Policy at Johns Hopkins university in baltimore. Policy at Johns Hopkins university in baltimore and also there. H or surgeon his latest book is the price we , good morning dr. Mccarrick. If you had to pick a breaking point for American Health care, where would you put it . Guest if you had to identify the issues that are driving our affordability crisis, it is number one pricing failures, number to the middleman industry, and number three in appropriate medical care. Collectively there is broad consensus in america about addressing these issues. Unfortunately our discussion has been sidetracked into this false choice we have into whether or not you are pro or con health care. I have yet to meet somebody who thinks that any industry has gone from nontransparent pricing to transparent pricing and then said this is a bad idea, lets go back to hiding prices. People are getting hammered out there. People are getting crushed. They are hungry for honest pricing and health care. It is ironic. I am a surgeon and i do pancreatic surgery. For most of my career, i could tell you 5000 things about pancreatic surgery except for 1 the price of surgery. People now need to know the prices. Think that is similar among your colleagues at Johns Hopkins and surgeons in general . Guest yes and it is not because we have bad people. We are just focused on taking care of the patient. When people come in, we like to take care of them. Have relied on our hospitals, our billing department, our administration to handle the billing processes. They are not bad people either. We have inherited this crazy system in health care where we mark up prices for the purposes of offering secret insurance discounts, secret and selective insurance discounts. Why do we have an army of staff negotiating discounts off of artificially inflated prices . This is the crazy game this crazy game has resulted in hundreds of insurance executives am a part saying i of this system, and i cannot say this publicly, but it is insane, after the book came out. Guest you host you went out into the field and interviewed people. Like your book says, you did your rounds. What type of people that you see . Guest like doctors do rounds on people, i thought it is time to do rounds on this issue as a professor of policy at Johns Hopkins we hear a lot of opinions. We hear a lot of stories of outrage and gouging in Health Wanted to take a comprehensive approach to identifying the factors leading our crisis. I spoke to hospital leaders, doctors, nurses, patients, who few people talk about. A lot of people are getting rich in health care, but not the one stakeholder the patients. Talking to pharma, large academic centers, i tried to put together a basic Health Care Literacy book so we can create a common language and really unite people by appealing to the best in them. People go into health care at every level at of a sense of compassion. People going to hospital administration, any aspect of health care, Insurance Companies, they work at any level for the purpose of contributing to society. We have got to appeal to the best in people and remember why we went into the field. Create price couching today price gouging today is threatening the public trust in hospitals. Host we would like to hear from you. Were talking about fixing the Health Care System. Talking about his new book. We would like to hear your experiences, your ideas. Here is how we are breaking down the phone lines if you get employer provider insurance, that number is 202 7488000. If you get your insurance through the Affordable Care act, that is 202 7488001. Through medicare or medicaid, that will be 202 7488002, all others, including uninsured, that would be 202 7488003, one of the things you write about early in the book leg pain. You said doing leg procedures for people who do not need them is one form of unnecessary treatment. The problem is even bigger in the preface i mentioned that doctors believe that 21 of things done in medicine is unnecessary. 11 of procedures are unnecessary. Aliens of dollars are spent on care we do not need. All of us have seen the tv ads on this. What do you focus on in the issue of treating leg pain . Guest when we surveyed doctors at Johns Hopkins in a National Survey and asked them what percent of medical care is unnecessary, they say it is about of a fifth of everything we are doing. 10 years ago we prescribed two point 4 billion prescriptions. Last year it hit 5 billion. Did disease really double in the last 10 years . No, we have a crisis of appropriateness. We have a consumerist culture, we have this fear amongst physicians that they have to cover themselves i doing things they know are not necessary and we have this problem of money on the table and this feeforservice system that incentivizes quantity over quality. I open with this story in the book of people being recruited for leg stent procedures at local churches here in washington dc because medicare is funding this entire system. There is no way to identify currently patterns of doctors doing this. Justify what they need to in the medical records, medicare to pay for it. Into throw good money medicare, that does not fix the problem. Politicians talk about different ways to finance health care we need to talk about how to fix health care. Host it is not just procedures, it is products like mobility devices and other types of medical devices provided through medicare. Abuse there is a lot of in a lot of areas. We have two issues in health care we have underuse and access issues and we have overuse. By far overuse is dominating our cost crisis today. Doctors are speaking up about it. Patternsing practice to identify actionable outliers who can then see results and we see that they autocorrect in the data. Host we have done a couple segments here recently about the in ruralf you will, hospitals. Some of these issues youre talking about, are they exacerbating it . Guest rural hospitals closing is a big problem. We are seeing a Record Number of closures. Big hospitals are on track to get record profits. At the same time, small and rural hospitals are closing. What we have got is this multiple multiple streams of cash into the big hospitals. You can name it. State subsidies, philanthropy. Small hospitals usually dont get that and they are the ones getting crushed. A bigJohns Hopkins is hospital. Is that a forprofit system . Nonprofit system. With that taxfree status comes an obligation to help the community. What we can see is if we can use the right lexicon, some hospitals are engaging in predatory building billing where they are taking patients to court. That is the most absurd conflict of a taxexempt organization. Before we get to the calls, the center for Medicaid Services the cost of health increased nearly 5 to forh 3. 6 trillion in 2018 11,001 hundred 72 per person. The insured share of that 11 ,172 dollars per person. 35 Prescription Drugs billion. Dental services, 135 billion dollars. We will hear from you. We go first to sneed phil, tennessee. Sneed phil we go first to tennessee. Caller i am with you on hospitals price gouging. Bandaid take a . 50 and charge the Insurance Company 15. That is ridiculous. Kind ofare needs some oversight over the price of whatever. They need to have a general standard they ought to have a guideline of pricing that they have to go by. That is not gouging the people. I was hooked on opioids. They came out with suboxone which is a great drug, but then you have the doctors who wont take your insurance and you have pay 300 25 ad to doctors visit, even though i had insurance i had to bay i 325 a doctors visit even though i had insurance. Guest it is a disgrace what is happening. Lets call it what it is it is price gouging. What i learned from going on tour, talking to Everyday Americans, and stakeholders in health care in the book is that most americans do not live like i do. Life has been good to me. Half of americans have 400 or less in cash on hand in their savings account. People are getting hammered with these crazy bills. If airlines did not have to provide prices on travel websites and instead argued that we have to bill you after the flight, we cannot tell you what the flight will cost, we would have gouging all over the airline industry. It would result in this loss of the public trust. Right now in health care, we have the same crisis. Host you put out there in your book, you do suggest that people asked the price. We do not do that. We do not ask before the procedure. How do you change that . Guest one of the exciting things happening is organizations are now showing you prices. Check out the mayo clinic price estimator. Check out the free medical freemarket medical Association Shop tool. Empty saves, sesame health, clear health costs. Md saves,ut the sesame health, clear health costs. It happened this week. A woman came in with the help a head cold and was charged 25,000 dollars. We need that bill forgiven and a public apology, and a systematic change in the system. The purpose ofor offering secret discounts is a crazy game that costs a lot of money to do and has nothing to do with bedside care. Callingts go to eric from rome, georgia. Caller the republicans and trump have no health care plan, but the democrats have several. Mcconnells medical health care is basically what you have to do in order to bring down the cost of medicare will stop care uncompensated care in hospitals. What you would have to do is that is where the largest prices are coming from. It is uncompensated so it is raising the prices on other people. You have to mandate that people pay a copay or some kind of payment at these hospitals. That would bring down the price. Next thing you would have to do is go to medicare for all. That is where you get the cheapest medicine. You drop the price down, you drop the age limit down slowly on it and what you do you negotiate the price of the drugs. Then the price of medicare is actually cheaper then any other insurance that is provided in the United States. First you have to have a plan. Medicare for all, drop the aide, stop the uncompensated hospital care. That is what is raising the problem. Host an additional comment from mark on twitter medicare for all, do you support that . Costs forimbursement health care. Guest we need to turn off the echo chamber of cable news that unfeasible,s these nonrealistic options and instead talk about where we have common ground. There is broad consensus on how to fix health care. We need to address pricing failures and inappropriate care. We have a study out of Johns Hopkins that shows that 48 of all federal spending right now is going toward health care in its many hidden forms, that is not just medicare and medicaid. Half of Social Security checks are going toward medicare copays and deductibles and coinsurance. It is the defense departments the defense departments divide half of the defense departments budget goes to health care. Partest on the debt is in interest on health care data. 4 of all federal spending think about this next time you file your taxes 48 of all federal spending goes to health care. Those arguing for medicare for all, what do they propose we twoe that 48 percent number to . Do we cancel all other National Priorities and spend all money on health care gecko even then we couldnt afford medicare for all. Do we cancelcut all other National Priorities and to spend all money on health with on health care . We couldnt afford medicare for all. We need those secret negotiated prices to be disclosed. Infuse transparency in the marketplace and do a lot of good. How about we give transparency a chance . Host the center for Medicaid Services with the figures for 2018 on spending private Health Insurance, 34 of that. 37 , doesedicaid is not include tricare outofpocket costs. 10 . Tulsa, oklahoma. Talkingwe are back to about price per pill. I am on the aca next year, she is on medicare. She has pain medication that hases . 12 a dose and she medication that costs 27 a pill. We need some Nonprofit Organization going and some kind of pricelist. I go into walmart, i know what im going to pay for something. If i go into the hospital i dont know one till i get the bill. This is getting too complicated with all the different types of insurance. My aca went from 250 a month to 1200 dollars a month. It is not really Affordable Care month. 0 a it is not really Affordable Care. It is ridiculous to pay 1200 a month for health care. I would love for you to address the guest it is important we filter what politicians are saying. During the democratic debates we heard a massive pylon on the insurance industry. There are things there that were correct. We do not have a primary insurance crisis in health care. We have a pricing crisis. That pricing is managed by insurance passed on to individuals. We have to address the underlying issues that are resulting in our affordability crisis. Spent 48 if we percent of all federal debt spendsrage household 20,000 a year on health care and then you get a bill on health care and here it is not covered people have a right to be angry right now. People are getting crushed. We need some public accountability around pricing. I recently met with an executive at google. Someone there had read the book and wanted to meet. When somebody googles the name of a hospital, instead of just putting the hospital, the address, and the phone number, how about put the name of the hospital, the address, the number, the average markup, sue patientst they and their markup quality doing host an callern earlier mentioned using opioids. If you have a chapter on that. For most of my surgical career, you write, i gave out opioids like candy. I was unaware that one in 16 patients become chronic users. My colleagues and i did not realize we were feeling a national crisis, but today opioids are the leading cause of death in america of people under the age of 50. As a medical student and a surgical resident, i spent thousands of hours learning how to diagnose Breast Cancer, how to cut out Breast Cancer, and chemo chemo and radiation after surgery, that at no point was i taught that the way we liberally issue opioids would kill more people than Breast Cancer itself. Tell people what you do differently in the pain medication arena now . About theeel terrible Opioid Epidemic because i contributed to it for many years with good intentions and arguably bad science. I did what i was taught and i prescribed opioids liberally after the surgical procedures i formed. As painful as it was to write about it, i think we need more humility in medicine. Out is Sutter Health paid 575 million in a settlement announced this week, part of the settlement was they would admit to no wrongdoing. I think we need more humility. The Opioid Epidemic is just one example. Opioids have become the number one cause of death in america among people under age 50. Doctors at construction sites were prescribing opioids to anyone who is injured and at certain sites, the majority of people longterm died from the opioid prescriptions that they were given. These are not people dying from injury or illness these are people dying from the care that they have received. T is a snapshot opioids are just one medication that we overprescribing. There are many more out there. Fatalas a particular addiction that has attracted National Interest that has gotten large, but there are many other issues. It is one glimpse into our problem of too much medical care. Host how do you handle pain relief now . Guest first of all, we went to the patients involved in the decision. Have a website called solve where we have patients watch a video. We do not want the pain to debilitate them where they cannot be active or walk. We use nonopioid alternatives and there are a lot of them. I had to educate myself on what we call multimodality alternatives, usually a combination of acetaminophen and local anesthetics. We use opioids judiciously. Our guidelines that should be specific to the operation, just why we have stated our consensus headlines on the website. Tony is on the line for those who get their insurance through the aca. Caller i came to the opinion that the government could service for the Insurance Companies by making comprehensive insurance required aca and also when they made it so businesses had to provide insurance for their itloyees and but it made so that they had, they were appointed as middlemen. Public a lot of harm because there was a lot of rate waste in the system because of people not shopping around when people are covered when something is covered. The other thing i think that is theput up with that other choice is to be price gouged and as dr. Macario was dr. Makary was saying, they rise the prices so they can start at a better negotiating position with the Insurance Companies. The entire thing got way out of hand from the beginning. Think we would definitely not have this requirement to ensure maintenance costs that a market would develop to lower prices. You need to have some taxes to who care of the people cannot become selfreliant, but certain people have enough good health and finances and maybe savings to not rely on the government. It would be like the equivalent of homeownership and you would not have to pay for host we will get a response. Guest we has a National Priority in the United States have basically realized that people deserve health care and no one should suffer because they cannot afford care. We already spend enough money