Transcript
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The speaker explains how frustration with the Affordable Care Act led him to write a book and outline his main arguments. He introduces the central problem of providing care to the uninsured without creating a new entitlement.
Speaker A
The night that the Affordable Care act was passed, some of you might refer to it as Obamacare, which its opponents do derisively.I got up in the middle of the night.I was so upset with both political parties and the disservice that I think they had done to the American public because of the opportunity that was missed to do something right.I began to write.And I found that only by writing could I exorcise the demon within me.
Three months later, I'd finished a book, and I tried to make several points in the book.Number one, we've asked the very worst people in the world, our politicians, to solve the most complex domestic issue of our time.People, for the most part, that had never cared for a patient, had never started a medical service, and many of whom had never even met a payroll.Secondly, I've determined, and I'm going to try to demonstrate this today, that there is sufficient money already in the medical care system to do what we started out to do, and that was care for the uninsured without creating a new entitlement.And thirdly, to attempt to explain why the health care system is so very hard to change.
In order to understand this, we have to go back just a moment and review how we think about the medical care system in this country.It is true that in the United States, we represent the very best and the worst of medicine in this world.Two Valentines ago, Baptist Medical center in Oklahoma City participated with Johns Hopkins University in Baltimore and Barnes Jewish in St. Louis to do a three state, three hospital, nine surgeon, 12 patient domino kidney transplant, the first time that had ever been attempted in the United States, as kidneys flew back and forth across the country on the same day.This is example of our technology that occurs in everywhere in this country, certainly occurs in this community on a regular basis.But here's the interesting part.
At the very same time that that miracle was happening, not two miles away from the campus of Baptist Medical, some of the most desperate people in the world were lined up to receive free care from volunteer doctors and volunteer nurses, hoping beyond hope that the resources of those of those meager clinics could meet their medical needs.Because if they could not, then we'd start this dance of trying to find a surgeon and a hospital and an anesthesiologist that might take care of their needs, a process that could take weeks, even months.And by then, the patients were worse off and often wound up in hospital emergency rooms, the very worst place and most expensive place to treat these kind of conditions.So the question is, how do we answer this very simple question.How do we provide the most care to the most people of sufficient quality and constrained cost?
He uses examples to show the disconnect between patients, providers, and payers, arguing that this structure pushes costs upward. He also explains why health care is not really functioning like insurance and why the system is so difficult to change.
Speaker A
Now, that seems like a very easy question to answer, but in fact, the answer seems to elude us.And let me give you sort of a real world example so we can compare how our health care system works compared to what all of us are familiar with.If I give my daughter my credit card and I say, dear, you go to the mall and you pick out anything you think you want when you're in the mall, I as a cardholder will pay the bill.My daughter goes to the mall, she goes to the dress store, she hands my credit card to the salesperson and tells the salesperson, you pick out for me what you think I need.What's the result of my card bill as a cardholder?
Well, my costs go up exponentially.That's what happens.There's a complete disconnect between the three parties at interest.The cardholder, me, in this case, perhaps the employer of the government, the person benefiting from delivering the service, the sales clerk, in this case, the doctor, and the person receiving the service, my daughter, in this case, the patient.It is this total disconnect that leads us to our out of control health care cost.
Health care costs that have exceeded inflation for the last 30 years, health care costs that exceed any rise in the cost of wages.
The problem is we think about health insurance as if it were insurance.It's not insurance.I'm not an insurance person, but here's what I think insurance is.It's taking of a little bit of money from the many to cover the extraordinary losses of the few.When we have homeowners insurance, we don't expect the homeowner's insurance to pay you.When someone throws a ball through our window when we have auto insurance, we don't expect the auto insurance company to pay when we have a flat tire.But yet every time we have a contact with a medical provider, we expect someone else to pay the bill in whole or in part.That by definition is not insurance.It's a transfer of payment system.So let me go over a couple of things that I think, and there's about 15 of them that I think make American medicine and health care so hard to change.
Number one is tort reform.Now, we all sort of know that the idea in the rest of the world of people suing doctors and hospitals for acts of negligence is not unknown, but we've taken it to the extreme.Every doctor in this country views every patient as a potential litigant that adds extraordinarily to the cost of medicine.But here's the interesting part that most people really don't realize.In our fee for service medicine, where the more we do, the more we get paid, we actually benefit.
Because to do more, because we think we have to do more, benefits us.So the thing we fear the most works to our economic benefit.Secondly, there's a lot of conversation about whether health care at its core should be market driven.If we just let the wonders of the free market work will solve all our problems.In 40 years in health care, I've never seen anything convinces me that health care can be market driven.
Can it be market driven at the fringes, at the margins?Absolutely.Can we train people to say, doctor, do I really need that mri or could I go get it over here?Because I've read on the Internet, it's cheaper, sure, but that's at the fringes.When it comes down to something serious, heart disease, cancer, stroke, you and I, our knowledge of medicine is so insufficient compared to our doctor, we in effect are uninformed consumers.
And an informed consumer is the essence of a free market.At the end of the day, when it's something serious, we say, doctor, if your mother, your father, your brother, what would you do?And that's what we do.We're uninformed consumers.
The talk turns to administrative overhead, billing complexity, and the incentives that push doctors and patients toward more testing and treatment. He then criticizes political slogans and media sound bites that distort serious health policy debates.
Speaker A
We have extremely high overhead.
One fourth that bears repeating.25% of every health care dollar goes to collecting a bill.That's unknown in the rest of the world.Every doctor has two or three patients do nothing but collect bills.Integris Health has hundreds and hundreds of people that do nothing but collect bills.
Let me go back to my daughter analogy.When my daughter goes to the mall, she takes with her two or three different lines of credit.She takes a MasterCard, she takes a Visa, maybe a discovery card.What if, in fact, the retailer had to meet 150 different lines of credit, all with different regulations, all absolutely bent on paying you as slow as possible?What does that do to the cost of that retailer that gets passed along ultimately to the buyer?
You and I are part of the problem.I talked to a lot of doctors in writing this book, and what I found is that to a person, they feel tremendous pressure to do something when doing nothing would be better.If a patient leaves their offices without a lab test, without an X ray, and particularly without a pharmaceutical, they feel cheated.And the doctor feels this.Why, in fact, do pharmaceuticals advertise to patients at night over the television, over the head of the doctor who asked to write the script because they know that 80% of the time when you ask for a medication by name, your doctor will write the prescription.
And the reason is simple.Doctors work on the basis of time.So if they take 15 minutes out of your schedule for every patient to explain why they didn't need that purple pill they saw on television, that's one or two patients less they can see.And finally, words get in our way.I invented a disease called the Pelosi Palin syndrome.
These two women could not be more different politically.But to me, they're the flip side of the same coin.They give absolutely no intellectual depth to any complex problem.Everything is.
Everything is decided on the basis of sound bites.And let me give you a couple examples of the sound bites.We have the very best health care system in the world.That's a sound bite.You hear it all the time.
Why would we say that?Why would we say that we don't rank near the top in World Health Organization statistics on any category except cost per capita.If we started out 50 years ago and said to ourselves, let's build the most expensive health care system in the world, we've been marvelously successful.
Secondly, death panels.We all heard this story about death panels.And both parties have used this recall during the presidential election.The number of times you saw a commercial depicting Congressman Ryan running for vice president, pushing his mother over a cliff because of the things he wanted to do to Medicare.And you know, the Republicans are just as bad.
The New York Times reported that the Obama administration was going to begin to pay doctors to handle life discussions with their employees.And the Republicans went crazy.See, we told you what they want to do to the old people.You know, it's crazy because every state in this union has a law and a requirement and an encouragement that each of us have an end of life discussion with our lawyer and we produce a living will so that someone can act on our behalf when we cannot.But yet we don't want to pay our doctor to have the same discussion.
I don't understand.
He proposes concrete reforms, including reducing insurance delays, paying for effective care, using evidence-based medicine, and improving real-time patient information. He also raises the broader challenge of building systems for an aging population.
Speaker A
Now, here's what I'm thinking here is part of the problem and maybe part of the solution.If insurance takes up 25% of every health care dollar, why don't we see if we can recapture that cost?The reason the insurance companies delay payment.And I will tell you right now, you're talking about a process that ought to take a week.You're taking a bill from a provider, you're comparing it to a benefit plan, and you're issuing a check.
It in fact, takes three to Four months at best.Because the insurance companies are working on the time value of money.They do not want to pay you.And if they pay you, they want to pay you as slow as possible.So let's take that incentive away.
Let's figure out a clever way using our tax system to make them not for profits, and then pay them on what it is they do, and that's adjudicate claims and pay them on how quickly they can adjudicate those claims.Secondly, the President said during this debate, something I really agree with, we ought to pay for only what works.The fact is we pay for a lot of things that don't work.Some estimate as much as 30 or 40% of everything that's done to us is unnecessary or duplicative.Let's use evidence based medicine.
There are very good systems in this country to follow the protocols.Every medical school, most specialty societies have protocols on how to deal with disease.And if you follow the protocols, you reduce variation.Most people don't realize the variation that's present in medicine.There may be a 30% variation between here and Tulsa, 90 miles away, on certain surgical rates.And you engineers out there know that variation is a sign of poor quality.We've got to follow the evidence and recapture that 25 to 30%.And thirdly, we need information available on us real time.If you go to South Dakota on vacation today and you have a heart attack in the middle of the night, you're going to be taken to a South Dakota hospital and the doctor is going to ask you some questions.What medications are you on?
Have you had a coronary arteriogram?What were the results?And in the absence of your memory being good, and your memory is not a very good medical tool, that will all be repeated again.There's huge redundancy in the system simply because there is a lack of information available real time.We need a system with an identifier that identifies each of us like our Social Security number does.
And then we use that identifier to locate our records and know specifically what's happened to us.You know, we have another issue too, and that is it is medically related, but it affects all society.We've got to begin to have discussion about what we're going to do as we age, because we are aging at a very historic rate.You know, if the 80 years old of today are like the 60 year old of yesterday and the 100-year-old of tomorrow is like the 80 year old today, the kind of systems, both medically and social, that we have to have for that population we haven't begun to address.
The speaker closes with a warning about end-of-life planning and then returns to the original goal of covering the uninsured. He ends with Lucy's story as a reminder that reform should focus on working Americans who still lack access to care.
Speaker A
And let me mention one other thing before I close.You know, those of you out there who are old enough and have to begin to think about a living will, the only thing I would encourage you to do is very, very careful.In my own instance, I changed my insurance policy, leaving a lot more money to my wife the same week that I executed a living will, giving her full power of attorney to make decisions for me.And the instant I was signing the document for the living will, I had a vision.And I was in an ICU hooked up to lots of machines, and my wife was standing at the foot of my bed along with my doctor.
And in this vision, I hear my wife saying, well, he looks dead to me.
You know what we've done?We have violated one of the specific principles of Stephen Covey.And that principle is to begin with the end in mind.And when we started this whole process, what we were talking about is how do we cover the uninsured, that fourth of the population that through no fault of their own is uninsured.And we've gone away from that.
I think we need to get back to that.And let me close with a story that I use in the book.This story revolves around a patient named Lucy.Now, Lucy's a composite patient, but nevertheless she actually exists.Lucy is a single mother with three children.
None of those jobs that she has.She's a domestic in two jobs and she works for a fast food restaurant in the third.None of those jobs, through no fault of her own, provide her no health insurance.Now Lucy's doing everything we could ask of a citizen to do.She's working three jobs to take care of her family.
Lucy makes $12,000 a year.That makes her too rich to qualify for the Medicaid program.So Lucy has to depend on free clinics for the care of her children and herself.I believe we've got to get back to the Lucy's of this world.I believe we have to figure out a way that in this very rich society we don't ignore Lucy.
Lucy is not an ER do well living in a box under a bridge.She's an American citizen, paying payroll taxes and paying property taxes through her rent.This is where we need to focus.This is what we've got to solve.And I think if we get back to the Lucy's and really focus and then do some really straightforward things like I mentioned, I think we can begin to get a handle around healthcare reform.
Thank you.