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HCCD Report Indiana 46526MCC-MMA Health Care Community Discussion 29, Dec 2008 Group of 18 people. Moderator questions in bold and underlined. Participant comments grouped in common themes underlined. Biggest concerns? - Cost of healthcare - Access - Cost is the reason there isn’t access - Portability due to lost job - - Disparity of rationing Cost comments: $1,500/year previous for health insurance tripled in 8 years, coverage is worse Copays and deductibles, add up Want affordable coverage Preventative doctor visit cost one $400 this week How high would this have been without insurance? How would I get the preventative care I need? Cost shifting - Why does aspirin and other small items cost so much from hospital. Some fees increased to make up for other non-billable items. When some don’t have access, increases costs for all. When everyone is covered, risk is shared equally. Hospital costs - how they pass on costs to those with insurance and inability to pay? - Maybe lower cost of malpractice insurance - Cost of malpractice insurance discourages doctors Response: Malpractice really isn’t a major cost contributor - Also cost of education; $100,000 + for medical school Those of us who are insured, pay for those who aren’t insured through higher premiums Need to get rid of For-Profit hospitals. What does not-for-profit mean? Two local hospitals viewed as for-profit being cheaper than not-for-profit Do we need hospital lobbies to look like hotels? Hospitals in other countries don’t look like that Lack of competition [pricing]? Catering to certain clients? Competing on hotel qualifications, service, quality [not price] What if everyone used medicare guidelines [for pricing; list prices mean nothing]? Still have to find a way to pay for services If hospital know how much they will receive Using medicare costs Expectation of consumers is way too high (note: Important and intense discussion surrounded this exchange) Obama couldn’t/wouldn’t talk about this during elections. Should We’re not going to find a way to pay for what we’ve come to expect 20% of costs [may be] preventative; too small [to make a difference] 80% of costs are big; accidents, etc How do we contain our expectations? How do we roll back Other countries with less costs per person have better quality of life and lower infant mortality rates But they don’t expect same life-extending measures No sense of what is best for wider community; selfish [US system] Portability comments - the uninsured - how many more are going to end up uninsured? - More will walk into ER to get care - Cost goes up - Already, a lot of employers don’t offer insurance - Changing jobs - lose insurance - become uninsurable - People change jobs more, every 4 years on average - Lack of health care portability is a hindrance to economy [reference to economic benefits of mobile workforce] - Small businesses big source of new jobs, find providing healthcare most difficult - Cost of preventative, tests - Comment; person looks for discount at hospital on preventative tests; hard to negotiate How do you prioritize these diagnostic tests? Some are very expensive Think we could do better at preventative care with a national system Is anyone here uninsurable? None answered for now - Two would have been had not reached Medicare age of 65 - Some would be if they would lose job - hits people who have pre-existing conditions - cancer is uninsurable How do people choose primary care physician or hospital? - Word of mouth - Family history - Has to be an approved HMO/PPO list - Can be hard to keep doctor then you change jobs - Not enough information about doctors - Rating and performance standards - Information should be available so consumers can make good choices Need national medicare that covers everyone That’s what we need Simplifies bureaucracy Is Healthcare a right? - Obama said it is a right, not a privilege - If you keep people out for pre-existing conditions, it’s not a right - (Physician) As a provider we feel heavily regulated - Socialized medicine has been a bad word in the states. Why? Bigger question; Is it proper for healthcare to be in a free market system? Parallel with mortgage and financial systems. If it’s not closely regulated, its vulnerable to collapse. - Right or privilege, complex question (note: Important and intense discussion surrounded this exchange) (Challenge provided participant): Everyone agrees that a child with a broken arm deserves to have it set and mended. What about a person wanting to spend $100,000 on a kidney procedure to extend life a few months? - Basic level of care could be right - Hard choices do need to be made - Who makes those decisions? There will be abuses in every system Do we like our current system so much that we’re not willing to tolerate some [new/different] abuses? Some unfairness will occur. We are at a breaking point We need to look at other systems - France Common health information database? Concerns? - Need to limit access - Wouldn’t want future employers to have access How should public policy promote quality health lifestyles? - consumers need access to performance data - incentive for hospitals and doctors - Should there be exit evaluations of doctor/hospital care [outcomes] - Should be some incentive for providers who perform well Another fundamental piece: onus should be on individual to take care of themselves - if we have universal education, do students have to study? - If there is a health insurance tax, tax smokers at higher rate? What if a predilection to smoking or obesity is genetic? - Lifestyle choices, some sharing of responsibilities is expected Doctors paid for service - More patients they see, more money they get - Some systems experimenting with more performance based systems - Some patients won’t follow up, take medications - If they can’t afford medicine, that’s a problem Again, contrary to American culture - individual choice Vending machines in schools Freedom not to wear helmets Gas should be $6/gallon, force people to walk more Americans idea of safety is to buy a bigger SUV (even if facts disprove it) Perception; more influential than facts. Example includes how other countries fare better on quality of life, life expectancy, and infant mortality while spending less per person. Americans want everything done possible regardless of costs without looking at results. Do you know how much your employer pays? (for your insurance) - Employee participants didn’t know; self employed participants did. Self employed example with private insurance $10,000/year for family of 5 plus $5,000 deductible Another individual buying direct pays $6,000/year for individual with $2,500 deductible Two plans: which one? 1. National plan - like medicare 2. Private insurance exchange But insurance companies don’t negotiate… Insurance exchange, prices public Will lower income folks be able to buy insurance? Even with subsidies? Will purchasing insurance be mandatory? If not, still will be a problem How many of you have family members without health insurance? Most raised their hands Stories Doctor - patient raging infection in elbow $40k+ Cut finger on car battery Trying to make meth Got her better Current system doesn’t provide resolution for drug addicts - no services Put in jail only Dr. Dan Tammy Has a relative with kidney stone; couple has no insurance due to loss of full time employment and working part-time Tens of thousands in multiple bills from multiple providers Multiple providers sending them to collections Same person with unrelated problems buying drugs off-shore due to cost while being uninsured Names Unknown 1. Relative with pancreatic cancer and diabetes Is this relative close to reaching lifetime maximum? [What options after maximum reached?] Part of family business with 30-35 employees How is that going to affect premiums for the rest? 2. Relative had non-hodgkins lymphoma Stomach cancer Bills were astronomical Didn’t take long before insurance was maxed out Doesn’t take long to get $1,000,000 Other comments: Do we start from scratch or build on existing system? Much of tonight’s discussion focused on health insurance - cost, access to, and medicare. I wonder if a key problem is caused by insurance. People who have insurance get services at a reduced price while those without pay extremely high fees for even routine care. Also, significant costs are incurred by medical practitioners filing all the paperwork for reimbursement. Perhaps to reform health care would be to get rid of health insurance. Free market theoretically would control the price and patients would pay for what they could afford. Major concern?
(story) Friend who decided not to take life-extending treatment, in order to do what was best for larger society was criticized (story) Widow wanted to consider costs for husband found it hard to override costly medical advice (story) Another made wishes known - advance directive on file People often feel powerless - go along with what doctors recommend Probably 99/100 cases, people want everything possible done to extend life DNR instructions get lost in bureaucracy We’ve done this to ourselves We expect the best (Two providers share stories) Litigation fears for screwups and limiting available care cause pressure on providers to promote expensive options; includes prescribing drugs. Again, have to prescribe the best, most expensive. Worried about malpractice What can Obama do to help contain expectations? How do we work at making this happen? Citizens talking to other citizens? Needs to get worse before it gets better ERs already shutting down As more people lose insurance… Can you change public perception? Baby boom generation - more challenges Elder care Uphill battle Medicare payment schedule Less providers Are we willing to go to South Bend [40 miles] to see a doctor? Are we willing to wait for services? Part of reducing expectations In some ways will reduce access [specialty procedures] In some ways will increase access [local primary family care] Some specialties may have to travel. Specialists don’t want to move to South Bend, IN Basic healthcare services would be more local Again, part of containing costs Cost to travel, loss of life… If you need a heart transplant, you can’t get it in Indiana. That’s rare enough you don’t want it here. The more basic services; getting son’s ear checked; can be pushed out to community locations Big services moved to big cities; more centralized Specialization concerns and the loss of family primary care. Doctors: going where money is Doctors moving to specialties - where money is Losing primary care, pediatricians Losing OB/GYN, neurosurgeons, paying for exorbitant rates for malpractice insurance (two physician stories; specialists in some regions paying up to $100,000 annual while local optometrist pays under $1,000 per year) Malpractice insurance should be capped Fine line - need to protect patients from negligence as well Also, goes back to expectations People make mistakes Medicare - national insurance tax Progressive tax? Sales tax is regressive. Food and gas are cheap; drives consumption Education; hasn’t been mentioned yet Will it help? Has worked with smoking Close relative adult, can’t work very well
[Uninsurable options] Able to use COBRA, state insurance [high risk pool], healthy Indiana program COBRA - no COBRA to buy when company goes out of business Not all states have high risk plans Still costs money to be in high risk pool; subsidized Group insurance Can a neighborhood be in a group? Can end up with just sick joining, unsustainable Healthy can get cheaper plans elsewhere Cancer clusters Healthcare more expensive GROUP 2 Discussion 1. Biggest problem in the health system? - Health care isn’t the right term. It’s a sickness-care system. If you’re well, you don’t need care. Glad to see prevention included in the discussion, rather than spending so much disease. - We don’t get our money’s worth out of the 14 percent gross national product. We have a higher infant mortality rate than other countries that spend less, and there’s an uneven distribution of services. - We need access, quality, and affordable health care. The going statement is that you can have two of these, but not three. That’s the issue. We need all three. - I’m a small employer. The basic problem is that instead of asking how we can provide basic health insurance, it’s all based on risk. If you’re a low risk, you’re invited into the system. If you’re a high risk, you’re not able to get into a larger health pool. As long as it’s based on risk, people won’t get the care they need. - Blue Cross/Blue Shield paid its CEO a $2 million bonus. As a doctor, I tried to save my patients (and insurance companies) money. Doctors are willing to take less pay if they see equity. I spoke up about this, and was told to keep my mouth shut and let the business world take care of itself. But it’s not. Insurance isn’t going to do it. The whole system needs revamping. - I don’t know how you can make a profitable system out of taking care of someone’s basic needs. It leads to perverse incentives. We still have rationed care in this country, but we don’t admit it. - We haven’t decided whether health care is a right or a privilege in our society. It’s a right for prisoners, and for members of Congress. - Let’s look at other countries that have national health care and see how they do it. Some in Canada also complain about their system. - We don’t have good statistics either. - Lack of efficiencies, huge bureaucracy. People are confused about what type of health coverage they have. - A CEO of a large hospital in Texas says he has to hire 200 people to do what Canada can do with three people. A single payer system would solve that. We have 1,500 different insurance companies. - The problem is so big, it’s going to take the government to solve it. - The fear is, can the government run anything well? - Having federal and state governments involved add inefficiencies. - One of the basic problems of our sickness-care system is lifestyle. That’s why our costs are so high. We take such poor care of ourselves. If I go to the hospital, I don’t even see a complete bill. Then, if I ask for an itemized bill, sometimes the amount billed changes. Costs aren’t accountable to anyone. - Hospitals also dealing with the uninsured. - We don’t take care of ourselves. Government rewards me on my tax bill for being sick. I spent money on prevention, but the government doesn’t reward this. 2. Choosing doctors? - Choose by them being in-network. I check with people I know to see who they like. Sometimes males go to males, females go to females. - The trouble is to determine which network. Usually start with your primary care physician, but if you need a specialist, they may or may not be in the network. - In our case, on Medicare, we can go wherever we want. [I think spouse chimed in, with “as long as they take Medicare.”] - I’m fussy. - I do know that because a friend went out of network, they had to pay more. - I could only choose a specialist in Fort Wayne or South Bend. I couldn’t choose one in Elkhart. - Years ago, children used to be assigned doctors in this area. Some families had children assigned to different doctors in neighboring towns. - Retired nurse – Yes, we used to swap children to keep families together. - I think it’s impossible. What would feel good to me is if there was a set of standardized coding. I’d like to see networks go away. Publish the data so people could make choices. - Unfortunately, some of that data is difficult to collect. Even if there was a superstar doctor, we can’t all see that person. It’s not as easy as choosing a new car or a sandwich. - Best practices, you can measure that. Don’t have to be the best to do a good job. 3. Difficulty paying bills? - One of my friends from Turkey (who lives in the U.S.) said she would never consider having insurance, because she could go to Turkey and have medical care free. - Canadians are worried about traveling to the U.S. because they’re afraid they’ll have an emergency, and have a bill they won’t be able to pay. What does that say about us? - We have been very fortunate to have employer coverage. When my relative had hip surgery, before we left the hospital, I asked, “how many bills should I expect to see?” No one could tell me. There were so many different doctors, services, and bills. One came a year later. Later, I read an article on someone who had hip surgery who didn’t have insurance. He’s negotiated for less than half what we paid because he paid it directly. That made me mad. - In a family I was acquainted with, the one family member had knee surgery. Another family member needed eye surgery, but they couldn’t afford it because of the bills from the knee surgery. I asked them, “Do you ever go to Sears and buy a hammer and not ask how much it’s going to cost?” No. How many people think that cost is something you can’t ask a doctor? When they checked into the medical care the second family member needed, they discovered they could afford it after all. - I used to not ask, but recently I did ask, and they didn’t know how much it would cost. - I had a broken nose. They didn’t know what the total cost was. Doesn’t make any sense. Anything else you’ll purchase, the seller has to be able to tell you. - We had to take my relative to the emergency room for stitches because there was no urgency care center. You can’t ask what the cost will be in that situation. My relative was bleeding. They stitched up an eyebrow. We figured out later we paid $200 an hour. We’ve gotten burned by emergency room cost. What are you going to do? - I was traveling in Italy and broke my arm. They gave me an x-ray, and set my wrist in a plaster cast. When I asked them what it cost, they said nothing because I hadn’t been admitted to the hospital. They didn’t charge me anything. That was an epiphany for me. It wasn’t a fancy building, just tile, but it was okay with me. - You hear that Canada has waits, but Canada’s paying their bills. It’s a huge stressor we have that other countries don’t have. - Having a plaster cast IS rationing. It’s not a more expensive alternative. We don’t have to have a Cadillac. - How many people forego treatment because they can’t afford it? For them or their kids? - With the system we have, do people take advantage of it? - Maybe more people without insurance are going to emergency rooms, than getting less expensive care. - I think people wait longer for treatment because they’re afraid of the cost. Then they’re far sicker. - There is a center in our area that helps treat the uninsured. But they have to turn people away every night. They need more volunteers, and more churches to support this clinic. 4. Option to purchase insurance? - In my opinion, the best thing is to get rid of employer-based coverage. - Assumption (the way the question is worded) seems to be that employer-based coverage would stay. - Obama’s not ready to take away what people have. Think of the Clinton plan. - But I think we’ve come a long way since then. - I’d like to see a comparison between my employer’s and other coverage so I’d better know what my options are. - I think we need to challenge the assumption that there’s no other way to go except to have employer-based coverage. I think it’s a new day, things are changing, and a single-payer system is less threatening. - Maybe we could move state-by-state toward a national system like Canada which went province by province. - You do have to find a system that covers everyone. - “Universal coverage,” “single-payer” seem to be buzz words, but people don’t object to Medicare, which is single payer, universal. Could we extend Medicare to people under age 18? Seems like it would be politically unacceptable to be against extending Medicare to people under age 18, then gradually close the gap. - I’d be afraid of Medicare Part D applying to everyone. I think it’s a horrendous thing we’ve done to seniors. I wished Part D could be more like Medicare. - As an individual, I really like Medicare. It’s working fine for us. We never got Part D. By the end of the 3rd, 4th, or 5th months, our friends who had Part D were paying more for their medicine. - In a 700 billion bailout, they threw in mental parity. Medicare paid 50 percent, but soon will pay same as everything else. - I got Part D. I pay $50 a month for a prescription that I would pay $4 a month for if I got it at Walmart. It’s the only prescription I take. But I got it because if I need another prescription later, I wanted the coverage. - Part D is bastard Medicare. It’s not what Medicare was meant to be. - I think Medicare Part D is worth discussing because of the way it got passed. Kept on the docket til it had all the votes it needed to pass. - Another problem with our system is that our hospitals haven’t identified the difference between prolonging death and prolonging life. 5. Cost of employer’s insurance? - Be interesting to know what percent of businesses actually have health care for their people. Some have such high deductibles, it doesn’t help much. - Two-thirds of people who have health insurance, have it through their employers. - Employer-based health insurance is not good. Should be knocked out. 6. Knowledge of preventive services? - [Nurse] We never take flu shots. They’re only good for one strain of the flu. There were just two articles in the paper that said that this year they don’t have the right one. - One of the things that’s so bad is that people are drinking water that’s not regulated. Public policy should be involved in ensuring we’re drinking pure water. - People don’t do preventive because they have to pay for it out of their pocket, and they can’t afford it. That’s why we don’t. It just costs too much money. - Medicine changes every five years. Preventive medicine changes all the time. What we tell people to do changes from year to year. - Diet and exercise are still worth doing. - Would the cost of having the preventive care be worth what you get for it? - A whole lot of diagnostics aren’t necessary. - Public policy would do a lot of good if it focused on sanitation – clean air, healthy diet, promote exercise. - Advertising medicines should be disallowed. Yes, people come to the doctor and ask for “that little purple pill.” 7. How can public policy promote healthier lifestyles? - We need to educate our government. For example, ozone layers. EPA and the FDA are not in sync. - How aggressive anti-smoking campaigns have become. Not yet on diet and exercise. There’s some advertising, but not enough. - Diabetes could be subject of public policy. - Some people won’t go to doctors, even if easy to get there because they don’t want to go. - Nothing here that prevents diabetes. You have scientists that invent food that tastes good and has higher fat, higher sugar, etc. And they promote those foods. - Airlines charge us according to our weight. - Most companies aren’t able to say, “I’ll give you $4 a week if you ride the bus or ride your bike to work.” Or to provide a 4-day work week. Money talks. Only bigger companies can do these things. - I talked to an HR director who just started a wellness program for her employees. She had 50 employees. Stories and contact info David– small employer who talked about high-risk people having to pay more for insurance, how this affects his employees. Also talked about cost of emergency room, when there are no urgent-care centers, and his relative needed stitches. Susan– talked about having broken her arm in Italy and being treated for free. Debbie– story about her husband’s hip surgery, trying to find out how many bills to expect, frustrated with extreme inefficiencies and bureaucracy. Dave– Stories about when his relative was a college student and being sure the relative had health insurance; as a pastor, health insurance premiums were so high, he could only afford catastrophic coverage; and how his needs are being met with Medicare. Anne– One of her friends married a Canadian, and she lived there for many years. Now that her husband died, she would like to move back to the U.S., but she can’t because of health care.
D and J– Story of asking cost ahead of procedure, even if you have insurance, Medicare. Also talked about a relative, who was kept alive for 15 years, even though the quality of life was unacceptable to them (not sure if they said “brain dead”). They did say they finally had to keep their views to themselves, in order to keep the peace with the rest of the family. They are very interested in more specific criteria for what is prolonging life versus prolonging death. |
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