INTERVIEW: 2015-16 MMS President Peter Bretan Jr., MD

Howard Daniel

When this interview was conducted, Peter Bretan, MD, was preparing to assume the presidency of the Marin Medical Society for the fourth time. He previously headed MMS in 2006, 2010 and 2011. He was born in 1954 to immigrant parents from the Philippines who grew vegetables and strawberries in Pismo Beach. From age 6, he worked as a farm laborer.

Dr. Bretan earned his BS in physiology from UC Berkeley in 1976 and his MD from UCSF in 1980. He remained at UCSF from 1981 to 1986, completing a residency in urology as well as a postdoctoral fellowship in radiology. He then went to the Cleveland Clinic where, in 1986-87, he completed a fellowship in transplantation and renovascular surgery. He remained on the Cleveland Clinic urology and renal transplantation staff from 1987 to 1989, during which time he was simultaneously a doctoral candidate in molecular biology and physiology at Case Western Reserve University. In 1988-89 he also served as renal transplantation director at St. Elizabeth Hospital in Youngstown, Ohio.

Dr. Bretan returned to California in 1989, where he first served as surgical director for pancreas and renal transplantation at Harbor/UCLA Medical Center and as assistant professor at the UCLA School of Medicine. In 1992, he moved back north and served as associate professor of urology and surgery at the UCSF School of Medicine, where, from 1994 to 1996, he was also director of the Kaiser-UCSF Transplant Service and performed nearly 100 transplants a year. In 1999 he entered private practice in Novato. He also instructs pre-med and medical students at UC Berkeley and Touro Medical School, where he is adjunct clinical professor.

He has published over 200 scientific articles on both clinical and original research subjects, winning multiple academic awards. He speaks internationally as an expert in kidney transplantation as well as prostate and bladder diseases. He also serves as a reviewer for six clinical and scientific journals—for the past 30 years he has reviewed or screened all submitted abstracts for the transplant sessions at the American Urological Association’s annual meetings and he regularly moderates many of its sessions.

Dr. Bretan is the founder of Life Plant International (www.LifePlant.org),a charitable organization that promotes disaster preparedness, organ donation and early disease screening worldwide. LPI medical missions to the Philippines since 2002 have included performing and teaching kidney transplants and laparoscopic kidney removals, saving many lives. Also a captain in the U.S. Public Health Service Reserves, Dr. Bretan has served on missions over a 25-year span, including as Team Orleans’ lead surgeon following Hurricane Katrina in 2005.

Dr. Bretan and his RN wife Melanie Jean Bretan have four grown children—Jon, a physicist; Anna, an obstetrics nurse (with three of her own children: Mason, 9; Preston, 7; and Tatum, 3); Mason, a doctoral candidate at Georgia Tech; and Mark, a recent graduate of the San Francisco Academy of Art.

This interview was conducted in Dr. Bretan’s office in Novato on April 15.

What made you decide to become a doctor?
When I was 8, my father was in a local hospital with impacted gallstones. He was so unstable that no one there dared operate on him, fearing he would die on the operating table. He had already been given last rites, and my aunts were telling me, a frightened kid, that I would soon be the man of the house. My dad was a World War II veteran, and in desperation, his doctors sent him to Sepulveda VA Hospital, which was affiliated with UCLA. They hoped someone there might be able to help. And one of the UCLA surgeons did. He tried a new procedure that had hardly ever been done anywhere—a staged procedure that worked!

As the surgeon walked toward my family, we all thought we were about to be told my dad had died. But the surgeon smiled and told me, “Your dad’s going to be OK. We tried something, and we were able to stabilize him. I think he’s going to be well.” As the surgeon walked away, I just kept staring at him and thinking, “Whatever it takes, I’m going to be one of those guys, somehow.” And all I’ve ever wanted to do since then is save lives and change lives.

That surgeon’s simple act of kindness—trying a new, unfamiliar procedure to save a life—made him my lifelong hero and inspiration. I can never repay that act, but I try to pay it forward. I know I would not have developed into the surgeon I am today if that hadn’t happened, because I know what it is to be on the receiving end of a lifesaving act.

I think medicine is one of the noblest of all professions. There’s no other profession that gets to save lives on a daily basis. Health care is a right. But for those who practice medicine it’s a blessing. We get the privilege of being with patients . . . of saving lives . . . of changing lives.

What drew you to the  practice of urology and your specialization in transplants?
I always wanted to be a surgeon. But surgery is a technical thing. Transplants, however, are a miracle. It’s incredibly intense, and miraculous at the same time, to be able to move an organ out of one body, put it in another body and save a life. I mean, that’s really exciting, even just talking about it!

And it was never done until relatively recently!
I was born into it. 1954—the year I was born was the year they performed the first successful transplant.

What organ was that?
A kidney! At the Peter Bent Brigham Hospital in Boston. Joseph Murray received the Nobel Prize for it in 1992. It had been tried 17 times before that. It seemed a miracle at the time! Immunology and immunosuppression were born around the same time, hand-in-hand with transplantation. The coming together of several different specialties!

I started off as a general surgeon. And it’s not that I didn’t like general surgery, it’s just that being able to transplant organs and immunology were my long-term goals, and I found urology fascinating. And you could go into urology and become a transplant surgeon. So it would help me achieve my goals.

Urologic procedures impressed me as innovative. For example, you could take a piece of intestine and create a new bladder to replace a cancerous one. General surgeons didn’t do that! Repairing organs out of other organs! Additionally, transplanting organs was pretty amazing. While it was competitive to secure a fellowship in transplantation, it was always my dream. With just two to three extra years of training, being a transplant surgeon was worth it.

And the most important thing was that I could save more lives doing it. That was the bottom line, saving lives. Just like the surgeon that saved my father’s life.

You’ve been in practice since 1986. What medical advances, if any, have improved your ability to care for patients over the past three decades?
You know, when I started out as an intern, the overhead PA speaker would announce, “Dr. Peter Bretan, outside call!” And then technology gave you a little longer leash with the development of the beeper. But with the beeper, you still needed to be near a phone. Six years later, as an attending transplant surgeon, I got one of those very early “brick” cell phones.

I then started commuting back and forth between the Cleveland Clinic in Cleveland and St. Elizabeth Hospital in Youngstown, Ohio, an affiliated transplant center about 90-100 miles away. I would be on call for transplant surgery or transporting organs for transplantation, and if I got caught in a snowstorm with the kidney or other organs I was transporting, surgery would be delayed. So they gave me this first cell phone, and I thought it was a great technological asset. But cell services were awful.

Now, fast forward to today. Everyone has a cell phone. And everything’s quick. Email or text. How could we function without these things today? And now, through this computer or my laptop, I can admit a patient into a hospital and put orders in from wherever I can get onto the Internet, and I can see the patient on my laptop later. I can check the labs right on my computer—no more getting put on hold for 15 minutes. I can check the labs on 10 different patients from six different hospitals at the speed of light. That’s technology!

The other part of technology is that I can cover six different hospitals with telemedicine robots. I’m one of only a few people that have that capability. It lets me see a patient at a moment’s notice up in Willits 150 miles away and admit them using my avatar robot persona. That’s a huge technological feat! And when I’m in the Philippines on a medical mission, I can actually see patients here in the USA, admitting them from the other side of the world.

And we’re at the cusp of still further technological surges.

Does technology have any downsides to it?
Well, some aspects of technology are a step back. For instance, we all complain about electronic medical records. Because it’s tied us down and increased the amount of time we have to put in without helping us see patients. The way we’re using it doesn’t save time.

We have to find a way to deliver care efficiently up front. When technology can improve up-front delivery of medical care, that would take care of the problem of back-end low reimbursements. Reimbursement per patient might be lower, but if you’re seeing many more patients safely and effectively, the compensation issue goes away!

That’s what usually happens with new technology. Look at widescreen televisions and how much the price has dropped. Look at computers! It’s just a matter of time before we do the same thing in medicine.

Right now with EMR, we have doctors inputting data. Shouldn’t the patients or an intermediate person be inputting a lot of that data and the doctors just reviewing it? Then we could spend more quality time with patients talking about their symptoms and treatment. New technology and thus EMR should free up more time!

We don’t see that investment in technology paying off yet because it’s still in its infancy. So there are a lot of things we need to fix. Can we fix them? Of course we can. Is it painful right now? Absolutely. We’re going through growing pains.

I want my young medical students and my colleagues to know: Yes, it will get better! We need to push together to help make it better. We should demand it through health care policy.

What about telemedicine? Is that going to have a positive impact?
There is a lot of  “telehealth” going on out there that is really no more than tele-advertisement for health! Let me give you an example. I once saw an ad from a medical center, which claimed: “Come to our site and talk with the five smartest docs in the world!” And what you get is basically a gimmick to sell you something or pull you in on referral.

I do something entirely different with my telemedicine robot. I use it with patients, and when I’m with a patient via robot, I’m responsible for that patient. There is no difference in terms of legal liability between my seeing a patient in person and seeing that patient with the help of a telemedicine robot. This is real telemedicine. An actual doctor-patient relationship is established and is ongoing.

Look at this [pointing to a computer screen]! Here’s telemedicine! Wherever there’s wi-fi, I can manage this robot at one of the hospitals I cover. So I can cover Marin, Sonoma, Mendocino, Lake—all these hospitals within 150 miles where I have privileges. And I’m the only urologist in six of them.

In a Marin Medicine interview you did in 2010, you mentioned that you want to make your skills available to people in relatively sparsely populated parts of the state . . .
This is the sparsely populated part of the state. Northern California, all the way up to the Oregon border. Maldistribution of specialists is worse in rural areas. For example, 20% of the U.S. population lives in rural areas, while only 9% of the doctors do. So there is a significant rural maldistribution of physicians, coupled with lack of specialist care. But with technology we can bridge this gap. Without telemedicine, most urologists would not see patients more than five or 10 miles from their offices.

How far north do you go when you do a physical procedure?
I go to Willits, Clear Lake and Fort Bragg on a regular basis. But I provide immediate assistance electronically. Patients can reach me 24/7.

When I work with patients with the help of my robot, they understand me just as if I were in the room with them! And if I sense they don’t want to follow my directions, I let them know they can get a second opinion. If they go with another doctor, that ends my responsibility, my liability. What we’re doing, whether in person or via telemedicine, is protecting the patient. It’s a patient-centric, doctor-patient relationship. We have to protect that, and we are going through a period of growth and change right now.

Among your many other activities and interests is basic academic research, the pursuit of which has led you to patent two organ-flush solutions. Tell me about the professional satisfaction of doing research. And are you still involved in research?
I still do some clinical research, yes. Let me explain. In whatever I do, my motivation is simple. It’s to save lives. You can always crunch that down, what motivates me. When I’m doing surgery in my practice or on medical missions abroad, it’s one life at a time. But if you publish a paper or patent something you’re eventually saving hundreds, maybe thousands of patients! There is great personal enrichment in doing research. I learned that at UCSF from my urology chairman, Dr. Emil Tanagho, who developed many urologic procedures. I asked him why I should think about doing research. “You might help save many lives!” he told me.

Now in a free, democratic society, science doesn’t always make everybody happy. A perfect example of this is the measles outbreak! The science is there . . . and you can take a horse to water, but you can’t make him drink. We have to get rid of this nonsense. And that’s what Richard Pan is doing. He’s a physician, a pediatrician who’s in the State Senate, and he introduced the bill to keep parents from exempting their kids from school vaccination requirements on the basis of personal beliefs not based on science. As a result he’s coming under attack from some unreasonable parents. But safeguarding public health is essential, and that’s the first responsibility not only of government, of course, but also of organizations like ours—the Marin Medical Society and CMA.

What do you see as the major medical challenges in Marin County, and how do they differ, in your view, from challenges around the state and across the country?
In Marin it’s vaccination. And parental waivers based on “personal beliefs.” Otherwise, we have the same challenges as the rest of the state, the rest of the country. We are implementing the Affordable Care Act, which is broadening coverage and decreasing the number of uninsured. That’s got to be a good thing.

Another problem is the inadequate reimbursement of doctors who treat Medi-Cal patients. With the help of Assembly Health Committee Chair Rob Bonta we have a bill out there that not only restores the 10% Medi-Cal reimbursement cuts, but increases reimbursements further, so they’re on par with Medicare payments. I think that’s the backbone of meaningful implementation of the Affordable Care Act, because the best way to increase the health of a population is to increase people’s access to primary care doctors. Two-thirds of all care is from primary care docs, and improving access to them could decrease emergency room visits, etc. We have to make sure the primary care docs don’t go bankrupt before our work on this is complete. In fact, one of the major campaigns just launched by CMA is to fully fund Medi-Cal for our patients. I feel that these health directives support the backbone of efficient health care delivery, leading to healthier and more productive California communities.

If we need more doctors, are the medical schools supplying enough physicians to meet the demand?
We can always use more doctors. But, as I said, the problem is in maldistribution. And it’s also that delivery of care is still hindered by aspects of electronic medical records that have taken time away from face-to-face contact with patients.

You have to work in concert—increasing the number of docs, increasing the distribution of docs in rural areas, increasing time available to work with patients, and increasing reimbursement for physicians who work with the indigent and Medi-Cal patients so they can keep their doors open.

And, by the way, most of the care being provided for the indigent and Medi-Cal patients is through solo practitioners or small-group practices. I am a solo practitioner. We’re all hard hit! And I don’t have a big lobby system. So I have to rely on the medical society to look out for my interests. That is why solo practitioners and small practices need to be shown that they should be part of the county medical societies and the CMA. In terms of funds spent on lobbying to affect health care policy in Congress, the AMA is second only to the American Hospital Association with each one investing about $20 million. Who’s going to represent doctors better in terms of lobbying and bringing about needed changes?

In an interview with Marin Medicine, one of your predecessors as MMS president, Dr. Irina deFischer, said that it can often be difficult for patients to access the community clinic safety net because they can’t get appointments or they have to travel too far or they can’t afford the copays. Is this problem likely to be resolved anytime soon? To what extent might ACA make community clinics superfluous by allowing the previously uninsured easier access to other providers?
Medi-Cal pays doctors $22 per patient visit compared to federally qualified health centers (FQHCs), which are paid $157 per visit. These clinics tend to be overburdened, but they’re getting adequate funding from the Feds. Increasing the Medi-Cal payments for doctor visits would help alleviate most of these inequities and open access to care for many waiting patients. This is the solution and it is what we should probably be doing, and hopefully can do in the near future. Although it was not specifically laid out in the Affordable Care Act, correcting this would even out most of these access discrepancies. Delay in health care is expensive, while providing access, especially to the indigent, would be very cost-effective. Thus to fund Medi-Cal at the small-practice and solo-doctor level would be very efficient. And that is why we’re lobbying for that right now, both in the AMA and the CMA.

It’s very difficult to take care of patients at $22 a visit. You’ll go bankrupt. You’ll have to close your doors. And once those doors are closed, it’s not likely they’ll reopen. A lot of doctors have to control the number of Medi-Cal patients they have because it’s almost pro bono. You can’t just say, “OK, I’m opening my doors and I’m going to take time away from the insured people.” Everybody does that to some extent, and you have all of these programs. But the funding is not available for the ordinary doctor out there right now. Hopefully it will be soon.

We have to tackle one thing at a time. Congress fixed—repealed!—SGR, Medicare’s Sustained Growth Rate provision, last night [April 14, 2015, the day before this interview took place]. So now we can stop worrying about having our billings cut 21%, which we have had to do for the past 15 years.

This, to me, and laws like the one Assemblyman Bonta has proposed to shore up funding for Medi-Cal, are fundamental to fixing care for low-income people and the indigent. If we can fix that, it would significantly decrease the health care disparities that disproportionately hurt the poor.

Hopefully, we can increase other reimbursements too. It’s not only primary care docs. We don’t have enough reimbursement for specialists seeing Medi-Cal patients either. As one of those specialists, I get almost nothing. If I ask for reimbursement, it costs me $5 to get $3 out of Medi-Cal. You just do things and don’t charge because you’re not going to get anything anyway. So, yes, we need to fix that.

How do you view the ways the Marin Medical Society serves the physicians of this county? What are the primary benefits it brings them?
There are three big areas where CMA’s lobbying efforts help physicians: financial benefits, scope of practice benefits, and implementation of ACA and public health.

The big financial success last year was winning voters’ support for MICRA, the Medical Injury Compensation Reform Act. When the lawyers got MICRA on the statewide ballot, polls showed that 60% of those surveyed supported the lawyers’ position. If it had passed it would have raised the average surgeon’s malpractice insurance premiums from about $30,000 to almost $150,000 maybe even $200,000. So with the “No on 46” campaign we saved MICRA and actually won the vote, 70% to 30%.

The most important thing that CMA did was to organize thousands of members and organizations to create the backbone of an effort that the insurance companies then supported with money. We raised $100 million altogether to fight this, of which CMA put in $5 million, including the seed money needed to form the winning coalition. The rest came from the insurance industry, hospitals and other organizations. It was a costly undertaking.

Could anybody have done that except a medical society that speaks for all doctors? I don’t think so. We took on the full weight of the trial lawyers, but fortunately patients still believe doctors do more for their health than trial lawyers, so we won! We won by advocating for our patients’ access to health care, and if that had been compromised, lives would have been lost.

And then there’s last night’s fix on SGR. I’m so proud of that. The AMA, with the support of the CMA and the other state associations, has been fighting that for a very long time. Just imagine if I were to tell you every six months, “Hey, I’m going to cut 21% from your paycheck retroactively. You might even wind up owing money.” Most doctors don’t have that kind of money in their practices. And most of us don’t want to take money out of our mortgage to sustain our practice. We’d rather just fold. But that’s the way we’ve been obliged to practice medicine for almost 20 years. That threatened 21% cut drove a lot of my primary care doc colleagues into group practices because they just couldn’t live with it.

These financial benefits have helped doctors keep practicing their craft and saved them a huge amount of money. Victories like these could not have happened without the help of the county societies and CMA, which provide the grass-roots support for these efforts.

What do you mean by scope of practice benefits?
These are efforts the CMA and AMA make to protect physicians’ scope of practice—to prevent things that could erode a practice—for example, the efforts of optometrists to be allowed to operate on the eyes. That would dilute medical practices. For example, ophthalmologists undergo seven or eight years of medical training, including three or four years of surgical residency, whereas optometrists get just four, or sometimes five, years of medical training, with far less preparation for surgery. Would the public tolerate such a drop in standards for surgery, as well as the accompanying explosion of complications resulting from this inadequate training?

And nurse practitioners want to be called doctors sometimes? Without being tethered to doctors? That’s another example.

When you go to somebody with a white coat you should know you’re seeing a doctor, and not a nurse practitioner or an optometrist. So CMA, with its component county medical societies, is fighting for doctors on scope issues like these.

And, finally, the third big issue—public health and ACA implementation. I’ll elaborate more on this subject shortly.

MMS/CMA/AMA serve as physician advocates in the State Legislature and in Congress. What do you see as the most important issues at present?
I like to crunch it down to the Three E’s—Economics, Education and Ethnic disparity. We’ve already talked about economics—Medi-Cal, MICRA, SGR, protecting solo and small group practices, and the availability of doctors, particularly specialists, in rural areas.

Education—measles, for example, and public health generally. These are important issues. We have to make sure our lawmakers know they’re getting good information. That applied to the “No on 46” issue, too.

The CMA was eloquent in explaining that MICRA was not just an economic issue, it was about access to care and how without that “more people would die.” Some 20,000 Americans die every year from lack of access to care. So when the lawyers said they just wanted to make it fair for people who aren’t being compensated enough from their lawsuits, the bottom line was it would have killed more people by limiting access to care for needy patients, because doctors—and ultimately society—would have to pay more to defend against frivolous lawsuits! We always fight when it comes to life. That is the core of what we do. It is a rationale most groups cannot argue against.

And then there is the issue of ethnic disparity in health care—minority indigent care. Health care disparities hit the bottom of our society. It is intolerable for the most powerful country on earth to have so many people getting inadequate health care. When the Affordable Care Act was passed there were 45 million people who were uninsured. That has decreased by 12 million now. We still have a long way to go, but hopefully we’ll chip away at it and make things better. In Marin County alone, 31,000 residents signed up for health care coverage via “Obamacare.” That is more than 10% of the people in the wealthiest county in the state! Most of those enrollees applied through the Covered California program.

You’ve already headed the Marin Medical Society three times. What prompted you to take on this job again? And what issues do you plan to tackle in this fourth term as president?
It’s a labor of love! I see the work we do in much the same way I see research. It’s important work that benefits the public and allows me to help save more lives than I can touch individually.

My intention is to work to better educate my colleagues about what the CMA does for them. My goals are first, education—spreading the word—and then, following from that, increasing membership and encouraging more active participation by our members.

I told the students this morning that they cannot unbundle health care funding from their future medical practice. I told them their individual efforts will never be able to stop attacks on the medical profession, which won’t be good for their careers. But, together, we can accomplish necessary and great things. That’s why I’m active in both the county society and the CMA.

You know, it’s hard to get people into leadership positions because a lot of them think it seems too self-promotional. But it’s not self-promotion. For me, it’s an expression of respect for the importance of this profession. And it’s volunteering at a level where I can put some of my talents to their best use.

The county societies, CMA and AMA are the comprehensive organizations that encompass the entire medical profession and can actually affect public health and health care policy, which impact millions of people. CMA and the county medical societies—those are the trenches we need to work in if we want to accomplish something for public health, if we want to extend our reach and save more lives than those of the patients we work with in our individual practices.

You plan on running for president of the California Medical Association. What motivates you to do this?
Again, the same thing that pulled me into medicine—saving lives. That motivates everything I do. I just know I can magnify my impact by working through organizations with enormous leverage to improve public health and expand access to care. That’s what’s behind my work for the county society, my CMA trustee position and my candidacy for president.

What motivates me are the same considerations I just talked about in connection with being president of the Marin Medical Society—helping more physicians understand the importance of what organized medicine does, not only for them but for the broader community in terms of improving access to care and strengthening public health.

That’s why I do this, why I’m so active in the Marin Society and CMA. Because this work can help save lives, change the world … and save even more lives. It’s a natural progression.

What do you hope to accomplish as president if you are elected?
I want to educate the medical community about the critical nature of CMA’s work. I’ll work to grow our membership and encourage more members to get active.

I want members to help spread the word further and push hard to make health care work better, not just for practitioners like ourselves, but, more importantly, for our patients and especially for the thousands of people who don’t have the kind of easy access to care that everybody reading this interview can just take for granted.

The CMA’s House of Delegates and Board of Trustees, of which I’m a member, go through 200-400 resolutions every year and craft policies that are the backbone of what we’re going to fight for. Then we take that to the AMA and go through the same process. In fact next month I’ll be in California’s delegation to the AMA. With our 40,000 members we are the largest state in the most powerful country in the world.

The CMA president is in effect a spokesperson for the practice of medicine in our most populous state, so the presidency presents opportunities to affect health care policy not just statewide but nationally. It’s the president’s job to bring passion to the messages our doctors want to deliver. And if passion is a prerequisite for the job, I think I’m pretty well equipped in that area. I’m passionate. I’m committed to this work.

Improving access to medical care saves lives, and the CMA works hard to improve that access. Others might see our efforts to improve reimbursements, for example, as self-serving. But they’re missing the point. It’s what we absolutely must do to keep our doors open, and open them still wider, for the benefit of the people and communities we serve.

In your last interview with Marin Medicine, you said one of the most important aspects of organized medical leadership is “to help fashion rational and sustainable health care policy.” Does this mean support for the ACA or, perhaps, amending it in some way?
You know, there are wonderful things about the Affordable Care Act. When we asked CMA members to tell us what they liked about the ACA, the thing they liked best was that it helps those in need. In fact, 38% said they like that it helps those in need and the uninsured, and 25% said they like that it covers pre-existing conditions.

Those are two huge things! Covering pre-existing conditions is critical. It changes the previous model, which was that they’d charge you more or, if you have cancer, you just couldn’t get insurance coverage at all. Those are huge benefits, very positive. As for the things that aren’t working so well . . . well, I’m an optimist. I don’t think you should throw the baby out with the bathwater. You fix those things or you give the baby another bath.

What are the aspects of ACA that need to be fixed?
Well, I already talked about Medi-Cal reimbursement rates, so that’s No. 1. Then there’s EMR. Why penalize doctors for a system that’s not very efficient? Once it’s proven that using it is going to benefit your practice, then yes! Make us do it! Because it would be better for the whole medical profession.

But ACA kind of put the cart before the horse: “We’ll punish you if you don’t adopt EMR, even though it is an incompatible and inefficient system. We’ll wave this carrot momentarily, but then we’ll penalize you.” These cuts can add up to 15% over the next three years! That almost eclipses SGR. So, yes, we’ve got to fix that!

There’s a bunch of other little things. Prescription drug implementation, a lot of little cuts here and there. But they also add up to about 15%. That’s huge! That’s another SGR-like pain to deal with. So, yes, that’s what the AMA and CMA need to do. We’ve got to improve ACA.

Another thing. ACA was supposed to bend down the perennially rising cost of health care. We are paying much more in the United States than any other country. We’re paying 18% of our gross national product for health care. The next highest is 11-12% in Germany. We could afford to cover everyone in the United States if health care dropped to 13-14% of GNP. We just pay too much for it today. But most of these excessive costs can be recouped if the system is made more efficient.

A lot of those high costs have nothing to do with the doctors. It’s hospitals buying new equipment every six months and writing it off. The growth in the cost of medical devices is 17 times higher than overall inflation. ACA was supposed to decrease costs, but they’re doing it on the backs of doctors and not where the problems actually reside. The problem is with the hospital corporations, the drug companies—it’s on the massive corporate side.

I strongly believe in a patient-centric, physician-led practice. Not hospital-centric, CEO-led. Not insurance-centric, financially led. It has to be doctor-led. We’re the ones who know the most efficient ways to deliver care. But they’re not cutting the hospitals as much as they’ve been cutting the docs. We need to change that. The SGR fix to the ACA is going to increase Medicare reimbursement by half a percent every year for the next three years maybe. That’s a pittance. The hospitals continue to get 3-5% annual increases. The difference is ludicrous! We need to fix that too.

In your last Marin Medicine interview, you said one of your core motivations is to protect the patient-doctor relationship. Protect it from what?
It’s being eroded! Remember what I mentioned earlier about something that people might see as “telehealth” but which is really just teleadvertising? Well, that’s the nose of the camel that wants to get into the tent. Because there are a lot of large Internet companies out there that would like to be able to advertise and have their doctors—doctors they employ—practice medicine online across the whole country.

That wouldn’t be a doctor-patient relationship. The AMA has a long list of requirements for what constitutes a doctor-patient relationship, when it begins and ends. When I talk with a patient, it’s just like the two of us talking here. “Hi, I’m Dr. Peter Bretan. So-and-So sent you here because of problem X? I’ll examine you, I’ll make sure your history is filled out, I might order some tests, and then we’ll talk again. I’ll tell you what I recommend. Here are the risks, the complications and the alternatives.” And it’s still a doctor-patient relationship when a portion of our interaction is done electronically in ways that allow me to serve a wide rural area efficiently.

For there to be a doctor-patient relationship you can’t be anywhere in the world or cyberspace. You have to be licensed in the state where you are seeing the patient. That enables patients to have their rights protected and know who is responsible, who is legally liable for their care.

California is the toughest state in the country to get a medical license. It’s certainly one of the toughest states to get into medical school, and because of this we have the best doctors here. I don’t think the state Medical Board or the hospitals here are going to want to let people with a national license practice here without a say, because we have established standards for the doctor-patient relationship, backed by a strong peer-review system for medical liability.

That is what I mean by protecting the doctor-patient relationship in the Internet age. Because no matter what happens, the practice of medicine must still be between the doctor and the patient. And if the patient wants to go see another doctor, then I hand off the baton and send over the medical records.

Ask any three people why medical care is so expensive in the U.S., when it’s free to patients—although probably not to society—in so many other developed nations, and you’ll probably get three different answers. If you exclude the fact that in the U.S. insurers and patients pay for it, while in Europe, for example, government generally does, is U.S. medical care really more expensive, or not?
There is no such thing as free. So when you say “free,” when looking at England’s health care, for example, they’re paying for it with a national health tax of 17.5%. So your question repeats a common misconception about U.S. health care. But that does not mean we can’t do much better.

The bottom line is that we have to be more efficient in covering everybody. You know, Germany has their system. It’s called Bismarck, and France followed it, Taiwan followed it. And it’s a very good multipayer insurance system, but heavily regulated with a common, nationally set payment fee schedule. Then there’s complete socialized medicine, which is what England has—paid for with taxes that would not be tolerated in the U.S. Then there’s a Medicare-type system, which is what Canada has. And finally there’s out-of-pocket, which is the most inefficient in terms of health care disparities.

What kind of system do you think we will ultimately have in this country?
Actually, I posed that question to AMA President Robert Wah. “What do you think we are ultimately going to do? Are we going to go Bismarck? Will we have a system like England’s?” He said, “No, I think we’ll have a uniquely American system.”

I agree with him. I’m an optimist. We have very bright, entrepreneurial people here, and we have a lot of immigrants. There’s something different about immigrants. My parents were immigrants. California is the 49er state. People were brought here by the Gold Rush and more recently by Silicon Valley. This country won World War II thanks to the strength and ingenuity of our industry—for instance being able to manufacture a Liberty Ship in just a few days, right here on Mare Island where Touro Medical School is located today.

So like Robert Wah, I think we will have a uniquely American system and that it will rely on our technology. Look what Google has done, look at Facebook, look at Silicon Valley. That’s where we are incredibly powerful. And we’re on the cusp of even greater things.

When Genentech found a way to mass-produce certain clones—to mass produce specific proteins across the board now—they exploded a whole industry. I have no doubt that’s where we’re heading. These things just keep progressing.

We haven’t paid enough attention to health care delivery. We’ve been looking at the cost side, the back end, the reimbursement side. Robert Wah thinks we need to pay attention to the delivery of health care up front. I’m already doing that with telemedicine. Not everybody is an early adopter. But they’re going to embrace telemedicine sooner or later. I think the efficiencies it makes possible will bring costs down.

We’re not always going to be delivering care the same way we are now! It’ll be much better! We don’t talk on phones the same way we used to. We don’t pay our bills the same way. We don’t bank the same way. We don’t live the same way we did 10 years ago, and we’re not going to be living this way 10 years from now. And hopefully health care will benefit. But it will have to change dramatically.

We have to foster technology that enables us to deliver health care more efficiently and less expensively. Then we’ll catch up with the rest of the industrial world in terms of health care delivery. But it won’t be a German system, it won’t be Canadian, it won’t be English. It will be uniquely American.

Again, doctors are going to have to keep up with technology, keep up with health care policymaking. You’ve got to be an economist and a techie as well as a physician. Not all of us, maybe, but more of us. Hopefully we’ll educate enough tech-savvy, economic-policy-savvy doctors so that we can craft rational, sustainable health care policy.

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Mr. Daniel is the editor of Marin Medicine.

Email: bretanp@msn.com