2009 Founders’ Day Address

2009 Founders’ Day Address

Stephen L. Ondra, MD, senior policy advisor for health affairs in the Department of Veterans Affairs, gave the keynote address at the Feinberg School of Medicine’s Founders’ Day Convocation.

August 28, 2009 – Stephen L. Ondra, MD, senior policy advisor for health affairs in the Department of Veterans Affairs, gave the keynote address at the Feinberg School of Medicine’s Founders’ Day Convocation on August 28. Following is a transcript of his speech.

It is an honor to be back at Northwestern, especially on this, the 150th anniversary of Northwestern University Feinberg School of Medicine.

I want to thank President Schapiro, Dean Jameson, Dean Curry, the faculty and guests here today, but most of all I would like to congratulate the Class of 2013, who today begin their journey in the medical profession.

Your journey is beginning at a historic inflection point for health care in the United States. While our health care system has served us well for many years, it is now widely recognized to be troubled and economically unsustainable.

Our country spends over 17 percent of its gross domestic product on health care, that’s over $2 trillion per year. This is almost 50 percent more than any other developed nation.

Even worse, this cost continues to rise at an alarming rate. It is estimated that by 2015, before you finish your residency, our national health care bill will be almost $4 trillion per year. While cost is important, this is not just an issue of dollars and cents, it is an issue of real people and our national well being.

We are all of aware that our health system has much to be proud of. I was lucky enough to practice and teach in this system and, for over a decade, that was here at Northwestern. During that time, I saw this school and its faculty find the causes of disease, pioneer new tests, drugs and treatments. I was lucky enough to be a part of that process.

While the United States continues to lead the world in many areas, especially the areas of highly technical specialty programs, there are also many areas that we lag behind other nations. For all the money we spend on it, our system does not provide us with a healthier population or longer lives.

Americans do not see their doctor more often than in other nations, but when they do, resources are used more intensely. We have seen over and over that more care does not directly correlate with the best care and, at times, can even be detrimental.

The high cost of the health system is also an anchor on our economy. Small businesses, the cornerstone of our economy, all too often must consider the unthinkable option of either laying off workers or not providing them with health coverage. Since the 1990s, a third of small businesses have stopped providing care to workers and another third has been forced to cut benefits.

It is not just small business that is suffering. Large companies are also feeling the pinch. Our competitiveness and security in a global economy is threatened by the burden of high health costs. We all saw this play out in the decline of our auto industry.

As the cost of health care is increasingly shifted to workers, the burden is being felt across the nation. Rising premiums and other health costs continue to rise far faster than wages. In fact, almost half of all bankruptcies involve a medical reason or medical debt. Increasingly, people must choose between health insurance or other bills – bills like paying tuition, mortgages and at times, even food. Insurance premiums average $12,000 a year for a family of four at a time that a family’s average income is around $65,000 a year. The unaffordability of insurance continues to add to the increasing number of uninsured.

Given this unsustainable economic model and unacceptable social condition, the option to do nothing simply no longer exists. So what does change mean for our country, the medical profession and you, the Class of 2013?

First of all, while many things will change, what it means to be a physician will not. These are the reasons that brought you here today and will remain constant. Your commitment to care for the sick and maintain the health of your patients will not change. The desire to care for and care about your patients will not change. The obligation to heal the afflicted not just in body but in mind and spirit, that will not change. What will change is the process by which that care is delivered and the system in which those values are practiced.

So, what might that system look like?

First, we must acknowledge that change always brings an element of the unknown and often a sense of unease. It is also important to remember that fear is always easier to manipulate and market than creative solutions to real problems.

We saw this in the 1960’s when the Medicare bill was passed. The concept of assuring that our aging population would be cared for was decried as the beginning of the end for our freedom. The purveyors of fear and dread spoke and wrote endlessly of the disaster that was being brought to our unsuspecting nation. Today, Medicare surely has problems, but it remains one of the – if not the – most popular program in government. Medicare boasts a satisfaction by its beneficiaries that is as high, or higher, than private insurance. It is run with administrative efficiency that is orders of magnitude better than the private sector.

Who here would suggest that we do away with Medicare today? Still, the same old naysayers that railed against the passage of Medicare now use the same stale arguments and the manipulation of fear to try to hold back reform today. Once again, these tactics will fail.

So what sort of system will we have when you, the Class of 2013 finally begin to practice? To answer that, we must first answer a fundamental question; is healthcare a right that we grant to all of our citizens or a commodity that will be given only to those who can afford it? How that question is answered will determine how reform will look and will say much about us as a people.

The President has clearly stated that that the access to affordable quality health coverage is a right that should be given to every American. He has also articulated the outlines for what such a system should accomplish. This includes access, efficiency and prevention.

I want to give you some examples from my own clinical experience, as well as from my time in the Administration, about some of the ways that we can make our health system both better and less expensive. I know that many of you think these are mutually exclusive goals. That is true only if we fail to think outside the box and look for new solutions.

To make our system better, we must begin by improving access. That can start with access to affordable prescription drugs. Too many of our senior citizens, almost one in ten, can’t afford their medications.

People like a man in his seventies who suffers from severe migraine headaches but can’t afford his medications. He is too proud to accept hand outs from others, even his family. He has made the choice to suffer with debilitating migraines to make sure that there is money to pay the bills, including the bills for his wife’s medication.

When a senior citizens like this can no longer afford the medication he needs, all too often, they simply go without. These aren’t people who don’t want care, they simply can’t afford it. They are people who have worked hard, played by the rules and asked for nothing. They are our parents and our neighbors. Not taking their medications results in them getting more advanced and often preventable illnesses. This adds to the cost of care in ways that can be measured economically and in personal suffering that is immeasurable.

The need to provide affordable insurance options is also an economic and moral imperative. It was an imperative for a patient of mine, a woman in her twenties who was diagnosed with a benign but locally aggressive tumor in her spine. I removed the tumor over five years ago. She did well and reliably had follow up scans and appointments for several years. Then, her job changed. Her new employer could not afford to give their employees health insurance coverage.

Unable to afford her scans, and too embarrassed to ask for help, she gambled that she would remain tumor free. After all, the tumor had not come back for several years. Two years later, last year, started out as a good year for her. She got a new job, this one with health insurance. She also got engaged. Just before her wedding, she decided to get the scan that she had skipped for two years due to the lack of insurance. This scan showed a massive recurrence of her tumor. Instead of a small operation that could have cured or halted the tumors progress, she needed a three stage massive salvage procedure. This was followed by radiation. Her wedding was delayed and her life has changed forever. As a surgeon, this is heartbreaking. As a citizen, this is an outrage.

We must make affordable coverage available to every American. We must have the courage to stand up for and, if need be, make some small sacrifice to make sure that stories like this no longer occur. The President has proposed a number of ideas to address this issue. Several bills are now before Congress. None of these will come in time to help my patient, but if we act now, we can prevent this all too familiar story from being played out again.

Building on our current system of employer sponsored and private insurance, we can add health exchanges and other options that will ensure access to affordable quality insurance and the care that comes with this. This is the first step in reforming our system. While this is the right thing to do and an important step, it alone will not solve our health care problems. We must also change the way the system functions.

Our system must move away from a simple utilization driven system to one that rewards quality and meaningful results. We need to incent providers to spend time to deliver preventive care and transform our system from one that not only provides disease care, but one that also maintains health.

Responsibility must also lie with our patients. The public will have to do its part to lead healthier lives. Physicians must be committed to and incented for helping patients make healthy life choices.

We must also work to rein in the cost of medical liability and how that adds to our nation’s health bill. As a neurosurgeon, I am all too familiar with this issue. This is a complex topic and a divisive one. It has more than one cause and will need more than one solution to address it.

In terms of improving quality and safety, there are many ways that we can transform our system to accomplish this. Health information technology is one of the powerful tools that we have to do this.

Health IT is something that we at the Department of Veterans Affairs (VA) have a lot of experience with. The VA’s system, known as VISTA, is widely regarded as one of the – if not the – best electronic health systems in the world. This system holds all of the health records for care received by any and every veteran in our system. That information is available when ever and where ever it is needed. When hurricane Katrina hit the gulf coast, millions of health records were destroyed, but not a single Veteran’s record was lost. They were all backed up and available through VISTA.

Interoperability of electronic health records also can improve the efficiency and safety of our system. When providers have access to a patient’s history in ways that are secure and protect a patient’s privacy, making a diagnosis is easier and faster. Tests are available and unnecessary repeat tests are minimized. This both improves safety and reduces costs. Having that information speeds evaluation, decreases patient frustration, reduces cost and, at times, saves lives.

An example of this comes with another patient, a woman in her seventies who several years ago had episodes of loss of consciousness. She was diagnosed with intermittent low blood pressure or orthostatic hypotension. She was placed on a medication to correct that and did well.

Recently, she was found to have difficult to control high blood pressure. Despite different medications and a hospitalization, her blood pressure remained difficult to control and she was at real risk for stroke. No one, not even her family doctor, realized that she was still on the medication that was prescribed by yet another doctor to raise her blood pressure. That medication was the cause of her hypertension.

An interoperable electronic health record could have prevented this. This story is even more tragic, and ironic, as this woman’s husband is the first patient that I spoke about, the man who could not afford his medication so his wife could get her medication. He has been getting ever more ill forgoing his medication to afford the very medication that was making his wife sick. This is a very personal story for me, as both of these patients are members of my family.

The VA is a leader in the type of information system interoperability that can limit or prevent such costly errors. While we are justifiably proud of this accomplishment, we are in no way satisfied. Taking direction from President Obama’s speech on April 9, the VA is working with the Department of Defense to develop a virtual lifetime electronic record or VLER. This approach will provide secure and authorized access to all the health and administrative data of our service members and veterans from the day they join the service to the day they are laid to rest.

We also recognized that many of our beneficiaries receive care in our system and also in the private sector. To fully deliver on the President’s vision and what our veterans and service members deserve, it is necessary for the VA and Department of Defense to not just succeed in interoperability between ourselves, but also with the private providers that care for our beneficiaries. That is why in June, the VA and Department of Defense agreed to a bold strategy for interoperability. This will allow us to connect through the nationwide health information network or NHIN to each other, as well as the private sector providers. In doing so, we will once again lead the way for how interoperability can look for the federal sector and the nation.

How else will technology help us practice more efficiently? How many of you have a smart phone of some type? If we can stream the latest sports scores, weather and your financial information to you in a secure manner, surely we can get access to patient data whenever and wherever a health provider needs to have it in a manner that is secure and authorized. The days of pagers and fixed computer terminals can fade into the past. By the time you finish training, your patient’s information can literally be in the palm of your hand.

At the VA, we are also exploring how to center care around the patient, rather than around the office. This approach will improve quality and convenience for patients. While nothing can replace the value of the hands-on personal relationship between a doctor and patient, that relationship can be enhanced by using tele-health and tele-medicine technology.

Such technology can be used to track patients in real time. Doing this can give a more clear picture of the course of disease and the effectiveness of treatment. Just imagine knowing how a diabetic or hypertensive patient is doing on an hourly or daily basis as opposed to an occasional office visit. It will help you understand what they need and how effective your treatment recommendations are. The VA will continue to work with other agencies and the private sector to lead the way in bringing this type of transformation into reality – a reality that will improve care while lowering costs.

In all of these ways, and others that we can just begin to comprehend, we are at the threshold of a revolution in health care through the use of information technology that will change and improve how we practice.

Government has an essential role in this process. Government can prepare the ground for business by establishing the standards that will catalyze the creativity and harness the power of the private sector to bring an explosion of new ideas in health technology. From interoperable records to tele-health, this revolution will transform our system to one that is better quality, lower cost and patient centered.

While technology can help us improve safety and efficiency, it is also important that we make certain that we provide the right care and the best care. We cannot simply hope that utilizing more resources will accomplish this. We must be diligent to make sure that what we are providing is indeed what will help patients the best, in the safest way. We can do this by carefully assessing what treatments are effective, in what situation and in which group. Such information must be disseminated to providers quickly and objectively.

The answers will not be perfect, as each individual patient is unique, but better understanding the relative effectiveness of treatments will help inform a provider’s deliberation and decision. It will not, and should not, tell you how to practice, but it can inform you to allow your judgment to be practiced more effectively.

In the technology world that we are entering, that information can come to you in the traditional forms. It can also come through clinical assist pop-up messages and other modalities that can be built into the electronic health record.

In conclusion, while this is a time of change and uncertainty, it is also a time of excitement and possibility. Our generation has been given the challenge to once again rise to the occasion and face an urgent need. Once again, we must build on the shoulders and experience of those who have come before us. From the Flexner report at the turn of the 20th century to Medicare in the 1960s, our system has witnessed the need for change before. Once again, history is calling our profession to be the stewards of our nation’s health care. It asks us to show the courage, innovation and leadership to transform our system to one of optimal access, quality and efficiency. This is your time, this is the time for the class of 2013 and all of your colleagues in this room, to rise to the occasion and be a part of that transformation that will bring this country a health system that it needs and deserves.

My best wishes to each of you as you begin your medical careers.

Thank you.