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Designing America's Bridge

June 17, 2008

2008 AMA Annual Meeting
Hyatt Regency Hotel
Chicago, Illinois

Nancy H. Nielsen, MD, PhD
American Medical Association


What a joy it is to be here with you tonight. And special thanks to my friends from across the country whose names are listed in your program. I do hope you'll have the opportunity to meet them later this evening.

They include my practice partners, colleagues from my medical school, the dean who allowed me to return to my alma mater 11 years ago. And all the deans who followed, and the deans at West Virginia University and the University of Vermont.

There are friends from home, from places I have worked and volunteered, from the quality enterprise where I devote a lot of my time, and from the health plan where I learned that there are many ways doctors can help patients get the services they need.

Some of these guests have been my patients, some my teachers, and some my students. All are my friends.

There are three special people I would like you to meet — who I could not have practiced medicine all these years:

First, the two women who ran my office, triaged calls, worked terrible, terribly long hours, helped and counseled patients. And also my mentor, inspiration and practice partner. We met when I was a medical student. He taught me as a resident, and recruited me to the Buffalo Medical Group. He was my partner throughout all those years. And he is not only the smartest doc I ever met, he also is the kindest.

Would Dr. Irwin Friedman, Carol Pesko and my daughter, Kristin Bartnik - please stand and accept my thanks and gratitude.

I would have been very proud to introduce my parents to you. But my mother is back home in West Virginia suffering from metastatic lung cancer, and my dad already died much too young.

I would like you to meet the rest of my family. My wonderful children and their entire families, my sister, and my dearest friends from high school. Without them, life would be barren indeed. Would they all please stand and accept my love and gratitude.

Now there is another remarkable person in the audience. She is an attorney. You know that doctors and attorneys don't always — well, you know.

But Linda Lacewell is a key individual in the office of the New York State Attorney General. She is Counsel for Economic and Social Justice. And through recent widely publicized settlements, she and Attorney General Andrew Cuomo have helped physicians and patients achieve fair treatment by health insurance plans. So Linda, please stand and accept the thanks of the American Medical Association.

Well, who knew — who could have ever predicted — that a girl from a small town in West Virginia would someday be president of the largest physician organization in the world?

And who would have predicted that all that would happen at a time when there's a wide open presidential campaign, when healthcare costs are out of control, when the number of uninsured is now 47 million?

Ladies and gentlemen: There are many talented physicians who could occupy this office — and have done so. You have heard recent AMA presidents call on us to "never, never give up"; to "light the way" for health insurance for all; to remain committed to "true north"; and to restore leadership and responsibility to our profession.

Last year you heard a call for commitment to public health from a man who did not know that, all too soon, making his own health public would be an act of courage and inspiration for us all.

Ron — I thank you for reminding all of us of the power that hope provides.

I know this office is not about any individual's accomplishments. It's about the opportunity we physicians have to be leaders in a very exciting time.

It is certainly exciting politically, it's challenging economically, and it's demanding scientifically. But there is another excitement right now. And that is our opportunity to build a new and better health care system in America.

Cynics say we don't have a health care system. They say we take care of sickness more than we preserve health. They say it's anything but a "system." And they say that "care" is the quality patients are looking for - but often fail to receive.

I have a response to the cynics. And it's not one they would expect. And maybe you, too, will be surprised. But it is one I firmly believe we must embrace.

Today. Right now. We have the opportunity to form linkages. To break logjams that have frustrated us for decades. To resolve differences that have come between us and our patients.

Today. Right now, we have the opportunity to forge connections that can resolve disputes. That can decide issues. That can put the focus where it should be, where it absolutely has to be: On our patients and on the strength and fortitude of our profession.

All of this may involve us in a new type of engagement with traditional adversaries. But, this is not conciliation. This is not capitulation. It is civil engineering.

I want you to think for a moment about bridges. All kinds of bridges. Close your eyes, and picture the Golden Gate bridge, the Brooklyn bridge, a covered bridge in rural America, the Ponte Vecchio, London Bridge. Or the Michigan Avenue bridge just outside this hotel. All of them have one thing in common. They bridge from here to there — across a gap or over an obstacle.

They also represent human greatness and ingenuity. Because at some point in time, there was no bridge there - only the chasm, the river, or the obstacle. Then someone, or some group got tired of the obstruction and came together - took the initiative and built a bridge.

In America there are more than half a million bridges. We rely on them every day to cross streams, valleys, railroad tracks - all manner of obstacles.

We are also mindful of the terrible tragedy when a bridge collapses, and of the folly of expending resources on "a bridge to nowhere."

My friend Tom Sanders is a civil engineer, and he taught me some things about bridges. There are only a few basic types. The difference between them is with how they deal with two important forces: compression and tension.

There's the beam bridge — just a horizontal beam supported at each end by piers. The weight of the beam and anything on it pushes straight down on the piers. The farther apart the piers, the weaker the beam becomes, and that's why beam bridges rarely span more than 250 feet.

Then, there are arch bridges, which have great natural strength. In Roman times they were made of stone; today they are made of steel.

And there are graceful suspension bridges, where the roadway hangs from massive steel cables draped over tall towers. The cables are really just lots and lots of individual wires — strands of wires bundled together to capture the force, carry the load, and deliver it to the support columns. And these are the bridges which are used to span the widest gaps.

I'm convinced there is an important analogy — between bridges that distribute powerful forces, withstand high winds and stormy weather, and provide safe passage across a chasm — on the one hand - and our opportunity to change the American healthcare system on the other.

Think about the chasm in healthcare. Not just the quality chasm so well described in the IOM report, but other gaps that divide us as a country and keep us from fulfilling our AMA vision — advancing the art and science of medicine and the betterment of public health.

And you can view those gaps from a number of points of view. Physicians see many obstacles:

  • We work harder and harder, but we face reimbursements that are flat or worse, while practice costs go up.
  • We are forced to spend less time with our patients, but patients have increasingly complex conditions and concerns.
  • Information explosion and advances in technology challenge all of us to keep up our knowledge and skills.
  • We came to medicine to care, to cure, and to comfort. But these values are often not reflected in payment systems.

Then, there is the patient view. Patients by and large like their doctors. They trust us. But they see healthcare as a vast chasm of uncoordinated, uncaring, complex parts that ignore their basic wants and needs.

Meanwhile, insurers see their own set of obstacles:

  • They complain about physicians who churn patients and maximize income with tests and procedures,
  • They blame others who — they say — don't keep up, and who resist efforts to improve quality, all in the name of preserving autonomy.

The nation's largest insurer — the government — sees its own set of chasms:

  • Fee for service, rewarding quantity but not quality,
  • Enormous inconsistency from one region to another — variabilities that seem to correlate more with the number of physicians than with patient needs.
  • And they look at the demographics and projections, and warn us Medicare is going bankrupt, maybe sooner than later.

Is it any wonder that these differing views of the obstacles we face got us where we are today — to an environment where we see anger, and mistrust, inflamed rhetoric, and finger-pointing?

Today, physicians stand, like surveyors, at the edge of a very large chasm in healthcare facing a challenging, sometimes hostile environment.

So what do we do? Do we fight, storm the barricades, hunker down, dig a moat around us to stave off invaders? Or should we despair?

Well, Henry Kissinger once said, "The statesman's duty is to bridge the gap between experience and vision."

So why not turn the problem into an opportunity? Why not take up tools to build a signature bridge for America over the health care chasm? Why not start weaving wires into cables — join with patients, employers and maybe even insurers to build a bridge to a better future, where the real enemies are not each other, but are disease, despair, and untimely death?

Each strand in a bundled cable must be strong — and each strand must be accountable - accountable not only for its own strength; and its own integrity, but to the paramount responsibility - the health of our patients. And we may need many bridges of differing shapes, depending on the obstacles to be overcome.

One major obstacle is the lack of affordable health insurance options for 47 million Americans.

There was a time, in the lifetime of many of us in this room, when insurance wasn't necessary and wasn't even available. My mother had no insurance when my sister and I were born, and when my father had his first heart attack. But those days are over.

Even those physicians who choose concierge care or participate in no insurance plans recognize that their patients need insurance for situations that are so expensive that cash reserves simply won't come close for the vast majority of us - maybe a hospitalization, a surgery, catastrophic illness, biotech drugs, or devastating chronic illness.

It is unconscionable that we, the richest nation in the world, have left 47 million people uninsured through benign neglect.

It is unconscionable that thousands of patients die each year because they delay care until it is too late.

In my year as president, I will use all of the power of this office — of this association — to give a voice to those patients; to let the nation know that we must cover America's uninsured.

Calling attention to the problem is simply not enough. It's time to design and build a solution. And figure out how to pay for it.

We claim to have an employer-based insurance system but two out of five employers don't even offer health insurance.

We have world-class science but the delivery mechanism is so expensive that health care costs actually threaten our global competitiveness, and medical expenses remain the number one cause of bankruptcy. And too much current rhetoric ignores the heart-wrenching realities you and I face every day.

I was recently in Florida about to speak to the Economic Club. As often happens while on the road, I met a woman who wanted to tell me her story. She was the general manager of the hotel where I was staying. A good job. She told me that her current employer covered all the costs of health care for all employees. A great plan.

But her previous employer didn't even offer health insurance. She purchased an individual health policy for six months as she prepared to relocate to Florida to work. The transition took a little longer, so she renewed the policy for another six months. And one week later she found a breast lump.

The insurance company refused to pay, claiming a pre-existing condition, despite a normal mammogram one year before and a normal breast exam three months before. When I met her, over four years later, she was paying off the final five thousand dollars of the $50,000 bill for breast cancer treatment.

Who in this room cannot empathize with that woman — and with millions like her across America? She did everything right and yet, the system failed her. She fell in that deep chasm and is working herself to the bone to drag herself out.

Stories like that take the "care" out of health care.

It is time to recognize that each of us should be able to purchase affordable health insurance, not be pawns of an employer's choices. Insurance that won't end when a job ends. Americans deserve choice, in addition to access. And they certainly don't have that now.

If we were to work with insurers — if we were to show employers the way — we can construct a bridge for all Americans to cross.

Instead of lurching inevitably toward government control in the current poisonous — partisan — atmosphere, we could craft all sorts of choices.

But we must work together to build that bridge with the goals of coverage and choice, combined with care and compassion.

Regardless of our political leanings, we cannot - simply cannot - allow the problem of the uninsured to grow ever larger. To do so in this time of economic downturn would be a national tragedy.

So let us lay down arms, take up tools and build a bridge. Not a pork-barrel 'bridge to nowhere." Our bridge has got to go somewhere very important.

We can and will work with others, if they participate in good faith. But we cannot use inferior materials. Doing that invites a bridge collapse and lives will be lost.

We will insist that the materials are forged in science, in educational training, in ethics and in professionalism.

We're going to differ on tactics, but the goal has to be clear. We're going to differ on details but we have to accept the shared responsibility to do what is right, what is ethical, and what is necessary.

Each of us is an important strand in one cable. But we cannot be the only cable. Each part of the healthcare system, indeed every American, must bear part of the weight, share the burden and distribute the force. If the bridge is to be safe, and strong, and sturdy, we need to craft a sustainable solution that can withstand high wind and stormy weather.

We can't do it alone. Insurance executives, health plans, policy-makers and economists have an important role to play but they cannot craft a workable solution without patient input and without the help of physicians.

I say to you — and I say to them — that this bridge cannot be built without the leadership of physicians.

So let me lay out some challenges for insurers, physicians, and the government.

For insurers: Instead of issuing that report card on what percent of my patients didn't get a mammogram — tell me the names of those patients so I can verify the data and reach out to each one — and offer a test that could save a life. Help me find out if my patient filled the script I wrote. Help me learn if my patient is refilling his meds in a way that shows he is taking them reliably and consistently.

Find out if your health plan's co-pay is so high that IT is the real barrier to control of her diabetes, her hyperlipidemia, her congestive heart failure. Stop referring to "medical loss ratio" to be ratcheted down - and re-focus on patient needs. That's how premium dollars should be used. Not on exorbitant CEO salaries. Not on soaring administrative costs. And not on shareholder dividends. Forget about lopping off physicians — and steering patients into tiered and narrow networks. Stop issuing faulty report cards based on flawed data, but instead, turn around and help us. Harness the available technology to feed information to both physicians AND to patients.

You insurers already reach out to patients — it's in your best interest anyway, since HEDIS data are reported publicly. So there are "shared interests" for us all.

Now, to be fair, some health plans have been innovative and collaborative. But, it is time for all of them to be so.

And what about physicians? To our colleagues, I say: Let us agree to lead. Let us come together to agree on national health care goals and a timetable to reach them. Then the bridge-building can begin. Let us demand comparative effectiveness trials that will generate scientific evidence so we can help patients make the best choices for their situation, using all the knowledge of genomics, drug discovery and design, and therapeutics.

We know that costs are important and we bear a responsibility to be concerned about that. But let's reframe the issue into determining what is "appropriate and effective" in a given situation. Our specialty societies are the absolute key to that work. Look what cardiologists and radiologists did when payers balked at the number of imaging studies being ordered. These two specialties sat down — separately and then together — and built a bridge that began with patient need and worked back to deciding when and if a test was appropriate. They developed, and published, appropriateness criteria for cardiac imaging. And saved money in the process.

I say we need more of that kind of bridge-building. And I say — further — that if we don't, someone else will make those decisions. And we won't like that at all.

We're being asked to be accountable. We should proudly accept that challenge. We physicians live and breathe accountability. It is woven into our profession and into every patient encounter, whether in the clinic, an operating room or an office. We are accountable to our patients, to their families, to each other.

Now let us show health plans, government and our patients how we can weave that accountability into strong, safe cables for the health care bridge.

Finally, to Government officials I say: It's really important that you get out of the way. Let innovations in health care delivery and in health insurance flourish.

In the great wars of our fathers and grandfathers, the Army developed portable bridges, pontoon bridges and other practical solutions to win the war. Let's use our American ingenuity to do what Clint Eastwood called, "Improvise, Adapt, and Overcome."

Let's say to policy makers — whether they are in Washington, D.C., Albany, New York or your state capitol — Do not demoralize dedicated physicians by demeaning them and denigrating their motives; Do not chart the transformation of health care by crunching numbers behind closed doors because every "number" is a patient who is sick or frightened or confused; And do not design healthcare bridges without physicians. It is doctors and their patients who have to cross those bridges every day.

We are the ones who bear the responsibility — and have the enormous privilege — to care for our patients. We have always been willing to adapt, but we will not compromise the integrity of our profession.

So it's time to decide if we dig another moat, or do we build a bridge. You and I can take the lead — take the initiative — take the well-being of our patients as our starting point — and start to take action. And if our efforts at cooperation with others fail, we can still employ the traditional methods of redress — litigation and regulation. Or refusing to participate in schemes that demean us.

We will no doubt continue to have struggles and strong differences with our traditional adversaries, but bridging some obstacles is in everyone's interest.

So to make rapid progress, while awaiting a new President and a new Congress, let's come together with others to figure out how much innovation can be undertaken quickly, without legislation.

And I will be the first to tell you that this will not be easy. It is not without risk. But physicians work with risk every day.

There is a reason why patients put their lives in our hands.

Every day in this country there are heroes: When a family physician says to a woman, "Do you feel safe at home?" When a surgeon says to his patient, "Here's my number. Call me if anything isn't going the way you think it should." When an obstetrician says, after an ultrasound, "I need to tell you something we have to face together." When a pediatrician holds the hand of a sick child with no hair.

This is the best of our humanity and our profession. We can use that commitment, courage, and compassion to come together with patients, employers and insurers to build a signature bridge that provides safe passage across the healthcare chasm.

Let's step forward and lead and design that bridge. Now is the time. We can build it strong, and beautiful, and with devotion. We know the problems better than anyone. And we must be the civil engineers who design the solutions.

So I say to employers, insurers, Congress and to both presidential candidates: Come, help physicians build America's signature bridge. Now is the time. Not soon. Not someday. The time is now.