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NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington. Doctors have been complicit in driving up health care costs. Many are influenced by fee-for-service financial incentives. They need to become part of the solution. Strong words from an editorial this past weekend in the New York Times.

Yesterday, President Obama acknowledged that doctors will be critical to health care reform in an address to the American Medical Association. Today we talk about doctors and health coverage with two doctors who have been kind enough to join us on this program from time to time.

We've spoken with Dr. Sherwin Nuland of the Yale University School of Medicine about his books, and we first met Dr. Karen DeSalvo, who's with the Tulane University School of Medicine, in post-Katrina New Orleans, and where health care, of course, remains a critical issue.

Later in the hour, John Bolton poses a nuclear what-if scenario that involves Israel and Iran. But first we want to hear from the doctors in our audience today. Are you the problem? Our phone number is 800-989-8255. Email talk@npr.org. You can join the conversation at our Web site. That's at npr.org. Click on TALK OF THE NATION.

And let's begin with Dr. Karen DeSalvo, vice dean of community affairs and health policy executive director of the Tulane Community Health Center at Tulane University School of Medicine - whew, what a title. She happens to be here in Washington today and joins us in Studio 3A. Nice to have you back on the program.

Dr. KAREN DeSALVO (Tulane University School of Medicine): Oh, it's nice to be here, thank you.

CONAN: So are doctors the problem?

Dr. DeSALVO: For the most part, it's good doctors working in a perverse system. So just like any problem, getting to the root cause means that you have to look at the entire picture, right, and you can't just name, blame, shame and say it's all about the doctors.

What happens to us across our lifespan is that we're incentivized to do more. We're incentivized to do more treatment, to admit people to the hospital, and in fact, the sicker you are with your diabetes, the better off financially I am.

So the critical thing to change that equation is to incentivize the doctors to keep people well and to make that part of the equation, but there's more to it. We have to have better data. We're basically flying blind. We don't really know how many patients we take care of. We don't know how sick they are. We really don't have good data at our fingertips. And then certainly set the right expectations.

For the most part, the way we're trained as doctors is to be independent, to work in isolation for the most part. We're not really trained to be part of teams and learn to rely on the social workers, the nurses, the pharmacists, who have better skills in some areas than we do and can be more effective in taking care of the patients.

CONAN: Dr. Nuland, let me put the same question to you there in New Haven. Are doctors the problem?

Dr. SHERWIN NULAND (Yale University School of Medicine): Well, I'm fascinated by your use of the the article, Neal, because clearly we are a problem. I think virtually everything that Dr. DeSalvo said is something I can absolutely agree with, but there are so many other problems. And part of what we will have to do in the next six months to a year is identify them individually and treat each one of the problems individually, as though the others didn't exist.

So doctors certainly have a role to play in the exchange. They've had a role to play ever since 1948, when the so-called Wagner-Murray-Dingell Bill, in Truman's administration came along for an attempt at universal health care.

They have always resisted and come screaming into and kicking into the fold, but it seems that this time there's much less screaming and much less kicking because the lives of doctors and their practices have become significantly overwhelmed by the problems they face, and I must add the temptations they face.

CONAN: The temptations? Tell us a little more about that.

Dr. NULAND: Well, one of the things that impressed me during my years of practice, and this is more prevalent in other parts of the country like the Southwest than it is in the Northeast where I work, is the number of medical entrepreneurs, the number of physicians who set up a radiology unit, an out-patient minor operating suite, own a large office building, and that's where the temptations come in. Because if you're one of 20 physicians who own a large office building in which there is a radiology suite, in which there's a minor surgery suite, in which there's a laboratory, a for-profit laboratory, and perhaps in which there's a for-profit pharmacy, the probability of being able to steer clear of the temptation of over-using those facilities is not great.

In other words, you've put an awful lot of money into something, and here you are, a doctor in this group, and one must make it work. One must make it profitable. Other investors perhaps will disappear. This is just one minor aspect of what I think of as the temptations.

CONAN: And Dr. DeSalvo, let me get back to you for just a moment. It seemed to me that one of the things you were talking about was that doctors, in fear of malpractice suits, practice defensive medicine.

Dr. DeSALVO: This is a dicey issue, and I think physicians as professionals would like to see that everyone is held accountable for the cost and quality in the health care system, not just the doctors. So we do often point to legal issues as an important point of reducing cost, etcetera, but the data hasn't necessarily borne that out entirely.

I think what is clear is that if you build it, they will come, and so the more hospital beds you have, the more hospital admissions you have; the more cardiologists you have, the more cardiac casts(ph). And so for example in Louisiana, when we had our tabula rasa post-Katrina and were putting all this back together, we were really looking at what is the supply we want to have, because we want to build primary care prevention, neighborhood-based care that people will use first as opposed to using ERs and hospitals. That is the opportunity, really, is to create the right doorway that's easy to get through and try to avoid the unnecessary incentives like hospitals or diagnostic imaging studies, no matter who owns them.

CONAN: Let's get some listeners in on the conversation. We want to hear from doctors today, and whatever Dr. Nuland says, we're going to pose the question the same way: Are doctors the problem? 800-989-8255. Email us, talk@npr.org. Let's begin with Robert, Robert calling us from San Carlos, California.

ROBERT (Caller): Hi. I'm an emergency physician, and I'm glad you're having this program with these distinguished doctors. There are a couple of things I thought I would like to share with you and get your response to. Number one, as physicians, there are many of us who are out on the front lines, who are emergency physicians, who are being called upon every day to do 30 percent of our care absolutely for free.

The government has mandated that anyone who walks into that (unintelligible) will be taken care of, and indeed there are, but there is no funding for that. We don't get paid, the hospital doesn't get paid, and it basically depends on the kindness of others.

In terms of defensive medicine, yeah, we practice it. When parents come in and they're worried about their child who has fallen off the bed or off the counter or had a head injury at school, and they're decided - they've already decided on a CAT scan for that child, woe be to the doctor who doesn't get it and is just waiting for that suit down the line.

Dr. DeSALVO: Yeah, my husband's an emergency medicine physician, so every day he gets off shift, he says, Karen, did you fix that primary care thing in New Orleans? Because I practice it all night in the emergency room, in the middle of trying to save lives of people who have had blood trauma, etcetera. and so I hear your pain, and I think there's some other element where patients will go to the emergency room, have fallen or have something that might be simpler in a primary care office. If I knew that person and I had a continuity relationship with them as a primary care doc, I can have a conversation that will often prevent extra tests.

And so I agree with you also about the point about the unfunded mandate to take care of all those folks. We have got to fix that so patients have more choice and are able to use primary care not just because they have insurance coverage of some sort but because there's a place for them to go that's open after hours.

CONAN: And Dr. Nuland, that problem with people using the emergency room as their general medical treatment facility, well, that relates to the unavailability of other affordable facilities.

Dr. NULAND: Well, it relates to the unavailability of other affordable facilities that the patients know about. One of the factors that hikes costs up is the uneducated patient, who has come to assume that the emergency room is his primary physician of choice.

Let's say we allow that to happen. Why can't many patients be screened by physician's assistants, by highly trained nurses, by technical personnel, so they don't need to see a doctor when they go to the emergency room, and the cost immediately drops right there?

My experience working in emergency rooms as a house officer, which went on for six years, was that about, oh, I would estimate - it's a long time, but I'll still estimate - that about a third to - a quarter to a third of the patients I saw did not need to see a doctor at that particular time and could have been treated by some other highly trained person.

Now, Dr. DeSalvo brings up an issue that hasn't gotten enough press, I think, certainly hasn't gotten enough discussion, and that's the issue of duplication of medical care. The number of hospitals in this country is excessive, I believe. In my small state of Connecticut that has something more than two million people, we've got 30 acute care hospitals, 10 of which are licensed to do cardiac surgery and everything associated with cardiac surgery.

Boards of directors become competitive, towns become competitive. We have a waste of resources, not just the doctors but highly trained other personnel, executive personnel, duplicating what's going on 20 miles down the road when, if we had a truly organized hospitalization system, we could oversee what each hospital is doing and among the physicians themselves make determinations about the strengths and the weaknesses of the various hospitals so that we could properly separate the sorts of patients they should be treating.

CONAN: Well, Dr. DeSalvo, you had a rare opportunity, in a sense, after Katrina in New Orleans, to make just those kinds of decisions. But absent a huge crisis, who gets to decide? Who rules?

Dr. DeSALVO: It's the framework of planning, health care planning. So thinking in advance, we have this many people, we expect that they're going to have this prevalence of disease, and therefore assuming that everybody who has asthma should never have to get admitted to the hospital, we still need this many beds for things that we can't prevent.

We don't do health planning in this country, really, but what you can do is use other market forces or regulation to try to influence the development of the health system. I'll give you an example.

Physicians workforce supply. So you can do loan repayment programs that are targeted to primary care physicians or primary care workforce to incentive trainees, young people, to go into primary care. It's worked great in Louisiana, so well that we're maybe going to lose our professional shortage designation. And that's the kind of workforce you want to get.

You can do similar things with payment for hospital beds, for cardiac casts. So you use the leverage you have in the absence of heavy regulation to try to drive the results you want.

CONAN: Robert, thanks very much, good call. We're talking today with doctors about health care. Are doctors the problem? Our guests are Dr. Karen DeSalvo, vice dean of community affairs and health policy executive director of the Tulane Community Health Center at Tulane University School of Medicine; and Sherwin Nuland, clinical professor of surgery at Yale University School of Medicine and a fellow at the Institute for Social and Policy Studies at Yale. Stay with us, 800-989-8255, doctors. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. Health-care costs continue to rise, that much we know. What's up for a debate is why. Some blame government, others lawsuits. Some point the finger at doctors, say they order tests and procedures that aren't necessary and drive up costs.

Today we want to hear from doctors in our audience. Are you the problem? 800-989-8255. Email us, talk@npr.org. You can also join the conversation at our Web site, npr.org. Click on TALK OF THE NATION.

Our guests today are doctors whose voices may have become somewhat familiar over the years: Karen DeSalvo, executive director of the Tulane Community Health Center at Tulane University School of Medicine in New Orleans; and Sherwin Nuland, clinical professor of surgery at Yale, and his latest book is titled "The Soul of Medicine." He was with us to discuss that, I think, just last month.

Anyway, let's see if we can get another caller on the line, and let's go next to Paul, Paul with us from Colorado Springs.

PAUL (Caller): Yes, thank you for taking my call. I wanted to address the one doctor's concern about the incentive when a doctor owns an ASC or a doctor owns his own clinic building, that that could drive up health costs because he has a built-in incentive to refer or do extra procedures because of that. A) number one, on the clinic side of thing, if you own your own building, then it's just a matter of putting equity into a building that you already see patients at.

That doesn't increase the number of patients that you put through that. And I'm also a member of an ASC, an ambulatory surgery center, where I perform surgery, and I do not feel in the least that it increases my volume because I want to make more money for myself.

My patients' care always comes first, and we have to have them sign a disclosure that they understand that I have a financial interest in that surgery center.

CONAN: Dr. Nuland, I think that's to you.

Dr. NULAND: Well, I understand that completely, and my guess is that at least two third or maybe three quarters of American doctors fit into exactly the category that your caller fits into, in other words three quarters or two thirds of the people who own their own facilities. But that doesn't cover everybody.

It was explained in the article that we all read that was in the New Yorker by Atul Gawande in his visit to McAllen, Texas, that administrators and doctors really had no idea of how much money they were spending on the various tests, on the various small OR procedures and matters of that nature.

So although a doctor with the best of intentions may not be thinking that he or she is over-using facilities, nevertheless it appears that they often do, and if these matters were studied individually in each significantly sized institution, I think we'd find that the caller would be shocked at how many times an extra test is ordered.

Radiology seems to be a particularly difficult area to control or even to think about, and yet if you ask most radiologists, do you ever use certain tests or recommend certain tests to the referring physician that you really don't think are important to carry out, they would probably, virtually to a man or a woman, say no, we never do that.

Investigation, as Atul Gawande did, indicates that so many of us do it far more often than we think.

CONAN: He's talking about a piece that was published in the June 1st issue of the New Yorker magazine, and we'll put a link to it up on our Web site at npr.org/talk. Paul, I wondered if you had a response.

PAUL: Well, I don't have any ancillary services as far as radiology or anything like that that I have an ownership in, but I do have to say that from the very beginning of medical school, back in 1990, we were taught that basically Dr. So-and-So, why did you not order this test? Do you realize that in a court of law the plaintiff's lawyer will blow this up on a PowerPoint presentation and show that you did not order this test, going back to the ER physician's call-in regarding, you know, routine headaches.

You know, you're taught as a doctor on the art of medicine that this patient does not have a tumor, this patient doesn't have any vocal neurological signs that lead to a CT scan or an MRI, but yet there's that nagging question that if I miss something, one in a thousand, that patient can come back and sue me.

So I think that tort reform, which goes against what President Obama has basically brushed aside, needs to be part of the formula.

CONAN: Interesting that in McAllen, Texas, where Dr. Gawande did his piece, there is tort reform, and that's not an issue. But let me turn to you, Dr. DeSalvo. You run the training hospital. Is that the way doctors are taught?

Dr. DeSALVO: I think that what I picked up out of what he was saying was a couple of elements. One is that there is a training mechanism and things embedded in what we do, but it - that affect our behavior, but really I think it points to this idea that it's not just the doctor, it's the whole system in place that's affecting the cost and the health of these patients.

I wouldn't let the patients off the hook either. People do ask for and expect quite a lot of diagnostic tests and expect them pretty rapidly. So I think everyone's going to have to realize that there are going to be limitations, but not limitations in the form of rationing so much but reduction of waste instead of the repeating.

CONAN: So it's Dr. House's fault.

(Soundbite of laughter)

Dr. DeSALVO: It's Dr. House - it might be Dr. House's fault. I want a good show about a primary care doc doing histories and physicals and learning about patients, which is the other point I certainly want to be able to make, and that is while we're thinking a lot about health care costs, which is a very important issue, but we haven't had a lot of discussion about health, meaning that our health care system, frankly, is designed to create wealth, largely.

It's a part of our economy, but it's not doing a very good job creating health for our population, and that means we are going to have to shift our focus upstream, towards prevention and primary care, to keep people from being sick, but remember that health care only affects about 10 percent, is responsible for about 10 percent of people's health.

We also have to make sure that they have appropriate education and economic opportunity. And we all have the stories of the patient, for example, whose barrier to care or health was lack of transportation or a language barrier that caused lots of tests to be done in a hospital that really were unnecessary because the person simply couldn't communicate appropriately. So we need to remember it's a bigger system, and it's not just the health system. It's the entire society.

CONAN: If only he'd asked him about the lead glaze on the china that he bought in Italy. That would've solved the problem right away. Paul, thank you very much for the call, appreciate it.

Dr. DeSALVO: You've been watching too much "House."

(Soundbite of laughter)

CONAN: Let's turn to Patrick, Patrick with us from Nashville.

PATRICK (Caller): Hello there, thanks for taking my call. Interesting conversation. Obviously there is a lot of defensive medicine going on out there that's driving up health care.

Two days ago I - I'm a vascular surgeon. I ordered an ultrasound on a post-operative patient with leg-swelling. I knew she didn't have clots in her legs, but I'm just waiting for the big lawsuit to hit me if I don't order that test and catch that one in a thousand vein thrombosis that ends up killing the patient.

One suggestion that I've never heard anybody make in the media recently is the cost of just billing and collecting money on what we're doing for patients. I spend hundreds of thousands of dollars, my group does, collecting money for patients that we've operated on, and that drives up our costs.

Blue Cross Blue Shield periodically just changes their billing address, and it takes us about two weeks for us to figure this out and then get all our billing back in. They do that to try to save on some money.

Medicare, if I make one error in one word that I say in the history and physical when I dictate it, Medicare can fine me $10,000 for each infraction. There's so many things that have to change, and we doctors may be part of the problem, but there's much larger problems out there.

CONAN: Dr. Nuland, do you agree?

Dr. NULAND: Oh, I more than agree. There are so many factors along the way, and this is what I've been saying for the last half hour or so, that to put all of the blame or even a very large portion of blame on the medical profession is a dreadful mistake.

The basic problem is that we do not have a medical system. We are completely unorganized. There are groups of individual practitioners. There are individual hospitals. There are doctors practicing alone. For some doctors, as much as they might want more oversight, there's no opportunity for oversight, and there's very little opportunity for comparing results, even within hospital staffs.

One of the very first things we need that people have talked about over and over again is the notion of outcomes research or evidence-based guidelines.

My thought is that we have to organize the system based on something that came up during the Johnson years. He called it - he didn't, but his people called it - regionalization of health care. That was to be part of the Great Society, that every hospital that existed in an area was to be in some way affiliated with a medical school, from which the fruits of the finest research in the country would become filtered down to each of the hospitals, and physicians on the staffs of those hospitals would have much easier and much more immediate access to the talents of particular individuals on that staff.

It's an easy to do thing in a state like Connecticut, where we have two schools in a small state. But it's much harder in other places. Once the system is organized along a regional basis, a lot of the duplication would disappear. For example, a lot of the competitiveness between smaller hospitals in a given area would disappear. And I think we'd save tens of billion dollars a year.

CONAN: Patrick, thanks for the call.

PATRICK: Thank you for your time.

CONAN: And here's an email from William in Durham, North Carolina. Three disparate observations from a doctor in private practice in Durham. When the AMA opposes a public option for health care, what I hear is it's more important for doctors to continue to be privileged and well-paid than it is for 50 million Americans to have access to health care.

Secondly, I wish the media would point out that it is the private option that is not affordable. Think about it. The CEO of a local Blue Cross Blue Shield makes around 2.5 million annually yet neither he nor anyone else in his company actually provides health care. They just siphon money out of the system.

Thirdly, think of all the money doctors would save if they didn't have to hire staff dedicated to filing insurance claims for over a hundred separate insurance plans. If there was a single payer, doctors could submit those bills themselves and cut overhead enormously.

Getting to the first part, the political one, which we focused on yesterday as President Obama spoke to the AMA, which I guess represents about a third of physicians in the country, something like that, Dr. DeSalvo, do you hear the political argument?

Dr. DESALVO: Well, there's a - the idea that not enough people have health insurance coverage has been contentious for a long time. I think most physicians have gotten over the point of saying that some people should have nothing whereas others have everything. And we've decided largely as a community of physicians that we should close that gap and everybody should have some form of insurance coverage.

Now, doing that probably makes the most sense to build upon what's already working, to build upon what we have and close the gaps rather than dismantle the entire insurance system and go to a single payer. I think that's been pretty clear from political parties, but...

CONAN: Also politically, it appears single payer is not going to get approved.

Dr. DESALVO: It's not going to get approved. And honestly, there are - I don't know how many, but there are people who are employed in those industries, and this particular issue about the billing and collection, this is a huge industry where people have employment. So we need to figure out how those jobs get shifted and redirected if we are going to make some changes.

I will say that short of a single payer, there are some solutions or options that have been thought about, experimented with, where for example the physician has a single form to fill out that's identical across no matter the payer and we're(ph) agnostic to payer. So I don't know if it's Blue Cross or Medicaid or Medicare or some other new program. I just submit my bill based upon what I did and then I'm reimbursed.

Now - and even other nuance to that system is I'm actually paid in primary care. We haven't had many call in, but we want to be paid actually some regular amount of money, routine amount of money for coordination of care for a population of patients that we are responsible for, not just for episodic care when they come in. But for surgeons, for ER, it makes perfect sense that they're paid episodically.

So we don't have to move to entire single payer. I do think most people agree that we need to close the gap and have - and get rid of this category, the uninsured, and all the associated things that go with it and then simplify the billing and collections process so that doctors aren't spending so much time and energy on that and can get back to patient care.

CONAN: We're talking with Karen DeSalvo, vice dean of community affairs and health policy executive director of the Tulane Community Health Center at Tulane University School of Medicine and also with Sherwin Nuland, clinical professor of surgery at Yale University School of Medicine.

You're listening to TALK OF THE NATION from NPR News.

And let's talk with Ralph. Ralph calling from Columbia, South Carolina.

RALPH: Yes. Yes. Thanks for taking my call. I'm not a doctor but I was a research scientist for many years at the University of California, Berkeley. I had an occasion to rub shoulders with a lot of pre-medical students and medical students over the years. I trained a number of them...

CONAN: Ralph, we're going to let you in if you make it quick, because we want to get to another doctor beforeā€¦

RALPH: Okay. My contention is having - if all the medical students that I knew were sworn to a vow of poverty, the ones that were left after the others have walked out the door would be the best doctors. Doctors aren't the problem in health care. Money is the problem. Medicine should not be a business. Nobody should get rich off providing health care.

The solution to the health care crisis may be complex in detail but it's very simple in principle. The remedy is the same for the crisis in our political system: get the money out.

CONAN: All right. Ralph, thank you very much for the call. We appreciate it.

RALPH: Okay.

CONAN: Let's see if we can get another caller in. And this is Chad. Chad with us from Baton Rouge.

CHAD: Hi. Thanks for taking my call. My comment would be just the opposite. Keep the money in. One thing that concerns me about the talk recently is that we somehow shouldn't incentivize physicians for what they do, rather we should incentivize them for health outcomes.

I would argue that every - or most professionals are incentivized for what they do. It concerns me that when you talk about the patient outcomes so much, that is non-dependent on a physician. A diabetic patient may make lifestyle choices that lead to poor outcomes for their disease, and that's very independent of the physician who is there to guide them but not necessarily control the final outcome.

CONAN: Let me hear from Dr. DeSalvo on that.

Dr. DESALVO: I agree with you to a certain extent. You know, the basic quality framework is structure, process, outcome. So the structure would say you have in place the after hours access for your patients so that we know that they can reach you and have an option besides the ER. That's a quality structure.

The process would be, are you actually measuring hemoglobin A1C, a blood test for diabetes. And then the outcome measure would be, okay, you've measured it, how good is the diabetes control? Which is much more in the hands of the patient but so is the process measure.

So those things are levels of sophistication and they probably all need to be looked at. I would tell you, I think in this country our structural quality leaves a lot to be worked on. So we definitely need to start from there. Process is just - can you actually measure the data? We have a long way to go there. We have to implement the technology, the electronic health records, to make that happen before we start looking at outcomes completely for payment.

But it doesn't mean we shouldn't know where we are and shouldn't have a set point and try to actually improve, so setting a cliff where you fall off and don't get paid I don't agree with. I think we should have incremental improvement and at least know what we're working with.

CONAN: Chad, thanks very much for the call. And thanks to our guests today. And we're glad we could solve this problem and move on from there.

Dr. Sherwin Nuland's latest book is "The Soul of Medicine: Tales From The Bedside." He joined us from the Yale University studios.

As always, Dr. Nuland, thank you very much.

Dr. NULAND: Thank you.

CONAN: And Dr. Karen DeSalvo, vice dean of community affairs and health policy executive director of the Tulane Community Health Center at Tulane University School of Medicine, thanks to you and nice to see you here in Washington.

Dr. DESALVO: It's nice to be here. Thank you.

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