John Kitzhaber, MD
President, Estes Park Institute
Director for the Center for Evidence-Based Policy, Oregon Health and Science University
Portland, Oregon
“My career path has been anything but linear.” (1:17)
My name’s John Kitzhaber. I’m an emergency room doctor by training; I served in the Oregon legislature and two terms as governor. My career path has been anything but linear. I didn’t set out to be a doctor or a politician. I was interested in being a naturalist, you know, in the best tradition of Dr. Doolittle and William Beebe, and I went to medical school because I wanted to learn more about human anatomy and physiology to pursue my research ambitions, which were really artificial organs. I was particularly interested in artificial vision. And then my senior year in medical school, a couple of things happened. In 1968, while I was still in college — completely apolitical — the Vietnam War was going on and the Civil Rights movement was going on, and that spring, both Martin Luther King and Bobby Kennedy were assassinated, and something turned in me that very moment he died in Los Angeles that made me want to get involved in public affairs.
And when I was a senior I discovered emergency medicine, and I enjoyed the pace of it — the fact that you were accountable immediately for your choices and decisions — and it also gave me a professional base with enough flexibility to run for office. So that was sort of the journey. I got into the House [of Representatives] in Oregon, served one term and then went to the Senate, and I practiced throughout the whole legislative career because the Oregon Legislature just meets every other year, so I had that. And then I ran for governor in 1994, and I had to stop practicing; I did that for eight years.
“Statistics are people with the tears washed away…health professionals can put the tears back in.” (1:40)
I do think having medical doctors or nurses or health professionals in the legislative process is nothing but good. They bring a certain unique perspective. But in order to prepare themselves for doing that, I think they have to school themselves much more broadly than most physicians. There are physicians in the legislature of the United States Congress who bring with them sort of a narrow parochial view of their specialty, or of how medicine was practiced in the last century.
So, we need health professionals who understand problems with the delivery system; that understand the relationship between over-treating one individual and the inability of another individual to get care. And I teach some classes up at the University of Oregon Medical School (I guess it’s called Health and Science University now), towards that end. And I think there should be a required course for young doctors coming out today, or young nurses, that basically grounds them in health policy and what’s going on. Because those voices are critical.
You know, one of the reasons we ultimately got the Oregon Health Plan, and did all that work, was because I was sitting in the legislature and practicing medicine at the same time. So when we re-balanced the budget, and in one case we disenfranchised, we just dropped coverage for a group of people on Medicaid — which seemed like a sterile budgetary exercise at the time — when I went back to my ER six months later, I started seeing people coming into the ER who had lost coverage because of that legislative decision. In one case it was a gentleman with a massive stroke because he could no longer afford his blood pressure medication.
So, that connection between making health policy in the abstract and seeing the implications of it at the point of practice is very, very valuable. You know people say that statistics are people with the tears washed away. It seems to me that health professionals can put the tears back in and show what’s happening right there in their own community, and why it should no longer be tolerated.
“If you can agree on what the system ought to look like, you change the debate from the destination to how you get there.” (1:39)
I think that health care is a crisis of huge proportions, and that, because of the cost implications of the retirement of my generation, it will impact the stability of the economy; it will impact our ability to get off fossil fuel. So it’s one of those issues that just has to be taken on.
My concern with the national debate is it’s focused on how to give everybody health insurance coverage. I believe that the problem isn’t how we pay for health care, it’s what we’re actually buying, and the relationship between that and the health outcomes. So that, the problem to me is the delivery system model; it has to do with people’s expectations, and some very perverse financial incentives — and none of those change just by changing who you pay.
So the first step is to have the right diagnosis. Secondly, I think we have to describe, be able to step back and take our stakeholder hats off, and say, “Look, if anything were possible, what would the ideal system look like that would achieve certain social objectives?” And I think the Triple Aim is the best set of social objectives I’ve seen. And if you can agree then on what the system ought to look like, you change the debate from the destination to how you get there.
The analogy I use is Kennedy’s challenge to go to the moon. He didn’t say, “Let’s just go find a planet.” He said, “Let’s go to the moon.” We had a clear destination; we had no idea how to get there, but then we worked together to make that transition. And I think the same is true with health care. I think it’s not that difficult to describe an optimal medical system. We know how to do that. The issue is how do you get there, politically? And that involves recognizing that there are legitimate economic interests embedded in the current system — not because insurance companies and drug companies are bad; not because interventional cardiologists charge too much. It’s because the financial incentives have created the system we have. And when you acknowledge that and figure out how you begin to change those incentives over time, how you make investments in changing the structure of the system, you get to this new reality. And that’s really what I’m trying to do.
“The reason hospitals have the potential to be change agents: they are in every community.” (1:21)
The thing that gets people’s attention the most is when you somehow create tension between the current system and something new; that’s really what we did with the debate over our waiver in the Oregon Health Plan.
The reason hospitals I think have the potential to be change agents here is they are in every community. There’s nothing more widespread than public schools. Every community has a hospital. They’re often the biggest employer in the community; they provide health care, and they have to change themselves dramatically to fix the problem. And they bring together their board, their employers, payers; they’re just, they’re well-positioned.
If you could select 100 hospitals that all said: Five years from now, we want to look like the system I just described. We want to be a risk-bearing entity; we’re going to figure out a new governance structure; the hospital will be a part of it, but it won’t be it; you know, we’re going to manage this population. Immediately, they’re going to run into a series of cultural, statutory, regulatory obstacles that say you can’t do it. They can’t be flexible with Medicare money. They don’t have the social money from other sources in the community.
And then you basically say: Okay, here are the obstacles; let’s knock them down. And if you had 100 hospitals, or even 50 hospitals, all trying to knock down the same obstacles — some of them are federal, some at the state level — suddenly you create a high level of awareness of credible people who are trying to make it happen on the ground. And I think that’s the way you jump-start this. But, who is committed to putting the sweat equity in, and to take the risks necessary to do this?
03/02/2009
