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SPEAKER 1: This is a production of Cornell University.
SPEAKER 2: My name is [? Nikki ?] [? Chopra. ?]
SPEAKER 3: And I'm [? Nishant ?] [? Trivedi. ?]
SPEAKER 2: And we are co-chairs of the Sick in America series. We'd like to welcome you to tonight's event. It is not only the kickoff of the Sick in America series, but it is also the first ever presidential lecture series on current affairs.
We've been working with a board of 15 enthusiastic students for about six months, planning this week's events. And we're thrilled that you could come to our first one. This series could not have been possible without the help of Dr. Richard Kiely, Dr. Robb Burlage, and of course, President Skorton.
SPEAKER 3: This series is the first of its kind, as it unites the perspectives and interests of over 12 undergraduate health organizations. Under the umbrella of the Cornell Undergraduate Health Cooperative, also started this semester, we hope to present the Sick in America series as a holistic overview of the problems facing the health care system in America, as well as the potential solutions. And now to introduce our keynote speaker, Dr. Garson, please give a warm round of applause for President Skorton.
[APPLAUSE]
DAVID SKORTON: Can you join me in thanking [? Nishant ?] and [? Nikki ?] and all the students who made this possible. It's really a terrific thing.
[APPLAUSE]
And if you have a chance to look at this brochure, you'll see all the things that these group of student groups, the group of groups, has brought together. And it also links together the two campuses in a way that has been a very high priority of ours for a couple of years. And you'll notice that next week, on the 30th of April, there's an event in New York City, a business and medicine symposium, that's going to be simulcast in Sage Hall in B-10. So I hope everybody will have a chance not only to enjoy tonight, which I'm sure you will, but also to enjoy the rest of the series. And again, [? Nishant ?] and [? Nikki, ?] thank you for making this possible-- very exciting.
Tonight's lecture, as [? Nishant ?] and [? Nikki ?] mentioned, is also the kickoff for a new series of lectures, which we're going to sponsor out of my office, to bring faculty to the university to talk about current affairs. And the reason we are going to do that is really twofold. The first reason is that even in this time of financial duress, where you hear so much-- at this university and at other universities like it-- about all the things that we cannot do right now, we have to remember that one of the things that we can do is to continue to support the intellectual ferment of the university and to, where it's appropriate, talk about things relevant to the world beyond the campus walls. And so the first purpose of doing this series is to do that-- is to look forward and to look up, to cast our eyes up, and to do it in an area that's relevant to the world around us. And we're going to start tonight, as I'll tell you in just a moment, in one of the areas of greatest concern to virtually all facets of American society, from the business society to all of us as individuals, to a place like Cornell as an employer.
The second reason for starting this new presidential lecture series is that I believe very strongly that the land grant universities like Cornell have as part of their public mission work that we can do to help the country and the state and the region dig itself out from the dilemma that we're in. And once again, one of the things that's contributing very substantially to that dilemma is the dilemma that we have in health care, health care delivery and public health in general. So for those two reasons, it's a thrill that the students who set this up allowed me to dovetail the first of these presidential lectures on current affairs with this. So I thank you very much for your graciousness.
I also want to announce-- for those of you who think even this part of the thing is already too long, and you're thinking, do I really have to stay for this-- that we're going to have dessert. And it's been the students who understand all these kind of things very well, know that they have to do this in a very strategic way. So rather than bringing the food in right now, so you could eat, get your fill, and leave, they have the dessert coming at the end of Dr. Garson's presentation. So you'll have this very tough internal dilemma. You'll have to decide, is it more important to sit through this-- no matter how painful-- and have dessert, or give them both up? And I can see it in your eyes, that you're already conflicted about it.
So now let me convince you that it's worth staying even if we didn't have dessert. It's a great pleasure, a professional and a personal pleasure, to introduce an old friend of mine-- and that doesn't mean that he's old, just we've known each other for a long time-- a colleague in pediatric cardiology and in broader aspects of academia, Arthur Garson, Jr. He goes by Tim. He's a very eclectic, open person. He's told me tonight that you can refer to him as Your Eminence. You don't have to call him--
[LAUGHTER]
Dr. Garson.
Tim Garson is one of the country's very, very prominent pediatric cardiologists, and had a hugely distinguished career as probably the most honored living practitioner of pediatric cardiology as it relates to the electrical activity of the heart-- literally wrote the book, a huge, three-volume tome that was and is the bible, the last word, on pediatric electrophysiology. He was president of the American College of Cardiology and hugely known, literally throughout the world.
Somewhere along the trail of pursuing this very distinguished career, Tim Garson began to see beyond the confines of the examining room where he was working, of the classroom where he was teaching, and of the university hospital or medical school that he was helping to lead. And he saw the importance of thinking more broadly about public health, about health care delivery, and about the larger issues that not only affect that interaction between doctor and patient but affect so many things in our country, went back and got further training and another degree, and then reinvented himself as one of the country's leaders in an aspect of public health.
This is very important for two reasons, not only having to do with his bona fides for sharing his ideas with us tonight, but to the students-- a few of whom I was talking with just a few minutes ago about this-- to imagine your career not only as you might see it through the lens of today, as a freshman, sophomore, junior, senior about to go out into the world, but through the lens of thinking that you've learned skills that will allow you to adapt to your changing interests and to the changing needs of the world. And it would be hard to imagine someone who has followed that siren call of change and need better than Tim Garson.
Tim graduated Phi Beta Kappa and summa cum laude from Princeton. He went on to earn his M.D. from Duke University, where he also did his residency in pediatrics. He completed his pediatric cardiology fellowship at Baylor College of Medicine in Houston, one of the very finest in this area, and then got his MPH from the University of Texas in Houston. Before moving to the University of Virginia in 2002 as vice president and dean of the School of Medicine, he had high-level posts at several other institutions, including Duke, Baylor, and the Texas Children's Hospital.
In addition to his leadership in medical education and as a clinician, he has been deeply involved in health policy. Tim served on the White House panel on health policy and chaired the National Advisory Council of the Agency for Healthcare Research and Quality. He chaired the health care program subcommittee of Virginia's Blue Ribbon Commission on health insurance and the uninsured, and served on the governor of Virginia's Health Reform Commission. He's also been a member of the Institute of Medicine Task Force on rapid improvements in the health care system, the Commonwealth Fund Task Force on health insurance and the uninsured, and chaired the American College of Cardiology's Task Force on the uninsured.
At UVA, Tim Garson teaches the introductory health policy course "Myths and Realities of American Health Care," and his book, Health Care Half-Truths-- Too Many Myths, Not Enough Reality, was published in 2007 to great critical acclaim. His topic tonight is "Health Care Myths and Truths." Please join me in welcoming the kickoff speaker of this event and the kick-off speaker of the Presidential Lecture Series, Dr. Tim Garson.
[APPLAUSE]
TIM GARSON: It's hard-- this is one of those great times where-- those of you whose parents might hear something like that-- this is the time when you'd say, my father would thank you and my mother would believe you. So thank you, President Skorton. We go back a long way.
There's actually part of the story that makes sense. And he may not know it. And it's probably worth sharing with you before we get started, because I'm about to put you guys to work. This is a-- you talk to each other and a little bit to me, not me talk to you. So if you're getting ready to think about dessert versus this, you might want to be thinking about that. I won't call on anybody that doesn't raise their hand, though. So don't worry about that.
The first night when I was a trainee in pediatric cardiology in Houston, I was taking care of a five-year-old girl who had been born a blue baby. And cardiologists in those days took care of all the post-op patients. Surgeons stayed in the operating room. We took care of them outside, in the recovery room.
She arrested three times that night. And each time she arrested, I went down the hallway and discussed what was going on with her parents and her grandparents. And the first time, it was the roughest of-- you know, this was their only little girl-- and them saying to me, we are trusting you to take care of her. Here I was, a first-night trainee. Back and forth three times, art of medicine at one end of the hall, science of medicine at the other end of the hall.
And needless to say, she made it through. We bonded-- parents, grandparents, [? Jenny, ?] me-- and traded phone numbers when she finally went home. I went to her grammar school graduation. She lived about 80 miles from Houston. Went to her high school graduation.
And at about 8:30 on a Sunday morning about halfway into her 19th year, the phone rings. And her mother is hysterical. And she's found her daughter dead in bed. And as we pieced the likely events back together, what it looks like happened is her Medicaid-- her public funding-- ran out at the age of 19. And she quit taking her medicine-- that was a drug that was absolutely keeping her alive-- and never refilled a prescription after the time that her Medicaid ran out.
So if you say, why would a sort of self-assuming pediatric cardiologist get into the uninsured and get into public health, it's a very simple one-person story. But when you hear numbers like 50 million-- and we'll get there awfully soon, if we're not there now-- 50 million uninsured, just think about these people are one at a time. These are not 50 million. This is not the population of Australia. This is 50 million individuals. So that got my attention. And that's a little bit the direction that I went. And hopefully, over the next several years, we'll make some progress.
Now, what I heard, very quietly, is that really, you had invited Michael Moore. And I am delighted that you did. And I thought that instead of just showing up and being me, I'd--
[LAUGHTER]
Show up as Michael Moore. Now, if anybody's got real thick glasses-- and I'm told the good news is, I need a little bit of a pillow. But I'm happy to at least try to fill in for him in a way that I'm sure that others could do as good or better a job. But I'll try, I promise.
Now, we're going to do this-- we're going to work together here, OK? And what we're going to do is we're going to sort of come up with a statement. And you're going to take a vote about whether something is true or something is false. And then we're going to talk about it. OK?
Now, [? Nikki ?] and [? Nishant ?] helped me to figure out some of the things that might be the most interesting. Perhaps I added one back in that might be a little bit controversial. But let's start with the following-- American medical care is second-rate compared to other developed countries. Now, you've got to vote, OK? I'm going to keep track, or you don't get dessert.
So how many true-- American medical care is second-rate compared to other countries? Way up. OK, how many false? All right, not bad.
Now, here comes another one. Take that hat off, Garson, right. OK. Now, here comes-- OK, [? Lindsay, ?] take that hat off, right? Here we go. American health care is second-rate compared to other developed countries-- how many true? How many false? And the rest of you are either too hungry to raise your hands or were not so sure.
OK, who would like to talk about the difference between medical care and health care? What's medical care? Somebody-- what's medical care? Go.
AUDIENCE: [INAUDIBLE] scientific and medical [INAUDIBLE]
TIM GARSON: OK, let me ask this. Let me ask a fact question. Do we need to be getting microphones to people? They can hear? OK, great.
All right, awful good. Hold that thought. More-- what's medical care?
AUDIENCE: Health care is the system. Medical care is the treatment.
TIM GARSON: OK, health care is the system. Medical care is the treatment. All right, more. Yes, sir?
AUDIENCE: Medical care treats the disease or condition. Health [? care treats the person. ?]
TIM GARSON: OK. One more. Aw, come on. Who said medical care is terrific? One more time-- medical care is not second-rate? OK, medical care is not second-rate. So why not?
AUDIENCE: [INAUDIBLE]
TIM GARSON: OK. OK, so a medical care index-- you want me to come back here, right? A medical care index is like breast cancer mortality. That's a medical care index, right? It's what doctors and patients and nurses and other care providers do together-- breast cancer mortality.
Now, the life expectancy in Harlem, in New York City, is lower than the life expectancy in Bangladesh. That's true. That's published. The infant mortality in southeast Washington, DC is worse than the infant mortality in Nairobi, Kenya.
AUDIENCE: [INAUDIBLE]
TIM GARSON: So both of those are true. Health care indices-- the major two health care indices are life expectancy and infant mortality. So now, what does that mean? Tell me a little bit more. Does that help you to sort of say, OK, I get it. This is what health care is. What's health care?
AUDIENCE: The general assessment across the United States. Who can go to the Mayo Clinic, who can go to [INAUDIBLE]?
TIM GARSON: Ah-ah-ah-- Weill Cornell, come on.
[LAUGHTER]
Golly. Why would you want to go to the Mayo Clinic when you've got Weill Cornell? Go ahead, OK.
AUDIENCE: Where you're examining [INAUDIBLE]. And if you raise your hand and say the whole system stinks, well, is it as a whole? I mean, if you have all this great technology and we've got super technology in the United States and you say, well, it's great, but for whom?
TIM GARSON: There you go. So here's the sort of-- take it one step further-- of life expectancy. In the United States, life expectancy is 40% lifestyle, 30% genetics, 20% public health, 10% medical care. One more time-- 40% lifestyle, 30% genetics, 20% public health, 10% medical care.
Now, that makes a guy like me go, wow. Only 10% of life expectancy is actually due to the stuff that docs and patients and nurses and others-- yeah. Because think about what's going on with obesity right now. Think about what's going on with smoking, drugs, right? Think about Harlem. Harlem is not medical care. Harlem is drugs, obesity, smoking, murders. That's all life expectancy. That's health care, OK?
Infant mortality-- very complicated. I suspect the infant mortality is going to be-- we're a long way from understanding infant mortality. Life expectancy, you can at least identify some things. There are people that talk about infant mortality being higher in poverty, higher in alcohol, higher in smoking, higher in African-Americans. That's very complicated. My guess is we're going to learn a lot better over the next 10 years about really what-- infant mortality is basically premature babies, little tiny babies. So there's a lot to learn there that probably will turn out to be something we understand and can help-- therefore, more likely to be medical care than social.
But these are complex interactions, as you're talking about, about who gets it. The uninsured-- 20% higher mortality between the ages of 19 and 64, 20% higher. So when you say, well, are those related, is medical care and health care related-- if you can't get to medical care you die. And you die sooner. The uninsured get about half the medical care they need. And so life expectancy among the uninsured, worse than life expectancy among the insured. So it's related.
So far so good? All right, questions? OK, this is about you guys-- not when can you have dessert. Not ready yet. Questions about that? Yes, sir. Nice tie.
AUDIENCE: [INAUDIBLE]
What lifestyle are they living? What is their dietary? What is the genetics? It's not simply medical care, I think. But it is [INAUDIBLE]
TIM GARSON: Oh, absolutely right. I mean, I'll give you one-- and I'll get it mainly right, because I just read this and haven't written it down. But there is a statistic-- and again, these things are also correlative rather than causative. But the life expectancy if you don't have a high school-- nah. I may have to answer it. He may be calling me. Put it over here, OK. All right. And you'll give it back to me next week when I forget it. There you go.
The life expectancy of people with less than a high school education is hurt worse than the life expectancy diminution from having diabetes. And when you say, well, the lack of a high school education doesn't cause you to die. No. But the lack of a high school education certainly-- likely doesn't get you health insurance. And so these things get very, very correlative.
So even obesity, diabetes, obesity causing diabetes-- there are plenty of articles now that are talking about, if we don't start to fix where obesity is going over the next five years, our life expectancy is going to go down in the whole United States for the first time since the Civil War. And it's going to be due to diabetes and heart disease and kidney disease, and those things that diabetes causes. So it's complicated.
When you then go look at other countries and you say, their health care indices are better-- so are their prison systems. So the sociologic issue-- they've got less people in prison. They, ounce for ounce, have less people doing drugs. And so this whole notion of the social determinants of health, really important. A lot of really good work going on here in that area. So congratulations, a lot of good work going on here in that area.
OK, another one. We waste half of our health care dollars. We waste--
AUDIENCE: [INAUDIBLE]
[LAUGHTER]
TIM GARSON: Pretty close, he says. OK, how many true-- we waste half of our health care? How many false? A few more trues. All right. The number is around a third, close to a half. And you go, where did that come from?
All right, talk to me. If I'm going to tell you we waste-- the number this year for the US health care system, even though the vast majority of that number-- they call it national health expenditures; they really mean national medical expenditures-- $2.4 trillion, with a "t." $800 billion a year wasted. Uh-oh. Where does it come from? Yes, sir?
AUDIENCE: Administrative overhead?
TIM GARSON: Talk some more. Terrific-- you got there quick.
AUDIENCE: [INAUDIBLE]
TIM GARSON: Go. You're right.
AUDIENCE: [INAUDIBLE]
TIM GARSON: Complicated, uh-huh. A little more, keep talking.
AUDIENCE: [INAUDIBLE]
TIM GARSON: OK, so let's hear a little-- we're going to say administrative costs. What are the components of administrative costs, when we waste a lot of money? And we do. Yeah?
AUDIENCE: Marketing--
TIM GARSON: Marketing. There you go.
AUDIENCE: Pharmaceuticals.
TIM GARSON: Right. More-- what do we waste money on? Yes, sir?
AUDIENCE: [INAUDIBLE]
TIM GARSON: Sounds like Sicko.
AUDIENCE: [INAUDIBLE]
TIM GARSON: So on average, in a physician's office-- hold that thought. On average, in a physician's office-- not in big hospitals, but in a physician's office, there are two billing people per one doctor. OK, so you've got 12 docs, you've got 24 billing people.
Now, there is a very well known and fun, neat health economist named Uwe Reinhardt who's at Princeton. And Uwe gave a talk at the College of Cardiology a couple of weeks ago. And one of the things he said was, you're right to cut out all the waste. Just not this year, please, because all of a sudden, that means jobs. And it does. Now, this is an important point as you start to think about-- we'll get there at the end. I've got three hours left, right, President?
[LAUGHTER]
Yeah, OK.
DAVID SKORTON: Three and a half.
TIM GARSON: There you go, OK.
As we start to think about-- and we'll get back to the end, about what do you all think is going to happen in the next six to 12 months. One of the things that people are talking about is, where's the money? Can you save it? And can you really get the money out?
The issue-- this is obviously an unusual time to be saying, OK, we can save a lot of money. But remember, in the whole health care system-- and $2.4 trillion is a lot-- somebody is going to lose a job if we save money. That's generally-- a lot of those things we're about to talk about mean that somebody is going to make less money, including doctors, including doctors. So we'll talk about that in a minute. More administrative costs-- so now we've got marketing. More-- what else? Yeah? Sir, go ahead.
AUDIENCE: The lack of a uniform and simple reimbursement structure?
TIM GARSON: Ah-- we are complicated, right. You're right, that's tough to quantitate, what that means. We can get to administrative. We know Medicare has about a 3% administrative cost. We know that the private sector has around a 25% administrative cost. That's got a lot of stuff in it, right? That's got inefficiencies, profit.
And you know, the fun thing about the United States is, we live here. You don't want to all of a sudden say, OK, we're not going to have profit. So that's a really interesting set of issues. Someone talked about pharmaceutical companies. So where does that work? Or do you need the top five pharmaceutical companies to be in the Fortune 50? That's a choice America can make or not make.
So we are in a for-profit society. Doctors make money. Hospitals make money. Lawyers make money. And so while we have a lot of not-for-profit hospitals, medical schools, those still have to-- while they're not turning money around for shareholders, they clearly have to take money in to put it on the bottom line to buy capital equipment.
So it isn't just, let's stop doing a number of things. What we clearly want to stop doing is having paper billing. We'll figure out how to train those people to do something else. We certainly don't want to do that. And you will hear a lot about electronic medical records over the next several years.
The stimulus funding did a really interesting thing. The stimulus funding that came out set up new rules where doctors, for the next four years, are going to get paid extra to put electronic medical records into their practice. And in the fifth year, after 2014, they're going to get penalized.
Now, that's fascinating. And physician behavior generally-- eh, give me 1%, maybe I'll pay attention to it. Cut me an eighth of a quarter of a tenth of a percent-- I'm out of here. So docs do not like to see payment go down.
And so Medicare-- I think they've done a very smart thing. If you really want to get docs to pay attention, after the fourth year payment goes down. So watch for the next two years-- eh, a little bit of sleepiness on the part of docs. At some point, beginning in around three, four, certainly the fifth year, you will see a bunch of physician practices-- now, what does that mean?
That means you walk into the doc's office. They don't ask you for the fifth time where you live, what your date of birth was. They know who you are. They know what your allergies are. They ask you to update them. There's a computer sitting there.
And in the best of all worlds, this isn't just about record-keeping. This is about providing advice to doctors, nurses, and other caretakers about what to do in complicated patients. So this is not just-- let's call something up in the middle of the night and look at the X-ray. This is advice on how better to take care of patients.
The words "cookbook" has been used over and over again, but like 20 years ago, of-- gee, cookbook medicine means there are guidelines. You've got to have a cookbook these days, because medicine has gotten very, very complicated. And there are guidelines. There are ways in which docs say, OK, this is a better-- this is the preferred way to practice. Well, you want to put those into an electronic medical record. So, sir?
AUDIENCE: Standards of care.
TIM GARSON: There you go. So administrative waste. What else?
AUDIENCE: Defensive medicine?
TIM GARSON: OK.
AUDIENCE: A tendency for physicians nowadays to, I guess, do over-testing in order to prevent the occurrence of malpractice lawsuits, and any negative consequences that occur.
TIM GARSON: Absolutely true. So malpractice, fears of getting sued. I'll tell you a story in a minute about a program-- we'll talk about access in a minute. But interestingly, in China a month ago when I was there talking about starting a new program, they asked about malpractice. They said, well, you're going to put new kinds of health care workers in. And we're worried about them getting sued. So even in China.
So malpractice-- big deal. And we could go on forever. And I'm standing between you and dessert. It is very difficult to tell whether someone is practicing defensive medicine without asking them.
And we tried this about 15 years ago, before the Office of Technology Assessment went away. About 10 of us spent a weekend trying to say, can you look at a patient's chart and tell whether the doctor ordered a test because she or he was worried about getting sued? And the answer is no.
So you have to ask them. You have to ask about motivation. You have to say, OK, here are a bunch of hypothetical reasons. And they can come up and give doctors 10 different cases and say, what would you do here and why? But you have to rely on the doctor saying, I would do it because I was worried about getting sued.
Please know that behaviorally in the same direction is doing more to make money, doing more because I am curious about the outcome-- not badly curious, just-- I really am uncertain; I want to know. Same direction for doing the right thing. And so unfortunately, there are a lot of competing things that when people do a lot, you then have to go ask them.
There's one study that I just pulled out again last week. It is a lot easier for a doctor to say, I'm going to do it because I'm going to get sued, than to say, gee, I have this new machine-- and this happens. I have this new machine. I'm in private practice. The salesperson that sold me the machine said I have to do 14 of these per week in order to figure out how to pay this back with the depreciation. They do that. It is impossible that that doesn't enter into people's thinking. So it's complicated.
Let me tell you that yes, financial stimulus does have something to do with doctors doing stuff. We think about Canada as being the land of single payers, non-US. When they first put in the Canadian health care system in the 1950s, what they did was they froze prices. That's all they did. They just froze prices. And the next year, the volume went up 6%. Trust me, Canadians did not get 6% sicker.
OK, so in fact, physicians in different parts of the world-- certainly in this hemisphere-- and they don't think about it most of the time. But in fact, the stimuli to do things are not as clear that-- we're going to do this because I'm going to get sued. I'm going to do this because I've got to pay this machine back. I'm going to do this because I'm not sure about the outcome of the patient. Complicated but true. OK, what else?
AUDIENCE: [INAUDIBLE]
TIM GARSON: Waste. What else? How are we wasting money?
AUDIENCE: For CEO salaries.
TIM GARSON: Ah, CEO salaries.
AUDIENCE: [INAUDIBLE]
TIM GARSON: Provost salaries-- oh.
AUDIENCE: [INAUDIBLE]
TIM GARSON: First of all, yes. All right, that falls into overhead. And again, yes. It's a little hard to know-- baseball player salaries, CEO salaries. It's a little hard to know where to draw that line. But yes, the guy that finished being the CEO of UnitedHealthcare four years ago, I was having dinner with. And after not much on my side and a lot of red wine on his side, talked about his $500 million in stock options that he left with. So there's real money there.
OK, what else do we waste? Yeah?
AUDIENCE: [INAUDIBLE]
TIM GARSON: So inappropriate care, or inappropriate billing. A little more-- is that right? OK, here's the big one, all right. So there's administrative waste. There's profits. There's malpractice. There is, across the United States, between a four and 10 times variation in the intensity of what doctors do in different parts of the country.
The rate of coronary bypass surgery in Miami, Florida, is four times per 100,000 the rate in Salem, Oregon, for the same sick patient. Same results three years later. Back surgery is 10 times, right? Spinal fusion, 10 times the variation. Same result three years later.
Therefore, the presumption is if you have the same result and you do more, you didn't need to do it. That number-- here's a statistic. You think about US medical care spending, year in, year out, it's between three and three and a half percent higher than general inflation. Many years, it's twice as high, right? So general inflation is 3%. Medical inflation on top of it is 3%. So it's 6%.
I'll come back to you in a minute. If you take the national average of three and a half percent and you practice the way medicine is practiced in San Francisco-- not in Boise, Idaho-- in San Francisco, that's 2.4%. So the raise, the rate of rise in San Francisco is slower than the average in the country $100 billion a year. $100 billion a year, because doctors are overdoing stuff-- for all the reasons we just talked about. But docs are overdoing stuff. Yes, sir?
AUDIENCE: I'm just wondering-- you bring up two examples of coronary bypass or spinal fusion surgery, both those areas, relatively speaking, in the literature are still somewhat controversial, even among very experienced physicians. So I'm just wondering, are there other examples of procedures which are much more clear-cut, that there's a tremendous amount of waste from doing unnecessary procedures?
TIM GARSON: Great question. And are you saying, are there any? I'm not aware of, really-- and I'm sure somebody will say, what about? OK, but in general, prostatectomy for prostate cancer or prostate hypertrophy, hysterectomy for fibroids. Cancer seems to be a little bit more standardized. But still then, the rate of mastectomy-- very different in different parts of the country.
Now, why is a really interesting question. But it will be very interesting. What is being said in Washington is, they're going to pay doctors differently in the next five years. And they're going to quit paying doctors as much on-- everything you do you get paid for. That's called fee for service. And they're talking about really complicated things of bundling services, where if you have a heart attack, you get paid a certain amount. You're done.
So we'll see the extent to which, if doctors are not paid fee for service, that changes, in fact, the difference from one part to the other. Yeah?
AUDIENCE: You said doctors doing too much. Wouldn't it be also true that [? they're responding ?] to patient demand--
TIM GARSON: Yes.
AUDIENCE: The cultural differences going on, if the patients down in Florida--
TIM GARSON: Perfect.
AUDIENCE: [INAUDIBLE]
TIM GARSON: Yes. It is a combination of patient-induced demand and doctor-induced demand. And they're both correct, right? We've got to fix both.
And I'll go very quickly through this. But what's the difference between access and coverage? Who knows the difference between access and coverage?
AUDIENCE: Is there a facility available and who's actually paying for it?
TIM GARSON: There you go. Well, OK. So access-- a little more. You're about there. What's coverage? When people say you've got coverage, what does that mean? Other than wearing a coat because it's cold.
AUDIENCE: [INAUDIBLE]
TIM GARSON: OK, coverage-- there you go. Coverage, very simply, means somebody else is paying the bill. No, no, no. That's too simple. No, it's not, because even if people-- if they are self-insured and they get real sick, somebody else is paying the rest of that bill. So even if you're self-insured, if you have insurance, either private or the government is paying for you-- Medicare, Medicaid, SCHIP, State Children's Health Insurance Program, county hospitals, all kinds of stuff-- that's coverage.
Access means you can get to the right person at the right time. It has nothing to do with coverage. So who can think of a time or a situation where a patient has 100% access and no coverage?
AUDIENCE: You might say Medicaid.
TIM GARSON: Hmm?
AUDIENCE: You might say Medicaid.
TIM GARSON: Medicaid, but what happens? OK, so they've got Medicaid, and that's coverage and no access. So are there parts of New York State with coverage and no access?
AUDIENCE: Medicaid has a better record of access than a lot. But the problem is now, that doctors don't want to take it.
TIM GARSON: That's right.
AUDIENCE: [INAUDIBLE] coverage, though, but if the doctor will take it, it's pretty good.
TIM GARSON: So that's coverage and no access.
AUDIENCE: [INAUDIBLE] then it's access.
TIM GARSON: Well, or no access if they don't.
AUDIENCE: If the doctors would get the hell out of [? their systems-- ?]
TIM GARSON: Uh-oh.
AUDIENCE: Then they would have access, all right?
[LAUGHTER]
TIM GARSON: OK, what's the classic lots of access, no coverage? Go ahead.
AUDIENCE: Elective procedures like breast surgery [INAUDIBLE]
TIM GARSON: Well, not in a lot of hospitals can you get somebody to do that without guaranteed payment. OK, emergency rooms, now called emergency departments, right? Anybody can walk in off the street and get care in an emergency department. Access-- 100% access, no coverage. We have a federal law that guarantees people who go in to emergency departments and can get care.
Now, you'll remember, the last president talked about that being enough. We don't have a problem, he said, because people can always go to the emergency department. Can you get your diabetes medicine? No. Can you get your preventive care? No. Can you get your mammogram? No. Can you get your follow-up care after your heart attack? A little.
So no, right? Emergency departments are not where you take care of people in the long run. So no coverage, initial access, the flip side of no access, plenty of coverage. I assume there are parts of New York State like that, where you just can't get to somebody. We certainly have that in southwest Virginia, out in the coal fields west of Detroit. Virginia goes a long way out there. And they can be four or five hours from a doctor.
So one thing-- and this is just a little bit of fun-- and I told President Skorton I'd tell you about it real quick-- is the notion of providing access by having a core of grandparents. This is real-- a core of people who have taken care of two generations of their children and their children's children, to work in their own communities to provide care that a good grandparent could take care of, so colds, sore throats, vomiting, diarrhea, sprained ankles, stuff that a good grandparent could do, in their own under-served area.
They get trained. They get given a mini-computer. The mini-computer has protocols in it. The protocols have electronic medical records associated with them. The mini-computer has Skype telephone, has video. So they can get back to a nurse in the middle of the night if they need to. And we pay them $20,000 a year. So that's being tested in Virginia, Mississippi, Houston, Shanghai, Beijing, Inner Mongolia, and Lesotho, Africa.
That's access. And trust me, as we get further-- I hope. And I'm not sure-- and I hope there are those of you in the room that are sure; I'm not-- about what's going to happen in the next year with Washington. But if everybody has an insurance card, we will still have a problem with access. We will still not be able to provide appropriate care to numbers of people.
The number in Massachusetts-- 400,000 people, after they got coverage, were found to have trouble getting access to a primary care doc. Well, guess what? Maybe they don't need to see a primary care doc as often as they think they do. So we'll see. That's the difference between coverage and access.
OK, are you ready to get your teeth ground, because this one always gets people. Preventive care saves money-- how many true? How many false?
AUDIENCE: Preventive care saves--
TIM GARSON: Preventive care saves money.
AUDIENCE: [INAUDIBLE]
TIM GARSON: There you go. False, false? OK, go-- false.
AUDIENCE: [INAUDIBLE]
[INAUDIBLE]
TIM GARSON: You sure did.
AUDIENCE: [INAUDIBLE]
TIM GARSON: OK, who else said no? Who said yes? This is one of the great half-truths. So it's both.
AUDIENCE: I say yes.
TIM GARSON: Because? You got an example?
AUDIENCE: [INAUDIBLE]
TIM GARSON: OK, so this is why people-- OK, if I say it three times we'll remember it. Preventive care is the right thing to do. Yes, please, it's the right thing to do. It saves people's lives. It keeps them alive, well, longer-- terrific. But in the macro sense, it does not save money. Here are two examples.
A study from Holland last year, total health care costs after the age of 20-- looked at their entire population. Smokers die at 77 and save $100,000 in medical care costs compared to nonsmokers who die at 83. Obese people die at 80 and save $50,000 in care costs compared to non-obese people--
[LAUGHTER]
Who die at 83. Just came out last week-- a study in Arizona-- and they would not. What they said was, smokers in-- and this is going to be really interesting if anybody picks it up-- Medicare, the data are that smokers die 10 years earlier than nonsmokers. Now, this is US-- to heck with Holland. They did not say what the savings were. But they said there are savings.
Now, you will remember, the cigarette companies paid Medicaid. Now, that's going to be real interesting if, in fact, the cigarette companies should be paid by Medicaid. So I'm not-- please don't-- let's come back to what I'd like you to remember. Preventive care is the right thing.
A personal story-- I've had two parents die of lung cancer. No, thank you. You do not want to die that way. So smoking is horrible. OK, being overweight-- if you're morbidly obese, there is a 28% reduction in the amount of work you do from day to day. This isn't just medical care costs.
OK, so prevention is the right thing. A study that came out last February 14th, 2008, in the New England Journal of Medicine-- some very good people, including a Nobel Prize winner, looked at whether preventive care saves money or does not. And 81% of preventive care costs money. 19% saves money. And they looked at a bunch-- 160 or something things.
AUDIENCE: [INAUDIBLE]
TIM GARSON: Oh, measles vaccination. OK, measles vaccination-- not all vaccinations, but measles vaccination is the one that people talk about, because what happens with measles is you don't die. You get something called encephalitis.
I've got to be real careful. I wrote an op-ed in USA Today right after this thing came out. And I said, you don't die from measles. And some pediatrician, literally, called up the editor at USA Today and said, of course you die from measles. Well, yes, you do, but one case in the last seven years in the United States. So they printed a retraction. So in general, you do not die from measles.
[LAUGHTER]
In general, if you get something awful, it's encephalitis. Encephalitis is a long-term-care problem. And you do not die from it. And so it is very expensive. So the reason, or a reason, that measles vaccination saves money is if you don't vaccinate people, a certain percentage of them are going to get encephalitis.
Some of the asthma preventive care that's coming out now saves money, because you don't die-- in one way or the other. And so it saves money in terms of emergency room visits. Some of those things are out there. But a lot of the things that we would like to think of-- why? Because you apply preventive care to a lot of people who don't need it. OK, so that's one of the reasons.
As we get better at determining who needs to take statins-- right now, all we know is that you have a certain cholesterol. And therefore there is an association of a high cholesterol with heart and vascular disease. So everybody with that cholesterol-- well, it can't possibly mean that everybody with that cholesterol needs it. But until we get better at genetic testing, protein testing, everybody is going to get it.
OK, so good thing, right thing to do. Let me end this with my father's statement, when he was 83. And he said, you know, in aging, what you really want to do is have early old age last as long as possible and late old age last 15 minutes. Now, if we can make that happen, then preventive care saves money.
OK, if I've got it right, literally, we've got five, six minutes before the food shows up. Is that right, folks? OK.
Let's finish-- and I think you know this one. There is a federal safety net for the uninsured, a federal safety net for the uninsured who have no money. How many true? How many false? How many are too tired to care?
[LAUGHTER]
AUDIENCE: Could you repeat the statement.
TIM GARSON: Federal safety net, federal program-- if you have no money-- that will provide medical care for you if you're uninsured. How many true? How many false?
AUDIENCE: [INAUDIBLE]
[LAUGHTER]
TIM GARSON: Here's the answer, OK. Between the ages-- [? Jenny-- ?] between the ages of 19 and 64, unless you are blind, disabled, have kidney disease, or pregnant, or all four at the same time--
[LAUGHTER]
Or any combination, you are not covered-- by federal statute. Now, states can vary that. But by federal statute-- New York State has changed that. By federal statute, there is no safety net for the uninsured between the ages of 19 and 64. That's why-- and I suspect you will hear that number, 50 million uninsured, awfully quickly. We had 45 last year.
The odds are pretty good. And you've got some very good people here. This has been a fun day. Thank you, President Skorton. The question of whether-- if you lose your job in this time period, over the last six months-- did those people, were they more likely to have health insurance than people that lost their jobs three years ago? Probably not. But I'll bet you we get to 50 million uninsured. Just so you're clear, that's more than the population of Canada and Australia. It's a lot of people.
Real quick, the notion of what's going to happen-- the last chapter of the book says, we'll never see substantive change around here. And we think, Carolyn and I, who-- we had brains and brawn. I wrote the book in five weeks and then Carolyn made it right. So that was the important part. The last chapter says, nothing's going to happen. There's nothing we can do. And we think that's a myth.
We got some stars that we thought were aligned. And then we have a budget issue. My suspicion is, we will have legislation. I mean, you'll see it-- two bills in the Senate, one bill in the House. And it should come down to policy for the United States saying, this is absurd that we have anybody who doesn't have coverage. Now, access is another issue, as we've heard.
I don't think there is, yet, the anger in the United States, quite yet, to carry the day. So I'm hoping, because-- it's sort of, I don't want to take it anymore. And I think there's a lot out there right now. It was coming-- a lot out there with the economy. And we'll just have to see.
But it is going to take the American public saying, this is awful. It's not about 50 million uninsured saying it. It's about the rest of us saying it. And given all the other pressures going on right now-- I wish it were different, but it may not be. So the old biologic term, chemical term-- the energy of activation, what's going to be required to get over that hump. I hope we get there, but stay tuned. We'll see. But the American public are going to have to want it. Nice people, President, thank you.
[APPLAUSE]
It's only a matter of time--and not much time--before the number of Americans without health insurance tops the entire populations of Canada and Australia. The number (soon to reach 50 million) is "awful," said pediatric cardiologist Arthur Garson Jr., executive vice president and provost of the University of Virginia and author of "Health Care Half Truths: Too Many Myths, Not Enough Reality."
Garson spoke April 20, 2009 in Goldwin Smith Hall's Hollis E. Cornell Auditorium, laying out the topography of the health care debate, defining terms and dispelling a few myths along the way.
The lecture was the keynote address and kickoff event for Cornell's first annual Sick in America series. It also was the inaugural event for the Cornell University Presidential Speakers Series on Current Affairs, a new series sponsored by President David Skorton.
