Interview: Former U.S. Surgeon General Richard Carmona, MD
"[Health care] needs to be handled with much more than the usual platitudes that come around during elections."
Richard H. Carmona, MD, MPH, FACS, was the 17th U.S. surgeon general, from 2002-2006. He earned his medical degree at the University of California Medical School. He later got a master's degree in public health from the University of Arizona after realizing that most of his patients' illnesses and injuries were completely preventable. As surgeon general, Carmona focused on prevention, preparedness, health disparities, health literacy, and global health. After completing his term, Carmona became vice chairman for Canyon Ranch, a health and wellness company. He is also the first Distinguished Professor of Public Health at the University of Arizona's Mel and Enid Zuckerman College of Public Health. WebMD's Washington correspondent, Todd Zwillich, interviewed him on the state of the nation's health care and how the election might affect it.
1) How big an issue is health care for the nation now?
It's a tremendous issue for America. The polls show it's the No. 1 domestic issue, and by any other measure, including disease burden or economic burden on society, it is a critical issue. It needs to be handled with much more than the usual platitudes that come around during elections. This is not sustainable, and we simply cannot afford the legacy we are leaving to our children and our grandchildren. I'm talking about both the economic legacy and the disease legacy, by the way. We are spending 16% of our gross domestic product on health care, and three quarters of that goes to treating chronic diseases, many of which are preventable. It seems to me that the handwriting is on the wall.
2) Is the health care system really broken?
I think another way to look at it is that we've outgrown the system we built after World War II. Until recently, health care often wasn't much more complicated that an X-ray, or a blood test once in a while. Now it's an extraordinarily complex environment, both economically and medically. The structures we've invented, Medicare, Medicaid, etc., really don't fit well with 21st century medicine and what we know about disease prevention.
3) How -- or should -- we go about lowering the number of uninsured?
I think a good business case and a good public health case can both be made for improving insurance access for all of our citizens. If for no other reason, we know that disease is disproportionately concentrated in the lower socioeconomic classes, the working poor, and minorities. The fact is, if we ignore that, then the disease burden and economic burden still continue to mount, and ultimately, we all pay. Now, we also have to take shorter term steps to spread access to health insurance. People have come up with all kinds of models for shifting resources around so that people without insurance now can get access to it. That is all fine, and my point is that while that happens, we need to couple it with shifting the culture of medicine and health care toward prevention and wellness. Otherwise, as we spend years arguing over who pays, the disease and economic burden just keeps mounting up. Then we're at 20% of the economy instead of just 16%.
4) What is the best way to begin to lower health care costs?
Lots of candidates have plans for the health system. The fact is none of them can be successful unless we fully embrace prevention. All we're arguing about otherwise is economics: who will pay all these costs as the expenses mount exponentially. Whatever mechanism we choose for short term relief for the uninsured, we must also zealously pursue prevention. Right now our system works by rewarding practitioners for waiting for people to get sick, and then paying them to make patients better again. And often the disease we're paying them to treat was preventable. So what we really need is that cultural transformation, along with an infrastructure change, that allows us to go after optimal health and wellness. Putting prevention first can drastically cut the burden of chronic disease, which in turn drastically cuts costs, and improves the quantity and quality of life. Plans that don't embrace prevention and simply talk about economics are only talking about shifting costs and not going to the heart of the problem in my view.
5) What should be done to cut prescription drug costs?
It is a very expensive and difficult proposition to get a drug from the development phase to the patient who actually needs it. We've heard the statistics: it takes 15 years and on average something like a billion dollars to develop a novel drug. There are a number of spots along the drug development path where we could intervene to try and cut costs. There are groups popping up with an eye toward increasing the speed and efficiency with which drugs reach the market. Those could help cut the cost of our pharmaceuticals but not impede the rich and robust pharmaceutical research industry we have. People raise the issue of direct-to-consumer advertising of drugs. As with all things in public health, I think the answer is moderation, not deprivation. In some cases advertising is good, it can make the public more aware of disease and convince them to get help. In some cases it can also go overboard. It can increase awareness of disease, but at what cost? If companies are spending a big part of their budgets on advertising and marketing, at what point do you cross the line? This is the subject of many debates.
6) How important is prevention to any health care policy we pursue?
Prevention has been absent from the national health agenda. Period. And it needs to be the cornerstone of all of our health policy. Prevention is cost effective, it improves quality of life, and it improves quantity of life. The data tells us that 75 cents of every health care dollar are going to chronic disease, much of which is preventable, because of poor eating, smoking, not enough exercise, not wearing a seatbelt or helmet, you name it. We have to come to the terms with the fact that we spend most of our money on things that are preventable. We need that cultural transformation I've talked about that prioritizes health and wellness. Any health policy that doesn't address is really missing something in my opinion.
Richard H. Carmona, MD, MPH, FACS, was the 17th U.S. surgeon general, from 2002-2006. He earned his medical degree at the University of California Medical School. He later got a master's degree in public health from the University of Arizona after realizing that most of his patients' illnesses and injuries were completely preventable. As surgeon general, Carmona focused on prevention, preparedness, health disparities, health literacy, and global health. After completing his term, Carmona became vice chairman for Canyon Ranch, a health and wellness company. He is also the first Distinguished Professor of Public Health at the University of Arizona's Mel and Enid Zuckerman College of Public Health. WebMD's Washington correspondent, Todd Zwillich, interviewed him on the state of the nation's health care and how the election might affect it.1) How big an issue is health care for the nation now?
It's a tremendous issue for America. The polls show it's the No. 1 domestic issue, and by any other measure, including disease burden or economic burden on society, it is a critical issue. It needs to be handled with much more than the usual platitudes that come around during elections. This is not sustainable, and we simply cannot afford the legacy we are leaving to our children and our grandchildren. I'm talking about both the economic legacy and the disease legacy, by the way. We are spending 16% of our gross domestic product on health care, and three quarters of that goes to treating chronic diseases, many of which are preventable. It seems to me that the handwriting is on the wall.
2) Is the health care system really broken?
I think another way to look at it is that we've outgrown the system we built after World War II. Until recently, health care often wasn't much more complicated that an X-ray, or a blood test once in a while. Now it's an extraordinarily complex environment, both economically and medically. The structures we've invented, Medicare, Medicaid, etc., really don't fit well with 21st century medicine and what we know about disease prevention.
3) How -- or should -- we go about lowering the number of uninsured?
I think a good business case and a good public health case can both be made for improving insurance access for all of our citizens. If for no other reason, we know that disease is disproportionately concentrated in the lower socioeconomic classes, the working poor, and minorities. The fact is, if we ignore that, then the disease burden and economic burden still continue to mount, and ultimately, we all pay. Now, we also have to take shorter term steps to spread access to health insurance. People have come up with all kinds of models for shifting resources around so that people without insurance now can get access to it. That is all fine, and my point is that while that happens, we need to couple it with shifting the culture of medicine and health care toward prevention and wellness. Otherwise, as we spend years arguing over who pays, the disease and economic burden just keeps mounting up. Then we're at 20% of the economy instead of just 16%.
4) What is the best way to begin to lower health care costs?
Lots of candidates have plans for the health system. The fact is none of them can be successful unless we fully embrace prevention. All we're arguing about otherwise is economics: who will pay all these costs as the expenses mount exponentially. Whatever mechanism we choose for short term relief for the uninsured, we must also zealously pursue prevention. Right now our system works by rewarding practitioners for waiting for people to get sick, and then paying them to make patients better again. And often the disease we're paying them to treat was preventable. So what we really need is that cultural transformation, along with an infrastructure change, that allows us to go after optimal health and wellness. Putting prevention first can drastically cut the burden of chronic disease, which in turn drastically cuts costs, and improves the quantity and quality of life. Plans that don't embrace prevention and simply talk about economics are only talking about shifting costs and not going to the heart of the problem in my view.
5) What should be done to cut prescription drug costs?
It is a very expensive and difficult proposition to get a drug from the development phase to the patient who actually needs it. We've heard the statistics: it takes 15 years and on average something like a billion dollars to develop a novel drug. There are a number of spots along the drug development path where we could intervene to try and cut costs. There are groups popping up with an eye toward increasing the speed and efficiency with which drugs reach the market. Those could help cut the cost of our pharmaceuticals but not impede the rich and robust pharmaceutical research industry we have. People raise the issue of direct-to-consumer advertising of drugs. As with all things in public health, I think the answer is moderation, not deprivation. In some cases advertising is good, it can make the public more aware of disease and convince them to get help. In some cases it can also go overboard. It can increase awareness of disease, but at what cost? If companies are spending a big part of their budgets on advertising and marketing, at what point do you cross the line? This is the subject of many debates.
6) How important is prevention to any health care policy we pursue?
Prevention has been absent from the national health agenda. Period. And it needs to be the cornerstone of all of our health policy. Prevention is cost effective, it improves quality of life, and it improves quantity of life. The data tells us that 75 cents of every health care dollar are going to chronic disease, much of which is preventable, because of poor eating, smoking, not enough exercise, not wearing a seatbelt or helmet, you name it. We have to come to the terms with the fact that we spend most of our money on things that are preventable. We need that cultural transformation I've talked about that prioritizes health and wellness. Any health policy that doesn't address is really missing something in my opinion.
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3 Comments:
I'm a doctor working with patients in the lower socio-economic class and dealing with their chronic diseases 80 hours a week. It doesn't surprise me that 75% of health care cost goes to stop preventable diseases; however, the Former Surgeon General is leaving out 2 very important facts that skew the picture towards a solution that sounds good, but really won't fix the problems.
1. In the pre-antibiotic era, the top 10 disease killer list was mostly infections. Because of antibiotics that eliminate would be killer infections, more people are reaching an old age; however, they must still die of something. Combine that with the medical advances that prolong lives that were always a certain death in days of old and you have a much more expensive health care system. Medicine in large measure is now saving people from dying from infections, but it is largely powerless to save people from themselves (preventable illness). Contrary to Dr. Carmona's theoretical view of medicine, doctor's today are interested in helping their patient's prevent their illnesses. I haven't met one that isn't. Is their room to improve? Sure, but it will not cure the cost problems in health care.
2. America is a freedom loving nation. Although I counsel my patients to stop smoking, high-risk sexual behaviors, drinking, using drugs, eating a poor diet etc. and offer them all the appropriate resources that give them the opportunity--most of them will continue treating their bodies just the same. In medicine, the ethical principle of patient autonomy give patients the right to refuse preventative counsel. Some do accept this and make life changes (those days make you happy to be a doctor), but many simply will do what they please; heck,even I frequently give in at the hospital cafeteria and get bacon on my sandwich. Preventative medicine is the ideal; however, substantial reductions in the cost of health care will not come about through preventative medicine unless you take away the freedom of Americans to choose how they wish to live. I personally wish a paradigm shift in focusing on preventative medicine were the solution to the economics of health care, but it is not. And the "data" doesn't prove otherwise. In fact, spending more money on prevention (it actually does happen already), would likely increase the cost of healthcare without substantial yields in cost savings due to freedom of choice. Perhaps the way to fund an even more emboldened preventative medicine crusade would be to annihalate the defensive medicine that is currently practiced in US hospitals--but that is another issue.
We're not seeing the whole picture here in my opinion. I am not a doctor but I do pay close attention to political issues and the past few years a good portion of it involves healthcare. What I don't understand is why drugs manufactured in other countries such as Canada are so much cheaper than those manufactured here in the U.S. The same goes with surgical procedures. Open heart surgery here in the U.S. costs close to thirty grand if not more, but you could have the same procedure done in India or Thailand for less than fifteen grand. With the high price tags attached to medical care here in the U.S., it's no wonder Health Insurance Companies Charge so much for coverage and why millions of Americans don't have coverage.
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Lots of candidates have plans for the health system. The fact is none of them can be successful unless we fully embrace prevention. All we're arguing about otherwise is economics: who will pay all these costs as the expenses mount exponentially. Whatever mechanism we choose for short term relief for the uninsured, we must also zealously pursue prevention."
Isn't that so true? nearly 50% of diseases are preventable; yet we continue spending almost 95% of our health care dollars on treating these diseases once they've been diagnosed and potentially ruined families and their finances.
It is time we changed our focus from a disease-care system to a wellness and prevention-driven system.
Sure, many can tell you that smoking is bad for your health. But do they know why? And why do they continue to smoke, other than the powerful nicotine addiction created?
We need to focus our efforts on preventing disease BEFORE it becomes an issue; not closing the barn door after the horse has escaped.
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