LYNN NEARY, host:
This is TALK OF THE NATION. Neal Conan is away. I'm Lynn Neary. Today, as part of our series of conversations on health care, we turn the spotlight on ourselves. We all have to make decisions about our own health, and those decisions can affect everyone else.
Some of us use emergency rooms for minor issues. We reach for an expensive drug to lower cholesterol but continue eating a high-fat diet. Maybe we insist on having the latest test when even a doctor says it's not necessary.
Those choices can increase the cost of health care and insurance for everyone. So today, we ask, as we look to overhaul the nation's health-care system, what is the patient's responsibility?
Later, "Bruno" - Sacha Baron Cohen and gay jokes are on this week's Opinion Page. But first, to what extent are patients the problem? What are you willing to give up to bring down costs? Our number here in Washington is 800-989-8255, and our email address is talk@npr.org, and you can join the conversation at our Web site. Go to npr.org, and click on TALK OF THE NATION.
We begin with Dr. Pauline Chen. She writes the Doctor and Patient column for the New York Times. She's also author of "Final Exam: A Surgeon's Reflections on Mortality," and she joins us from member station WBUR in Boston. Welcome to the program, Dr. Chen.
Dr. PAULINE CHEN (Surgeon and Author) Thank you, it's an honor to be here.
NEARY: So to what extent are patients the problem as we look at health care and how - our health-care system and how it needs to change?
Dr. CHEN: I think that's an interesting question. I don't think that patients are the problem, per se. I think what really is the problem, one of the problems, is the fact that doctors and patients have stopped talking to each other and don't talk about issues of import in their health care, in their sort of education about prevention, etc., etc.
I think one of the interesting things for me to have seen, going through the process of becoming a doctor - because ultimately, we're all patients, correct? - but is that in the process, you start out wanting to help people.
I mean, I don't know of - I know - I would say that most doctors I know go into medicine because they want to help people and oftentimes, you know, quite passionately so. But the ironic thing is that through the process of medical education and medical training, by the time we get to the end of it, we end up about as far as you could possibly be from the very people we started out wanting to help.
We don't speak the same language; our patients don't necessarily want to talk to us when they have a life-threatening diagnosis - they want to talk to their rabbi, their pastor, you know, a social worker, somebody else on the health-care team. And I think that's a real issue, that communication.
NEARY: Yeah, maybe - let's break that down. Maybe you can give us an example of what - how that might affect a patient's decision, in other words the lack of time they have with a doctor. I know from personal experience, you don't spend a whole lot of time with your doctor, even just on routine visits - and certainly, I haven't had a serious illness. But how might it affect a patient's decisions about medication, about the route they should take in dealing with something when they don't have that doctor's time and attention and the conversation that you were talking about?
Dr. CHEN: Well, in an ideal world, you would have all the time that you would need. You would have, from a doctor's point of view, you'd be able to spend an hour per patient and really sort of get to know that patient and that patient's family and their issues on where they're coming from.
You know, one of the, I think, great things about health care now is we're talking more and more about patient empowerment and patients being part of the team, and I think that's a really important concept. However, it is based on - it's premised on the idea that patients have all the information that they need. And I think one of the important roles for doctors is to help to supply that information. In fact, one of the important roles of the medical establishment is to supply that information. But we haven't done a very good job of it.
On the other hand, I think that one of the important things for patients to do is to grasp this opportunity to be empowered but to also realize, as well, that there are certain constraints that we have on the patient-doctor relationship - the time constraint, for instance.
Many doctors are working under incredible time pressures to - you know, as you said earlier, we only see patients - we can only see patients for 15 minutes. And I think that if there were more, sort of understanding between both parties, I think that the relationship would be improved, but that…
NEARY: I just want to focus a little bit more, though, on the patient's responsibility because, you know, on this program, we're talking about different aspects of the whole system, and we've talked a lot about doctors, and so let's return to that whole subject of patients for a moment.
Even given the problems of communication between doctors and patients that exist now and the lack of time that you've been talking about, do patients sometimes demand that doctors, you know, order tests that perhaps aren't needed or, you know, maybe aren't as responsible about their own health care, or their own preventive health care, as they could be?
Dr. CHEN: They may be, but I think it's really difficult, as a patient, to fully take on that responsibility. I think everybody is capable of it, and I think everybody is fully capable of understanding medical issues. I think the problem is that we don't have the time to talk to each other, to educate each other about the issues.
So for instance, doctors don't have, necessarily, the time to explain all the medications and what they are doing, or the pathophysiology of a certain diagnosis. At the same time, patients don't have the time, or don't feel they have the time, to answer the questions, or they may be - for some reason feel like they can't ask their doctors certain things or that their doctor's in a rush.
NEARY: All right, we're going to…
Dr. CHEN: Oh, sorry. We know that there is a time constraint, but I think that one of the issues that has come about as a result of that is that we stop talking to each other. We figure there's not enough time. Let's forget about it. Let's - there are too many issues. I think that if we just started to try once more to begin to talk to each other, I think some of those issues would be addressed.
NEARY: All right. We're going to bring another guest into the program now, as well. Marge Ginsburg is executive director for the Center for Healthcare Decisions. That's a think tank that's focused on health policy, and she's been surveying how we see our role as patients. And she joins us from Capital Public Radio in Sacramento, California. Welcome to the program, Marge.
Ms. MARGE GINSBURG (Executive Director, Center for Healthcare Decisions): Good morning.
NEARY: Now, do people understand - to what degree do people understand, or think of themselves, as part of the problem in health care?
Ms. GINSBURG: They really don't. Unlike - or actually the same as other stakeholders in the whole paradigm of health care, patients tend to think that the problem of rising costs really belongs to everyone else, particularly the health insurance companies, the pharmaceutical companies, who they believe are really gouging the system, where there's unnecessary waste and greed, but don't see themselves as part of that role, and consequently don't see themselves necessarily as part of the solution, either. And that really can be a problem.
I think Dr. Chen's points are well-taken, but the fact is we start with spending 50 percent more on health care in this country than we do everywhere else. And we use more drugs, we use more scans, we do more surgery, we see more specialists, and our health care isn't any better. And I think that's what the Obama administration and what Congress is trying to do right now, is get a handle on why are we spending so much and not getting better health, and what can we do to reduce the costs?
So when this comes back to the role of the patient, one has to ultimately ask: How are the patient and the doctor - who together, really control the bulk of how health-care dollars are spent - how does it turn out that all these expensive interventions are being prescribed when they may not be necessary?
So getting to the patient in terms of helping to control some of the demand for health care is really going to be critical, and we have been looking at that for a number of years, on how people respond to rising costs when they put on their citizen hat rather than their patient hat.
NEARY: Well, how can people be made more aware of these issues that you're talking about?
Ms. GINSBURG: Well, I think part of it is we really do think of health care as something personal, and it is personal. It's like all politics is local, all health care is personal. But that makes it a little difficult, then, to start looking at the big picture when in fact, it is all of society that is helping to pay for health care.
So anyone who's part of a health-insurance plan, whether it's private or public, in fact is part of a pool of resources that's being contributed by everyone - by a lot of people, anyway. And yet we see it as our own personal stash, our own personal benefit package that's there for us and there to meet all our needs.
I think for us, and for the rest of society, what we need to do is begin looking at health care from a somewhat different lens, that it's not just about the person at the bedside. It's about everyone else in this country that somehow is contributing to the cost of health care and is also trying to benefit from it. So it's - I think it requires a new way of looking at health care beyond that of the individual, to the greater good.
NEARY: You know, it seems like a tough task to me because I think that when it comes to health care, it may be when people might be, in a way, at their most selfish because they just want the best for themselves, and they want the best for their loved ones in particular. You know, often, you know, if you have a child involved or your husband or a parent, you know, you just want them to get the best. And so it makes it hard for anyone to think communally at that moment, I would think.
Ms. GINSBURG: Well, part of the problem is that what we often conceive of as best, in fact, isn't best at all. And that's why the president is really moving towards the whole idea of comparative-effectiveness research in trying to really identify what really does bring value to people and what doesn't.
Clearly, physicians have a major role in this because they're the ones that, in fact, prescribe probably - 80 percent of health care is delivered when physicians prescribe it. So if they're not part of this whole re-looking at what works well and what doesn't, then we'll - I'm not sure we'll ever get there.
One thing that's particularly interesting that we've learned is that when people - we do a lot of discussion groups with people, and we ask them to look at the problem from the perspective of a member of society and to make decisions on how resources should be best spent. And to a person, they come to conclusions that in fact, we really do need to be paying close attention to how well certain treatments work, and not cover things that are not effective.
So they're very much in line with where Congress is trying to go, but they're never really asked these questions at the bedside. It takes sort of a broader societal view for people to kind of create the rules under which we can all live, and all live comfortably and successfully.
NEARY: Marge Ginsburg, we're going to continue this discussion after a short break. When it comes to the fight over health care - patients, are you the problem? Give us a call: 800-989-8255. I'm Lynn Neary. It's TALK OF THE NATION from NPR News.
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NEARY: This is TALK OF THE NATION. I'm Lynn Neary in Washington. We are talking about the fight over health care. Republicans and Democrats spent another weekend arguing over details on how to pay for any overhaul. That's a policy debate, and a discussion for another time.
Today, we're continuing a series of conversations on the problems with health care and who's to blame. Last time, we focused on doctors; today, the rest of us, the patients. Are we the problem?
What are you willing to give up to lower health-care costs? 800-989-8255, or send us an email at talk@npr.org. In a few minutes, an economist argues that we'd all be healthier if we had to pay thousand-dollar co-pays. We'll talk about that in a moment.
Our guests right now are Dr. Pauline Chen, she writes the Doctor and Patient column for the New York Times; also Marge Ginsburg, executive director at the Center for Healthcare Decisions. That's a think tank focused on health policy.
And we're going to take a call now from Kevin(ph), who's calling from Wilmington, North Carolina. Hello, Kevin.
KEVIN (Caller): Hey.
NEARY: Go ahead.
KEVIN: I just wanted to mention, you know, I don't think patients are the problem if they are responsible. I think one could argue that insurance is the problem. I have a - I'm self-employed. I have a $5,000 deductible and a $3,000 max out of pocket. I just had a baby in June and did it the cheapest way possible. I brought my Ibuprofen to the hospital. I didn't want to get charged $20 a pill. I had a midwife. I spent hours - or me and my wife spent hours - talking to the midwife up until the birth. We educated ourselves. We wanted to do a natural birth to save money and also to enjoy the experience.
But you know, John Stossel did a great story on this back in 2007, and he hit on the fact that what if doctors competed in the free market. I mean, just imagine car lots competing for you to buy their cars, zero percent for five years. What if you had a doctor, you know, saying hey, I'll transplant a liver for zero percent for five years? If you had that kind of free-market solution, and you didn't have insurance companies in bed with the doctors and the pharmaceutical companies, you would have more competition, and doctors would want your business. And I think they'd be more likely to give you, you know, the generic off-brand instead of the latest and greatest prescription.
I pay my bills, I always get generic, and I don't take advantage of the…
NEARY: You know what? It sounds to me, Kevin, like you're exactly what we're talking about, the patient who is taking a lot of responsibility on himself. Let me ask Dr. Pauline Chen to respond to some of what you are saying here, particularly this whole idea of doctors competing with each other, and how is that going to help bring down the cost of health care, and Kevin, thanks so much. And again, Kevin, an example of a patient who seems to have taken some responsibility for keeping costs down for himself, which then keeps costs down for other people as well. Dr. Chen?
Dr. CHEN: You know, I think it's admirable what Kevin has done with his health care and with taking responsibility, but I think that for the vast majority of patients out there who don't have either access, or do not have the background, are not health-care literate, so to speak, I think it's much more difficult to do that, and I think that group, that part of the population is a group that we need to address and to help in this problem, as well.
NEARY: Is there a way to do that? I mean, is there a way to make people more health-care literate?
Dr. CHEN: I think one simple way - I mean, if you want to get down to very, very small steps - are to take a look at, for instance, the consent forms in hospitals. They're incredibly difficult to understand, and most patients don't understand. It's usually the doctor that is explaining what is on the consent form, and then the patient signs. If we could make every single form - and I think it's possible - every single drug form readable, legible, you know, so people could understand, I think you could really help to improve some of the cost issues in the states.
For instance, there has been research that has shown that among the elderly, those who are health-care illiterate are twice as likely to die more quickly. And that if you made things more health care - made things more understandable, comprehensible to the public, that you could save up to $50 to $70 million. I mean, I think that's a huge amount. That's a huge area that we haven't addressed.
It is in the patient's area of responsibility, but it's also in our area of responsibility, the medical establishment's.
NEARY: All right, let's take another call now from Victoria(ph), calling from Greensville, North Carolina. Hi, Victoria.
VICTORIA (Caller): Hi. I'm not only a caregiver, but I've also been a patient. I think one of the problems - and I'm a teacher, I'm sorry, I should say, and I work with working-poor children and families, and one of the problems I have seen over 21 years of teaching is lack of access.
We have no free clinics in the city that I live in. We have the health department, which is almost impossible to get into without a lot of paperwork for people who are illiterate or semi-literate. When children are ill, when your children are ill with things like - and I'm talking about basic access -worms, children with worms, children with lice or bed bug bites, or a lack of immunizations or dental care. And I've taken so many families to the emergency room because we had no other place. I've called doctors, doctor after doctor, asking if they take Medicare or Medicaid, and doctors don't.
So I think it's really irresponsible to blame patients. Someone like me, who's informed - and I try, and I try to find access for these families, and our whole school does, really. That's one of our big problems, our children not being in school because of illnesses, simple illnesses that they don't have access to regular health care.
NEARY: Marge Ginsburg, this is really an issue that has to be addressed. I mean, here you have somebody who is knowledgeable, is bright, knows what's going on, and has to take people to the emergency room because otherwise, they wouldn't have any place to go to get care.
Ms. GINSBURG: The access issue is a very big problem, and in some way it's different, in some way it's related to the issue of do we overuse health-care resources. Because I think part of the problem with access is we funnel so much of our money into high-tech specialty care and then give short shrift to primary care, particularly in rural and more isolated areas, that where the need really is doesn't get met. Instead, the need - health care goes to the biggest cities, the places where there's the most amount of potential income. So they're definitely related. If we did a better job of how we decide how we're going to distribute our resources, then we'd have a system that's much fairer for everybody.
There was one other point I wanted to make, and the previous caller saying he really didn't believe it's the patient's fault that so much is being spent. One thing that's important to keep in mind for at least some patients, patients' belief about health insurance and what it should cover and how they want, you know, the best of everything and no compromise and complete choice and fast service, in part, large part, is because this is what we've been telling them for years.
I mean, if you look at all the advertising that goes on for pharmaceutical companies, even hospitals, medical plans, medical groups, it's all about how you can get everything - the best, the fastest, the quickest, most choice. And now, we're turning around and saying to them hold a second, we were kidding. We really can't deliver this high expectation that you have.
So consumers came to this for very good reason. It's what we've been telling them.
Dr. CHEN: Right. I think that that is one thing that - one area that we could work on, the whole sense of expectations that patients may have. For instance, the previous caller also brought up the idea of liver transplantation, that doctors could compete and sort of offer transplantation at a certain price.
The expectation, the sort of subtext under that is that every transplant will come out 100 percent perfect, and that there will be no complications and no sort of natural - it's a human endeavor that there will be no problems at all. But health care isn't that way. It's a really human endeavor. There will be errors. There will be ups. There will be downs, and you are also talking about sort of bringing people together in a very relationship-based endeavor. So I think all of those have to be sort of put into the mix.
In regards to this current caller, the woman who is bringing all these children to the emergency room, I think that brings up another issue. Again, it goes back to health-care literacy, which is the parents of these children. It's most often the patients, the people who have the least, that are least confident about going and accessing health care, about educating themselves. And that's something that we have to work on.
Yes, you could say that that's the patient's fault, but really it's our responsibility - the medical establishment's - is to go out there and educate those people and to help give them the confidence to ask questions, to seek care, to bring their children to get whatever care they need.
NEARY: Dr. Pauline Chen writes the Doctor and Patient column for the New York Times. Thanks so much for joining us today, Dr. Chen.
Dr. CHEN: Thank you.
NEARY: And Dr. Chen joined us from member station WBUR in Boston, Massachusetts.
Joining us now is Anthony LoSasso. He is professor at the University of Illinois at Chicago's School of Public Health, and he joins us from his office in Chicago. Welcome to the program.
Dr. ANTHONY LoSASSO (Professor, School of Public Health, University of Illinois at Chicago): Hi, great to be here.
NEARY: Well, let me ask you this. If consumers were exposed to the actual price of health care, do you think that that would make a difference in how we actually think about our health?
Dr. LoSASSO: Well, I think that a $1,000 deductible, as my little intro there said earlier, won't make us any healthier, but I think the important point is that it most likely won't make us any less healthy. And that, I think, is the key distinction.
NEARY: Well, how so? Make that distinction for me. Explain…
Dr. LoSASSO: Well, so I think that - I just want - I think a general point is that, you know, we've kind of collectively, at least in regards to health insurance, I think we've kind of collectively forgotten or overlooked the fact that insurance, insurance as a concept, is for indemnification against catastrophic financial risk, okay? So it really - it's the financial risk associated with a catastrophic health event that causes, you know, severe straits for people.
So I think the caller, Kevin, from North Carolina, had it partly correct in the sense that a high deductible policy is - insurance is still necessary. And a high deductible policy would still provide the indemnification against the risk associated with having a catastrophe - you know, cancer diagnosis, getting hit by a bus, something really bad happening that costs a lot of money to fix. That's why we still need insurance there.
He went too far, I think, when he said, you know, we need to get rid of insurance companies because, you know, we can't afford - most people can't afford to pay those kinds of bills.
But for the more routine stuff, the more predictable stuff, the stuff, you know, an annual physical, for example - I mean, by definition, you're supposed to go annually. You know, it doesn't really make a whole lot of sense to insure that event when it's entirely predictable. So that's a distinction.
I think in terms of the broader point about, you know, will getting less care make us less healthy? I mean, I think there's a lot of studies and a lot of evidence to support the fact that we're sort of - most people, at least - the U.S. population is kind of more or less at the flat part of the curve.
I mean, we have these studies out of Dartmouth, the Dartmouth Atlas Project, showing that there are wide disparities in health-care spending across different parts of the country. But we don't see any resulting health - or any major resulting health differences based on higher levels of spending.
And then you can go back a couple of decades to the RAND Health Insurance Experiment, which was really…
NEARY: Tony, I want to get some more calls in here.
Dr. LoSASSO: Yeah.
NEARY: We just have about - we don't have too much time left. And I also want to remind our listeners that you are listening to TALK OF THE NATION from NPR News.
So we're going to take a call now from Will(ph) in Rocky Ford, Colorado. Will, go ahead.
WILL (Caller): Hi. I wanted to comment, I that in large part in our experience, my wife and I's experience, was that doctors are very much (unintelligible) at least in our personal (unintelligible) care. We (unintelligible) very readily had fewer tests in our recent pregnancy...
NEARY: Will, we're having a hard time understanding you. What I've understood so far, and I'm going to ask one of the guests to respond, is that you would be willing to give up some tests, perhaps.
WILL: I mean, in our pregnancy, I should say, we would have been willing to give up some testing because it would have made no difference in how we approach the pregnancy. And the doctors simply were not hearing that. We told them over and over, and they just didn't hear it.
NEARY: Okay. Marge Ginsburg, let me hear you respond to that.
Ms. GINSBURG: That's a great example of patients who are taking control of the information and are really acting on it in a responsible way. And increasingly, the use of patient decision tools, ways of helping people understand what their options are and what the benefits and costs are for those options, can go a long way in making sure that the role that patients have is a meaningful one in determining what makes the most amount of sense for them.
And the fact that his doctors did not listen to him, did not seem to care, is really a sad commentary on where medicine is right now in being sensitive to the issues of both cost and benefit.
NEARY: All right. Let's take a call now from Jessica(ph) in Sanford, North Carolina. Hi, Jessica.
JESSICA (Caller): Hi. I have a comment. I'm a nurse, so I see a lot of this right up close. Patients definitely are a part of the problem. One thing I used to see all the time in the hospital is you send the patient home with certain discharge instructions. You explain it to them, they sign that they read them and everything. And then they come back with these horrific infections, have to spend two weeks on major I.V. antibiotics, you know, with the whole MRSA thing and all this stuff. So absolutely, patients have to, you know, really accept some responsibility for their care.
NEARY: That also, I mean, for me raises a question of are we sending people home too quickly? And I don't know if we're getting to another whole subject there. But that gets back to the insurance question, Anthony LoSasso, because that's often determined by the insurance companies, isn't it?
JESSICA: Yes. Yup.
Dr. LoSASSO: Yeah, that can be determined, in a lot of cases, by the insurance company. I mean, I think, again, the key issue here is that, you know, regarding tests and these other procedures is that, well, if there's no - if the patient has no incentive, if it doesn't cost them anything more to get an additional test, there's really - there's no reason to say no to it.
And so, you know, I think - and I'm sympathetic to what the caller is saying there. But at the same time, you know, I think it's - it really comes back to a lot of the issues in insurance design and really, patients being, you know, insulated from the price of health care. And again, that's not to say that they should bare the brunt of a catastrophic event.
NEARY: All right. We're going to go to Jack(ph) and he's in Elkhart, Indiana, I believe. Is that right?
JACK (Caller): Yeah. I'm in Elkhart.
NEARY: Okay. Go ahead, Jack. You have about a minute. Not even a minute.
JACK: Yeah. All right. I got a minute.
NEARY: Less than.
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JACK: I have full-blown AIDS symptomatic. I am one of those ones that cost the taxpayers a fortune. And I got a bill about three years ago for my doctor's visit along with my labs, and it came to nearly $11,000. Now, the taxpayers are going to pay that. And I put money into the system, but I had to do something about it because I was so guilt-ridden over the fact that I could do something, anything, what can I do? Well, I decided to do a little bit of research and I found out that while my meds are the same, I'm healthy to a point. Even though I've had two bouts of pneumocystis, I've reversed a lot of my T-cell count and my viral load.
NEARY: What did you do? Tell us quickly.
JACK: (Unintelligible) to be healthy on my own, why do I need to go to a doctor every month and spend…
NEARY: Jack, you got to tell us right now what you did because we're almost over.
JACK: Well, I've gone to a nurse practitioner and they write - and she writes all my prescriptions, anything I need to do, any tests I need to have done, she refers me out to a specialist.
NEARY: Great. Thanks so much for calling. That's very interesting.
And I want to thank our guests. Marge Ginsburg is executive director of the Center for Healthcare Decisions, and Anthony LoSasso, associate professor at the University of Illinois at Chicago School of Public Health.
You're listening to TALK OF THE NATION from NPR News. I'm Lynn Neary.
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