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Interviews
John Nelson, M.D. interview
Medical Director, HealthInsight
Interviewer
John I think what does make you unique is the different experiences you've had, the different qualifications you have to talk about this issue, being the past president of the AMA... Just briefly, would you tell me about your perspective?
John Nelson
Well the things I have seen, I've seen through the eyes of a physician because I am a physician. I have been trained that way. I look at things differently, perhaps than others might. One of the opportunities I had while President of The American Medical Association was to travel around the United States and to see firsthand what my colleagues were facing. I guess in a nutshell I'd say that most doctors feel beleaguered. I feel like they're afraid to put their head out of the foxhole because they don't know from which direction is the incoming artillery. Is it the federal government today? Is it the local government tomorrow? Is it an insurer? Is it an attorney? Is it a patient with a severe disease? Is it a personal problem with the physician? Is it a financial concern about keeping the practice afloat? There's just a lot going on right now and oh, by the way, we're suppose to take excellent care of the patients before us. So we have a lot of things about which we need to speak as physicians. And we need to make sure we take care of ourselves and that's a very appropriate role. But our real role as physicians is to care for patients. And so I think that whenever we're able to look at a health care issue with the patient in mind, that we do a better job of understanding what that problem is, and so some of the problems that I've seen are patients who can't get in the door--patients who don't have access to healthcare. Now in the United States because of the EMTALA law, the Emergency Medical Treatment and Active Labor Act, EMTALA, every person who presents him or herself to an emergency room must by federal law be seen, evaluated and stabilized. So people do come to the emergency room, but they come too late. A person might have had a simple upper respiratory infection or ear ache comes in with advanced pneumonia. A person who might have had a small lump or bump someplace on their body comes in with metastatic cancer. A person who might have had an obesity problem leading to early diabetes comes in with diabetic neuropathy and significant kidney problems. So although we see the patients, we see them too late and in a very inefficient way. We have to find a way to make sure that patients have access to the system much sooner.
Interviewer
Why don't people have access to the healthcare system?
John Nelson
Probably the biggest reason patients don't have access to the system is they don't have access to health care coverage--they don't have a way to pay for what's there. Isn't it an interesting paradox? We have more care available in the United States of America, more technology available, new innovations that were unheard of when I was a medical student, and yet sitting within the shadows of the wall where that technology is given, people can't get in the door. There's something dramatically wrong. We have phenomenal world-class leading edge care for some and no care for others. The paradox is stunning to me.
Interviewer
But we've known this for a long time. This isn't a new problem. How come we haven't found solutions for it?
John Nelson
The solutions to a complex problem will be complex... they'll be costly. I think the real reason we have not come up with the solutions is that there has been no leadership. There has been no entity, no individual stepping forth to make this the national priority that I believe it needs to be. The other part is I have a friend named Stewart Altman. Dr. Altman, a professor at the Brandeis University, makes the statement that every group or every individual has his or her own way of wanting to reform the American Health Care System. But as soon as we don't agree with that person, we revert to the status quo. So I have not seen any group or any individual willing to put aside his or her own personal concerns long enough for the benefit of society.
Interviewer
Is that what it's going to take?
John Nelson
Well I think that we all need to participate. Take physicians for example. We can't have meaningful health system reform without the participation, and I believe the leadership of physicians. Physicians need to be able to share what it is we do in clinical medicine that works. What doesn't work? How can we be more efficient? How can we shift the paradigm from interventional care to preventive care and wellness? How can we be more effective in reducing costs? How can we keep people out of hospitals? How can we use lower cost modalities and so forth? At the same time we do that, we have a gun held to our head. That gun is the liability concern we have if we don't do things to the greatest of our ability. So if I were to suggest something that the patient didn't want or didn't like, I may be liable for them. If I don't give the purple pill because it's expensive, I use another pill and don't get the result, I may be liable. The defensive costs are astronomical. But even so, we have not been as a profession willing to put aside enough of our own concerns for the betterment of everybody. The same goes for the hospitals, the insurers, the federal government, the patients, and liability carriers. Everybody has a part in this because health knows no bounds. I mean I will tell you that a SARS bug doesn't need a visa to get across the United States border. And a cancer cell doesn't recognize a republican from a democrat. We've got to make sure that we understand... I mean really get it, that we're all in this together and therefore the solution has to be something that we as a society, as a nation decide upon.
Interviewer
That's one thing I've noticed too is that there are people from all over the political spectrum that are ultra liberal to ultra conservative and everyone is grappling with this issue. Is this is a political issue?
John Nelson
I believe that Tip O'Neal indicated that all politics is local. All health care is personal--very, very intimate. Certainly there are going to have to be some roles for the federal and state governments, but how can health care be political? I don't understand that. We've got to find ways that are available for everybody. There shouldn't be one kind of care for the poor and another for the rich. There shouldn't be one kind of care for the old and another for the young. There shouldn't be one kind of care for those in the rural area and another for the urban area. There ought to be excellent care for all. And to the extent that we can provide that care earlier in a preventive way, or earlier in the disease process, the better off our health will be and the lower the costs will be.
Interviewer
It seems like nearly everyone agrees we need healthcare reform, but we're still not doing it. It has got to be frustrating.
John Nelson
Well the cynical part of me would say that every dollar in the health care system is a benefit to somebody, so as soon as we start talking about changing the system, as soon as that affects one in the dollars, wait a minute, now you've got my attention. And again we're not able to put aside our own pecuniary or other professional interest long enough for the benefit of everybody. But I say that about every single segment. I again believe that physicians need to be substantially in the lead of what's going on in the health care portion, particularly the clinical part. But there has also got to be some concern by the payers, the insurers, the governments and the like.
Interviewer
We all have a role. You were saying that health care providers haven't even been brought to the table in the national debate. Is that true?
John Nelson
It's impressive to me that many times when health system reform is talked about, we talk more about the payment system rather than the clinical part of health care, and I guess that's one of the reasons that we often have physicians, nurses, and other health care professionals excluded from the debate or brought in very late. If you go back to 1994 when the Clintons tried to put together a package about health care, physicians were fairly routinely excluded from that debate. I'm sure there were some that talked to the Clintons, but for example, the American Medical Association was totally excluded. Those who could have perhaps helped were not allowed at the table. We've got to find a way to get all of us to the table to understand what's going on. We each have a part we can contribute. We've got to go back to the John F. Kennedy quote, “Ask not what the health care system can do for us. What can we do for the health care system for all of us?” If we're going to be in a global economy, and I say we are, we've got to be able to compete with other nations whose health care is taken care of. Do we understand the cost of disease? If a person misses a day at work, it's more than 10-15 hours that's lost--it's a lost productivity as that patient is becoming sick, it's a 10-15 hour while they're gone, it's a training of another person to do the temporary job not as well as a person can do. As a person is home recovering and comes back, the job is not being done as well. We lose a lot of money by not keeping that person healthy and not treating that patient early, so from the financial perspective it makes a lot of sense to involve the employer, for example. But it makes a lot of sense also to involve the occupational health physicians--those who can prevent the disease and the injury from occurring in the first place. And of course the insurer has a role in making sure that the care is paid for correctly and appropriately, and it goes on and on and on. So it's all very interconnected. There isn't just one part that can be fixed in a vacuum, and that's why this becomes so complex. If you fix one part, another part goes out of whack. We've got to do this all at once. But fundamentally, this is not a discussion about a different way to pay for what we have. It's a discussion about a different way to pay and a new system for which to pay.
Interviewer
I'm thinking about what you said earlier that we can't even agree on something as simple as, we'll have everybody covered by the years 2012. Where do we need to start this discussion?
John Nelson
Where do we need to start? Someplace! It almost doesn't matter. If one wants to make the biggest bang for the buck in the quickest fashion, I'd make a strong argument for covering every single American with access to health care coverage. Why do I say that? Well, first of all it's the right thing to do. It's fundamentally un-American to have some people with world-class health care and others with no health care at all. That makes no sense. From the public health standpoint, it makes a lot of sense to get diseases nipped in the bud. If you have multiple drug-resistant tuberculosis, you don't care if you have insurance or not--you're just as susceptible to that bug whether or not you have insurance. On the other hand, if the person who has that had insurance, maybe they never would have gotten to that point thereby saving you from the disease. But there are some other things that really, really bother me. If one looks at the Institute of Medicine Report of 2003, the estimate is that every year in the United States of America, 18,000 people die from diseases that we can prevent or cure simply because they do not have access to the system. That's unconscionable! That's wrong... and it's expensive. I just participated in a about a two-year program, a group of 24 organizations, to look at ways to cover the American population's access to health care coverage. It would be expensive. It would cost 200 to 300 billion dollars per year more than we're paying now and that's not insignificant money. But what does it cost not to cover 47 million Americans--our friends, our neighbors, our brothers and sisters, our family members and the like? Well if you look at the Institute of Medicine report they'll say that it costs 95 billion dollars to take care of the actual health care needs of that population. About a quarter of that is paid out of their pockets, some is paid by those who have insurance part of the year, lose their job and then get another job. The result of the rest is being paid by the federal government. But go further. What about the hidden costs? What about the jobs lost? What about the wages not earned? What about the taxes not paid? What about the goods and services not consumed? If one adds those up as the IOM did, the estimate of the cost is staggering. Their estimate is as high as 3.2 trillion dollars per year to the United States economy. We pay around 2 trillion dollars for all of health care--so half again as much is lost by the fact that we don't cover our own fellow citizens. We have got to do better. It's the right thing to do ethically. It's the right thing to do from the public health standpoint. It's the right thing to do economically. Let's do it. That's the way to get the biggest bang for the buck first.
Interviewer
When does health care become a crisis for us, for people, for America?
John Nelson
Health care becomes a crisis for you when you don't have insurance and you're sick. Could it be a nurse in Bixby, Arizona who is not able to go to the hospital where she practices because they've closed their obstetrical unit and she's pregnant and is in labor and drives 100 miles to the next hospital to deliver, but doesn't make it and delivers by the side of the road in the middle of the night in the desert by herself…and this is the United States of America. Or could it be when a doctor closes her office in a rural area because she can no longer make a go of it because the payment is not sufficient? Or it a person who would have been able to be cured easily with preventive measures or early intervention into the diabetes, but didn't have insurance and so didn't go until kidney failure had become the issue? That's when it becomes a crisis. It's a very, very personal issue. When does it become a crisis for the country? Several years ago! It's a crisis now when GM pays 5.1 billion dollars for the health care of their employees and their retirees. By the way, Japan, which has a nationalized system, doesn't have to pay that cost. You may be aware that Toyota just became the largest auto manufacturer in the world, replacing General Motors, partly because of that issue. Now while I do not favor a national single payer system, we've got to find a system that does in fact include everyone for the reasons we've talked about.
Interviewer
Why don't you favor a single payer system?
John Nelson
I think there are three reasons that a single payer system won't work: one is Medicare, two is Medicaid, and the third is Tricare. Medicare is going belly-up. It does not provide that which has been promised. Medicaid is abysmal. There are 9 million children who should be eligible for Medicaid--they don't get it. The categories are so complex that no one can figure it out. And Tricare is the same as Medicare. We have not been able to do a one-size fits all because we're the United States of America. We've got to find some choices for people to make so they can have the kind of health plan that's best for them. I fear that if there were a national single payer system, it would have the cost spending habits of the Defense Department. It would have the efficiency of the United States Postal Service and the compassion of the Internal Revenue Service. I just don't think that's a way to go. And by the way, I don't think there is any real evidence that it would be less costly.
Also, Americans love choice. We like to choose what we're going to eat for dinner. We like to choose what we're going to wear. We like to choose where we're going to school. We like to choose what kind of health care we have. We like to choose our doctor, our hospital. We like to choose the care that they're going to give to us. I think that to take those choices away, which are very much valued by Americans, will not be helpful. I also think it will be hurtful to the system overall. The care that's needed by a 65 year old diabetic man is not the same as a 19 year old pregnant female. We've got to find a way to deal with care in an individual enough way that the care that is needed by the individual can in fact be given in a cost-effective, patient-centered efficient way.
Interviewer
It sounds like this is a very personal issue for you…that you've experienced first hand. You've seen people who haven't been able to get care. Is this a very personal, frustrating issue for you?
John Nelson
Well it's personal for several reasons. It's personal because of patients I've seen. I'm thinking of a young woman. I was walking to the hospital on my way to the car after having done a delivery in the middle of the night and heard a woman weeping and was asked to see this patient. The doctor who was suppose to be on call was at another hospital or unavailable. So I saw this person who had a very significant gynecological problem; was losing blood dramatically and needed to have a surgical procedure. She had no insurance, she had no money, she was from another country--didn't speak English as a first language. I was able to find a friend of mine who’s a great anesthesiologist and we determined that we would care for the patient. The hospital which I practiced also was able to kick in and help this person and we literally saved her life. I didn't know that her mother worked at our hospital. Her mother, obviously from the same country, was a person who cleaned up after the deliveries; washed the blood off floor and picked up the placenta and did all of the stuff that we don't want to talk about that has to occur in a hospital. I'll never forget when I saw the mother the next time. She ran up and threw her arms around me and in Spanish thanked me for saving her daughter's life. There was no pay for that nor should there have been. We as a team did the right thing. So it became very personal.
It's personal in another way. When I became president of The American Medical Association, I had to close my practice because I was gone so much. I, like others in a small business, had provided insurance for myself and for my staff. When I was no longer able to do that, I lost my own health insurance. In the process I had a surgical procedure and became hypertensive and I'm uninsurable. So now I'm paying my own insurance at the rate of $2,205 per month. One of the reasons I'm working right now instead of retiring at this advanced age is to be able to pay for my own health care insurance so should there be something to happen to me, my family won't become destitute for that care. So yes this is personal in both those ways.
Interviewer
It seems ironic that somebody like you with your education and your background and has given so much is still struggling with the same issue.
John Nelson
I'm no different than anybody else. I'm a person. I'm a citizen. I happen to have chosen to become a physician instead of some other profession. I'm no different. I'm not special. There's nothing that should make me be held out from the masses. I'm one of the people. I'm an American. I'm a Utahan. I'm a Salt Laker. There is nothing special about me. The only thing that is different is that I've experienced from both ends--I've experienced at the macro level. So I've seen patients around the country go uninsured. I've experienced it at a micro level as I've had my own insurance be cut off. We've made what sacrifices we have felt we have had to make so I can have the insurance personally, but that's a personal issue and that issue shouldn't get in the way of the bigger picture. There needs to be some way where all Americans can have access to care. By the luck of the draw I've been able to find employment which allows me to make sufficient money to pay for my health care insurance so I'm again insured. Don't worry about me. We need to worry about those millions of Americans who are working, who have a job, or live in a family where someone has a job, who still can't afford to purchase health care insurance and therefore they go without health care, often needed health care, especially preventive health care. So it becomes very costly not to be insured.
Interviewer
The majority of people are insured. Why should somebody who is insured care about this issue?
John Nelson
Every time you pay your insurance premium, realize that a substantial portion of that premium that you're paying is helping to pay to offset the cost of care for those who don't have insurance. So what it's costing you in a real way is taking money out of your wallet. When a patient comes in to the emergency room with an automobile accident or with an advanced disease, the hospital, as we've suggested by law, cannot turn that patient away and must in fact take care of that patient, as do the physicians and nurses and other health care professionals. But there is a cost to the system that must be more. You can't make things out of nothing, and so that cost is born by increasing prices, by increasing the subsidies that insurance pays and so forth, so in a very real way, you indeed are paying. More specially, your employer who probably provides your insurance is paying as well and in large amounts, and that's why many more employers are not able to afford the coverage, thereby increasing the ranks of the uninsured.
But there's another way that it affects you. It affects you potentially by the patients who didn't get the care at an early stage; the person with pneumonia who coughs in your face, the person with SARS who affects a member of your family, the person with multiple drug-resistant tuberculosis who coughs on a neighbor or friend of yours and thereby gives you the disease. The public health ramifications of this are real. They are not made up. It's not hype. It's not something that we're trying to trump. We're trying to tell the truth as it is. Microbes know no boundaries and they don't know if you're insured or not. They just know that you're a likely target, and so in real ways diseases, particularly in schools where some children are insured and others are not, (or communicable diseases) are rampant, has real effect on real people, so at least from those two ways; the financial and public health aspect.
My guess is there's another aspect, if I might wave the flag for a moment. This is the United States of America. This is the place where there's hope for everybody, well except for those who don't have insurance perhaps. We've got to find a way to go back to the roots of what our Founding Fathers were about. I can't imagine that they'd be very comfortable the way we have chosen as a system and as a nation to care for some of our own Americans.
Interviewer
Are we more like a Third World country at times?
John Nelson
In Salt Lake City, not far from the hospital in which I practice there's a zip code with a neonatal mortality, the maternal mortality--the number of babies and mothers who die, and it approximates that of the Third World. In the state average we do very, very well, but there are pockets where that care is not existent that is costing us all a lot of money. It doesn't need to be that way. We can figure this out. Let me ask a hypothetical question. Which is more difficult--to invent the computer, or to put a man on the moon, or to figure a system which allows payment for health care for every American? This is not rocket science. It's going to take political will. I've decried that already. It's going to take leadership from all sectors. It's going to take the willingness of every one of us to put our own concerns aside long enough for the benefit of everybody. That's the way we've always done it in America before. It's time to do that again.
Interviewer
It seems this often comes down to funding. Do you think we have the right priorities in terms of spending money on healthcare in Utah?
John Nelson
I am not in the legislature and I don't know all that has been faced there. I truly respect those of our fellow citizens who take the time out of busy personal lives to make themselves accessible to the legislature and who are barraged with a variety of concerns on all fronts. They understand that there is a finite pot of money for the Utah Government in which to operate. They understand that there are competing concerns of education, agriculture, transportation, health care, business development and the like, and so I am not privy to all that goes on there. I simply would point out that particularly when it comes to Medicaid, when a state dollar is allocated from Utah; it's matched by three federal dollars. So every time a dollar is taken away from Medicaid, we lose in effect four dollars. So I would think there ought to be some priority for that vulnerable population of Medicaid recipients and those in the SCHIP program to be funded as a priority. I would think further there ought to be some look at those things we can do as a society for preventive care--what we do to stop the spread of certain diseases. Are there ways in which we can improve immunization rates, which traditionally lag in Utah far behind the national average? What can we do as a society to make these things better? Can the government as it affords health care to its employees, find better ways to provide that care that are more efficient and less costly and so forth? It is I guess fun politically to take a poke at funding a soccer stadium and not paying for the health care of Utahans, and that's the politically savvy fun thing to say. I don't know what the priorities were. I don't know what choices I would have made. Would I have made different choices? Probably. Would they have been better choices? Not necessarily, just different. So I applaud those in the legislature who have taken time to do this. If I had been there I would have voted differently.
Interviewer
You have lived with this issue for a long time. What solutions do you see?
John Nelson
My concern is for the individual who doesn't have the access to the health care system because that person doesn't have access to health care coverage, is denied benefits which you and I take for granted because we have health care insurance. This isn't the way we should be. This is not the kind of humane society that we should be.
Are you aware that a prisoner who has broken the law has better health care than some of our citizens that are working every day for a living and trying to be productive members of society? This doesn't make sense. Are you aware we take better care of our pets than we do of our own fellow human beings in some cases? We've got to find a different way to do this. I think there is a way to do this. The way I'd propose is in the private sector. I'd advocate for a system of tax credits. Remember that an employer, a large employer pays the health insurance of the employees, then what's left over, pays taxes. A small employer does it just the other way around. The small employer pays the taxes first and if there is any left over, then pays health insurance. And because a small employer doesn't have the same access to the market of health insurance, that person often pays much higher rates. Consequently the smaller employers don't have as much health insurance, and as the employee has to pay more of his or her share, they can't afford it, so they go and become uninsured. A tax credit would level the playing field so that everyone got the tax benefit of paying for the health insurance. But the tax credit needs to be more than just available.
The tax credits need to be large enough to be able to have people pay for real insurance in the real marketplace--probably $6,000 to $7,000 per person--that's a lot of money, and the excess cost could be 200 to 300 to 400 billion dollars a year in the current system. Years ago there was a man on television who sold Fram oil filters. He said you can pay me now or you can pay me later. We can choose to pay the 300 or 400 billion dollars that it would cost to do what I propose, or we can continue to pay the 3.2 trillion dollars for not insuring our fellow Americans. Now that's if we continue the system as it is. Of course the American Medical Association and I am an advocate of making sure we change the system as well to make sure that we use evidence-based guidelines and follow those guidelines as clinicians--that we get far more into getting disease caught early. If we work more prevention and wellness we can do a lot to improve the quality and thereby decrease the cost. It's the costs that seem to be the issue. The quality of care is uneven across the country. There are pockets where excellent care occurs in and out of the state. There are pockets where the care isn't as good as it could be, and we need to be better about making sure the care is even and excellent in all areas. We also need to make sure that the costs are the same. There are a lot of issues that have to deal with the costs that the physician can control. Probably the most significant medical instrument is the pen because the pen writes the prescription. The pen writes the order for the MRI or the expensive procedure or whatever, so we need to learn to control our pens as we control other parts of health care costs. We need to learn to use generic medications when they will be appropriate for our patient, at the same time, reserving the right not to use a generic medication when the brand name is what's best for our patient. Similarly, it would be said about the procedures we use, the days in the intensive care unit and so forth. We can do nothing currently to change the number of people who have heart attacks or the number of people who come to us with heart failure and diabetes. But we can do a lot as clinicians on how we treat those patients individually. So the volume of the disease we cannot yet control, but the volume of services for that disease we have great control over. If we do that in a better more efficient way, that's patient centered, effective and so forth, we can improve the care dramatically and decrease the costs.
Interviewer
Why is it that you go to one doctor for a procedure that costs "x" amount, and you go to another doctor, same procedure and the cost is different. Why is there so much variety inside of costs with physicians?
John Nelson
The true answer? GOK--God Only Knows. I don't know how you figure out what the prices are. Indeed--I'm not in practice now--I have been until recently. I would have a code sheet that had the code of the procedure, but no charge on it. The reasons... it didn't matter what the charge was. I'd be contracted with an insurer or the Federal Government for the payment. So I could charge $1, $100, or a million dollars and I'd be paid the same depending upon what the charge is. Now there are costs of drugs, there are costs of procedures, there are costs of hospitalizations, intensive care units and so forth, and utilization of those services and those modalities we can control, but the cost of each we cannot control. I think there are some doctors who believe that they have better outcomes. Some doctors will believe that for whatever reason they are "worth it" and charge that. Interestingly, some patients are attracted to that and feel that because a doctor charges more, she must be better. There are those on the other hand who believe that those who are more efficient should be those who are rewarded, and we're in the process right now of trying to parse out what the costs are of the care. It is very difficult. If a person came to me and said, how much does it cost for an obstetrical delivery I'd say, "Well here's my charge. Your insurance will pay whatever they pay. If you go to this hospital it will cost this on average. But you better take a look at what's in that bundle of services because they may vary dramatically." So one of the thing we're trying to do at HealthInsight is to be more transparent to make sure that people really do understand what the costs are, why the costs are as they are, what is included in the cost, and we hope that by being more sensitive by allowing people to know what the costs are, there might be some competition that might lower the costs where that could be helpful. This is a federal initiative as well. Governor Leavitt has been out here just recently to talk about it, so we favor the issue of transparency particularly as it applies to price.
Interviewer
Are there other areas where transparency won't work?
John Nelson
Transparency has a down side. What transparency do you need to see? My wife needed a surgical procedure on one occasion. The surgeon we chose had the highest death rate, lost the most blood, had the most patients in the ICU, and had the most patients who died. He was a gynecological oncologist and took care of very, very sick patients and had excellent skills, which treated my wife well and she did just fine thank you. So transparency on its face may be helpful. Without placing it in context, it may not be helpful. There's another part. As we get to transparency, if I'm going to try to look good to my patients or to the insurer, what will I do? If in fact I am taking care of say a diabetic and I want to follow the hemoglobin A1C which level we know is a report card on how well that person is doing--if I took really good care of all my patients except for you--if your hemoglobin A1C were poor, I might fire you. I might send you to another doctor so that my statistics would look good. If transparency is complete, you're going to want to score me against other physicians. Let’s say I take care of diabetics and I take really good care of diabetics, the hemoglobin A1C which is a marker of how well that diabetic is really low in all of the patients except for you. Do you know what I'm going to do with you? I'm going to fire you. I'm going to send you to Dr. Jones down the street so that my data will look good. Now what if there were a group of patients known to do poorly with their hemoglobin A1C? What if that group happened to be African-American? Native American? Hispanic-American? Asian-American? All of which as a group are known to have much, much poorer care under any circumstance, and much poorer hemoglobin A1C levels. Do you know what I might do? I might try very hard not to see any patients in that group, thereby exacerbating their access problem to start with. So I think the transparency has at least two sides to it; if I'm going to look good, I'm a physician, I'm smart enough to game the system. So we've got to make sure that the system is not gamed, that the transparencies are aimed at helping people choose better health care in ways that are meaningful.
Interviewer
We have cultural disparities in our health care system. Do we have a two-tiered system?
John Nelson
During my time with The American Medical Association, I had the privilege of sitting on the National Advisory Council of the Agency for Health Care Research and Quality (AHRQ). AHRQ is an amazing organization. I wish there were time to talk about that. That was the first time that the Federal Government made a law that that agency would report annually on two things; the quality of care, and the disparities in health care. Disparities had to do mostly with the kind of care that a person in the minority community might get. We learned, for example, that an African-American male who had severe diabetic disease would more likely have his leg amputated as compared to a white individual who would have limb-sparing surgery. We noticed that African-American females tended to get their breast cancer diagnosed much later and at a much higher mortality rate. We noticed that Hispanic-Americans had a much higher hemoglobin A1C than their white counterparts and so forth. When we tried to drill down to find out why, we eliminated the fact that insurance was a variable. These people all have the same insurance. In fact in one study not long ago of 719,000 all on Medicare, they have the exact same insurance, and yet the disparities persisted. We're working hard at Health Insight, at The American Medical Association, at The Commission to End Health Care Disparities and other places to find out what the causes of these disparities are; first of all to identify the disparity, let the world know that the disparity exists, and then using an evidence-based protocol to see if we can eliminate the disparity one at a time. We're making some progress, but there is still a lot of distrust by the minority community of the mostly Caucasian Health Care System. We've got to find the ways to break those barriers down and that's what we're about.
Interviewer
Nationally, does President Bush have a plan to deal with rising healthcare costs? I know he’s mentioned a tax credit.
John Nelson
The President has some ideas on how he feels health care might be better dealt with. The good news is that he has an amazing Secretary of Health and Human Services in Utah's former Governor Mike Leavitt. Governor Leavitt is a person who I have immense respect, and with whom I have worked closely; a person I know well personally who if allowed to do what he could, could make amazing progress in the Health Care System. My observation is that he has a fairly short leash and the White House is calling the shots. In an administration which is absolutely consumed by the conflict in Iraq, there have been little health care access concerns expressed. The President is very pro-business and believes that the major issue is cost. He is right, but his attempts to deal with the cost have done little to look at the entire Health Care System, so I would think that we need to get back to the basics--what we do to make access to health care for everybody a reality? That's what's going to save the most money. The second part we haven't talked part. What's the second way to save health care costs? Remember we talked about the Health Care System--the last year we have data for is 2004, about 1.9 trillion dollars, 2 trillion dollars. Think of these subjects; obesity, teen pregnancy, sexually transmitted disease, violence, suicide, accidents, tobacco and alcohol use. Those eight behaviors, those eight choices or groups of choices that people make for the most part account for 1.13 trillion of the 1.9 trillion we spend. Now I'm not Pollyanna--we're not going to eliminate all of those things at once for sure. What if we eliminate those by 25%? Gosh, there's 250 billion right away that we could use towards access to health care for all people. We've got to do a much more serious job about finding the plagues of society that we're facing. In the state of West Virginia in a study recently done, in the 5th grade, 47% of children were overweight or obese by body mass index. The favorite food at the Alabama State Fair was a Twinkie deep-fried and rolled in sugar. We've got to find ways to help our young children learn how to eat more efficiently, more effectively. We've got to find ways to get them off of the couch and move them a little bit. We've got to get them away from the video games and onto the soccer field and so forth. We've got to be much more concerned about prevention of these diseases. We are not just worried about type 2 diabetes in later life. We're worried about type-2 diabetes in children now, which is causing a tremendous stir and a large increase in expenditures. So we've got to do a lot better job in the preventive field than we're doing. We need evidence-based ways to teach people how to eat correctly, how to exercise more, how to stop smoking, how to get away from alcohol abuse, substance abuse and the like. Not just say it's bad for you, stop it, but actually have a regimen that has been shown to work that is individually tailored to an individual's needs and we've got to do that pretty darn quickly.
Interviewer
How about Utah, do we need to anything specifically as a state? Are we positioned to find answers for healthcare reform?
John Nelson
Utah is unique. We have the ability to communicate amongst the various aspects or sectors of the health care community--we always have. The Utah Health Information Network, for example, isn't owned by anybody. It's a community resource, and abject competitors--insurers and the like--have come together to make sure that UHIN functions. About 90% of our billing information goes electronically now, in the savings of millions of dollars to patients and insurers and so forth. We can do that, again we must... this time folks in a different way. We have a very good history and track record in the state of Utah of competitors working together for the common good of the state. The Utah heart transplant circumstance, before it was broken up by the Federal Trade Commission was a great circumstance for Intermountain Health Care at the University of Utah, and the VA worked together and had some of the best outcomes in the world, but because of potential antitrust violations was broken up. We've got to make sure that the law doesn't get in the way of practicality and we can get back to where we can be. Cooperation/collaboration is the name of the game. To the extent that we do that, we'll be successful. To the extent that we become silos and competitive and anti, we're going to fail, and we've had a history here working together.
There are currently about 292,000 Utahans without health care insurance. That's quite a number for a state as small as ours. Governor Huntsman called a group of us together to talk about what we might do prior to the legislative session. We decided that we couldn't do it all at once, but one thing we could do would be to take a big bite out of that by covering all children--those below the age of 18, (seventy something thousand), so it would be about a fourth of all who were uncovered be covered like that if we covered the kids. Children don't really have legislative advocacy. I mean there's some talk on behalf of the kids, but the kids themselves don't go and talk to the legislature. They're relatively cheap to cover, and it's the right thing to do. That didn't get anywhere in the legislature this time. We have made no progress currently on this issue. Children continue to get sick. Diseases continue to occur. Those without access to the system continue to get sicker while we're fiddling. Indeed we're not fiddling as a philharmonic orchestra playing, but be that as it may, we have got to find a way to work together like we have in the past. To their credit, places like the 4th Street Clinic are seeing anyone who comes in. There are many physicians, members of the Utah Medical Association, who voluntarily take on people without insurance, usually the sickest. Our hospitals are seeing some of them without charge. We're putting a band aid on a huge gash and to the extent that we're able to do that, I salute all of my colleagues who are doing that. We've got to find a way to close that wound and we can only do that together.
Interviewer
What’s the biggest plague we're facing right now? Is it access to health care? Is it prevention?
John Nelson
If you look at the biggest plague in terms of dollars, it's certainly access to health care coverage. That's the 3.2 trillion that the IOM says we lose each year for the 47 million who haven't got access to the care. The other parts of that though are just as important. Remember, not only is it costing a lot, but we're losing 18,000 Americans... they're dying every year because they haven't got access to the system. They're dying of diseases we can prevent or cure. There is something very un-American about that. And then the public health consequence, particularly of communicable diseases; SARS comes mind. We were lucky with SARS when it occurred a couple of years ago. We may not be lucky the next time. There are diseases which come from animals not yet described. HIV AIDS is a concern and so forth. But somebody with something as simple as multiple drug-resistant tuberculosis coughing on a person... the person may not even know they have that disease and can transmit that. So the public health implications of not having access to health care are real. That's the first issue. The second issue are the behaviors, to a large extent, of the eight things we talked about, which need to be changed in such a way that we don't need to spend money. A person not obese, they don't need to worry so much about heart disease, diabetes, heart failure, sudden death, certain kinds of cancer and so on. If a person does not abuse alcohol they don't need to worry about liver toxicity, the DT's, driving under the influence and so forth, and so we've got to find ways to deal with that. I think we lose something like 467,000 Americans every year to the plague of tobacco. We don't bat an eye about that. When an airplane goes down it's front page news. I figured out one day, that's the equivalent of three 747's going down every day, and we pay no attention to it. How can that be? The cigarette... the only device currently legal for sale in America, which if used according to instructions will infect its user, and cause his demise. What are we thinking about? Tobacco should be banned, end of discussion. How do we allow people under the influence of alcohol to drive an automobile? That is just... this is the public health part of me talking... I realize the political ramification of what I have said, but it really bothers me when a family killed on the route that I drive to work every day not long ago in Salt Lake City is proof of why people who drink alcohol ought not to drive automobiles, and those who do ought to be treated with the utmost disdain and significant affects of the law. I know how I'd treat it.
When there's a bad automobile accident in the big emergency room, you can count on the following; usually the driver was a male, usually about 19-21 years of age, never wearing a seat-belt, usually inebriated, and uninsured. It's almost like a syndrome and the havoc that an automobile can cause is unbelievable. Look at what happened just the other day. I think a person who is found drinking under the influence should lose his or her license for one year, end of discussion no exceptions. I'd actually weld a large orange license plate on their car and if they were seen driving they'd go to jail for one year, no exceptions. It will only take a couple of those to happen. If they're found a second time they go to jail for five years no exceptions, no parole. We have got to get drunk drivers off the street. Are those significant issues? Yes they are. Is that a radical solution? Yes it is. What's more radical? Allow them to do what they're doing now? Most of the people who are drunk drivers have been convicted many times and continue to go on. This is just wrong. I don't get it.
Interviewer
It seems there’s a lot people don’t get. I was talking to a family physician in a community health clinic. He deals with issues of billing and it drives him insane because he spends 15 minutes talking to somebody about how they can get their diabetes under control. He can't bill for the same charge as if he actually did the procedure. It's frustrating. The system out there is frustrating, especially those doctors going into family health or some form of public health. Do you have any advice for them?
John Nelson
Well you follow your heart and you do what you want to do because that's the way you satisfy your career. But the payment incentives are really quite perverse. If I do an unnecessary procedure and can convince the insurance company that it was necessary, I make a lot of money. If a physician sits down and counsels a patient about wearing a seat-belt, safe sex, stopping alcohol, losing weight, stopping smoking he gets paid nothing... literally doesn't get paid anything and so the incentive is to do procedures. So what happens is the current payment system causes us to do things to make money that we shouldn't be doing and doesn't pay us for the things we should be doing. So we've got to find a different way to have the payment system incent us to do what is right. We've got to figure that out. I have never understood why a physician who thinks or does something with his or her mind is paid less than a person that does something with his or her hands. It doesn't make sense to me. Now that's not in any way to degrade or denigrate my colleagues or surgeons who are absolutely spectacular, who save lives on a daily basis. They should be paid well. But so too should the physician who sits down and says, you know when you lose your 50 pounds you won't be diabetic anymore. When you take your anti-hypertension medication you're going to be well. When you stop smoking the chronic lung disease you have will dissipate. We have got to find ways to make sure those caring physicians are paid in a reasonable way for what they do. That's where the rubber hits the road.
Interviewer
What’s the future for people who want to go into family practice?
John Nelson
For the primary care doctor I see a bright future. The primary care doctor is going to be the person who is going to be the medical home for an individual patient. That's going to be the person who knows the patient intimately, inside and out literally, to be able to help that person seek care from specialists when necessary and not to seek care when not necessary, and to be cost-effective--to be able to take the telephone call and by simply talking to the patient avert the ER visit that wouldn't be necessary, or to cause one early enough that it's a benefit. That's what we need to encourage in our primary care colleagues. They're the front line of medicine. They're also the people who are going to be seeing the plagues and the epidemics coming our way. They're the people that might be the first to see a biologic disaster should there be something like anthrax or something of that type come our way. So we've got to empower and encourage our primary care colleagues, and I think that there's a bright future.
Interviewer
What about clinics, do you see a brighter future or darker future for community health clinics out there?
John Nelson
The community health clinic is a little different story. The community health clinic has got to be one of the major bastions of defense against disease for those who haven't access to the system in other ways. They are underfunded, they're understaffed, and they're overworked. We've got to find a way to make that be more equitable. But the long story short is we've got to find a defense line to make sure that those people who would be subject to disease or other conditions had access to care in some fashion to defend them against those very diseases.
Interviewer
We have a safety net of state programs, community health centers, and other clinics designed to help people who can’t afford care. Is the safety net working?
John Nelson
The safety net works for some but not for all. One of the major safety nets in our state is Medicaid. Medicaid was well-intentioned in 1965, even though it was an afterthought to Medicare. It used to be for those who are poor. There should be two categories: if you're poor you get Medicaid, if you're not poor you don't get Medicaid. You can make a sliding scale so if a person is at the poverty level or just slightly above, they can buy in. But there are so many categories now, that if one is not in a category, they don't get any Medicaid. So the paradox is the very people for whom the Medicaid was intended don't have access to the system that is supposed to be there to protect them, so many children go without health insurance... children without health insurance. Well kids don't get quite as sick as adults, but when they do get sick, it's dramatic. A kid with meningitis, with pneumonia... boy there's nothing worse than a little kid burning up with fever. We have got to find a way to deal with that and oh by the way, immunization, primary preventive care... We do abominably in the state of Utah with our immunization rates. We've got to find ways to find these time-proven, effective, clinically appropriate, scientifically derived methods to all of the people of Utah. So the safety net, unfortunately, does not work for all.
Interviewer
Is there anything you'd like to add on the subject of access that we haven't covered?
John Nelson
I guess one of my problems has always been I'm not smart enough to know when I'm whipped. I believe with all of my heart that if we each put on the table what we can and try to divorce ourselves with as much as we can of our baggage, that together we can come up with a solution, whether that's going to be done at the statewide level, different in Utah from Colorado or Washington or done on the federal level, I'm not sure. We've got to marshal our resources. These problems are real. They are especially real for people who don't have access to care; the people who have chronic disease, the people who are literally dying because they haven't got access to a world-class system. We've got to find a way to pay for that. We've got to find a way to make sure that we're competitive in a global market. If we really, really understood the stakes for all of us--financially, morally, and the public health standpoint, I think we'd all want to do our part to go forth. There's a quote I like from... I think it was Ralph Waldo Emerson. He said, "What lies before us and what lies behind us are tiny matters compared to what lies within us." I hope he's right.
