Sen. Tom Coburn, part 2: Reforming health care
Sen. Tom Coburn (R-Okla.) is a physician and the author of “The Debt Bomb: A Bold Plan to Stop Washington from Bankrupting America.” This interview, which focuses on America’s health care system, is the second in a two-part series. The first interview, which focuses on debt, was published last week. The transcript is lightly edited for length and clarity.
EK: To go back to the question of whether Democrats have put forward a plan on entitlements, I agree that Senate Democrats haven’t put forward a budget. But in your book, you say that what President Obama has done and wants to do on Medicare, namely the Independent Payment Advisory Board, is a rationing board. You’re not for it, obviously. But you treat it as a very aggressive proposal. And to them, that’s a plan. They think it’ll work to control costs. And it often seems Republicans say Democrats don’t have a plan on entitlements when what they mean is they don’t like the Democrats’ plan on entitlements.
TC: How well has it worked in England? Barbara Mikulski wrote that section of the bill. She spent time with the head of NICE [National Institute for Health and Clinical Excellence] in England. What has been the response of England as you ration away care? Is that how we want to do Medicare? When we know that $100 billion a year isn’t working right? When we know one in three dollars in our health care system doesn’t help anybody get well? Is that the way to do it? From central planning? You’re right. But that’s outside the bond of how the average American expects Medicare to operate. The better way to do it is to create a more efficient system to allocate the resources better without somebody here making a decision about your care. The reason I object to IPAB is you’ve got someone between the patient and the physician, and that can never be in the best interest of the patient.
EK: I think it goes a bit far to compare IPAB to NICE, given the powers it has, but even so, in terms of the cost portion, in terms of them having a plan, Britain’s health care system is among the cheapest in the developed world.
TC: Sure, but their cancer cure rates are half ours. I can document that for you.
EK: I’ve gone through those numbers. A lot of that is an artifact of earlier detection which may or may not help our outcomes. But I agree, broadly, that the U.K. system gets somewhat worse outcomes than we do. Still, there’s a two-step here: On the one hand, Democrats don’t have a plan, and on the other, their plan is very aggressive rationing.
TC: Sure, then they should say here’s our plan. It’s to ration. The reason they don’t want to come out and say it is they think America would reject it.
EK: So you don’t believe the studies saying that with better data on what works and what doesn’t, we could bring down the 15-30 percent of our health care spending that doesn’t seem to be helping?
TC: The core question is do you trust markets or government? I know markets aren’t perfect. They fail sometimes. But the question is, for me, one of philosophy. Do you trust market forces where you have the regulation you need to work more efficiently and at less cost than a state-run program? And every time, I’ll bet on markets in a true, protected, regulated environment to beat government agencies over time. And they have! Give me an example where properly regulated markets did worse than the government.
EK: Well, if you presuppose “properly regulated,” then I doubt there are many examples. But IPAB seems like an effort to deal with something you’re worried about: The inability of Congress to act to reform Medicare. It’s an effort to more properly regulate the Medicare market.
TC: That’s me treating the symptom of the disease rather than the disease. The disease is that Medicare has set a price at which they’ll pay a physician for something. So why are we 125,000 primary care physicians short right now?
EK: I imagine you’d argue we’ve underpriced primary care.
TC: Why do we have an excess of orthopedists, of general surgeons, of urologists — why do we have an excess in all these other fields?
EK: The question is how do you define excess? In the market version of this, it’s not clear that people know the care that’s best for them. When you say how how many primary care physicians we need, it may just be that Americans like a lot of specialty care.
TC: But there are studies showing that when you go to a primary care doctor with the same symptoms that you might take to a specialist the care costs half as much. We’ve distorted the market through government pricing where you don’t have a competitive market in primary care. So what are we doing? We’re using physician extenders. That saves us some money. But on the 10 percent who needed to see a real physician? It costs you 20 or 100 percent more because of the misdiagnosis. I make the point in the book that the Amish are the best health care purchasers I know because they’re informed and they question everything you do.
Let me give you an example. I just had a bout with prostate cancer. I got radiation implants. Eighty little radioactive seeds. They make you radioactive for six weeks.
EK: I enjoyed your work in “The Avengers,” by the way.
TC: [Laughs] So they called me up and asked me to come in and get a CT scan. I said, why? They said, to see if we’ve placed them right. I said, what will you do if you didn’t? They said, uh, it’s part of the protocol. I said, you didn’t answer my question. What will you do if you didn’t place them right? Will you place more? They said, no, you can’t take any more radiation. So I said why are we doing this scan?
About a month ago the American College of Urology was in here with their president. And I asked these doctors, do you all get a CT scan after you place these? I said, why? No informed consumer had ever challenged them. They were just following the protocol. Best practices. Market forces would have said, that’s stupid. You’re charging me and my insurer thousands more for this scan and there’s nothing you’ll do to act on the knowledge.
EK: One thing that confuses me about health care is that, even if you take Medicare as a dumb government bureaucracy, employers should be smart purchasers. They’re in this market. Why haven’t they gotten rid of these kinds of things? I don’t like having an employer-based health care market, but they should be able to purchase health care smartly. They have every incentive to try and save money. What’s preventing them from exerting this discipline?
TC: We’ve created this aura that it’s not a market and you can’t question it. And my point is the best care I give is when the patient is active and questioning what I’m doing. Don’t question the doctor? We can’t afford not to question doctors anymore. You need to know why you’re getting a test, where you can get it cheaper, and what they can do about it.
There’s some good stuff coming out about concierge doctors showing they’re ordering half the tests they were before because they’re listening to the patient. You have to invest some time. But you know how long it is before the average doctor interrupts the average patient for the first time? Seventeen seconds. Because we have a fixed-price system and they need to get to the next patient. So instead of me practicing the art and science of medicine, I’m practicing a scheduling-driven practice and ordering a bunch of tests to cover my rear end. So can markets totally work in that? No. But they’ll lessen this $850 billion we’re spending in health care every year that’s not helping anybody.
EK: You talk about needing more primary care, one possible option would be deregulating the licensing structure, letting nurse practitioners do more, letting Minute Clinics take a larger role, but that’s not something you hear from the left or the right.
TC: I think scope of practice and licensing is a state issue. The federal government, if you read the Constitution, has no role in that. But you never see the downside of less than well trained physicians in the care. It sounds really neat that I can use a nurse practitioner, but I don’t think nurse practitioners or physician’s assistants should practice alone without a physicians. No one ever studies the long-term consequences. Can you, with two years of training as a PA, compete with somebody with eight years of medical training?
EK: Haven’t there been studies looking at outcomes? I feel like I’ve read a number of them suggesting the care is fairly good.
TC: Sure, on sore throats and things like that? You bet! I’ll give you a good example. In our hospital back home, we don’t allow any primary care doctors to deliver babies. They can be trained to do it. But what we found is they waited too long to call one of us to come do the surgery that was required. And so, consequently, their judgment was impaired by their dollars. In other words, they thought if I delivered it, they would lose their fee. That sounds crass, but there’s greed in medicine. The point is we stopped having significant bad outcomes as soon as we instituted a policy that if you wanted to deliver babies at our hospital you needed to be able to deal with all the possible complications.
The question when you use physician assistants is, sure, there’s a group of patients for whom they’re probably better than physicians, as they’ll spend more time with them. But there’s a lot of stuff they’ve never seen and they miss and have no idea they missed it and the consequence shows up a week or a month or a year down the road. I’ll never forget a PA saw this kid with a fever, sent him home, and the kid had leukemia.
EK: But isn’t there a tension here where we say that if we expose consumers to more market pressures they can make better decisions and get rid of useless CT scans after brachytherapy but the market can’t take care of who should see a doctor and who should see a nurse practitioner?
TC: It can. I have friends who see naturalistic doctors. That’s their right. But we don’t want to mandate it. If Oklahoma wants to let a nurse practitioner do whatever they want, that’s up to Oklahoma. And let’s see how Oklahoma does. Let’s compare outcomes. But let’s use proven data.
EK: In terms of a better regulated market, one thing I’ve found surprising in the health care debate is that if you look at what’s in the Ryan budget for Medicare and what’s in Obamacare, the actual insurance markets are structured very similarly. Competitive bidding tied to the second-lowest cost plan that meets an actuarial standard. But conservatives who are very confident that that can save lots of money in the Medicare space are very skeptical and even dismissive that it will save any in the under-65 space.
TC: I think that’s a legitimate criticism. I think you can use competitive bidding for both. The problem is you’ve got a much bigger purchase capability with Medicare. You’ll get a greater discount for the huge volume. But you make a great point: Why have you seen costs on the outside go up? And the reason is we don’t have the market forces working. The data is important in creating a competitive model. So maybe this idea of real competition based on outcomes and efficiency. If you think about Medicare’s SGR, SGR would have worked if Congress would have enforced it.
EK: Why do you say that? That’s a pretty sharp price control.
TC: It’s not a price control. If Medicare is going up at this rate, with a stable population of patients, then who is writing the prescriptions for the Medicare costs to go up? Physicians. So if it’s going up, we want them to be responsible for it. So there would have been a financial incentive, if we had made the cuts, to force them to think whether these tests they were doing were really necessary. The idea was right but it was never enforced. If we had given them that first 1.8 percent cut across the board, if we’d shown we were serious about this, it would have created market discipline. Your price gets cut because you overutilize the system because you’re padding yourself.
EK: Isn’t IPAB a supercharged SGR in certain ways? It has more flexibility about what to do when costs rise. it doesn’t have to rely on such blunt cuts. But they do a lot of provider payment cutting.
TC: Yeah, and that’s exactly what they’ll do. Control the price. But the only way that works is to mandate every physician takes Medicare. Because they’ll quit. So we’re going to take more freedom away. Now you can’t practice medicine unless you take Medicare patients.
EK: But the bill doesn’t do that.
TC: But it’s what will happen. Forty percent of the doctors practicing won’t take a new Medicare patient.
EK: Are there any international systems you admire?
TC: Yeah, the Swiss. They’re a combo of a socialistic system and a free-market system. Everybody has to buy.
EK: They’ve got an individual mandate.
TC: Yeah, but you get a rebate back based on how healthy you are, how much you utilize.
EK: I’ve always wondered if the Swiss system is our endgame. If you took something like Wyden-Bennett, which already folded Medicaid into the exchanges, and then eventually you brought Medicare into that, too, and you have people in these regulated markets throughout the life cycle, that’s basically the Swiss system. That’s always seemed to me like a plausible possible evolution for us.
TC: One thing you want to do is to get a long-term investment between patient and caregiver so the physician can look at the long-term risks and treatments. Forty percent of health care is not medicine. It’s relationship building. It’s how do you use the art of medicine to get them to go where they need to go for their own health when their natural tendency is not to do that?