Transcript of remarks by dinner speaker John W. Rowe, M.D., chairman and CEO of Aetna, Inc., presentation of the AETNA Voice of Conscience Award to former
First Lady Rosalynn Carter, and her acceptance remarks during the 21st Annual Rosalynn Carter Symposium on Mental Health Policy dinner, Nov. 2, 2005.
Introduction by Rosalynn Carter:
Prior to joining Aetna, Dr. Rowe served as president and chief executive officer of Mt. Sinai NYU Health, which is one of the nation's largest academic healthcare organizations. Prior to the Mt. Sinai NYU Health merger, Dr. Rowe was president of the Mt. Sinai Hospital and the Mt. Sinai School of Medicine in New York City. Before joining Mt. Sinai he was a professor of medicine and the founding director of the Division on Aging at Harvard Medical School and chief of medicine at Boston's Beth Israel Hospital. He has authored more than 200 scientific publications, mostly in the physiology of the aging process, and a leading textbook of geriatric medicine. Jack has received many honors and awards for his research and health policy efforts regarding care of the elderly. He was the director of the MacArthur Foundation Research Network on Successful Aging and is co-author with Robert Kahn, Ph.D, of "Successful Aging." He is a member of the Institute of Medicine, of the National Academy of Sciences, and the American Academy of Arts and Sciences. Dr. Rowe is a former member of the Medicare Payment Advisory Commission and is chairman of the Board of Trustees at the University of Connecticut. He is going to speak to us tonight about "The Integration of Mental and Physical Health: The Role of Health Plans."
Dr. John W. Rowe, M.D.:
It is a great pleasure to be here. It is an honor, obviously, to be associated with The Carter Center and Mrs. Carter and to have the opportunity to talk with you. It is a pleasure to be with Dr. Mary Jane England, who chaired the IOM panel which has done such a critically important piece of work for us as a guideline for all of us as we move forward in this field. It is a special pleasure to be again with my good friend and colleague and the best Surgeon General ever, Dr. David Satcher. [Applause]
I am the Chairman and CEO of a very profitable corporation in healthcare. And there are some people here, other than those sitting at the Aetna table, who think that is a moral hazard. I would like to talk with you about the opportunity that presents to be part of the solution rather than part of the problem, which is why I took this job. As Mrs. Carter mentioned, most of my career - all my career until I took this position - was in the not-for-profit area, and in fact the first two-and-one-half years at Aetna were not-for-profit. [Laughter] In fact, some of the people at Aetna were beginning to think maybe it was not such a good idea to hire a not-for-profit guy; maybe he does not understand we are supposed to make a profit.
The situation in managed care can be described as changing a little bit, but certainly a couple years ago - I am in my sixth year at Aetna, and basically when I got there it just could be described as all the managed care companies who had worked so hard in the '90s to control costs and manage care had been driven off the playing field, and they were hiding in foxholes. They were driven off by a backlash of patients who did not like the restrictions, doctors who hated the restrictions, elected officials, and screenwriters. [Laughter] No, no - I mean, have you seen that movie "As Good as it Gets" with Helen Hunt and that poor kid with asthma? I went to that movie with my wife. I was a health plan CEO; my wife got up and moved a couple seats away from me. How could she sit with a health plan CEO? So the screenwriters were important. What happened was health plans just said, You know what we are going to do? We are going to pay the claims, we are going to keep our head down, we are going to take the increase in cost year-over-year, we are going to pass them through to the customers, and we are going to keep our mouths shut, because we have been out there trying to manage care and we got killed.
And I live in a different part of the forest, and I came to Aetna because I saw the opportunity to use the connections with patients and doctors and the database that we had as an opportunity to influence the quality and the access and the cost of care. Most health plans think about their strategy as what is known as "local market presence" - have as many members as possible and eat up the doctors and the hospitals, because you have leverage, because you control their volume. Now, I am not trying to say Aetna is a small company - you know, we have 15 million members - but our strategy is more along the lines of innovation in medical management. We have tried to develop consumer directed health plans and disease management programs and active evaluation of pharmacy data to identify errors, and we have developed to date, until this morning, three major clinical initiatives, one in each of the last three years. The first one was we decided to pay for clinical genetic tests and counseling. Everybody rolled their eyes when I said this: 'Oh, why are you going to pay for that? Nobody pays for that; that's stupid.' But it seemed to me, as a doctor, that it made sense to make a diagnosis early, and in the long run it would save cost and it would improve quality. It was the business case for quality in health care. We did it, we took a lot of heat, it worked. A year later, the American Association of Health Insurance Plans adopted our guidelines as the industry standard.
The next year, and I think Dr. Satcher might recall this, I decided to collect data on people's race. This was the rail of politics in health insurance - you are going to ask people what their race is? My argument was if we know, because of what Dr. Satcher and others taught us, that there are racial and ethnic disparities, and that African-Americans, for instance, do not have access to as much care, and the care they get is not as good, and their outcomes are not as good, and I do not go and ask people if they are a member of that group that is susceptible, that is racist not to ask. And so we tried to make the case, and with some luck, and some help from guys like David, we were able to do that. But the exciting thing for us, and actually I am embarrassed when people thank me for that - people say it is courageous; I was actually too stupid to recognize how risky it was. But anyway, to make a long story bearable, now AHCQR, the Agency for Health Care Quality and Research, has an initiative to get all the health plans to collect the data along the lines of the way we have approached it. So there is a way that we think we have changed things.
And last year we had an initiative on Care at the End of Life, because we did not believe it was appropriate to force people to make a choice between hospice and potentially curative care, and that is what Medicare does. And that is what all the health plans did. You had to sign a paper if you wanted to go to hospice saying you will never accept potentially curative care. It is like asking you to walk through that door, there is a sign over the door, '"Abandon hope all ye who enter here.'And that is not the way I practice medicine. I told my patients, you know, it is not going well, we need to think about what we are going to do if you do not respond, the tumor is growing, let's get your family in here, think about hospice, we want to control your pain, but I am not going to give up on you and if there is a treatment that comes along, I am going to make it available to you; I am going to talk with my colleagues. But in the interim, let's think about this. And I am happy to say that other plans are following in our lead.
As we began to think about this, we began to think about integration. We began to think about what it means to have true integration, particularly with respect to mental and behavioral health, because we had sold our mental and behavioral health services to a very, very good high quality ethical company that was doing a very good job, but it was a separate company; and my feeling about it was that if a woman had a normal pregnancy and postpartum depression, she did not need two health plans; if a man had a heart attack and developed an anxiety disorder, he did not need two health plans; and that we all know that people with severe persistent mental illnesses have more medical problems and people with severe chronic medical illnesses have more mental and behavioral problems. So it was a compelling argument for integration. And so we integrated things and we brought back this initiative into our health plan, which will start in January, 2006,and my colleagues who are here have done a fabulous job with that.
And I started thinking about integration with a capital I, such as we have been urged by Dr. England and her colleagues at the IOM to do. So we came along with an idea which we have, in fact, implemented starting today.
Now, here is one of the great advantages of a for-profit. I said we should do it, and we did it. [Laughter, Applause] I am not trying to say I was right, but this is a new experience for me. I have three grown daughters, I have a wife of 38 years, I was the president of the Mt. Sinai Medical Center, where in the faculty center a vote of 275 to 1 was a tie vote. Two seventy-five to one - but Sam does not want to do it; we cannot possibly do it if Sam does not want to do it. But if you are in an American corporation, and this is not a small corporation - it is not a big deal like Coca-Cola or UPS, but it is a $25 billion corporation, and I have 15 million customers, or members or patients or clients or whatever you want to call them. So we decided we were going to integrate with a capital I, and we took the MacArthur program that had been developed under the supervision of Leon Eisenberg and Phil Holzman, rest in peace, Floyd Boom, and done by colleagues at Williams and Duke, and they had shown that they could educate primary care physicians to be more effective in identifying depression and treating it. And my colleagues put this educational module on the Web, and we are going out to our physicians, and we have a large network - we have about 675,000 physicians. This is a big thing. This is one of the great things about it.
We pay claims, you know, it is a part of our business. We pay 800,000 claims every 24 hours. Not every month, not every year - every 24 hours. It is just a big thing. And that is part of the message here about the for-profit enterprise. If you can link with it effectively, your leverage is enormous. And we are identifying physicians who are primary care doctors, internists or family practitioners, who have significant numbers of Aetna members in their practice, and we are educating them on the Web-based educational program based on these published papers, and then we are giving them CME credits and professional recognition, and then we are going to do something really, really interesting - we are going to pay them more. We are going to pay them 35 to 50 percent more for every patient they see where they make a diagnosis of depression or they treat the patient. We are going to make a psychiatrist available to them as a consultant and colleague, and we are going to make a case manager available to them.
And you know what we are going to do? We are going to save money. We are going to decrease the cost of healthcare. And this is the answer for me. This is where the juice is for me in all of this. This is the business case for quality, and the business case for quality is not your enemy. The business case for quality is the way your ideas are going to get infused throughout the American healthcare system, and it is a great, great opportunity that we have to do this, and I think I and all my colleagues at Aetna, many of whom have joined me here tonight, feel really good about the fact that we are part of the solution and that we have the opportunity to work with colleagues, like many of the people in this room, particularly Dr. England and her colleagues, who can do the work that we can use in the practice of medicine every day. Thank you very, very much. [Applause]
Now we get to the part that I get to tell my wife about when I get home. I get to honor Mrs. Carter and to provide her with a small recognition of our tremendous respect and admiration for her work. One of the things we wanted to do tonight is honor Mrs. Carter with the Aetna Voice of Conscience award.
This award pays tribute to the legacy of a long-term member of the Board of Directors of the Aetna Corporation, Arthur Ashe. For more than a decade, Arthur was a member of our board, and he became a chairman of the Aetna Foundation Board of Directors, a position that I am honored to hold. He was a man who worked tirelessly for fairness and equal treatment for all people, and we give this award each year to someone who embodies that spirit. Last year's recipient was David Satcher. This year's recipient is Rosalynn Carter, who we recognize for her long-term work as a mental health advocate and her commitment to improving the lives of people around the world.
Through her efforts over more than three decades - hard to imagine - she has focused much-needed national attention to the plight of people suffering from mental illnesses, Mrs. Carter has been able to use the convening authority that comes with her position and her position in the field to bring together people who hardly ever would talk to each other otherwise. She has been a driving force to improve access to mental health services in the United States and it is a great pleasure for Aetna to provide her with the Voice of Conscience Award, which, parenthetically, comes with what some would consider a generous check which will I am sure will be used to support the Mental Health Program here at The Carter Center, which is a national treasure. [Applause]
Mrs. Carter:
Thank you very much. I am honored by this recognition, and I want to thank you, Jack, and Aetna for this award. I am deeply grateful to you, and also deeply grateful to you for the program that you were talking to us about, and the wonderful things you are planning to do to help people with mental illnesses, and to help those who care for them to have better resources and time to spend with people with mental illnesses, which is so important. We are deeply grateful to you.
I have had an interesting life before, during, and since the White House, and Jimmy and I founded The Carter Center soon after he, or we, were involuntarily retired from the White House. We had not finished the things we wanted to do, and The Carter Center has given us a wonderful forum from which to work on issues that are important, and you can see over here that our mission is waging peace, fighting disease, and building hope. We work on issues of peace and health. We have programs in 65 countries, the poorest and most isolated countries in the world, and it is wonderful work. People ask me all the time, 'Why do you keep doing this?' Well, I will give you one example. I will just tell you one story.
We work on five health programs:
The World Health Organization has a program that they call SAFE - Surgery, Antibiotics, Faces, and Environment - and we work on all of them, but our main focus is on Faces and Environment. We teach people to wash their faces, which they are not in the habit of doing in these countries. For the Environment, we show them how to build latrines. Jimmy says that he has come from president of the United States to the largest latrine builder in the world. But to go back a little bit, when we go into a country, Jimmy signs a contract with the head of State. They furnish all of the workers. We send one or two people in. We teach their workers and they pay for them. We teach their workers how to do these things, work on these health programs and so forth, and agriculture programs.
And so this time we had sent this one person, but that happened to be the best possible person you can get, this man, actually. This was in Ethiopia, and the man who is in charge of our program worked on the eradication of smallpox with Dr. William Foege and Dr. Don Hopkins. We sent this person over and he showed them how to do a latrine. Well, this is really a women's story because the women got so excited about it. They could clean up the place, and also we learned that the women could not go to the bathroom in the daytime. They could not be seen going to the bathroom. So it was terrible for them, and when they had the latrine, which was just a hole with some red brick that they make, or clay, at the top, they put a little grass shack over it and the women could go to the bathroom. Well, the women in the next village saw it, and then the next village saw that, and we thought they might build - they would do their own - they might build 10,000 latrines I think last year. They built 89,000 latrines. It has totally changed the lives of the people in those communities because they are able to clean up the community, which does more than just do away with trachoma. Trachoma, I am sure everybody in this room knows what trachoma is, and it comes from filth and flies suck moisture from the eyeball and the eyelashes turn in and they go blind over a period of time. So now we are teaching them to wash their faces.
So we were going to Ethiopia anyway, and I wanted to go to this village, so we went a long way off into the rural area, and the people were so excited. That is another thing that makes this so fulfilling, they are so grateful for any little thing you do for them. And also they do it themselves and that gives them such a sense of being able (unintelligible). And sometimes they have never been successful at doing anything, so it gives them a real feeling of self-esteem. I could tell you lots of stories, but of course I am closest to the mental health program. Mental health has been the issue that I have worked on for over 30 years now and it has been challenging, sometimes discouraging when the same problems persist, but also it has been fulfilling to me because I started when Jimmy was governor, in 1971, and that was when nobody would mention mental health, mental illness; nobody would admit having a mentally ill person in the family; nobody knew how to treat them so they just mostly kept them sedated and hidden away out of sight. To come from that to today when recovery is possible has just been a journey for me, and it has been really wonderful. Recovery is something, even when we did the President's Commission on Mental Health, we never dreamed that recovery would be possible. And it is exciting. I have been very fortunate. I have had a lot of opportunities and I have had a platform from which to take advantage of them. It has been a good life, and I thank you again for this honor. [Applause]
