Transcripts For CSPAN2 Dr. Vivian Lee The Long Fix 20240712

More television for serious readers. Thank you for the support of our sponsors. The true Brown Foundation and the waco foundation. It is a member supported organization and i would like to thank all of our members watching tonight. They are under significant strain. We hope you will consider ascending new generosity with this time. Our partner book sellers that you might know as well. Its certainly going to be interesting with going paper. With going paper. He has been a healthcare administrator for over two decades. Among the leadership roles dr. Lee has served as the chief scientific officer. At the medical center. She was the vice chair for research in the department of radiology. She served as the ceo of utah health. Among other roles. She was elected to the association of american medical colleges board. The university of pittsburgh medicine. Speaking of other publications we spoke with an academic page turner i am told not for the faint of heart. In the 15 years ive been on that job. That was the first and terribly joke that ive ever told. It has brought up together tonight. Along fixed. Solving the crisis. Please join me in welcoming dr. Vivian lee. Thank you so much. Its really wonderful to go to you tonight. Really looking forward to healthy and hearty set of discussions. There are some complex times. Im in a speak for about 30 minutes or so and then i will welcome the questions. For this time of what i would talk about. Questions first what you wrote this book. In the main premise with the 12 chapters i thought i would dive more deeply into two or three topics depending on how much time we have. Let me start with why i would write this book. In a series of presentations i have made to our broadway medical students when i was that dean of the medical school at utah. The first year were fresh out of college relatively new to healthcare. And i really wanted to share with them what i wish i had known before i have gotten into healthcare. I wanted to answer the questions they head about how healthcare works and to prepare them for how they could really make a difference when they were beyond the practice of medicine and experience of working within healthcare. One of the questions i wanted to answer was the same questions i got the alphabet healthcare company. I have met a number of really talented great product managers. And they were also all try to understand how this very complex system we call healthcare works and how they can make a difference. I think we all know in the news or for my own personal experiences that there are many components of healthcare that feel broken with the rise of costs for medication. The lack of insurance. What we hadnt heard so much about our the solutions. And as i had worked in healthcare for over two decades and traveled around the country i never got the chance to share how they were new and different ways of providing healthcare and paying for healthcare and how theyre working really successfully. In sharing those Success Stories i found that i was able to reap weve together those narratives. The clear sense of how we can extend those solutions into a National Strategy for healthcare. Thats really why i wrote the book the long fix. I think that something we very desperately need. It was called the long fix because of the clarification that i have was a former secretary of the health and human services. The trajectory of change in healthcare a might be in the middle of one of these. Since the covid19 pandemic and feeling im feeling theres a much greater sense of urgency the long fix might be a slightly quicker fix. Look into how the book is structured and what i talk about. I start by laying out the fundamental print premise premise of the book. The central problem in healthcare but really about how we pay for it. Its really the economic way of healthcare. If i was to prioritize just one thing its really changing the dynamic of that model. Not so much who is paying for the healthcare a lot of the discussions should we have medicare for all. Who is paying for than the individual level. From a policy perspective i think its really more important for us to solve what is that we are paying for in healthcare. Really how are Healthcare System is really focused on pain for action procedures we call it a safer Service Healthcare program. It would create a completely different set of incentives. And if we did that i will talk about example of where that is happening in our country today. To Work Together instead of in conflict as mortal enemies. We will talk a little bit about that as well. Theyre already happening in the country where we are pain for Better Outcomes. In the second section i look at specifically how Healthcare Industry would act very different in this model. It was motivated like almost any other industry in this country to actually compete with Better Health. In delivering value to its customers. Instead of just doing procedures as we head in our current system. I start with safety and talk a little bit about how hospitals can learn from other industries to the aviation industry. To make healthcare safer. I talk about the Critical Role that doctors play and how our Healthcare System works. It was a motivated personality can in even reduce the cost of care. Patients might actually move into the center of the unit healthcare business. Their health would be driving the Business Model of healthcare instead of today where those are the ones with the physicians that generate that in the paper world. On the data and technology sectors. And tell stories and reflect on what they could be doing differently if they were competing to make people healthier at lower cost. And then a system that actually provides big picture news of how our Healthcare Systems look completely differently. With the two biggest pairs of healthcare in our country. The foot of the healthcare bills for about half of all americans. Instead of talking about the medicare and medicaid i talk about the military Health System and we use their systems to shed light on how government run healthcare could actually pay for Better Health outcomes and produce better results and lower costs. It really summarizes the action plan. Each chapter is filled with narratives in each chapter ends with an action plan for what individuals can do. The structure of the book and the content of it. Now just to add into a couple of ideas that are in the book and see how much time we have. I will talk through two or three ideas. The one big thing. In the course of researching this book i interviewed over a hundred different people in healthcare. The Patient Advocates Community Workers and i asked them one what is the one thing you could change in healthcare. They said the same thing. They said but i also believe. They would change the Business Model of healthcare. Our current model we refer refuse to look at. Its basically paying for action. Our current model Healthcare Providers they are pain paying for doing things to people. Operations procedures regardless of whether it approves health. The Health Systems and physicians are really incentivized to do more and more things to people and to document that theyre doing more and more things to people. Instead really we should be expecting as consumers to really only pay for care when it improves health. Even if that means not doing much of anything that is ideally how we should be thinking about it with our Healthcare System when i say that private insurance and the government also is paid in a feeforservice basis. It is still medicare. Our Healthcare System are the things that generate fees like imaging centers. Like cancer centers. They are absolutely essential which are Public Health and primary care. It doesnt really generate any fees. We have a some of the best Healthcare Facilities in the world its because we havent invested in the things that dont generate fees. We havent managed to do that. When we have a showing dollar healthcare trained dollar Healthcare System that is focused on making itself a four or 5 trilliondollar business. To do more things to people. I would stop and say that i believe most physicians and clinicians are really trying to do good. They are trying to practice the best healthcare that they can you just head to acknowledge that the economics are sense that they air on the side of overtrading. Our legal system only further supports that. We have hospitals and doctors who are incentivized to do more and more. So the people paying the bills the payers the Insurance Companies the government the spending and procedures of overdoing for the Insurance Company that means saying if the dr. Recommends an mri if they are recommending that. The Insurance Company can manage the cost. I dont think thats authorize or necessary. With prior authorization. In order for that study to be done and paid for. Its just really a barrier. An enormous amount of work. Insurers and payers in diet dividing that. Its a trillion dollar tugofwar. At the end of the day in an enormous administrative waste. About 8 of our healthcare dollars on administration. Most of our counterparts spend 3 . That is a huge amount of waste. The money that is not paid for falls to the individual. Thats what we call surprise billy. As you can imagine it also generates approximately 25 to 30 of our healthcare in our countrys three and half trillion dollars is considered waste. When they have discussion about how we can extend health care to all of those who are underinsured there are clearly opportunities in terms of being able to recover some of that waste. The implications of having this. Its what i call flying into the headwinds of capitalism. Instead of innovation working towards a better Healthcare System they are really focused much more on doing more and more even if its wasteful. We need to think about how we can evolve our Healthcare System into a model where we have the terrorisms many of us who are in healthcare. And the goal of success. As in a pilot project. And now expanded into Medicare Advantage. It is a the Health System for seniors. It is a subset of medicare it covers about a third of our medicare patients. And within the Advantage Program there is a special model where the government actually contracts with medical groups and says to the medical groups. Working to pay a little bit differently. We just need to keep seen patient after patient. Working to give you a fixed amount of money for all of the patients in your practice for that year. Its cannot depend on how sick the patients are. If theyre generally there generally Pretty Healthy the pay a little less. Its really up to you how to spend those dollars organ a track how healthy your able to keep those patients you have to keep them healthy otherwise there are penalties. These patients can take their business elsewhere. If theyre dissatisfied with you. What happens in these medicare Advantage Programs. They have now expanded to about 70 clinics across the country. There are many of these now across the country they give a little attitude. They have a fixed amount of money to keep people healthy. What happens is if they are able to keep people healthy and they start less than medicare gave them for that year. If they end up not keeping the patient healthy. Going to the hospital and emergency room. Multiple times they can actually go into a deficit from doing that. I talk about that. And how our health is in the book. The dr. Spent a lot more time with the patients. They know that these often have multiple medical conditions and they need quality time with the clinician. Instead of eight to ten minutes they spent 30 minutes to an hour with each patient. They had Shuttle Services they offer yoga classes as part of their Fall Prevention program. In the long run while they spend a lot more money and time upfront they see more of the savings to make up for that. Theyre keeping their seniors healthy. And actually there is some of the most Resilient Systems because they have a set amount of money. Theyve actually been able to stay open open and functioning during this crisis. Theyve had to laugh at doctors and nurses. Thats an example of a new model. And when i talk to seniors and others i really recommend that they look at clinics for these types of services. The second topic i wanted to talk about which i havent been really speaking about much. A very important thing to me which is really the issue of safety in healthcare. It may be surprising to you right now we had been hearing a lot about the struggles of the hospitals. Aside from the coded patients. Even when they are full. It may surprise you to hear that there not always the safest piece place to be. One of the most heralded organizations in this country. About 20 years ago they put forward a report to air is human. And they estimate it at estimated at the time this is 20 years ago that about a hundred thousand americans each year were dying from medical mistakes hundred thousand. In america we just crossed 100,000 lives lost to covid19 this year. But ever were. Since then their efforts have been revised upward. No one wants medical mistakes on the death certificate. Sony research has actually suggested that between 250,400 thousand people each year. That would make it the third leading cause of death behind cardiovascular diseases and cancer. The statistics are really shocking. When you think about hospitals you think about places that are sterile and clean and organized. In this chapter i talk a little bit about where some of those mistakes arrive and what we could do to really address some of them. One of the most common causes his medication errors it has estimated that every time a hospital administrator. Its about a 25 percent of one clinical error. I think it was given more or less than 30 minutes around. There are times when there are significant and serious errors. One of those cases is because the names of many of these medications can be very confusing for example it is an arthritis medicine. Its seizure medication. And one is called celexa. They sound almost the same. You can imagine getting them confused. If you go on and search. The fda and institute for medication practices actually publishes online dozens of these look like and sounded like names for drugs. And what they recommend if you have multiple confusing names. Three of those letters when you write out the prescription they would put three of their letters in ouppercaseletter we could differentiate. There is a clear obvious solution to that. That they could actually prohibit them from making names for drugs that sound like others on the market. That is one reason why many medical mistakes happen the other is interruptions and distractions. Distractions interfere with performance. In the book i talk about a rather tragic story of a nurse that was caring for a patient. On average they are disrupted during medication rounds. They are interrupted about every six minutes. Many things that are going on. I would talk about some examples of how they have really adopted best practices from other injured industries. And the rules in the cockpit of no chatting. No distractions. In the implementation of some of these practices in the healthcare environment are certainly improving practice. Especially in the operating room. They wrote an excellent book called the checklist manifesto. The third area of medical error and the related issues really comes i should say the third perspective about it is really now practiced in the risk of malpractice in the fact that many of the fears that are associated with some of these medical mistakes to lead to the over testing and overly cautious approach to healthcare. As many 50 of studies have been considered unnecessary in just reflecting those senses. I talk about nofault insurance models. Its really interesting. It started where there is something that does happen to patients they can file claims and essentially there is a Government Fund that are used to pay to cover those costs. And we didnt even have to show negligence for these families to be able to collect funding. Interestingly. Many people are aware that in the u. S. We actually had two seats virginia and florida. They havent nofault insurance plans. They have shown that they are comfortable with payouts. Considerable savings to society. Im just about to the 30 minute mark. Maybe three or four more minutes left. A third topic that i would like to share from the book. And this is really a topic about individuals and how we can contribute to the long fix and we can learn about our own health. We can make our Healthcare System note more effective. The idea that i want to share is this notion of coproducing health. Those of us who have lived our life and Health Care Profession as a ceo of the healthcare profession. The educator, we really think about healthcare as what happens within the four walls of the hospitals and clinics. Which assisted medical school as well. The vast majority of the Overall Health is really determined by what you do outside of the hospital and clinic its really based on what you eat and how you sleep and exercise what you inhale. Those of course are very much in our own individual control. This idea of how Health Systems and individuals Work Together to coproduce health. It actually comes from an economist at stanford. Who wrote a paper in the late late 1950s about the economy with the u. S. Economy from manufacturing or industrial economy to the services economy. He talks about how an investor the suppliers tend to produce their goods. And then they sell it to the customer. And they basically handed over to the customer. In these economies. Its really much more about the coproduction. Public safety. We dont just rely on the police to provide public safety. Lets say education. We dont just rely on schools for education for our kids. We help our kids with homework. We coproduce education we were thinking about it as if it was good. As if they deliver Better Health to patients in fact its about coproducing health. An example of how we can start to use this mindset or framework that were thinking about. Particularly in the use of Technology Comes from one case study that i talk about its the application to care for people that had type two diabetes. As one of the most chronic conditions in this country. It can be managed it turns out in the home setting. As you know with type two diabetes the primary interest is for people to be able to manage their blood sugars. If they can manage them while they can live productive lives. Its ever more important for diabetic patients to be able to manage the blood sugars. They actually have a product and i will discuss it because its one that i know better than others. There are other products like it on the market. And it consists of accommodation of technology as well as i think insight into patients and psychology in a technological the technological way of coproducing health. It is a device the size of a key five. It goes on your app. It measures your blood glucose 247. It turns into an app on your phone where you can actually see it continuously. The factor that considers your blood sugar. We ask them to keep a food log of course they never do because who wants to record all of the things that they eat. With this app you can just take pictures of your meals and snacks. You could make a visual association between the foods that youve eaten and see how it has impacted your blood sugars going up and down as well as exercise and sleep for example. If you having trouble making the association. So for example if i cannot resist that fudge brownie the app can say hey, weve noticed that fudge brownie. May be cut maybe cut that piece in half. This is what it did to your blood sugar the last three times you did that. There is their ability to text a code into even do telehealth and video conference. It is now increasingly important in that covert environment. Where there nervous about going into clinics. And then it enables them to really coproduce their own health. It can be assessable to people in urban areas. This is just one example of telemedicine and Digital Health. Other examples that i talk about include pregnant women who dont necessarily need to see a dr. In person. The advances and mental health. And Digital Health Technology Many of the technologies are starting to be covered by insurance but i think this is an example of how we can see opportunities through other technology to improve that. Lets stop there. This is just a few ideas that i wanted to share from the book. Maybe we turn now to some questions that i can answer. I will just read these questions allowed so the first question as where hearing lots of stories about how the bad of the current pandemic is. Its so strange to care about healthcare workers. With the model that you described you do a better job of keeping the Healthcare Industry afloat in a pandemic like this. A really important and wonderful question. In our current feeforService Model. While some of them have their intensive care units filled with patients who had treated to most of the other beds in the hospital had been empty for the last couple of months. For the Service Model of care has really been teetering the last couple of months and i think in april they showed almost one and half million healthcare workers were laid off in april alone. The systems life and medicare Advantage Program. I actually followed up with them in the last few weeks. Asked them how they are doing in this pandemic. They are paid this fixed amount of money. Its like a subscription model. As a result they had been able to use for some some of those payments to actually make sure that they can provide care for their seniors even while the seniors are sheltering in place. They actually set up even in urgent care facility in their clinics so that their patients could come when they needed to be seen to know that they didnt have to go to the emergency room. On the hospital side probably the best example of the same kind of model that is more secure and less dependent on service. Are the hospitals like the military Health System does are all paid on what we call a global budget. To care for all of those that are in the military Health System. As a result they had been much more resilient during this pandemic crisis. Some of the alternative norms of payment they could create a more resilient Healthcare System. Thank you for that question. Are there other nations that followed this Health System . Most of the of the countries that we admire the most follow more the fee for help model. They are all different. I talk a little bit about them in the last chapter in my book. Some of them are completely government run. In the uk where the government runs the hospitals for the most part. They do have some private health insurance. In the government runs the benefits program. Others actually use a mix up private and public sector. In all of those cases there was a core offering of health that was a super health model. That is one of the reasons why i think many of us in the u. S. Feel like we have a lot to learn. While its nice to be unique in this particular case we are spending on average two and half times as much for healthcare in the u. S. As others in canada and the uk our Health Outcomes are far worse. This is one of the reasons why we are very optimistic. Feeforservice versus be for health. Lets see. Will the supply to the wide variety of Healthcare Providers they have recently discovered that many in my practice are moving to the cash only system. I would really like to work in a different setting than that. I know that part of this is because of lobbying and tape shoe insurers. It means a physical therapist and if i have that wrong right another question in. And so this i would say that in the Medicare Advantage model and the models that i talk about at the hospital level system like the military Health System where they are paid a global budget or a fixed budget. It applies to all of the providers. All of the healthcare professionals. They receive the payment from medicare and then they spend the money the doctors in the Medicare Advantage they would be paying the physical therapist to try to keep them healthy. I love the fact that you are a physical therapist. One of the examples that i call out actually from seattle. Is the work that they been doing with employees as i mentioned. Employers pay for health for about half of all americans its a huge part of employer costs on average each Employee Health care for healthcare for each employee in america is about 15,000 per year. One of the things that this whole group of employers in seattle did like cost goes nordstrom starbucks they been together to demand a virginia mason that they provide lower costs and Better Outcomes to their employees. They would expect those consumers. We want to get our employees back to work. And we want it to be consistent. One of the pet peeves was when they have back pain if they have relatively straightforward back pain they ought to be getting physical to be and not going straight to the mri. And straight to the back surgery. In this pain for health world. Im glad you want to become a physical therapist. Im excited about that. The next question as how is a patients level of healthiness determined in a system like Medicare Advantage. That is such a terrific question. Anything that involves money its a source of dispute. There are disagreements about how to categorize how healthy a person is. We have received a set standard way of calculating it. Its around what we call risk adjustment. There are definitely ways to do it better there are definitely people who make a gain on the system. We do have ways of estimating based on the patients diagnosis and how many diagnoses they have and other measures basically based on their medical records. Thank you for that question. How do you empower people and not depend on pills to treat them. It would lower healthcare costs which would lower healthcare costs for everyone. This question reminds me of a point that i think is important to remind people about. If we are fortunate enough to have our healthcare covered by our employers or the government i think sometimes we forget and we believe that the cost of healthcare is not really our problem. Because maybe we see a dr. And we have a copayment 20 to 25 or we get a prescription filled and maybe we only had a modest copay on that. All of us are paying for this exorbitant health care in this country again. We are spending too two and half to three times as much per person for health care as most of our european and canadian peers for example. We pay for in at least three different ways. Copayment in our deductibles. Its called the percentage of our hospital bill. That we may have to pay. Those outofpocket costs for our employees had been yearbyyear such that right now employees are paid about 30 of our Overall Healthcare bills they are paid a smaller percentage we do pay out of pocket. He pay a lot on our taxes. Also for our medicaid and other government run healthcare programs. The most insidious way in which we pay for healthcare is that it is coming out of our wages and we dont even realize it. If you look at the data that in the last 50 to 60 years for the average american wages have essentially stayed flat. Even though the American Economy has grown considerably in 50 to 60 years. Instead of sena and rising wages. Most of the difference is actually going to cover our healthcare costs. Employers are using their increased earnings to just cover our healthcare. Is not just our healthcare for today. One piece of data that i discovered it when i was working and doing research was that employers taking money out of our retirement. In the past we have gone to our retirement funds. Is actually being used for covering our healthcare today. We are paying for it multiple times over. That were all aligned about Peoples Health being the most important thing. Those doctors want you to be as healthy as possible. Another one of these groups that has these contracts a lot of times they are described prescribing. It turns out about half of our americans are on at least one medication. And of those who are on a medication on average are on for. On average the people that had that. The founder of iowa health. They would come in with baskets of these bottles. They will sit down with them as you can imagine theyre going to see different specialist. They actually help doctors. They are not without side effects or cross reactions when you take them altogether. And then youre just simply confusing. In the long run can really do a lot of good for these patients into lower their healthcare costs exactly as you point out. The kinds of Digital Health Solutions Like the virtual diabetes clinic. It is as effective as keeping it under control as medication. As you can develop more technologies that can get people to eat healthier diets. And to realize what they are eating is affecting their bodies in certain ways. Just like they do with the blood sugars or for example blood pressure. The less dependent they would be on medication. In all of that would definitely lower healthcare costs. The last question i will answer. In the Medicare Advantage type program how do you prevent practices from cherry picking the healthiest patients without preexisting conditions. That is a very savvy very smart question in the truth of the matter is there are definitely stories like in every other industry. Healthcare has its own share of bad apples. Thats true. And there are stories of where people put their Medicare Advantage signup clinics on the third floor of a walkup building. So only those that can climb the stairs up can actually go up. Ive deftly heard those stories. The way it works now. The earlier question about risk it adjustment is actually trying to combat this. The government is probably is probably overpaid. They are pain generously for patients that had just to prevent this from happening. To try to help with healthier patients. That is how they are trying to do it now. Lastly i know i was in a finish. Based on what you just discussed. As we head in the past which some would like to have again. I will and my q a session by saying yes. I totally agree with that. I think we need to focus on nutrition and lifestyle. And the military has really embraced this. Exercise more and eat healthier diets. I cannot agree with that more. Thanks for the chance of being with you tonight. I just want to thank everybody for tuning in this evening and thank you to dr. Lee for this wonderful you can find many more just like it. We hope you will consider making a donation. Your support will allow us to continue to provide evidence like you just saw. If you are interested in person purchasing the copy. Solving the Health Care Crisis with strategies that work for everyone please use the link on the lifestream page. And finally, thank you again for being here tonight. Have a great evening everybody. Politics and prose bookstore in washington dc. They reported on the deutsche bank. And the relationship with president trump. Here is a portion of his talk. If they ever become public or not can you show us some of the most important things we want to know about trumps finances. They will not show his business partners. They will not give a real view of his assets available. The things that they have that are much more valuable are going to be the other financial statements. Any documents around very detailed charts. Where all of the money is coming from. They have the documents for a lot of them and they also have documents that show some of the concerns that went on in the accounts. It has not gotten a munch attention as i thought it would. With the compliance officers who raise repeatedly red flags about what they deem to be suspicious transactions. Including in the kushner case. It was never reported to the government in one case the employee was fired after speaking out about it. Visit our website. And searching for david and rick for the title of his book. Dark towers using the search box at the top of the page. Look tv is television for serious readers. All weekend every weekend join us again next saturday beginning at 8 00 a. M. Eastern for the best nonfiction books. Cspan has unfiltered coverage of congress, the white house, the Supreme Court and Public Policy events. You can watch all of cspans Public Affairs programming on television, online, or listen on our free radio rap and be part of the National Conversation through cspans daily washington journal programs or through s