Remarks by William R. Brody, President
The Johns Hopkins University
"Health Care '08: What's Promised/What's Possible?"
Friday, September 7, 2007
The National Press Club, Washington, D.C.– 12:30 p.m.
[NOTE: PREPARED TEXT. NOT CHECKED AGAINST DELIVERY.] [Introduction by National Press Club president Jerry Zremski] Coming to speak at the National Press Club is one of those opportunities that really makes you sit up and pay attention.
When I was first invited, I asked a friend who is a member, How big is the audience?
He told me the room seats 300, but two years ago they managed to squeeze in 350. I said, Great, what does it take to get hat turnout? Who was the speaker?
He said, Angelina Jolie.
And I said, No problem. I mean, she's a pilot … I'm a pilot. What's she got that I don't have?
He said, Do you want a list?
I am very grateful to all of you in the audience today. Thank you for being here. I plan to make this an hour well spent in your busy lives.
Jerry, thank you for that kind introduction, and for the very warm reception I have received from all the staff and members of the National Press Club. It is especially gratifying because part of what I want to do today is dispel some wishful thinking that is going on in America about reforming our health care system. This wishful thinking is what we often read in the press, and frequently hear from the presidential candidates.
But we're not getting the whole story.
People often ask me to explain the contradictions in our health care system. So I tell them this story:
I say, Well, you know, every time I go to the British Isles I cringe at the thought of having to drive on the "wrong side" of the road. But with all the push back from tourists, the British Tourism Authority decided that cars should all start driving on the right side of the road.
This was welcome news to many of us. Unfortunately, the London cabbies and truck drivers (or "lorry drivers," as spoken in the Queen's English) complained bitterly about the high cost of converting their vehicles to left-hand-side steering. So they came up with the following compromise:
Beginning next year, cars will drive on the right side of the road. However, lorries and taxis will continue to use the left side of the road.
They're calling this the "American medicine" compromise, in honor of the world's only health system where everyone gets to play by their own rule books.
Can you imagine? What a nightmare!
Yet here in America, it's exactly what we experience when we get sick. We have hospitals and doctors driving down one side of the road, and insurance companies, pharmaceutical and device companies using the same lanes but going in the opposite direction. It's a high-speed game of chicken, where no one is directing traffic—and it's your job, as a patient, to try to cross the road!
So I am very pleased to have been asked to come here today to speak about America's health care crisis. To do this, I'd like to tell you about the "five C's" of health care. These are the basic issues in our health care system that illustrate how we are driving two different ways down the same side of the road.
Two of these five C's you already know—cost and coverage. These are the issues we hear about all the time. The residential candidates are all talking about rising costs and falling rates of insurance coverage.
But if you're only reporting cost and coverage issues, you're missing a big part of the story.
That's the other three C's, and I'm going to tell you about them today, because they are the key to understanding what we need to do. Cost and coverage solutions alone will not solve our problems.
But no one wants to hear that. Health care is emotionally charged. Every one of us cares deeply about the kind of medical treatment we and our loved ones receive. When someone is sick or injured, that person is uniquely vulnerable. We understand that.
Yet, all too often, we see stories indicating our medical system—a system in some regards considered the finest in the world—is making mistakes, is leaving people out, is failing to provide the best possible care for all. American health care is the world's most expensive by far, measured both in costs per person and as a percentage of gross domestic product. And yet when the World Health Organization ranked all the national health systems by performance, the U.S. placed 37th, behind countries such as Morocco, Cyprus and Costa Rica.
Why do we spend so much on health care, and why aren't we getting our money's worth? We all want to know.
And while everyone is talking about the costs of health care and lack of coverage, meaningful change will only come when we address other issues.
These are the other three C's—the issues we're not hearing about: consistency, complexity and chronic illness.
We can't provide health insurance for all unless we control the spiraling costs of health care. But we won't control costs until we deal with these other issues.
These are the questions we should be asking the presidential candidates about their health care platforms. This is why, as the president of The Johns Hopkins University, I have joined with the National Coalition on Health Care and the Retirement Living TV network to invite the major presidential candidates, and other leading health care experts, to talk about how we can solve our health care crisis. We have asked them to sit individually with me, and a national news anchor, for meaningful in-depth conversations focused only on health care, to be televised during the campaign.
These programs will give each individual an opportunity to explain in detail what he or she proposes we do about this issue. Polls show health care to be our No. 1 domestic concern. Americans expect action.
But this subject is vast, and complex. Health care expenditures in America are now $2.2 trillion a year, and climbing relentlessly. It is enormously difficult to understand—or even to accurately describe—our health care system.
In fact, the biggest problem is that there really is no American health care system. You can talk about the British medical service, or the German medical system, or the Canadian national health plan. But when you try to describe American health care, there is no one system you are talking about. Medicare is different from Medicaid is different from private insurance is different from no insurance. Individuals in these different situations have different medical experiences—and often, different health outcomes.
Simply stated: The U.S. does not have a health care system.
Instead it has what could best be described as a patchwork quilt of different responses to different problems. And as the years have gone by, that quilt has frayed and developed some gaping holes.
To mend things, we will have to address the other three C's—consistency, complexity and chronic illness. In the next few minutes, I want to describe how these issues will determine how we provide, and pay for, health care in America in the coming years.
First, and perhaps most importantly, we have to tackle the problem of consistency.
One of the candidates says, I'm sure America must have the best health care system in the world, because all the time I get calls from European friends asking me to help refer them to an American hospital or specialist.
In one sense, that is true. Every year, thousands of wealthy patients travel from all parts of the globe to access world-class treatments for heart disease, cancer, neurological diseases, joint replacements and so forth.
Yet, here is a dirty little secret: While the best of the best of U.S. health care is the world's finest, on average, our health care system performs poorly.
The Rand Corp. looked at 30 common medical conditions in a dozen American communities. They found that patients get the appropriate treatment only about 55 percent of the time! In other words, roughly half the time people go to the doctor, they do not receive care that they should. And this is for conditions in which physicians have virtually universal agreement on the appropriate treatment guidelines.
The No. 1 medical challenge we face in our system is variability.
For instance, anyone who has had a heart attack and is being discharged from the hospital should be prescribed aspirin, beta-blocking drugs and, if they have high cholesterol, lipid-lowering drugs. This is the holy trinity of prevention of further heart attacks—confirmed by NIH research—and all doctors know this. Yet this Rand Corp. study also found that only six out of 10 patients being discharged from the hospital after heart attacks were going home with these prescriptions in hand. And those numbers varied tremendously by hospital. Some get close to 100 percent. Others are far less than half.
Consistency—which is often just another measure of quality—is the great challenge we must overcome.
In other words, while the best of U.S. health care is the best in the world, not everyone is getting that care. The bad news is that if all of us in this room fall sick tomorrow, that side of the room will get good and appropriate care, and that side of the room—sorry—likely won't. And it's not a matter of whether or not you have insurance coverage. It's all about consistency of care.
In other countries with organized health systems, physicians practice according to established guidelines. Not so in the U.S., where practice standards are mostly nonexistent.
Did you know that it is three times as costly to treat a Medicare patient in McAllen, Texas, as one in Lynchburg, Va.? Dr. John Wennberg at Dartmouth Medical School studied 1996 Medicare data. He found that after you adjust for differences in cost-of-living and risk factors, it costs about $3,000 a year to care for a Medicare beneficiary in Lynchburg, Va., compared to slightly over $9,000 a year in McAllen, Texas. Yet there was no improvement in health outcomes for the more expensively treated Medicare recipients in Texas.
We need to ask the candidates: How can we consistently deliver the best possible care?
The second "C" is complexity.
It used to be, if you were hospitalized, you needed a doctor. Nowadays you need a doctor, possibly a lawyer and almost certainly an accountant to help you figure out your hospital bill.
High administrative costs for providers and payers is only the beginning of a hopelessly fragmented, uncoordinated care delivery system.
The sad truth is, in two areas of health care, America is the undisputed world leader: in our high health care costs, and in the complexity of how we deliver and pay for care.
It should surprise no one that these two situations are closely related. Has anyone here been to the hospital for a procedure and not been confused and confounded by the billing process that followed? If you're out there, we'd like to arrange to have you bronzed! Hospitals are asked all the time, "Do you go out of your way to hire complete idiots to staff your billing offices?"
In fact, just the opposite: We have to hire bright people and spend a great deal of time training them. But the outcomes are abysmal because every insurance plan has different rules, different eligibilities and different coding systems. Health care billing is the modern day Tower of Babel, in which no one speaks the same language.
Even Medicare, which is the nation's most efficient payment system, is difficult to understand. I once had a meeting with John Breaux, who at the time was senator from Louisiana and a leading expert on Medicare. He observed that the Medicare regulations were three times the size of the IRS tax code. He told me, "I have to decide whether Medicare should reimburse for colonoscopy or for a barium enema to screen for colon cancer." Then he said, "Dr. Brody, I've had both, and I don't like either one of them."
It used to be, a hospital like Johns Hopkins had to deal with only a small number of organizations that paid for medical care. There was Medicare, Medicaid, Blue Cross/Blue Shield and a handful of private insurers.
Yesterday I asked Rich Grossi, the chief financial officer of Johns Hopkins Medicine, how many payers we deal with today. He did some digging, and the number shocked even me. He said that at The Johns Hopkins Hospital we have to bill more than 700 different payers and insurers. These are HMOs, PPOs, MCOs, IPAs and an alphabet soup of other organizations. Each one has their own set of rules regarding what services are covered, the level of reimbursement and what kind of documentation and pre-approval is required. It is an administrative nightmare.
Nationally, this kind of inefficiency costs patients billions of dollars. Billing, collection and payment administration represents, by conservative estimates, 20 percent of health care costs. If there were a common format that all payers and providers were required to use, much of the administrative burden would be removed. And patients might be able to understand their medical bills at the same time.
And so we need to ask: How can we eliminate unnecessary complexity from our health care system?
The last "C" is chronic illness.
Did you know that two-thirds of all Medicare spending is for beneficiaries who have five or more chronic conditions? Eighty percent of all health care costs involve patients with one or more chronic illnesses. These are illnesses like hypertension, diabetes, chronic obstructive pulmonary disease, arthritis, asthma or depression.
Part of the miracle of modern medicine has been its ability to turn killer diseases into manageable lifelong chronic conditions. American medical research, funded by the federal government through the National Institutes of Health, has revolutionized our ability to treat the sick. Our nation has been very well served by that investment. Diabetes is an example of this. HIV infection is another, as is the significant decline in deaths from heart attacks over the past two decades. Formerly, diabetes, HIV and heart attacks were death sentences. Now they are typically managed conditions that require daily medication and regular medical attention.
But chronic conditions are both difficult and expensive to manage. If we begin to focus on disease management, there are big gains to be made, both for better patient care as well as reducing costs.
Two strategies could have profound impact on lowering the morbidity and mortality of these conditions, not to mention drastically reducing the dollars spent treating them. The first is developing more effective means to prevent or delay the onset of these diseases. The second is promoting more co-coordinated cost-effective therapies to treat them. We need to be doing both. As an example, right now, today, we are creating a nationwide epidemic of obesity, which in turn is generating a nationwide epidemic of diabetes. The last place—the worst place—to be treating this is in a hospital operating room 20 years from now, performing amputations.
Yet our whole health care system remains oriented toward the care and treatment of acute illness. We can't provide the nutritional counseling to prevent obesity, but we are well equipped to perform amputations on diabetics. There is a huge disconnect here.
A recent poll found that more than three-quarters of both patients and physicians believe that fundamental reform of the health care system is needed to provide better care of people with chronic conditions. Medicare beneficiaries with five or more chronic conditions see an average of 13 different doctors and fill 50 prescriptions during the year. For these patients, their illnesses become a full-time occupation.
We need to ask: How can we better manage and care for chronic illness?
Consistency, complexity and chronic illness: These are the three riders of our health care apocalypse. These are the three challenges we must confront. The presidential candidates have been talking a lot about costs and insurance coverage. But until we confront consistency, complexity and chronic illness, no effective cure for our ailing health care system is feasible.
Today it has been my honor to suggest to members of the press three critical questions we should ask every candidate about health care.
It is now my pleasure to answer the questions you'd care to ask me.
Thank you.
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