Transcript: Renegade Top Cardiologist Tells How to Get Good Care

Dr. Michael Brickey interviews Dr. Richard Schneider

©Michael Brickey–excerpts permitted with attribution

 

MB: This is Dr. Michael Brickey with Ageless Lifestyles Radio, cutting-edge thinking for being youthful at every age. On each show I interview experts on what it takes to live longer, healthier, and happier. Our program takes a holistic approach in addressing anti-aging psychology, medicine, alternative medicine, fitness, nutrition, and wellness. Our emphasis is on innovative thinking and practices that have solid data and results.

 

Today’s guest, distinguished cardiologist Dr. Richard Schneider says because the healthcare system rewards quantity rather than quality, many doctors follow the money by ordering unnecessary tests and surgeries and cutting corners. Further, a good old boys atmosphere often discourages doctors from examining their mistakes. Dr. Schneider’s book, The Cost of Courage, describes how he successfully practiced compassionate, ethical medicine and was often punished for doing it.

 

In the first part of the program, we’ll offer advice on how you can make sure that you are getting appropriate, effective services from your cardiologist and other physicians. In the second part of the show, we’ll share surprisingly doable solutions for fixing our healthcare system and saving 30% of the nation’s healthcare costs. And I also want to mention that May 11 to 17 is Whistleblower Week in Washington, and Dr. Schneider will be testifying at that, and is also scheduled to testify before Congress. Dr. Schneider, what are the tests that cardiologists often conduct that may not always be necessary?

 

RS: Let me preface it by saying that most of the time, most of the tests that are ordered by cardiologists are necessary. But sometimes there is a real financial motivation to do tests that aren’t absolutely necessary. Tests would include those that are noninvasive testing, those which are safe and are done to establish a diagnosis, and then there are invasive tests which sometimes are unnecessary and can cause serious complications. The type of testing that would be noninvasive that might not be necessary might be doing too-frequent stress testing, exercise treadmill testing, or doing testing with nuclear or echo imaging when a plain stress test might be adequate, or repeating the tests too frequently – for example, if someone has a mild heart problem and has an echocardiogram one year, it’s usually not necessary to keep repeating it on a yearly basis. Another example would be – on the other side – would be a cardiac catheterization, which is usually safe and necessary, but complications from the catheterization can be very serious, can include a heart attack, a stroke, or a death. And at one point a few years ago, I read that the Harvard School of Public Health indicated that 40% of the heart catheterizations done in the United States were unnecessary. And I can say in my career, I saw numerous, numerous catheterizations done that weren’t necessary and that sometimes resulted in serious injury to the patient.

 

MB: 40% sounds like a huge figure, and that’s not a light operation. How is a patient to know whether the test is necessary or not?

 

RS: The most important thing is just to ask your doctor when he orders the test, “Is this really necessary? Can I be treated without this test? Is the test to find the diagnosis or is it a treatment? And what are the risks and possible complications?” Keeping in mind that, in order to ethically do a test, the benefits of the test or the procedure should always outweigh the risks, and the risks and benefits need to be discussed with the patient. That’s the number one thing to do. The other thing you can do is to ask for a second opinion. If it’s a major procedure like the catheterization, it’s not always necessary to get a second opinion, but if you’re not satisfied that this is a really necessary thing to do and it’s a little – you know, potential side effects that are serious, you’re not going to insult your doctor by asking for a second opinion. And then the other things you can do are to talk to lay people, and if possible, talk to a nurse. Nurses have no financial interest in any of these things, and as long as they know that nothing they say will be repeated, they’ll probably give you an honest appraisal.

 

MB: Possibly you could even ask the doctor, “On a scale of one to ten, how necessary is this test?”

 

RS: I think any way of asking is a good way to ask. Sometimes that would be difficult to accurately quantitate precisely where you’d stay on the scale, but I think that’s a very reasonable way to ask.

 

MB: What other procedures might be overdone?

 

RS: In cardiology, the more serious procedures, the more dangerous procedures like heart operations, pacemaker implantation are usually not overdone. But I can tell you this, that angioplasty with stents and balloons to open up arteries, has recently been shown to be inferior to bypass surgery in many instances, and the number of angioplasties being done in the last 12 months or so has actually diminished. On the other hand, if you have a serious heart problem, the alternative to angioplasty is frequently a bypass surgery, and that’s probably a little more risky. So I wouldn’t say that these procedures are necessarily overdone. But I can say that some angioplasties are definitely not necessary as people can be treated with medication just as effectively, and that’s an important consideration. What happens is the doctor gets a lot of money for an angioplasty but he doesn’t get much money for an office visit where he prescribes medication.

 

MB: I get the impression that cholesterol is the primary thing that doctors are talking about, and yet there’s probably at least a dozen factors equally important in whether you develop cardiovascular problems. Why aren’t doctors talking about the other factors?

 

RS: Well, I don’t know that they’re not, because I haven’t been in the office with other doctors, but I know that I always talked about the coronary risk factors – high blood pressure, diabetes, cigarette smoking, family history, obesity. So I think probably most doctors do talk about preventive efforts in coronary artery disease. I don’t think they necessarily talk enough about it. And frequently what will happen is a paraprofessional will spend time with the patient talking about modifying their risk factors. One of the problems we have is that doctors are too frequently limited in the amount of time that they have to spend with their patients and talk to their patients. And that’s more of a systemic problem, with the system.

 

MB: Are statin medications over-prescribed?

RS: Probably not. The first statin agent came on the market in 1988, and since that time, the mortality of coronary disease has been dropping dramatically, so statins are a miracle drug, in my opinion. My fathered died from coronary disease two years before statins were put on the market. There are very few risks for statins and they’re extremely effective, without question.

 

MB: One of the things that really impressed me in your book was you described what you residency was like at Mount Sinai Hospital and how there was just a commitment to excellence and staffing the cases, looking for any different view on what might’ve gone wrong or how to improve it. And then when you left New York and went to Pittsburgh, you found that that just didn’t happen.

 

RS: Well, it did happen, but not necessarily to the same degree, and it wasn’t as uniform. I can say that the cardiologists that I worked with when I first came to Pittsburgh, they were excellent doctors and they did really want to get everything right. But as the years went by, I encountered more and more people who felt that quality of care had to be subjugated to the politics of medicine and the finance of medicine. It became more and more difficult, the need to deal with the situation, although I was able to effectively deal with it most of the time.

 

MB: You described often when you would try to talk with a colleague about a way to improve patient care, they didn’t want to hear it.

 

RS: Some of my colleagues took it in the vein in which I meant it, which was just to improve patient care, and I always addressed the issue in private and I didn’t circulate it to anybody else. But there were people who just took offense whenever a mistake was pointed out. And I’d like to say that I always told my partners and colleagues to let me know right away when I made a mistake, which I certainly did. I just wanted to know I made a mistake so that I wouldn’t repeat it.

 

MB: One of the cases you talked about was with Coumadin and how tricky that is to get just right. Could you tell us more about what’s involved in monitoring Coumadin and how a patient can make sure that he’s got the right balance?

 

RS: Monitoring Coumadin dose requires a lot of commitment to making sure you put the time in to do it, and it has to be done in a timely fashion. Unfortunately, many people require Coumadin, and today people with an arrhythmia called atrial fibrillation require Coumadin. But up to 30% of people who require it are not getting it, in the latest study that I read. And that’s probably because it’s difficult to administer. It requires getting blood tests on a relatively frequent basis. It requires for the doctor to get those blood tests done promptly. It requires input from the doctor to the patient immediately as to whether or not to continue the same dose of the drug or change the dose and when to give the blood test. And if you don’t do it properly, the patient can have a blood clot or they can have a serious bleed, which could be potentially fatal. And I have seen cases where the Coumadin was not monitored adequately and patients had serious problems and occasionally died from it.

 

MB: So with atrial fibrillation, you’ve got two issues. One, that it’s being under-prescribed in a lot of cases, and secondly, that it’s not adequately monitored.

 

RS: Right.

 

MB: Another thing that impressed me was how many of the critical cases boil down to a very difficult decision process between is it a heart problem or is it a pulmonary problem. Can you tell us about that?

 

RS: When the lungs fill up with fluid, it can be difficult to determine whether or not it’s because the fluid is due to heart failure or it’s due to an internal problem with the lungs themselves. And this can require a lot of time and thought to determine which is the problem. Fortunately, it’s almost always a heart problem, and a lung problem directly is fairly rare. So if you guess on the side of the heart, you’re usually going to be correct. But we have tests that we can use to differentiate the two. And all it takes is a little time and effort to administer those tests and to come to the correct diagnosis.

 

MB: Is there a way a patient or family members can make sure that that process is being completely thought out?

 

RS: That kind of situation usually only occurs where it’s difficult to determine in a high-risk setting, like an intensive care unit. Well, the best way to start off with that would be to ask the doctor precisely, “Is the fluid in the lungs coming from heart failure or is it a lung problem?” And demand that you get an answer, and push it a little bit and say, “How do you know?” And then, talk to the nurse on the side, if you can – they’ll always be available – and see what they think.

 

MB: So the nurses are a wealth of information?

 

RS: They’re a wealth of information, but they’re still not doctors and they won’t be able to give you the same level of understanding and sometimes they’re going to be misinformed or won’t understand precisely what’s going on. So there’s really no substitute for talking to the doctors, but talking to the nurses is a very important complement to talking to the doctors. And you’d be surprised that a lot of the nurses think that some of the doctors are not very good and they will steer you in another direction.

 

MB: I think they’re a great source for referrals of the best surgeons and physicians.

 

RS: Absolutely. I had to decide about which heart surgeon to use for my patients. Frequently in the hospital cafeteria, I’d be sitting having lunch with the nurse and I’d ask them, you know, what goes on in the operating room, to get the real scoop.

 

MB: What should we know about stents?

 

RS: Stents are a major advance. They keep the arteries open much better than just a balloon. There are metal stents and stents that are coated with medication that prevents the tissues from re-narrowing down the artery. The technical details of which stent to use or which kind of coating to use pretty much is a question that the cardiologist answers. I don’t think there’s much in the way of patient input on that, except as to whether or not the procedure is indicated. In other words, if you’re going to have a stent, you need to be sure that the situation can’t be handled just as well with medication. And you also need to be sure that the stent is inadequate for the situation and that you should have bypass surgery instead.

 

MB: What kind of failure rate is that with stents?

 

RS: Oh, it’s probably less than 10%.

 

MB: Oh, that’s pretty good.

 

RS: It’s very good. But it also depends upon what you mean by failure. There are all different ways of measuring failure. And I don’t think it’s necessary to go through each in detail, but for the most part, more than 90% of patients do well with stents.

 

MB: Other than nurses’ recommendations, how can a patient know whether he or she has a good cardiologist?

 

RS: That’s the problem. Because to know how good your cardiologist is would require knowing how well his patients do on average, and that data is not collected. And so there’s no real source that you can go to. I can tell you that some of the most famous cardiologists in the world were not very good doctors, because I worked with them. And I can tell you that some of the most obscure cardiologists that I worked with were absolutely superb doctors. It’s very difficult to go by reputation and it’s also very difficult to ask your friends and neighbors, because that’s only a small slice, and I know cardiologists who have enormous practices that I didn’t think were necessarily very good doctors, and visa versa. That’s really a tough thing and that’s one of the things I think that we need to change the system is to make sure that every doctor is evaluated by an independent agency, preferably the same agency for all doctors so they’re done uniformly, so that the public can know who’s good and who’s not. But what we can do is you can talk to people who have gone to these doctors, talk to nurses who have worked with these doctors. And the other basic thing is to see what the doctor’s credentials are – in other words, is he board-certified (which is of course necessary to be a cardiologist)? Is he a member of a major medical society? Where did he go to school? Where did he do his residency? And in general, the better the institutions that he went to and attended school at will reflect a higher level of expertise – but that’s no guarantee.

 

MB: And currently there’s no information that patients can get from hospitals that would give any kind of report card?

 

RS: The hospitals don’t give a general report card to doctors in terms of their outcomes, and if they do, it’s not made public. Now, there is a website called HealthGrades.com which has some basic information on different doctors, but it’s not adequate to really tell you how well that doctor’s patients do.

 

MB: We’re starting to see lists of the top 100 cardiologists or physicians, and the best doctors in New York City, that kind of thing. Are those accurate?

 

RS: No!

 

MB: Okay.

 

RS: In a word, no. I know that when I was in New York where they list the best doctors in New York, etc., etc., I can tell you with absolute certainty that some of those doctors on that list – I would never allow a family member to be taken care of by one of those doctors. They become famous because they publish a lot of papers and do research and become chairman of the department or something. But those people are so busy doing research and administrative work that they hardly take care of patients. And if you don’t do it very often, you’re not going to be very good at it. I mean, you wouldn’t want somebody batting for the Yankees who only played once a week. He just wouldn’t be able to hit very well.

 

MB: It’s like having the coach play instead of the best players.

 

RS: It’s kind of like that, yes.

 

MB: Outside of cardiology, what are some of the biggest abuses or inappropriate things that you see in medicine?

 

RS: Oh, that’s a tough question. I can’t really think of a list. I can tell you, to me, the worst thing that I saw on a routine basis was patients having cardiac catheterizations they didn’t need to have, and that was the worst from my perspective. And I spent a lot of my time stopping patients from having catheterizations that I didn’t think they needed. I wasted a lot of my time on it, but it was a pretty frequent event. The other worst abuse, which is not a live-threatening abuse so it was not about care, was the ordering of unnecessary testing just to generate income, and that the worst abuses that I consider to be abuses was that cardiologists will purchase machines that are very expensive, and then in order to pay back the price of the machine, which can cost $200,000 or more, they will do the testing on that machine on as many patients as they can, whether or not it’s necessary. And this just drives up the cost of healthcare for everybody, and I just consider that a serious abuse. We’re talking billions of dollars a year on that. There’s an enormous amount of money to be made in cardiac testing.

 

MB: You’re listening to Ageless Lifestyles Radio on Webtalkradio.net. We’re talking with distinguished cardiologist, Dr. Richard Schneider. He is author of The Cost of Courage. It’s a unique book that is both a fascinating memoir and a study of how medicine works in the United. While not light reading, I found it fascinating, gripping, and often appalling. His website is RichardRSchneiderMD.com. Again, that was RichardRSchneiderMD.com. And you can get the book on his website on the home page or at BarnesandNoble.com. And if you aren’t already a subscriber to my free Defy Aging Newsletter, you’re missing a lot of practice advice on how to think, feel, look, and be more youthful, so check out NotAging.com. So what’s the solution for our dysfunctional system?

 

RS: The solution is really simple but it’s difficult to implement. What it really requires is that we measure how well every doctor’s patients do medically, and we must adjust how well they do based upon how sick they were when they first came to see the doctor, how bad is their disease. It wouldn’t be fair to look at how well the doctor’s patients do if we didn’t take into account the fact that some doctors take care of patients that are much sicker than other doctors. And the less sick your patient is or your patients are before you treat them, the better the outcome. So that’s the big hang-up, and that’s what most doctors are afraid of having them measured because it’s not taking into account how sick they are to begin with. But we can measure that. We can do this. And all of the tools, all of the scientific and mathematical tools necessary to measure severity of illness prior to treatment are already available, have already been devised and worked out over the last several decades, and it’s the same tools that we use to do medical research and to quantitate the nature of the illness in each patient. Once we do that and we know how well a doctor’s patients are doing, we also have to measure how much of resources is that doctor utilizing per patient in dollars every year. So for example – and this is the example I use in my book – is heart failure patients. So let’s say Dr. Schneider has 1,000 heart failure patients in his practice. You measure how bad the illness is for all 1,000 patients, on average, on January 1. And then on December 31, you measure it again, and you see whether the patients have gotten better or gotten worse. But it’s based upon the change in their illness and their symptoms – not where they ended up, but where they end up compared to where they started. And then you look at those 1,000 patients and you say, “Now, how much money of the system did Dr. Schneider spend to take care of those 1,000 patients? How much did he spend on testing? How much did he spend on hospitalizations? How much did he spend on surgery?” And then you look at how well the patients did and how much did he charge. It’s just like the analogy to buying a car: How good is the car and how much did you pay for it? In today’s medical system, we do not know this information for each doctor. And then the key to saving money and making sure doctors respond to this is that the doctors who have the better outcomes and use the fewest dollars to get there get paid more for each service they give to the patient – more for an office visit, more for a treadmill test, whatever it is – more for a visit in the hospital, more for a consultation. And you will – overnight, if we implement this system, we can overnight change healthcare in this country to be higher quality and lower cost. It is all based upon doctor behavior, because the doctors are the only ones who order the tests, the doctors are the only ones who can take care of the patients, and they’re the ones in charge.

 

MB: If the doctors rate the severity of the condition, they might be tempted to stack the deck a little. Are they going to be the ones doing the ratings?

 

RS: Absolutely not. The ratings will be done directly from the medical record and it will be done independently of the doctors. For example, let’s say a patient comes to see me with congestive heart failure. I do a medical history. How old is the patient? Does he have high blood pressure, diabetes, chest pain? Is he short of breath? And I a treadmill test. What is the outcome of the treadmill test? That’s numbers, how many minutes did he go? It’s all done scientifically, it’s all in the medical record, and that medical record is available and analyzed, and it’s done strictly off the data scientifically.

 

MB: Now, are we talking about every cold and flu and sinus infection, or just more serious cases?

 

RS: I think at the beginning, you have to start with just a few diseases and a few specialties to get the system up and running. And then over the decades it will evolve and become more and more universal. And, for example, heart failure is the most expensive disease in the United States right now, in terms of hospitalization for heart failure for Medicare patients. That’s the number one expense, at least the last time I looked. So we start with something like that, which is very quantifiable, very serious. And then we gradually expand it into knee surgery, pneumonia, and if it’s a skin rash, we look at melanoma and see how those patients do, and then to less severe skin lesions. But theoretically, it can be applied to any disease and any specialty. There’s just a question as to how far along you go, as to how much of this is evaluated.

 

MB: When we’re putting how much resources are used as part of the equation in evaluating doctors, it kind of reminds me a little of HMOs and the quandaries we might get into there. How do we avoid making the mistakes that HMOs made?

 

RS: Which mistakes do you mean?

 

MB: People almost universally hate HMOs because we get a bureaucracy and we’re often denied services that we thought were reasonable.

 

RS: Just basically, we need to get rid of all the HMOs.

 

MB: Okay.

 

RS: We need to put the entire country on Medicare, from conception to death. And if we do it uniformly – because Medicare takes doctors fee for service, and that we know how much we’re paying, the doctors know how much they’re getting. They’re not what we call capitated, where they pay the monthly fee. But the HMO model was done back in the ‘70s where you pay to see upfront and then the way the HMO makes money is by denying care and keeping the difference, you see. They get a certain amount of money, so the less care they can provide, the more money they make. But the problem is, if you provide less care, your patients aren’t going to do as well and your outcomes are going to get worse. By measuring outcomes, we will see that these HMOs, their outcomes are worse and their costs are higher or the same as the others, and then we’ll see that they’re just not economically efficient, and they will lose out, good-bye. They will be out of business – as long as we measure them, too.

 

MB: And part of your system is to pay doctors with good results higher rates per patient?

 

RS: Per service. When you have a patient, you bill for each service. In other words, if you see the patient in the hospital, you bill Medicare for that visit, and then the length of time you spend with the patient and other variables goes into the amount of money Medicare pays you. So there’s a whole list of every single thing that a doctor does and how much Medicare pays for it. And when you submit your bill to Medicare, every single thing that you did on that patient is on the list on the bill that you submit to Medicare, and they pay you a certain amount for each of those services that you provided, whether it’s a bypass operation or a ten-minute visit in the office or an echocardiogram or a catheterization. So each doctor has a – the amount that that doctor gets is determined by Medicare for each service. So if Medicare evaluates that doctor and finds that he has excellent outcomes and 20% less cost for each patient he takes care of, they’ll say, “Okay, your fee for an office visit, instead of $100, is now $110. And this will motivate doctors to get the best outcomes at the lowest cost. But ultimately it can’t be regulated outside the doctor. The doctor is the one that controls everything, whether they work for an HMO or an insurance company or a medical school or a private practice, the doctors are the ones that determine the outcomes of the patients and the cost and the utilization, because only a doctor can order a test or do a procedure.

 

MB: It’s kind of “The buck stops there.”

 

RS: Absolutely.

 

MB: What organizations are likely to buy in and support this, and what ones are going to resist it the most?

 

RS: I can tell you this, that the American College of Cardiology met last week, and Sunday they had a whole session on paying for quality. This is now starting to gain momentum. We’re beginning to see more and more doctor groups supporting the concept of paying for quality. There was just a recent announcement that a number of doctor groups, including the AMA and other groups, were going to be formulating ways of paying for quality, and this was done by Medicare under Mark McLellan a couple of years ago, and he was actually speaking at this symposium in Chicago about paying for quality, because he instituted a pilot try with twelve different hospitals around the country where they paid a 3% increase in fee for institutions that met certain quality criteria. And I think that more and more doctors are going to be supporting this idea as we go forward, but there’s going to be an enormous amount of resistant to it; you’re absolutely right. But there’s no other way to solve the problem. Simply put, there’s no other way to solve the problem. And ultimately, doctors will realize it’s in their best interests, because it will put them back in charge. Doctors now are frequently working for bosses whose responsibility is to the stockholders and to the executives at the HMO, and not to the patients. And most doctors really do want to do a good job, and many of my friends who are still practicing feel that they’re being prevented from doing that by the people who control them, and doctors want to be in control of their own patients and their own lives. And if they accept this system, they will be rewarded with higher income and professional autonomy that has been removed from the doctor profession and is really driving doctors crazy.

 

MB: I expect most of the resistance to come from the insurance companies, because they in effect would be out of business. Is there any way to sweeten it for them so that they would resist less, or even support it?

 

RS: No. The only way to do this is through Congress and the president. And it has to be done in a very clever way to put it through Congress. You can’t just do it. It wouldn’t work. But the way it’s being proposed now is to set up a competition, an economic competition between the insurance company and Medicare. You tell the people of the United States, “You can either get private insurance or you can go on Medicare,” the people will vote with their dollars. See, the problem is that if you run a private insurance company, you have to take a profit out of that to give to your stockholders. But if you’re Medicare, you’re working directly for the people – you don’t have to pay off your stockholders – so there is more economic efficiency. And by putting the two systems into direct competition, Medicare will provide better care for a lower cost, and that’s what people will choose. And these private insurance companies will get fewer and fewer patients and eventually go out of business because Medicare will provide better care, better service, at a lower cost, because they don’t have to take money out of the system to give to the people who aren’t providing the care – namely the executives and the stockholders. The way you set this up is you pass a law that says that insurance companies have to take everybody. Right now they only take the healthiest patients – that’s how they make money. And they leave the sickest patients to be taken care by the government, through Medicaid or whatever, Medicare. But once you pass a law that requires them to take everybody, which is a lot of what’s going on now, then they can’t do what’s called cherry-picking, where they won’t take you if you have a preexisting condition. But if we mandate that they do that, just the way Medicare does, then they’re going to have to compete on a level playing field and they’re going to lose, because they won’t be able to provide the same care for the same price, because they have a middle man, and the middle man is taking the money out of the system and therefore cannot provide the same care at the same price, because they have that overhead that they have to pay to their stockholders.

 

MB: Even though we often think of things run by the government as terribly inefficient, Medicare is actually a remarkably efficient insurance program. I think one of the tweaks, though, is that in a lot of people’s minds, Medicare is a second-class program in that a lot of doctors say, “Well, I don’t accept Medicare,” and so people want the “regular” insurance. How do we up the status of Medicare?

 

RS: Well, I don’t know what regular insurance is anymore, but I can tell you, very few people have the regular indemnity plan insurance where you get everything you want at any place, any doctor, and everything is paid for. It’s kind of – I had that kind of insurance for a long time, and the price is absolutely exorbitant now. I mean, I have friends who have that kind of insurance who are paying $18,000 a year for them and their wives. I can tell you this, that in Medicare you get exactly the same services as you get from the highest-priced indemnity plan. You choose your hospital, you choose your doctor – I don’t really know any doctors that I’ve worked with that didn’t accept Medicare, at least here in Pittsburgh. Now, I know probably in Manhattan, it’s much more difficult, again, to be on Medicare. But you need to adjust the reimbursements based upon the cost of running an office in that location, which they do do, and maybe it needs to be modified. But I can tell you that probably Medicare is the best health insurance program in the world. I can back that up. Because you have access to the best hospitals, which are in the United States, the best doctors, which are in the United States, and you have total choice, there is no waiting. For me, working with my patients, working with Medicare as a physician was much easier than working with any of the insurance companies or any of the HMOs. They always paid on time, they never put any real limits on things that I needed for my patients. And the private insurance companies, they would always give you a hard time. They do everything they can not to pay. Medicare doesn’t do that.

 

MB: Now, one of the things Medicare hasn’t done yet is really control medication costs the way VA has. Is that coming?

 

RS: Say, for example, you have a patient that comes to your office and they have heart failure – I’ll continue to use the same disease to make it easier – and you have a choice as to which medication to use. If one is the generic, which is very inexpensive, and the other is an expensive name brand, you’re going to have to think twice: “If I use this expensive medication, that goes on my cost. I’d better be damn well sure that it results in better outcomes for my patients or it’s going to cost me money!” So the doctors now are going to be looking at the literature, they’re going to be reading the science, they’re going to be looking for proof that this expensive medicine actually works better than the cheaper, older medicine. You brought up the question of statins before. We know what happened with the more expensive statins this past week, right? We found out that these new expensive drugs, in the ENHANCE study really aren’t any better than the older drugs, right?

 

MB: Right.

 

RS: It didn’t affect doctors if they were prescribing the more expensive drug because they didn’t have to show that that resulted in a better outcome. So they could do it and nobody’s minding the store. Now, for a statin, for example, I can tell you, Mevacor was the first statin when it came out in 1988 and it’s been a generic for ten years now probably, and it cost maybe, I don’t know, a nickel a pill or something like that. No one has ever compared directly the outcomes, how many heart attacks a patient has if they’re on Mevacor as opposed to, say, Lipitor, which is the biggest-selling statin, right? And Lipitor is $2-3 a pill. But there’s no scientific evidence that absolutely shows that on average people on Lipitor are going to do better than people on Mevacor, because nobody’s going to pay to do that research. All the research is done by the drug companies; they pay for it. So we really don’t know that Lipitor is a better drug than Mevacor, even though it cost 100 times a much or ten times as much. So if you’re measuring outcomes and you’re measuring costs, the doctors are the ones who are going to have to sort this out through scientific investigation to find out if these drugs are really worth the price, and the system will do that. Now, in terms of Medicare drug costs, every other country in the world controls drug prices except the United States, and we pay double, at least, what everybody else pays for a brand new medication in the world. And the drug companies’ profits are driven by their American sales, and they’re forced to sell at lower prices elsewhere. The excuse is, “Well, we have to get more money so we can do research to get more drugs.” So the result is that Americans are paying for research that benefits everybody else in the world. Why should we have to do that?

 

MB: I don’t know.

 

RS: Well, we shouldn’t. Doctors’ fees have been regulated by the government since 1992. All the HMOs, all the insurance companies base their fees on the Medicare reimbursement schedule. And since 1985 or ’86, the hospital fees have been completely determined by the government, controlled by the government through Medicare. So the idea that there are no price controls in medicine is ridiculous. Doctors are price-controlled, hospitals are price-controlled. The only thing that’s not price-controlled are the drugs. And I don’t see why pharmaceutical companies should have any special treatment over doctors and hospitals.

 

MB: Any last thoughts you’d like to share with us?

 

RS: The last thought would be that there are a lot of people who understand these issues the way I do, and many of them are in Congress, and that when you go to the voting booth, make sure that you know what each person running for office says about healthcare. And hopefully that, you know, listening to what I have to say and where we need to go, evaluate the people running for office based upon what they’re going to do to make healthcare better for everyone, and vote for the person who has the best healthcare proposal.

 

MB: Right. We’re talking with distinguished cardiologist, Dr. Richard Schneider. He is author of The Cost of Courage, a unique and fascinating book that is available through Barnes & Noble or on his website, RichardRSchneiderMD.com.

 

RS: Oh, Michael, please tell your listeners that that book is for charity and any profits from the books will be going to medical charity.

 

MB: Wonderful. Dr. Schneider, I thank you for being with us and I salute you and thank you for being a whistle-blower.

 

RS: You’re very welcome, and thank you.

 

MB: I like to have each program generate a baby step to help us live longer, healthier, and happier. I think the baby step that comes out of our interview with Dr. Schneider is that we need to carefully choose our physicians, and it’s not about picking the most prestigious physician; it’s about finding out who is very thorough, conscientious, and skilled. And one of the best ways of finding that out is to ask a nurse that works with them. For example, if you go to a large cardiology practice, you might, off the record, ask one of the nurses who they chose to be their cardiologist or whom they would send their family members to. We also want a physician who explains things and is open to questions. And if you’re particularly interested in alternative medicine, someone who is at least open-minded about choosing alternative approaches. Just as an ounce of prevention is worth a pound of cure, carefully choosing our doctors can make a world of difference in our health, and it’s best to pick them when we’re healthy, as opposed to when we’re in a medical emergency or crisis. I would footnote this by saying, when it comes to surgery, the biggest criteria is how the surgeon is at this particular surgery.

 

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Information on anti-aging psychology and the Defy Aging Newsletter, which is free, is at DrBrickey.com.  This is Dr. Michael Brickey with Ageless Lifestyles Radio. thanking you for joining us on our quest to live longer, healthier, and happier.