America's Bitter Pill: Steven Brill on Fixing a Broken Healthcare System

Mark Masselli:
This is Conversations on Healthcare. I’m Mark Masselli.

Margaret Flinter:
And I’m Margaret Flinter.

Mark Masselli:
Well, Margaret, with Martin Luther King Day behind us, I’ve been thinking quite a lot about the dream of equality in this country. In some ways, we’ve come so far and yet, it still seems we have far to go, but at least, we’re starting to see some meaningful parody with the passage of the healthcare law.

Margaret Flinter:
Well, I think we’ve seen that in our own organization, Mark. So many people who struggled in the past to afford health coverage due to near poverty or pre-existing conditions, now covered, not just covered, but covered with good insurance making a big difference in their lives and for that matter, millions of lives around the country according to a recent survey by the Commonwealth Fund.

Mark Masselli:
One note is, a study recently revealed that there’s a notable drop in the number of people who put off accessing healthcare services due to the cost, or lack of coverage, that percentage dropping from 43 percent of Americans down to 36 percent. It’s the first time those numbers have gone down since the Commonwealth Fund began tracking those numbers.

Margaret Flinter:
Well, I think it’s important to note too though that the study showed that folks who live closer to the poverty line, still had trouble paying all their medical bills and that’s primarily due to the plans with higher out-of-pocket costs, but even those numbers showed some improvement, the number of people who received treatment, but had difficulty paying their bills dropping from 41 percent to 35 percent.

Mark Masselli:
These data are also supported by findings made in a recent Urban Institute Study, which showed that the ACA was reducing coverage differentials due to race and age and gender and as we know Margaret, the best pathway to better health is facilitating access to preventative care and with millions of Americans newly covered under the healthcare law, we should continue to see some steady improvement.

Margaret Flinter:
But how we access care in general is also changing Mark. We have a new era of healthcare where televisits will be very sufficient to fill many of our healthcare needs, especially our episodic needs and smartphone apps can track most of our essential health data. All this, hopefully, serving to help patients be more empowered in their own care and that’s something our guest today is one of the worlds thought leaders on.

Mark Masselli:
Dr. Topol is a practicing Cardiologist and the Director of Scripps Translational Science Institute. He’s the champion of the potential for genomics and telemedicine to reshape the future of healthcare. He’ll be chatting with us about his newest book, The Patient Will See You Now – The Future Of Medicine Is In Your Hands.

Margaret Flinter:
Well, it’s always a pleasure to hear from Dr. Topol and Laurie Robertson will be checking in. She’s always on the hunt for misstatements spoken about health reform in the public domain.

Mark Masselli:
But no matter what the topic, you can hear all of our shows by going to www.chcradio.com.

Margaret Flinter:
And if you have comments, email us at www.chcradio@chc1.com, find us on Facebook, or Twitter, we love hearing from you. I will get to our interview with Dr. Topol in just a moment.

Mark Masselli:
But first, here’s our producer Marianne O’Hare with this week’s headline news.

Marianne O’Hare:
I’m Marianne O’Hare with these Healthcare Headlines. What you pay depends on where you live as tens of millions of Americans gain insurance coverage under The Affordable Care Act. Rates do vary widely across the country. While insurance rates in Colorado actually went down slightly, largely due to more choices for those purchasing insurance, folks in Alaska saw an average 30 percent hike in cost for standard silver plans on The Exchange.

Turns out, Sunbelt states tend to have rates on the lower end of the spectrum on average. California, which has been considered something of an ACA success story, is grappling with some supply and demand issues, not enough options in certain parts of the state, in 22 mostly rural, northern California communities, only one choice of insurer is available and it’s causing problems for consumers there.

A milestone in the Ebola outbreak, schools were reopened last week across the small west African country of Guinea, one of the hardest hit Ebola hotspots. So far, the disease has been largely contained to that region of the African continent. More than 20 thousand have been infected, roughly half of those patients have died.

One of the challenges for scientists battling this current outbreak of Ebola, the genetic structure has changed, about three percent from its 1970s genetic makeup, The mutations makes drug development a little more uncertain.

China is confirming at least 15 serious cases of Bird Flu in recent weeks, three of whom have died, the rest are critical. There have been ebbs and flows of outbreaks since 2013, 450 cases so far and while China is beginning to look to renewable energy as a replacement for current fossil fuel use, air quality continues to deteriorate across the country to multiple times the legal limit for breathing. Toxic air in China is believed to be responsible for 750 thousand deaths per year.

Smoking is a choice that leads to an estimated 450 thousand deaths per year in the US. The online financial site _____ (5:09) did an analysis showing smoking costs the American economy some 300 billion plus dollars per year. The average smoker, if they smoke and survive over a lifetime, will have spent about 1.2 million dollars on cigarettes and will incur an average of 150 thousand dollars in medical bills and will lose an average of 200 thousand dollars of lifetime earnings due to smoking related illness.

I’m Marianne O’Hare with these Healthcare Headlines.

Mark Masselli:
We’re speaking today with Dr. Topol, Cardiologist and Director of Scripps Translational Science Institute in Loyola, California, an expert on the use of telemedicine and genomics in healthcare. Dr. Topol has written several critically acclaimed books, including, The Creative Destruction of Medicine and most recently, The Patient Will See You Now – The Future of Medicine Is In Your Hands.

He is Editor and Chief at Medscape, a web resource for physicians and health professionals. He earned his medical degree at the University of Rochester where he was awarded the highest honor, The Hutchinson Medal for his contributions.

Dr. Topol, welcome back to Conversations on Healthcare.

Dr. Topol:
Thank you.

Mark Masselli:
It’s been about three years since you joined us on the show and so much has changed over this short time since we chatted. The discipline of genomics and telemedicine have exploded in areas that you say are poised to be the two biggest game changers in healthcare.

Your new book, just recently published, The Patient Will See You Now, you examine how far we’ve come in putting the power of healthcare into consumer’s hands. Tell our listeners what have been some of the most exciting developments in the medicalization of smartphones,

Dr. Topol:
Well, thanks Mark. It’s really been an extraordinary jump in the technology where what was a smartphone, that change our everyday lives, it has now become capable of a hov of medicine that is not just that you can capture all your sensor data like your vital signs, do your labs, do imaging, but also of course, things like your physical exam, being able to summon a doctor, either immediately through your video secure link, or even to your home. So it’s become this little device that could really transform medicine, it could democratize medicine by super empowering consumers.

Margaret Flinter:
Well, Dr. Topol, I want to pull that thread a little bit. You’ve likened this phase we’re entering in the world of healthcare as _____ (7:42) the development of the Gutenberg Press, which democratized access to the written word in the 1400s. You note that there is a long-standing tradition of what one could call paternalism in medicine and healthcare that goes all the way back hundreds of years B.C., but as you said, this medicalization smart phones, the free flow of information from patient to providers, has the potential to democratize healthcare in a way never seen. So expand on that a little bit for us.

Dr. Topol:
Right Margaret. Well, it’s not just the access, but we’re talking about leveling the playing field, that is, for all these years, millennia, the doctors have been in control and the information flowed to them and patients didn’t have access to their own data and in fact, really had a hard time getting it. Well, that’s going to change drastically because not only are things digitized, but now, patients are generating their data, whether it’s their blood pressure, or their glucose, that data is going to their phone that they own about their own body and it’s not longer real acceptable for the medical community to own the information.

In fact, what’s going to happen in the short-term, I believe, is that we have a whole new model where the patient will see you now, that is, calling the shots, much more in charge than ever before and in fact, access to information not just about themselves, but for example, cost data. You know, cost data has been an unmentionable part of medicine. Doctors didn’t know the cost or didn’t want to discuss it, but now, that all that data will be accessible through ones mobile device and whether it’s a scan or a lab test or an office visit or whatever, the person will know what the cost would be before they have this.

So these things are all happening at once, it’s happening quickly and of course, we have this paternalism that you mentioned and this of course, has to give way to this altered, I think, very improved model.

Now, your point about the Gutenberg and democratization of information and reading and the printed material, I do think, although some would say that’s a reach, I do think that this has the parallel of our time in medicine because we go from the medical community controlling everything, having the real information flow, to a whole different look where it’s bottoms up, a great inversion of how medicine is practiced.

Mark Masselli:
We just recently had entrepreneur and Angel investor, Esther Dyson on the show talking about what she looks for when investing in health technology and she said, we don’t need another _____ (10:25). There are tens of thousands of them on the market already, but she thinks non-invasive sensors hold the promise for disrupting the status quo in healthcare. It’s going to generate a lot of data, all that needs to be secure to travel through it. That’s an area that still needs some work. Tell our listeners where we are in this, what needs to be enhanced to make sure the information is secure?

Dr. Topol:
Right. Mark, you’ve brought up two critical points. One is about privacy and security of the data, which we do not have safeguarded in any way. There’s been great white papers written by the Whitehouse, but no action has been taken to control the data, to prevent its sale, you know, so this is, right now, the medical data, which is precious an needs to be preserved as private, we don’t have that nailed down at all. It has to get righted.

The other thing that you brought up is about the analytical side and in the Wall Street Journal piece, I talked about how we’re pathetic at analytics and we are. That is, we hoard all this data, big data, enormity of data, but we do very little processing in analytics of data and part of that is, we don’t have the talent, that data scientists, the code developers, also known as code doctors to write all the algorithm and do this great analytics.

We have, right now, for example, Ester Dyson is right, the sensors, whether they’re wearable, or there are other ways that we can track one’s own information in the context of their lives, but what about this immense data torrent, how is that going to get processed and ultimately, how is that going to be used for predictive analytics to prevent and preempt illness, which is certainly possible. So this is exciting, but we are way behind in the analytics, we’re way behind in the security and privacy. We’ve got to work on that. That’s what’s holding us back right now.

Margaret Flinter:
Well, I’d like you to take a closer look at telemedicine and the promises it holds for increasing patient’s direct access to a provider. Are we seeing with the versioning of telemedicine and virtual visits, which I read and was astonished that one in six doctors visits were virtual in 2014 according to an analysis from Deloitte Health. Certainly, there’s still some resistance from the medical establishment, maybe from patients, but you see telemedicine as a game changer and I’d like for you to just paint a picture for us, if you would of how practices will need to change to embrace this promise of telemedicine and is it in the context of a relationship with a provider, or is it a commodity from any provider?

Dr. Topol:
Yeah. I think that telemedicine is just one dimension to this mobile device makeover, rebooting of medicine and that is because it takes so long to get an appointment with a primary care doctor. The average is over two to three weeks in some cities, as much as six weeks, well, that’s not going to work. We live in a whole different culture of I want what I want when I want it and you know, this whole concept of instead of there’s an app for that, there’s an _____ (13:52) for that and that is this whole thing about you can get what you want immediately.

If it’s two o’clock in the morning and you need to get a consult, you can do that now. Now, that doesn’t mean to undermine your primary care doctor, but the mismatch of demand and supply is profound. So it turns out we need to really gear this up and part of it is, financial, that is, it costs the same to get an immediate video consult, as it does for a co-pay if you go to the doctor and wait several weeks.

So it’s $30 to $40 dollars and you get your answer to your question on an immediate basis and not only that, telemedicine is going to get enriched because you can do a lot of the physical exam yourself. You can do all this data accumulation about yourself on the relevant condition and you can send that in advance or during the consult. So we’re not talking about just two people having a video chat, we’re talking about actually reviewing of information about the person, or the child, or whatever.

So this is a very exciting area. We’re not geared up for this. None of the medical schools in the United States, 140 schools, teach their students how to be good telemedical doctors. Someday, that’s going to be part of every medical practice of people who are…not surgeons necessarily, but those who are involved in primary and medical care.

Mark Masselli:
We’re speaking today with Dr. Topol, Cardiologist and Director of the Scripps Translational Institute in Loyola, California, an expert on the use of telemedicine and genomics in healthcare.

Dr. Topol has a new book, The Patient Will See You Now –The Future of Medicine Is In Your Hands. Let’s take a look at the role of genomics. Genomic testing is getting cheaper all the time, but it’s increasing the playing of a role in tailored protocols for treating things like cancer. In fact, you site a case of Angelina Jolie who lost her mother to ovarian cancer and she had herself tested for the BRCA gene, which increases the likelihood of both breast in ovarian cancer and chose to take a proactive approach to that likelihood. Can you tell us why you find her case so compelling?

Dr. Topol:
Well, she is an essential character in the bookmark because she’s a real sign of our times. That famous op-ed that she wrote, My Choice, everything about it was her choice. Her choice of having this mutation screening that is sequencing her BRCA 1 and 2 genes and then, after finding that she had one of the serious mutations, to have the bilateral mastectomy and her choice of trying to teach the world about her whole situation and the choice that she made, this wasn’t possible just a few years ago.

What’s happened in a rapid period of time is that each individual gets to make the call. This isn’t for everyone, but the point is, is, it’s an opportunity of having access to their information. In her case, it was about her genetic information. She’s also going to undergo ovarian removal.

So this is, I think, a totally different look of how medicine’s been practiced and these are not a lightweight decision. So the fact that she is such an immense public figure is also part of this thing and of course, genetics is…you know, you can have your own genome sequence and over the next few years, millions of people are going to have their genome sequence and that’s going to help in making choices for each of those individuals.

Margaret Flinter:
As a cardiologist and hypertension being one of the things that cardiologist colleagues, along with primary care treat, day-in an day-out, I guess the question is, is it possible to do this absent, ever having in-person contact, or having a relationship with the primary care provider of hypertension would lend itself to being diagnosed because you checked your own blood pressure, certainly, the physical exam one could use the stethoscope component of the smartphone. One could do a micro drop of blood pretty soon and get all of their lipid panel and so forth, I guess, as a cardiologist are you comfortable with thinking that all of this can happen outside of ever needing to see the person in situations. Are we really moving to a place where all of this can be done remotely?

Dr. Topol:
Well, not all of it, so much of it. The fact that the intimacy of the human touch factor between a doctor and patient, I don’t’ believe that’s ever going to get lost, but I do think it’s going to be decompressed. So the fact that you can offload back to the patient a lot of this data election.

For example, you mentioned hypertension, Margaret. Well, there will be a watch or a way to give blood pressure, every heartbeat going to your phone and graft and while you’re sleeping, while you’re in traffic, while you’re having a stressful experience, times we never even had that measurement before, but then, the person can say, “Well, I was under stress because of such and such.” These are not things that doctors have that context, but the consumers do and that’s what’s a whole different look here.

So basically, you’ve got this consumer-patient armed with their information. They have that knowledge that we, as doctors, don’t have. Then, we come together for providing the discussion of guidance, the wisdom and experience of the doctor, but that is so much of the doctor’s work today, besides having to fill out forms collecting data, ordering the tests that the person eventually will do almost all their routine lab tests themselves.

Mark Masselli:
Dr. Topol, we recently had Dr. Eric Viirre on the show, the Medical Director of the XPRIZE Competition and we’re getting closer than ever, hand-held diagnostic tool that really puts the power of healthcare management in the hands of consumers and I know we’re all excited about it and I think those of us who grew up in the Star Trek generation remember the tricorder, not that far around the corner and you also note that things are changing in the medical school arena, as well.

For instance, medical students at Mt Sinai in New York are no longer being given stethoscopes, but instead are being treated and trained to use smartphones with sensors. I don’t know how we’re going to recognize them as physicians without the stethoscope around their neck.

I think actually, that raises a question about the cultural changes that are going on, but also, tell us not only about the cultural changes that are going on within medicine, but the revolution in technology, how’s it going to assist clinicians in their task and the implications for training new providers.

Dr. Topol:
Well, this is all part of this through-and-through, across-the-board revolution and the stethoscope, which is the icon of medicine and as you’ve pointed out Mark, it’s how you identify healthcare professionals. It’s an obsolete, 200-year-old analogue, not recording anything,

Margaret Flinter:
But I love my stethoscope.

Dr. Topol:
I know, but it’s worthless. Basically, listening to sounds…I mean, I used to teach on rounds, I mean, that’s how I was trained, all the splitting of the second heart sound, all these things, all that stuff and diastolic rubs. Anyway, it’s all a bunch of past tense. It’s like, you can see everything with a high-resolution ultrasound, you can carry in your pocket and once you see everything, you say, “Why would I ever listen to that stuff, that is so old.”

So that’s just really another part of, not just education, but this rebooting of doctors because we order 130 million ultrasound studies a year in this country, which is well over a 100 billion dollars. If we just used this as part of our physical exam, we wouldn’t have to order so many of those studies.

Mark Masselli:
Well, we just said Stephen _____ (21:45) on the line last week on the show and he would agree with you.

Dr. Topol:
Yeah. I know Stephen is right on. In fact, in his book that just came out, I mean, he didn’t really get into this whole side of the innovation, which of course, that what was really, to me, so extraordinary, so remarkable that we can harness things that exist today and have drastic reductions in costs, but we’re not doing it because of the profound resistance within the medical community.

Margaret Flinter:
We could go on for hours with you, but let me just see if I can wrap up with…the question is always front and center in my mind on this, all of this makes perfect sense, particularly around single, isolated issues for patients, but when people and particularly, we would say perhaps people were most familiar with people who are low-income and confronted with lots of different complex challenges in their lives present, it’s really for an issue, it’s for an entire multiplicity of issues, what’s the solution out there for complexity in healthcare, as complex as treating hypertension or rashes or those things, which are often put forward when we talk about telemedicine and e-consults and apps.

It’s when you wrap all that up. Wrap it in the context of people’s emotional lives, their health habits, past histories of trauma, chronic illness, as well as preventative care needs that things get kind of sticky. What do you see out there? Is that the place where the provider still sort of has a place for separating things out with people and helping them get a handle on many issues, not just single issues.

Dr. Topol:
Right. I mean, this is, I think, as you’re alluding to, not a simple matter. I do want to just touch on the poor and the digital divide for a moment though, because you mentioned that Margaret and that is, it may wind up being far more prudent to give people smartphones who don’t’ have them and service contracts because that’s a total minor cost compared to 45 hundred dollars a night in the hospital and all the other things that are involved with emergency room visits in our healthcare system today.

In fact, we’ve just done a randomized trial where we gave half the people the device and service contract, so there is a digital divide that exists. There is a problem around the world with access to care, but there’s a new way of collecting data and information for each individual and what I’ve learned is that, patients are really eager to have their data. All the surveys indicate 80 to 90 percent would like to have their data information, but the precious involvement to review that with a doctor will never be lost. It’s just that it’s a different way of going forward. It’s an evolving way of a partnership and to me, that’s exciting if we put an app in.

Mark Masselli:
We’ve been speaking today with Dr. Eric Topol, Cardiologist and Director of Scripps Translational Science Institute in Loyola, California. Dr. Topol’s new book is out, The Patient Will See You Now – The Future of Medicine Is In Your Hands. You could learn more about his work by going to www.stsiweb.org or you can follow him on Twitter at Eric Topol.

Dr. Topol, thank you so much for joining us on Conversations on Healthcare.

Dr. Topol:
Oh, thanks so much for having me.

Mark Masselli:
At Conversations on Healthcare, we want our audience to be truly in the know when it comes to the facts about healthcare reform and policy. Laurie Robertson is an award-winning journalist and managing editor of www.factcheck.org, a non-partisan, non-profit consumer advocate for voters that aim to reduce the level of deception in US politics.

Laurie, what have you got for us this week?

Laurie Robertson:
Well, do retiring members of Congress get free medical care for life? No, they don’t. A chain email about house minority leader Nancy Pelosi makes that false claim and also greatly exaggerates what Pelosi could receive as a pension. We’ll stick with the healthcare claim.

Members of Congress don’t receive free healthcare while they’re in office or upon retirement, Under The Affordable Care Act, beginning in 2014, insurance coverage for members of Congress switched from the Federal Employees Health Benefits Program, that’s the government’s employer-sponsored, private insurance market for Federal employees, so the healthcare marketplace is created by the law.

Under both systems, workers and the government both pay for insurance coverage. Like most employer-sponsored plans, the government pays a certain percentage of premiums, in this case, 72 percent and the workers pay the rest. That’s still the case for Congressional retirees. They don’t get free insurance. They pay the same share of premiums as active Federal employees.

According to the Office of Personnel Management, retirees will be eligible to purchase insurance through the Federal Employees Health Benefits Program if they meet certain criteria. They must be eligible for retirement and they must have been continuously enrolled in one of the government-sponsored health plans for five years before retirement and that’s my fact check for this week.

I’m Laurie Robertson, Managing Editor of www.factcheck.org.

Margaret Flinter:
www.factcheck.org is committed to factual accuracy from the country’s major political players and is a project of the Annenberg Public Policy Center at the University of Pennsylvania. If you have a fact that you’d like checked, email us at www.chcradio.com, we’ll have www.factcheck.org Laurie Robertson check it out for you here on Conversations on Healthcare.

Margaret Flinter:
Each week, Conversations highlights a bright idea about how to make wellness a part of our communities and everyday lives. It’s a known fact that the current generation of American children is more obese than any previous generation and at a Washington DC Community Health Center, Unity Healthcare, a pediatrician was in a quandary over how to tackle this growing health scurrage.

He began with a unique solution targeted to a teen patient whose body mass index, or BMI had already landed her in the obese category. What he did was write a prescription for getting off the bus one stop earlier on her way to school. Dr. Robert
Zarr of Unity Community Health Center understood that without motivation to move more, kids just might not do it. The patient complied with the prescription and has moved from the obese down to the overweight category, certainly an improvement.

He then decided to expand this program by working with the DC Parks Department mapping out all the potential walks and play area kids have within the city’s parks, mapping 380 of them so far.

Robert Zarr:
How to get there, is parking available if someone’s going to drive, bike racks?

Margaret Flinter:
Dr. Zarr writes park prescriptions on a special prescription pad in English and Spanish with the words RX for outdoor activity and a schedule slot that asks, “When and where will you play outside this week?”

Robert Zarr:
I like to listen and find out what it is my patients like to do and then, gage the parks I prescribe, based on their interests, based on the things they’re willing to do.

Margaret Flinter:
He wants to make the prescription for outdoor activity adaptable for all his patients and adaptable for pediatricians around the country. He has planned to create an app for his parks database where providers and patients alike can use it and one day, he’d like to be able to track his patient’s activities in the parks. RX for outdoor activity, partnering clinicians, park administrators, patients and their families to move more yielding fitter, healthier, young people. Now, that’s a bright idea.

This is Conversations on Healthcare. I’m Margaret Flinter.

Mark Masselli:
And I’m Mark Masselli. Peace and health.

Margaret Flinter:
Conversations on Healthcare broadcast from the campus of WESU at Wesley and University, streaming live at www.wesufm.org and brought to you by the Community Health Center.