Bill Moyers: Money-Driven Medicine

Original Link: http://www.pbs.org/moyers/journal/08282009/transcript1.html

BILL MOYERS: Welcome to the Journal.

The world of medicine has changed radically since I was a kid in East Texas. Back then, Dr. Sam Tenney made house calls for a couple of bucks a visit. Dr. Granbury raced to a patient's side with such speed you could hear his tires screeching around the courthouse square blocks away. And if you needed a prescription, Dr. Wyatt would offer to drop it off at your door on his way to the hospital - a non-profit community hospital, by the way, run by civic-minded citizens who counted every penny.

If any of them were around today, they would surely marvel at our high-tech medicine. But as prudent folks, they would also marvel - in a horrified way, I think - at the cost of it all. How did we get here?

Maggie Mahar wanted to find out. She's one of our best financial journalists - now, after years of research, she has written: MONEY-DRIVEN MEDICINE: THE REAL REASON HEALTH CARE COSTS SO MUCH. During their summer recess, if every member of the House and Senate would read it before returning to Washington, the outcome of the health care debate might be very different.

In this broadcast we will share with you a film based on Maggie Mahar's work. The book and the film couldn't be more timely as our country wrestles with what to do about money-driven medicine.

DR. NORFLEET: All right, I'm Dr. Norfleet. And Joel has been talking to you about the build-up pain you're having right now.

MR. WILLSMALL: Yes ma'am.

DR. NORFLEET: Is it the same kind of pain you've had before Mr. Willsmall?

MR. WILLSMALL: Uh, no. It started about a month ago.

DR. NORFLEET: The pain you are having now?

MR. WILLSMALL: Yeah.

DR. NORFLEET: And who is your primary doctor?

MR. WILLSMALL: I don't have one right now.

DR. NORFLEET: Okay. You've been admitted to the hospital before though? You've been here before?

MR. WILLSMALL: I've been? I was admitted to the Centennial Hospital.

DR, NORFLEET: Okay.

MR. WILLSMALL: I had chest pains and that's when they found the hepatitis.

DR. NORFLEET: Oh boy. Hepatitis B or C or both?

MR. WILLSMALL: Both

DR. NORFLEET: Wow! You have a history of ulcers or anything like that?

MR. WILLSMALL: No ma'am.

DR. NORFLEET: And you haven't seen anybody else about this, huh?

MR. WILLSMALL: No ma'am.

DR. NORFLEET: Okay.

MR. WILLSMALL: I went to the downtown clinic cause when this happened I wasn't able to work. I lost my job. I lost my apartment.

DR. NORFLEET: Okay.

MR. WILLSMALL: And so, I'm just trying to get help.

DR. NORFLEET: Yes, Sir. We are going help you, okay?

He's complaining of vomiting blood. It's been going on for a month so it's not really considered an emergency anymore. It's considered a chronic problem, but we get a lot of patients like that, that the emergency department is the only place they know they can go to, to maybe address their problem.

He didn't have the luxury of having a primary care provider, which is a luxury in this country, which is kind of sad. We're like the richest country, you know, and a lot of our people don't have doctors so they use the emergency department in order to see a physician.

NURSE: Say, "Ah." You've got a lot of congestion in the back of your throat. Do you feel like its kind of sitting there?

DENTIST: Well, that second to last tooth is infected and the very back tooth looks broken off.

PATIENT: All right.

MAGGIE MAHAR: Over the last 12 years a number of people visiting America's emergency rooms has soared. Yet here's what's surprising: The number of low-income people going to ERs has not increased. The increase has come almost entirely among middle-class people and many of them have insurance.

NURSE: Whose insurance do you have?

PATIENT: Blue Cross.

NURSE: Do you have your card with you?

PATIENT: Yeah.

MAGGIE MAHAR: So why do they go to the ER? Why aren't they seeing their own doctor? Many people think that they know what's wrong with the health care system in this country. Millions of people are uninsured. And sure, that's part of the problem. But that's not the whole problem. The whole problem is bigger than that.

DR. JOHN NIXON: I am on top here. Any problem up there? Any problem in the back?

DR NIXON: There're just not enough resources out there for, not only your uninsured patients, but also your insured patients. Insured patients have a problem also because their doctors, when they call their office and says, "I need to see?" ? "We can't see you for three weeks." "Well, what am I going to do for three weeks?"

DOCTOR: Open your mouth.

Health care costs keep going up, up and up and up. But the access seems to be going down down down down.

All right. Do you need anything for pain right now? You do? Okay, we'll get you something all right? We've got to run some tests and we'll be back.

PATIENT: Okay, thank you.

I'm just glad, you know, that there's a place to come to, you know. I mean, dying is not no big deal to me, but you know, people have to go through a lot before they get there.

MAGGIE MAHAR: When I was a financial journalist at Barrens, I wrote many stories about health care. And what I learned was that much of what we think we know about health care isn't true. And much of what is true is counterintuitive. So eventually I decided to write a book about health care. And when I did I knew I wanted to talk to a lot of doctors. So I began putting out phone calls. I didn't know most of the doctors I was calling. I was hoping that maybe 20 percent of them would return my call. To my utter surprise 5 out of 6 of them called me back. And they talked. They talked for 30 minutes. They talked for longer than that. They said, "Please, we want someone to know. Please tell people." To a man and to a woman what they were most passion about was the declining quality of care in this country. Not about how much they were paid or how much they weren't paid. They were concerned about the quality of care, about what was happening to their profession and how little power they had to do anything about it.

DR. DONALD BERWICK: It is, I guess, politically correct, widely believed, that to say that American health care is the best in the world. It's not. There's a much more complicated story there. For some kinds of care my colleague Brent James calls it rescue care. Yes, we're the best in the world. If you need very complex cardiac surgery or very advanced chemotherapy for your cancer or some audacious intervention with organ transplantation, you're pretty lucky to be in America.

You'll get it faster and you'll probably get it better than in at least most other countries. Rescue care we're great. But most health care isn't that. Most health care is getting people with diabetes through their illness over years or controlling the pain of someone with arthritis or just answering a question for someone who is worried or preventing them from getting into trouble in the first place. And on those scores: Chronic disease care, community-based care, primary care, preventive care. No no, we're no where near the best. And it's reflected in our outcomes.

We're something like the? We're not the best health care system in the world in infant mortality rates. We're like number 23. There is an index that is used in rating health care systems, which is the rate of mortality that could have been prevented by health care. There are at least a dozen countries with lower rates of preventable mortalities than the United States and not one of those countries spends 60 percent of what we do on health care.

MAGGIE MAHAR: Dr. Donald Berwick is a pediatrician and a revolutionary, really. He wants to overthrow a health care system he sees shot through with waste, inefficiency, self- interest and disrespect for patients. Berwick believes that the people working in our health care system are by and large dedicated and caring people, but they're stuck in a stupid system. And he calls that a national tragedy.

DR. DONALD BERWICK: If you look at the way we pay for care in the country and say, "Well, what is the underlying theme here?" We pay for doing things. A piece of surgery, performing a test, doing a procedure. Even a visit is a thing. So specialties or medical practices that do a lot of things, a lot of tests, a lot of surgeries, a lot of procedures; They'll tend to be the higher income earning specialties.

Medical students leave medical school today with enormous debts. Primary care specialties are the lowest paying. If you have a choice between taking 15 years to pay off your debt or seven, you might decide on seven, and that means you can't be a primary care doctor.

DR. DAN LARSON: I wonder what your blood pressure is first thing in the morning.

MAGGIE MAHAR: What's interesting about the fee schedule is that it's all about what it costs the doctor to produce the service in terms of time and education. Never does anyone ask, "How much benefit is there for the patient?" This might be a service that, on average, lengthens the patient's life by 5 months, as opposed to having your diabetes controlled for 30 years, which means that you live a lot longer and you never have an amputation. And yet we would pay much more for that technically very skilled procedure that gave you another couple of months, because we look at it entirely in terms of the work on the part of the doctor rather than the benefit to the patient.

DR. DAN LARSON: He has a very soft, like maybe one or maybe two out of six systolic near the apex. Take a listen; let me see if we've ever evaluated that...

MAGGIE MAHAR: So we don't value primary care doctors, generalists, family doctors highly at all. The compensation is relatively low and that's why we have fewer and fewer of them.

DR. DAN LARSON: Albany Med's Internal Medicine residency this year, I believe, none of them are going to primary care. They're all going to sub specialize in cardiology, gastroenterology, endocrinology, etc. I believe it's none are going into primary care.

STUDENT: I think I can hear it. It's very soft.

DR: DAN LARSON: Yeah. It's very soft. It's a little mid-systolic thing. It's probably nothing.

KRYSTAL IRIZARRY: Finances does play into the decision. People say that going into primary care can be a burden compensation-wise and the worry about their future. What does the future hold in terms of health care? It's really hard to make a decision. I wish there was an easy way.

DR. DAN LARSON: If the dollars to dollars ratio were even vaguely similar to specialty and primary care, I'd choose it again every time. I like the variety. I like doing different things. I wouldn't like doing the same thing all day long. And I'm willing to take an income hit to be primary care, but it's affected the quality of primary? the ability to deliver quality primary care in this country, because not enough people are going into it and, makes it harder to put together an integrated system. And everyone pretty much acknowledges that if someone doesn't have a primary care doctor they go to multiple specialists, there is more duplication of services at higher total health care cost.

KRYSTAL IRIZARRY: Do you have any pain when I press in your stomach?

LARRY CHURCHILL: There are very few relationships in which we're asked to take off our clothes and be examined by people with the idea that it's going to be safe to do that and tell them about intimate parts of our history that we probably don't tell anyone else about. That makes it special. That's making oneself vulnerable and sometimes a fairly profound way. Or going under anesthesia for an operation. If someone says, "I'm going to put you to sleep and we're going to cut you open and do certain things to you and it is all going to be fine and good for you," that's a pretty big leap of faith.

MAGGIE MAHAR: Larry Churchill is a bio-ethicist and one of the heroes of his profession. A discipline that struggles with the hardest moral questions regarding medicine. He doesn't just ask his students to wrestle with end of life care or stem cell research. He takes a clear-eyed look at the most difficult ethical questions regarding how you deliver care in a profit driven system.

LARRY CHURCHILL: We're now treating medicine as if it were an industrial product. Through put. How many units of care can you deliver? The idea that you are going to see a patient on average for between 12 and 15 minutes, no matter what their condition or how many kinds of problems they have or how complicated their diagnoses or how much reassurance they might need is an idea that you can treat medicine like a production line product and you can turn out patients in the same way like we produce widgets. That's a commercialization and an industrialization of the relationship. So this is a system which is fundamentally broken in terms of the kind of conflicts it raises in the minds of physicians and, also, in the minds of the patients.

DR. ANDREY ESPINOZA: Hi. Dr. Espinoza, nice to meet you. How are you? Karen, daughter? Wonderful, pleasure. Okay. Dr. Lynn was kind enough to send you in my direction is that correct?

PATIENT: Yes it is.

DR. ANDREY ESPINOZA: Do you have an understanding of why you're here to see me?

You can't just fix things in medicine. Medicine is a process. It's a duration of treatments that occurs over the course of somebody's lifetime. Yeah, there are things that we do that are very systematic and very matter of fact, so to speak, where you fix and "boom" they're are on their way, but it's just not a good way to develop a relationship. You need a rapport, you need trust, you need that patient, you know, having the ability to say, you know, "Yeah, Dr. Espinoza, that's my doctor."

DR. ESPINOZA: How've you been?

PATIENT: Fine.

DR. ESPINOZA: The thing I miss most is being able to sit in a room and talk to a patient for an hour. But, you know, we're so compressed with our time and the amount of patients we have to see, you know, 15 minutes is a long time these days. That's a long time. Basically, you know, you get on the assembly line.

DR. ANDREY ESPINOZA: Have we met before?

PATIENT: I think so.

DR. ANDREY ESPINOZA: Just get hooked up and the chain keeps moving.

Hello.

It doesn't allow you to have an intimate relationship with somebody without someone else trying to always pry, you know, that relationship apart.

PATIENT: Because you had told me to go to White House, I think, and I couldn't get there because they told me my insurance wouldn't cover it.

DR. ESPINOZA: Ah, okay.

The insurance companies, you know, are clearly in the room with us. You know, employers are in the room with us. You know, you get into these issues of out of network, in network; we're only going to pay 20 percent of your hospital visit versus 50 percent if you go to this hospital. These are all brokered deals and negotiated contracts and things like that, that in larger insurance companies have with specific hospitals, which specific testing centers. You know, so you're dealing with a lot of things that, you know, this is not stuff that's taught at medical school, this is not stuff that, you know, your partners are familiar with other than being exposed to it. You know, and we've kind of turned the blind eye or done the ostrich thing with, you know, burying our heads in the sand saying, "You know what, we're just doctors we want to just deal with what we do." But all of those other entities now live in our bed, in our bedroom with us. You know, you can't just pay attention to your wife and go to sleep at night. You're sleeping with six or seven other people that are trying to break your marriage up. That's a big problem. That's a big problem.

DR. DONALD BERWICK: When you go see the doctor and the doctor listens to you and then sends you a bill, there's profit in that bill. That's the doctor's income after he or she has paid the receptionist and the lights and heat and the rent and the equipment. He keeps the rest. That's profit. Just as long as it's a human enterprise, yeah, at some level, someone's got to make some money or why would? they won't do it. So we're going to have profit even if you call it a non-profit system. What are the incentives? Right now the incentives in America are if you want profit, do more. You make money by doing stuff and there's no limit. So we do and do and do and we get this oversupply, this excess activity because that's how people, hospitals, doctors make money.

DR. ANDREY ESPINOZA: Carl, you gave him already a little cocktail from the bar. All righty. If you need anything more, just let us know. Right now you are going to get a little bit of a local anesthetic down here in your leg. Let's start with the right heart.

You know, if you're a hammer, everything looks like a nail. You know, I'm an interventional cardiologist and that's what I do for a living is I fix blockages.

Six front checks B35, please.

Does the hospital like you doing lots of procedures? Sure, you know, these procedures are reimbursed, fairly substantially. You know, even within your own group there is a component of productivity. You know, you wish things would just be about taking care of patients and doing the right things but, you know, are there external pressures? Absolutely. Absolutely.

PATIENT: Do you have to push the cath in or does it find its way just naturally?

DOCTOR: Um, all roads lead to Rome.

PATIENT: Terrific.

DR. ANDREY ESPINOZA: But, at the end of the day, if you just remember the fundamental principle that you have to have done something for that patient in order to make them feel better, live longer, you know, engage in a lifestyle that they weren't able to engage in before, and if you stick to those principles, it allows you not to, kind of, drift from what you know is right and fall in to this arena where, you know, you're just slamming a stint in every blockage that you see. Because if you did that, then clearly it becomes? I would hate to use the term immoral, but it becomes an issue where you are doing things just to do them, not because it's the right thing to do.

DR. LARRY CHURCHILL: There's an awful lot of technology involved even in ordinary outpatient kind of encounters now. We have been so good at finding new and innovative ways to treat illness, and we love this. The idea that technologies can be turned into cures is really a fundamental thing in our society.

DR. JIM WEINSTEIN: I'd like to suggest that if we looked at the population of people with a problem: Back pain. And said how many MRI's do you think we need to do as a nation? We could probably cut the number in half and not have hurt anybody. Yet we keep opening more and more MRI machines and do more and more pictures. They're beautiful, they're incredible- incredible technology. But then that causes somebody to have to make a decision about a back surgery that maybe they didn't need.

DR. DONALD BERWICK: I think the main driver, the difference between our costs and other countries costs that have health care systems as good or better than ours, is supply-driven care. It's this work that Elliot Fisher and Jack Wennberg have explored at Dartmouth. It's that we overbuild and, therefore, we use, and there's no limits, there's no cap, there's no control. And so we just spin the wheel.

MAGGIE MAHAR: What's truly staggering is how much waste there is in our health care system. Up to one out of every three of the more than two trillion dollars that we spend is wasted on ineffective, often unproven procedures, overpriced drugs and devices that are no better than the drugs and devices that they're replacing. Unnecessary hospitalizations, unnecessary tests. Now this may seem like an overstatement. I mean, how can it be that 1/3 of the money is wasted? We actually have close to three decades of research done by doctors at Dartmouth University proving how much waste there is in the system. What the Dartmouth research ended up doing was looking at health care all across the country and what they discovered is that in some high treatment states, like New Jersey, Medicare was spending 20 percent more per patient than the average. And in other low treatment states, like Iowa, Medicare was spending 25 percent less than average. They tended to focus in on what happened to patients during their final two years of life.

So in that way you're comparing apples to apples, pretty sick patients, and they began looking at sick patients who had the same disease etcetera- Finding these enormous differences in what Medicare spent. Some people said, "Well maybe patients in New Jersey are simply more demanding than the stoic citizens of Iowa." But, in fact, very few people demand a chance to spend more days in the hospital during their final two years of life. Very few people cry out for a chance to die in an ICU or to have that fourth procedure or to be poked and prodded by eleven or twelve specialists during your final six months of life. In the states where Medicare spends more, these are the things that happen to people.

They're getting more aggressive, intensive, and expensive care. And here's the stunner: The outcomes are no better. Often they are worse on average in states like New Jersey or New York or California than they are in low treating states like Iowa or North Dakota.

RASHI FEIN: You have a situation where the doctor provides a service, is paid for providing this service, and controls, to a significant extent, the demand for that service. It's not I saying, "I'm going to get a high definition television." This is a doctor saying, "You ought to have a high definition television." More correctly, "You ought to have an MRI or a cat scan. It's called for in this situation." Who in the world? I don't have the ability to say "Is this MRI necessary?"

MAGGIE MAHAR: The fact of the matter is that insurance companies tried saying no in the 90s, in that era of manage care, when the great many HMOs would say, "No, we're not going to pay for that." The problem is that HMOs made their decisions on what they are going to pay for based, too often, simply on cost. If something was too pricy, they would say no. But they weren't looking at the quality of the procedure. They weren't asking, "Well, would it really benefit the patient?" They were simply saying, "Well, where does it fit on our schedule of costs?" So, sometimes, they denied ineffective, unnecessary, expensive care and sometimes they denied very good, effective, expensive care.

There was a backlash, needless to say, in the media, on the part of patients, on the part of doctors, so by the late 90s HMOs began to say, "Okay, okay, we won't try to manage care. By and large, we will pay for whatever Medicare pays for. Medicare tends to pay for whatever the FDA approves. We'll just pass the cost along to you in the form of higher premiums." And that's why, since 1998-99, premiums have just skyrocketed.

REPORTER: In fact the average total premium for a family of four last year topped ten grand.

REPORTER 2: Doctors here in Boston say they're seeing an increasing number of patients who cannot afford the most basic preventative health measures, like a blood test.

REPORTER 3: 72 million Americans had trouble paying for medical care last year.

REPORTER 4: Hospital bills are now a leading cause of personal bankruptcy.

DR. JAMES WEINSTEIN: I think it's interesting that a country that has a 12-trillion dollar budget spends a sixth of it on health care. And our work would suggest that we're not spending it wisely.

The Dartmouth slogan is "Vox clamantis in deserto," which is that voice crying out in the wilderness, and I thought it was a good analogy for me because I came here because I heard another voice, Jack Lindberg, talking about the disparities in the delivery of our health care system and the irrationality of its utilization. And, now, having been here for 12 or so years, I realize it's an uphill battle. You can't fight city hall, but we're going to try.

MAGGIE MAHAR: In the early 1990s Dr. Jim Weinstein made a courageous decision. He decided to walk away from tenure and an endowed chair in the University of Iowa to go to Dartmouth, where he would participate in devising ways to help patients become involved in making decisions about their own care. As a surgeon, Weinstein had long felt that patients just weren't getting a fair shake, as he put it. They weren't getting the information they needed about the risks of treatments. Too often, informed consent was informed persuasion. Ultimately, illness in his own family would drive that lesson home.

DR. JAMES WEINSTEIN: My daughter's name is Brieanna. She had beautiful blue eyes, curly brown hair; your first child, the light of your life. 13 months later I get a call from our pediatrician saying, "Could you come over to the hospital?" And I walk into the pediatrics hospital and I ask my wife what's wrong and she says, "They won't tell me. They won't tell me." The doctor walks in with about, it seems like, 10 other people other people. Very intrusive. And said, "I think your daughter has leukemia and we need to treat her, immediately."

The protocol for a treatment was very intense chemotherapy. She would lose her hair quickly. She would be sick. She would develop sores in her mouth. She wouldn't be able to eat because of sores from the chemotherapy in her esophagus. She would have all kinds of rashes. Her blood counts would be almost zero so her risk of infection would be very high. We couldn't take her any place. She had to be protected. And it sounds, "Well, that's not so bad, we can do that for a week." But the protocol was for 3 years. She did pretty well for about, I think, 2 years and then the leukemia came back. And they said, "We need to re-induce her with the bad medicines again and we have to consider brain and spinal radiation.

So spinal taps every day for three weeks." I said, "I don't get it. I mean, you just told us if we followed this protocol, these are the results. We did everything you said and it is still not working. And now you want us to do something worse." "Well, you have no choice and if you don't do that we will sue you." I said, "What?" "If you don't do what we tell you, we'll sue you."

MAGGIE MAHAR: Why would doctors threaten to sue a parent whose child is dying? In all probability, the physicians were concerned that if they didn't followed the protocol and go on with the further treatment that they had planned to give her, they might be sued for malpractice. Even though the doctors couldn't explain the protocol or give them any assurance that they knew that the next treatments would do Brieanna any good.

In a way, I think it's a response to the uncertainty that they say, "We are the doctors. We know what we're doing and this is the way we do it and this is what we do next." And if anyone, whether it is a resident, a patient or a relative, says, "Well, why?" They say, "Because it's the way we do it. Period."

DR. JAMES WEINSTEIN: You know, doctors are trained, I hope, in every case to think about what's best for the person that they are taking care of. They're trained to give medications, to do operations, to measure different tests with blood sugars or blood pressures. They're not really trained well in this decision process of giving information to patients to empower them to make decisions. That is a big short fall in the American health care system.

DR. DONALD BERWICK: We have really good data that show when you take patients and you really inform them about their choices, patients make more frugal choices. They pick more efficient choices than the health care system does. Wonderful work of a researcher named Annette O'Connor studied patient shared decision-making with respect to surgery. What she found across a range of studies was when patients actually got to participate in the decision, surgery rates fell by almost 25 percent. And satisfaction in outcomes improved. So an activated patient really engaged. I'm not talking about payment here. I'm not talking about shifting burden of cost. Just engaged with knowledge and shared decision- making. Better outcomes, lower cost, higher satisfaction. You know, what more could you want?

COMMERCIAL: Intensive care requires a finely orchestrated team led by physicians and nurses passionate about patient care.

COMMERCIAL 2: Some of the world's finest?

MAGGIE MAHAR: It's interesting how hospitals advertise. Who would make a decision about where to have their baby or where to be treated for cancer based on an ad they saw on TV?

COMMERCIAL 3: Number one for heart surgery in New York State.

COMMERCIAL 4: A magnet hospital for nursing excellence.

MAGGIE MAHAR: Hospitals are not advertising to the patient. Hospitals are advertising to doctors. Hospitals don't have patients, doctors have patients. And hospitals want doctors to bring their well-healed, well-insured patients to that hospital.

COMMERCIAL 5: Our award winning full service cardiology department has been nationally recognized as the best in the region. And in the?

MAGGIE MAHAR: Hospitals have engaged in, what many call, a "medical arms race".

COMMERCIAL 6: Using advanced micro technology physicians determine?

MAGGIE MAHAR: Typically, 4 or 5 hospitals within a 5 mile, 10 mile, 15 mile radius will all buy the same technology because they're competing with each other.

COMMERCIAL 7: When you need us, rest assured, we will deliver an exceptional performance.

MAGGIE MAHAR: One time Dr. Donald Berwick called a hospital in Texas and said, "We've heard you have a very good procedure for treating a particular disease. We'd like to learn more about your protocol so other hospitals can use it." And the hospital said, "We can't tell you that. It's a competitive advantage in our market that we're better at treating this disease and it is very lucrative. So this is proprietary information."

DR. DONALD BERWICK: We believe in markets, right? Isn't that the American way? Well, markets mean competition. Isn't that the American way? Competition makes things come out right. Well, what does that mean in health care? More hospitals so they compete with each other. More doctors compete with each other. More pharmaceutical companies. We set up war. Wait a minute, let's talk about the patient. The patient doesn't need a war.

MAGGIE MAHAR: The patient isn't the center of a collaboration. The patient is the victim of a competition. There's a saying in Swahili, "When?" I can't remember this one? "When the elephants fight the grass is trampled." The patient is essentially the grass.

SONG: If you've got the money, honey, I've got the time. We'll go honky tonkin'. We're gonna have a time. We'll hit all the night spots, dance, drink beer and wine. If you got the money, honey, I've got the time.

DR. CLIFTON MEADOR: Somebody says, "Nobody in Nashville makes anything. We just do stuff and people send us money." I've been told they never had a recession in the history of the place. This is music row. Every one of these houses is now a recording studio. There's Love Monkey Music, Flashville, Sharp Objects Music, Seasac, whatever that is. This is the heart of "music city" USA.

Here's what a nurse told me. "Tell patients to remove the foil from a suppository before insertion."

MAGGIE MAHAR: Clifton Meador has had many careers. He's been an author, a family doctor, an epidemiologist, a health care administrator and the youngest ever Dean of the University of Alabama Medical School. Over the years, he's watched the business of health care turn into a driving force in the US economy. Much of it headquartered in Nashville.

DR. CLIFTON MEADOR: This is Marilyn Way. Marilyn Way is a center road of Marilyn Farms. Marilyn Farms is a huge complex. The predominant business in here is health care corporations of one sort or another. This goes on and on for over a mile here and this is not called for-profit hospital row, or anything like that, but this, this is the equivalent of the music row that we went down for the recording industry.

SONG: If you've got the money, honey, I've got the time. We'll go honky tonkin'. We're gonna have a time. But if you run short of money, I'll run short of time. 'Cause you with no more money, honey, I've no more time.

DR. CLIFTON MEADOR: This is titled "The Nashville Health Care Industry, The Family Tree 2006." Every little square here is a health care business industry or spin-off. We have 3 mother corporations here: HCA, which is the Hospital Corporation of America, spun off all of these. Hospital Affiliates, which is a spin-off of HCA, spun off all of these. And Health Trust, which is a spin of Hospital Affiliates and HCA, spun off all of these. So this is a massive, industrial health complex that's headquartered here in Nashville.

MAGGIE MAHAR: After World War II, while other countries let their government begin to intervene in health care to make sure everyone got care, to regulate it to make sure it was good care, in this country doctors very, very strongly opposed any government involvement or anyone being involved in telling a doctor what to do. After Medicare was passed in 1965, elderly patients were getting far more care than they had been before then.

Then that's when our industrial medical complex, I would say, took off. By the early 70s, there were so much money involved that suddenly people began to say, "You know what? Medicine is too important to be managed by doctors. We all know doctors are bad managers. What we need are businessmen managing health care." And that's when health care went from being physician centered and controlled, to a large degree, by doctors to being controlled by the corporation and the CEOs of those corporations.

And, over time, more and more the CEO of the Hospital would not even be somebody with a MD. He would be somebody with a MBA. And CEOs bent on growth, bent on higher quarterly earnings, quarter after quarter, and year after year, are always pushing for more sales, more revenues, more and more and more. It produces more. But more may not be better for our health.

DR. DONALD BERWICK: I've heard it said that the official bird of health care is a crane. Look around at any hospital in your community there's a crane on top adding rooms. You know, we just, we overbuilt it. And then, having overbuilt it, we use it and then we think using it is necessary. It's a spiral.

RASHI FEIN: The worst thing that could happen to a director of a hospital is that everybody, all of the sudden, would be healthy. I'm not saying that he's overjoyed when there's an epidemic. Clearly, he isn't. I'm not saying that he's overjoyed when people are sick. Clearly, they're decent folks. But they're running something where what they are selling is hospital beds.

MAGGIE MAHAR: If you can believe it, Rashi Fein has survived 5 decades of the battle for health care reform. In 1953 he served on President Truman's commission on the health needs of America at a time when Truman was pushing for universal coverage. Then he worked with JFK when he fought unsuccessfully for Medicare, a battle that LBJ would later win. As a professor of medical economics at Harvard, Fein has never given up. He firmly believes that medicine should not be all about money. As he puts it, "We live in a society not just in an economy."

RASHI FEIN: Well, we spend more than any other country and we spend a higher percentage of our gross domestic product and our gross domestic product is larger than most other countries'. So we are spending per capita one heck of a lot more than anybody else, which ought to be disturbing, if only because there are lots of other things we could be doing with money. We could have more money for education or more money for infrastructure or more money for bridges and transportation or we could put money into high- speed trains or we could have tax cuts.

On the other hand somebody could say, "Well, we have chosen to spend money on health care and that's also a good thing." True. But interestingly, disturbingly, frighteningly, pick your own word, we spend more money and we are not healthier. We don't live longer. We don't seem to be getting as much value for money.

LARRY CHURCHILL: It shouldn't be any surprise that there is a huge disconnect between the amount of dollars that actually poured into health care and the health indicators of a population because this system was not designed to serve this end. That's a fundamental realization that we need to come to. And until we do I think, you know, we'll still be trying to tinker with the market in some kind of funny way. Just a little tweak or adjustment to make it work better, but it was never designed, actually, to meet health care needs.

DR. JAMES WEINSTEIN: We got through and had a few weeks over the years of no treatment and everyday without a smile. Ever. She was a great big sister. They had a lot of fun together as sisters. I was in Germany giving a lecture and I could tell in my wife's voice something was wrong when I called home. Gone one day. And she wouldn't tell me that she'd had another relapse. I got home from Germany, and she said, you know, "Brieanna relapsed again." So I picked my daughter up and I hugged her.

You know, said, "This isn't possible. We've done everything." So back to the doctor. Another protocol. Radiation she has to be put to sleep for, she has to be taped down onto a table. Imagine the effects of radiation on your child's brain, on the spinal chord when it's developing. Will there be brain damage, doctor? "Oh, your daughter's so smart, there'll be no problem." Will she get a secondary tumor from the radiation? "Oh, it's possible, but it's twenty years away." "Oh, okay. I guess I'm supposed to just accept that." We take her for radiation.

She'd have to go for five days in a row. They'd put her to sleep. She'd come home and she, we couldn't comfort her. We had to put padding all around the room so she wouldn't hurt herself. It upset her so much and bothered her brain so much. Am I helping her? Am I hurting her? Is this barbaric? Is this treatment? Eventually, she had her final relapse when she was twelve. Her sister, Shelsey, is probably about eight at this time. And I said, "Shelsey, I think your sister's going to go to heaven soon."

And she grabbed my hand, and she said, "Daddy, that's okay." She said, "I always thought heaven is where life is and that life is just a dream." I said, "Shelsey, I hope you're right. I hope this is just a dream and that we're going to go some place where life really is." And I've always? that's such a profound statement, for anybody. It made such incredible sense to me. When Shelsey and I went for a walk, her sister died.

DR. KEITH JUNIOR: Good morning, Ms. Elma. How you doing?

ELMA: Hurting, right now.

DR. KEITH JUNIOR: You're hurting?

ELMA: I hurt real bad. My pain is from here all the way up.

DR. KEITH JUNIOR: I'm sorry. I'm sorry. I'm sorry. It hurts that bad?

ELMA: Yes.

DR. KEITH JUNIOR: When did this first start?

ELMA: Yesterday.

DR. KEITH JUNIOR: What time yesterday? That hurts just touching you? That hurts.

ELMA: Up here when you touch me.

DR. KEITH JUNIOR: This doesn't hurt?

ELMA: No. It's just uncomfortable, but it doesn't hurt.

DR. KEITH JUNIOR: Medicine is everything I thought it would be and a whole bunch of things I didn't put into the equation. But I just love doing what I do so much that it just doesn't bother me to do those extra things. I'm willing to go the extra mile, because, hey, this is somebody's mother, this is somebody's father, this is somebody's brother. And if I don't do right by them, just understand, people die in my profession. Unlike other professions where, oh, I get a recall, I'll tell you what, I'll give you a free sandwich? No. I can't get you a free momma. You can't have mine. Mine is good. And you just have to keep the one you've got and I'm going to help you do things to keep her around.

Does it hurt to lift your arm?

PATIENT: No.

DR. KEITH JUNIOR: You don't have any problem combing your hair?

PATIENT: No.

DR. KEITH JUNIOR: Has anyone ever told you that you have high blood pressure?

PATIENT: It just happened today?

DR. KEITH JUNIOR: No, no, no. I don't believe that.

PATIENT: I was upset, because I got here. I was supposed to see Dr. Knox or somebody, so she was not here.

DR. KEITH JUNIOR: Well, she's not here anymore.

PATIENT: Well I don't know. You can take it again because I never had high blood pressure.

DR. KEITH JUNIOR: What I try to do is to make sure that I inform my patients and get them to understand what's going on with them. Inform them of what's going on.

Yeah. She may not have got it right. It's even higher. You should have taken the one she gave you.

You know, let the patient know. You've got a stake in it. It's not something magical I'm going to do, you know, wave my wand and you're going to be better. I don't. I mean, you've got high blood pressure; you will have high blood pressure when you leave here. But I'm going to give you a way in which you can manage the problem. And, so, manage the problem. Just don't stand there. Do something.

Anything change about your family history?

PATIENT: No.

DR. KEITH JUNIOR: No chest pain or shortness of breath?

PATIENT: No.

DR. KEITH JUNIOR: Prevention is the key and we in this trench need to make sure we prevent certain things, rather than wait for certain things to happen.

PATIENT: No, I get headaches. I've been having them for years.

DR. KEITH JUNIOR: You'll always have a bill, but the thing is, you can't always have good health. That's a window, something you work on, and if you've got it, maybe you can keep it. And even that's not a promise. But, the thing is, if you ignore it and neglect it, we can expect to have more recs of people who want to end up in the emergency room and when they go to the emergency room, they find that they have metastatic cancer. That's just not the way it's supposed to work. You know, access to care, and someone who does care about what's going on, not the dollar that comes into your pocket, but actually cares about that person, what they represent, is what we need more of.

MAGGIE MAHAR: A physician takes an oath to put his patient's interests ahead of his own. A corporation is legally bound to put its shareholders' interests first. And this is part of the inherent conflict between health care as a business, part of our economy, and health care as a public good and part of our society. Health care has become a growth industry. That means higher health care bills. That means more and more middle class people cannot afford health care in this country.

LARRY CHURCHILL: For Americans right now I think the primary question is, "How vulnerable am I in terms of the current system? Am I just a pink slip away from being uninsured and potentially uninsurable?" And I think there's a very profound question about whether we are creating a health care system that is sustainable over time. Some people have suggested, and I agree with them, that, actually, the end product of all of this mess and confusion in technological innovation, is going to be a system that cannot be sustained, because it will be so expensive that only the extremely well to do, the elite, will have access to it.

DR. ANDREY ESPINOZA: When you have a system that's built around generation of revenue, when that revenue is going somewhere, and that money is not being put back into the system to help people, you've really kind of lost, you know, we've lost our way.

DR. DONALD BERWICK: I think that health care improvement at the systemic level has some of the properties of major social movements in this country: civil rights, environment. So many oxes to be gored, and a lot of people with oxen that won't get gored but think they will. And this, you know, the coalition of the people who would be better off and the people who are needlessly afraid of change, that is, they don't need to be afraid of change but they are, that's an immense coalition. That's eighty percent of America.

DR. JAMES WEINSTEIN: In my life my daughter caused me to change my life. And I said, "I don't want other people to have to do what she had to do." We have the compassion. We have some knowledge. We have technology, but we let so many things get in the way of the real ideals, the hippocratic principles, that we get lost in that system that Brieanna shouldn't have had to face and so many millions of other people shouldn't have to face.

DR. DONALD BERWICK: I think health care is more about love than about most other things. If there isn't at the core of this two human beings who have agreed to be in a relationship where one is trying to help relieve the suffering of another, which is love, you can't get to the right answer here. It begins so much for me in that relationship that everything that's built around that had better make damn sure that it's supporting them and not hurting it. And a lot of the structures that I am talking about-fragmented structures, transaction-oriented structures, competitive structures, forget that- forget that this is about two people meeting and that's all it's about.

BILL MOYERS: MONEY-DRIVEN MEDICINE, a film produced by Alex Gibney, Peter Bull and Chris Matonti; directed by Andy Fredericks; and based on Maggie Mahar's book of the same name.

Log on to pbs.org and click on BILL MOYERS JOURNAL - Maggie Mahar will be there to answer your questions online. We'll link you to the Money-Driven Medicine website where there's more info about the book and the film. We'll also link you to some analysis of what advocates of reform are up against in taking on the health insurance industry, the drug lobby, and the Wall Street equity firms.

Take a look at this recent cover of BUSINESS WEEK. Reporters Chad Terhune and Keith Epstein write that the CEO's of the giant insurance companies should be smiling - their lobbyists have already won. Quote: "no matter what specifics emerge in the voluminous bill Congress may send to President Obama this fall, the insurance industry will emerge more profitable."

And remember that television ad Barack Obama made as a candidate for president?

BARACK OBAMA: The pharmaceutical industry wrote into the prescription drug plan that Medicare could not negotiate with drug companies. And you know what, the chairman of the committee who pushed the law through went to work for the pharmaceutical industry making $2 million a year. Imagine that. That's an example of the same old game-playing in Washington. I don't want to learn how to play the game better. I want to put an end to the game-playing.

BILL MOYERS: Now look at this recent story in the LOS ANGELES TIMES. Lo and behold, since the election, the pharmaceutical industry's $2 million dollars a year superstar lobbyist Billy Tauzin has morphed into President Obama's pal. Tauzin says the President has promised not to pressure the drug companies to negotiate with the government for lower drug prices and has agreed not to allow cheaper drugs to be imported from Canada or Europe - contrary to the position taken by candidate Obama?

Each of these stories illuminates the scarlet thread that runs through Maggie Mahar's book - the story of how today's market-driven medical system gives Wall Street investors life and death control over our health care, turning medicine into a profit machine instead of a social service to meet human need. That's the conflict at the heart of next month's showdown in Washington.

I'm Bill Moyers. See you next time.