Summary Advocacy Grand Rounds - Addressing Greed in Health Care (Youtube) youtu.be
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Kate Kelly Alright. Hi, everybody. My name is Kate Kelly. I am the host of tonight's advocacy Grand rounds. I'm just going to slide share our program for this evening We're joined by Len Nichols on Mar, who's our program manager.
Kate Kelly So access to affordable care, impact area of doctors from America. So I'm gonna share my screen, and start with the presentation. We're so glad you all are here. So I will do this slide Alright. So thank you all for coming.
Kate Kelly We're really happy for you to all take time of your busy schedule to join us for our... I see grand rounds. This... And 5 grand rounds is patient over profits, addressing greed and healthcare care. Just really quick to run through the agenda, well...
Kate Kelly Do welcome introductions. We'll have a presentation and then have plenty of time for audience Q and a. So there's a Q and a function within this webinar, encourage you all to use it. We will try to get through all of your questions and answers as soon as we can. And then we'll have a closing.
Kate Kelly Couple reminders before we get started, This is a doctor's for America session. We will be recording this session. There is no such thing as a stupid question. Speaking of questions, please remember to use a chat function we'll address your questions during the second half of our session. Also look out for the comments in the chat, Cfa staff will be helpful in making links and help you in this session.
Kate Kelly So those are those are us and we'll we'll go ahead and get start. I'm gonna stop screen sharing so I can talk to you and you can... See in my face and the blend. Give me 1 second to stop the screen share. Okay.
Kate Kelly So again, my name is Kate Kelly. Just a little bit about myself before I get started, I am the mini chair for the greed and health addressing green and healthcare committee doctors for America. I'm the immediate pasture that access to affordable care impact area. And currently, I'm a family medicine board certified physician in Cleveland, Ohio at Metro health, which is the Safety at Hospital in C County, which is the the county that causes Cleveland. I I'm a doctor of Medicine for Northeast At Medical University and a Master of public health.
Kate Kelly I wanted you to feel free to ask any questions. This is really done a informal and informal presentation, but we really value your participation and we're really excited to to have you all here. A couple of quick notes about the Agreed Healthcare care committee. The green healthcare care work is housed under the access to the affordable care impact area. It's 1 of 3 areas a D works in.
Kate Kelly The campaign is a multi year multi strategy cultural change program to promote a partnership and economic justice. Then includes a call for economic justice with the declaration that we hope, fellow physicians, healthcare advocates and organizations will sign on. We're actively recruiting for folks to be in this work, both as partners in our advocacy work and as organizations that you may represent that could be good partners for greed healthcare. If you're interested in joining us, please put your name in the chat and Marley will be able to help connect you. A couple of other notes in a personal matter that I want to share with you all.
Kate Kelly This work really began from frustration in the part of many of our physicians that we felt private entity and profits over patients is really getting the way of how we can care for our our patients. I'm sure you've all felt out it this way. I'm sure yu all have been experiencing this, and I hear all the time from physicians who are frustrated with private equity buying out their practices or feeling like they are bound my insurance companies with the way they care for patients. And we felt it's physicians that this was important to really center the work of doctors for American advocacy organization that puts patient over politics. To be the leader in this movement.
Kate Kelly Additionally, Dr. Don Bur, a very influential physician, thinker, activist advocate, I wrote an article and Jam that was linked, I believe in the original invitation to this talk that really talked about the underlying greed and economic driver of private profit over the health patients. And this was really a fundamental moment of change within our organization and within how we want to present ourselves to the world to protect our patients. With that being said, there's a lot of work to do. We have a lot of minds to change.
Kate Kelly It's cultural and not policy specific, and we hope you can join us. We'll be working on messaging partnerships on advocacy to really change the tide for for folks and patients to really get better care. And we thought no better an advocate and speaker tonight as we kind of launch this campaign to D and so the rest of our community then lynn Nichols. I'm thrilled to pass the baton to him. Dr.
Kate Kelly Nichols is a health. Economists and a long history of commitment to health justice. Lens career has been academia and Welles College and George Mason University, public policy research institutions from Urban, New America Foundation and government, the office management, budget and agency for healthcare research and quality as well as the federal trade. Since his experience is a senior advisor for health policy in the Clinton administration, Doctor. Nichols has consistently added moral arguments to technical health and social policy debates.
Kate Kelly He is a popular speaker. At activist academic meetings. His current collaborator approach to public goods investment or C Project at Urban Institute. Is a culmination of lessons learned while teaching, researching writing, testifying, advising and listening throughout his career. He has earned his Ba from Hen College in 19 75 his M and economics from the university of Arkansas 19 76.
Kate Kelly And his economics from the University of Illinois 19 80. And with that, I am pleased to pass first speak speaker doctor Nichols. He also a lovely Arkansas accent. And so I hope that you all enjoy. We will give dr.
Kate Kelly Nichols the floor, and then we'll open up questions and answers after. So please feel free to type anything in the chat, and I look forward to talk Doctor. Nichols, please.
Dr. Nichols Thank you, Kate. The much kind introduction and I deserve, but I appreciate all that. I'm I'm really just a simple country health economist who happens to live in New Orleans now, but my wife's home hometown. But let me see if I can... Share these slides till you won't have to look at me during all this.
Dr. Nichols Okay. Can you see it okay? Great. Basically, when Ken F off approached me to speak to your group, I was quite humbled and honored to be asked to do so. And he said, why don't you organize it around just, you know, number 4 injustices in the Us healthcare health system today.
Dr. Nichols And I said, well, you we they're are 40, but we don't have time for that. So I thought I would pick the before that seemed to me the most maybe salient is the right word, maybe the biggest amount of money involved, I don't know. But in any event, the that's the idea behind the talk. And and I I would define them at least those injustices that stand out the most to me, access to mental health care. Access to specialist, pharmacy prices, pharma and prescription drugs, And then 1 that may seem a little odd, but I'll just say as an economist, it's always bug me and I think it's worth.
Dr. Nichols Pursuing sort of what it means, reserves of profit hospital, which are sort of a real thing. Anyway, but, I'm not you, I'm not going to give you a bunch of statistics, you guys know all this stuff better than I do. I just would call myself someone who can maybe make some list that you can remember later on. Obviously, the slides would be shared. But when I think of mental health, I think about basically, those people who do not have access to begin with and of course the uninsured are the unwanted who are most left out of everything, and there are still, you know, 10 to uninsured people in the United States who live here.
Dr. Nichols And and so we know that that's a a very serious problem. I will say if you look at the last bullet, the withdrawal from insurance related payments, vast majority of, of psychiatrists that I know in Washington, D. In New Orleans and for that matter, other places around the country don't take insurance anymore And so in a way, we're all uninsured for for mental health care. And I think the consequences of of the combination of the system that have produced this, which is partly driven by insurance and their unwillingness to accept the reality of mental health of and driven by psychiatrists frustration with the way insurers deal with all the utilization review and ridiculous payment rates and so forth, it is led to this disconnect so that essentially if you're not well off you do not have access to mental health in our country. It becomes most evident that is to set a most salient in our daily lives, when you see the people experiencing homelessness.
Dr. Nichols And you know, I'm sure between a half and 2 thirds of those folks have some kind of mental issues or substance use disorder or both. And of course, they end up has been a lot of people, but they in particular have a lot of interaction with law enforcement. And so fundamentally, our inability to provide the mental health justice that we should. Leads to higher and higher cost and more and more problem in the rest of our society. Suicidal aviation as a personal story here.
Dr. Nichols I won't go into. I'll just say that it is deeply personal to me and my family and I had I did look up statistics here, 1200000.0 people try every year, about 50000 plus or minus succeed. I will say those are both under understatement because a lot of us they'll called death of despair alcoholism or even car are really Suicide attempts that are hidden from the way we count things. And so the point of this, of course, is to simply take our unjust access to mental health leads to all kinds of serious problems, which affect all of us ultimately because we're all affected by the environment in which we live where people aren't getting the mental health they need. Specialist acts assess this again is particularly salient to those people who are living with a relative or themselves having a complex problem.
Dr. Nichols I will say as an economist, it's important to remember relative market power is what determines relative prices and the truth is, of course, as you all know, probably this the specialist got control of the Ama process a long time ago when we were making the Medicare payment schedule, probably and so the get paid a heck of a lot more than primary care in the family brackets got kay who enabling med this this this webinar off. Those specialists prices bake in a difficulty of access in general And then when you add to it, the fact that Medicaid pays so much less than Medicare. At the end, you can look at different statistics. It's roughly 30 percent. And Medicare pays look 30 percent less in private insurance.
Dr. Nichols So it's quite a gap between what Medicaid pays and what private insurance pays. And I will say that doesn't mean what private insurance pays is the right amount, but it does mean that Medicaid paid way too little and of course, that's why. The problems of access are greater for Medicaid and you can imagine for getting insured. Sees, primary care positions all across our system, report various degrees of difficulty getting referrals for specialists. Interestingly, you often can talk among failed and explain why orthopedic seems to be the number 1 problem in getting referrals for folks.
Dr. Nichols And out of those context. And of course, as you know, again, better than I do, the quality of care and outcomes suffer for complex patients. I can tell you lots of stories, but you know them as well as I do. I'll just say, in the absence of access to specialists here when it's really valuable, you end up doing sub par things that either costs more or make the patient suffer more or reduce the quality of life, which is the fundamental point. On farmer prices, I could go on for decades here, I'll just say the facts and they are that if you look at pharma companies versus non pharma companies in the U.
Dr. Nichols S. Economy, the rate of return is about twice. The average rate of return profit rate, whatever going to say margin. Of other companies in the U. S economy, then you probably know if you don't you should, Pharma has the highest margins in healthcare by far their margins are roughly 17 percent to 20 percent whereas hospitals are typically 3 percent or 4 insurers are typically 4 percent to 7 percent So they're just way higher than everybody else.
Dr. Nichols They spend more as a consequence on lobbying and and campaign finance, of course, And I'm sure you know they they've fought to nail against Widened Senator W the the from from Oregon who... Have been leaving in charge for some time, trying to bring about Medicare negotiation. We finally got a modest element of that in piece of legislation. Just passed, they... All the pharma companies have declared it unconstitutional and they filed sued in court Yet, they agreed last this this week to to participate.
Dr. Nichols So they'd like to get the money, but they're also gonna say unconstitutional. If they can, they want no part of any kind of governmental interference and their ability to charge what the heck they want. An interesting fact that is not well known is that for most large commercial insurers today, pharmacy spend is actually higher than hospital spend. Which if you think about the big pie of national healthcare spending, that's a stunning fact. And it means that pharmacy is taken more and more and more, of the healthcare dollar and of course, these margins mean a lot of that is is unnecessary.
Dr. Nichols Meanwhile, of course, food simple example, diabetic can afford insulin of and cancer is a basically a diagnosis of bankruptcy. Now let's see if I can make this do right. I this is the beginning this is a really interesting article just came out a couple months ago on profit hospitals and their cash reserves. Versus their Charity care and here's the chart that takes the point. If you I'm not sure you can see my cursor, but if you can, the first 4 columns or for non profit hospitals in the last 4 columns or for 4 profit hospitals and what this research study did was compare basically averages and deviation from 20 12 to 20 19.
Dr. Nichols So it's pre Covid post Aca implementation of coverage expansion. And what you see is that the offering these are averages means across all hospitals in this category, non profit profit operating profit is roughly 43000000 dollars on average in 20 12, it's gone up to 58000000 dollars Charity care, didn't go up at all statistically or in fact, went slightly down, absolutely. And I will say that wasn't shocking because uninsured went down between 20 12 and 20 19. But interestingly they look over the. For profit Charity care actually went up.
Dr. Nichols From 2000000 dollars to 6300000.0 dollars which is kind of interesting when you think about non profit not moving all. But here's the point I'm trying to make. Cash reserve almost doubled. Even as operating profit went up about 20 percent, maybe 30 percent and cash reserves doubled and look at the standard deviation here. There are some very wealthy hospitals who are basically stocking away cash and investing it in all kinds of ways.
Dr. Nichols And I would say in ways that are not related to patients versus profits. Okay. So think about what hospitals and health insurers for that matter could do for social determinants of health, if we moved our system to paying for health and not for health care. And that's sort of obviously where I wanna go. Policy must change to enable this, but I would submit it is possible.
Dr. Nichols So to summarize my would be simple remarks. I would submit we tolerate injustice because we think we can't change it. We tolerate out a fatigue to and what seems to be intra policy barriers to change. And that's why I'm so supportive of Cad and D attempt took marshal physician credibility to improve the conversation at the National and state levels. Tar this injustice like we do mean in effect, we accept that some lives really are worth less than others.
Dr. Nichols And I'll just say, that's what happens when you give up when you say, okay, we can't change it. We just got a label the way it is. Solutions tier are not really that complicated. They would require changing the way we pay almost everybody. But you know, there a lot of comments who would help you do that.
Dr. Nichols I'll just say, it will create winners and losers. It it it is not however, that difficult to figure out how to pay what adds value and pay less of those things that don't add value. The question and the fundamental question, I I... Turn back to Kate and you all, does the political will to challenge the lobby that it preserved our system and created it, Does the political will that challenge them in unprecedented ways really exist. That is the question you have to answer?
Dr. Nichols And I hope we all agree on the answer. So I will stop there and let Kate take it away.
Kate Kelly Thanks, Len. Please put all in questions you. You have in the chat, the Q and A part of this webinar. It's really the best way and we'll we'll be sure to get see everybody if we can given time. Thanks so much, Dr.
Kate Kelly Nichols, I think you know, part of what you laid out, was really what we're trying here at D to to fight against. And, you know, turning away from caring for patients and instead, lying the pockets of shareholders. And I think we all experienced that if, you know, Any actor on this call when worked to a hospital, they've they've seen the pop he of administrators versus those who actually doing the work and not physicians as much as, you know, Lp, M, etcetera. So kind to summarize what you talked about. I wanna mis characterize it So please correct me.
Kate Kelly We have a couple of major issues. 1 is mental health. And the difficulty of accessing mental health care including care for the un housed and the social determines of health. And then really addressing the profit driven model for healthcare care, corporations including hospitals, medical device companies, pharmaceutical companies, and even those sue called themselves profit and really calling out the the profit versus profits mis, if you will. And then the final question is, do we as physicians have the power?
Kate Kelly Do we as health care Consumers have the power to really push this political and policy change. And I'm sure many the people on this webinar are will also agree, what can we really do? So...
Dr. Nichols Very much.
Kate Kelly Share your questions. All. Well, I'm a family doctor. Send used to 20 minutes of the summary statement. So we have some great questions in the chat.
Kate Kelly The first 1 is from Greg Ba. Mental health insurance. Coverage is confusing to me, then the Ac aca require Ac aca compliance insurance plans to cover mental health services as an essential benefit. Coverage Why is access still poor? Is it mainly the withdrawal from insurance related payments?
Dr. Nichols So really good questions. And the first... Answer I think has to do with the reality that mental health parity is kind of a name only. The idea is that you cannot make people have higher c or longer weights or whatever for mental health and you can for physical health. That's in the law.
Dr. Nichols So technically, those barriers have been removed, but big but. But insurers say psychiatrists won't join my network, what can I do? And psychiatrists say, I don't wanna to join your network over what you'd make us go through. And so you've got this impact and then you don't have the supply. That you need to make mental health parity reality.
Dr. Nichols So what you you know, I mean, there's lots of reasons I would submit, 1 of them and perhaps the most important is the actuarial view that lot of mental health is not effective, is still prevailing in and the way the insurer organize themselves. And you know, there's we can argue about what is and is not effective and what is and is not improvement But I will just say they still think everybody Woody Allen wine cousin. And then because of that, they pay they keep rates really low. They're extremely tight on authorizing 6 more visits, whatever. And it drives psychiatrist crazy.
Dr. Nichols It completely interrupts everything kate talked about appropriate patient care. And a lot of psychiatrists. In fact, again, I would submit most of them have figured out, they can make a sign live and thank you very much. Talked just charging the higher resource people, what they wanna charge it, and and that's what most mental health is for middle class population and upper middle class population. We still have crisis mental health and we still have, you know, ways to deal with the years actively still a suicidal an Ed.
Dr. Nichols We will put you an inpatient cycle court for 4 days. That is true. Right? And we will keep you safe for 4 days. And we turn you loose, and we say good luck.
Dr. Nichols And so what we don't have is any kind of I would say, a serious attempt to make access real at the point where it really matters, which is when people needed. So there's a lot of work to do, but to me, it's making mental health parity works, not going to work until insurers and psychiatrists have to have to agree on how to make condition. Reasonable and that's not gonna happen as long the are driving, what's going on. Mh...
Kate Kelly Yeah. I think know, the county house Working and I think we see that all well. I have follow ups questions of that, which I think you answered is Jim asked, The uninsured for mental health, how you kind of said that is so well put. Can you expand on that? What are the underlying reasons?
Kate Kelly And I guess if I could extrapolate and Jim's question, is it the greed of practitioners that wanna make that 500 dollars an hour? In private practice or is it really a breakdown of the system with reimbursement rates are too fair are unfair to those providing mental health.
Dr. Nichols So I I would observe that the low payment rates is what drove the psychiatrist away from insurance. The low payment rates and the hassle of getting their patients allowed to visit for 6 more time to try more times or whatever they thought at the moment. Sort of the administrative hassle and the low payment rate. Then they discovered there's a market out there, of the demand for Elk mental health is so great among which people who have money, they discover they could charge real money and so... But if you look at the at least the Amazing income statistics, I don't know of any 1 who does a better job, unfortunately.
Dr. Nichols So fundamentally, they still don't make that much compared to the interventional cardiologist the North Feed is been yada. So So I don't think it's they're charging too much per s. I think that they were driven away by the insurance attitude, then mental health is not affected therefore wanna shut it down.
Kate Kelly Yeah. It's like, it's very... I mean, I work in addiction medicine World it's extremely difficult to find a find a psychiatrist as you... Everyone this call knows. So Robert asked, what do you think you're requiring hospitals to invest a percent the percentage of their reserves in cd i's in their market area as a regulatory requirement.
Dr. Nichols Wow. Well, that's a really provocative and specific question. And, you know, hey, Robert, I'm in favor rules big time. I'm not certain I would say you have to spend it on Cd I Pdf is a a community development financial institution. It's the thing that invest in local housing and and basically, anything that improves the community as a whole and they tend to be sort of subsidiary financial institutions and some of them are done great work around the country and various places.
Dr. Nichols I'm not opposed of that. What I would do is give them a choice. I would say you gotta spend x percent of revenue period and that can be spent on Sd, she can be spent on community to Cd, can be still on your own. You know what? A whole lot of hospitals are having trouble hiring people, because they can't afford housing where they live.
Dr. Nichols Sd And so building housing for, let's just say sub rn end level workers could also be housing for local people who are not sub in our end workers, but they are indeed other kinds of workers. So you could imagine a world in which the requirement, spend a certain amount of revenue in the community could be given flexibility, yes, you could turn it over to, but I think it'd be better off if the hospital actually directed it to toward those things that are more likely to affect both their workforce and the health of the people around them
Kate Kelly Great answer. I think, you know, if we could expand housing, I think we would do a lot for for health. Greg asked, there was a recent provocative prospective article in New england Journal Medicine or Jam about spending healthcare care money and health. Care, social determinants of health? The author felt other money should be dedicated to social determinants.
Kate Kelly What are your thoughts about this?
Dr. Nichols So She leads is a friend of mine and and she's a very good writer, and she's very smart and I would say she's... Providing a perspective that I think can be characterized as saying Health has got enough issues, don't be adding to a, the utopian dream of having everybody get what they need in the social service sphere. III sort of understand the impulse and Understand the gut reaction. In my opinion, it's misguided because while healthcare care cannot solve all social problems, health care is uniquely positioned who observe people who need those social services to enable them to become healthier. And if you cut health care out of that equation and depend upon housing money and food money.
Dr. Nichols And I might know I might observe. We don't have enough housing money, food money coming anyway. So why not let health get more involved. Again, I mean healthcare should pay all of it. And I don't mean to say we should divert.
Dr. Nichols Every health dollar upstream, you know, would make perfect housing and they have crappy hospitals. No. What I'm saying though is that I want health care involved very deeply involved in deciding how to integrate social and and medical care because that's how you're going to have a healthy population. Not acting like, well, just depend on hud for that. Because you know, for whatever set of complicated reasons, we decided a long time ago and now at the Aca, we decided kind of big time every American has a right to decent healthcare, not great insurance, but decent insurance, I I would I would op pine.
Dr. Nichols And that's a bigger deal than we've ever done for housing or for that matter food and transportation. And so I would say, we don't have enough money in general. Health knows how to direct money specifically. Health probably should hire it and not do it themselves. The last thing you wanted a bunch of doctors and nurses going in people's houses.
Dr. Nichols You will want our community health workers, maybe social workers, you know, don't send any the economist either we're work. But the point is you want people, what who understand the consequences of the social deficits and that's what health does because healthcare sees it every single day and
Kate Kelly Yeah. I mean, I think if we're d fact facto doing that anyway. I mean, my... The ed of the hospital I work for. I'm sure many people on the call have had this experience is d facto shelter for many folks, especially in the cold cleveland Ohio winters.
Kate Kelly And we can't help as people that have taken a hip oath to help then things that are outsiders fear, including housing, including food, including transportation, I mean, how many of you have written forms for bus passes or written a bill to provide air conditioning for a patient who asthma or not to get their electricity cut it cut off. Like, these are things we're already doing, and it's time that and the budget really reflects that and treats health care is part of and part of that system. Jeff asked to what extent are the equities in healthcare care just a smaller part of the overall tolerance of wealth and equity earn inequality through neo economic ideology in Usa culture.
Dr. Nichols Well, who's.
Kate Kelly Okay. Great question, Jeff.
Dr. Nichols Yeah. I mean, you know, look, there's no question, Jeff, Our tolerance of inequality. Comes from a set of beliefs that it's either just as a result of effort or whatever or there's nothing we can do about it probably with you always sort of fatal view of bridge religion and civilization. I think at the same time, it's important to emphasize a lot of people are not accepting this. And about 47 of them are on this call.
Dr. Nichols I mean, I do think there's a lot of people around the country, who don't want the kind of inequality we see. You know there's you may remember the Harvard soc Robert Putnam a Motor book a decade or so ago bowling alone. And he sort of summarized the decline of Civic participation in the United States. He got a new book and it's called the upside. And what he does is he compares today's complete.
Dr. Nichols Everything that's wrong with us today. He compares it to 18 90 to 2010. I mean, we're 19 10. He says basically, we're living to another gil at age, what did we do back then? Well, first thing we did was we sue John Rockefeller and the Antitrust and we beat it.
Dr. Nichols And guess what? Ftc just filed against Google and and Microsoft. I mean, you know, these big companies are are and and and, you know, Amazon. So fundamentally, we're starting to do this. And his point is, we can do this.
Dr. Nichols Again, we can come back from gross inequality and growth because most of the techs don't accept it. It's just that it seems like everybody deficit it because we don't really try to change it. And our politics are broken and we can talk about that later, but we any more liquor into that part.
Kate Kelly We are new. So... Yeah. Yeah. Is there good source to get reliable history about the role of physicians and the Ama and the current payment structures.
Kate Kelly This is from Sarah, Heartfelt, What about the makeup of the committee at Cms? Think you're I think you're talking about the rock?
Dr. Nichols The rock. Yeah. The rock has definitely been captured. By the specialist of the Ama for, you know, since civil, since it
Kate Kelly was Greece
Dr. Nichols in 89 But I I think honestly, what I would do and I'll put his email in the chat. You wanna send an email to Bob Barron at the Urban institute. Bob is kinda like, I would say the guru of physician payment in the United States, and he's been around a while. And he can he can point you to and tell you what you need to know. And I will put that in chat right now.
Dr. Nichols Well, maybe a little later. But maybe I'll send it around later. That's the best thing do. But, yes, there are there are people who can walk you through this essentially did have to do with the way that... You know, when when when we set up the Medicare program, we basically said, okay, we're gonna do a Blue Cross.
Dr. Nichols Did in 19 65, because that's all we knew. And what a Do Blue cross do, they paid usable cost very reasonable. They which meant what act rays thought was reasonable, which had to do with basically a probability distribution of what came in over the Transcend, when Medicare started doing that, they had to publish it, Blue Cross had kept in secret And as it got published, more and more doctors said, what, hell. He charge net. And so prices went up really fast.
Dr. Nichols And that's when we made a fee schedule. And the fee schedule was designed to stop the inflation. And if fee schedule, however, got captured by the people who were in the Ama and the majority of people in the Ama even then for specialists and that's exactly why specialists get paid the heck a lot more than primary care and we'll until you get control of the rock. So hanging in there and Ask Bob and and act accordingly. I'll say.
Kate Kelly Howard asked, many opponents of publicly funded single payer universal covers claim that they fear that the plan will not provide the services they want. And want there to be an option for private I. E. Enhanced coverage, what should our answer me to that?
Dr. Nichols Well, it is fear. There's no question that people in United States particular are afraid of government limits and you may remember at the time of age of the Aca particular a time of the Clinton plan, and all this stuff about debt panels and you know, they're gonna say no, and won't let us have this and that. A interestingly, they cannot not mine when private insurance says no. But I'll just say, look, it all comes down to what are we willing to pay for? Okay.
Dr. Nichols A single payer plan doesn't have to be par anymore than United healthcare Cadillac plan for the executives. To run united health has to be part. It all has to do with what he you willing to pay for and how are you going organize the payment system to to get the results you really want and make sure you've got the help workforce and technology forth that you really really need to So I don't think there's any reason that public payment versus private payment is gonna be. Higher or lower, All have to do with what do you willing to pay for. I mean, I look at Germany, they don't think we having trouble getting specialist activities I look at Switzerland that I look at trans and look at.
Dr. Nichols You know, now England had some issues with rationing, they probably spent too little for some time. Canada is somewhere in between. Right? You know, Canadians coming united States to get elective surgeries because they I can get it quicker here. And so forth.
Dr. Nichols So there are some issues, but that all has to do with what he willing to pay for and how are you willing to organize your system. So it's not inherent to public or it has to do with how you want to organize your system. But you do have to organize it completely if you're gonna avoid those kind of disparities.
Kate Kelly When I I think that you know, patients love the idea that they're the consumer and we really internalize this as Americans. And it's hard because I In my practice, I've had a lot of people who are frustrated with the the care they they received and their answer is not... Well, what shame that our system is owner funded? Their answers. Well, I'm gonna go to hospital on the street?
Kate Kelly And people really... As Merrick it really this idea that there a healthcare care consumer which has been pushed. So I don't know if you have an answer to that that type of internal realization of happiness.
Dr. Nichols I I
Kate Kelly don't know
Dr. Nichols if there's an answer. I would observe. Americans are very deeply, you might even say condition to accept individual responsibility. K and to accept like, it's us... It's us.
Dr. Nichols It's our problem. It's not a social problem. And so I wanna go to the Hospital down the street. I wanna change health plans. They wanna get a different doctor.
Dr. Nichols All that has to do is, I'm gonna solve my problem and I'm not gonna worry about the bigger system. And that... That's the way we're taught to the thing. Pay, it's got in our water. But at the same time, that's kinda what's interesting about in my view the current moment.
Dr. Nichols Look, the whole movement toward the Aca was the movement of saying, we cannot be on our own against insurance company. We will never win if we do that. And that's why we have insurance regulation, much tighter than ever before before they could discriminate against you if you had any health condition at all and then and not even cover it and you had no power to change that as as 1 person. So you need to have rules to make the market work more fairly. And those same rules can affect any part of the system you want.
Dr. Nichols It's just you really have to get it a comprehensive approach to changing the rules. And you I don't think it's I don't think it's rocket in science. It's not simple, but it's a whole lot of people can help you do it and you you guys know everything probably needs. Be changed. But I think fundamentally, it's about being clear about what people deserve, how you're going to organize a decision deliberate it, then how you're gonna pay people fairly to get them to deliver.
Dr. Nichols And then, you know, your your yours... You got a sustainable system. I would just keep looking around the world. There's lots of places where they're doing it better than we are, and we could learn from them. And they don't have the same I guess you could say intense individually.
Dr. Nichols They don't believe there's supposed to solve the problem by themselves. Mh. We can work together. We just have to remember how. Regarding?
Kate Kelly Bill, a great response. Bill asked, is there a legal obligation for non nonprofit hospitals or Hmo to provide charitable care? Is there any states that have laws requiring a percentage of profits to go to charitable care?
Dr. Nichols So the federal into, which... Something like emergency medicine and active Labor Act requires hospital to to stabilize a patient. Well, you come in and you got a broken arm, you come in, and you're bleeding, that stop the bleeding, they have to sp the arm. They do not have to treat the cans. They do not have to give you everything you might need, but they do have to stabilize.
Dr. Nichols That's what is required. Many states have laws that say you've got the sort of tell us what you're doing on on community benefit. And you may recall the Aca had a requirement that all hospitals the United States all non product those United States, which is the vast majority of them have to have... And a report of the community health needs assessment, and then they have to say what they're doing about that. They do not, as far as I know, no state requires anybody this spend x percent on those community benefits.
Dr. Nichols Pennsylvania played with it for a while. California played with it for a while. I don't think anybody ever acts pull trigger and requires it. And so that's a place to start because the Aca laid in the foundation of okay now we know what everybody no needs and star, We knew that before, but now we got a documented it. And we can compare what the hospitals are doing.
Dr. Nichols I will say Star you know, all those reports are interesting. Covid came along and it really did done knock hospitals for a loop, and you can't blame them for that. And now given everything that happened with the workforce during Covid, essentially the nursing workforce now costs 20 percent more. And so hospital are not in great shape at the moment because of all the Sequel from that. And so they're not keen on both having a new spending requirement imposed tomorrow.
Dr. Nichols So maybe don't want do it tomorrow, but you do want to do it over time and you want to think about again, what's the best way to marshal those resources to maximize the health of the communities in Which the hospital, it will sit. And I would argue that's giving them some kind of Sd h or Cd or some kind of community benefit requirement. If it's the same for all hospitals, they can't claim competitive disadvantage, And and you can kinda go from there.
Kate Kelly Correct if I'm wrong, but I do think there at least in the state where I live. I feel like there is some restriction on... How you can call yourself a non profit?
Dr. Nichols Well, sure.
Kate Kelly How to reinvest that money?
Dr. Nichols The non nonprofit typically has to do With you have to agree to provide charity care under certain conditions for certain people. Okay? But what I'm trying to say is every serious analysis I've ever seen of it shows they're getting way more of a tax benefit and they're giving away in benefits. So we're not getting our monies worth. Let's put it that way.
Dr. Nichols Kind of benefiting the poor profit it'll actually come out looking better in some of those experiments it's kind of shocking for history.
Kate Kelly This is a great question. How do we start the conversation between primary care and specialists when the pie continues to be the same size?
Dr. Nichols So that is a good question. And if I knew a very su and pit answer, I'd be a very rich band, but I will say that at the end of the proverbial day, it's it's kinda like... I mean, not to be too heavily relying on proportional personalities, but it's kinda like, how much you pay the quarterback back. Okay? Versus the tackle and the ends and the and the.
Dr. Nichols So because you can't have it... Quarterback won't lay very long without the other people blocking for him. So you gotta have a team. So to me, the way to solve the problem is to think about what should the team be paid? And then how do we decide, decide relative worth of the team members.
Dr. Nichols And I would argue within the team itself? Exactly not that must dispute. It's disputed when you get Team Versus Team B vying for the same quarterback in that. But at the end of the day, everybody knows exactly. Is worth more.
Dr. Nichols And everybody knows that those people at the bottom of the food chain right now, already be paid more. And you know what if we did that, might not have the Kaiser strikes and that kind of stuff going on. Go fundamentally, it's about red distributing the pod, but in a way that people agree with? Now does that mean an interventional cardiologist next day money made this year no? Does that mean interventional cardiologist won't have arguably a better, more enthusiastic team and maybe a better life.
Dr. Nichols I would argue it's entirely plausible. I know surgeons who have done less surgery and then much happier when they reorganized, the way who got to them, what were the role of Pt was before patients got to them. And what kind of patients they were operating on, which improved both the efficacy and the long run sort of, you know, health improvement and made them all happier even though they made month So I... There's more to life and money. I know it's hard from the economist to say that.
Dr. Nichols And I'll just say, somebody light make 3000000 bucks a year probably doesn't need that. They may feel like They already bought their 3 homes and they gotta maintain their mortgages, so you may have to have transition period, but I'm just trying to say, have a conversation among the team. Pay the team and let the team figure out because the team can't work without all of them, and that's how you make it them.
Kate Kelly My doesn't mine doesn't by happiness sounds definitely more like psychologist in an economist. So if you want a career change, I think you're you're in a good place. Mrs is from Cad First off. Some advocacy focused exclusively on the greed of insurance companies of private equity, which focus more money than health. How do you think possible to be critical of all breed oriented subs sectors in American health care.
Dr. Nichols Whoa. Well, so It's It is interesting when you think about, you know, what is enough? What what is the goal? Right? And I have met people who run physician practices who say the goal is to make...
Dr. Nichols For my docs make as much money as possible. And provide excellent patient care yada yada. And I would just say, you know, if that's your metric maybe and that's what Bur wrote, maybe this is the wrong business for you, right? And maybe what we should do is if you think about my team conversation, which ultimately gets enforced right? Regulatory rules that Medicare would would have to agree to.
Dr. Nichols You may not be possible to make this much money doing this stuff, anymore. And if that's what you're in for, I think we can probably do it without you. Because I think there's plenty of people who are doing it for the right reasons who are now so frustrated at the way this thing is organized, they would gladly step in and do this stuff. Now maybe we'll lose some brain surgeons, maybe Although I doubt it. Maybe we would lose some interventional cardiologist orthopedic.
Dr. Nichols I don't know. I kinda think they would g and and and live with it. But I do think it comes down to, everybody's got believe the equilibrium is fair. Okay? Right now, I don't think a whole lot of people think it's fair.
Dr. Nichols And even those who are at the top of the food chain, they know what ain't fair, they're just taking what they can while they can't. So if you're gonna have a conversation about making it fair, I don't... Think they would all run screaming from the room. But if they do, well, then, you know, we'll have to do without them.
Kate Kelly That Yeah. Well like, well, cross that bridge comes through. Right?
Dr. Nichols Yeah. We're lost From here. Not.
Kate Kelly This is from Pat Her in and I think this is a great question Something I think about a lot. What happens when you change the fundamental nature of healing systems and institutions into a public utility.
Dr. Nichols Wow, that's a really thoughtful question. And I would say it in a way, public utility calls to my mind anyway, the notion that everyone has to have beds. It's an absolute necessity for living water like you see through would broadband today. Would take students. But turning health during the public utility is we would changing the nature of the individualistic relationship between the patient and the he.
Dr. Nichols That that is true. It does not mean in my mind, it would be impossible to maintain the fundamental sacred, of the of the relationship between the healer and the patient because the healer and the patient are still in relation to each other, what's different is who's paying whom and how much they're getting paid maybe and what the rules of engagement really are. I don't know why you couldn't write a better public utility than we got now. I mean I mean, if you get we to Joke, the phone assignment and health economics 01:01 is design a system this badly, any other part of the economy and no 1 can. The incentives in healthcare care completely screwed up.
Dr. Nichols We can't do worse. We could do better for we gotta be careful. And it seems to me all the lessons you guys know should be baked into utility conversation. But but it it's a very good question because it makes you mindful of the fact, you're giving up something when you move away from that individualistic. Ethic, and you would be moving to a more social ethic, and you just gotta be careful when you go down that path.
Kate Kelly Right. And everyone likes the idea of a public good. So we have 2...
Dr. Nichols People are afraid to change. That's. Yep. Yeah.
Kate Kelly The change is healthy. So just like... You just as doctors we know that. Right? So 2 more questions and I just wanna point out.
Kate Kelly That we did have a question that chat that says, an economist making house calls made them smile. So We can go at house calls together. I I like that idea. And economist and a family doctor walk into a room. But someone had asked about the Kaiser strike, and I...
Kate Kelly They said they 75000 employees on strike. I wonder how many physicians were there I didn't... We talked about it briefly before, and I don't wanna get us too derail in the last couple minutes, but maybe this would be a great time for you to to give us your take and it as a health economist?
Dr. Nichols So I think it's interesting. No doctors are striking. No nurses are striking. People who are striking are either pharmacists or opt alzheimer's in the East Coast or what I will call nurses aides and folks like that from tax West. And it has to do with, I would argue the people at the bottom of the payment food chain saying the working conditions that they've been settled with since Covid.
Dr. Nichols Have been into for years. Everybody's burnout is real and it's true up and down. The health care worker. You all know this deeper than I do. And they're saying, look, I I don't feel like we're doing good patient care.
Dr. Nichols I don't feel like we're doing safe patient care given how our units have shrunk and we're being forced to stay in here and just basically do more with lyft. And so and they're asking for more money, but that's almost like a like a secondary thing, they're really asking for a reorganization of the Healthcare delivery system. And that's why I think it's it's a different kind of strike. Than we've had before. But Kate, you may have take difference.
Kate Kelly No. No. I I agree. I think... Know just finished residency and there's a big movement for residences to union eyes.
Kate Kelly And I think it has to start small and I think doctors are, fearful of their positions as they aren't protected and, you know, and thing the state I live physicians, attending positions can't union by law. Quote me on that. Anyone was in the state of a ohio. So I think it's it's encouraging to see that people aren't gonna stand for the the substandard working conditions and patient care. So finally, this is kind of a question that's been in the Q and as with the kinda sprinkled in through a lot of folks.
Kate Kelly And really, the big question, the big take home from this event, which we are so glad that all of you joined We've had so many questions. And as this is our our kind of kickoff events to work on our addressing green and healthcare care and economic justice campaign. Then And for those of you wanna join us, we're be thrilled to have you. We're working on a declaration about this. We're working and partnering with other major national organizations who serve patients and represent physicians.
Kate Kelly We'd love to have you work on messaging and partnerships and getting the word out and educating your fellow colleagues and healthcare friends and neighbors. But how can we empower... How can physicians empower patients to get involved in changing the broader injustices we fall victim into and also how can we get more people to vote and change some of these policies? What... What's an next?
Kate Kelly Like, what what can we do? We're all frustrated role at our woods and we want we want to change.
Dr. Nichols So well, first of all, you do what you're doing. I I think you organized physicians voice and you organized physicians voice to speak very clearly about what your priorities are. And why the current system does not permit you to deliver first rate patient care, which you know you're capable and we're capable of delivering to the to our nation. So first, you articulate what the hell is wrong. And then I think you enlist your pet your your patience as your ally they know you are their spokesperson.
Dr. Nichols They know you are their best friend and in their troubled health management. And and the vast majority of us, you'll trust our dock. I mean, you know, I've always said it's because we get naked in front of you, We have to trust you. And but still we do. And so because we trust you, then you got this thing.
Dr. Nichols And let me tell you what, Trust is a scarce asset in our you right now. So build on that. And I would say everything y'all do together, do with patient that amplifies both your voice and do it with nurses and do it with students them and do it... I mean, I'm just saying, movements grow from that Colonel of trust and trust is an asset that will grow if its share. So demonstrate to the world how your trust is is being manifested and why you're c advocating for changes in the system.
Dr. Nichols How do you do it well, look, know, there's 10000 ways and and right now in Washington, I wouldn't recommend you drive down there this afternoon. But I would say you focus on people and there are some in Ohio, and there are some from Ohio and there are some in every state actually, even Louisiana, that know what the hell we're talking about and are in a position to listen and do something about it. So I think you talked to your elected revenue representative did you try to get people elected who are more simple, but Betting. But you start with what you got and you start with the trust, you've got your patients and you show these people why we have to change and why their own care is threatened if we don't. I think that's the message that almost every and let's be Frank, older, congress senator will relate to because they're they're pretty worried about their own health every single day.
Dr. Nichols Mh
Kate Kelly Yeah. I think that's a really great note to go out on lynn. I think we sometimes is underestimate. Our power as individual physicians when we can come together. And trust of a patient and trust of the public is really an honor.
Kate Kelly And a privilege. And it is our duty physicians and people who took, you know, an Oath to care for patients to to really take that seriously and to continue to advocate for our patients and everything we do, both inside the exam and outside the exam room. Thank you so much for your time. We have 2 minutes left. Any takeaway points before we log off.
Kate Kelly I feel like a psychiatrist, you know, or times almost up. But is there anything you can leave us with before we hop off the evening And again, for folks that are interest in this work interesting in joining us in D. We have a lot of different impact areas from... Abortion access to gun violence prevention to Covid relief efforts. We'd love to have you join us.
Kate Kelly If you feel angry, And he wanted change D is the place for you. So land any final thoughts before we we end up... Oh?
Dr. Nichols I think both of us... So I I would just say never underestimate the power of your voice when you join it with others. And and you guys have unique credibility and everything you're talking about and all those issues, Kate just mentioned and just go forth. And and and say it loudly.
Kate Kelly Thank you. Alright. Well, thank you, everybody. Thank thank you again to lend. For joining us.
Kate Kelly We really appreciate you taking the time. And we'll be in touch, and please feel out the C form to get credit. If you need anything for feel free to contact us directly, and we will talk again soon. Alright. Have a good night, everybody.
Kate Kelly Thank you.