HLOL Podcast Transcripts

Health Literacy

The Future of US Healthcare (HLOL #81)

Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month, and your host of Health Literacy Out Loud. In these podcasts you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today I’m talking with Dr. Timothy Johnson or, as he likes to be called, Dr. Tim. For 25 years, Dr. Tim was the chief medical editor at ABC News, appearing regularly on “Good Morning America,” “World News,” “20/20” and “Nightline.”

With a unique insight that reflects his training as both a minister and a physician, Dr. Tim has a long history as one of America’s best-known and most respected medical and health communicators. Welcome, Dr. Tim.

Dr. Tim: Thank you very much, Helen.

Helen: I’ve had the pleasure of meeting you a few times now. I read your fabulous new book, The Truth About Getting Sick in America,and have really started to learn your views about the future of US healthcare.

I’m delighted that you can share these views with the listeners of Health Literacy Out Loud. Let’s take it from the beginning. What’s wrong with our US healthcare system today? What are some of the big problems we’re facing?

Dr. Tim: I’d say that there are three big problems that most everybody agrees on. First, our costs are out of control and we’re spending twice as much per person on healthcare as the average per-person cost of all of the developed countries lumped together. We’ll be spending well over $8,000 a person this year for a total of $2.7 trillion.

Our outcomes are no better and we’re the only developed country that doesn’t have universal health insurance, so we’re spending much more and not getting anything for our dollars as compared to other developed countries that spend about half of what we do. Costs are clearly an issue. If they keep going at the present rate, we’ll bankrupt the country.

Helen: Unfortunately, we see that in our future at this point. What are the other problems? You said there were three.

Dr. Tim: The other problems are access and quality. It’s in part because of cost but also for many other reasons, including roughly 40 million people who don’t have health insurance. A lot of Americans fall between the cracks in terms of getting into healthcare somewhere or somehow when they’re sick or think they’re sick.

Again, unlike all of the developed countries, without universal health insurance, we have people who when they get sick either go to the emergency room for trivial reasons or don’t go anywhere because they’re worried about payment and wait until they get really sick. Then they go to the emergency room when it’s going to cost a lot more and be much more difficult.

The third problem is quality. We don’t have a very good way of guaranteeing quality and safety in our healthcare in this country. It’s a big country, and there’s a lot of variety. Unlike the airlines, for example, where you can get on a plane anywhere in this country and be guaranteed the pilot is well trained and the plane is well maintained, that’s not true in American healthcare with doctors and hospitals.

Helen: Thanks for all of that. When you talk about costs, some of our listeners are from around the world too. Is the cost of health or the cost of being sick today an issue in other countries? Is that a factor everywhere?

Dr. Tim: I would say that all developed countries, meaning countries that have ready access to new technology, are struggling with this issue. There’s no question about it because the public demands the newest and the latest, thinking it’s the best and we simply can’t afford to do everything for everyone at every age that modern medical science might dream up.

Yes, it’s a struggle, but all of the other countries are at a better starting point than we are. They have lower costs and some of them are developing ideas and ways of controlling costs in a better fashion than we are.

Helen: The next point is about access. I know from our conversations you’ve been an emergency-room physician. Have you seen this in your practice where people can’t access care?

Dr. Tim: Yes. I haven’t practiced actively in the emergency room for many years since I went full time with ABC in 1984, but I certainly know what’s going on. I saw what was going on when I was in the emergency room, which is that it is really the medical court of last resort.

When people don’t have anywhere else to turn, they go to the emergency room, understandably, but it’s the most inefficient and most costly way of dealing with primary care problems. Yet that’s where a lot of people are forced to go.

Helen: Quality and safety are certainly all over the place in that. You talk a lot about universal healthcare. The whole country is not in agreement that this is the way to go. Can you explain what you mean by that and why you feel so strongly that that might help us out of this mess?

Dr. Tim: I’ll make a distinction between universal healthcare and universal health insurance. We do have universal healthcare in the sense that anybody can go to the emergency room and the emergency rooms are obligated to take care of them. The way in which they take care of them can vary considerably obviously.

In that sense, we don’t let people die in the street. If they get sick enough, they’ll get to an emergency room one way or another and we will try to take care of them. As I said, it’s very inefficient and very costly.

Universal health insurance means that everybody has at least some kind of basic health insurance that will allow them to get into the system or a place of medical care when they think they’re sick and to do so early on when we usually can take care of things much better and at less cost.

The concept of universal health insurance is what I’m talking about. As I said, all of the developed countries have it now. I think we have to have some form of it in this country in order to get costs under control and improve access and quality.

Helen: Thank you for making that clear and vivid to us. I’m interested in health literacy, our listeners are interested in health literacy, and we all care about what’s going on in health and medicine today. How can we be part of the solution? You’ve made it very clear what the problems are. How can we help?

Dr. Tim: I think one of the most important things we have to do in order to both control costs and ensure quality is to involve the patient and their family when appropriate much more intensively and pervasively in health-making decisions.

The traditional model in this country has been when you’re sick, you go to the doctor. The doctor finds what you need and orders it and then you do it.

That’s one of the reasons that healthcare costs are so out of control. It’s because this so-called fee-for-service model basically says to our healthcare providers, hospitals and doctors, “The more you do, the more you’ll make.” That’s one of the reasons we have so much unnecessary care in this country.

Here’s a stunning statistic. Most health economists on all sides of the political spectrum agree that about a third of what we spend on healthcare in this country is unnecessary, meaning that it doesn’t really make any difference in the outcome. That includes outright fraud in Medicare, but that’s a relatively minor problem.

Most of that is unnecessary care, and that would be about $9 billion, a third of our healthcare dollars. Most of that are things that we do because they’ve been traditionally done and we believe they help, we think they might help, it might bring income into the doctor or hospital or whatever. There’s absolutely no good science that proves it makes a difference.

We’ve got to involve patients and families in dialog with our providers to make sure that what we get is necessary and that we don’t get stuff that’s unnecessary.

Helen: I just read in the paper recently that there are 45 tests that now people say we don’t need to have. I have even done a podcast on mammograms when the guideline changed. I know the screening for prostate cancer is changing. When people feel like something is being taken away, there’s a big hoopla about that. What are your thoughts about these tests that they’re saying we don’t need?

I’m trying to think of an example. For instance, if you have lower back pain, you don’t always need an MRI right away. Is that correct?

Dr. Tim: That’s right. That is one of the 45. By the way, I’ll point out that it’s not just people in general who said that. These were nine very highly regarded specialty organizations that came up with this list, so these are experts in the specialty societies who say, “These are tests that we do all of the time that we shouldn’t do routinely.”

Getting a chest X-ray before minor procedures is another example, or having an EKG automatically with every visit to your doctor and things like that. I think it’s really quite significant. These aren’t politicians or so-called healthcare experts. These are the physicians who run these major specialty groups finally coming out and saying, “We’re doing a lot of unnecessary stuff.”

Helen: I read a book recently by Jerome Groopman and his wife. It talked about how patients and family members are divided two different ways. Some of us are maximalists and say, “Bring it on. I want everything that could be done. I want the latest, the greatest and I will do everything. Give me all of the tests, please.”

Then there are minimalists. I fall into that camp. We say, “Are you kidding? I really need that?” Is there a role for patients and families in there as far as what we expect and what we request?

Dr. Tim: Absolutely. In fact I think that ultimately there can be no real solution to all of this unnecessary care unless we bring patients and families into the discussion and they agree to it.

You’re right that there are a lot of people who automatically want everything and at the other end of the spectrum are people who are suspicious of anything. I suppose most people are sort of in the middle, sometimes one way and sometimes another.

The fact of the matter is that ultimately the demands of patients and their families are probably the biggest problem in terms of unnecessary care. I think that has so much to do with the culture in this country. We’ve all been raised to believe that new technology is automatically better than anything we had before.

We now know from a lot of painful experience that new tests, new devices, new surgeries or whatever are not automatically the best. When we throw them out there without thorough study, we learn over a period of time that not only are they not more effective than other things but they may be even more dangerous. We’ve got to inform patients and families about what our choices are and then together make wise decisions.

Helen: The people that we advocate for in health literacy are all of us. It’s everyone who is a patient, family or caregiver, but I think that we pay extra attention to those who face more challenges, be it through issues of literacy, language, culture, age, disability or emotion and cognition.

These conversations to bring people into the discussion, especially when you’re saying, “No you don’t really need that test,” take longer. What do you recommend we do about that in the hubbub of everyday practice?

Dr. Tim: That’s a very good question. There’s no easy answer because if there were, we would probably be trying it. It is a complicated matter in terms of thoroughly and honestly informing patients, especially when there are complicated issues involved on either the medical side or the cultural side.

What we hear so much talk about today is that we can’t count on a single physician to be everything, including the educator for the patient and the family. I think we’re just starting to figure this out and test models and come up with new ideas.

There is a lot of talk today about the so-called medical home. It’s a setting for primary care, meaning a place that patients and their families learn to trust not only primary care physicians but physician assistants, nurse practitioners and health educators who are working as a team to provide this kind of information.

That way it doesn’t fall on the doctor to be everything in terms of being the provider, educator and the business person. It’s just impossible for a doctor to do all of that, so we’ve got to figure out new ways of helping to educate patients and their families.

Helen: I’m glad you’re saying that. Many of our listeners are health educators or public health specialists but perhaps not always with a clinical degree, so I resonate with that message. It takes all of us to communicate this health message.

When I talked about the team, I’m not thinking about just the people who are in a clinic or hospital but people in the community. Is there a role for librarians, literacy teachers or businesses in the community? Do you see that we can all help fix this?

Dr. Tim: Ultimately, everybody does have to participate, at the very least as consumers of healthcare. If we haven’t yet, we are all going to be consumers of healthcare, not just once but many times in our lifetime, and some of us for huge, extended period with complicated illnesses.

I think the only way we’re going to get the public, meaning all of us as health consumers, to accept the idea that hard choices sometimes have to be made is to have the support of the wide spectrum of society. This means librarians, as you said, who are often our primary sources of information, especially in our younger years.

You mentioned business. Business still pays for a lot of health insurance for employees in this country. They’ve got to step up and help their employees understand what needs to be done in order to provide quality without going over the cliff in terms of cost. Everybody has to get on board from whatever perspective they may be coming.

Helen: You have a long background on national television and you’re renowned for that. How can media help? Do they help or hurt? What can they be doing?

Dr. Tim: I can give you a two-hour lecture on that question based on my experience.

Helen: Try a quick one.

Dr. Tim: When I started doing this television work in 1975 on “Good Morning America,” I would say that there was actually a lack of good healthcare information. In those days, healthcare information was pretty tightly controlled by the medical establishment so that information had to be thoroughly studied, vetted and then published in peer-reviewed journals before it could be released to the public.

The media in those days pretty much played by those rules. I remember vividly those rules. Now I would say that the situation is far and away at the opposite end of the spectrum where they have almost too much information without being carefully vetted. The internet obviously provides huge amounts of information, some good, some terrible and a lot of stuff in between.

I think the real struggle for the public today is that the media is pouring out too much information. In that sense, I think we can do as much harm as good. I really worry about the huge information highway that we have now. It’s like any busy highway. There’s a lot of traffic and a lot of chance for accidents or litter on the sides of the highway. It’s a dangerous place.

Helen: I really like that metaphor. I’m almost stunned when I think back to when you got started and there wasn’t a lot of health information. I can’t turn on the TV, radio or computer without getting health information today. Right or wrong, it’s all out there.

Dr. Tim: Yes, it is for all kinds of reasons. One of the reasons is that the people who run the media know that the public likes this kind of information, so they respond to it. That’s what they’re in business for, to get viewers, listeners and readers.

Another reason it has become so popular is that it has been a money maker for everybody who participates, so there is a lot of money flowing into the health information business today that pushes out a lot of information.

Helen: Do you mean with the new technology out there or just a grabber so that you will turn on the next show because it’s about health?

Dr. Tim: Yes, it’s a grabber, so they respond to desires of the viewers, listeners and readers, but also there’s a huge industry that has been built up pushing this kind of information for their products and places. Riding in the car today, you can hear so many ads for different health insurance programs and different hospitals advertising their newest gizmos, like St. Miraculous hospital. It’s almost overwhelming.

I was told once that in the Twin Cities somebody calculated that they spend more money now on health advertising than on beer advertising, which is quite an achievement. I can’t verify this, but it sounds reasonable.

Helen: That’s quite a factoid there. You’ve given us a lot to think about. I know from talking with you that it’s not all doom and gloom, or maybe it’s just me trying to be an optimistic sort. Do you see any glimmers out there? You articulated the problems a lot, and we can all advocate, try to be part of it, try to sort through this information, and be part of decisions and educate ourselves.

On the big picture which is where you look at this a lot, do you see any hope?

Dr. Tim: There are a lot of models or healthcare organizations, insurance programs or plans that are trying to do it the right way. In fact, I just happened to look down on my desk where I’m sitting. I would recommend the June 2nd, 2012 issue of The New York Times where there is a major editorial called “Treating You Better for Less.”

They describe some of the outstanding programs in the country that are not trying to put into practice some of the things we’ve been talking about in terms of running healthcare in the right way, making good decisions and improving quality but also saving money. I read that editorial, and I find that encouraging.

The question is whether or not that kind of model works. There are models where they really do involve the patient and the family on one hand, and provide good information and decision making by the providers on the other hand in order to achieve both quality and cost control.

Mayo Clinic is an example, as is the Seattle Healthcare program which is called the Virginia Mason Medical Center, and we’ve all heard of Kaiser Permanente. Yes, there are many pockets of hope. The question is whether it will really become a standard model for the entire country.

The reason I’m pessimistic about that is that the healthcare technology industry, once labeled by the other physicians of internal medicine as the medical industrial complex of the country, is very organized and has a lot of money behind it. There were eight lobbyists for every congressperson during the debate over the ObamaCare bill.

They’re not going to take this sitting down. They’re going to fight back and try to preserve their part of the big, $2.7 trillion honeypot. I think it’s going to be a real dog fight in terms of people who are pushing to make money and people who are pushing reform to spend our money more wisely.

Helen: Thank you for that big picture. I’ll give you my experience from today. Just this morning I was giving a health literacy presentation to one of the major hospitals in Boston, and I was delighted to see the response of everybody who attended. They seemed to say, “Yes, I’m going to make a difference. There’s something I can do.”

What we can do about that huge industrial complex, I don’t know, but I met so many caring people who want to make a difference to the patients they treat today. I hope we can balance all of that.

Dr. Tim: I think that’s true. I look at the younger physicians who I come in contact with. They come into the healthcare industry knowing that it’s got a lot of trouble and that things need to change. They want to be a part of that change. They’re not coming in to make huge fortunes anymore, as did some doctors.

I don’t mean to suggest that all doctors do this by any means, but I think the younger generation knows that we’ve got to make changes or we’re going to go over the cliff in terms of cost, and they want to be a part of it. I’m encouraged by their attitude. The question is will the system, or non-system, as we should call it, allow them to do it?

Helen: Thank you for putting all of this into context. Whether I liked hearing the whole message or not, you sure are a big dose of reality. I hope that health literacy is part of the solution.

Before we end, Dr. Tim, can you tell people about your book? I think it’s terrific. I have a signed copy from you, so I’m extra lucky.

Dr. Tim: For most of my career, I spent my time talking about new clinical developments like new tests, drugs, devices and treatment, etc. That was what we did. As I entered this new century, I started realizing more and more that the real problems for future healthcare in this country were not completely new discoveries but the delivery and financing of what we already had and what we were anticipating adding to the mix.

I started thinking about it, and I started reading and talking to experts. I have great access to experts. Finally, I decided to write down my thinking about it in a very small book for the general public. It’s called The Truth About Getting Sick in America. It’s available in paperback on Amazon and other sources. It’s written, I hope, in a way that’s very comprehensible to the non-expert.

Helen: I give you an A in health literacy.

Dr. Tim: That’s my attempt to add to the discussion and the debate. Quite frankly, we are trying at ABC, where I am still a consultant, to tackle this subject for the public. We all know it’s important, but it’s a question of getting beyond the fears of the public that something is going to be taken away and getting beyond the politicians who are more than happy to capitalize on this fear.

We need to have a really open, honest discussion about what we have to do if we want to save our healthcare from going bankrupt.

Helen: I am so glad that you are part of that discussion, and thank you so much for sharing all of these views with Health Literacy Out Loud.

Dr. Tim: It’s my pleasure, Helen.

Helen: I’ve learned a lot from Dr. Tim Johnson, and I hope that you did too. Health Literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there sign up for the free e-newsletter, “What’s New in Health Literacy Consulting.”

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, on the mobile app Stitcher Radio and the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.


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