Transcripts For CSPAN2 Dr. Vivian Lee The Long Fix 20240712

Your screen or becoming a member and our partner booksellers as you might imagine are really right now as well, theyre going to be interested in going deeper on the subject of tonights talk use the link to purchase your copy of the long fix through thirdplace books. Doctor vivian lee has been a practicing physician, scientist and healthcare administrator for over two decades. Among her roles, doctor lee has served as inaugural chief scientific officer and vice dean for science at Nyu Langone Medical Center and prior to that she was the vice chair of research at the department of radiology and for six years he served as ceo and dean of the university ofutah school of medicine among other roles in salt lake city. She was elected to the association of american medical Colleges Council of the administrative board and is a member of the Advisory Board of Massachusetts General Hospital and university of Pittsburgh School of medicine and her writing is has appeared in the Harvard Business review, journal of the association of medical colleges and other publications. Speaking of other publications please first book was an academic page turner on cardiovascular mri and im told not for the faint of heart. In the 15 years ive been on this job that is the first intentionally terrible joke ive ever told an introduction. I read this book and what we product tonight is the long fix, solving Americas Health crisis with strategies that work foreveryone. Please join me in welcoming doctor vivian lee. Its wonderful to be with you tonight and im thrilled to be part of this event and really looking forward to a healthy and hearty discussion. And i also want to acknowledge that we are living in some very complicated, complex times and i just want to thank you all for joining us tonight. Im speaking for about 30 minutes or so and welcome your questions so for this time of prepared remarks what i thought i would talk about would be maybe a series of three questions. First, why wrote this book and then i thought i would talk about how its structured and the main premise of the book. And then of the 12 chapters i thought i might dive more deeply into two or three topics depending on how much time we have area so let me start with why did i write this book . I wrote the long fix. It has its origins in a series of presentations i made to our brandnew medical students when i was the dean of the medical school at the university of utah and these firstyear medical students were fresh out of college. New to medicine, relatively new to healthcare and i really wanted to share with them what i wish i had known before i had gotten into healthcare. One is to answer the questions they had about how healthcare works. And in particular to prepare them for how they could really make a difference in the field beyond the practice of medicine. To actually the experience of working within healthcare itself. And many of the questions that i wanted to answer were the same questions that i got when i joined where i now work which is alphabet Healthcare Company and where i have met a number of really talented, bright product managers, research grantors, researchers and the like they also were all trying to understand just how this very complex system we call healthcare works and how they can make a difference. I think that we know we all know in the news or from our own personal experiences that there are many , many components of elf care that feel broken. We know about the rising cost of medications. Balanced billing or surprise billing period or lack of insurance for so Many Americans in this country. But what we havent heard so much about are the solutions. And as i have worked in healthcare for over two decades and traveled around the country and even around the world, learning from others, i wanted to have the chance to share some of the stories of where new and different ways of providing healthcare and paying for healthcare are working really successfully. And in sharing those Success Stories and those bright lights, i found that i was able to weave together a narrative and reached an increasingly clear sense of how we can extend those local solutions into a National Strategy for healthcare. And so thats really why i wrote the book the long fix. I wanted to write an optimistic book that actually offered solutions which is i think something that we very much very desperately need. And it was called the long fix because of the conversation that i had with mike leavitt who is a former secretary of health and Human Services and former governor of utah who was reflecting on the fact that he felt the trajectory of change in healthcare took maybe 30 or 40 years at the time and he was in our conversation he felt that we might be in the middle of one of these cycles of say 35 or 40 years. Since the covid pandemic i feel theres a much greater sense of urgency about tackling some of these problems so im hopeful the long fix be a not so long or maybe slightly quicker fix. Im optimistic about that. So let me now turn briefly to how the book is structured and what i talk about in the long fix. Start by laying out fundamental premise of the book. Which is that the central problem in healthcare is really not so much about the delivery of healthcare really about how we pay for it. Its the economic or Business Model of healthcare. And if i were to prioritize, there would just be one thing i would say we need to focus on and its on changing that economic or Business Model. And that its not so much who is paying for the healthcare, we can talk more about that if folks are interested in the q a. So a lot of the discussions about it we have medicare for all for example. I dont believe it is as much about who is paying for it. Although of course at an individual level it matters tremendously but from a policy perspective i think its really more important for us to solve what is that were paying for in healthcare. And specifically what i mean by that is how our Healthcare System is really focused on paying for action. Paying for procedures, what we call a feeforservice Healthcare System where as paying for Better Health would create a completely different set of incentives in healthcare. And if we did that and i will talk about some examples of where that ishappening in our country today , we would find ourselves investing far more in prevention and in primary care. It would incentivize fiddles and physicians to Work Together instead of in conflict as mortal enemies. As ill talk about a little bit as well. And again, examples of this are already happening in the country where we have situations where we are paying for health, a for Better Outcomes. So thats really what i talk about in the first section of the book and in the second section i look at how the Healthcare Industry would act very differently in this model. Where it was motivated by almost any other industry in this country to actually compete on Better Health, compete on delivering value to patients, to its customers i should say instead of just doing more and more prestigious commitment as we have in our Current System so in the second section of the book i start with safety and i talk about how hospitals can learn from other industries. Ranging from airbag manufacturing plants to the Aviation Industry for example , to make healthcare safer. I talk about the Critical Role doctors play in how our Healthcare System works and how with the right incentives , there are type a , very intrinsically motivated personalities can and are to really improve quality and even reduce the cost of care. And finally the business of healthcare, patients might actually move into the center of the universe of the healthcare business because their health would be paramount. Their health would be driving the Business Model of healthcare instead of the way it is today is really where physicians tend to be the center of the universe in healthcare because the physicians are the ones who generate all the actions and generate all the fees in a feeforservice world. In the next section i delve into the pharmaceutical industry and eight in Technology Sectors and tell stories that reflect on what they could be doing differently if they were competing to make people healthier at lower costs. And finally i focus on systems that actually provide big picture views of how our healthcaresystem could work completely differently , taking the perspective of the two biggest payers of healthcare in our country employers for the Health Care Bills for half of americans in the government but in this case instead of talking about medicare and medicaid i talk about military Health Systems and the va period and use those systems to shed a little light on how government run healthcare could actually pay for Better Health outcomes and actually produce better results and lower costs. And then finally i close in a chapter that summarizes the action plan for the health and in each chapter, its the stories, the narratives, these examples each chapter ends with an action plan for what individuals can do for what physicians can do and lawyers, payers and policymakers. So thats essentially the structure of the book and the content of it. Now let me Just Transition into a couple of ideas that are in the book. And see how much time we have and ill talk through two or three ideas. Let me start with the one idea, one big thing and actually in the course of researching this book i interviewed over 100 different people in healthcare. Our physicians, insurance executives, patients, advocates. Community workers and i had asked him what the one thing you can change in healthcare if you can wave your magic one and two thirds of them said the same thing. They said what i also believe witches they would change the Business Model of healthcare. Ive heard models where you refer to as a feeforservice model. Or what i refer to as paying for action. And in our current model, Healthcare Providers, physicians and hospitals are paid for doing things to people. Laboratory testing, imaging studies. Operations, procedures and infusions. Regardless of whether it produces health. So as a result, Health Systems and physicians are really incentivized to do more and more things to people. And in fact document they are doing more and more things to people so that they can charge and bill insurance for them. And instead, we should be inspecting more as consumers or individuals to really only pay for care when it improves health or when it is likelyto improve health. Even if that means not doing much of anything. Thats really ideally how we should be thinking about the Healthcare System is whether its delivering Better Health. But if you have a feeforService System as we do predominantly now and when i say that i mean that private insurers, payment spaces, the government also is dominantly paying for service. Its still, medicare is predominantly a fee for Service System and what that means is our Healthcare System invested things that generate fees like imaging centers, like surgery centers. Like Cancer Centers and we really dont invest in the things that we see right now during this covid pandemic are essential which are Public Health and primary care. Because Public Health doesnt generate and achieve that so if youre wondering why are Covid Response has been so lame when we have some of the best Healthcare Facilities in the world, its because we havent invested in the things that dont generate fees, we havent invested in a Public Health infrastructure even though plans have been laid out for that we havent managed to do that so we have a 3 and a half trillion dollar Healthcare System that is focused on making four or 5 trillion and the only way to do that is to simply do more things to people. I will stop and say that i believe that most physicians and most clinicians are really trying to do good. They are trying to practice the best healthcare they can. But we have to acknowledge that the economics are such that they are incentivized to air on the side of over treating or over diagnosing and our medical legal system only further supports that or maybe even incentivizes that so what happens is you have hospitals and doctors who are incentivized to do more and more to people so for the people paying the bills, the payers, the Insurance Companies and the government, the only way to limit that spending and that perceived overbilling is to place barriers. For the Insurance Companies that means denial. That means saying if a doctor recommends an mri, im an mri radiologist and i use that as an example. If a physician is recommending an mri the only way the Insurance Company is to manage its cost is to say i dont think thats authorized or i dont think thats necessary or they put into barriers things like whats called prior authorization which simply means amount of paperwork that the physician has to complete in order for that study to be done and paid for so its just really a barrier thats put in and what it generates is an and normas amount of work. So you have doctors and hospitals, the payers denying and putting in more barriers and their fighting back and forth. Its like 1 trillion tugofwar and at the end of the day it generates enormous administrative waste. In the us we spend about eight percent of our healthcare dollars on administration whereas most of our european counterparts will spend three percent, 80 percent versus three percent. That is a huge amount of weight and when we cant resolve this dispute, what happens is we have billing so the money isnt paid for fall through the individual, the patient and thats what we call valid billing or supply filling. At how our system works. And it as you can imagine also generates an enormous amount of other kinds of ways in this system, so much so that today, approximately 25 to 30 percent of all healthcare in this country again, around 3 and a half trillion dollars is considered waste. So when we have discussions about how can we extend health care to all those who are underinsured and uninsured, there are clearly opportunities in terms of being able to recover some of the ways and redistributing that to be able to cause our Health Insurance for a lot of people for everyone. Now the implications of having this completely backwards Business Model of feer flying into the headwinds of capitalism is that instead of competition and innovation working towards a better Healthcare System, our capitalistic tendencies are focused much more on doing more and more. Even if its wasteful. So what we need to do is to think about how we can evolve our Healthcare Systems into a l where we have actually the tailwinds of capitalism driving us forward and of course many of us within healthcare and government have been thinking about this for a while and one example of success is in a Pilot Project for what started as a Pilot Projectand is now expanded in Medicare Advantage. So most of us are aware that medicare is the Health System for seniors in this country and Medicare Advantage is a subset of medicare area it covers about a third of all medicare patients and then within the Medicare Advantage program, theres a special model where the government actually contracts with medical groups. And says to these medical groups were going to pay you a little bit differently and instead of paying you in a fee for service way where you just need to keep seeing patient after patient in order to get paid. Were going to give you a fixed amount of money to care for all the patients in your practice for that year. And that fixed amount of money will depend on how sick thosepatients are. So if there are coe complex patients with many medical conditions we will pay you more. If theyre generally healthy we will pay you a little less but we will give you that fixed amount of money and its up to you how to spend those dollars to keep those patients healthy and were going to track, the government says were going to track how healthy your able to keep the patients. You have to keep them healthy otherwise there are penalties and you have to keep them satisfied because these patients can take their business elsewhere next year if they are dissatisfied. Whats happened in these Medicare Advantage programs, these special programs that include like can met in miami and theyve expanded to about 70 systems across the country. Care more, leon health, theres many of these across the country is that we find these positions when theyre given the latitude, when they have a fixed amount of money to keep people healthy they start to practice in completely different ways from traditional medicare clinics. The cause what happens is if theyre able to keep people healthy and they spend less medicare pays them for that year, they actually will not profit and if they end up not having the patient healthy and having the patient go into hospitals and Emergency Rooms multiple times they lose money and its actually their ownmoney. T from doingthat. So i talk about chen med and i talk about that in the book but there are many other wonderful examples across the country is that doctors spend first of all a lot more time with the patients. They know that these seniors often who have multiple medical conditions need quality time so instead of 8 to 10 visits a spend 30 minutes to an hourwith each patient. Onsite pharmacies, shuttle services. They offer tai chi and yoga classes as part of their all prevention programs. And they in the long run while they spend a lot more money and more time upfront , they see more than enough savings to make up for that in reduced hospitalizations and of course they are keeping theirseniors healthy. These Medicare Advantage models are incredibly promising in our preauntran11a era and there some of the most resistant because they had a spent amount of money every month regardless. Theyve actually been able to stay open and functioning during this process while so many of our other clinics have had to furlough, layoff doctors and nurses thats an example of a new model, a relatively successful model and when i talk to seniors and others including family members, i recommend they look for clinics that offer this. The second topic i wanted to talk about was i havent been thinking about much as ive been talking about this book. Its a very important thing to me which is really the issue of safety in healthcare. And it may be surprising to you. Right now weve been hearing a lot about the struggles of the hospitals financially with the relatively empty awards and the clinics derived from the Covid Patients but when these hospitals are full, aside from covid, aside from Infectious Disease issues it may surprise you to hear that they arent always the safest places to be. About 20 years ago the institute of medicine which is now called the National Academy of medicine but one of the most heralded organizations in this country and one that im proud to be a member of, 20 years ago they authored a report called to various human. They estimated at the time, this was 20 years ago about 100,000 americans each year were dying medical mistakes. 100,000 and if youve been keeping up with the news youll know that in america we just crossed 100,000 lives lost to covid this year. Its a devastating loss every year, the National Academy was estimating that hundred thousand americans would die from medical estates. And since then theres those estimates been revised upwards because as you can imagine, if you do a death certificate research project, nobody writes medical mistakes for death certificate so theyre difficult to uncover and so new research has actually been suggesting between 250,000 and 440,000 people each year are dying from medical mistakes in this country and that would make the third leading cause of death behind cardiovascular disease andcancer. If youre like me these statistics are reallyshocking. Because when you think about hospitals you think about places that are so, that are clean, organized and there places you go toheal. And so in this chapter i talk a little bit about where some of those, how some of those mistakes arrived and what we could do to really address them. One of the most common causes of the mistakes is medication errors. Some research actually has estimated that every time a hospital administers a medication theres about a 20 to 25 percent chance that at least one clinical error. Sometimes its a minor, relatively minor error so the medication is given same or less than 30 minutes when it was supposed to be administered. It probably makes it less effective but probably not devastating. But there are times whenthere there are really significant and serious errors. Of those cases is really because the names of many of these medications can be very confusing. So for example, there are three medications. One is called an arthritis medicine, one is called sarah x, its a seizure medication and the third is called alexa, its an antidepression medicine area a sound almost the same. Celebrex and celexa, imagine getting the two confused and this happens all the time. If you go online and search you can see the fda and institute for safe medication practices actually publishes online dozens of these lookalike and sound alike names or drugs. And what they recommend is if you have multiple confusing names if they recommend we as physicians that three of those letters when they write up the prescription that we put them three of the letters of the names in uppercase just so that we can differentiate them from other names. Its absolutely ridiculous. So theres a clear obvious solution to that at the fda could actually prohibit pharmaceutical Companies Making names for new drugs that sound just like others on the market. Theres nothing about the biochemical makeup that isnt reflected in these brand names like celebrex or cervix. So thats one reason why many medical mistakes happen. And another is interruptions and distractions. It may not surprise you to hear that distractions interfere with performance and in the book i talk about a rather tragic story of a nurse who was caring for a patient in cattle childrens hospital. On average nurses are disrupted during medication rounds about once every 2 to 5minutes. Emergency room doctors are interrupted about every six minutes on average in some studies reedit and its a stressful environment already to begin with and many things that are going on and so i talk about some examples of how systems have really adopted best practices from other Industries Like the Aviation Industry, who face the same problem you need to go and created rules in the cockpit of no chatting, no distractions and then checklists. And the implementation of some of these practices in the healthcare environment are certainly improving practice and reducing mistakes, especially in the operatingroom. Go on the road an excellent book called the checkers manifesto that describes some of those practices and finally, the third area of medical error or related issues really comes, that i mentioned or the third i guess i should say perspective is malpractice and the risk of malpractice. And the fact that many of the fears associated with some of these medical mistakes do lead to the over testing and maybe overly cautious approach to health care such that 30 percent of all lab tests and up to as many as 50 percent of radiological studies have been considered potentially unnecessary and just reflecting spending so i talk a little bit about nofault insurance models which i think are really interesting. It started in new zealand, in scandinavian countries where if something does happen to patients they can file claims and essentially theres a Government Fund or pool set aside to cover those costs. And you dont even have to show negligence or these families to be able to collect funding and it does not mean theres no accountability and interestingly many people arent aware that in the us we have two states, virginia and florida where they have nofault insurance plans, nofault models for babies who suffer neurologic industry injuries at birth and they are comparable paths for the families, there are no legal fees so considerable savings to society. So im just about i think run through this 30 minute mark and i think i have three or four minutes left so let me just fit in very briefly a third topic that id like to share fromthe book. And this is really a topic about individuals and how we can contribute to the long stakes and how we in looking after our own health and the health of our family members can be part of making our Health Care System more effective, better for us and also more costeffective. The idea here that i want to share is this notion of coproducing health. Coproduction or coproducing health. Though many of us who have lived our lives in the healthcare profession, myself as ceo of the Health Care System as a practicing physician, as an educator, we think about healthcare as what happens within the four walls of the hospital and clinic. But in fact most of us as individuals know and we teach this in medical school itself that the vast majority of your Overall Health is really determined by what you do outside of constant clinics, its based on what you eat. How you sleep, exercise, what you inhale. And those of course are very much in each of our own individual control. And this idea of how Health Systems and individuals Work Together to coproduce health or this term coproduction actually comes from an economist at stanford, victor fuchs wrote a paper in the late1960s. About the economies transformation of the us economy from a manufacturing or industrial economy to a service economy. And in his paper he talked about how in an industrial economy or manufacturing economy, the suppliers tend to produce their goods like a pair of jeans, a car or some kind of item and then they sell it to the customer and they basically handed over to the customer and the customer leaves. In service economies, its really much more about a coproduction and some of the examples that people use include Public Services like public safety. We dont just rely on the police to provide public safety. Maybe i should use a different example area lets say education so we dont just rely on schools to provide education. We participate in the pda. Wehelp our cohorts so we coproduce education. And in healthcare , weve often been thinking about it as if it were a good read as if it were the doctors deliver Better Health to patients when in factreally about coproducing health. And an example of how we can start to use this mindset or this framework for thinking about Better Healthcare, particularly in the use of Technology Comes from one case study that i talk about is in its application to caring for people who have type ii diabetes. Type ii diabetes is one of the most common conditions in this country and it tends it can be managed in turns out in the home setting. As you know with type ii diabetes, the primary interest is for people to be enabled to manage their blood sugars and if they can manage blood sugars well, they can live long and productive lives. It is a risk factor for diseases like covid so its more important for diabetic patients to be able to manage their blood sugars for Better Health overall. Our company has a product called in duo and i will describe this product that i know better than others but i will say there are other products like it on the market and its consists of a combination of technology as well as i think really inside into patients psychology and a technological way of coproducing health so the technology starts with a continuous monitor, they device the size of a key bob where it goes in there arm or on their abdomen and it basically measures your blood sugar 24 seven so instead of picking your finger for a drop of blood to measure blood sugar you focus the lights on in the signal to end app on your phone you can actually see your blood sugar tracing continuously area and the most important factor is that it affects your blood sugar is your diet and we tend to ask medications to keep a food log which of course they never do because who wants to record all this. And so instead of doing with this app you can take pictures of your meals and snacks so now you can actually make a visual association between the food youve eaten and actually see how it impacted your blood sugar going up and down as well as exercise for example. If youre having trouble making that association, the Artificial Intelligence in the can make some insights for you so for example if i just cannot resist that fudge brownie, on wednesday evening , the accent can say ive noticed that fudge brownie, not so good. Maybe hes in half or instead of waiting its finger at me say if you beat that fudge brownie this is what it didto your blood sugar the last three times. Theres also the ability to test and to even do telehealth, videoconference with a physician which is of course now increasingly important in the covid environment where we are nervous about going into clinics so the commendation of having the technology and having it really be personalized to the individual. Enables them to really coproduce their own health or mostly producetheir own health. Its much more costeffective and it can be accessible to people in urban areas or in remote areas. This was just one example of telemedicine and digital technology, Digital Health. Other examples that i talked about include pregnant women who dont necessarily need to see a doctor in person. Every 2 to 4 weeks most of that can be done remotely. Significant advances in Mental Health and depression offerings through digital Health Technology and it is one of the Silver Linings of covid now that many of these technologies are starting to be covered by insurance. But i think this is an example of again, how we can see opportunities to Leverage Technology toimprove Health Outcomes and cost of care. So lets stop there area those were just a few ideas that i wanted to share from the book and maybe turn out to see if there is some questions that i can answer. So lets see. So ill just read these questions. So the first question is we are currently hearing lots of stories about how bad this current pandemic is. Economically for hospitals. Its so strange to hear about healthcare workers being laid off or furloughed during a Health Crisis but the funding model you describe would do a better job of keeping the Healthcare Industry afloat in a pandemic like this lesson mark absolutely. That is a really important and wonderful question. So yes. In our current fee for service model, really hospitals and Healthcare Systems are livinghand to mouth. And so while some of them, not all of them thankfully but some of them have their administrative units filled with patients, we know that there clinics and most of the other beds and wards in the hospitals have been empty for the last couple of months so our hospitals have because of their feeforservice model of care have really been teetering for the last couple of months and i think april they have showed that almost 1 and a half billion of care workers who were laid off or furloughed in april alone and im sure we will be getting our may date soon. Systems like the Medicare Advantage programs that i described janet mentioned, i followed up with them in the last few weeks, ask them how they were doing in this pandemic and christian said to me, its being paid this sort of fixed amount of money per month is almost like a subscription, like a gym subscription model. We get paid no matter what so weve been able to use some of those payments to actually make sure that they can provide care to their people even when their seniors are sheltering in place and they set up even an urgent care facility in there clinics so that their patients could, when they need to be seen know that they didnt have to go alone. Thats outpatient clinics. On the hospital side, probably the best example of where this same kind of model thats more secure and less dependent on the four service would be our hospitals like the military Health Systems and the va hospitals. Those are all paid on what we call the global budget. They get paid a fixed amount of money to care for all the folks that are in the military Health System like the va system. And as a result also been much more resilient during this crisis. So yes, the answer to the question is moving from fee to service from to some of the different forms, some of the alternatives of payment could create a more resilient Healthcare System thank you for that question. Clicks next question. Are there other nations that follow this before Health System instead of a fee for Service System. Thats a great question. Most of the countries that we admire, the most are follow more of a fee for health model. In a fee for service model. So so theyre all different and i talk a little bit about them in the last chapter of the book. Some of them are completely government run like the nhs in the uk where the government run by hospitals for the most part although they do have some private health and the government pay for most of the doctors except for little private insurance business. The government runs a benefit program. Which is the insurance government run program there. Others actually use a mix of private and public sectors like switzerland for example. But in all of those cases, there is a core offering of health that is really essentially a fee for health model and thats one of the reasons why i think many of us in the us feel that we have a lot to learn from Healthcare Systems around the world and while its nice to be unique, in this particular case i think theres, we are spending on average about 2 and a half to 3 times as much for healthcare in the us as others in canada, in the uk, in france and germany. Even switzerland, in japan and our outcomes are far worse. So i think we have a lot to learn and this is one ofthe reasons why we areoptimistic that before health model is much better than feeforservice. Thanks for that question. Lets see. Will this apply to a wide variety of Healthcare Providers and looking to be a dvd and have recently discovered that many in my intended practice are moving to cash only systems. I would like to work in a different setting than that. I know part of this is because of lobbying and validation care type to the church. This is an interesting question and the dpt i assume means a physicaltherapist. And if ive got that wrong, right another question it. And so i guess i would say that in the Medicare Advantage models and in the models that i talk about at a hospital level system like the military Health System or da system where there paid a global budgetfor a fixed budget , and those systems it applies to all the providers. So all of the healthcare professionals. The Medicare Advantage doctors receive the payment from medicare and then they spent the money, yes, doctor of physical therapy. Thank you for verifyingthat. So the doctors in the Medicare Advantage clinic would be paying the physical therapist to try to keep them healthy. And to try to keep patients healthy for example. And i love the fact that youre a physical therapist because one of the areas, one of my pet peeves and one of the examples that i call out from seattle for folks at the virginia mason Medical Center is the work theyve been doing with employers. 15,000 per employee per year for healthcare. One of the things that this whole group as employers in seattle did, like cosco, nordstrom, starbucks, they banded together, and they tell the story in the book, they banded together to demand a virginia mason that virginia mason provide lowercost and Better Outcomes to their employees. The actually said we only want 100 satisfaction. We want to get out employees back to work. We want you to get out employees back to work and we want to know what its going to cost and want it to be consistent. One of the pet peeves was when our employees have back pain, unless they have neurologic symptoms, complicated back pain, but if they have straightforward back pain they ought to be getting physical therapy and not going straight to the mri, which is what i do, and straight to the back surgery. Theres a huge role for physical therapy and allied Health Professionals in this paying for health world. Some glad you want to become a physical therapist. Im excited about that. Okay, the next question is how is the patients level of healthiness determined in in a system like Medicare Advantage . Has there been disagreement about how to judge how syncopation is . That is such a terrific question. Anything that involves money usually is something that is the source of dispute. So the short answer is, there are disagreements about how to categorize, how healthy a person is, but we have reached a standard way of calculating it, which is really around what we call in healthcare risk adjustment. There are definite ways to do it better. There are definitely some people who may game the system is a bit and, of course, medicare tries to prevent that from happening, but we do have ways of estimating it based on the patients diagnoses, how many diagnoses they have, and other measures basically based on their medical records. So thanks for that question. Okay. How do we empower people to be healthy and not depend on pills to treat them which would lower healthcare costs for everyone . Yes, i agree with that. Actually this question reminds me of a point i think is often important to remind people about, which is in healthcare, if were fortunate enough to have our healthcare covered by our employers or covered by say the government, i think sometimes we forget and we believe that the cost of healthcare are not really our problem. Because maybe we go and see a doctor and we have a copayment 20, 25 or we get a a prescripn filled and made we only have a modest copay around that, if were lucky. What id like to remind people that all of us are paying for this exorbitant health care in this country, again like i said where spending 2. 5, three times as much per person for healthcare as most of our european, canadian peers, for example, australia and so on. We pay for it and at least three different ways. We do pay for it in our out of pocket cost, copayment and are deductibles, coinsurance which is the percentage of our hospital bill, for example, that we might have to pay. Those outofpocket costs for employees have been inching up yearbyyear such that right now employees are paying about 30 of the Overall Healthcare bills. So the employers are paying a smaller percentage we do pay outofpocket. Of course with a a lot in our taxes for medicare. We see that actually in our paystub but also from medicaid and other government run healthcare programs. The third, the most insidious way in which we pay for healthcare is that its coming out of her wages and we dont even realize it. If you look at the data from economists, action issues in the last 5060 years for the average american, wages have essentially stayed flat. Even though the American Economy has grown considerably in 5060 years, but instead of us seeing that in rising wages, most of the difference is going to cover our healthcare costs. So instead of paying is more, employers are using their increased earnings to simply cover our healthcare. Its not even just our healthcare for today. One piece of data i discovered when i was working, doing research was that employers are actually even taking money out of our retirement money. What would it been in the past gone to our retirement funds, its actual also being used now increasingly for covering our healthcare today. So we are paying for it multiple times over. Empowering people to be healthy, i think that its very important that physicians, Insurance Companies, hospitals, that we are all aligned around Peoples Health being the most important thing. So in these Medicare Advantage programs that i described, those doctors want you to be as healthy as possible. Another one of these groups has these Medicare Advantage contracts, their physicians spend a lot of time doing prescribing. We hear a lot about prescribing, recommending more medications and so on. Turns out about half of all americans are on at least one medication. And of those on at least one medication, on average were on four. On average the people who are on medications are prescribed italys four medications. The founder tells me stories about how the stations will come in with literally baskets of these comodels. Their doctors will sit down with them because as you can imagine they have gone to see different specialists and every time they got prescribed a couple more medications. These Health Doctor sit down and d prescribed cassation of these medications are not without side effects and cross reaction when you take them altogether and theyre just confusing to keep on top of it. So they d prescribed which no one went into a lot of good for these patients and for the healthcare cost exactly as you point out. And i should also mention that the kinds of Digital Health Solutions Like the virtual diabetes clinic that i described, is as effective in keeping peoples blood sugars under control as medication. So as we can develop more technologies that can enable people to eat healthier diet but to know what is healthy and to realize what theyre eating is affecting their bodies in certain ways and have how that information just like they do with the blood sugars or for example, Blood Pressure the more people can eat healthier diets and live healthier lives, also the less dependent they will be on medication. And all of that would definitely lower healthcare costs. Okay, we are almost out of time but lets see. The last question that i will answer which happens to be the last question up, is in the medicare type Advantage Program how do you keep practices from cherry picking patients or ones without preexisting conditions . That is a very savvy, very smart question. The truth of the matter is that are definitely stories, like in every other industry, healthcare has its own share of bad apples. And there are stories of what people put their Medicare Advantage sign up clinics on the third floor of a walkup building so only those who can climb the stairs up can sign it. I dont know if they are true but i definitely heard those stories. The way Medicare Advantage works though now is that the earlier question for some estimate risk adjustment is trying to combat this. The government is probably in some ways even overpaying. I dont know, i probably shouldnt be quoted as saying that but there paying quite generously for patients of multiple chronic conditions and who are more complex, just to prevent this from happening, just to prevent physicians from avoiding sick patients and preferentially trying to treat healthier patients. Thats how theyre trying to do that now. And lastly, i know is going to to finish but i love this question. Based on what you discussed i i would say as we had home x class in the past, we should have comprehensive nutrition lifestyle class in all public high schools. I will end my q a session by saying, yes, i totally agree with that. I think we need to focus on nutrition, lifestyle, how people can actually the military has embraced this, how people need to sleep more, exercise more and eat healthier diets and i could not agree with that or, thank you very much. Thank you for the chance to being with you tonight. Really enjoyed it. And on behalf of townhall i want to thank everybody for tuning in this evening and again thank you to dr. Lee for this wonderful discussion. If you enjoyed this event you can find many more like it on our website town hall seattle. Org. We hope youll consider making a donation to town hall seattle. Your support will allow us to continue to provide events like the one you just saw. If youre interested in purchasing a couple of this book, the long fix, please use the links on this page to purchase through our friends at third place books. Finally, thank you again for being here tonight. Have a great evening, everybody. During a a Virtual Event hod by st. Louis Left Bank Books Bakari Sellers recalls his childhood as a son of the civil rights activist and his experience as south carolinas youngest state representative. Heres a portion of his conversation. When you knock on doors you want this resolved. I knock on doors with Confederate Flags, you know because i really wanted to be people where they are. I had to simply that no matter white, black, democrat or republican that you wanted to have a Grocery Store in your community, that you didnt want your grandparents having to choose between whether or not they were going to pay their the utility bills or get the pharmaceutical drugs. We went through, what do these steps to mama i could literally change the lives of people, i wasnt yet jaded by reality and im proud to sense send still t jaded by that reality. In walking in a house, i was educator son, i was walking to a statehouse where its the same state that put my family through so much trauma. I was there to help change that, putting a face on that cared and the systems of injustice from within. I dont how successful i was at that but i tried my damnedest. So there was that sense of being a young that everybody looked at me, because i was 21, 22 and i was the youngest i like a decade so administering at you in the first time you open your mouth there want to see which are all about, who is this young black guy from denmark who is the son of a civil rights hero . And i dont think people really remember, but when i was elected every day i went outside when i was having a rough day, thickened Confederate Flag still flew proudly in federal or state capitals. Visit our website booktv. Org and search for Bakari Sellers using the box at the top of the page. Coming up on booktv, english professor donna harringtonlueker looks at the rise of some reading in the 19th century, and former acting attorney general Matthew Whitaker argues insiders at the Justice Department tried to subvert president trump. That all starts at now. Check Program Guide for more information here. My name is gavin kleespies, and director of exhibition and Committee Partnership for the massachusetts historical society. Our program is seasonal. It is a look at the tradition of summer reading. Were joined by professor donna harringtonlueker who bespeak a new publication books for idle hours nineteenthcentury publishing and the rise of summer reading. She is a professor in the department of English Communications at Salve Regina University in newport, rhode island. Shared undergraduate degree from Merrimack College and a masters and phd from university of illinois at urbanachampaign. As a former magazine writer