By Laura Turner
SDN Staff Writer
Dr. David Sundwall was confirmed in January 2005 as Executive Director of the Utah State Department of Health. In this capacity he supervises a workforce of almost 1,000 employees and an annual budget of over $2.0 billion. He currently serves as Immediate Past President of the Association of State and Territorial Health Officers (ASTHO), serves on the Executive Committee of ASTHO and is Chair of the ASTHO Government Relations Committee.
Dr. Sundwall has extensive experience in federal government and national health policy, including:
- Administrator, Health Resources and Services Administration (HRSA), Public Health Service, U.S. Department of Health and Human Services (HHS) and Assistant Surgeon General in the Commissioned Corps of the U.S. Public Health Service under Reagan administration (1986-1988).
- Director, Health and Human Resources Staff (Majority), U.S. Senate Labor and Human Resources Committee (1981-1986).
He currently has academic appointments at the Uniformed Services University of the Health Sciences, Bethesda, Maryland; Georgetown University School of Medicine, Washington, DC; and the University of Utah School of Medicine. He is board certified in internal medicine and family practice. He is a volunteer primary care physician in a Utah public health clinic one-half day per week.
Dr. Sundwall recently took time out of his busy schedule to talk to the Student Doctor Network about health care policy.
David Sundwall, MD
What do you think are the greatest issues facing the U.S. healthcare system today?
“Cost” control, i.e. restraining the rate of growth of spending for health-care services. This is not unique to the U.S., but is a global challenge in that our capacity and technology have outstripped our ability to pay for them.
The U.S. is the only industrialized/Western nation without single-payer health care. Why do you think that is?
It is a historical fluke, in some respects, in that the passage of Medicare/Medicaid in 1965 was made possible by compromising to use existing private health insurance to administer the programs, even though paid for by federal (and federal/state ) taxes. The general skepticism of “government” has long been a significant factor in the various health policies we have enacted, and avoided.
What concerns do you have with the single-payer model?
Few, but we all need to acknowledge that if we eventually embrace a “ single payer” system it will likely result in delays, inconvenience, and frustration with coverage policies that will be based on the “public good,” not necessarily the best new technologies.
What impacts would you anticipate to physician income and quality of life if a single payer model were to be implemented?
There will likely be a more fair, i.e. “narrower” distribution of compensation among physicians, regardless of specialty. Primary care physicians would be paid more, sub-specialists less but still more. I do not necessarily think income is closely related to quality of life, but most strive for high incomes and associate this with “success”.
What do you think the best solution is for the U.S.?
Eventually we will have a single payer system, not because it is necessarily “the best” but because it will be more fair, and enable restraint of spending. It will be a difficult but necessary transition in that we are accustomed to getting what we perceive we need and want and when we want it. This is simply too expensive to sustain, so we must acknowledge that “he who pays the piper gets to call the tune,” and to the extent we pay for health care with public funds the “government” could and should determine what services are covered and at what level.
The health reform bills currently under discussion in the House and Senate all require that every U.S. citizen carry health insurance (“individual mandate”) – do you think this is a necessary element of any solution?
Short of a “single payer” system, this is an essential component of health reform. If it is not an entitlement, it should be required.
Proponents of nationalized health care often cite information that U.S. health care lags other industrialized countries, including the U.S. being 42nd in life expectancy and 41st in infant mortality. How do you respond to such criticisms?
When you compare health status of Americans with health insurance coverage with other countries we compare favorably (better than most aggregate data from other countries). This is pretty good evidence that having health insurance coverage is important to improve health. However, there are other important factors that are not necessarily related to coverage, e.g. economic status, race, access, etc.
What are the incentives a for-profit health care model to focus on preventative medicine and keeping people healthy versus having them consume as much care and incur as much cost as possible?
Not many – though there is little hard evidence that “preventive” health services pay off over time. We still don’t have consensus on what constitute best practices for preventive care and what will improve health status and reduce costs over time.
Critics claim that pharmaceutical and medical device companies make egregious profits. Do you agree or disagree, and what reforms, if any, would you like to see in this area?
In a free market economy, I believe there should be opportunities for medical device and drug companies to compete and charge what the market will bear. However, there may be justification for imposing regulatory restraints when “public” health insurance programs (financed with tax dollars) are purchasing such.
What solution would you propose address the criticism that overseas businesses have an advantage on costs because they don’t have to provide private health care?
I haven’t proposed a “solution,” but I believe our country’s ability to reduce health care expenditures will improve our ability to compete, whether it is accomplished by private or public-based health reforms.
What will be the impacts on physician income and quality of life of the proposed reforms?
See the answer I gave to the fourth question. “Quality of life” and income are not necessarily related. Physicians motivated primarily by income will be disappointed and possibly seek other ways to make a living. Those of us who value the rewards of patient care, service, and life-long learning of new biomedical science will still find being a doctor very rewarding.
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Suzie, you have no idea how much I know about the issue, my intelligence, where I get my information, or even where I stand on this, but it’s interesting that you’re so certain so as to relegate me to my undergraduate “cubicle”.
I was commenting on your abilities to engage in discussion on this forum, which clearly you are not very capable at. Generally, being able to have a mature, clear, and reasoned presentation is key to convincing others – something you seem to want to accomplish here.
I’m actually very well versed in much of the text you’ve smattered about here, as I have a masters degree in health policy, I have traveled to countries with socialized healthcare, and there’s much that I disagree with in what has been presented by the committees thus far. Unfortunately it does look like the plan will not meaningfully decrease health care costs nor will it improve quality of care; and hospitals and physicians will bear the brunt of the effort to contain costs.
But apparently you do not value any sort of respectful conversation and will continue to barrage this posting with things you’ve cut and pasted, without being able to critically read and respond to others, which is unfortunate for this board. Good luck having to deal with people in the real world without any regard for socially mature behavior, I’m sure it won’t affect your test taking abilities (or your ability to google things written by others), but it will affect your social and professional progress.
off to the cubicle!
I’m not a huge fan of his answer about Dr compensation in the new system. Basically he’s saying, “Those of us who like to work hard and not get paid very much will still be happy. The rest may want to find something else to do.” Very discouraging for those of us nearing 10 years of medical training and under a mountain of debt.
830,000 Canadian are currently waiting to be admitted.. so waiting period can be one minute or three hours. Last time I went to the ER for emergency birth-control pill (before it went over the counter), I waited over 4 hours and paid $900 for the visit and the pill.
And suzie, you need to calm down. Capitalizing all those words will give you high blood pressure. How do you propose to increase the number of physicians without losing quality? And we already import a large number of physicians, how do you think its politically smart to steal developing country’s newly trained doctors away from people who really need them?
Before you completely discount Obama’s plan, do you really think that your proposal will be effective? How many people will support you either way? If you can’t do the president’s job, why are you arguing and complaining as you are. Honestly, Obama’s plan will be the stepping stone for better improvements for the future, and I think we all need to admit that better system is needed. Without this stepping stone, we won’t get anywhere better in the future. You can forget about quality care and more physician output.
To conclude, you have great ideas, but too idealistic and very single minded.
New system needed….don’t see you offering any proposals at all…..just empty rhetoric as Obama does. Do you ever notice that he hasn’t actually proposed any specifics….just broad parameters under which he would like to see something done. Here’s what I think should be done, lest you reply that I’m not willing to propose anything myself:
1) There needs to be some provision made that would allow Americans to do a couple of things;
a) Allow people to purchase catastrophic coverage to cover major medical expenses. This would be relatively inexpensive coverage that is similar to high deductible health plans available in some states today. For example, I checked on a HDHP for my family recently and with a $5k deductible, coverage for a family of 5 was around $225/mth, but could be less if govt. regulations didn’t limit these types of plans.
b) Improve health savings accounts so that people are incentivized to save for their healthcare expenses by expanding the pre-tax breaks that are currently given, and loosening the withdrawal requirements upon retirement age so that the account could serve 2 purposes…..have an account that someone could contribute pre-tax dollars to each month that will grow like an IRA/401k etc to cover medical expenses up to the deductible on their HDHP, and upon retirement/medicare age be able to use that account to help subsidize their retirement
c) Get people to use these HSA’s to pay for their primary care instead of relying on their insurance “co-pay”. Since they would be able to withdraw money from the HSA for medical expenses (via a check tied to the account or a debit card), they would see the amount of money that they are spending (their money), and therefore be able to take a more active role in their healthcare and how much they access it. If someone stays very healthy, then they may not use their HSA but once/yr for a PCP checkup, thus their HSA would grow even more in value. People who actually pay for their healthcare, take a a more active role in it.
d)Take some of the 1+ TRILLION that Obama is trying to spend on his current overhaul proposals and help provide subsidies to “bridge” coverage so that while people are building up their HSA, they can have back up coverage.
2) People who are below “some” level of income be offered subsidies to purchase private insurance, be it through refundable tax credits, vouchers, whatever. Obviously the income level is debatable. Currently, these people are eligible to be covered under Medicaid. If you can use the Medicaid money to help people get private insurance instead, they will actually increase their access to care because more and more physicians are opting out of Medicaid all together.
3) FIX the Medicare trust fund. This is actually the ONLY place where I think raising taxes may have to be employed. I think that there is no getting around the fact that the baby boomer generation is the largest group of the population. We may have to raise medicare payroll taxes to help fix the medicare trust fund. The boomers paid into the trust fund their entire lives, so they deserve to be able to use medicare when they need it.
I have more but I have no more time for now. I AM completely discounting Obama’s plan because you can’t trust anything he says. As an independent who voted for him, I am truly disgusted at myself for being sucked in to his “feel good” propaganda web. The man has no substance, only empty rhetoric. We would all be served better if he used his talents in Hollywood.
“1. “sub-specialists less but still more.”
What does that even mean???? A single payer system will ruin this country. I think their still needs to be some oversight, but complete government take over will kill people.”
I think he means that instead of being paid 3-5 times as much, maybe they’d “only” be paid 1.5-2 times as much.
“When was the last time you went to a Veteran Affairs Hospital? Did you enjoy that experience? BTW, these hospitals were built by our government and for our veterans!”
Yes, indeed. I suggest you research the VHA before you slam it: http://money.cnn.com/magazines/fortune/fortune_archive/2006/05/15/8376846/
Woops, should clarify that all primary care average earnings in 2004 was $161.8k, while the average specialist was around 300k, though invasive cardiology was closer to 3x at $427.8k. So yeah the 3-5x was an overstatement. But I do think that was the gist of what he was saying. Specialists would still be paid significantly more, but not by the same margin.
Suzie and Jimmy
It is refreshing to see someone has actually taken the time to know the facts about HR3200 before sounding like they do. Another topic you have missed it Obamacare states that in order to curb costs, the govenment (with the bill) will penalize hospitals and doctors who admit people with the same disorder more than once. This means the hundreds of thousands who suffer kidney failure, diabetes, sickle cell anemia, asthma, epilepsy, or neurological disorders like Guillian Barre Syndrome will be able to be admitted one time for these disorders then it is up to them to foot the bill. And by the way, it was quoted that there will be no death panals, but just what do you think limiting Medicare further will do? Most elderly can’t afford all of their medications as it is and you propose to cancel it all together? The program that should be disbanded is Medicaid. It primarily provides care for people on welfare. It also supports the illegal aliens as that is the only program they can get into without a social security number.
I have been without health insurance for over a year because of GBS and have not been able to continue my rehab because I don’t qualify for Medicaid. I was informed by the intake person that the reason I don’t qualify is they tend to provide it for minorities only.
What a time not to be a minority-can’t even get the medication my daughter needs for her epilepsy.
But Canada’s form of health insurance isn’t the answer either. I started my 32 year career of nursing in NY state and I remember the number of Canadian nurses who came across the border to work because to be more cost efficient their local governments closed the hospitals they had been working in.
Dear Melanie:
Very few people on this site will understand your post, b/c this is a STUDENT site.
Almost no one who posted responses to the column has had any EXPERIENCE practicing medicine and has no knowledge of the regulatory environment that is suffocating American medicine today.
The older physicians will not participate in opposing HR3200: they made their money in better days and have enough savings to retire from the field entirely.
Most MD students are smart and ambitious, but are terribly misinformed and undereducated. They do not understand what kind of transformation this country is undergoing right now.
Obama is bankrupting the country. We are about to become a Banana Republic.
Ok ok ok time out-
I just want to say this and then move on….I AM NOT WORKING FOR LESS MONEY WHEN I AM DONE RESIDENCY AS COMPARED TO TODAYS PAYOUT RATES!!!
Why won’t anyone just say it? I do not feel as doctors we should be embarrassed about talking money….No it doesn’t make you look bad.
There is no reason why i can’t be a great doctor and be compensated for it at the same time. I see it as incentive to perform better. If you just cap me off and say well here is what you get regardless of your performance or ability i might just say ok well i’m leaving today at noon, bite me.
Sorry but i didn’t go through this much schooling and hard work to be told what to do now.
Oh yeah single payer insurance is a bad thing, not really for what i said above that was mindless ranting and foot stomping. It is bad because ultimately the people suffer. Waiting for care and specialized testing, higher tax rates, and ultimately the need for supplemental insurance (wow won’t that make you feel stupid).
Please America get over your sense of entitlement
The insurance companies make 2-4%??? That is unacceptable in America! These EVIL companies are profiting off of sick people. They should be running revenue-neutral charities to help all Americans! How dare they make a profit in this country….
The U.S. is the only [b]industrialized/Western[/b] nation without single-payer health care. Why do you think that is?
Since when did the word industrialized and Western become synonymous?
What about the countries in Asia that are also industrialized?
Isn’t Susie a medical student at Ross?
Oh, I forgot they don’t call them medical students more like bottom-feeders…reliably picking up the scraps that US MDs and DOs leave behind.
Honestly, I just don’t understand when any MD would say these things. Oh right, he’s old and already rich! Didn’t have 150K in student loans, didn’t see strigent admissions processes like today, didn’t sacrifice what current students have to today. This is retarded, there will be no neuro/spinal/cardiac surgeons in the future.
I’m entering medical school in the upcoming year. After reading a majority of the posts (skipped the all capitalized ones), it seems as though we are doomed to a single payer system, and people with syndromes that are recurring and normally end up in the hospital multiple times in their lifetime are also in bad shape (does anyone know if there is a time limit in those repeat visits?). Along with all of the strings attached that senators have put into the bill, it will put the nation further into debt. Debt isn’t necessarily a bad thing, because our economy runs on it, as the golden rule in economics is to never pay for something with your own money when you can use someone else’s. As we go further into debt, foreign countries just bail us out even further because we are necessary to the global economy.Printing more money, however, just leads to more inflation. If the world ever switches (which it might soon) to using euros instead of dollars to transact a majority of its business,the US will lose trillions of income that it gets freely by that use. I hope that by the time that I exit medical training, that this whole mess will be figured out at least a little.
One thing to add is that a nationalized healthcare system works on a very basic level (from living in England). If you need anything above very basic care, it is completely useless, which is where private systems work much better. if we follow the route of allowing individual states to run their own systems (which I do find interesting!),it would further bankrupt many states who cannot currently pay for services demanded by its residents.
Sorry to jump this far
, but like the rise and fall of civilizations, I think that a sort of revolution is needed at multiple levels
Typical responses you might expect from a lifelong government lackey. Typical liberal claptrap. Reduced income = reduced talent. Lets own up to human nature. People are greedy, they want money, that may not be the reason a bright eyed 22 year old sets foot in med school for orientation but once he hits 3rd year, residency, etc. it quickly becomes the only reason he continues to put up with what he once thought was a profession more about the reward of helping those in need rather than doing what 95% of what every other American does: work for a paycheck.
Im a medstudent in Sweden. Its really scary to read what you are writing on this page.
In sweden we have free health care for everybody. How could you not? Since when is one life more worth than another? Obama is by far the best thing that happened to you for a long time, and you dont even see it. The day any terrorists succed to get rid of USA, will probably be the day Jesus returns and declares his Kindgom of peace and justice in the world!
What a politician. This guy never provides direct answers to any of the questions and just comes off as a complete capitalist with little compassion for people. Yikes.
@Jonas, I think what is far scarier is that a medical student would wish for the annihilation of an entire population (my country, by the way). Anyone who is so full of vile and arrogance as you doesn’t deserve to be a physician. You are antithetical to the values of the profession.
To “current resident”
Haha, you’re NOT working for less than current reimbursement rates? Ok… then don’t. Exercise your right to the free market. But, what do you think you can do to make more than what you would have made even if reimbursements are cut further? Sorry to inform you, buddy, but you’re basically stuck. Chances are you’ve got a hefty little loan under your belt that you’ll have to pay back no matter what. And your 8+ years of training would be moot without you practicing medicine.
Face it. Doctors have no leverage. They never did. The entire reason American MDs are making more than European MDs is due to a historical glitch in the system. Get ready for lower reimbursement, boys and girls.
Whoops, Jonas, I think you jumped the shark with that last sentence. I understand your anger at what you’re reading, though. I am thrilled to be starting a postbac-premed program in the fall, and looking forward to practicing medicine as a way to contribute to all of our lives.
And no, I am not naive to the challenges people are talking about on this thread.
A big factor in my decision to pursue medicine was the passage of Health Care Reform. One reason I had avoided it before was not wanting to find myself in the kinds of faustian situations doctors in our current system face, with so many people unable to pay for care.
While I think it’s appropriate that doctors be well-compensated, it’s not a valid reason for entering the field. If the changes to our system drive away candidates who are miffed about making less money, that’s the field of medicine’s gain.
I am appalled at people claiming that the only reason people do things is for the paycheck. If that’s what you believe, I’d be uncomfortable having you as my doctor.
Yes, human beings are extrinsically motivated, i.e., we chase carrots. But we are also intrinsically motivated, i.e. we do things because we want to. The reasons we want to are often deeply meaningful. Intrinsic motivation is far more powerful than extrinsic motivation. Unfortunately, extrinsic motivation can displace intrinsic motivation. We all lose when it does.
It cracks me up that people continually talk about Obama bankrupting the nation in the wake of some other person’s mistakes. We are pretty screwed either way. The expenditures were too expensive and only getting more costly. Medicine doesn’t follow normal business rules. I don’t know what people really think could happen.
Reimbursements have been going down for quite sometime.
The same people that say Obama is bankrupting the nation don’t seem to complain about the 100s of billions of dollars for questionable wars.
Insurance companies and privatized institutions have NO incentive to do what is best for the patient. NONE. The extra tests, the low-balling reimbursement…it is all financially motivated.
One can b!tch and moan about their pay, but docs will always make a fair wage. We won’t be rich, but if that is your primary concern over your patients and the people you treat then perhaps you should reevaluate your career decision. So much melodramatic b.s. without any real evidence to back it up.
No, single-payer is not inevitable, unless of course that single-payer is the individual citizen. We should not, and must not, have socialized medicine or government as the single-payer. Health, and healthcare, is an individual responsibility, not an entitlement, not a right. I’m sure that Dr. Sundwall is very wise in many things, but he’s not right about the future of healthcare.
Incentives? People’s whole perspective here is fundamentally flawed. The incentive for preventative care lies not with insurance companies, or government, or healthcare providers. The incentive for preventative care is a long healthy life! The incentive is for the individual, and rests with the individual. No one else, nor no “entity” or institution should ever have to provide an incentive, or pay, to encourage a private citizen to be healthy. This is an issue of personal responsibility, not of cost-efficacy or ratios. We live in a free country. People are free to choose to live healthy, or trash their health. They’re free to be vegetarians, or to smoke 3 packs a day for 40 years and cough up a lung and die young.
The main point is, we are free to choose our own health outcomes (barring genetics or accidents of course), and must never be forced by government to spend our hard-earned money on a commodity that they, not us, dictates to us.
Cost? This is simple supply & demand people, and you don’t need a MS in Health Policy to understand it. There is more demand for healthcare than supply right now. We need more doctors, pharmacists, nurses, techs, more drugs, more supplies, more devices. Ask yourself, honestly, what restricts the supply of these things? …government does. Government is the problem, not the solution. Most health professional schools are public. Classes are limited. Funding is limited. Debt upon graduation is astronomical. Government (FDA) regulates drug & device approval and the current system is broken – too long, too expensive, good drugs are held up, and bad drugs still get on the market. Supply is low, research incentive is low, new development is low, margins are narrow, costs are high, to everyone at every step of healthcare.
What is fair? Fair is when you as an individual make your own decisions, and pay for your own mistakes, rather than casting your responsibilities onto your neighbors.
Who deserves an exception? Veterans, the retarded, the truly disabled and indigent, American Indians, refugees, and the oldest-old. These are a vast minority of citizens, and should not dictate the direction of care for the majority. Who instead are now sucking down the majority of reasources? Lazy ghetto slobs and WT who would rather enjoy welfare than work a real job like the rest of us. Reform that first.
I don’t see how anyone can say lowered reimbursement won’t lower the quality of physicians. As a pre-med I faced a very tough decision. I will be graduating at the absolute top of my class. I hold a 4.0 currently (at the end of my senior year), and have been granted admission to Case Western Reserve School of Medicine, contingent upon graduation of course. I received a score of 43 on the M-CAT as well. I have a Physician for a father, who is willing to mentor me through the entire process. I see myself as a very promising candidate for the job. However, I will be attending the University of Akron for law school. Many of those in my position are making similar decisions.
In addition to our promising students being deferred from medicine, we face other travesties. America has been “stealing” FMG’s for years now. We net the most talented foreign graduates, they care for our citizens. If we lower reimbursements we will no longer incent them to come here to practice. So our citizens will lose them as an option too.
Granted the current system is pricey. How can’t it be though? The all knowing Dr. Sundwall said it himself “our capacity and technology have outstripped our ability to pay for them.” If we wish to maintain our technology and capacity, we must continue to pay for them. I fear we are headed down a terrible road. I’m just happy to know that being an attorney will allow me to afford top of the line medical treatment wherever I am. I will be able to afford to go to the small number of self-pay only health systems which will surely take rise. I doubt anyone who continues their journey through medicine will though. To all you docs out there I suggest turning your Medicare patients around at the door and saying “Call another doctor, or your congressman.”
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