>> coming up, a special edition of "Need to Know" by the people.
100 local citizens spend the day talking about our health care system, sharing their experiences, opinions, and ideas.
[CAPTIONING MADE POSSIBLE BY WXXI]
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>> Rochester's newsmagazine's since 1997.
This is "Need to Know".
>> thank you for joining us.
I am Julie Philipp.
A few weeks ago, WXXI and Rochester Institute of Technology took part in a national initiative called by the people.
Hundreds of Americans gather to talk about health issues.
In this special edition of "Need to Know" we're going to look at some of the questions local citizens ask, including one about who is in charge when it comes to health care, doctors or insurance companies.
>> My question is how does Insurance Co. oversight impact the ability of health care providers to deliver quality care and receive adequate compensation?
The question basically is how much are doctors controlled by the insurance companies in the care they give?
>> there is a limitation as to how much I can receive the reimbursement based on the contract -- the contract I have with the insurance company.
If I choose not to accept it, it costs the person.
I think the other part of your question is how many taxes -- tests can I order based on what the insurance companies say.
Part of this is trying to contain costs to deliver care.
It's there -- there are some studies that show using the generic equivalent of a medication will say that several billion dollars that is something we should do.
When you come in my office the first thing that pops in my mind is not the generic equivalent of a drug i have used five seconds ago, or the drug i know works the best or has the best outcome or the latest research which might necessarily not be the first -- best thing for you.
We need to look at a cost of the medication.
There are some cases where there are proper authorizations I have to do for medications or services such as X-rays or other services.
Author is the -- authorizations to refer to specialists.
There is a balance as to what a physician can and cannot do but you also have autonomy.
>> earlier you said you have to see four patients an hour to cover your overhead.
Some of us worked 40 hours.
The overhead does not include --
>> you got it.
I work about 15 hours a day.
>> how many days a week?
>> 5 days a week.
I am on call 24/7.
>> but that is 15 minutes per person.
You have to cover more than your overhead.
>> exactly.
>> therefore your down to 10 minutes per person.
>> 7.5 minutes per person.
>> that is all you can allow an order to put food on your own table and cover your overhead.
>> basically.
>> and your working 70 hours a week.
The challenge is how do you provide an encounter when you are meeting the needs of a patient with a limited amount of time.
There are ways you can do that.
>> as usual I am going to dodge and slightly alter your question.
You ask two questions -- how do it and pop -- but as oversight -- The premise of the question is, what do insurance companies contribute to health care?
Or are they a drain on the system?
I would ask the session -- the question differently.
How much of the money insurance companies make and that contributing to the health care?
It is not enough.
That may not be the way we want to structure the health-care system in the first place.
>> you're going to have fun at the end.
>> I will try to stick to the original question.
We talk a lot about systems, but basically human nature is at play.
Doctors are the people who run hospitals and health-care systems are the people who run the systems.
We are all subject to human nature.
I think people in the field are basically well motivated around providing patient care and doing things right.
Like anybody, we respond more effectively to challenges and incentives and to the earnings from different and better ways of doing things.
What I mentioned in response to the last question, I think the federal government's, and that it did -- government's the emphasis on providing tools have helped specifically hospitals responded provide a higher level of health care.
I think something's that insurance companies do have the same result.
There is a policy now where patients who need eight ct scan for a variety of things, if doctors want that they now have to go through a process patient I patient to get that approved prior to its being provided.
It seems to be, from the point of view of doctors, basic tests for basic things that have become the standard of care.
One thing that will result rather than have the office staff go through all the steps to get this approval, not being able to schedule while the patient is in office, it will be easier for the doctor to say, you need a ct so go down the street.
The hospital has a higher number of patients coming into the emergency department and I think in fairness to Medicare, Medicaid, and the insurance companies, there are incentives, there are directions that have the impact of improving care and those that are counterproductive.
>> Do you want to have -- do you have a comment?
>> [LAUGHTER]
>> let me skip around on the comments that have been made.
On the issue of value which is the one that receives some applause, the alternative is that the companies are not there.
You either have government or you do not have insurance at all and there's no cooling mechanism and is self pay.
If he were to draw a contrast in particular to government, there have been some researchers from Massachusetts or Harvard who talk about in Medicare for all situation.
They say the it ministered of cost is 3% in medicare.
That number is right if you look at Medicare compared to an insurance company that is running up to 15%.
What is the light in those statistics -- the costs three times as much to take care of Medicare patients.
You take that three% and multiplied by three, you do not see a huge difference.
You also see Medicare contrasting with the private sector for administration.
It is really just Medicare policies out there governing what is done compared to what is not.
People need to remember that.
Go back to what I said earlier about choice and pluralistic financing.
Let me digress.
They might have a comment here.
We have in Rochester one of the best infopreneurs' surgery department in the world.
-- one of the best narrow surgery department in the world.
People come from all the rubble to have surgery on their backs and heads.
Rockstar types of people if you go over the list of patients.
I will not tell you who they are, but some of them played for the NFL for example.
They have one fellow coming out of that program each year.
You can only shake -- only train one surgeon per year.
You need about 1 million people to see enough disease to do that type of training.
In the last 11 years they did not keep one of those.
They all went someplace else because they could make more money someplace else.
The doctor came to me and said they could go to Houston, they could go to Virginia and make $700,000 being a surgeon.
Great out of fellowship.
Can you help us?
Because if you look at who is in my group, most of them are in their 50s and we're going to have access to care problems.
My problem -- My company showed up and provided a $4 million grant.
Now we have solved that problem.
That is the value of pluralistic financing.
If you only have one source of money, you do not have the ability to solve that problem.
Going back to your other questions about access to care and the extent to which it affects doctors practice or -- there is a state law out there called external review.
Any time we have said no because something is viewed as medically not necessary, experimental, investigational, conditions like that out of contract, a patient has the right to go to the external review panel.
Every insurance company is subject to the law.
When we go -- when we have a denial they can go through external review.
About half of the time our decisions are overturned.
Not 100%, but half of the time.
When they are overturned, it is absolutely a judgment call.
Back to the radiology talk, the gatekeeper type of situation, we are one of the last places in the country that has installed this type of programming.
Our expenses in radiology from 2006 to 2008 are going up 17% per year.
We said, what is going on here?
We grabbed a little bit of data, it looked like 30% of the studies were being done for duplicates, higher cost studies, or the study simply did not make sense.
How did we make that judgment?
We went to the American College of radiology guidance, we went to the profession itself and set against the data, it doesn't make sense?
When you have that type of number out there how could you ignore it?
Now we have the absolute factor.
When this first rolled out it was a complete disaster.
I checked this morning coming over.
A call to that call center, " presented -- four second wait time.
If you need to talk to the nurse, the nurse cannot deny.
When transferred to a position, 14 seconds until you get to a physician.
An average call is 4.5 minutes.
Against the 7% inflation I do not know how we cannot do that.
Going back to the economic security.
I do not know how we cannot take that type of action.
>> we are at Group #four.
>> My question is how can the medical community at large shift from a model of illness to a model of health and prevention?
>> Do you want to start with that?
>> that is a wonderful question.
I think it is something we are very interested in doing.
I think it is going to take a long time and I think it is going to take the involvement not only of the medical care systems, but also of our communities at large.
We really need to ask the question and look at the facts about what is really causing us to be built.
We need to look at basic causes rather than looking at outcomes.
Of I asked everyone here what the number one cause of death in the U.S. was, you would probably tell me heart disease.
If you think about it, hurt disease is not a cause.
It is an outcome.
We need to ask the question what is the cause of heart disease and then begin to address those issues.
It is a switch for us in this country.
We have focused all their time, energy, and finding on treatment parts of the health-care system.
We really need to shift to thinking about prevention, not just secondary convention -- not just secondary prevention, but preventing it from happening at in the first place.
That is not something the health care system can do by itself.
We need to do it as a community.
We need to demand the health-care system support that and provide access in ways that it needs to to preventive health services, but there are a lot of other things that the community as a whole need to do.
We need to redesign our communities so we can take walks in the evening.
We need to make the streets safe so we can be outside the houses.
We need to make sure everyone in the community has access to healthy food.
We need to make sure we have legislative solutions that make sense, harder to buy cigarettes for example, or hard to -- harder to by fatty foods.
We need to think about coming out -- coming at this problem from every angle.
>> [APPLAUSE]
>> the go to Joe on the legislation part of it.
>> it is a great point and one of the things I am reminded of over and again is how difficult all of this is to resolve without people being willing to sacrifice something.
The conversation about trans fats or smoking or how you legislate personal responsibility, because it is about personal responsibility.
People are resistant to change.
If we were to pass legislation sang cannot have trans fat in restaurants which they have done in New York City, and I think it is the wave of the future, you hear from the same people who complain about the cost of health-care insurance will be complaining that the Legislature and governor decided to limit their personal choices.
It is interesting because I do not think we will get to a point where we have affordable, accessible health care without virtually everyone in our society giving up something.
Are people prepared to make the sacrifice that David talked about in other industrialized nations where in England, -- hear, in a society and country where we value individualized -- everything is individual freedoms and that is the hallmark of our lives and governance for 200 years, the notion that he would have to get permission and stand in line for certain kinds of health care is going to be difficult for people to accept.
I think legislate -- but is legally we are changing.
When the changes as it relates to purchase of tobacco and alcohol.
We made complaints -- we got complaints as soon as we do it.
We mandated seat belts, you're not allowed to talk on the telephone while you're driving.
Those are restrictions of personal freedoms, but they do reduce the cost or at least reducing the increased cost of premiums.
The question is when we are all done with the -- all done with this discussion, but as we focus on it, part of the question for me and those elected to serve, we have to make the choices -- do we have to tell our constituents that they cannot have this hopefully in return they get reduced premiums?
It is a question that is not easy to come to because people -- it is easy to talk and for all of us in the room to talk about what the future will be, but it is different for all of us making personal sacrifices.
My doctor said that I was healthy but I should lose ten pounds.
I have taken some personal responsibility.
>> I will tell the truth.
When you first came in, I thought you got a haircut.
I know where that Waite went.
>> [LAUGHTER]
>> I think this is the best question.
I think the next by the people should be all about this.
I think it is where we all have to come together.
The governor did start the whole conversation by saying we should build or have the health care system we need, not the health care system we have.
There are a lot of things we need to change along the way.
We have to change the financing.
We have to make it so it is as easy as can be for people to go to primary care, understand prevention.
People have 22 different coalitions, committees, task forces.
We find that two of them, the African-American and Latino collisions are desperate for information.
I think the communities are ready.
A lot of things can change.
I think all of you are here today because you know the system is broken.
You're welcome -- willing to take responsibility to fix it, but I think other things have to change, too.
>> we were looking at what could we as a community do to help control health-care costs and be a healthier community.
One of the areas we focused on in an area of employer can be helpful on is supporting wellness initiatives within their organization.
This past three -- this past spring wheat sponsored a program called eat well, live well.
Very simple.
Eat fresh fruits and vegetables and start walking.
It is exercised and healthy food.
We had over 90 employers in the community and 40,000 people that were counting steps and trying to eat five cups of fruit and vegetables every day.
The grocery store loved it.
It was a program they gave to the community.
I think you'll see more employers embracing this.
I think schools are becoming more aware of the fact that the meals they serve children have to be healthy.
My guess is that if you go into your canteen areas, you will see perhaps less chips and crackers and more apples and fresh troops.
Those are the things that we as a community can do.
Long term, it will take us some time, but that is the kind of effort we need to become healthier.
>> I will give you the last comment.
>> your question is how to shift from an illness to a prevention model.
Look at models that have already done so.
It is relatively simple.
If you have a fee for service orientation health care, where is the money?
It is in providing service for those already built.
Those countries who do not have that spend more on prevention and have fewer illnesses to deal with in the long run.
If it is a fee for -- fee-for-service in a profit system, you will treat people who are already killed more regularly.
>> Colleen.
>> in our group we had many interpretations of one subject.
We were asking how would you define universal health care and what impact would have on our region.
>> it is a difficult concept to wrap your mind around basically because of the way we have provided health care in this country until now.
David talked about the system in England.
There things you get the night and there are services you cannot have if you are older and sicker and have more complicated diseases.
Those are things we are not as a surly ready to accept in this country.
I ask, where the heart disease patients and a chronic diabetics.
The patient dying of HIV/AIDS.
We are more attuned to prevention and acute care.
I think universal access or care would have to be a system -- I am not sure that having one care would be the answer because I think that limits your ability to have a free-market society and make sure you are providing adequate care.
I think you need to have a system where everybody is able to access the six services and at least means access to primary care physician with prevention model incentives for prevention.
A program called help the Blue -- Blue Cross/Blue shield just created a program.
It makes me crazy.
If I tell you you are diabetic and had heart disease and I need to help you lose ten pounds and use a fork at it and you go by Burger King and I have a mother is taking their children out to buy fast food because they forgot how to cook, we have become a fast-food society.
We need to have basic asset -- basic access but we need to teach people.
>> [APPLAUSE]
>> a terrific response.
Could he speak into the microphone.
You're leaning and closer in to that person.
I am saving David and Tim.
Is there someone else?
>> the question on public policy is what universal coverage is.
It is a great question because I think we all have different ideas of what that will be.
I agree with the doctor that preventive care, primary care has to be part of preventive coverage.
But also catastrophic care has to be a part of universal coverage so when you have an episode, having cancer or being involved in some kind accident that you really need as part of universal coverage have catastrophic care as well.
It is the part in between that there will be a debate about.
In order for you to have coverage -- it may be another question we will grapple with.
Should be mandated?
If you choose to opt out, let's assume affordability is not the issue.
With the ability to opt out, you do leave and -- lead exposure in the pool of export -- insurers.
I think a lot like mandatory care.
I think it is going to be primary, preventive, and catastrophic.
The debate will be what other pieces will need to fill in to be universal.
>> if wheat the Greek universal access is a political and social good, I think a universal system is the appropriate outcome.
But the actual arrangements cannot be brought wholesale.
We are at a different place.
One of the things we have at -- as an advantage is we have a lot of debris kinds of experiences trying to finance health care in a variety of states all of which have different difficulties.
I do not think there is one system that fits all, but I think there is a state-by-state system driven in the universal direction is the private direction to seek.
>> I am not in variants.
I think it is a part of prevention, catastrophic, I think it has local focus and as I said a number of times, a number of sources of financing and payment.
I think the devil is in the details.
If it was easy, it would have been done.
>> I am Julie Philipp.
You have been watching a special edition of "Need to Know" d during part of a daylong dialogue of health care at Rochester Institute of technology.
This is the final part of a three part series.
To find out more about By the People, go to our website, www.wxxi.org.
>> By the People is a special initiative organized to bring citizens and national the such a discussion on the important issues of the day.
Btp is partnering with the colonial Williamsburg Foundation on the dialogue in Democracy project.
By the People is nonpartisan and does not support any particular policy, position, or viewpoint.
Its sole purpose is to encourage informed dialogue.
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