Costs and got provided guidance to consumers. Shes interviewed by doctor david blumenthal, president of the Commonwealth Fund. Its a pleasure to be here with you. I want to congratulate you on an incredibly readable review of our Healthcare System and proposals. I have a ton of questions based on my background as a physician and of course as a id like to ask a couple questions for context and why did you write this book and why did you write it now . I had worked for a couple years on a series with the New York Times. I first got the necessaries from the Commonwealth Fund to learn a little bit more about our Healthcare System and it had gotten expensive and then during that series we solicited a lot of stories through social media and at the end of the series 2 years later i had this bank of kind of patient stories, people who were smart and for the most part the New York Times reader just hadnt been able to make the system work so that was one aspect to another aspect was in the newspaper series you take off little parts of the system and examine them one by one and as so often happens as a newspaper reporter by the time youre finished you realize that you just kind of scratched the surface and i felt like i needed to know in that series we show how prices have gotten high and looked at some of the factors but i really wanted to understand the evolution about process because as a physician, who trained in the 80s and as someone whos in that decision i knew healthcare have always been that way. Guest i dont want to say by accident but i always loved both writing and medicine. My family has a lot of physicians in it and id always done a lot of free lance writing on the side. The irony of this book and my career is in the early 90s i was working in an emergency room in new york and in an emergency room at that time i felt the Health System already wasnt working very well for people who were poor or uninsured. It was largely working pretty well for people like me, who had good insurance. So there was something in the early 90s call the Clinton Health reform plan, and the times asked me if would like to write about that, and i assumed i will come, be a journalist for a few years, write about that. And then that will pass, ill can go back to being a physician, and of course it didnt, and i didnt, and here i am, more than 20 years later talking about the same issues or steroids. The system has kind of spiraled out of control, especially in terms of its costs and prices, and as we all know, without Getting Better results for patients. Host so, before we get into the substance theres a lot of substance to talk about one thing that is very special about your book ive read a lot of books about the Healthcare System is the way you ground it in stories, stories about doctors, stories about patients, stories about hospital administrators. You have lots and lots of stores, all very detailed. How did you get all those stories . How did you what caused you to take that approach . Guest well, yeah. This is something id learned from my years of journalism. Obviously my first story was about bone marrow transplants and i realized from that moment on it kind of became a mission, whatever i was writing about, to understand how it affected real people. So, even when i was covering climate change, i would get a nice family who had been impacted by climate change. So i think thats so important. Id read a lot of Health Policy books and stories and i also read the stories about the Million Dollar bone marrow transplant, and i them the way most readers see those is they say, wow, thats really terrible, or i dont understand the policy. Thatster is heartbreaking but i hope i dont get that kind of cancer or hope i dont insist of everything the end of life. What i tried to do in the series, and again with the book, is to make that connection between all these kind of acronyms and obscure debates going on in washington and how it affects you on the ground. This is really an issue that plays out on our wallets our bodies in our living rooms and our kitchens, and so the people in the book i mean i was very fortunate in this age of social media, most of those people came to me and said, i want to share my story. And they were tremendous volunteers and vehicles for making readers and happening readers helping readers to understand this is about you, and theyre great characters. I often feel like i want to have a kind of dinner party or club of everyone in the book because they were fun, interesting, thoughtful people, who talk to, and i hopes as readers read their stories, theyre are compelling stories actor little kafkaesque and absurd but they drive the narrative in a way i hope will get people to understand a lot more about the kind of backend policy and economics without suffering through the kind of diagrams and the charts. Raid because im a Health Policy wonk but most people dont have an appetite for. Host of course, doctors are about their patients stories, arent they . Guest in the end, one of the things that really, like, struck me as i was researching the book, is like many of white house have watched health reform, i repeated the phrase, 100 times, about were looking for patient centered, evidencebased care. And then at some point i step back when i started researching the book and thought, wait a second. What other kind of health care could there be . This is about patients and if its not patientcentered and evidencebased, then its terrible care, and i think what i learned in researching the history is that too often the finances are on the front burner and the Patients Center and Evidence Base is on the back burner average thats the shift id like to say. Host you organized this book in a very doctorly way and started by talking about the problem, describing the problem, what we in medicine call taking a history, the history of the present illness and then went on to offer some diagnoses and then went on to offer therapies and those are the way doctors organize their interaction with patients and their problems. Id like to take our viewers through the three segments. And maybe you can start by describing the problem. What is the american sickness that is presenting itself to you. Guest i think i was a new york doctor so the chief complaint, as we said, was its high prices. Its high prices and Unaffordable Health care. Dont think anybody, republican, democrat, independent, libertarian, would disif a free with that. Disagree with that. Host how did we get to these high prices . Whats the diagnosis . Guest well, this is where the kind of history of present illness kind of has to spool itself out, and i think what i realized as i was digging into that is this is kind of a classic case of, the road to hell is paved with good intentions. So at each step of the way in the history over the least decades, you see a new idea come in that was a good idea, and then it somehow gets kind of perverted as a kind of how can we make money from this . So i think people have often said the problem is the middle of the last center a lot of people got Health Insurance. That is not to say that Health Insurance is a bad thing. We need it. That was because health care was get more expensive, historical reasons which i dont want to good into here. So we end up with a lot of people on medicare or employerbased insurance. For those of us who have been lucky enough to have Health Insurance, in those days your Employer Paid your premiums and you had very little in the way of out of pocket costs. So what happens if youre kind of entrepreneurial in businessminded under that setup . Nobody is paying. So in my dads day, an office visit would cost 10. Once it feels like nobody is paying, maybe that becomes 100 and maybe 200. And then at some point i would say around the 80s and 90s, Business People start coming in to health care and saying, what will the market bear . What could you charge for that . And then when it was just the physician and his office he was still homecoming 0 her office what does this mean for patients . What is reasonable for health care . When the Business People start coming in sometimes its as direct as consultants from delight mckenzie being hired by hospitals and consultants come in and they not medical people. Dont know what is the best treatment for your liver failure or your pneumonia. Theyre thinking, how can be squeeze more money out of this system and make more efficient . And the answer they come up with over and over again, which is kind of these answer for squeezing more money out, just bill differently. Do the exact same thing you have been doing, but you can charge a lot more for it because it feels like nobody is paying, so suddenly you see charges come in, which are what was 200, may be 2,000 and then layers of administrators and mbas a come in. When we were in hospitals, many of the ceos were former chief physicians, medical people. They didnt have much business training, and of course, as a result, hospitals were not very efficient. They could have used a little dose of efficiency. But somehow the kind of we went over a boundary where business became primary and the Business People became primary and the medicine became secondary. And what you see at that point is many of the physicians this where is it moves to the physician question say, they get resentful and understandably so. They think, here i am doing all this work, doing this surgery and seeing the patients and im looking at this layer of 20 administrators with mbas who are all making a Million Dollars a year. I want more. And not all physicians do it but many get into the entrepreneurial spirit, others get angry and resentful theyre being judge not by how well they take care of patients but by how much revenue the generate, how much money they generate from the hospital and they start being compared with their fellow physicians, and again, this is the logic of business. Who is generating more revenue, and maybe youll get a bone fuss if you ben news if you bonus if you generate revenue. And you see the value of business which is efficiency, revenue generation, revenue max jimmization, and push out, can i extend time with i patient . Can i understand the problems . Aim being sensitive to his or her needs . Are my infection rates low . Hospitals know much more about their rbus and billing cycles than infection rates. Was shocked this week when i saw that centers of excellence for bariatric surgery have widely varying rates in their complication rates, and even though the certifying organization for those complication rates for those centers know what the complication rates are, patients cant know them. Now, that seems crazy to me if were asked to be a good consumer. We kind of deserve that information. And its our health, after all. So, anyway lets move on. To talking about when youre already beginning to deal with and that is the treatment, the solution to some of these problems. As you have pointed out, some of them are valuebased. You have a lot of suggestions. One thing that i think very special about your book is the extent to which you spend time on prescribing things for people and for the system. So could you say just a top few top lines about how you think we should go about reversing the problems you have described. Guest well, i think if we wait for a solution to come from washington, we may be waiting for a very long time. I want to say that i think the Affordable Care act i always have to say it didert important things for our health care in that it covered people with preexisting conditions as a reasonable cost, which is in the balance again. It covered 20 more million people. It put an emphasis on value. Put that kind of whats good for patients kind of back in the bulls eye, and it also kind of i think an important way changed the notion of should government think of this as its responsibility to help people get good, Affordable Health care . And i think you ask why now . I think its a crucial time because i think many patients are kind of at a Tipping Point where they really just cant afford this anymore. So i hear from people who are spending 2030 of the Household Income on health care. The preinsurance and minor medical bills, thats more than food, more than housing, not going on summer vacations, having trouble sends kids to college im tragically hear from people who are leaving the u. S. Because they have an illness like theres someone the book who has type 1 diabetes. She is a grad student and only looking for jobs outside the u. S. Because even with good insurance, she is worried she wont be able to afford her disease. And i think that is not just an american sickness. Its an american tragedy. Thats really sad. What i do with the book and aim to do is to help people understand that if there are solutions, theyre stepbystep solutions as we see the Healthcare System got be writ is in a kind of stepwise fashion, and likewise, we can start reeling it back in a sevenwise fashion and stepwise fashion and part another that is what individuals can do. Little things they found silly but they work. Ive used them. Became the bill troubleshooter for everyone in the newsroom the New York Times. And so i have used these things and got an lot of bills reversed, reduced, and negated. So, one thing i tell people you have seen patients, you know his works. Its uncomfortable for doctors when patients do this but when i go see my physician, when he says, maybe we should get some blood tests, i feel okay about saying not because im a former physician but because im a patient and i believe its my right to say, well, why . As we both know, often when doctors are ordering tests, in my era of training there was a, why dont we just order these tests . The tests of will onbe a long check sheet and youre just going down, check, check, check. I think the question now should be, why . How is it going to change my care . That requires a little bit of mind shift in terms of patients. I like to say my mom goes to the doctor and shell call me and say, i saw my doctor and i really liked her but she didnt even order a blood test. And we want as patients we have to kind of say, maybe the answer is to wait. Maybe the answer isnt to jump in all the time. But when its time to jump in, then i say to my physician, whews whose computer is now programmed to send my test to the hospital lab. No please send it to the two commercial lab is know in my network because lab core and quest may charge ten dollars for the exact same lab test that a hospital would charge 500 or a thousand dollars for and you and i both know that theyre both putting tubes of blood into a machine which spits out numbers. So, likewise, think we can say to tower to our physician if i need an xray of my knee, which are the dozens of xray centers within a mile radius of this office do an xray at a reasonable price witch know that most doctors dont have that information now, but i think the more patients ask, the more they will have that information, and i think sadly those of us who run into medicine didnt go into it to, like, be bean counters or to think about bills, but that is the position were in now to advocate for patients. I would say, its kind of the doctors responsibility to know which xray centers are good value now and to say to the one who is charging a thousand dollars for a 100 stray, xray, saying im not going to refer parents because youre representing off my patients. Not a work for doctors but not only will that that save money but will send a message to the centers that are overcharging that, hey, were going act like this is a market now and we care and price matters and, p. S. , now we are raying for that with my 5,000 deductible plan, it matters to me. This is an important theme of your book, you do put a lot of burden of containing costs, reducing prices, and also of deciding what youre going to get and where youre go to get it on the consumer. Was struck by the recommendation you made that people actually review the papers they are asked to sign, which of course they sign without looking at them, to make sure that theyre not being referred to doctors and hospitals who are not going to be paid by their Insurance Company because theyre out of network. I had the picture of a patient on a stretcher, you know, clutching his chest and having to go through that paperwork, or running down the list of drug prices the hospital or the lab tests and saying issue dont want you to do these and these and these things because theyre not covered or you see the point im making. Guest yes. Host fair and railistic. Guest it is a big unfair burden to put on patients, but its the situation that we find ourselves in. Of course, i dont think this is the ultimate solution, but the a. L. Tentative right now is ick the alternative right now, nasa book, somebody being rolled in on a stretcher for an emergency appendectomy and the Business Manager comes in in a gown, saying we need your credit card before we can proceed with the surgery. Im naked and i dont have my wallet and the Business Manager says, well, do you have someone you know who we can call and get a credit car number so we can proceed . That is the alternative now. So its not like of course in an emergency you cant do the things but a lot of parts of our medical care are not emergencies so, where to be yes, its unfair and a burden but if we dont take these steps, then the system wont respond, and the ultimate goal, of course, is not to have to go through those forms and write in as i do, you know, i will pay anything my insurance doesnt cover so long as its in my insurance network, but the ultimate goal is to prod hospitals to respond to us and to say, okay, if you go to an innetwork hospital, its our job to ensure that the er doctors, the radiologist, the pathologists, the new yearsolist is all in our network. The goal of the prodding is not to say this is the final answer but to say to push all the providers who are not paying attention to this to do so and its unfortunate that hays fallen into the patients lap and on the backs of sick people who should be thinking about how theyre healing and on to the into the laps of doctors who should just be thinking about what this right thing to do . As we all know, physicians spend a lot of time dealing with this out of control system, feeling as helpless as patients. I have to file out paperwork and do preauthorization for drug that 100 years old, unless we start squawking, i think thats going to just get worse and worse. So. Big ask of both physicians and patients. Host this relationship between physicians and patients, nurses and patients, clinicians and patients theyre all part of this very complicated system that we now have traditionally its been based on a certain level of trust, hasnt it . Thats an important part of the therapeutic relationship, an important part of a healing relationship, and none of us, even those of us who are trained in medicine, are in a position to make decisions about our own care, when were in the midst of an illness. And so what is left of trust in our Healthcare System and is it have we lost irretrievably something that was always an important part of relationships between clinicians and their patients . Guest i hope is a not lost irretrievably, because as anyone who reads the book can see, many of the best sources are physicians who are equally distressed, who desperately want to keep that connection with their patients. I think its been severely diluted. And some of that may have been needed. Maybe it was so inefficient that you its not realistic to think in this day and age you can spend an hour with the patient, but this kind of notion that just doing things more efficiently will result in good care. One example its minor but is really telling. So much has been replaced with technology. Right . Telemedicine. Just give everyone an ipad and it will all be better. Thick all of those things are Electronic Medical records which you were a big part of. All of those things can be really useful tools but too often theyve kind of been used as a substitute for that kind of facetoface interaction, which is so crucial to trust. It was just hearing at my hoves in Kaiser Health news about a program to give patients in hospice ipads, at home hospice, ipads. Thats great at some level if its used for certain kinds of things but if its used in stead of a nurse coming by and holding someones hand and talking to them, which is what a lot of people need in home hospice then its just diluted everything that is kind of so precious to me about health care, and what both physicians and patients really want. So, efficiency is a business metric. Health care could have been loot more efficient than it was 30 years ago, but it shouldnt be the primary goal of health care. Host as you and i are speaking, the house of representatives is deeply engaged in the future of the Affordable Care act and Health Care Governance and policy the national level, and underlying that discussion is a big philosophical question about whether health care is a market good, whether health care is a market like any other market, and whether it should be ruled by Market Forces or some other mechanism, and is a read your book, i sometimes felt like i was watching a market gone mad; that it was being treated like a market but that none of the forces that constrain markets were at work. I wonder if your book gave you any thoughts about whether health care is a free market, whether we can solve our problems in health care through free Market Forces. Guest well, i think what we have seen is the answer is probably not. The beginning of the book i put a somewhat tongue in cheech list of the economic rules of the dysfunctional healthcare market, whether if you think of health care as a business proposition that the market will solve, you get to crazy places like a lifetime of treatment is preferable to a cure. Im not saying for a second that anyone really thinks about but that it is where Market Forces put you right now, where type 1 diabetes is a beautiful example of this. Its a chronic illness with great treatments now, better insulin, pumps, monitors, peoples lives are much, much better than they were 2030 years ago. Be but heat come of a huge price. Someone came along and said we can treat diabetes with a drug. Thats an Industry Worth tens of billions of dollars. Theres a researcher at mass general who is working with a very old vaccine to see if that will cure type 1 diabetes. It may or may not. Right . Its early stages. Who knows if it will pan out. But she cant get pharma funding which is who we trust to fund drug attempt E Development because they look at this and say, you know, prettied but if it works, youve killed our market, our business. So, think this notion that Market Forces lead us to a rational place in health care is just it doesnt work. Thats the simplest way to say it. And its because a market depends on a lot of forces that just cant not only dont they exist in health care, they cant exist in health care. You need to be able to make a choice. Right . When youre lying on the stretcher, you not in a gown with your appendix burst youre not in a great position to do that. Mostly our doctors choosing for us. You can work with your doctor to choose better, but as we have seen now, the choices often rather limited unless youre willing to fly to another city. Many cities have had so much healthcare consolidation, theres one or two choices. So, the fact that colonoscopies are cheaper in baltimore and doesnt really help me if im in new york. So its not a market in that sense. Like wise, where there is hospital consolidation, and, therefore, all of the studies have shown that leads to higher prices after a point, not better care, the ftc wail occasionally come in but their philosophy is, well, if a certain hospital is cornered all the cancer care in a certain part of florida this hays happened the answer is, well, the market will work how will the market work . Many some oncologist will see theyre getting high prices in florida so well open up a christian can. No tot easy. Takes time for a doctor to move a practice, to establish a patient pool, and, yes, that may take three years, five years. What happens to people who have cancer in the meantime . This is not a market. The biggest failure of the market is look the price variation that we see for medical procedures. Right . The same tests that cost 30,000 in like a knee replace, white cost 1300 in france. What we have seen at we look around the world thats why i kind of look a little bit at other countries Health Systems theres no place its work as a free market. Always some degree of price regulation or national some systems choose a more governmentbased approach, socialized medicine, as canada and the uk, others choose a singer pair where theres a lot of single payer where theres private hospitals and doctors and theres one pair and rates are set and a national negotiation. Others have what is kind of a more marketbased approach, but even there, like in switzerland, there is a degree of price regulation. You cant just let the market decide. This market is going to decide exactly what our market has decide which is prices will rise to whatever anyone will pay, and someone will always pay a lot. Host you do have a series of recommendations for the Public Sector as well. You recommend that the Public Sector require prices be published, what we in the Health Policy world call Price Transparency. Remed that insurance commissiones, which mostly work the state level, be much more aggressive in negotiating what the Insurance Industry does in their states and youre recommending that the federal government and other governments negotiate drug prices, something that the congress has specifically forbidden for the medicare program. So, obviously youre moe sympathetic to government than the prevailing political consensus seems to be. Can you say a word on that. Guest i hope host on the practicality of the sunny didnt mean the last part to be recommendations. Theyre more a menu of options. Im a journalist so i have my preferences but i wanted to opoint out to people there are a lot of different options and what were doing now is choosing none of the above and none of the above doesnt work. And i think so, sure, i think none of no one of those things is a solution. Theres some people going, the answer is Price Transparency and then the market will work. Im not staying that is an answer. Im saying that, okay, if we are going to have to try to be consumers, at least we deserve that. It happens in other countries. In france, there are prices on doctors walls and australia its considered for elective surgery. You right to have a binding estimate before you go into the hospital. Thats not a solution in and of itself but i think its what patients deserve to know as long as were paying part of the bill, and i think its one of those areas where if the hospital where i had my kole loinscopy had to write, were charging 11,000 somewhere in the lobby, than it wouldnt charge that much of the theres an element of a lot of these prices have gone to where they are because they happen in darkness. So transparency will help in and of itself. I do think we have too little whatever system we choose in the end we ask too little of our state Insurance Commissioners. Theyre in i really didnt know much about this world. They are either an elected or appointed official. If elected theyre really downballot. They have a lot of control or power or at least a big bully pulpit to make sure that insurance works better for citizens. So, you know, just a tiny example, we all know that insurance direct director directories are inaccurate. Innetwork but not take including patients or you good hood winked and go to a provider listed as network but this physical therapist is not in your network. Surprise. So i think Insurance Commissioners can do a lot to be more consumer advocates rather than Insurance Industry proponents, which they are in most states. So is it that we pressure our governor to appoint someone who will stand up for patients . Is it that we Pay Attention to this downballot issue and get someone who will promote patient needs. We dont think of ourselves as having the same rights in health care as we have in shopping for groceries or for a car, and i think thats kind of crazy because that is what wear paying for now were paying for now. California hat an activist insurance commissioner in dave jones, and has he solved the problem . No. But has he made it better for patients . Yes. He actually doesnt have a lot of legal tools. To use but he can make lot of noise and he has. Host so, we touched on the Affordable Care act little bit earlier and this is absolutely critical time for that law, and some of the issues that are front and center in the debate that is going on today, issues like whether insurance should have to cover certain things. Called the essential Health Benefits or whether Insurance Companies should have to charge everyone more or less the same amount, something that goes by the name of community rating. Those two issues are very much under debate right now, and as you from what you have learned in your study of the u. S. Health care system does it leave you with opinions about those ongoing debates or at least observations . I know youre a guest im not allowed to have an opinion but a i can tell a couple of stories i think everyone should think about. I started my series before the aca came into effect. So i interviewed many, many people that year who were uninsured because they had a preexisting condition and, therefore, couldnt afford insurance. And in some cases at any price couldnt get insurance. Now, that included people whose preexisting conditions were as minor as having had an abnormal pap smear or needing an asthma inhaler. If i had not had moyer provided insurance i would have been that pool even though im a really healthy person because we all have some kind of history. So i think likewise, if we talk about were going to pull out essential Health Benefits. In those days, insurance policies didnt have to cover maternity care. I think most people didnt realize that, but there were many policies that didnt. So i interviewed one young woman who discovered once she was pregnant her policy didnt cover maternity care, and the people can say, well, consumers have to be better shoppers, but im sorry, insurance policies are really hard to read through. Its not always so obvious. So, she went about shopping for her maternity care, and she did it as a religiousal shopper. Radicalizational shopper. She went to the hospital and said give in the a ballpark. My husband and i are willing to pay. They said we cant tell you, who knows, and in the end they came back to her and said, okay, it will be between 5,000 and 45,000. Okay . This is the preaca experience of shopping for health care, and no essential benefits. I think the thing is, stuff happens in health care you cant predict so to allow people to say, im not going to cover pregnancy because i am i dont want to get pregnant or im a guy, right, so im not going to i dont want to have to pay for prostate cancer. That doesnt work in terms of the numbers and also leaves people out in the cold, and a moment in their lives where i dont think anyone in this country wants to say, were not going to treat your cancer or were not going to, like, say you cant come into the hospital to have your baby . That doesnt work. So, i think health care is something that we have to think about holiesicly and you may be healthy today and maybe really sick tomorrow. Host one packet of the Affordable Health care act that doesnt get much attention but you touch on in your book and you actually suggest or that Insurance Companies could do more of this the Affordable Care act promoted the socalled bundling of payment or the changes in the way we pay, and there are lot of folks who believe that part of the Affordable Care act, which is not under debate right now and has a lot of bipartisan support. Is an important addition to the fiscal scene in health care. Could you say more about that those kind of reforms. Guest part of the way the prices got so out of control is this phenomenal called unbundling, which is kind of the healthcare extreme version of walt we see on airlines, where what used to be all included, now youre paying for a bag and youre paying for a drink and youre paying for priority boarding, and in health care, that is happened exponentially. So youre having a baby instead of just being maternity care. Having a baby the hospital now is he heating pads, delivery fee. One wonderful patient who is a physician. She thought, im not going to buy this unbundling thing. She came to the hospital ten minutes before delivery, brought ore heating pad, motrin, decided to keep her number born insure number newborn in the reek and was called a inroom board feeling and a lactation fee which she didnt need. This motion of Rebundling Services and its become kind of a novel thing but in fact, its healthcare done a long time ago and done in most other countries is a smart idea and taken tee the extremities the hmo concept where all of the patients care is paid for by an annual fee. And in the bundling, what were seeing enough is medicare did some really interesting pilot projects with bundling knee and hip surgery, as have some employers in california, called reference people, saying hospital and doctors well give you a price that we know is reasonable, where you can gate good hip or Knee Replacement and you guys figure out how to divvy it up. Thats your problem, not ours. And in california where calpers has didnt or medicare has down it, the price ranges between 20,000 and maybe 35,000. Thats way less than most fee for Service Hospital bills bille youre billed for each component outs the knee, the screw, the anesthesiologist, the three ours of Recovery Room time because the Surgical Team was having dinner the last hour. So, its a wonderfully sensible concept that has worked very well where its used. Hospitals were trying the medicare model, and most of them found there was a lot of stuff they were doing for hip and Knee Replacements that didnt add very much to the care, if anything. For example, the long period of inpatient rehab or long periods of physical therapy after a hip replacement. When they looked at that carefully, when they were told they werent going to be paid separately for it, they discovered, you know what, it doesnt change the outcome, and p. S. In europe they have never done that because they knew instant do didnt change the and you can better hmos dont do that because i doesnt change the outcome. Again in am i immensely sensible experiment that was headed for policy under the Affordable Care act, i know the new hhs secretary has expressed his dislike of this concept, and so i dont know where it will go, but it is the kind of thing that we should be as guardians of our healthcare dollars, we and our physicians physicians shoule enthuseisic about and not theres always this narrative of, oh, if theres a fixed price, maybe someone will be skimping on our care. And i think what we see in our Health System and what i learned in researching the book is theres so much that we do that is excessive because its paid for, not because its good for our health, and we could eliminate a lot of that. Dont think well get to the france level of Health Spending or germany level of Health Spending tomorrow, but we can certainly start turning this kind of very expensive ship around and we really need to. Otherwise well all end up bankrupt. Host let me turn back to another topic, but ill reference the Affordable Health care act in the transition. Hospitals as charities. Hospitals as nonprofit entities. The Affordable Care act does increase the requirements for hospitals, nonprofit hospitals to report on the community benefit, the charitable benefits they offer in return for their tax deductible status and many, many people in the United States volunteer in their hospitals or serve on hospital boards or donate to their hospitals as charity. You have some pretty striking things to say about hospitals as nonprofits. Guest im going to make host elaborate on that. Guest a few enemy monday business here. One thing that having written this book and done the series really, really, really gets under my skin is i go to a hospital in new york, i get the bill, and then the next thing that comes in the mail, maybe even the first thing, is were so happy you liked the service. Wouldnt you consider dough a donation . Im like, ah. I donate to charities but these houses fivestar hotels many of them dont feel like charities the moment, and that is not to say there arent hurting hospitals. Hospitals that may not have a good pair mix, dont good payer mix, dont have the wealthier client who are willing to donate art or time or in rural places. They are really struggling now often to stay afloat, and from a business perspective, we see a lot of them shutting down because they dent have a Good Business model. And we hear, we have to close that emergency room because not enough people come at night in that rural area. Well, right. That is not why we keep Emergency Rooms open at night in rural areas. We keep them open because people are sick and might be an emergency. But once the business, the logic of business if applied to hospitals, the kind of structuring of hospital care we end up with a lot of weird decisions so, again and again people say to me, wow, get all these requests asking for money, and the Hospital Executives are saying, you know, theyre medicare doesnt pay them up in, medicaid doesnt pay them enough. Well, the first thing i say is, okay, walk interest the lobby of your local Teaching Hospital and tell me it feels like a poor suffering place. Im sorry. Know we both have been involved in wealthy Teaching Hospitals, but hospitals today look like fivestar hotels. There are i spoke to one Trauma Center who wanted know come look at their zen garden. Im like, wow, this is a weird priority. Some hospitals now hire Hotel Executives for to improve the customer experience, and theyll advertise high thread count sheets and great meals. Thats great immigrant dont think hospitals have to be like prisons but i think we patients have to wise up to what is important. I mean most hospitals in europe look like high schools. Much more basic. And so what are hospitals doing . Do they feel like charity . Do they feel like theyre serving a community . I recommend that everyone look at the 990 tax form of their local hospital. Look how much the executives are paid. The highest paid executive in most cities is the crowe of the ceo of the local hospitalment i dont want nib anything going broke on health care or have to day a vow of poverty but hospitals dont need the top 20ed a are inners played over a Million Dollars a year and they say health care is really complicated my immediate answer is, yeah, well, the Ford Foundation is really complicated, too, and it operates in 90 countries and the ceo of the Ford Foundation doesnt make nearly as much money as the 15 administrator in a local hospital in new jersey. So i think thats a kind of false narrative, and i think the aca did something really important, and that is one of the things im afraid of will go away, is this reporting on what youre doing, hospital, to deserve your big tax break. What are you doing to benefit the community . What are you doing to in the way of charity care. Again, that was transparency was never defind. What are the level we want, the kind of community ben ben benefits to merit the tax brake . Tax breaks. To there have been some local merits who sued hospitals to take away their tax exempt status so if hospitals arent going to serve communities with what they need, like cheaper rates or marsh remediating mold infested house organize treating kid at school, then maybe they dont maybe you can better use the tax dollars, and as someone said to me, apple gives away a lot of computers each year but that done make them a charity. So, i think we have to define what is the bar that we expect of these big, wealthy institutions in our midst, in order to deserve a tax break. Long answer but its something i think every mayor and every city council should be looking at. Host sure. Your book takes on the whole a pretty negative view of our Healthcare System and youre focusing on the problemmedment are there in good parts of health care in the United States . Anything that we should feel good about as citizens, as patients, as taxpayers . Guest well, i think there are many, many, many good people in the system. I think there are parts of medicare that work very well for patients. I mean, i run a Facebook Group called the paying until it hurts Facebook Group, and people in the group there are 9,000 members and talk about arriving the promised lands of medicare so they dont have to deal with the unpredictable and crazy bills they deal with the commercial world. I think it is true that there are some kinds of treatment that we get first, that narrative, which we hear over and over again. Yes, drugs often come to the u. S. First. They often come to the u. S. First because theyre far more pricier here and it makes sense commercially to market them first in the u. S. Because then you set a high bar for prices in the rest of the world. I would say also that reliance on the profit motive to bring us new drugs and new treatments leads to pretty bad results. The overuse of expensive treatments. Some great new machines, like the Proton Beam Therapy which was invent for a very small segment of patients who couldnt be treated by other means, and now its used far more widely in the u. S. I think theres one proton beam machine in canada and the uk still sends patients to the u. S. There are dozens in the ewes now and for that reason theyre used on many patients who dont athlete them and wont benefit from them. So i think, yes, we get them first, and, yes, for people who really need them, thats great. But then theres this kind of diffusion to places where these treatments are not useful. Also, i think the flip side of that is, treatments that are not useful, or that nor reremain remunerative are not used. There were vaccines against meningitis b in the market in australia and canada and other countries but never been marked in the u. S. Because it was clear it was going to be used in a limited way for outbrecks on College Campuses and it just wasnt worth going through that whole fda approval process for the manufacturers. So, we get some kinds of treatments much quicker and then there are others which eventually that vaccine did arrive in the u. S. But it was only after the cdc and the fda jumped through a bunch of extraordinary hoops after i think it was close to a year that the vaccine finally arrived. Host we are nearing the end of the hour and it has been terrific to listen to your description of the book and i highly recommend the book. It really personalizes a lot of these issues we all feel. There is much more we could talk about. I am looking forward to seeing what you do with your reporting going forward. Any comments on what you are planning to do next placed on what you learned . I am editor and chief of Kaiser Health news now. We are a nonprofit Investigative Health news service. You know, what i think i am trying to do in that roll is continuing to look at role why economic theories of health care dont work on the ground, what makes our system expensive and what we can do about it. The area of drug pricing is one thing we havent talked about and why we are not negotiating at a national level. Medicare is prohibited from doing that. You know, there bipartisan support every time there is an epipen crisis, we should allow medicaid to negotiate or allow for controlled imports or reference pricing with canada. Those dont know anywhere and i think that is because of hobbying and they are looking more at that. Lobbying. Host it has been a pleasure. Wish you luck with the book and luck with kaiser news. Thank you very much. It is good to be talking to you again. Take care. Cspan, where history unfolds daily. In 1979, cspan was created as a Public Service by americas Cable Television companies and it is brought to you today by your cable or satellite provider. Host linda len