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Almost 50 years into practice, a cardiologist says American health care is getting worse by the day. Peter R. Kowey specializes in heart rhythm disorders and ran a cardiology division for 25 years. This episode is based on his article “Why a broken health care system keeps getting worse,” published on KevinMD. You’ll hear how the lack of universal health care puts cost into almost every exam room decision, from tests to prescriptions. He describes administrators setting 15- to 20-minute visits to generate revenue, and why he says physicians ceded that control themselves. You’ll also hear why he doubts more medical schools will fix the doctor shortage, and how hard it is for foreign-trained specialists to practice here. His fixes start with basics: cheaper drugs, care for everyone, more use of nurse practitioners and physician assistants for high blood pressure and diabetes, and bipartisan pressure on lawmakers. Hear why he warns even his wealthy neighbors that no one is immune.
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Transcript
Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Peter Kowey. He’s a cardiologist, and today’s KevinMD article is “Why a broken health care system keeps getting worse.” Peter, welcome to the show.
Peter R. Kowey: Thanks, Kevin. I appreciate you having me.
Kevin Pho: All right, let’s start by briefly sharing your story, and then we’ll jump right into your KevinMD article.
Peter R. Kowey: Well, what got this all started, Kevin, was a book that we published last year called Failure to Treat. It is an anthology of twenty short stories, all true, anonymized stories about people who have been harmed, and practitioners who have been harmed, by our health care system. It provides some perspective from my point of view as a person who has practiced medicine for almost fifty years. My particular area of specialty is cardiac arrhythmias, so I take care of people who have cardiac rhythm disorders. But I’ve also seen many, many general cardiology patients, and I have a perspective from a practitioner’s point of view.
The idea was to try to begin a conversation, Kevin. As you said at the very beginning, and you’re absolutely on point, it’s not getting any better. It seems to be getting worse by the day. There’s almost no day that I pick up a newspaper and don’t see a news story about something that makes me wince as a practitioner and as a patient. So the idea here was to try to bring forward a number of issues and look for solutions.
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Kevin Pho: There are obviously so many directions we could go with this when it comes to fixing our broken health care system. In this particular article, you chose this particular angle. So what led you to write this particular article? And then talk about the article itself for those who didn’t get a chance to read it.
Peter R. Kowey: Well, about the book, by the way: We were very gratified last week that we got two national awards for it, the New York City Big Book Award and the Independent Publishers Gold Medal Award. It’s an Amazon bestseller, and it’s been very popular. I don’t really care how many books we sell. The idea is to try to get this message out to as many people as possible.
What motivated me is my mentor, the Nobel laureate Bernard Lown, who toward the end of his life was very, very sad about what’s happened with our health care system. I had several conversations with him near the end of his life, and I thought one of the best ways to pay him back for mentoring me for all those years, and for being such a great role model, was to tell the stories of people who have been harmed, in an effort, as I said, to try to find solutions.
After publishing five hundred scientific papers and textbooks and so on in academic medicine, what sent me in this direction was that I felt it was time for somebody to really speak up, to be bold about it, to bring up these problems, and, as I said, to try to get the public galvanized.
Kevin Pho: All right. Where do you want to start? What issue or problem do you want to tackle first?
Peter R. Kowey: Well, Kevin, I don’t have any problem selecting one. We in this country have failed our public. As you know, we are the only developed country in the world that does not have medical care for everyone. The fact that we do not have universal health care is a disgrace.
Now, I know that this is a political issue, and I know that some people get very upset when they hear terms like socialized medicine or Medicare for All. I’m not necessarily advocating for any of those things. But it’s pretty obvious that until everyone in this country has the opportunity to go to the emergency room if they need to, with the expectation that they can pay for it; until they can find a primary care doctor and have their basic needs taken care of; until they can get peripartum and prepartum care; until they can get vaccinations when they need them; until they can be well-fed and have good nutrition; until all these things are in place, the problems we have with our health care system are not going to be fixed.
What we have is a patchwork payment system that is highly influenced by people who want to make a lot of money. We’ve provided perverse incentives for physicians, so that they do things to generate revenue rather than to take care of their patients. The system is pretty rotten. But the basic problem with the system is that we have failed to provide good health care for common diseases and preventable diseases for a large segment of our population.
Kevin Pho: So you’ve been in practice, like you said, for almost fifty years, and I know that the lack of universal coverage has been an ongoing issue for decades now, right? Despite multiple political attempts to fix it. So from your perspective as a cardiologist over the last fifty years, how has this particular problem, the lack of universal coverage, affected the patients you see every day? Just from your firsthand perspective, give us some stories.
Peter R. Kowey: It’s pervasive, and it’s overwhelming. I can safely say, Kevin, that I never saw a patient in my office without it going through my mind that there were going to be issues from the economic perspective that would influence the way I took care of that patient. How sad is that? First of all, did I have to worry about whether they had insurance or didn’t have insurance? How good was their insurance? Would their insurance cover the kinds of tests that I wanted to order for them? And in the worst-case scenario, if they went on to require a major procedure or some kind of major intervention, was this going to be something that they could handle or not handle? That should not be a factor in our decisions about how we take care of patients.
Here’s another example, Kevin. I remember distinctly sitting in business meetings in my practice in which a suit would be standing in front of us, telling us that we needed to order more tests so we could generate more revenue for the practice. What that means is that we’ve insinuated a profit motive into the way we take care of patients, and that’s so destructive. So the fact that we don’t have a mechanism for everyone to get care at an affordable level has influenced almost everything that we do.
Think about drugs, Kevin, and you know this very well. Before you prescribe a drug, you have to sit there and think: Is it a generic? Is it on a formulary? Can this patient afford it? Can I get them samples? When I talk to my colleagues in Europe, they think that this is a joke. “What do you mean you can’t prescribe a drug for your patient who needs it? Why? What do you mean you can’t get a drug for their cardiac arrhythmia because they can’t afford it?” The book, by the way, has many examples of this situation, where patients, again in true stories, have had adverse outcomes because they were not able to access the correct care within the system.
Kevin Pho: How much of the cognitive load would you say is spent thinking about the economic burdens of the patient? Whenever you thought about a particular drug or about ordering a particular test, how much did you really have to think, “Could this patient afford it? Would this be covered under that patient’s insurance?” Again, take us into the exam room. Take us into your thought process. How much cognitive load did it take for you to think about the economic implications of the diagnostics and treatments that you would prescribe in the exam room?
Peter R. Kowey: Well, I’m the kind of person who tries very hard to get inside the head of my patient and to anticipate the issues that they’re thinking about. I try to know my patients. I try to know their social situation well enough that I can anticipate. I had some very wealthy patients for whom this conversation would be a joke: “What are you talking about? I can afford anything that I want.” At the other end of the spectrum, I had patients who were hopelessly disadvantaged.
But Kevin, I’ll tell you where this economic issue impinged on my practice in much bolder relief: the amount of time that I had to spend with my patients, because of the economic models we have, where physicians have to generate revenue at a high level. We had fifteen minutes to see a complicated arrhythmia patient, many of whom had devices. What really had a major impact, even more than the question you asked, was how long I could stay in the examination room and answer their questions. How much time could I take to think about what I was going to do with their care? Kevin, think about that. Fifteen or twenty minutes with a patient who has all these medical problems is a disgrace. It’s a disgrace that we have to run the system at that kind of level in order to generate revenue.
Kevin Pho: In terms of the pressure for you to see patients in fifteen minutes, I can obviously sympathize with that. I’m in primary care internal medicine, and it is a quantity-based system, right? Was that pressure just implicit? Or was an administrator literally telling you that you had to schedule patients every fifteen minutes? Give us a sense of what kind of pressure, implicit or explicit, you were facing.
Peter R. Kowey: Oh, it was highly explicit. Of course, I’m an obsessive-compulsive person. So if they have somebody on my schedule, I don’t want to get an hour and a half behind. I know what it’s like sitting in an examination room or in a waiting room when I have a problem, having to sit there for an hour and a half and wait for the doctor. It’s very stressful. So I always tried to run my schedule on time.
But the reason I had to see patients every fifteen to twenty minutes is that our administrators decided that’s what we needed to do to generate revenue. I didn’t have much of a voice in that decision at all. Even as a senior physician, I wasn’t really able to push back on that. I have friends who quit their profession, people like you in primary care, who said, “I can’t do this anymore because I’m not caring for my patients properly.” They either went into the concierge model, which you know quite well, or they left altogether and went into industry or retired because of the pressure of having to see patients at that kind of level.
Kevin Pho: Comment on what you just said as a senior physician. You’ve been practicing for decades. You did not leave, and you felt that you didn’t have a say when an administrator implied, explicitly or not, that you had to see patients every fifteen minutes, with a focus on revenue. We’ve talked on this podcast about how administrators do not take the Hippocratic Oath, so their motivations are inherently going to be different from those of physicians. What does it say about our profession that we feel powerless to push back against these forces?
Peter R. Kowey: It’s our fault, Kevin. Years ago, when I began, we had total control of the profession. When I started practicing in the early 1980s, and when I became chief of cardiology for the division that I ran for twenty-five years, I had an amazing amount of control over what happened within our division and within our hospital. Over the course of time, with the increasing complexity of trying to run a practice and run a hospital, we ceded control to administrators. Over time, they have assumed more and more of the responsibility and power, to the point where they have, for the most part, managed to push physicians into employee status. We punch clocks. We’re told what to do. We’re told how many tests to order. We’ve become completely dependent on administrators to tell us what we’re going to do with our time.
The real crime here, Kevin, is that young physicians coming into practice now take this as reality. They don’t have any way of comparing it with what happened in the past. They become employees and clock punchers. And when that happens, patients simply don’t receive the same kind of care that they do from people who are invested in their outcomes.
Kevin Pho: Now, in your article, you brought up many other issues with our health care system, and discussing all of them goes beyond the scope of this podcast. I’m sure we could spend hours and hours on this. One of the things you did bring up was that 40 percent of U.S. counties don’t have access to a cardiologist. As a senior cardiologist, tell us why that is and how it affects patients who simply don’t have access to a cardiologist.
Peter R. Kowey: There are shortages of just about every specialty in medicine. In our area, I guess there are a lot of dermatologists, and we have a lot of eye doctors. But when you get into things like endocrinology, neurology, cardiology, and now, because of the abortion issue, obstetrics, these are becoming critically low-interest specialties for medical students. We’ve created these, and I know you’ve used the term in some of your literature, because I’ve read it, and by the way, you do great stuff.
Kevin Pho: Thank you.
Peter R. Kowey: You’ve used the term deserts, medical care deserts. We’ve created them not just for hospitals, where we have large areas where patients don’t have anywhere to go, but also for multiple specialties, and cardiology happens to be one of them. We’re anticipating that we may be as many as 20,000 cardiologists short of what’s needed in this country before the end of the decade. And since cardiovascular disease is the most prominent disease in the elderly, and since we’re producing many, many more elderly people, you can see that we’re approaching crisis level in this regard.
The solution, again, may be to do something with our medical education system, maybe to attract more people into medicine and into the general specialties. But what’s happened is that people are gravitating to money-generating, procedure-related specialties like orthopedics and ophthalmology and are not at all attracted to the specialties where you simply have to take care of patients.
Kevin Pho: So is the answer really as simple as having more people go to medical school? I think a lot of these new graduates graduate with hundreds of thousands of dollars in debt, and you can’t really blame them for gravitating to more income-generating specialties, right? So what about the medical education system itself? Because if we just accept more people into medical school without changing the underlying structure and incentives, more of those doctors are just going to go to urban areas.
Peter R. Kowey: Oh, I couldn’t agree with you more that putting more people into medical school is not the answer. In fact, I worry about the quality of some of the new medical schools that are being created. They’re being put in areas where there are only community hospitals. The basic science departments are thin. I don’t know how well the training is going to go in these new medical schools. In addition to that, as you point out, there’s no guarantee that any of these people are going to go into the specialties where we need help.
One area that I brought up in the book that I think is very important is that we have laws that do not allow us to utilize foreign physicians maximally. The pathway for people who have been specialists in other countries to come here and practice their specialties is ridiculously difficult. They have to go back and repeat their residency, and they’re not going to do that. So we have an undersupply of physicians at a time when there are people who would love to come from other countries and practice medicine here. You know, Kevin, almost 50 percent of the primary care doctors in this country were not trained in this country. That’s an unbelievable statistic. And yet we’re choking off the supply of foreign physicians with crazy immigration policies as well as training policies.
Kevin Pho: So let’s start talking about a potential path forward, and there are so many places to start. Let me just ask this: If you were in charge of our health care system, the proverbial health care czar, where would you start?
Peter R. Kowey: Well, there are so many things that we could improve. One thing that we could certainly do is make drugs cheaper and more accessible for patients. That would be one of the easiest fixes of all time. We just take a page from other countries, where these drugs are available at a much more reasonable price. So controlling the big pharma industry and its lobbies, and getting them to be much more reasonable with regard to the way they produce and price drugs, would be a great boon for everyone.
I’ve already said it, and I thoroughly believe that having access to health care for everyone in this country would certainly be an advantage. Again, I’m not talking about the highest level of care and multimillion-dollar procedures for everybody. I’m talking about things like being able to go see a practitioner, and making better use, by the way, of our nurse practitioners and physician assistants to treat things like hypertension and type 2 diabetes. The impact of treating those diseases, and of making people better with regard to those risk factors, would be amazing. It would be phenomenal. We would be able to improve our patient outcomes to the point where cardiovascular death would no longer be the most important cause of death in this country.
So there are relatively simple things that we could do, but unfortunately it’s going to require some political might. We need to have legislators who have the stomach to enact changes in our laws that will allow us to put these things into place.
Kevin Pho: And it is a little bit grim given our political climate and how polarized it is, because any substantial solution is probably going to require some type of bipartisan support, and in this climate, that is going to be increasingly difficult. I do want to echo that there is more than one way to provide universal coverage, right? You hear things about Medicare for All, and I think there are many, many paths to the goal. If you look at European countries, for instance, there are multiple ways they provide universal coverage. Look at Australia; there are different ways it provides universal coverage as well. So I think the goal should be agreed upon by everyone, but in how to get there, there is some flexibility.
Peter R. Kowey: Yes. I live in a very, very wealthy part of Philadelphia’s suburbs, and what I tell my neighbors is, “If you think you have a lot of money and you’re protected against what’s coming, you’re out of your mind.” With the erosion in Medicaid, Medicare, and veterans’ coverage, our emergency rooms are going to be choked with people who have diseases that could easily have been treated at an earlier stage and have become catastrophic. It’s going to create a major, major problem for everybody’s health care. So nobody can think that they’re immune from the implications of not fixing what we need to fix, and fix soon.
Kevin Pho: We’re talking to Peter Kowey. He’s a cardiologist, and today’s KevinMD article is “Why a broken health care system keeps getting worse.” Peter, as always, let’s end with your take-home messages to the KevinMD audience.
Peter R. Kowey: Well, I just want people to begin to think about what we’ve just been talking about. It has to enter their consciousness. We are deluged with information about medical care. Obviously, the internet is choked with information, a lot of it, by the way, misinformation. I think people really need to sit down and think about the fundamentals of medicine, not so much the fancy-schmancy stuff. They advertise drugs for rare diseases on television, and there’s so much noise in the system. We need to get back to basics.
We need to pressure our legislators to sit down, as you said, and I completely agree, in a bipartisan fashion and come up with solutions that allow people to get care for simple diseases, things that are common, things that are highly treatable, in order to improve our public health. The vaccine issue, by the way, Kevin, has brought this into bold relief. That something as simple as getting vaccinated can become so controversial and so difficult is really kind of a crime, and it’s something that we need to work as hard as we can to prevent from happening on a larger scale.
Kevin Pho: Peter, thank you so much for sharing your perspective and insight, and thanks for coming on the show.
Peter R. Kowey: It’s a pleasure, Kevin. Thanks for having me.
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