Q&A
MANAGED CARE April 2000. ©2000 MediMedia USA
The colorful president of the People's Medical Society foresees fewer hospitals, more DM, "teledocs," and an end to legislation by body part.
Charles B. Inlander has been president of the People's Medical Society since the group's founding in 1983. The idea for the organization came from Robert Rodale, second-generation head of the health and horticulture publishing company. The mission of the society is "to get information to the public about health care that it generally doesn't have available, and to reform the health care system to be more responsive to consumers," says Inlander.
The organization, which bills itself as the largest consumer health-advocacy organization in the United States, gets its message out largely through Inlander's books and his appearances in the news media. A Chicago native, Inlander is coauthor of nearly two dozen titles, including Family Health for Dummies, Take This Book to the Hospital With You, Medicine on Trial, Medicare Made Easy, and the Consumer's Medical Desk Reference. Inlander, a graduate of American University in Washington, D.C., is a faculty lecturer at Yale University School of Medicine, an adjunct faculty member at Chicago-Kent College of Law, and a Fellow of the Institute for Science, Law and Technology at the Illinois Institute of Technology. He spoke recently with Senior Contributing Editor Patrick Mullen.
MC: How has your view of managed care changed over the years?
INLANDER: We were strong advocates for managing care and for managed care itself as far back as 1983, when we were formed. Some managed care, particularly when it's focused on disease management, has effectively improved outcomes. In the last eight or nine years, the rest of managed care, unfortunately, has focused on managing costs rather than care. Managing costs is useful and important, but it hasn't accomplished what managed care should have accomplished: improve outcomes and cut inappropriate services. Managed care should be able to rein in costs by buying the best quality, not just any quality.
MC: Should consumers care how doctors are paid or about the debate over capitation versus fee-for-service?
INLANDER: No. It doesn't matter at all. I don't think consumers care, and I don't think it's important because it's too complicated. From a consumer's perspective, if someone is managing the care, then he should figure out the best way to pay doctors to get the best outcomes. Some people buy a car and others lease a car. It's still the same car. Consumers want to know that however doctors are being paid, they're being paid to maximize outcomes, not to maximize or minimize utilization. It's the managed care company's job to manage that, not the consumer's.
MC: So the job of consumers is to choose the managers of their care wisely?
INLANDER: Yes. I think it's stupid when I hear members of Congress, with whom I speak every week, argue that it's important that consumers know how their doctors are paid. That's because doctors want them to know how they're paid so that consumers will pressure the insurance company to pay them more. It's just not going to happen. Docs are out of the loop now, and so are hospitals. Doctors tried to create managed care companies on the theory that they could do it better — and most of them failed. Most hospital plans and physician hospital organizations failed. Insuring people is a huge business. When biggies like the Blues and Harvard Pilgrim and Aetna get in trouble, don't expect 25 docs in four hospitals to know what the hell to do. They don't know what to do, and most of them are going bankrupt.
MC: When you say doctors are out of the loop, do you mean in terms of running the business side of health care?
INLANDER: They're out of the loop altogether. Their style of practice is becoming obsolete. We virtually don't need any primary care doctors. Advanced-practice nurses can do everything a primary care doctor can do. The only reason they aren't doing it all is because doctors say that nurses can't do it. Advanced-practice nurse training and nurse practitioner training are not much different than training for a primary care doctor. So why are we wasting all this money training primary care docs? They get 90 percent of their questions answered by using technology that somebody else could read. We should be spending that money on getting higher-tech doctors at high skill levels to do the exotic things. Let the advanced-practice nurses and nurse practitioners do the primary care. We should close down the third of our hospitals that are obsolete, unnecessary, and empty. We should focus our money on home care and telemedicine, technologies that bring health care to the community, rather than having people go to the hospital.
MC: What's changed to render hospitals and primary care doctors obsolete?
INLANDER: Hospitals were created because we had to do surgery with blood and sterilization involved. One reason we don't need hospitals now is that we're doing basically bloodless surgeries. Home care and outpatient surgery can do most of the things we've done in hospitals. We only need a third of the hospitals we have now, for the limited number of people who truly need hospitals. We probably have 200,000 excess doctors, according to the studies. That's why we have [specialists like] sports gynecologists.
MC: Medical schools continue to turn out graduates, and there's a powerful profession that is determined not to let your view of the future come to pass. How do you get around that?
INLANDER: The market is driving it that way. They told me 18 years ago that we'd never have shorter hospital stays, that a seven- to eight-day average length of stay was going to be the average for the next 40 years. It lasted about three years. They told me that AIDS was going to fill every hospital bed in the country. All the people hospitalized in the United States with AIDS today would fit in 12 hospitals, at most. We have an aging population that's hardly using hospitals at all, thanks to home care. We have pharmaceutical products replacing almost everything doctors did 25 years ago. Patients are treated by taking pills now. Within 10 years, the pharmaceutical industry will develop a pill to clean out your arteries. Take a pill or get an injection, and there goes the plaque. If that happens, say goodbye to the rest of the hospitals.
MC: There goes the coronary bypass industry.
INLANDER: Hospitals are only open for heart disease now. Most of what's going on in hospitals is nursing care, not medical care. We don't need hospitals for that. We could provide good home care and bring technology into people's homes. It's starting to happen. It took a long time, from about 1940 to 1960, for the railroads to get down to the level that they needed to be at. This is a much bigger industry, so it will take a little longer, but it's getting there. Docs and hospitals and medical schools can jump up and down and lobby Congress. They can't reverse what's happening. As we now know them, they are becoming obsolete. I predict that in 25 years you'll do your own knee surgery as part of your home-care program. You'll connect a laser to your computer television at home. The teledoc on the other end of the line will say, "Move it over a little bit to your right. Now, to your left. Now hold it there." They'll push a button — and boom, it's done.
MC: Who stands to gain from these changes?
INLANDER: We're moving toward a pharmaceutical-driven health care system and moving away from a procedure-driven health care system. The pharmacy and medical equipment industries are beginning to recognize where their bonanzas will be. Broadband technology will allow them to deal directly with large numbers of consumers, rather than having intermediaries called doctors and hospitals.
MC: Do you foresee a universal payer system or national health plan?
INLANDER: We are going to have national health insurance. It's going to happen when we hit the 50 million uninsured mark.
MC: We're getting close.
INLANDER: Yes, we are. That's going to be the key. Since 1990, I've been predicting that the 2004 election is going to be built around national health insurance. The trends have been clear since then. The cost of care will keep rising. Technology is making much of what health care was in the 20th century obsolete. It's going to have to change just to keep up. The third factor is consumer demand. We baby boomers are becoming the biggest users of the health care system. Our generation has always said we expect accountability, so the system has to be more accountable.
MC: What will universal coverage look like?
INLANDER: We'll basically extend Medicare to everybody and add maternity and mental health coverage. Medicare is still a private system, but with a single payer. We can have a system that's not government-run, but government-regulated. Private insurers would provide supplemental policies. Believe me, I don't know any private health insurers, even the allegedly profitable ones, that want to be in the primary coverage business anymore.
MC: It's a low-margin business with massive headaches. The executives go to Wall Street and they aren't heroes any more, like they were for a few years.
INLANDER: That's right.
MC: You've said that patients' bill of rights proposals are actually provider-protection acts. Why do you see them that way, and do you think they would have any long-term impact if enacted?
INLANDER: Plans have been doing most things in the Patients Bill of Rights for years anyhow. I don't think most federal or state representatives are particularly astute about health care. They are reactive, mostly to what they hear in the media. Legislators now are seeing their own weaknesses, and they're becoming far more discerning and serious. Most state legislators around the country who were jumping up and down about the drive-through baby stuff realized they got burned on that issue. It was a nonissue. In most states they couldn't find any women who suffered as a result [of postnatal hospital stays fewer than two days]. So where did they get the information that this was a problem? They got it from docs who didn't like being told what to do by managed care companies. The average length of stay for a healthy birth in that state may already have been 1.2 days, even before managed care. But doctors didn't like being told by somebody else, so they ran to legislators claiming that women were suffering and quality was being hurt because of managed care rules. There weren't any rules and people weren't being hurt. Women wanted to get out of the hospital. Length of stay did not go up as a result of those laws, which suggested there was never a problem in the first place. Because of bills like that, legislators are beginning to take a more serious look at health care quality and legislation. We should look at health care the same way that we look at the environment. We're going to start to see legislation at the federal level, and it's not little nit-picky legislation.
MC: So we won't see more legislation by body part.
INLANDER: No. Congress will grant broad authority to HHS and to other agencies, like it did when it created the Environmental Protection Agency. I expect Congress to create stringent reporting and monitoring laws. I also think that HCFA will get a tremendous amount of authority in the future with sharp teeth in it to assure quality in the Medicare system and Medicaid. The public is starting to tell the government, "Look, you guys contracted for this system, so you have an obligation to make sure we're getting good care."
MC: Is it your sense that Republicans might be more likely to expand federal authority over health care? After all, the EPA came into being under Nixon's watch.
INLANDER: I don't think so. Historically, Republicans have been against big government. The EPA could have been created with Johnson sitting there as easily as Nixon. The EPA came along because the time was right. In health care, it could happen with a Republican Congress, with a Republican president, or with a Democratic president or Congress. We are getting to the point of critical mass in the public mood. The public is beginning to say, "Do something about this, because things are getting out of hand." They are astounded with the fact that they can't get information about doctors, that the National Practitioner Data Bank is kept secret, that Congress has responded to the hospital and physician lobby and the insurance lobby, who have clearly not been working in people's interest. It kills me that in every state discussing a new mandated benefit, insurers lead the fight against it.
MC: Should health care be a for-profit business?
INLANDER: I don't know any not-for-profit doctors, so I have no problem with for-profit managed care. We see some problems with the for-profits. A good example is what Aetna is going through. It recently rejected a takeover offer from WellPoint and said it's going to split into two companies. When it got rid of [former CEO] Dick Huber, Aetna proved that it's not interested in managing care. The fact that it put [investment banker and former New York Stock Exchange president William] Donaldson in as the acting CEO shows that it's merely interested in satisfying Wall Street and stockholders.
MC: It's at the point of maintaining its corporate survival, which for the executives, means their jobs.
INLANDER: It's not like Aetna was going to go away. It was all about stock and stock price.
MC: Sure Aetna could go away. If it gets taken over, all those folks who are there now get tossed out.
INLANDER: But as is clear with the split, it doesn't have to be taken over. There's going to be some very wealthy people from this split, and it's not going to be the little guy. In the meantime, no one at Aetna is discussing health care. I'm not suggesting that this is just a problem with for-profits. It's been a problem with probably 90 percent of mergers that have occurred among not-for-profit hospitals. The goal of those mergers is the survival of the egos and the jobs of the board and of the employees. Meanwhile, 50 percent of hospital beds are empty in the United States.
MC: You've long favored direct-to-consumer advertising of prescription drugs. Why?
INLANDER: We have been for it since the day we started, for three reasons. First, we think that advertising in this country is a form of consumer education. It's not the only form and it's not the ideal form, but it's a form. Therefore, direct-to-consumer advertising brings product awareness to consumers. That's important because we had a system — and still do, to a large extent — that is driven by doctors telling patients about products. They don't necessarily talk about all available products and options. Direct-to-consumer also creates dialog. The patient can say, "You've been giving me this drug for my allergies, but it hasn't been working. What about the one that I saw on television that promises blue skies?" The third reason, and this was by far the main reason, is that there are no laws that require physicians to disclose side effects and other information you need to know about prescription drugs. If you advertise, under the truth in advertising laws, they have to provide that disclosure. When you walk into the pharmacy, even though they are required to tell you about the drug, 50 percent of the time they don't.
MC: They say, "Sign this."
INLANDER: That's right, and you just signed away counseling without realizing it. The law requires that drug makers disclose the major side effects of advertised drugs. So they give you an 800 number to call to get more written information. This is all to the better of consumers. I know docs hate it, because their customers are walking in empowered. I know a lot of people say it raises the cost of pharmaceuticals. It's not raising the cost of pharmaceuticals by any studies that I've seen. I'd like to see generics and other things advertised but I can't run the whole market.
MC: Thank you.