize that as we are looking at the American system, it is uniquely different, by size, by complexity, and by many of the very silent but very real responsibilities that we take on to benefit global health care. We need to move thoughtfully, deliberately, carefully as we address health care reform. What we are doing today, and I think all would agree, is the kind of discussion from those who are deeply embedded in health care that needs to take place so that those who are legislating the process have the benefit of these best practices and the wisdom of seniority and experience.
Dr. Friedewald: How do you view research in this debate on health care reform?
Dr. Yancy: We have to understand that the reason we are able to provide services and do procedures is that we have had a very robust research engine in the USA for many years. We must continue to support research. Without significant new knowledge, without the transformation of our understanding of health care, we cannot transform the payment systems or the delivery systems. We have to identify new best practices that provide the outcomes we seek with less expenditure and with better delivery. We cannot walk away from these responsibilities: research, the regulatory environment, addressing the differences within the population, paying attention to the education of future physicians, tort reform. Our health care system is a very complicated system with lots of interfaces, all of which are important if we hope to have any success.
Dr. Friedewald: We have made huge strides in cardiovascular and stroke prevention and treatment in recent years. Are you concerned with the direction we are going that those trends may not continue to improve or even be reversed?
Dr. Yancy: In the last decade, we have seen a 30% reduction in death due to coronary artery disease and a 26% reduction in death due to stroke. These are wonderful metrics, and we should all embrace them. But there are threats to these advances. The penetration of important risk factors, led by obesity, is such that we will lose ground. We already see early epidemiological evidence that we are losing traction in women, and so we have a disproportionate penetration of risk factors in women. The reason we have had these wonderful reductions in the risk of death due to heart disease and stroke are directly attributable to research discoveries and to prevention strategies. We must have the incentive to continue to embrace prevention, which should be a big part of whatever emerges as health care reform. We must continue to invest in research. It is only through better understanding that we can provide better care, particularly if we are providing better care to more patients. We need to provide care sooner, before diseases become more complicated and require more hospitalizations and procedures. If we lose our ability to invest in research, if we lose the incentive to focus on prevention, we will lose all the gains that we have made in recent years.
Dr. Friedewald: I am a strong advocate of consensus guidelines, in which the American Heart Association has played such an important role. The main problem is that they are underutilized. Would you go so far as to say that it should be a mandate, that the government cannot enact policies that would run counter to such expert-generated guidelines?
Dr. Yancy: I write guidelines, and they are important, but we all fear use of the word mandate . I think all of us in the cardiovascular community, established leaders like those in this meeting, organizations like the American Heart Association and the American College of Cardiology, need to own the definitions of quality and inform the process. The people who are most involved in the health care reform discussions, I believe, are sincere and they want to do the right thing. But they are not always equipped. We must strive to give them the definitions of quality, share with them the proven-to-be-effective quality metrics, and explain to them what real process-of-care improvement strategies mean. There is an entire science behind quality. We must have the kind of dialogue that is necessary to interface legislation with strategies that have proven to be effective. Only something that is definitely proven should be supported and encouraged. But even the best guidelines are just that: guidelines . Exceptions do occur, and reasonable physician judgment should always take precedence. I think a better approach would be to define what is necessary. How do we inform the process? How do we equip those who are making the assessments understand what is best?
The other thing we have to do is recognize that we cannot control who shows up at our office doorstep for care. I have been a practitioner for 20 years. Some people will show up early in the disease process, and some will show up late in the disease process. I am concerned about those persons who are already burdened with disease. When we make the penultimate metric on an outcome measure like survival, we ignore the fact that what is really important is the process. If we subject a proven-to-be-effective process of care to everyone, then the benefit in aggregate will be seen. I would hate to get into a situation where because a patient is immediately identified as having high risk or having more disease, that patient is not allowed entry into the system or delisted or is triaged elsewhere. Such a system is nothing that we would want to embrace. This kind of dialogue bringing forth best practices using common sense and coming up with uniquely American solutions for a uniquely American health care system really makes sense to me.
Dr. Friedewald: Bill, your thoughts?
Dr. Bill Roberts: I do not claim to be an expert on what is the best health care system for the USA. Clyde mentioned a focus on prevention, which is one of the missions of the American Heart Association and other organizations. But how do you get people to lose weight? If everybody in America lost 10 pounds, we would save a lot of health care money. One way is for physicians to set the example for good health practices. Physicians who themselves have body mass indices >30 kg/m 2 do not set good examples. Physicians and other health care professionals should not only be advisers for the non–health care group, but they should also set the example . President Obama has set a good example by his lean body weight, and I hope he has stopped smoking.
Certainly, the insurance companies have to report profits to their shareholders. Physicians, however, should not have to call insurance people to see whether they can perform a necessary procedure, and the insurance system should be able to cross state lines.
The malpractice business that causes physicians to worry about being sued can and must be changed. In Washington, that has only recently started being discussed, but plaintiff lawyers are a powerful group. I enjoyed what Robert Roberts had to say about fee for service. There has been a lot of discussion in this country that maybe that is not a good way to do it. I have always been on salary. I like that. But how do you do that across the country?
We need insurance for children and for catastrophic expenses and for major care for chronic illnesses.
We have, as I understand it, about 160 million Americans covered by insurance right now. I gather that most of those individuals are relatively happy. We have about 80 million who are covered by Medicare or Medicaid. That leaves about 46 million persons who are not covered. Obviously, something has to be done about those other 46 million, but how do we bring them into the system and not increase the cost? That is the great challenge.
Dr. Friedewald: What do we have to say about taking care of people who are not legal citizens of the USA?
Dr. Cohn: We take care of them. A patient arrives on your doorstep with critical aortic stenosis and he happens to be here illegally from Guatemala. You will take care of him. That is your job.
Dr. Friedewald: But the government may not pay us for providing that care.
Dr. Cohn: I think the medical centers have a certain responsibility to humanity in general. The issue of illegal aliens is a tough subject.
Dr. Friedewald: Our job is to get on the record what we would like to see the government do. Granted it is tough, but they are going to be voting soon. What would we as physicians responsible for people’s lives like to see the government put in this legislation about their care?
Dr. Yancy: We as physicians, we as health care providers, are terribly impacted by the preservation of life. This issue bringing forward resources for persons who are not citizens reflect conversations that go beyond our purview as health care providers. These really are social-political conversations. Those kinds of statutes have to be established with a different set of people around the table. None of us would walk away from an ill patient, regardless of circumstances—language, economics, citizenry, it would not matter. We are obliged to provide care. But our system, at another level, has to have this conversation.
Dr. Cohn: I do not think it is a question for us. If you see a sick person in the emergency room at a hospital, you are going to take care of that patient. This is a problem for administrators, insurance people, hospital administrators, and others responsible for reimbursement. We have an obligation to take care of the sick. That has got to be our position, but it is a difficult problem.
Dr. Friedewald: I want it on the record that we are going to take care of them. The main thing is that our legislators need to know that we as physicians and other health care professionals are going to do what we are trained to do, without regard to whether a patient is here legally. The burden on them is to decide whether they are going to let us be paid for it or not.
Dr. Cohn: My whole take on the reform issue is one old-time proverb: haste makes waste . I am frankly very worried that we are going to be forced into rushing into something that we are not going to be happy with. When I say “we,” I mean the American people. I do not understand this incredible intensity to do this. It is such a complicated problem. We ought to get more blue-collar doctors in these discussions. The medical and the surgical societies have got to come into this in a big way. But to just race this thing through, I do not get it. I think we are going to make some costly mistakes. The outcome, on this track, is not going to be good, and it is going to be costly. I would prefer to defer it and call all the leaders of the various interest groups—and physicians are a vital part of that mix—together and say, “Ladies and gentleman, please be seated. We are going to do it, but we want everybody involved.”
Dr. Yancy: There are many moving pieces in this equation. Even though deconstructing it and focusing on 1 issue seems intuitively clear, if you take the issue of access, how do you force the equation to increase access without realizing that you have to create a vehicle to provide access, you have to create funding to support access, and all of these pieces move together. Some of this necessarily has to be a mosaic or a fabric and not just a piece of cloth.
Dr. Friedewald: Where do we draw the line between responsibilities of the health care system itself and societal activities that can impact the system, such as cigarette smoking and overeating?
Dr. Bill Roberts: I think the biggest change is going to be made not by physicians but by politicians and money. Insurance companies charge more for premiums to cigarette smokers than non–cigarette smokers. Every time the tax has gone up on cigarettes, the number of cigarette smokers has diminished. A pack of cigarettes, as I understand it, in New York City now costs $10. If you put $10 in the bank every day from age 18 to age 65, you would be a very rich person. I think cigarettes should be taxed to the hilt. We should also find a way to tax excess body weight.
Dr. Friedewald: That is probably unconstitutional, but what about taxing hamburgers and other foods when they exceed a certain calorie level?
Dr. Cohn: I tell patients that if you do not lose some weight, I am reluctant to operate on you, because postoperatively it will take longer to recover.
Someone comes to me and they are smoking cigarettes, I say, “If you don’t stop smoking for 6 weeks, I am not doing your heart operation, because the postoperative respiratory complications may be difficult. I am not going to take the risk for you while you are smoking.” If obese people come into offices, they get very offended if their doctors say, “You are fat. You have got to lose weight.” This is a very important health problem in the USA.
Dr. Bill Roberts: It is illogical for a business to have to provide the same amount of insurance for somebody who has ideal body weight and is very health conscious as it provides for the 300-pounder working in their company.
Dr. Friedewald: We hear figures such as 50% of people’s lifetime health costs occur in the last year of their lives. This is a misleading statistic. I was nearly killed in a car accident, and a lot of money was spent on my care. Had I died, that money would have been spent on the last year of my life. But by contrast, I lived, thanks to all that expensive care. And a lot of other people live because of expensive care. What better way to spend our money than the last year of someone’s life, because such care implies that we also are saving a lot of lives , which is the other side of the equation. Would we rather say we are spending half of our health care dollars on adolescents with acne?
Dr. Bill Roberts: The purpose of health care is not to prolong life but to make life tolerable and pleasant. If a procedure does not make life more pleasant, should it be done?
Dr. Cohn: Many arguments in the same vein are aimed at very elderly people undergoing heart surgery. When I was at a business conference recently, I surprised some people when I mentioned that I do open heart surgery on some very alert, healthy 90-year-old patients with very supportive families. They might live for 4 more years and then die from cancer or something unrelated to heart disease. But people ask, “Why should we do that?”
Dr. Bill Roberts: Many 90-year-old people are relatively healthy. If you have severe aortic stenosis and you are 90 years of age, the only therapy is to replace the valve.
Dr. Cohn: This last-year-of-life issue is a real paradox, because if somebody is sick, you do the best you can to take care of them, unless they are brain dead. We are doctors, and that is our obligation, just like caring for people who are in our country illegally.
Dr. Friedewald: Clyde, I would like to conclude our discussion with your summary of the American Heart Association’s position on health care reform in the USA.
Dr. Yancy: What is espoused by the American Heart Association is a platform with 6 tenets: increased access to care, a focus on prevention, a continued focus and a further embrace of achieving best quality, elimination of health care disparities, a significant improvement in our research support, and an increased diversification of the health care workplace.
Dr. Friedewald: Thank you.
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