Ep. 10 Pushback, Part 2

This kind of relationship that they're touting is, is trying to make the patient physician relationship no more important than the person who checks out your groceries in the store.

This is Dr. Patient, a podcast that examines all the aspects of the patient provider relationship. I'm your host, Heather Johnston, MD, a real life doctor and patient. I have to say, I've gone down a rabbit hole in the last week's over today's topic. And I want to admit openly that even as an actual physician that practiced at a top notch University for 12 years, I actually had a lot of trouble understanding all the ins and outs in history regarding health insurance in the US, especially with Medicare. It's grown so complicated, that I feel like I might need to go back to grad school to do a thesis on this just to get through it. But let's dive in and see where it goes. Last week, we heard about two practice models where patients pay the doctor directly for unlimited care - concierge medicine and direct primary care. This week, we're going to the opposite end of the spectrum of how doctors can provide care to patients by ultimately changing the health insurance system. We're going to explore the idea of Medicare For All. My guest is Dr. Susan Rogers, an internist from Chicago, who's now the president of Physicians for a National Health Program. Before we start, here's some background information and how we got to where we are today with health insurance. And as usual, I'm putting lots of references in the show notes, including what amounts to basically a glossary this week, because you're going to hear so so many terms and acronyms, because government. Medicare is a federal program that gives government funded health insurance to those over 65 and sometimes under 65 with certain disabilities. It was created in 1965 by President Lyndon B. Johnson. Incidentally, he got the very first Medicare card, though multiple presidents before him actually tried to pass legislation for a national health program that would cover everyone, not just over 65. From what I can glean, Medicare was going pretty well for a while until health care costs started skyrocketing in the 1980s, and frankly, haven't stopped rising yet. Why that happened is a long discussion for another day. So this tripped a wire with federal oversight and lots of little changes started sneaking through regarding how Medicare works, some good and many not good. The history of legislation regarding Medicare reads like a mystery or true crime novel depending on what chapter you're on. From the constant creation and dissolution and amending of changes to outright lobbyist control of the decisions that are made. It's been a bit of a shitshow. One of the most disturbing examples was in 2003, when President George W. Bush created part D of Medicare, which added optional drug coverage. Sounds good, right? But part of that legislation specifically forbid the government from negotiating on drug prices with manufacturers, and this still holds true today. Who would agree to something so stupid? Either it was a serious lack of foresight, or a serious intent to just line pockets, since the folks that benefit from that directly are the pharma companies who also coincidentally contribute to political campaigns. The other huge legislative change that brought us to where we are today was in 1997, when President Clinton created the Medicare Choice, now called Medicare Advantage, program. This increased privatization of Medicare, which already had been around since the 70s, to some extent, but this program really increased it. And now over 40% of Medicare enrollees are in Advantage programs. These give enrollees more benefits, like vision and dental and more. But the cost we're all paying for that isn't necessarily in dollars, it's in quality of care. Because ultimately, private payors providing care is an inherent conflict of interest, every time. Okay, let's jump in with Dr. Rogers.

What the the underlying issue that our organization has is that we have a healthcare system that is based on profit. And so once you have something that you know, who gets it is determined by what they can pay is always going to be inequitable. You have people who can go to the hospital with cash in their pocket to pay for their bill, versus other people who don't even know where dinner is going to come from. So what is affordable for everyone is totally different. So trying to make health care affordable, really isn't the way to address this inequity. You just have to make it a public good of which everyone has a right to and that's the whole basis of what um my organization is about - a single payer, meaning the government is the payer. It's the only single payer, it's not Aetna, or Blue Cross Blue Shield, it's the government, who then pays the person providing the care whether it's the internist, the pediatrician, the hospital, the pharmacy, they get paid through this one payer system. And that's simple. It's equitable, every price is the same, people who have less don't have to pay more. And so that's the whole premise of Medicare For All. And that's how traditional Medicare functions; it's every person over 65, or who is otherwise qualifies for Medicare has the same benefits, and they get paid the same rate physicians or any other provider gets paid the same rate, but providing care to them. And it's simple, it's not a question, well, I don't know if you can get this medicine, I don't know if you can see that doctor. Those are non issues. And so that's what we advocate for, what we call Medicare for All which would be like a traditional Medicare system, although we would improve it and provide some things that aren't there now, like a hearing aids and dental coverage, long term care, and, and would all be provided by the government, and it would be a public good. And they do that in almost every other industrialized country, and they pay less and get more. And we just can't seem to understand how anything different from what we do can be better. And so that's a cultural issue in this country. But so that's where we are.

I'm kind of curious, like, why aren't more doctors behind this? Why aren't more of us standing up and getting behind this.

Within our culture, the way this country is function, there has never been a for all concept on anything we do. It's never been driven by providing something for everyone. If you can afford to pay for it, you get it. But even if you look at when health insurance started back around World War Two, when you couldn't provide you couldn't increase wages. So what they decided to do was to provide health insurance so they can get more people to work in the factories that were making the things for war. And who were most of those people's mostly women, white women actually were who benefited from this, the most a lot of men were overseas fighting the war, the women were left here, who were married and their spouses or whatever were fighting the war overseas. So it was health insurance was never created to cover everybody. It was not felt that people of color should have this. It was not felt that poor people should have this. So it was never a system that was rooted in equity. And so it's not surprising that as it has grown and evolved, equity has never been one of the variables that was discussed and how it should grow. That was not the purpose of it. That's a sad

reality. It is really shocking when you take a moment to just step back and think that the person, the entity that's responsible for paying for your care, will make the most money if they don't pay for your care. It is absolutely ridiculous. When you think about the basic premise of it, my health insurance company does not want to pay for my care, because then they make less money. But so now it's a fight every single time. You know, there's a thing that comes up. It's just really shocking. But I have to admit, as more of a patient these days than a provider, it feels like an insurmountable hill to climb to get it changed. Where do you feel like things are at with making progress?

Well, I know that we talk with legislators a lot. We don't lobby at all, the only thing we give Congress is information. They get no money from us. But we have talked with Congress. And I think politics is now it's taken on a life of its own. And you know, before we used to call them civil servants, that they were serving the community, and now they're just filling their pockets. The whole, the whole focus has changed along with other things in this country. But I think it's the way with Citizens United and the ability to fund campaigns and all, as you know, just changed what the focus of Congress should be. So now it's more on how do I get more campaign funds versus how do I take care of my constituency and So they are now taking care of their funders. And that's the biggest difficulty, I think in making major changes about anything in this country, whether it's health care, whether it's where you should build roads, where you should build schools, where you should have, who should get clean water, you know. It's all becoming privatized, actually. And so that's the diff, the most difficult part of changing healthcare is getting people to believe that everyone is entitled to it, you know, just like you're entitled to walk down the street, whether you paid any taxes for that sidewalk, you're still allowed to walk down the street. Yeah,

I agree completely. It's when you're not looking out for the person next to you, it's not going to go well. If the US switched to a Medicare For All or single payer health system, what would that look like for the average employed adult?

Well, for one, tying your insurance to employment can be a good thing, it can also be a very bad thing. For one, it's a fragile relationship, because nothing in that relationship is guaranteed. You can't say no, you can't fire me because you can be fired. You can lose that insurance in a minute. You may have to stay in an awful marriage, because that's the only way that you can get your health issues covered, get taken care of. People change jobs, companies change their benefits. So it's not a system that's really created to be ongoing. And I think that one of the things that a Medicare for All system would do is that you are provided with health care, regardless of whether you're working or not. And so you know, if you're not, if your employer doesn't have to pay for your health insurance, they that cost would be replaced by a much smaller tax, that would be more dollars in your paycheck. It would be a financial win.

So let's get into let's pull that apart a little bit more. I mean, there are pros and cons to Medicare for All system. It would mean taxes for the average person. But on the other hand, it implies that the average person would be saving money in their pocket for, for example, co-pays or how much money is taken out of a paycheck if they're employed for that same health insurance. So is your belief that it would be a positive net profit for the average person?

Oh, definitely, definitely. Because one of the things that has happened over the years, especially since the Affordable Care Act, a lot of attention has been focused on the premiums people put pay for their insurance. And a look at just an employer based insurance, about two thirds of that premium is paid by your employer, which is money you don't get in your check, and then you come and then there's the other third that comes out of your check. They're dollars that you never see. And along with that also is a deductible. And that's can be several thousand dollars for a family family plan. So what is happening is that we are coming out of pocket so much before the insurance company steps in to pay a dime for our care. Whatever tax would be, would be what we call a progressive tax, it would be based on your income, because right now, when you work for a company and you everybody has the same family plan, the premium is the same and everybody gets deducted the same amount from their check. Whether you make twice as much three times as much as another employee, the lowest paid employee pays the same as the highest paid employee, which is a very regressive way to pay for this. And then you've still got a deductible deductible that can be several thousand a year and that's recurrent. Every year that deductible comes in and a lot of us have healthcare issues that may not rise to the level of our deductible. Let's say you cut yourself you need stitches, you know or something minor, you have a minor infection most of us don't have ongoing health care needs. If you look at who really are the biggest users of health care in this country, it's about 20% of the population that uses 80% of the health care.

We talked a bit about direct contracting entities DCEs. These are private third parties that the government has now allowed in the door to act as financial intermediaries between Medicare beneficiaries (patients) and health care providers. The entities can be almost anyone - clinics, provider offices, commercial insurers, venture capitalists, you name it. They don't even have to have experience with healthcare to become a DCE. This is how it works. The government gives the DCE a lump sum every month. And it's their job to use it right to do things like invest in technology, expand resources, and also reimburse providers through payment arrangements. They dole the money out to health care providers and get this, they are allowed to pocket any funding that doesn't end up being used on health care. In addition, while traditional Medicare spends about 98% of its budget on patient care, DCEs are required to spend only 60%, the rest can be profit. Medicare allows DCEs to automatically search through a couple years of people's claims history without their full consent, to see if they've had visits with a participating DCE provider. And they're allowed to automatically enroll people in this program. Be scared people.

What they were delegated to do was to provide new ways to deliver healthcare. But they can do it on their own, there was no congressional oversight for them. So they didn't have to tell anybody what they were doing. They had, there was nobody in charge of what they were doing, there was no oversight. Congress was completely taken off guard because they didn't know anything about that. And they didn't need to know according to how the program was set up. So what they have done is they are just expanding the privatization of Medicare. And by direct contract entity, what that is just an entity that will help deliver your health care for you. Whether that's a private insurance company, whether it's a doctor's group, whether it's a private equity firm, or venture capitalists that we know, the only thing they see are profits. They know nothing about delivering health care. And so this was put this was created to actually transfer patients like me, who are enrolled in traditional Medicare, I chose traditional Medicare. But it could be that the doctor that I see - my primary care physician, who was part of a group, and remember, there's about 70, or 80% of all physicians are now part of groups. So they're like employees, they can't decide who they'll see and who they won't see or what they'll do or what they won't, do, you know, they're their employees. And so if that group is taken over by one of these direct contract entities, I as her patient will have to follow her, which means I will now be in that direct contract. And, and I I won't know,

You wouldn't be told as the patient, I imagine. You wouldn't even know that it was happening.

I mean, they're they're sending a letter that looks very benign, that starts out saying you do not need to respond to this, we get that all the time. And it goes into the recycling bin.

Have you gotten a letter about DC about DC, this DCE change?

Not that I know of, not that I know of, but I haven't been back to see her you know, so I don't know. But so people get assigned to these DCEs and they don't even know. And so now you become restricted as to where you can go where you can see, and you may not have, and if you want to get out of the DCE, you're told well, find another doctor. But the pool of available doctors number one is getting smaller and smaller. And the reason I chose traditional Medicare in the first place was so I can choose the doctor I want to go to.

Yeah, this generally sounds bad for the doctor patient relationship. Because I think especially as you I mean, as you age, you're statistically more likely to have more health problems. And so that's a time in life when it's even more important to have a doctor or some other kind of provider that you feel trusting of. A nd that's only going to happen if you know them. And that's only going to happen if you can continue to see the same person and have access to them.

Yes, and I can tell you as a primary care provider for years, the doctor patient relationship is very, very special. And as a physician, I had a window into my patients lives that I I knew things even their spouses probably didn't know. You know, it stayed within the confines of that room, it was very special. And that and that's important whether you're 25 or 85 you know the discussions that go on in that room. And so this kind of relationship that they're touting is, is trying to make the patient physician relationship no more important than the person who checks out your groceries in the store.

I want to say what my understanding of how DCEs operate is, and then can you tell me if I'm right or not? Right? Sure. My understanding is that the direct contracting entity, whether it's a group of primary care docs, or whether it's some other kind of for profit system or startup will get an amount of money from the government. And then they will disperse whatever they think is appropriate to the doctors that are enrolled in their direct contracting entity to provide care. And anything that's leftover they pocket as income. Is that correct?

That's kind of correct. They are what we call capitated. That is they get X number of dollars to care for each patient for 12 months. And the number of dollars that they get depends upon what your medical problems are - your age, they're talking about putting in the demographics of where you live to reflect how important the social determinants of health are in your health. But that's a capitation that they get paid to take care of you. Now, if they if they spend less on you, they get to keep more of that money. If they spend more for you, then they will, they are at risk of losing money. So ideally, what you want is a large pool of healthy people who probably won't cost much, or they also do a thing that we call upcoding, which is making people look sicker than they are so that on paper so that the capitation is larger, and you make more money for somebody who isn't really sick, they've gotten you know, $10,000 for the year to take care of me. And if I only use $2,000 worth of care, whether I came come in for whatever they because if they have to pay for test or pay for blood work, or do all this other stuff that will come out of that capitation regardless of what my point is, they're not billing me for that complaint. That's what capitation is. So what you want to do is try to get that capitation as high as you can. And so, you know, yeah, my knee was hurting the other day. So now I've got arthritis, and it's all on paper, and it makes me look sick, or even though they're not doing any work or spending any money to take care of these problems they've now listed for me, but it increases my capitation.

So why did this happen? Why are we here in this situation?

Because we have a system that is geared to make that is driven to make money. But I mean,

like government, like with regular Medicare, the government was the Centers for Medicare and Medicaid were in charge of that. And they were having profits and losses. Why are they farming it out now to these for profit companies?

Well, this all started way back. I mean, during the Clinton administration, they started the Medicare Choice Program, which was bringing private insurance companies into Medicare. And it was all marketed, that this is better. You'll get more, and you did get more with these Medicare Advantage programs you got you know, access to dental, you've got a hearing aid if you needed. If you're young and healthy and you want to go to the health club, you can get the SilverSneakers classes at you know LA Fitness if you want. So what they were doing then is trying to they've inserted a for profit middleman into the government which is paying Medicare. They're putting the for profit middleman in between the government who's paying the bill and the physician who's providing the service. So anytime you have a middleman, I mean, I'm not an economist, and I have an MD, not an MBA, but to me, my Eco 101 that I know tells me when you have a middleman, you're going to increase your costs, period. I mean, that's.

So that's why I circle back to think why are they doing it? Why is it happening?

People think that this private insurance is providing them something but it's not providing them anything. It's providing a way to pay for work, it's not providing them anything. So all they've done is changed the way things are paid for the Hammond change care, because and they've actually worsened care. Because before if I thought you needed the chest X ray, we'd order the chest X ray, you'd get it. And then we talk about what it showed or didn't show and what the next step is. But now they don't do their doctor doesn't even decide if you can get the X ray or not. It's decided by the person who's paying for it. And that's what's destroyed the relationship. You can talk for an hour with your doctor about what needs to be done, but nothing that you decide coming out of that exam room is guaranteed to happen, because it's not up to the two of you.

That's just a crazy sounding idea. Can we talk a little bit about other countries that have a Medicare For All type of plan, single payer health system plan? When I bring this topic up to people in my circles, I hear a lot of well, I'd have to wait for six months to get an MRI or see a specialist. What do you say to them?

I'd say, yes, that's awful. And that's not the way it should be. In other countries that do have a, they may not have a single payer system, but they have universal coverage. And even when they have insurance companies involved, they're highly regulated. And this country, for some reason, doesn't think you should regulate anything. And that's why things cost so much. If you look at how pharmaceutical companies, what we spend on a pill for certain disease here may be 100 times more than what they'll pay for that same pill in France or Spain, it's the same exact pill. But here, they can charge whatever they want.

Not if Mark Cuban has anything to say about

But in other countries, they you know, it. they're regulated, they can't charge. And so our system costs so much because the costs are so high. That it's not because we overuse, that's never been proven. There's not a single paper out there, that tells you that overuse is what is driving our costs up. It's because we have no regulation. And it's interesting how people fight that because we regulate the price of milk, we regulate the price of soybeans, but we can't regulate healthcare. And that's what other countries do to control their costs. And even here within the VA system, they control their pharmaceutical costs, they were able to negotiate with the government. But our Congress didn't let them negotiate. They didn't allow Medicare to negotiate with pharmaceutical companies for the costs of the drugs that they provide. And the reason for that was because they wanted the pharmaceutical companies here to continue to make money. And again, that gets back to who was providing the campaign funds to Congress.

Yeah, totally. So to circle back to the question about wait times and cons of the system that could you know, I guess the question is, like, why is that happening in Canada? I know that I was reading on this site called the Fraser Institute. It's like a think tank outside of out of Vancouver, and they were quoting some wait times in Canada of about, I think it's about up to 12 weeks for an MRI. I mean, honestly, I called my cardiologist this morning to make an appointment and get one in November. And it's what are we still in April now? We're in April? Right, April. So that's how long I'm waiting already in this country just to get in to see my cardiologist.

But if you didn't have insurance, what would your wait time be to get to see that cardiologist?

Well, I might end up in the ER and then I'd see her next week,

but that's the problem

and cost 10 times as much

So you're not paying in money to expedite you're paying in your health to get an appointment. Yeah, there are wait times there is no question but a lot of that depends upon networks. It depends upon what hospitals are around you that provide that care. And one of the things in Canada is that you don't wait for an emergency. You know, there's it's elective things that people have to wait for. And Canada has fewer specialists than we have in this country. And part of the problem that we have specialists overburdened here too is because there's not enough not enough primary care docs to take care of things. So my air hurts, well, I have to go to an ENT doctor rather than my PCP because there's not a PCP available.

Yeah, yeah, I'm bringing it up because I think it's an unfair assumption that people make that somehow, if you go to the Medicare for All plan, that is what will happen. But there are so many factors that affect that. I mean, one thing that's on my mind is the doctor shortage in the US. And, you know, aging, of the population is such a huge driver of increasing demand. I mean, partly that so much more of the population is older and will be older in the next decade. But also a lot of doctors are nearing retirement age. So we're going to be losing a lot. So we are statistically, it looks like we're headed into a big doctor shortage in the next decade or two. How do you think a Medicare For All system would help or hurt that?

I think it will definitely help that because doctors would be happier and they'd be less likely to retire. Because there's a lot of people who are leaving medical medicine earlier than they really want to stop working.

So what would a Medicare For All system look like to a general pediatrician?

Physicians could still be in medical groups, there still could be clinics, you may work in a hospital or what, but you wouldn't be guided by profits so that you would be there to take care of the patients and get down get done what they needed. Being part working in a medical in a single payer system is similar to how I worked at Cook County Hospital in Chicago when I trained and then continued there as an attending. Because in a way, it was globally budgeted. The hospital had a budget from the government. And the government covered everything that happened in that hospital - covered my salary, it covered the Kleenex boxes that went on the bedside, and it covered all the tests, all the medicines. And so when I saw patients, you know, it was decided what needed to be done. And our biggest obstacle was actually dealing with the volume versus more people who needed services than we could provide. There's only so many people I can say in one day, there's only so many surgeries you can do on one day. So the volume was a big problem there. However, what we were able to do was still take care of who we prioritize based on need. And that's one of the things that would happen in a Medicare For All, the system would not be overwhelmed by people because there's only so many people we can see. And I think people will start in terms of how they see their acuity, it just sort of settles down itself. And people who may have been seen by their private doctor once a month, because they felt that they needed that can now be you know, three months, four months, so it settles out. It settles. Yeah. And so working in a global budget would provide all the care needed in that community. And we would put resources where they're needed, versus where they can make money. Right now a hospital will build another cancer treatment center because the hospital that's a mile away also has one and we have to have one too to compete. But you're you're duplicating resources, but then you have medical deserts, you know, five miles away where there's absolutely nothing. We have communities in this country that don't have pharmacies. And we don't acknowledge these problems. And then when we make policies like go to Target or go to CVS or Walgreens to get your COVID shot, and you have communities that don't have a Target, that don't have a Walgreens. And so we make these policies that don't acknowledge that there's areas that can't benefit from this. Again, the inequities are being recreated. And that's how we treat healthcare now, because it's based on providing care where it can make money versus providing care where it can provide the most need, where the need is the greatest. I think that we really have to look at this isn't something that that doesn't health care is something that affects everyone. And, you know, there's a lot of talk about you have to buy the plan you need or this and that, but we don't buy insurance or provide for our health care based on what we have today. We have to buy it and what we have tomorrow and we don't know what we'll have tomorrow. And so that's what health care coverage is for. Is to protect you for the unexpected. And knowing the financial inequities, especially with people of color, the ability to pay for health care becomes a critical factor in how minorities and people of color can access. We can't live in a world where we can seclude ourselves from the issues that other people are facing. I mean, we have to get beyond that and see that, you know, on some level doesn't have to be everything, but on some level, we all have to have access to some basic needs, to public goods, and we were losing that we're losing that.

What can people do, who are not doctors who want to voice their serious support for this issue?

There's a lot of organizations that support single payer that not are not physician-run, like Physicians for National Health Program is. There's a large group of that under the umbrella of Medicare For All that work with that there's nursing groups, there's just, work with labor groups who have fought for so long for health care benefits. There's a lot of labor groups now that say that Medicare For All is really what they should be driving for. Because you can't be assured that no matter how great your employer based insurance is today, you don't know if you're going to have it tomorrow, because it's not up to you. It's up to your employer. And so, you know, labor groups are working with health care, nurses, you know, other people in you know, who work in the hospital. And I think that, you know, it's to our benefit that we are all covered. And there's in any social activist group, that, you know, is, if it's working with the Poor People's Campaign, public citizens, there's a lot of grassroots social activist groups, that healthcare is on their agenda. Because it's it's not an isolated issue. It's related to lack of housing, it's related to a lack of safe neighborhoods, it's related to the increased violence in this country, it's related to police abuse, it's it's all part of the same dysfunction. Each little thing has their own symptoms. But the underlying thread within all of these social activist groups is similar. And they disproportionately affect poor people, they disproportionately affect people of color. Health care, though, does affect even wealthier people.

Thankfully, I mean, I hate to say it, but that might be the one saving grace of getting some shit done in this area, that it affects people who are unfortunately in power through their checkbooks, you know?

Yeah, yeah, I remember reading a story when the Affordable Care Act, and there was some older Republican in the South who, you know, they didn't expand Medicaid in his state, and he had some glaucoma issues or something with his eyes, and now he could no longer afford his care. And then he went somewhere, and he got Medicaid. And now he was rah, rah rah the ACD you know. And so a lot of times until it affects people personally, they choose not to see that it exists. But health care on some level in your life through family members through friends, co-workers, you see the effects.

Yeah, everybody is touched by it in some way or another.

Yeah. Yeah.

Susan, this has been so eye opening. I really appreciate your time to talk about this. It's a complex issue, but I hope that we brought it down to an understandable level I think we did for me, so that's a good test. Okay. Thanks for listening today. To catch up on more episodes and to get new ones delivered directly to you. Subscribe wherever you find your podcasts, Apple, Google, Spotify, iHeartRadio and more. If you'd like to be a guest or have an idea for an episode, let me know at www.drpatientpodcast.com That's doctor patient podcast.com. Here's the disclaimer. Even though I am a doctor, I'm not your doctor. These stories, my comments and all discussion is purely reflection about what's working in the healthcare system and what isn't. Don't use any medical information that you hear in these episodes too. diagnose or treat yourself if you have a question about your health get in touch with your doctor or local health clinic