I am so so far behind getting my transcripts of podcasts up here that it’s not funny. But this was one of the most recent and one of the most fun that I’ve ever done. It was a discussion with Shannon Brownlee. author of Overtreated,  of which everyone in America should be forced to read at least the Cliff Notes version. (Warning, it’s long and the two of us had far too much fun talking with each other….)

Matthew Holt:  It’s Matthew Holt with the Health Care Blog, and I’m back with yet another podcast. This time I’m talking with Shannon Brownlee. Shannon is a senior fellow at the New America Foundation and, more importantly, has just written a great book called "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer." Shannon, first of all, thanks for coming on The Health Care Blog. I’m really excited to have you here.

Shannon Brownlee:  Oh, I’m delighted to be with you.

Matthew:  My feeling about reading this book is that I thought I knew all this stuff. I’m sure in the last 15 years of hanging out in healthcare, I know all the Wennberg stuff, and I’ve known all this and I’ve known all that. I pretty well read all the studies. I’ve got to confess that when I read the first chapter, and you can introduce the first chapter in a little bit, it’s kind of like a homage to Jack Wennberg. You went and hung out at Dartmouth and it’s kind of almost like a folksy introduction to his character.

And I guess I started reading this and going, yeah, but is this is a serious way to treat a health policy issue. So why did you go about starting in that fashion?

Shannon:  I started it that way because I found Jack Wennberg to be one of the most interesting people I’ve ever met, and the fact that he kept plugging away at this idea that started, oh gosh, almost 40 years ago, now 40 years ago, that he saw this enormous variation in practice patterns in the state of Vermont, and sort of puzzled over it and puzzled over it and puzzled over it. And then he finally started to say, "Yeah, this is real, there’s a variation in practice patterns. It’s not driven by how sick patients are. It’s driven by what the doctors are doing."

When he would present this to physicians, they would say, "You’re
crazy." And he kept at it. It was a way of introducing the idea that I
hoped that readers who are not policy wonks would really grasp. I mean,
I really wrote this book for my mother. I wrote this book for smart
people who are interested but who aren’t the cognoscenti. And that’s
why I started it that way.

Matthew:  Well, you know I think it’s fabulous because I
guess I’m a policy wonk, right? So I started reading this thing. Well
everyone knows this stuff, but I’ve met Jack Wennberg a couple of times
briefly, and I’m forming a minor committee to get him awarded the next
Nobel Economics Prize. They all need to understand what he’s done is so
significant and so important that we can’t say enough about him. Plus
all the other guys, you know, Elliot Fisher and the other guys working
with him, guys and gals.

But I guess my sense of the book as I read this and thought, it’s a
nice folksy way of doing it but I know all this stuff. By the end of it
I felt like you’d been smacking me around the head with a four by two
because, oh, I’d forgotten about this and I’ve forgotten about that.
And you go through this piece. You go through hospitals; you go through
heart surgery and stenting; you go through the whole bone marrow cancer
quote unquote cure. You go through the whole issue of CT scans, and how
they’re actually dangerous and haven’t changed diagnosis that much. You
go into the drug companies; you go into the whole issue of managed care
and what is it, primary care. By the end of it, it’s like I’ve been
taking a bath in three years of health services research. And I think
what you’ve done is just a remarkable achievement.

So let’s back up for a second because I don’t know enough about your
research past but you’re a journalist and journalists are pretty smart,
but don’t sort of have a lot of training in this. How much of this
stuff did you kind of know and how much did you figure out with your
researching the book?

Shannon:  Oh boy. You know I’ve been doing medical reporting
for a decade at US News and World Report between 1989 and 1999. I have
a background in basic biology. I have a Master’s in biology, and so I
went from reporting on evolutionary biology and geology and space
science for Discover Magazine, and then got this job at US News where
they had me writing about "breakthroughs" in medical research.

I wrote cover story after cover story about this new treatment; gene
therapy was going to save our butts, and that new therapy was going to
save our butts. All of a sudden I started realizing that all the
stories sounded the same, and in fact when I sort of went back and
looked at where this basic research was going, it hadn’t panned out, a
lot of it. But I had this sort of grounding in clinical science and
clinical research, and I had the grounding in science, in basic science.

So I started getting very interested in healthcare policy, in sort
of around the turn of the century, which sounds very funny doesn’t
it? Around the turn of the 21st century and I got really interested in
how high dose chemotherapy for breast cancer came into the medical
system. This was this sort of awful Draconian treatment that was used
on breast cancer patients, and it got into the system because it was
highly profitable and because everybody thought that it worked.

Then eventually the clinical trials come out and it turns out it’s
no better than standard therapy. I’m thinking to myself, now wait a
minute. How does something like that get used so routinely as if it
works when there’s no evidence that it works? And I started realizing
that the evidence wasn’t there for medicine, and that we had this
incredible problem with rising costs, and that got me  that eventually
lead me to the Dartmouth Group.

In the process of sort of trying to understand what they were
saying, which was. You know it turned out to be really hard stuff. It
seemed really easy to understand on the surface but then the more I
dug, the more difficult it became. In the process of really
understanding it I realized that that’s how I had to write the book.

Matthew:  So say a bit more about that. I mean, I have a
chart which I just used when I do my speeches talking about this stuff,
all I do is I have a simple chart. Basically it has more money on one
axis and quality on the other and it goes at the bottom left of the
chart, less money or less quality. And I either put Target or Motel Six
there and at the top right of the chart I put Nordstrom’s or The Ritz
Carlton or something. And say, hey, we accept usually if we pay more
money for something we usually get higher quality and that’s the way
that real economics works.

And then I take them off the chart and stick on the chart, well any
number of the Wennberg charts, but the one I actually tend to use is
the one which has the quality by state and the expenditure by state in
the Medicare population, and you’ve seen that from Health Affairs.
Everyone’s seen that chart.

Shannon:  That’s the Baker and Chandra, right.

Matthew:  I can’t remember which one it is, but anyway, the
answer is it’s from the Dartmouth School and it’s  it has the line
going exactly the wrong way and it ends up in Louisiana, which is the
most expensive state and has the worst quality.

So, and I keep on saying it. I was doing a health plan crowd and I
would say, surely pointing this out to a wider audience is actually
your job because it’s not your, Shannon’s job, but your health plan’s,
somebody’s job. Because in the end, if you connect the fact we are
spending all this money and we’re not getting any increase in value
from the extra money; in fact we’re actually getting less value by the
more we spend, then somewhere along the lines somebody has got to point
this out because someone’s got to connect that fact to the fact that
healthcare costs are going up like a zillion percent a year; and we
have 20,50 or 80 million uninsured depending on who you believe and
that it’s such an overall problem for all of us.

So I’m kind of wondering, you’ve got there, because you were
thinking generally just going through the process of being told that
there was a miracle cure for this, that and the other and the fact was
that they weren’t. Now you’ve done this great piece of work showing
that there are all these different threads to the same story, but
they’re basically telling the same story, that we do more and we don’t
get enough for what we do.

How do you think we go beyond that to actually sort of get this into
the sort of DNA of Americans the way that US News and World Report will
put "breakthrough miracle cure" on the cover every second week because
we love that stuff?

Shannon:  It’s an enormous problem in journalism and just to
sort of circle back to what you just said about your wonderful chart,
it actually was two charts that really got me going on this, and
they’re incredibly simple minded. One of them was the chart of costs,
healthcare costs over time. So you look from 1958 to 2005 and you look
at how costs have gone up exponentially in many years, and then I
looked at the same period time, 1958 to 2005, and looked at longevity
and thought well now, wait a minute. How come we’re not getting the
outcome? We’re spending more and more and we’re getting less and less
in terms of outcome.

There’s lots of reasons why longevity is not going up as fast as it
was, and there are lots of reasons why when you make international
comparisons, you’re not going to see  Americans spend more but we don’t
get the same kinds of things like mortality is very high in the U.S.
compared to the OECD.

But those two graphs hit me and I said, "Why is this. What is wrong
with this picture?" And that’s really what got me going on it. So I’m
delighted that you’re still using a version of this kind of basic
logic, which is why are we spending more and more to get less and less.

But the issue of journalism is huge here because I think media feeds
this perception that medicine is an unbroken string of advances and
breakthroughs. I think there are a number of reasons why the media do
it. One of them is that this is what sells newspapers and magazines. I
mean, people want to hear good news.

Another reason though is that I think editors are actually in the
thrall of medicine, and it’s been actually very difficult for people
like me and a number of other journalists out there who are writing
about sort of the foibles of medicine, to get our stories published
because nobody wants to believe you.

Five years ago, I tried to get a story published about the problem
of cancer screening, and basically editors just said we don’t believe
you. We don’t think this is true.

Matthew:  …[laughs] And do you know maybe that’s it. It’s
like… I guess Wennberg had the same stuff, right? He tells a great
story about how he, when he was in New Haven and went to Boston, and he
basically shared the fact that the New Haven guys were doing three
times the amount the Boston guys were doing in Caesarian sections, I
think it was. Then after he showed them the data, he switched the names
at the top and said actually, while you’ve been defending your
position, actually you were in the other position. I mean…

Shannon:  …I know. I loved that. That really was a parlor
trick. He’s say, "Oopsy, my mistake. I switched the data. You guys are
actually the ones who are putting people in the ICU all the time."

Matthew:  Actually, I think if you go, and I’ve been
tracking, I’m sure you have been too, the evolution of the New York
Times on this.  And actually you mentioned Gina Kolata in one part of
your piece, but I mean there was a series of articles in the New York
Times last year, 2006, that basically were to people like you and me
an anathema. They were saying, "Oh, well we’re planning on spending 20%
of GDP because we want to and we’re getting more for it," and ignoring
the fact that there’s this political infrastructure of healthcare
which is to basically allow things to happen, that allows new
treatments to go in very quickly without much evidence and allows
things to happen which very quickly add to the bottom line of basically
all the players in the system, as you demonstrate quite ably in your
book. For that matter, others like John Cohn and Maggie Mahar have done
a similar soliloquy on that.

It seems to me, perhaps, that the worm is turning a little bit and
that for the first time in many years I think the New York Times had a
good piece actually on Wennberg’s group and the work that they were
doing this year and actually looked at it with some significance. I was
pleased that that’s actually starting to happen, because, if you look
at healthcare seriously, and you want to talk about changing  about
solving the problems of the uninsured and some of the problems of the
cost explosion  this is the only place there is to really look, to look
at saving money. Even so, some of the stuff that you brought up in this
book maybe I’d read, but I’d forgotten.

Say, a little bit for people who haven’t read it yet, just give a
little taste of your chapter about the CT scans and basically the
increase in the use of CT scanning and what we’re getting for it in
terms of diagnosis.

Shannon:  The whole imaging area is really very interesting
because there are two forces at work here to drive increasing rates of
imaging, and imaging rates are going up faster than almost anything.
They’re going up faster; costs for imaging are going up faster than
costs for drugs.

Everybody’s all running around saying,"’Oh my God. We’re spending so
much on drugs." In fact, drugs represent a pretty small percentage of
our total spending, and the area in medicine that’s going up even
faster than spending on drugs, is spending on imaging, CT scans, PET
scans; to a lesser degree MRIs, X rays.

X rays, the poor lowly X ray is the only thing that’s not going up.
There are two things that are driving this. One of them is that it’s
enormously profitable for hospitals. In the 1990s there was sort of
this depression of the urge on the part of hospitals to go out and buy
new equipment and it was called managed care, because managed care was
bringing patients to the hospitals on the basis of low cost. And so the
hospitals very wisely figured out that they couldn’t run out and buy
the newest CT scanner.

But when managed care lifted a lot of those restrictions at the end
of the 90s, it was like there was this explosion in pent up desire to
buy new new new equipment. And hospitals went, in effect, on a buying
spree, in what some people have called a medical arms race, where
hospitals are buying all kinds of imaging equipment. They’re buying new
CT scanners for a million, two million dollars a pop. They’re now
buying PET scanners because Medicare has loosened some of the
restrictions on the use of PET scans.

So the hospitals do this because radiology is one of their profit
centers. And I love the language that hospitals now use. They use
business speak, even though they’re incredibly badly-run businesses for
the most part, and one of the terms that they use is "centers of
excellence," but what centers of excellence really means is centers of
profit. You call it excellence so the patients think that you’re really
a wonderful place to go.

So they buy up this equipment, because radiology is really quite
profitable, and the amazing thing is, is you can buy all kinds of CT
scanners, and doctors will fill up the waiting line for patients to get
into the CT scanner.

The reason is physicians are as enamored of this stuff as patients
are. Physicians think seeing is believing. This is not to take away
from the power of imaging to help diagnosis and treatment, because it
has in many, many areas, but the sort of slavage belief that it always
helps is wrong. And we know that it’s wrong in a number of ways.

One of the ways we know, for example, is in appendicitis. My brain
is going. In appendicitis, because you use a CT scan. You’re supposed
to use a CT scan when you’re really not sure of your diagnosis. So your
patient comes in and the patient has all the classic signs of
appendicitis. They’ve got the high fever; they’ve got the serious pain
in the lower right quadrant of the belly, and when you press on the
belly, when you palpitate the belly, they have this classic guarding
symptom.

But the emergency room doctor goes, "Well, I think I’m going to give
this person a CT scan anyway, because I know the surgeon’s going to
demand it." The surgeon’s demanding it because they think CT scanning
is so wonderful but also because they want to delay the time when the
patient actually comes to the OR, because they’re busy.

And so the emergency room doctor sends the patient off to the CT
scan and lo and behold the CT scan comes back negative. So everything
is telling this doctor that this patient has appendicitis and the CT
scan comes back negative and the doctor goes, "Uh oh, I’d better look
for something else."

So then he gives the patient an ultrasound to look for ovarian cyst.
He does all kinds of stuff and he finally says, "Oh my God. I guess I
was wrong. This person just has gas," and he sends the patient home.

Lo and behold the patient comes back with a burst appendix two days later.

The lesson here is that images are static pictures of the body. And
they are only one way that doctors need  only one of the tools that
physicians have to make correct diagnoses. The belief in them is
completely exaggerated. And so this confluence of forces, the hospital
wants more CT scanners because they make money on it, and the
physicians’ sort of belief system has driven this cost and the number
of images up.

Also, physicians in private practice make a lot of money on doing CT
scans and MRIs as ancillary services. So this is another part of what’s
driving it.

Matthew:  I think that the most remarkable, just to pick a
bit out of your book, is that you quote a study done at the University
of Washington which basically looked at the rate of misdiagnosis of
appendicitis over a 10 year period when they introduced all these CT
scans, and the answer was [laughing] it hadn’t changed at all!

Shannon:  I know it! I know it! Isn’t that amazing?

Matthew:  Well, I mean, it’s remarkable it did not make any
difference at all and just added more to the confusion. I guess, you
know, in some ways, if I was to make a criticism of your book, it would
be that: it’s almost like there aren’t any advances in medicine at all,
and that nothing that gets done actually has any impact. And we do know
that in some areas, particularly in things like longevity after MIs and
that kind of stuff, there has been some good evidence there’s been some
fairly significant impact in improving outcomes and improving longevity
in certain areas. And definitely a lot more debate about that in other
areas like chemotherapy and oncology and things like that. So I don’t
know if that’s kind of one of the feeling, rather than actually being
able to put my finger on it, saying, "Hah hah, Shannon is ignoring
these five things." That’s kind of a feeling I have a little bit in
reading the book.

But I’m, you know, in general fairly bought into the thesis with you
that we’ve added this stuff for reasons obviously other than sort of
double blind clinical trials showing they’re a good idea. But also
we’ve added this stuff, in many ways, not only in the absence of really
getting the expected results out of it.

Shannon:  Well, you know, I mean, having spent ten years of
my career going, "Rah, rah, rah, rah, rah! Medicine is wonderful! It’s
saving us!" I first felt I’ve done that side of things, and it was now
time to say, "Well, let’s take a second look. Let’s see what the
advances really are."

I really did try in the book to sort of say, "Look, there are many,
many, many advances. I have friends who are alive because of Medicine.
I acknowledge that…I mean, you know, getting reperfusion when you’re
in the midst of a heart attack saves your life. That’s an amazing
thing. And I would not want to go back to 1950s medicine. But at the
same time, you know, there’s this enormous sort of waste in the system
and excess in the system." That’s what I ended up really trying to
focus on.

Matthew:  So I guess the other place I’d like to talk a
little bit about is sort of, and this is back to some of the sort of
combination of the Wennberg work, but also a combination of some of
this where it’s going to make a big policy differential, is around end
of life care.

You have this story of an elderly man who basically had an advance
directive which kind of got ignored, and then ended up being "treated"
[laughing] in inverted commas  you know and tied to a bed because he
was being kept, you know, in order to not pull out his feeding tubes
and this kind of stuff, and was basically kept alive for six or seven
grisly days before he died. That the standard of care for end of life
somehow has gotten warped even in people who have advance directives.

So give me your sense from the research of how common you think that
is, and, whether there’s something practical that patients and the rest
of us can do to sort of change that.

Shannon:  It’s a really interesting question, because I
think, what’s so important here is that patients themselves and their
families should be able to decide how aggressive they want the care to
be, within reason. I mean, there was the very interesting piece in the
New York Times Magazine about a year ago or maybe two years ago by
Susan Sontag’s son, who told the story of how she had a very aggressive
form I think of leukemia, and opted for this hugely expensive treatment
that had an incredibly tiny chance of even lengthening her life by a
matter of months, but which certainly had no chance of curing her of
the disease. He was in some respects arguing that, you know, that we
all should have paid for this, because it’s the dying person’s right to
have everything thrown at them.

I’m not sure I believe that, but I do think that to a large extent
patients and their families should be able to choose what they want.
The bottom line of my book is that what you want isn’t what you’re
going to get, because what you want is less important than where you
live. Where you live determines how much care you get at the end of
your life. I find that a very disturbing thought. If I live in Los
Angeles, the chances are that at the end of my life I’m going to land
up in an ICU with, you know, fingers and tubes in every orifice, as
physicians put it, regardless of what I might want, is a little
unnerving.

So I think what patients have to do is really start choosing
hospitals. The problem is that the qualities that we want in a hospital
are not necessarily the ones we that we can find out about. For
example, U.S. News and World Report where I worked for 10 years has
this Best Hospitals issue that they put out every year. And this issue
is based more on reputation than it is on the things that patients
might really want to know, if they understood what’s at stake. What’s
at stake especially at the end of life.

So what patients need to do is to start finding the sources of
information that will tell them what they really need to know.
Unfortunately most of us don’t know what we really need to know. And so
the Dartmouth Atlas is this incredible resource if you want to find out
about the hospitals in your area. That’s one of the ways you find out.

But it starts earlier than that. It starts with having a
relationship with a primary care physician, a long standing
relationship. I really believe that this is key to having good health
care in this country, and we have abandoned this principal. If you talk
to doctors in academic medical centers, especially if you talk to
specialists, they’ll say, "Oh, primary care is dead. Anything a primary
care doctor can do, a nurse practitioner can do, or a physician’s
assistant can do."

Well, maybe mechanistically they can do a lot of what primary care
doctors do, but this relationship that you develop with a physician who
knows you, who starts to understand what you want in your life, what
you value in your life, what your spiritual and emotional needs are, as
you approach death, this person should be very, very important. And
right now because we’ve pretty much destroyed primary care in this
country, that’s harder and harder to find.

Matthew:  Now you suggest here, and this may be an area where
we disagree a bit, that managed care in the 1990s destroyed primary
care, because it basically broke up the relationship between patients
and their physicians by causing them, basically moving people on and
off panels and using contractual terms and all the rest of it. And that
certainly didn’t help, I’m not going to argue that it helped.

But I’d argue and this perhaps is a point of contention between
us that you can get an approximation for what you’re talking about, in
terms of, what’s now being called a "medical home" by the folks at the
AAFP and others. You can get an approximation for that, I think, by
using some form of technology. I’m not sure you necessarily need a
single human being. In fact, I’m somewhat dubious about the abilities
of single human beings to manage that.

But, you know, there are other things that have gone on, not the
least of which is that the medical profession as a whole has
undervalued primary care, and the players involved in the medical
profession as a whole have systematically underpaid primary care, and
the people who set Medicare payment rates and all the rest of it, by,
as we know, valuing intensive procedures over cognitive and management
therapies.

So I’m not sure, if I was to criticize you, I think you blame
managed care for the death of primary care…I think it wasn’t an ideal
situation before managed care came along, and managed care made it
worse. And most sensible doctors looking around the room go, "Well, you
know, I can make $450 a year as a diagnostic radiologist or $120 as a
primary care doc. What do you think I’m going to do?" [laughs]

Shannon:  Yeah, exactly, I have a hundred thousand dollars in debt, what kind of dummy am I?

Matthew:  Exactly. I would say perhaps you over blame it a
bit. There’s blame to be shared around in the medical profession and
the way the government has paid for medical care. And to a certain
extent amongst the patients. So having said that and given that we are
where we are with primary care with the average primary care physician
getting grumpier and older and trying to move the concierge practice.
What do you think we can realistically do, both at an individual level
but more perhaps at a policy level?

Shannon:  At a policy level there are a lot of things we can
do. Number one, we ought to forgive the debt of anybody who goes into
primary care and agrees to stay there for five to ten years. The cost
of medical school has made it a gentlemen’s practice once again. It
used to be that only gentlemen went into medicine and once again it’s
only gentlemen and gentlewomen who go into medicine because the cost is
prohibitive. It’s very, very difficult for anybody from a lower middle
class or poor background to get a medical education. In fact those are
often the people who are going to be more willing to go back to work in
places like the inner city or in rural areas because they have ties
there.

So number one, we need to find a way to finance medical education in a way that will foster and promote primary care.

Number two, we have to change the attitude in medical schools. They
are really, really focused on the specialties. All of the prestige in
the academic medical centers and the medical schools is aimed at the
super specialists. You are sort of considered one of the dummies in the
class if you went into primary care. I’ve had primary care physicians
who were at the tops of their classes at prestigious medical schools
tell me stories that their professors went to them and said, "You’re
throwing your life away if you go into pediatrics." "You’re throwing
your life away if you go into internal medicine." So we somehow have to
restore the prestige. We have to make it easier for a person to get
through medical school and not come out with such a heavy load of debt.
We have to kill off the RV RVU system that is making the proceduralists
so much better paid than the primary care doctors.

Matthew:  And don’t forget that RBRVU was brought in to try and correct that.

Shannon:  Yeah, and it failed miserably because everybody on
the panel is a specialists. We’ve got two primary care doctors and 25
super specialists. Who’s going to get paid well?

Matthew:  So let me give you a counter example. In my ideal
world this may be fantasy, but let’s play it out. So I train up a bunch
of nurse practitioners or advanced nurses or PA’s. I have a few primary
care docs and then I equip patients with some combination of,
especially chronically ill patients we’re talking about. Obviously it
matters to everybody, but chronically ill patients are the people who
we’re really talking about costing a lot of money when treated by
specialists when they weren’t properly treated in the community.

What if I equip a combination of disease management companies,
nurses on the phone, better communications, electronic medical records,
telemarketing at home, and the stuff that I kind of like, like online
chatrooms. Communications between patients and patient led groups, the
kind of stuff that Kaiser has been working on with Kate Lorig at
Stanford. I can have a few primary care doctors managing a much larger
number of patients without necessarily requiring this one to one
relationship that you are discussing. Because we also know that the
important thing is what happens in the patient’s day by day 24/7 life,
not what happens in the half an hour that they get with the primary
care doctor three times a year?

What I’m asking you is argue with me and say why could that not be a
better solution than what you’re talking about which is kind of closer
to the AAFP, the idea of a medical home where one primary care doctor
is responsible for a certain number of patients and that’s the primary
relationship.

Shannon:  I guess I don’t see them as mutually exclusive, but
you have to get over the barrier that we don’t have the slots for the
assistant and the nurse practitioners. I do think that the one flaw in
this idea is that you can have this primary care doctor, uber doctor
overseeing this huge staff of people is that the relationship turns out
to be very, very important. A heck of a lot of medicine is sort of
persuading people that they are going to get better. That they are OK
or that what’s happening is perfectly normal, that getting older
entails a certain amount of pain; it entails a certain amount of not
being able to run as fast as you could, all this kind of stuff.

As you really get old and you really get sick, in a lot of ways what
you need is somebody to hold your hand and manage your care. Certainly
some of that can be done by nurse practitioners and physician’s
assistants. In fact, I think physician’s assistants are fantastic. They
are incredibly well trained and you can have a relationship with one of
them. I’m not saying that’s not possible. But don’t discount the
importance of the relationship in this view of how we manage care.
Talking about managing a person’s care turns the person into.. I can’t
even think of the right metaphor off the top of my head. But it takes
away the fact that being ill is scary; that being a patient is almost
this sort of child like position and you really need somebody to help
you and carry you through and hold your hand.

Matthew:  I was at an information therapy conference in Utah
a couple of weeks back. David Cohen from Kaiser gave a great talk, and
a couple of things he said were great.

One was the patient’s self management piece. Kate Lorig of Stanford
did this experiment program where they put patients in groups, and the
patients did this self management themselves. More important, they give
the patients the script but it’s led by a patient. It’s more important
for the patients to do it on their own and it has better outcomes than
if a white coat comes into the room. It will add a flavor if an PA or
doctor come into the room.

They figured out that the process is more important than the
content, which I thought was quite interesting. He said also that along
with that, the attitude the patients had rather than their changing
their behavior  the doctor’s attitude and it was kind of like The
Secret or something in one of these counter culture books, about how if
you just think good things, good things will happen to you  actually
the attitude the patients had about how they felt about their life
actually carried through into better outcomes rather than just purely
mechanistic changes in their behavior

Shannon:  Now is that good data or are they just saying this?
Because you know in cancer we’ve heard this for years. That if you have
a good attitude you’re going to survive breast cancer a whole lot
better. And the downside of that is if you have a bad attitude you’re
going to die and if you have a bad attitude it’s your fault.

Matthew:  I get that, and I don’t think he’s talking about
cancer. I think he’s talking more about long term illnesses and self
management. Where he related to this and I’m telling you about a speech
he gave where I was sitting in the back and I should’ve been paying
better attention. I believe that’s good data from the Stanford studies,
but we can look into that separately. But the other thing he said that
rang very true with me was that 70% of what he saw in the primary care
practice had no systemic cause by disease. It was more psycho-social.
And that you can change people’s lives and look at the whole person,
including their situation at home, domestic violence, family situation,
and all these other things that are weighing out. What you are seeing
in the healthcare system and the primary care provider’s office was the
consequence of all that other stuff going on in the background. There
were some things that you just couldn’t handle, and you had to go look
at the wider social environment.

I guess what I’d probably be thinking is that if you say to the
primary care docs that you have to deal with all of that, but you’re
not giving them the surrounding team to go help with that and the
surrounding ascendants to go deal with that. If he’s right, you may be
putting them onto a hiding nothing to a certain extent. If he’s right
about that.

Shannon:  Yeah, I think that’s totally right. That an
enormous amount of health. I just got an interesting email from
somebody who was asking me why I said that the poor often have worse
health, and they have less access to healthcare,and they have poor
health And he said, "Aren’t you arguing that health care is bad for you
than better health?" I had to explain that your health is this
constellation of factors that is partly genetic (little tiny bits of
genetics.) Certainly a part of it is what kind of medicine you get and
the majority of it is your behavior.

It’s your environment. Whether you live in an environment that’s
full of pollution and if you’re in a violent home etc. etc. and what
you do. If you smoke, if you eat too much, if you don’t exercise, all
those things have an enormous effect on our health…

So you are absolutely right. Primary care cannot solve the
fundamental social and behavioral problems that contribute to poor
health. It can do some. When your doctor says you really need to stop
smoking and if your doctor says it enough times to you, it turns out
people take it quite seriously, and eventually some of them will stop
smoking. But we can’t expect physicians to solve the social ills and
environmental ills that are facing people, that’s a much bigger problem.

Matthew:  I guess the last question I’d ask you or something.
It’s not a small question. Given that you are associated with a….I
don’t know. How do you describe New America, as a kind of centrist
democrat?

Shannon:  Yeah it’s called a third way think tank because it really…Because it’s not coming out of ideology.

Matthew:  I had a long argument with somebody about this. I
gave a talk at the Western Region Blue Cross on Monday, and then I had
dinner with them afterwards.

Basically my talk had been, you guys sitting around here as non
profit blues plans, if you don’t shape up, you will find that because
of the way demographics is going and because of the way health care
cost is going, because of the way insurance is going, you will find
that sometime in the next decade you will be facing a government which
is not so pro free market, as the ones you have seen for the last 30
years. Then I go in this long discussion at dinner as to whether or not
Dianne Feinstein and Hillary Clinton were quote unquote conservative
democrats.

Shannon:  [laughs]

Matthew:  They were conservative! They were conservative! I
was trying to explain to them that I felt there was a difference
between Dianne Feinstein, as opposed to Barbara Boxer and Dennis
Kucinich. That there was a spur with the Democratic Party and I was
arguing with some Republicans who clearly believed that anybody to the
left of Rudy Giuliani is some kind of criminal loving…

Shannon:  Pinko!

Matthew:  …criminal loving Pinko. Well that’s not probably
true. In this book, you spend a lot of times talking about problems and
talking about the basic understanding. I think getting the basic
understanding of the issue, getting the Wennberg mantra out there with
all this other stuff is a fantastic achievement, and I’m very happy to
be promoting that.

Unbelievably, people know little about this. I gave a talk to 450
CIOs of hospitals who work in health care everyday if they were
familiar with this and four hands went up. I mean, these were techies
but my God they work at hospitals. It just blows my mind that people
still don’t know about this stuff.

So I think the act of getting this out there and you’ve been on
small blogs like this and hopefully on the chance to share where else
you are going to show up with this, which is to my mind a fantastic
thing in itself.

But given that there are obviously huge differences of opinion
between people on the thinking free market side versus the centrist
side versus the left. What I mean by that is "left" in American terms,
not "left" in the rest of the world terms.

Shannon:  [laughs] You mean there’s a difference?

Matthew:  The answer is what Hugo Chavez is doing and what John Edwards is talking about is not the same thing.

Anyway, what I wanted to ask you is where do you come out
solution-wise? Given the heavy interrelations you’ve got the main
Democratic candidates with various proposals that are very similar. All
of which include a kind of agency that will do the kind of the things
you are suggesting in terms of at least looking at this. What do you
think the answer is and what could you get behind as the solution?

Shannon:  You know it’s very interesting about the three
Democratic candidates. John Edwards’s plan is less developed than Obama
and Clinton, and yet they all share certain things in common. They all
want to cover everybody which is the right thing to do, and besides the
uninsured distort the market in very strange ways.

Barack Obama and Hillary Clinton talk about an agency for clinical
excellence, which is a sort of federal funding agency that would
prioritize the research that we desperately need in medicine to find
out what works and what doesn’t, and then would fund the kind of
research that’s needed.

We’ve been leaving that to the drug industry for too long, and it’s
now time to do this federally because it’s for the public good. They
have a provision in there. They talk about improving quality, and
mostly they talk about reducing undertreatment which is what Medicare
Pay for Performance is talking about.

What’s interesting is if you look at the references in both their
plans, they both understand at least the outlines of the overtreatment
problems of the Wennberg stuff.

They reference the right papers, they are aware of it, but I think
talking about overtreatment is really really scary politically because
it brings up the problem of rationing. It brings up the "R" word, and
that is a killer in American politics when it comes to healthcare.

So they’re not talking about it, but I know that they are aware of
it. I know that Hillary Clinton understands a great deal of this stuff
very intimately.

The question is how do we get from step one, cover everybody; step
two, improve quality by reducing under treatments; step three, start
doing the research that we need for comparative effectiveness; step
four, start reducing the over capacity that is driving so much of the
over treatment and thus reduce some of the over treatment. It’s the
step four part that is going to be really hard.

I don’t have perfect solutions. I have things I am thinking about.
I’ve been talking to Jack Wennberg about it. I am listening to other
people, but I don’t know what the perfect solution is because so much
of being able to accomplish this politically depends on people actually
understanding the fact that they’re getting enormous amount of care
that isn’t contributing to their health. So that is like step number
one which is why I wrote the book.

Matthew:  Yeah, I think step one is a great piece. My sense
is that we will get there in a nasty and more brutal way. Unfortunately
because your step four requires in the end that some of the more
powerful interest in America give up all of their income?

Shannon:  Yeah. But it’s called downsizing the health industry, and it’s downsizing in a big way.

Matthew:  They understand that very well. You can look at the
one when they used the U.S. News and World Report to look at the end of
life care, and a number of folks did that. Yes we really should be
emptying New York University hospital and blowing it up.

That’s right because we don’t need it. Because as the officials say,
if you look at the number of physicians we have and if we just use them
effectively, as effectively as they do at the Mayo Clinic then we have
a bunch too many.

You know once you go down that path, you know you are spoiling for a
fight and it’s so so easy for the AMA to put out a bunch of elderly
ladies on the street saying, "The evil government is going to stop
giving us the care we need." I don’t know how you fight that.

Until you get to the brutal moment when you really can’t afford it,
and you get on the rationing path. I think that’s why we end up with
doing nothing for another ten years and then going on 15 years then
going to some sort of brutal version of single payer. I think that is
what is actually going to happen. That is not what I want to happen.

But so, I understand how difficult it is. And then it runs into the
whole short term, long term piece that everyone gets concerned about a
business. Everyone says, "Well, we should think long term," and in
fact, Wall Street says "What have you done for me this quarter?" The
guys running the hospitals/health plans/whoever else, they’re all
retiring in five years anyway, so they don’t care. So I think we run
into that problem in a big way.

The one piece where I see some optimism, is in the desire of the
Baby Boomers who are going to flooding into Medicare essentially as
soon as whoever becomes the next president. Maybe it will be Hillary or
potentially even Obama or even… it doesn’t matter if it’s Giuliani or
Thompson or whomever, it’s still going to be the same problem.

The Baby Boomers that are going to be going there, are going to
think somewhat differently about this end of life stuff. I think if the
message gets to Oprah about what’s going on, so the moment health
insurance has just got to Oprah… Michael Moore and Karen Ignagni were
on Oprah shouting at each other, something I haven’t seen yet. I must
download it. My sense is that if we get to that point where people
start really going on about what happened to Grandma or what happened
to Mom, when she was in the hospital, and in the last five days of
life, what good did that do being in the ICU with all that stuff going
on. How did it help, really?

I know that’s a very contentious issue because sometimes they may
not make it out of the ICU, but we know in general that a lot of this
care is expensive, and it’s also fundamentally futile. I go back to the
Gerald Ford issue, and I wrote this post about Gerald Ford that got me
a lot of abuse. I was told I was a murderer. I was told I was doing all
these terrible things, because I said Gerald Ford had a great life. He
was 94 years old, and then the last six months of his life he had two
angioplasties, and he had this and he had that and he had the other.
And we probably extended his life by maybe three months and maybe we
spent $100,000 or $200,000 doing that.

"What the hell was the value in that?" was what I was essentially
saying. Wouldn’t it have been better if he’d been given palliative care
and left at home to die in peace? It probably would have been. Now it’s
a very confusing issue but my sense is that’s the one area where I
think we can move the needle on what actually happens in end of life
care, and do it in such a way that people will go, "Well, that’s the
right thing to do, and in general I’m more comfortable with that than I
am with Mom or me having  having tubes in every orifice for six days."

So I don’t know, if that’s optimistic on my part or whether we’re
close enough to a change that can be achieved in that, just to stave
off the more brutal future, and just not be able to afford this stuff?
That would be my hope. Do you think I’m maximally optimistic or do you
think there’s something in that?

Shannon:  I don’t know, because it requires that Americans become grown ups…

Matthew:  [laughs] Ooh, vicious.

Shannon:  We’re just a very juvenile nation, and we want to
pretend that death is optional. Certainly my profession has perpetuated
that idea  all the language that we use, that "you save a life," "you
don’t save a life," "you delay death." Despite the fact that, as Susan
Love says, in California, we like to think death is optional, it’s not.
So certainly you want them to live as well and as long as possible, but
the fact is that Americans really have not come to terms with the idea,
that we all have to die, and that there can be better ways to do it
than being hooked up to every machine possible in the ICU.

It’s interesting. I just want people to spend time in the ICU, and
one would think that they do that when their own parents are dying, but
somehow the sort of we’re not able to connect our personal experience
into a framework that says this is part of a system that is really not
treating people well and not treating people in a way that they would
like to be treated if they really understood what was at stake. I don’t
know how to get that across except to keep writing about it.

Here’s the other problem. When you pitch a story about death and
dying, editors go, "Oh, it’s such a bummer." They don’t want to hear
it. They don’t want to know. It’s a huge problem.

Matthew:  …you need to start your own blog because then you can write what you want [laughs].

Shannon:  I admire your writing so much, because it’s got
this sort of pissiness to it, and quickness to it. You are able to aim
at your audience so perfectly. I’ve spent most of my career writing
about very complicated stuff for people who know absolutely nothing
about it. So, I have to I may have to work on being able to be a really
effective blogger and aiming it right at exactly the right audience.
But…

Matthew:  …I do something that’s much easier than what you
have done. In fact I was this token new media blogger for this group of
young journalists in California, a couple of weeks back. The issue is,
people that come to The Health Care Blog are an incredibly self
selected audience. Everybody listening to this, knows they’re self
selected because they’re interested in this stuff in the first place,
and there are some avid readers who are very smart and like this. It’s
predominantly people who got there because they have a large body of
interest. I have no idea how you communicate any of this stuff down to
the… How does American Idol do it? How do they get people fascinated
about these types?

Shannon:  [laughs]

Matthew:  I don’t know how they do it. But the information
therapy people talk about marketing to get people to understand about
their healthcare. In this country, the whole concept of sophisticated
political debate is… Then, there’s a huge chunk of the population
which either self excludes or who is excluded anyway, and we know that
that’s going on.

So I think you’re trying a much, much harder thing than what I do,
which is just to rant around or about amongst the group of people
who… although they may not agree, fundamentally understand the
concepts that we’re talking about.

What you’ve done is a great, great step to try to sort of evangelize
and publicize about something which as you say, Jack Wennberg’s been
trying to get this out there for 40 years. Beyond a few policy wonks,
in academia, no one knows. The fact that nobody knows about it, that
400 CIOs from America’s community hospitals, only five of them knew who
the guy was, it just blows my mind. So, if you could…

Shannon:  Well, what about the boards of those hospitals, do they have any idea?  What about the CEO?

Matthew:  …they didn’t have the boards guys in the… no,
the boards wouldn’t know. The board would be community people. They
know even less. The CEOs might know more about it. I don’t know. But
the health plan people know about it but they haven’t figured out how
to communicate to the world that, that’s their job is to help this
stuff out and get this out and to make this right.

They haven’t been doing it, but at least if they have a role, that
would be doing it, whereas they could be doing that, whereas, as you
say, it’s not in the hospital’s interest to know about this.

One of the… I hope I’m not breaking a confidence, but one of the
journalists I met, who is young and punchy and wanted to get out and do
something, she was working on this story about… she’s the one I gave
your book to, she was working on a story about how she’s in a small
town in California, I think it has less than 100,000 people… no, less
than 50,000 people. It has two hospitals, both of which just bought 64
slide CT scanners because…

Shannon:  Oh god.

Matthew:  Well, they needed it, and she was trying to sell her editor of this tiny paper about how this may not be such a great thing.

Shannon:  Yeah, well, she’s swimming upstream, and if she wants to call me, I’m happy to give her moral support.

Matthew:  Exactly. That’s why I gave her your book. Here,
read this chapter and try writing the local angle. Idon’t know how you
do it. I’m in a privileged position where I don’t really reach outside
the healthcare industry much.

The few times I do and go and talk to sort of non healthcare groups
about healthcare, I just sort of sit there shaking my head because it’s
like, it’s so… there is so much propaganda to be undone, that you
don’t even know where to start. So, I absolutely salute you.

So anyway, I’ve kept you for a long time and I’ve really, really enjoyed our conversations.

So to wrap up, I’ve been talking to Shannon Brownlee. Shannon is the
author of "Overtreated." She is also a senior fellow at the New America
Foundation in Washington, D.C. If you haven’t taken a look at
"Overtreated" yet and read the book, you should. Anyway, Shannon, it’s
been a great pleasure. So thank you very, very much for coming on the
Health Care Blog and I look forward to having you on here again.

Shannon:  Thanks so much for having me.